Vol.

V (LXVII)
47 - 53
No. 1/2015

The effectiveness of Sandplay Therapy in reducing

symptoms of separation anxiety in children 5 to 7 years old
Hamideh Mohammadi Nasab*a, Zohreh Mohammad Alipour*b
a
Department of Clinical Psychology, College of Psycology and Education, Allameh
Tabataba'i University , Tehran, Iran
b
Department of Guidance and Counseling, College of Psycology and Education, Al'Zahra
University, Tehran, Iran

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
(CSI-4), 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

1. 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 pre-school
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

* Corresponding author.
E-mail address: Hamide.mohammady7@gmail.com
* Corresponding author.
E-mail address: arad_karafarin@yahoo.com
 H. M. Nasab, Z. M. Alipour /Journal of Educational Sciences and Psychology 48

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 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
 H. M. Nasab, Z. M. Alipour /Journal of Educational Sciences and Psychology 49

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 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.

2. 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 (CSI-4), 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.
 H. M. Nasab, Z. M. Alipour /Journal of Educational Sciences and Psychology 50

Margaret Lowenfeld’s sandpay therapy model

Agenda of the session Sessions
Goals: establishing emotional and friendly relationship with the children First
Goals: building trust in children Second
Goals: simulating the environment of kindergarten and home and expressing interest in
Third
the environment of the kindergarten
Goals: simulating stressful conditions for children Fourth
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

3. Findings
3.1. Description of Research Variables

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
2.5 20.53 1.8 20.27 Pretest
Posttest Separation anxiety
2.5 19.53 2.9 14.47

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.

Figure 1. Column chart for groups’ separation anxiety in pretest and posttest
 H. M. Nasab, Z. M. Alipour /Journal of Educational Sciences and Psychology 51

3.2. 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.

Table 3. A summary of ANCOVA test for measuring the effectiveness of sandplay therapy in reducing
children’s separation anxiety disorder
Effect Significance F Mean Degree Sum of Source of
size level ratio square of
freedom squares changes
0.635 0.01 46.9 129.2
0.699 0.01 62.7 172.7 1 129.2 Covariance
82 1 172.7 Group
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.
4. 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
 H. M. Nasab, Z. M. Alipour /Journal of Educational Sciences and Psychology 52

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 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.

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