The fetus develops a unique type of sensory play at a very early stage of gestation and begins to develop its tactile system due to the surrounding amniotic fluid. The fetus swims smoothly in a way that activates the vestibular system and sense of direction, which helps to develop a sense of proprioception when kicking and pushing the inner sides of the womb[11]. The fetus starts to hear the mother's body sounds, such as heartbeats or stomach rumbling, by the 18^th week of gestation and starts to react to these sounds by the 26^th week. After the 32^nd week of gestation, the fetus can recognize certain vowel sounds from the mother language, suggesting very early language development even before birth. The fetus can memorize his mother's voice and more complex auditory external sounds with considerable discrimination capacity[12]. Fetuses may startle or even cry when exposed to sudden loud sounds. The mother can start playing with her fetus by touching or rubbing her abdomen in response to fetal movement. The father can massage the fetus's bump if the mother is happy with that. Both can talk, sing and read, so the fetus can get used to sounds[13]. These maneuvers help to strengthen feto-maternal bonding and enhance fetal development. The auditory and olfactory systems also develop in unique ways. A previous study has shown that the baby feels comfortable if his pillow is sprayed with the smell of food that the mother used to eat while she was pregnant with that baby. Babies who ate cereals with carrot flavor showed better facial expressions if the mother consumed carrots during gestation. Moreover, if the baby listens to music that the mother used to hear while she was pregnant with him, he will sleep deeper and more comfortably[14].

Playing with newborns helps them learn about the new world and how to interact with it. Play permits their brains to grow and develop, build muscles, and develop gross and fine motor skills. The mother's play with the baby helps her understand her baby and helps the baby feel love and build trust with the mother. Play strengthens the bonding between the mother and the newborn. Playing with the newborn needs simple actions such as singing, chatting, tickling, counting toes, blowing raspberries, smiling, laughing, rolling the eyes, or poking the tongue out. Even during the nappy change, the mother could have an excellent chance for face-to-face play[15]. In other words, the mother needs to use what is called “serve and return,” in which the child gives action, and the mother or the father must respond right away to keep the child engaged[16]. The mother can use rattles, soft toys, or cloth books with painted pages and different textures. This tactile play helps the neonates to feel different things and learn about the external world. Reading can start soon after birth. The mother should hold books close to the baby's eyes within the visual range of 20 to 30 centimeters. Early reading helps infants get used to sounds and words to build language and enjoyment with books[17,18].

Play is a central component in typical child development and learning and is a fundamental right of every child. Play is the main occupation of children. Play is critical in maintaining children's physical and mental health. The main intention of the child’s play is to have fun; however, play enhances psychosocial development and helps children to discover the surrounding world. It helps children enface reality and adapt it to their wishes[19]. Play enriches the children's physical, social, cognitive, and emotional abilities and sense of well-being. In the meantime, play promotes the children's skills and abilities to study and work. In addition, it hones their relationships with their peers and community and helps them gain independence, confidence, self-esteem, interaction, resilience, curiosity, and coping with challenging situations[20]. The degree of playful behaviors during play varies between 0-100% depending on the presence of purpose, pleasure, and enjoyment degree, and how much the child is process-oriented[21].

Children are affected by day-to-day changes in the world around them. Consequently, the degree of playful activities depends on the child's age, the local culture that impacts the parents' concepts of playing, and the type of the child's play. It is also affected by social class and urban or rurality[22]. Playtime is also affected by the media, local culture and tradition, fashion, books, sex, and ethnicity. Unfortunately, children currently spend less time in actual playing due to the stress of study and school testing, even though play establishes the foundation for effective lifetime learning. Therefore, pediatricians must promote the importance of playful learning to young children by supplying children with rich play practices and assisting the parents to understand better the significance of playful learning in children's lives. Parents playing with their children establish the base for children's ability to play with their peers effectively[23,24].

Play could help to build motivated, happy, and healthy children to be the future of a productive society. There are different types of social play the children can do. In the solitary play, every child plays alone, while in parallel play, the children are engaged in similar activities, but each child plays separately. In associative play, children play individually, but they may share, pay joint attention, and occasionally communicate with each other. Meanwhile, in cooperative play, children are involved in play with a shared goal, and they play together to achieve this goal. Consequently, play helps to increase social interaction, which usually increases over time[25,26].

In object play, children actively playfully manipulate objects. This active manipulative play is used to either explore or construct objects. With time, manipulating and visualizing objects and toys improves visual-motor integration skills necessary for reading, writing, and many other daily-life activities[16]. It starts as early as the fifth postnatal month when the infant starts exploratory playing by putting everything in his mouth. By age two, the child starts constructive playing as he can combine objects when playing, such as building a tower from some blocks or lining small cars beside each other[27]. Over the next few years, constructive play increases to be combined with imaginative and pretended play, where children start to construct more complex creative models blending constructive and pretended play together, representing the world around them. Constructive play is established when the child develops a constructional praxis ability[28]. By year four, children spend about half of their free-play time in constructive play, extending to preschool and elementary years. Object Play significantly impacts the children's physical, cognitive, and social development by enhancing fine and gross motor skills and manual dexterity. Interactive, cooperative object playing with adults or peers significantly impacts the child's social development more than solitary, parallel, or associative play[29].

Pretend play is characteristic of early childhood, in which the child creates an imaginary reality alternative to the real world. The child assumes other people's roles or imagines other places, things, or other times. The child can also use objects as a symbol for what is imagined. For example, the child uses the banana as a telephone. Pretend play can occur in a group, where a group of children cooperate and assume complementary characters, which enhances social interaction[30]. Pretend play may appear by twelve months when the infant pretends to sleep. Later, children direct their pretending towards other people and surrounding objects. They may animate the surrounding objects in their imaginative play. They may use models like dolls or stuffed animals in their acting play. The child also can respond to pretend play as early as two years old; for example, when a person pretends to do something, the child may pretend to do a complementary or opposite action[31]. Overt pretend play usually diminishes by middle childhood when the child acquires more interest in organized games. Pretend play performs a crucial role in the cognitive and social development of the child with a marked impact on a wide range of cognitive, cultural, emotional, social, and competence skills. It also helps to enhance the child's creative and problem-solving abilities and language skills[32]. The earlier the pretend play, the better literacy outcomes, especially for reading and comprehension abilities and communication skills, particularly speech and writing. Pretend play is also a prominent factor in developing the child's self-regulating abilities and different aspects of executive function[33]. These abilities, in turn, impact school readiness, memory development, attention empowerment, intelligence enhancement, morality, and emotion regulation. Pretending also helps children to understand others. When they step into the shoes of a character, they imagine what he would say, do, or feel, which helps them to understand other people. Pretending and fantasy could also allow children to express their feelings, regulate their thoughts, and better cope with their emotions[34].

Physical play involves any physical activity performed in a playful and joyful context, such as running, climbing, skipping, gambol, hopping, kicking a football, and chasing. It has an inverted U-shaped curve, gradually rising from infancy across the school years and then decreasing during adolescence[35]. Physical play is essential nowadays, especially with increasing obesity and insulin resistance rates among children and adolescents. Physical activity improves insulin sensitivity, helps fight obesity, and promotes healthy lifestyles[36]. Encouraging childhood physical play and gross motor skills is essential to boost physical activity levels with enormous health benefits, including aerobic endurance, strengthening muscle growth, better coordination, enhanced growth stimulation of crucial organs, and augmented bone mineral content[37,38]. In addition, physical play improves cognitive, mental, and academic fields, contributes to self-regulation development and expression, and improves school-age children's executive function, particularly with organized and planned activities like sports. It also enhances academic outcomes through increased attention to educational tasks[39,40]. Physical play promotes the sensory integration, incorporation, and processing mechanism between the central nervous system and the body. Thus, sensory integration enhances cognitive, social, emotional, academic, and communication skills to higher levels[41]. Physical play and sensory integration are evidence-based methods that support the development of children in general and children with ASD. Figure 2 shows the application of sensory play in the Genomics Childhood Sensory Play Center, the first epigenetic play center in the world, based in Manama, Bahrain. Unfortunately, physical play is markedly affected during the COVID-19 pandemic reaching alarming rates. This environmental deprivation affected children’s physical, emotional, communication, social, and academic learning abilities[42].

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Figure 2 The application of sensory play in the Genomics Childhood Sensory Play Center, the first epigenetic play center in the world, based in Manama, Bahrain.

Technology plays a crucial role in children's lives today, much more than before. Before the COVID-19 era, children younger than three years spent 3-4 h/day on-screen media. This number increased to 7.5 h/d by eight years of age. In the COVID-19 era, the number of hours children spend on media screens has significantly risen[43]. There are contradictory opinions about the effects of media on children's behavior and development. A popular opinion suggests that media and gaming are responsible for increasing obesity rates, reducing social skills development, encouraging violent behavior, and negatively affecting language, social, cognitive, and emotional development[44]. On the other hand, other studies endorse that media and video gaming enhance athletic participation and decrease the rate of obesity. Those studies suggest that video game players are more likely to be open-minded, show more obedience to their parents, have more academically minded friends, and are no more violent or aggressive than non-video game players[45,46]

Technology-based games construct a powerful tool to enhance playful learning, especially when the interest in traditional play starts to wane. In addition to fun, these games allow children to practice high self-control and self-learning with trial and error. These games also varnish their memory, skills, critical thinking, executive function, qualitative thinking, and creativity in problem-solving and advance their knowledge through escalated levels of complexity impregnated into the games. In addition, these games used different tactile, visual, and auditory modalities with increased visuospatial abilities, allowing children to have various learning styles[47,48]. These games teach children to stay on task for longer and be more patient in reaching their goals. For instance, Genomics Childhood Sensory Play Center uses interactive projector games that enable children to use tactile, vestibular, proprioceptive, auditory, and visual systems more effectively.

Moreover, they have specific reaction times to give an adaptive response and functional performance. Thus, they promote self-esteem, self-confidence, mind, brain, and behavior. That being experienced, children achieve higher and innovate throughout their future education, career, family, and life in general. However, the degree of benefit from media and video games is age dependent. For example, television viewing has mostly negative associations for children younger than two years, particularly for executive function and language. Conversely, television viewing has positive and negative outcomes for preschool children[49].

Meanwhile, media play has more positive results in older children. Educational video games targeting middle-school to college students increase learning achievement by 7%-40% more than lecture-based learning[47]. We should also emphasize that technology will never replace traditional play. Children still need outdoor playing, pretending, hard book reading, manual drawing, and other forms of play that enhance manual dexterity. Media and video games should only be considered tools to enhance child play and learning within monitored contexts, age groups, and evidence-based practices. It is critical to mention that the effects of flat-screen media usage on developing brains are detrimental, especially for children below two years old. Children between two to five years old are advised to have no longer than one hour of daily flat-screen use[50].

Play is an emotionally pleasing and creative experience that raises oxytocin levels. The Oxytocin hormone boosts feelings of emotional well-being and trust. Thus, Oxytocin facilitates the therapeutic relationship between the play therapist and the child, which helps the child to use his imagination and makes him ready for behavioral change. Play also activates the mirror neurons, which helps the therapist to read and interact with the child's emotional status accurately. Play therapy encourages the formation of new neural circuits and promotes neuroplasticity[79]. Play therapy-induced neuroplasticity through four main pathways: empathic harmony, which provides the ideal chemical environment to develop new neural pathways; emotional provocation, which consolidates and integrates the neural pathways; affect and cognition integration which helps the emergence of complex, elegant neural outlines, and co-constructing nonverbal narratives of self-cognizance and changes[80,81]. Play therapy allows the child to integrate the creative, emotional, and expressive functions of the right brain with the logical, rule-oriented, and analytical functions of the left brain. The brain needs 400 repetitions to develop a new synapse; play helps the brain create a synapse for every 10-20 repetitions.

Although play therapy can help people at any age, it is characteristically used to help children 3-12 years of age. Play therapy may be helpful in various circumstances; some examples are mentioned in Table 2. Play therapy can help three categories of children; healthy kids, children with organic diseases, and children with mental or psychological problems.

Play therapy can help the child become more responsible for certain behaviors, develop coping strategies, enhance creative problem-solving skills, learn self-respect, respect others, express feelings, and strengthen family relationships. Play therapy is indicated for children passing through a transition time in their lives, such as a change of place of the house or school environment, parental divorce, a loss of a loved person, or the birth of a new sibling. Play therapy also helps children suffering from bullying phenomena, domestic violence or abuse victims, or suffering social withdrawal[82]. It could also help children with functional disorders such as toileting, eating, or sleep disorders[83]. Play therapy helps to release the child's tension and facilitates the adult's communication with the child's inner world. Play can also help prepare the child for routine vaccination. An exciting study by Pontes et al[84] showed that children prepared with therapeutic play before vaccination are more cooperative and accept more than those without preparation.

Children with a chronic medical condition that needs frequent hospitalization, such as cancer, are more liable to stress, anxiety, and fear related to their illness and treatment. In addition, children who are undergoing major surgery usually encounter significant preoperative anxiety and fear. Play therapy can help minimize the worries caused by hospitalization or surgical procedure, assist in the fight against the disease, and modulate the child's immunity. Play allows proper lymphatic system pumping, boosts the immune system, and decreases stress, reducing the over-responsiveness of the hypothalamic-pituitary-adrenal axis system[85].

Children with certain illnesses hampering their emotional and social expressions usually benefit significantly from play therapy. For example, play therapy may have moderate to high positive effects on children with post-traumatic stress disorder (PTSD); however, these effects need more studies[86]. Children with mental and developmental retardation have a reduced attention span, poor eye-hand coordination, restricted memory, and weak concentration. Play is more effective, long-lasting, and understandable than traditional teaching activities[87]. Play also reduces the impact on parents after having their child diagnosed as mentally or developmentally disabled. It also helps to build more bonds and interactions between parents and their disabled children[88]. Children with aggressive behavior have reduced expressive or reflective verbalization capacity, reduced dramatic or imaginative play, and tend to feel highly threatened by the therapist's slightest observation or inquiry. However, play therapy helps reach these children when chosen and performed correctly. It is most helpful when used to assist these children in developing mature adaptive social skills and responses through building nonthreatening relationships[89]. Attention deficit/ hyperactivity disorder (ADHD) is prevalent in children and adolescents. Abdollahian et al[90] found that play therapy can significantly decrease the symptoms of ADHD. The significant differences between the experimental and control groups indicate that play therapy could be an effective treatment method for children with ADHD aged 7-9 years[90]. Some children with autism spectrum disorder (ASD) have deficiencies in play. In this article, we will review the efficiency and limitations of play therapy in children with autism.

Child-centered play therapy is one of the most comprehensively studied types of play therapy in children with autism. This type of therapy is a relationship-based intervention, where the therapist enters the child's world and uses the built relationship to intervene rather than train the child. Schottelkorb et al[110] investigated the intensive child-centered play therapy effectiveness in children diagnosed with ASD. They found that children who received intensive child-centered play therapy significantly reduced ASD core symptoms and behavioral disorders, such as attention problems, externalizing problems, and aggression, than control group children[110]. Novita et al[111] found that child-centered play therapy effectively improved joint attention skills in children with ASD. Joint attention is one of the first types of visible communication that implies the child's ability to coordinate his attention around an object or event with a social partner. It is observed when the child displays evident skills such as alternating gaze between an object and a person, drawing attention to, pointing, or offering to share or show[111].

Carrizales[112] showed that child-centered play therapy showed positive growth in a range of areas in young children with ASD. She studied three children with ASD who showed varying degrees of improvement concerning play skills. Three of them showed more natural play, two of them showed advanced play skills, and one of them showed fewer play skill changes. These findings support the theory that a safe, acceptable environment provides children with ASD with more motivation and capacity to freely and naturally interact intimately with the external environment and improve their self-healing power[112]. This type of therapy is not only child-centered but also therapist-dependent. Goodman et al[113] showed that the child's response to the treatment differs according to the therapist, even though the child remains constant. Child-centered play therapy is part of an integrative treatment approach that includes behavioral techniques and parental training. It improves parent education, training, and the child's social skills to improve the child's functioning and correct maladaptive behavior. Child-centered play therapy is a promising intervention in increasing children's emotional and social behaviors with ASD[114]. However, we still need more research to establish whether child-centered play therapy is effective in children with ASD.

Since it is very challenging to direct children with ASD to do specific actions, especially in severe cases, we need to find a way to attract the children's interests while helping to pull them out of their shells; so they do not stick to their repetitive behaviors. This method is called a non-directive approach in which the therapist follows the child’s choices and adapts the tools and environment to serve the therapeutic goals. Child-led play is an approach that allows the child to choose the activity they like to do, and the therapist joins them. It is usually helpful in severely affected children with autism, but it takes a longer time to see significant gains[115]. Child-led play therapy has improved children's social and communication skills with severe autism. It differs from child-centered play therapy, in which there is a preset specific thing and rules the therapist will do and not to do and a specific way of being in the playroom. Gengoux et al[116] showed the efficacy of a pivotal response treatment package (PRT-P) for children with autism. PRT is play-based therapy initiated by the child. They investigated 48 children with Autism with PRT-P for 24 wk. PRT-P demonstrated more significant improvement in child social communication skills and in teaching parents to implement PRT[116]. de Korte et al[117] also showed a significant improvement in spontaneous initiations during the 14-wk protocol of PRT with a semi-structured therapist-child interaction and widespread increases in overall clinical functioning[117].

Floor time-play therapy is one of the most famous play therapies to treat children with ASD, discovered by Wieder and Greenspan[118] in 1980. It can be done at home and in the therapist's office, in a calm environment for a session between two to five hours. It can be provided by child psychologists, occupational therapists, speech therapists, special education teachers, parents, or caregivers with adequate training[118]. Essentially, the therapist or a caregiver sits on the floor to play with the child according to the child's own terms. In this therapy, the therapist or caregiver starts playing, following the child's way of playing (non-directive; the therapist follows, and the child leads). Then, the therapist introduces new elements, such as new toys, acts, or some words (hidden directive). This way of playing with back-and-forth conversations between the child and the therapist ultimately helps the child focus his thinking, improve his emotional skills, and expand his communication circles[119]. With the child's progress, floor time play can also be practiced with typically developing peers when done in a preschool setting. The main aim of floor time play therapy is to meet the child's developmental level, build on the child's own comforts, interests, and strengths, and create relationships during the play course[119].

Floor time play can help the child to improve different critical developmental milestones. It provides him with two-way communication that may progress to more complex communication. It helps him to develop inspirational ideas and emotional thinking, which enables him to enjoy intimacy and engage in relationships. Ultimately, it helps the child improve his self-regulation, enhance emotional and intellectual growth, and empower his interest in the world[120]. Studies show that children with autism significantly improved overall development with 25 h of floor time play per week for a minimum of two years. Wieder et al[118] showed that spontaneous 'floor time' play sessions for three years helped a young boy improve his attention, engagement in simple and complex gestures, and problem-solving skills to guide the child into the outside world with lots of ideas and improve abstract thinking. Solomon et al[121] studied the effects of 8-12 mo of floor time play therapy in 68 children with ASD. They encouraged the parents to deliver 15 h per week of 1:1 floor time interaction. They found that 45.5% of children achieved good to excellent progress in their functional development with significant increases in child subscale scores[121]. Pajareya and Nopmaneejumruslers found that 14 h/week for one year of floor time parenteral playing with their children showed improvement in the development and decreased signs of autism in 47% of 31 children with autism[122]. In addition, Liao et al[123] found in a pilot study involving 11 children with ASD that the floor time home-based intervention program for ten weeks significantly improved mean scores for the children's communication, emotional functioning, and daily life living skills with positive changes in the parent-child interactions. However, the success of floor time play depends on many factors. Praphatthanakunwong et al[124] showed that being married, with a lower income, and having higher awareness of floor time play theory are associated with higher parent engagement. They also found that the more severe the autism and the longer the treatment continuation, the more parent engagement and child development improvement[124].

Clown therapy is currently an essential aspect of managing hospitalized children worldwide. Clown doctors help to minimize the child's stress and anxiety related to the hospital atmosphere during surgical procedures or particular devastating therapies[125]. Clown therapy should be differentiated from the clown person that enters the hospital to cheer up kids and alleviate their tension. Clown therapy (or medical clowning) mimics drama therapy, which helps patients to discover their inner clowns and release clown-like behavior in group settings. This therapy helps patients to discover the absurdity and paradoxes in their everyday lives. They also find new o communication methods[126]. There are scarce data about using Clown therapy in treating children with ASD. However, Shefer et al[127] showed that medical clowning sessions enhanced communication in children with ASD during the interventions compared with other interventions. It caused a reduction in stereotypic movement frequency in children with ASD over time[127].

The 3i play therapy was induced by Catherine de La Presle in 2004 in France to help her grandson, who had autism. It. It works through play and is conducted at the child's home, with the involvement of many volunteers to provide several hours daily of individual therapeutic relations to the child. It is an educative method with several elements, including the importance of play, with a low-intrusive approach that emphasizes interaction and behavioral dialogue and ensures the child's excellent and long-lasting mental stability. Developing self-consciousness and mental capacities are obtained through developing relations and stimulating the need for communication with others[128]. Tilmont Pittala et al[129] studied 20 children with autism using the 3i method for two years. They showed that children treated with the 3i method for two years had significant behavioral and developmental skills improvement with an evident decrease in autism severity. Their results suggested that the 3i method can be a valuable tool for children with ASD by improving their daily interactions and social environment[129]. Brefort et al[130] did a more extensive controlled study that involved 90 children with ASD receiving 3i therapy (intensive developmental play therapy) for two years. They found that 3i therapy improves ASD severity with observed interaction, communication, and repetitive behavior improvements[130].

This model is a play-dependent intervention intended to develop meaningful peer relationships and adequate play and social-communication skills in children with ASD through adult-facilitated peer interactions. It involves neurotypical children, "expert players," and children with autism ("novice players") playing together so that the latter can learn better social skills. A trained adult facilitator serves as a "play guide" to assist and outline interactions between expert and novice players. The facilitator divides the children into mixed groups. Each group has three to five children’s groups. The facilitator sets the tones and rules for the play before they take control[131]. Yang et al[132] investigated the effect of integrated play groups (IPGs) on children with ASD playing with typically developing familiar (siblings at home) and unfamiliar peers (at school in Taiwan. They studied the effect of IPGs on the symbolic and social play of two children with ASD in early elementary school. They noted significant gains in symbolic/pretend play and reciprocal social interaction while participating in IPG[132]. Recently, Wolfberg et al[133] studied the effects of 12 wk of IPG therapy on 48 children with ASD participating in play groups with typical peers. They found significant increases in symbolic and social play using unsupported play with both familiar and unfamiliar peers, which maximizes the developmental potential and social inclusion in children with ASD[133]. A 30-min IPG session twice weekly for 16 wk can improve the child's ability in pretend play and his interaction with his peers. IPG also helps the child with ASD learn how to use the toys more typically.

Joint attention symbolic play engagement and regulation (JASPER) is a well-studied naturalistic intervention to improve developmental behavior. This method aims to improve the attentiveness of the child with autism by training him to focus on a toy and another person simultaneously (joint attention). This method improves the child's language and play, making it more effective and reactive with his peers, increasing pretending abilities, and expanding the range of play with different toy types. The child may need to spend up to 25 h weekly in a one-to-one meeting with his therapist. In addition, some preschools can provide this type of therapy. Most studies showed that children who received JASPER intervention significantly improved as a minimum outcome related to joint child engagement, joint attention, play, and language skills compared to the control groups[134]. Goods et al[135] tested the effects of 30 min of JASPER intervention twice weekly for 12 wk in children 3 to 5 years old. The intervention induced greater play diversity upon standardized assessment. This effect also appeared in the classroom, where participants in the intervention group started showing more signs of engagement and spent less time without than before[135]. Shire et al[136] investigated how toddlers with autism engage with their peers. They found that children who experienced peer intervention (JASPER ) had more engagement with their peers, more receptive language, and better combination and presymbolic play when an adult was present, but not when the children were left unsupported[136]. JASPER can also be conducted online. Shire et al[137] showed that a technology-enabled adaptation of the evidence-based caregiver-mediated JASPER successfully provided the caregivers with online materials that helped them conduct home-based JASPER. The caregivers navigated the content smoothly and gave positive feedback and suggestions to improve the content[137].

However, children may differ in their response to JASPER. Some may show incredible progress, while others may have slow or no progress. Panganiban and Kasari studied 99 preschool-age children with ASD and limited language for their language improvement after JASPER intervention to predict their response to JASPER. They divided the children after the intervention into super responders and slow responders using traditional standardized assessment tools of behavioral and cognition data. They found that children who could play appropriately with a more comprehensive toy diversity before starting the intervention had the best improvements in their expressive language[138]. However, we need more research to verify whether it can also improve a more comprehensive range of symptoms and outcomes in children with ASD.

This approach identifies the significance of the comprehensive therapeutic experience the child is exposed to, including different factors in the therapy, such as the child himself, the therapist, the parents, and all other factors that could impact the child's progress. So, this approach that Lisa Dion created tries to use all the details of the child's life to work in harmony to create a balanced and all-encircling response to the problem the child enfaces. This approach determines a specific role for everybody in the child's life, such as a sibling, cousin, classmate, friend, grandparents, and every other tie they live into[139]. This approach is not straightforward as it is a system of life and existing that concentrates on a more natural and comprehensive approach to therapeutic interaction. When done correctly, this synergetic play therapy (SPT) approach helps the child to co-regulate his internal experience, overcoming his challenging, uncomfortable memories, thoughts, and body sensations. So SPT is a comprehensive play therapy approach that concentrates on the child and the therapist realistically interacting with each other and themselves in an attempt to become more thoughtful. This approach allows for better child development and maturation[139]. Dion and Gray[140] showed that SPT provoked significant improvement in emotionally tolerant behaviors percentage in response to trustworthy therapist expressions from the first to third sessions of SPT. SPT also had a 100% success rate in inducing emotionally tolerant behaviors by their fifth session[140]. Unfortunately, there is very scarce data about the effects of SPT on children with autism, and there are no well-controlled studies. Simmons[141] studied two children using SPI, one of them was a nine-year-old boy with high-functioning autism suffering from aggressive behaviors and difficulty managing his emotional range. He had a one-hour session weekly for 13 wk. The boy has made noticeable progress across several parameters; he was more able to control his anger, engage in cooperative play, and make eye contact effectively[141].

Equine-partnered play therapy (EPPT) is a distinctive type of play therapy intended for children aged three to nine. It uses the special relationship between animals and children. This model of therapy is a modified child-centered play therapy (CCPT) that blends Equine Assisted Counselling with CCPT. In CCPT, children see, explore the world, and express themselves through play[142]. In EPPT, the child will express his thoughts, feelings, needs, and wants through horse riding rather than the toys used in play. In EPPT, horses serve as group members, allowing the child to enhance his social skills while getting feedback from the horses. Including miniature horses (small ponies), EPPT can support the child to feel safe and accept to be her/himself[143]. Horse riding helps the child to express complicated feelings, receive nurturing from the horse, receive feedback from the horse to ground the session in reality, gain self-control and decision-making abilities, and enhance personal responsibility, self-expression, self-direction, self-respect, and acceptance. The EPPT team consists of an equine specialist and a play therapist. However, safety and ethical considerations should be in mind while conducting EPPT. The environment should be safe and comfortable for both the horse and the child[144].

Bass et al[145], during their controlled study, showed that children with ASD who had horseback riding intervention for 12 wk demonstrated more excellent sensory seeking, sensitivity, and social motivation. They also had less distractibility, inattention, and sedentary behaviors. These results confirmed the therapeutic benefits of horseback riding in treating children with ASD[145]. Harris and Williams[146] showed a significant reduction in the severity of ASD symptoms and hyperactivity and improved social functioning in children with ASD after horse riding sessions of 45 min weekly for seven weeks compared to the control group. Another self-controlled study by Steiner and Kertesz[147] showed significant differences pre- and post-intervention in the length of the gait cycle that became more stable in the sagittal plane in 26 children with ASD who were subjected to horse riding for one month of therapy. A systemic review by McDaniel Peters and Wood showed that four types of equine-assisted therapies were identified from eight studies that reported improvements in motor control and self-care of children and adolescents with ASD[148].

Art therapy is a form of expressive and communicative therapy that uses the act of arty interest to decrease anxiety, enhance self-esteem and settle any psychological conflicts. This therapy is entirely different from play therapy. However, child art therapy is sometimes confused with play therapy, as many play therapists include art-based activities during play therapy. Meanwhile, some art therapists use specific play tools such as toys, puppets, or even physical games to enforce and promote the child's artistic expression. While play therapy is more valid for children aged 2-12 who can express themselves through movements, creative media, and play, art therapy is more suitable for 3-12, who can use visual language better than movement. Art therapy can be practiced individually or in groups, with a session usually lasting 30 to 50 min[149-151].

Wypyszyńska et al[152] showed that art therapy has a positive therapeutic effect on speech, social relations, and unusual behavior in children and adolescents with ASD than in the control group. A systematic review by Schweizer et al[153] showed that art therapy might provide a more compliant and relaxed approach that can empower the self-image and improve the learning and communicative skills of children with ASD. Art therapy can help to overcome poor social communication and repetitive and restricted behavior patterns in subjects with ASD. Art therapy, with its sensory experiences such as sight and touch, can increase flexibility and attention abilities and improve the social behavior of children with ASD[153]. Moghaddam et al[154] investigated the effects of family-based art therapy with the enforcement of verbal interaction, imitation, and phonation in children with autism. They showed that these practices helped children with autism to use art to express their connotations and feelings. Family-based art therapy also effectively reduces stereotypical behaviors and increases social interaction in children with ASD[154]. However, there is a strong need for further empirical well-controlled research to confirm the outcome of art therapy in autism.

With the rise of the COVID-19 pandemic, there was a significant increase in the number of children with special needs, including those with autism. Besides the high morbidity and mortality related to COVID-19-, the pandemic negatively impacted the health and educational-related issues of children with autism. The lockdown negatively altered cognitive abilities, sensory-motor development, sleep, morale, and social and behavioral interactions in about 50% of children with special needs[155]. With the need to continue the services provided to children with autism, telemedicine, including teleplay therapy, provides significant help during the pandemic. Despite teleplay therapy being initially created to provide services to those in remote geographical locations, the pandemic experience paved the way for a new virtual platform where therapeutic play can continue regardless of the place and be provided across borders. Therapists can provide their services to another country and continue their services when traveling or when the child in need of the therapy travels. So, teleplay therapy decreases users' barriers to the therapists and the therapy procedure. Through teleplay therapy, children continue interacting with the world, communicating with others, practicing problem-solving, discovering their emotions and empathy, and provoking their brilliant imagination[156]. However, we emphasize that virtual play therapy does not replace face-to-face play therapy. It needs specific considerations to be followed to ensure safety, accessibility, and efficacy while conducting teleplay therapy. Despite many advantages, such as exploring the child's environment and less anxiety when enfacing strange people, teleplay therapy has many disadvantages. Teleplay therapy may enface various problems, including privacy, possible easy distraction, technological problems such as digital ecosystem malfunction, and connectivity problems[157,158].