1. health and fitness
2. therapy

Jurnal UMP Social Sciences and Technology Management
Vol. 3, Issue. 2,2015
The Effectiveness of Sandplay Therapy in Reducing
Symptoms of Separation Anxiety in Children 5 to 7 Years
Old
Hamideh Mohammadi Nasab,
1Department of Clinical Psychology, College of Psycology and Education, Allameh Tabataba'i University , Tehran,
Iran.([email protected])
Zohreh Mohammad Alipour
Department of Guidance and Counseling, College of Psycology and Education, Al'Zahra University, Tehran,
Iran.([email protected])
Abstract
This study has been conducted with the aim of examining the effectiveness of sandplay
therapy in reducing symptoms of separation anxiety in children 5 to 7 years old. The present
study is a quasi-experimental with the pretest-posttest control group design. Statistical
population of the study included all the 5 to 7 years old children suffering from separation
anxiety disorder who went to psychiatry clinics in Tehran in 2014. Sample size of the study
was comprised of 30 participants who were selected through random sampling and were
selectively divided into two groups (15 persons in experimental group and 15 persons in
control group); but control group was waiting for treatment. Before and after 10 treatment
sessions, all the participants were tested by using abnormal Child Symptom Inventory-4 (CSI4), parent checklist. Besides, participants received psychiatrist’s diagnosis of the
aforementioned disorder. The CSI-4 is a behavior rating scale whose items correspond to the
symptoms of disorders defined by the Diagnostic and Statistical Manual of Mental Disorders
(4th edition). The validity of this scale has been approved of by the specialists of American
Psychological Association (APA). The reliability of this inventory has been 0.78 through
Cronbach’s alpha. Analysis of the data obtained from administrating CSI-4 was carried out
by using SPSS software in two descriptive (frequency distribution table, mean, variance and
standard deviation) and inferential (covariance) sections. Results obtained from covariance
analysis indicated that sandplay therapy reduces separation anxiety disorder in posttest.
Therefore, the findings revealed that sandplay therapy can be effective in reducing symptoms
of separation anxiety disorder.
Keywords: sandplay therapy, separation anxiety, children
Introduction
Anxiety disorders are very prevalent among children and adolescents and this disorder leads to problems
in academic and social performance and family life (Warner, 2009). The anxiety disorder which mainly
occurs during childhood is separation anxiety disorder. Abnormal separation anxiety occurs during preschool ages and it may last for many years. Such anxiety is seriously provoked in any situation possibly
leading to separation and compels the individual to prevent situations requiring separation (Dadsetan,
2011). There has been different statistics regarding the prevalence rate of this disorder which is the most
prevalent anxiety disorder among children. Darouz (2010) has reported that the prevalence rate of this
disorder in children 2 to 4 years old is 17%. In 11 studies conducted by Hatton et al. (2006) on the
prevalence rate of anxiety disorders among children under 12, they found that the prevalence of these
disorders has been reported differently in the studies. The minimum rate has been 2.6% and the
maximum rate has been 41.2%, and separation anxiety disorder has been the most prevalent anxiety
disorder diagnosed in this age group. Presence of three symptoms of serious separation problems such as
intense and continuous worry about being deprived and hurt, fear of separation, physical complaints,
repeated nightmares, fear of school and sleep-related problems which last at least for 4 weeks is
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necessary for diagnosis of this disorder (Abdkhodaee and Ordobadi, 2011). Based on Lost’s (2007)
report, three quarters of the children who shrink from school suffer from separation anxiety disorder, and
if they do not receive timely treatment, they may suffer from secondary severe anxiety, and they may
also exhibit disorders such as social phobia, fear of open spaces and panic (Lewinsohn et al., 2008).
Children suffering from separation anxiety exhibit extraordinary anxiety, or even become frightened
when they get separated from their parents or familiar environments or people or objects they are
attached to. Such children often complain about nausea, headache, unnatural pains or fast heartbeat. In
other cases, when it is time to get separated, their behavior is accompanied by symptoms of anxiety
and/or panic (Liberman, 2006).Anxiety disorders during childhood are a predictor of psychiatric
disorders during adolescence (Bithner et al., 2007). Thus it is important to pay attention to treatment
methods, particularly in pre-school ages. Jaffe, Segal and Yeanne (2009) stated that psychotherapists use
different treatments for children’s separation anxiety, some of which include cognitive behavioral
therapy, family therapy, bibliotherapy and play therapy. An effective way of reducing children’s anxiety
over time is play therapy (Althy, 2005). Play establishes a connection between child’s inner thoughts and
the outside world, and helps the child to gain control of the foreign objects. Play allows the child to show
his/her experiences, thoughts, feelings and tendencies which are threatening to him/her (Wethinton et al.,
2008). Play therapy is described as a dynamic interpersonal relationship between a child and a trained
therapist in the process of play therapy, which facilitates the development of a safe relationship for the
child, so that the child can fully express him/herself (Landreth, 2001, cited in Ray, 2004). The child can
better learn self-control skills through play therapy (Porter et al., 2007). Sandplay therapy is a kind of
indirect play therapy and the therapist act as a facilitator and children can freely express their emotions
and create their mental images by using sand box and miniature objects inside the sand box. For a
therapist, regardless of his/her orientation, this kind of therapy is a valuable resource. It may not be
surprising to say sandplay therapy has found a new position in the treatment world, especially for
treatment of children (Abdollahi et al., 2010). History of sandplay goes back to Margaret Lowenfeld,
pediatrician and child psychiatrist. Lowenfeld employed world technique consisted of sand box, water
and miniature figures for the treatment of children. Dora Marie Kalff, student of Lownfeld, after having
found several different miniatures, wet and dry sand, delayed interpretation, etc., invented a new way of
dealing with children and named her technique “sandplay” therapy, to distinguish it from Lowenfeld’s
world technique (Bradway, 2006).Sandplay therapy is a technique that is a potentially valuable tool for
guidance counsellors working in the context of challenging school environments. It is particularly suited
to work with children and adolescents as it provides unique and developmentally appropriate
opportunities for them to engage in the therapeutic process. In fact, as it is play-based and
developmentally appropriate, sandplay may be a useful adjunct for the mainly cognitive and behavioural
techniques most commonly used by school guidance counsellors. It provides a multiple intelligences
perspective and may meet the specific needs of children with particular cognitive and socio-emotional
difficulties more effectively than the traditional ‘talking’ therapies (Campbell, 2004).Carmicheal (1991)
reviewed the literature concerning the role of play therapy (particularly sandplay and nondirected play
therapy) in the improvement of reading. Results indicated that that the role of play therapy is to support
the child, encourage the child, and build self-esteem thus creating the optimal learning environment for
reading improvement.Cockle (1993) examined differences in play themes, play characteristics, object
use, and narratives, elicited by the sandplay technique, with 5 coping (CG) and 5 difficulty-coping
(DCG) 6–8 year olds. The CG tended to view their world as more balanced, vital, and organized, where
others guide them, and they are safe. They showed resourcefulness in dealing with adversity and had
hope for the future. The DCG tended to perceive their world as barren, a struggle, and consisting of threat
and danger. The tended to lack resourcefulness in dealing with adversity and had a lack of hope for the
future.Hunter (1996) called sanplay nonverbal thought. According to his findings, tools and emotional
expressions of the children who have been emotionally hurt can be reinforced and boosted through
sandplay language (cited in Zolmajd, 2002).Landreth et al. (2009) stated that play therapy has a positive
impact on children’s behavior and emotions. Baggerly and Parker (2005) also stated that group play
therapy affects the improvement of social skills, self-respect, self-acceptance and acceptance of others,
and decrease of depression and anxiety. Bratton and Ray (2002) stated that play therapy has had positive
results in self-concepts, behavioral change, social skills and anxiety.Therefore, since play for children is
the same as utterance for the adults, and it is a tool for expressing emotions, establishing relationship,
describing experiences, revealing wishes and self-actualization, it is preferred in the treatment of
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Jurnal UMP Social Sciences and Technology Management
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children’s separation anxiety. As a result, in this study the effectiveness of sandplay therapy in reducing
the symptoms of separation anxiety in children 5 to 7 years old is examined.
Methodology
The present study is a quasi-experimental with the pretest-posttest control group design. Statistical
population of the study included all the 5 to 7 years old children suffering from separation anxiety
disorder who went to psychiatry clinics in Tehran in 2014. Two clinics were selected out of psychiatry
clinics in Tehran. Sample size of the study was comprised of 30 participants who were selected through
random sampling and were selectively divided into two groups (8 boys and 7 girls in experimental group
and 7 boys and 8 girls in control group). The children in experimental group were treated with sandplay
therapy in 10 one-hour sessions; while control group was waiting for treatment. The criteria for selecting
children included being 5 to 7 years old, suffering from separation anxiety disorder and not suffering
from other psychiatric disorders. It is to be explained that in this study, in order to follow moral
considerations, it was first attempted to establish an intimate friendly relationship with children by using
methods such as play-doh, play with clay, play with finger paints, etc., and then they were invited for
sandplay. Data collection instrument of the study has been abnormal Child Symptom Inventory-4 (CSI4), which is the screening tool for the most common psychiatric disorders, whose items correspond to the
symptoms of disorders defined by the Diagnostic and Statistical Manual of Mental Disorders. This
directory is consisted of 21 symptoms of emotional and behavioral disorders. Its first version called
SLUG checklist was designed in 1984 by Sprafkin et al. based on the classification of the third version of
Diagnostic and Statistical Manual of Mental Disorders. This inventory is scored in two ways.1)
Screening cut-off score method and 2) symptom severity score method. In this study symptoms severity
score method has been adopted. In this method, items of never, barely, sometimes and more often are
respectively scored by codes 0, 1, 2, and 3. For separation anxiety, group J was used. The reliability of
this inventory has been 0.784 through Cronbach’s alpha.Analysis of the data obtained from
administrating CSI-4 was carried out by using SPSS software in two descriptive (frequency distribution
table, mean, variance and standard deviation) and inferential (covariance) sections.
Margaret Lowenfeld’s sandpay therapy model
Agenda of the session
Sessions
Goals: establishing emotional and friendly relationship with the
children
Goals: building trust in children
First
Goals: simulating the environment of kindergarten and home and
expressing interest in the environment of the kindergarten
Goals: simulating stressful conditions for children
Third
Goals: trying to reduce children’s anxiety
Fifth
Goals: proposing new pedagogical strategies
Sixth
Goals: playing a role in reducing the children’s anxiety
Seventh
Goals: gradual recovery
Eighth
Goals: enthusiasm without anxiety
Ninth
Goals: disappearance of all the symptoms of children’s anxiety
Tenth
Second
Fourth
Findings
1. Description of Research Variables
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Table 1. Mean and standard deviation related to separation anxiety according to the groups in pretest and
posttest (n=30)
Control (15)
Experimental (15)
Measurement
Variable
SD
M
SD M
1.8
20.27
Pretest
2.5 20.53
Separation anxiety
2.5 19.53
2.9
14.47
Posttest
Based on the above table, the mean for separation anxiety in experimental group in posttest has decreased
in comparison to pretest. While, in control group, the difference between the mean for pretets and
posttest is not considerable. These results are shown in the following table.
Befor experimental
Ex-group 20.53 ,
Befor experimental
Ex-group 20.27 ,
After experimental
Ex-group 19.53 ,
After experimental Exgroup 14.47 ,
experimental group
prestets
control group
posttest
Figure 1. Column chart for groups’ separation anxiety in pretest and posttest
2. Analysis of Results
In this section, covariance analysis has been adopted in order to answer the research question:
Research question: is sandplay therapy effective in reducing symptoms of children’s separation anxiety?
The significance level of F-test indicated that regression slope is homogenous in groups (p=0.26,
df=1.26, F=1.3).
Assumption of homogeneity of variance of the groups has been measured by Levene's test and a
summary of the calculation are presented in the below table.
Table 2. A summary of Levene’s test for measuring the homogeneity of variances
Significance level Degree of freedom 2 Degree of freedom 1 F statistic
0.08
28
1
3.3
As it is seen in the above table, the significance level of Levene's test is larger than 0.05, so the
hypothesis of equal variances is accepted.
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Table 3. A summary of ANCOVA test for measuring the effectiveness of sandplay therapy in reducing
children’s separation anxiety disorder
Effect size Signific
F ratio
Mean square
Degree of
Sum of
Source of changes
ance
freedom
squares
level
0.635
0.01
46.9
129.2
1
129.2
Covariance
0.699
0.01
62.7
172.7
1
172.7
Group
82
27
74.3
Error
30
9066
Total
The above table shows that by controlling the effect of pretest, the effect of between-group factor is
significant at the level of 0.01 (P=0.01, F(1.26)=62.7). In other words, the difference between the scores
of posttest of groups is significant. Comparison of the scores indicates decrease of scores. Thus the null
hypothesis can be rejected at the level of 0.01 and it can be concluded with 99% confidence that sandplay
therapy is effective in reducing separation anxiety disorder in children 5 to 7 years old in Tehran. It is in
such a way that 69.9% of the changes in children’s separation anxiety can be explained by attributing to
control and experimental groups.
Discussion and Conclusion
The aim of the present study has been to examine the effectiveness of sandplay therapy in reducing the
symptoms of separation anxiety in children 5 to 7 years old. Thus this technique was implemented for
this group of children. It seems that one of the appropriate techniques for counseling and solving the
problems of these children is play therapy including sandplay therapy. The convincing reason why this
technique is useful is that it is indirect and nonverbal which allows the child to reduce the anxiety in a
safe and peaceful environment without the intervention of the therapist. In this regard, the results
obtained from statistical analysis indicate that the research hypothesis (sandplay therapy is effective in
reducing symptoms of separation anxiety in children 5 to 7 years old) is significant at the level of 99%.
This finding suggest that sandplay therapy technique is effective in reducing symptoms of separation
anxiety in children. In fact, statistical analyses indicated a significant difference between children’s
separation anxiety in posttest and in pretest. Altogether, the findings of the present study are consistent
with the results of other studies, including Allan and Berry’s (1987) study who examined the impact of
sandplay therapy on solving children’s disorders and concluded that sandplay therapy is effective in
children’s disorders by providing the safe conditions through imaginative release and development of
sense of skill and control of inner impulses.
In a study, sandplay therapy was used for adolescents afflicted with traumatic brain injury. The sample
size included adolescents with language, communication, psychosocial, and executive function
impairments. They exhibited their social, emotional and behavioral problems through creating images
inside the sand box and solved their problems with the guidance and advice of the therapist. Hence
sndplay therapy provided a safe and free environment for the adolescents with traumatic brain injury to
exhibit their problems and solve them (Plotts et al., 2008).
Dyke & Wiedis (2001) employed this technique for preschool-age children in order to improve their
emotional problems. In this study in which children up to 8 years old participated, they found interesting
results. They, as therapists, could unveil many effective and practical factors in the inner world children.
Besides, they identified and treated conflicts which were the cause of children’s maladjustment in school.
Sandplay therapy actually has been very effective in reducing children’s emotional problems as well as
positively forming their inner world (Zolmajd, 2002).
Dermott (2004) adopted Sandplay therapy for a girl afflicted with cerebral palsy, who could only utter
‘yes’ or ‘no’ and could only use her hands. The results indicated that sandplay therapy has been useful in
emotional release and boosting the understanding of the girl with cerebral palsy.
In explanation of the above findings, it is to be mentioned that children, who were present in 1-hour ten
sessions, experienced how it feels not to be with their mothers and objectively experienced that absence
of parents does not lead to being hurt or having problems. Besides, in sandplay therapy sessions, when
children were engaged in plays in regard to children’s anxiety of separation from their parents,
particularly play-doh, play with clay, play with finger paints, they exhibited their feelings at time of
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separating from their mothers, and also they realized that other children’s attitudes and noticed that this
fear is not only for them, but other children have similar feelings and this helped emotional release
regarding the separation from parents; besides, the repeated experience of being with other children in
the absence of parents greatly helped these children. Isenberg and Quisenberry (2002) said that play
improves attention, planning skills, and divergent thinking.
Therefore, the result of this study is a reconfirmation of the effectiveness of sandplay therapy. So it is
suggested to take practical measures in all kindergartens of the country in harmony with counseling and
social welfare centers in order to identify and treat children suffering from anxiety disorder, especially
separation anxiety disorder. Since the study was limited to one district of Tehran, it is suggested to carry
out separation anxiety screening in all kindergartens of the city for boys and girls and estimate its
prevalence. Besides, application of positive results of sandplay therapy in different cases such as
behavioral adjustment, social skills, emotional adjustment, and intelligence should be examined as well.
References
1. Allan, J., &Berry, P. (1987). Sandplay. Elementary School Guidance and Counseling, 21, 300-306.
2. Althy, A. L. (2005). Effects of a trained therapy dog in child-centered play therapy on children’s biobehavioral measures of
anxiety (Dissertation). University of North Texas.
3. Abdollahi, Gh., Sharifi, P., & Dolat Abadi, Sh. (2010). A study of the effectiveness of sandplay therapy in reducing
aggressiveness in deaf children. Psychiatric Studies, 6(1).
4. Abd Khodaei, M., & Sadeghi, A. (2011). A study of separation anxiety in children and effectiveness of play therapy with
cognitive-behavioral approach to reducing it. Journal of Clinical Psychiatric, 3(4), 51-58.
5. Baggerly, J., & Parker, M., (2005). Child-centered group play therapy with African American boys of the elementary school
level. Journal of Counseling & Development, 83, 387-396.
6. Bithner, A., Egger, H. L., Erkanli, A., Castello, E. J., Foley, D. L. & Angold, A. (2007). What do childhood anxiety disorder
predict? Journal of Child Psychology and Psychiatry. 48(12), 1174-1183
7. Bradway, K. (2006).What is SandPlay. Journal of Sandplay Therapy, 15 (2), 7.
8. Bratton, S., Ray, D., Rhine, T., & Jones, I. (2005). The efficacy of play therapy with children: A meta-analytic review of
treatment outcome. Professional Psychology: Research and Practice, 36(4), 376-39.
9. Campbell, M. (2004). Value of sandPlay as a therapeutic tool for school guidance counsellors. Australian Journal of Guidance
and Counselling, 14 (2), 211-232
10. Carmicheal, K. (1991). Play therapy: Role in reading improvement. Reading Improvement, 28 (4), 273-276.
11. Cockle, S. (1993).Sandplay: A comparative study. International Journal of play Therapy, 2 (2), 1-17.
12. Dadsetan, P. (2011). Transformational abnormal psychiatry: from childhood to adultness. Tehran: Samt.
13. Darouz, A. (2010). Combination of play therapy and cognitive behaviour therapy (Gh. Ramezani, Trans.). Tehran: Vania
Publications.
14. Dermott, D. M. (2004). Sharing our hands with the handless: Assisted sand play with the handicapped (unpublished
manuscript).
15. Hatton, C., McNicol, S., & Doubleday, K. (2006). Anxiety in a neglected population: Prevalence of anxiety disorders in preadolescent children. Clin Psychol Rev, (26), 817-83
16. Isenberg, J. P., & Quisenberry, N. (2002). Play is essential for all children. Association for Children Education International.
Retrieved from http://www.Altavista.com.
17. Jaffe, G., Segal, E., & Yeanne, R. (2009). Separation anxiety and anxiety disorder. Retrieved from
www.helpguido.org/mental/separation-anxietycause- prevention-treatment.htm.
18. Landreth, G. L, Ray, D. C., & Bratton, S. (2009). Play therapy in elementary school. Psychology in the School, 46(3), 1-9.
19. Lost, C. (2007). How to overcome fear and anxiety in children (B. Rahmati, Trans.). Tehran: Dor Danesh Publications.
20. Lewinsohn P. M., Holm-Denoma, J. M., Small, J. W., Seeley, J. R., & Joiner, T. E. (2008). Separation anxiety disorder in
childhood as a risk factor for future mental illness. J Am Acad Child Adolesc Psychiatry, 47(5), 549-556.
21. Liberman, L. C., Lipp, O. V., Spence, S. H., & March, S. (2006). Evidence for retard extinction of aversive learning in anxious
children. Behavior Research and Therapy, 1491-1502.
22. Plotts, C., Lasser, J., & Prater, S. (2008). Exploring sandplay therapy: Application to individuals with traumatic brain injury.
International Journal of play Therapy, 17(2), 138-153.
23. Porter, M. L., Hernandez- Reif, M., & Jessee, P. (2007). Play therapy: A review. Early Child Development and Care. Taylor &
Francis.
24. Ray, D. (2004). Supervision of basic of advanced skills in play therapy. Journal of Professional Counseling: Practice, Theory
& Research. 32(2), 28-41.
25. Warner, C. M., Reigada, C., Fisher, P. H., Saborsky, A. L., & Benkov, K. J. (2009). CBT for anxiety and associated somatic
complaints in pediatric medical setting: An open pilot study. Journal of Clin. Psychol. Mmed. Setting 16, 169-177. Retrieved from
http://www. Springer.com.
26. Wethinton, H. R., Hahn, R. A., Fugua-Whitley, et al. (2008). The effectiveness of interventions to reduce psychology harm
form traumatic events among child and adolescents. American Journal of Preventive Medicine. 35 (3), 287-373.
27. Zolmajd, A. (2002). Play therapy (A. Hajaran, Trans.). Tehran: Keyhan Publications.
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