Extended Abstract
Introduction
Anxiety disorders are among relatively common problems during childhood, which are not considered a normal part of school-age development. Separation anxiety disorder, which primarily manifests in childhood, is one of the most prevalent anxiety disorders. It typically emerges during the preschool years and can persist into adulthood, intensifying in situations that involve potential separation.
The primary characteristic of separation anxiety disorder is excessive fear or anxiety when separated from home or attachment figures. The severity of these symptoms is beyond what is developmentally expected. Children with separation anxiety disorder may experience intense and inappropriate anxiety when separated from their home, parents, or caregivers, as well as excessive worry about the health or death of loved ones and the occurrence of negative events, such as getting lost. Children with separation anxiety disorder may exhibit various physical symptoms, including headaches, dizziness, gastrointestinal disturbances, sleep disturbances, and certain types of behavioral, emotional, and cognitive disorders, such as behavioral avoidance, worry, panic, excessive fear, and cognitive distortions. In the meantime, separation anxiety is particularly prevalent among elementary school students, significantly interfering with their daily activities and responsibilities.
Play therapy is one therapeutic technique used with children, and Theraplay-based play therapy is an appropriate and recommended approach for improving parent-child relationships. Theraplay-based play therapy is grounded in attachment theory, which posits that a child’s initial relationship with their primary caregiver and the surrounding world plays a crucial role in their life because this relationship serves as a model for future interactions. This study aimed to determine the effect of Theraplay-based play therapy on separation anxiety among elementary school girls.
Methods
This clinical trial was conducted involved 60 elementary school girls in Aliabad-e-Katoul County in 2023.
Inclusion criteria included an age range of 8 to 10 years, completion of preschool period, a separation anxiety disorder score above 50, written parental consent, and verbal child consent. Exclusion criteria included chronic illnesses, a history of frequent hospitalizations, and the use of anti-anxiety medications.
Initially, Hahn et al.’s Separation Anxiety Assessment Scale (SAAS) (parental version, 2003) was completed by parents of students from selected schools. A total of 90 individuals obtained a score of 50 or higher, of which 8 did not meet the inclusion criteria, 2 did not attend the information session, leaving 80 participants. A number of 60 participants were then randomly assigned to either a control or intervention group.
A demographic information form included variables such as child’s age, mother’s age, mother’s occupation, and mother’s education level. The SAAS (parental version, 2003) was employed to measure separation anxiety. This scale has both parent and child versions, each with 34 items that measure specific dimensions of childhood separation anxiety. The four primary dimensions of this tool are fear of being alone, fear of abandonment, fear of physical illness, and worry about dangerous events. Respondents rated the frequency of separation anxiety symptoms on each item using a four-point Likert scale ranging from 1 (never) to 4 (always). The total score ranged from 34 to 136, with higher scores indicating greater frequency of separation anxiety in children.
In the intervention group, a 45-minute daily play session with the mother was conducted for 10 consecutive days. The focus of the play therapy intervention was on the fun and entertaining aspects of play, and mothers were emphasized that the goal of the Theraplay-based play therapy was for the child to enjoy playing with their parent and that the play sessions should in no way be transformed into a learning or competitive class. The structure of the sessions was based on Booth and Greenberg’s model (2009). The first five training sessions were conducted at the school, with the researcher present alongside the mother to ensure that the instructions were implemented correctly. From the fifth session onwards, the training was conducted at home by the mother, and the contact information of the participants was provided to the researcher so that the educational program could be monitored daily, necessary follow-ups could be carried out, and questions could be answered. Throughout the intervention, the researcher also monitored the control group, and the child and mother were allowed to continue their usual play activities at home. After the intervention, the SAAS (parental version, 2003) was completed again in both the control and intervention groups. Data collection took two months. After the completion of the intervention, to adhere to ethical principles and avoid depriving one group of a beneficial intervention, the training program was also provided to the control group.
Results
The mean total separation anxiety score in the pre-test was 82.2±9.27 in the intervention group and 83.53±8.8 in the control group, showing no statistically significant differences. Similarly, there were no significant differences between the two groups in pre-test scores for separation anxiety dimensions.
The mean total separation anxiety score in the post-test was 78.36±7.87 in the intervention group and 84.03±9.01 in the control group. This difference was statistically significant (P<0.01). Furthermore, significant differences were observed in all dimensions of separation anxiety except for the frequency of events in the intervention group before and after the intervention (P<0.01).
Conclusion
The implementation of Theraplay-based play therapy culminated in a significant reduction in separation anxiety among the elementary school girls in the intervention group compared to the control group. These findings suggest that such attachment-based play therapies foster a deep emotional bond between the child and their caregivers, which is developed and extended in child-parent interactions, particularly in child-mother interactions.
Ethical Statement
This study was approved by the Research Ethics Committee of Islamic Azad University, Dezful Branch (IR.IAU.D.REC.1402.024) and registered in the Iranian Registry of Clinical Trials (IRCT20230516058208N1).
Funding
This article has been extracted from the master’s thesis of Ms. Rozita Kaviani in Pediatric Nursing at the Faculty of Nursing, Islamic Azad University, Aliabad-e-Katoul Branch.
Conflicts of Interest
No conflict of interest.
Acknowledgement
The authors would like to thank the esteemed Research Vice-Chancellor of Islamic Azad University, Aliabad-e-Katoul Branch and the participants and their families for their invaluable contributions to this study.
Key message: Theraplay-based play therapy significantly improves separation anxiety in elementary school girls.