1. Background
Anxiety disorders have significant negative effects on children's academic performance, peer relationships, and family functioning (1). Among anxiety disorders, separation anxiety disorder is known as one of the most common anxiety problems among children (2). In a study by Shear et al., 4.1% of children had clinical levels of separation anxiety, and in almost one third (36.1%) of the cases, they remained until adolescents (3). The main characteristic of separation anxiety disorder is severe fear or anxiety related to separation, which are some of the symbols of attachment or anticipation of separation (4). Some of the separation anxiety naturally appear in early childhood and are part of a child's normal development. However, when anxiety is severe, it persists until later childhood and the diagnosis of separation anxiety disorder is raised (5). In other words, the main point in the diagnosis of this disorder is the disproportionate anxiety and distress in the child during separation, in terms of their age and developmental stage. So, in such cases, fear of separation interferes with daily activities like going to school or participating in activities related to the age (6). Effective childhood intervention not only improves current adjustment, but also significantly reduces future psychological trauma (7).
There are several factors contributing to anxiety disorders. One of the most important changes in today's life that can affect child care is the increase in the number of mothers who are working outside home (8). The findings of some studies indicated that, the supervisory role of the working mother decreases in different aspects of the child's life, and this less likely supervision in parenting styles increases the likelihood of behavioral problems (9). Also, full-time mothers' employment reduces the family mental health while mothers' part-time jobs can not only balance work and family, but also increase positive mentality in mothers along with increasing the mental health of family members (10). Nursing is among the jobs where an individual spends lots of time with the patients (11). Because of their overwhelming workload and specific occupational conditions, their general health and mental health are also at risk. Therefore, nurses need to maintain a strong mentality and complete mental health to continue their careers (12). Otherwise, nurses who are not in good general health cannot provide effective patient care, and this will increase the risk of errors and occupational accidents that will ultimately affect both the patient and the nurse (13). Nursing is one of the occupations that exposes nurses to work-family conflict due to its difficulty from the beginning of education to retirement, including long shifts and overtime, willingly or unwillingly (14). Accordingly, due to the importance of nurses' health, as key members of the country's health system, who are responsible for their own family and community health, and the since nurses' health is directly related to the quality of their performance in patient care and family roles (15) the need for this research is becoming increasingly clear.
Nowadays, psychotherapists use various therapies to treat separation anxiety disorder (16).
Despite good empirical support for cognitive and behavioral therapies for the treatment of anxiety disorders in children with the age of 7 years old and older, research on children under 7 years old has received little attention. This may be due to the fact that, existing cognitive-behavioral therapies are likely to be beyond the cognitive abilities of a young child (under 7 years old) with separation anxiety disorder. Moreover, the effectiveness of cognitive-behavioral therapies requires active participation of the child in therapeutic sessions and the active collaboration of the therapist and the child, a degree of cooperation that is not usually achieved in children with the age under 7 years old (17). One of the relatively new approaches to the etiology and treatment of childhood disorders, including anxiety disorders, which emphasize on the role of parents, is the parent-child interaction approach. Moreover, parent-child interaction therapy, as an approved parenting behavior training program, was established in 1970 by Eyberg for the parents and young children aged between 2 and 7 years old with malicious behavior disorder (18).
This approach targets and corrects inappropriate parenting behaviors by focusing on the parents and their behaviors, rather than concentrating on the child (19). This model is in terms of the assumption stating that, improving the parent-child interactions will lead to the improved child and family performance. This training directly targets parental overconfidence behaviors identified to play a major role in causing anxiety in children (20). According to the above-mentioned explanations, it is emphasized that, many childhood disorders are rooted in parental misconduct and negative parent-child interactions (21).
2. Methods
2.1. Sampling and Procedure
This study was a pre and post-test interventional study with the control group. The study population consisted of 3-6-year-old children of nurses working in educational hospitals of Qazvin in 2018. Using the formula
Inclusion criteria for the children in this study were as follows: having 3 - 6 years old, the required score based on the preschool children anxiety scale, and not having attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). Moreover, the inclusion criteria for the nurses of both sexes were as follows: working hospitals associated with the Qazvin University of Medical Sciences, having children with such inclusion criteria, being resident in Qazvin, and the tendency to attend educational sessions. The exclusion criteria were also as follows: missing 2 training sessions by parents and unwillingness to continue participating in research.
This treatment consists of three stages. In the first stage of treatment child directed interaction (CDI), parents learned the skills of positive attention to their children. This step was done with the aim of increasing positive behaviors in children and reducing negative behaviors. The second step was the bravery directed interaction (BDI), providing a structure for families to understand anxiety and create the conditions to practice separation. The third phase of treatment, parent directed interaction (PDI), focuses on increasing compliance and further reducing destructive behaviors. Parents learned to provide effective guidelines, reinforced adaptive behaviors, and took steps to address dissatisfaction.
According to the principles designed for the control group, no intervention was performed.
2.2. Measures
The questionnaires used in this study were: demographic information questionnaires, which were completed by the researcher. Moreover, pre-school children anxiety questionnaire developed by Spence et al., was used, which is a five-factor model for anxiety disorders in preschool children. The overall anxiety score can be calculated from the sum of sub-scales. Also, this scale has 28 subscales that have been validated by Ghanbari et al. (22). All subscales of preschool anxiety scale questioner (PAS) displayed moderate to high internal consistency (0.64 to 0.76) and had good reliability. Validity evaluation yielded positive results, in addition to face validity that was confirmed by specialists, criterion-references validity was supported by moderate to high (0.41 to 0.67) and high correlation in test-retest (0.73 to 0.82) demonstrated good reliability of this scale (22). In this self-report instrument, the parents were asked to rate the child's frequency of behavior on a 5-point Likert scale from never (0) to always (4). The scale demonstrated a very good internal consistency, with a Cronbach's alpha coefficient of 0.92 for PAS composite score (23). The children with a score above 7 were rated as having separation anxiety. In addition, explanations on the purpose and method of study, agreement with the participants, explaining the rights and duties of the parties, voluntary participation in the research, non-use of any recording or filming equipment, withdrawal from the study if desired, observance of confidentiality and the presentation of the results were generally explained to the samples.
The intervention group received parent-child interaction training and both groups received post-test after the intervention. The training was performed for 8 sessions and the duration of each session was 45 - 60 minutes. Accordingly, these trainings were performed by a senior psychiatric student with the supervision of a supervisor.
The intervention was done based on the parent-child interaction intervention by the researcher and with the previously stated goals (Table 1). In each session, to increase the parent's mastery of the skills described, some homework assignments were provided for the parent for performing at home, and at the beginning of each session, the homework assignments were reviewed. This study was approved by the Ethics and Research Committee of Qazvin University of Medical Sciences (IR.QUMS.REC.1397.269).
Table 1.Summary of the Parent-Child Interaction Treatment Sessions
| Sessions | Details |
|---|---|
| First session | Introducing the team members, gathering information about the child and the current problem, introducing PCIT to parents, express the therapist's expectations for attending the sessions and performing appropriate assignments, and explaining the first homework. |
| Second session | Presenting child-parent interaction goals, explaining the 5-minute homework per day, explaining the important rule of allowing child guidance, teaching the child-based interaction skills, and learning to do interactive skills in child-based interaction. |
| Third session | Overview of the previous sessions, using strategic considerations, using selective ignorance, managing disruptive behaviors that cannot be ignored such as those behaviors that are harmful to the child or others, toys that are appropriate for child-centered interaction, and assigning homework for this step. |
| Fourth session | Teaching parents about the nature of anxiety, separation anxiety, its cycle, expressing the relationship between thoughts, feelings and anxious behaviors of the child, asking parents to identify and identify the thoughts, feelings and anxious behaviors of the child as homework and reporting it in the next session, An overview of the assignments and actions taken in the previous week. |
| Fifth session | Reviewing homework assignments and discussions of the last week, exploring the causes of separation anxiety behaviors, highlighting and examining specific parenting behaviors that inadvertently generate, maintain, and reinforce separation anxiety behaviors, parent education on the fact that modifying these behaviors can affect the overall cycle of separation anxiety, training the parents to use child-centered skills during separation situations, encouraging children to build courage stairs, and setting a reward for practicing it. |
| Sixth session | Learning the skills of the parent directed interaction (giving effective instructions, admiring child obedience, correct execution of the deprivation process in the event of a child's disobedience), parents are asked to use this stage's skills in issues that child obedience is important to the parents. |
| Seventh session | Providing an opportunity for parents to practice and properly implement the skills of the parent-directed interaction process. |
| Eighth session | Preparing the family to complete the treatment, teaching the child's behavior control tips in a public place, reviewing the issues that hinder skills mastery, and evaluating the criteria for completing the education along with introducing other behavioral management techniques done at this meeting. Explain to the family that they have a problem at any time can contact the therapist and if necessary, an extraordinary meeting will be held for them. |
After the approval of the ethics committee and the submission of a formal letter to the research authorities and their consent, data collection phase was started and the data were then analyzed using STATA 14 software. In addition to descriptive statistics and table of descriptive statistics (mean and standard deviation) for the obtained data, ANCOVA test was used to evaluate the results and P < 0.05 was considered as significant.
This study aimed at investigating the effect of parent-child interaction therapy on reducing the symptoms of separation anxiety disorder among the nurses' children aged between 3 and 6 years old working in educational hospitals in Qazvin.
3. Results
Among 67 children of nurses from the educational hospitals in Qazvin who met the inclusion criteria, there were 43 boys, and 24 girls, 47.8% were 4 - 3 years old, 59.7% of their mothers were 26 - 35 years old and 61.2% of them had only one child. 77.6% of children were the first child, 40.3% of the nurses had 6 - 10 years of work experience, 94% of nurses had circular shift works, 61.2% had employed spouses and 35.8% of the children of this study were cared for by other family members. A comparison of the demographic variables of the two groups can be seen in Table 2.
Table 2.Demographic Characteristics of Nurses
| Individual Profile | Control a | Intervention a | Sum | Chi-Square |
|---|---|---|---|---|
| Total | 34 (50.7) | 33 (49.3) | ||
| Child age (y) | P = 0.274; χ2 = 1.937 | |||
| 3 - 4 | 19 (57.6) | 13 (38.2) | 32 (47.8) | |
| 4.1 - 5 | 8 (24.2) | 13 (38.2) | 21 (31.3) | |
| 5.1 - 6 | 6 (18.2) | 8 (23.5) | 14 (20.9) | |
| Child gender | P = 0.927; χ2 = 1.595 | |||
| Male | 21 (63.6) | 22 (64.7) | 43 (64.2) | |
| Female | 12 (36.4) | 12 (35.3) | 24 (35.8) | |
| Parent age (y) | P = 0.368; χ2 = 4.931 | |||
| Less than 25 | 0 | 1 (2.9) | 1 (1.5) | |
| 26 - 35 | 18 (54.5) | 22 (64.7) | 40 (59.7) | |
| 36 - 45 | 15 (45.5) | 11 (32.4) | 26 (38.8) | |
| Number of children | P = 0.457; χ2 = 1.390 | |||
| 1 | 19 (57.6) | 22 (64.7) | 41 (61.2) | |
| 2 | 14 (42.4) | 11 (32.4) | 25 (37.3) | |
| 3 | 0 | 1 (2.9) | 1 (1.5) | |
| Birth order | P = 0.720; χ2 = 1.809 | |||
| First | 25 (75.8) | 27 (79.4) | 52 (77.6) | |
| Second | 8 (24.2) | 7 (20.6) | 15 (22.4) | |
| Maternal employment history (y) | P = 0.161; χ2 = 10.451 | |||
| Less than 5 | 3 (9.1) | 2 (5.9) | 5 (7.5) | |
| 6 - 10 | 11 (33.3) | 16 (47.1) | 27 (40.3) | |
| 10 - 15 | 10 (30.3) | 14 (41.2) | 24 (35.8) | |
| More than 15 | 9 (27.3) | 2 (5.9) | 11 (16.4) | |
| Working shifts | P = 0.572; χ2 = 1.556 | |||
| Morning | 0 | 1 (2.9) | 1 (1.5) | |
| Evening | 0 | 1 (2.9) | 1 (1.5) | |
| Night | 1 (3) | 1 (2.9) | 2 (3) | |
| Rotation | 32 (97) | 31 (91.2) | 63 (94) | |
| Spouse occupation | P = 0.142; χ2 = 3.649 | |||
| Unemployed | 0 | 2 (5.9) | 2 (3) | |
| Employee | 21 (63.6) | 20 (58.8) | 41 (61.2) | |
| Self employed | 12 (36.4) | 9 (26.5) | 21 (31.3) | |
| Military | 0 | 3 (8.8) | 3 (4.5) | |
| Working shifts of spouse | P = 0.308; χ2 = 1.951 | |||
| Morning | 7 (21.2) | 13 (38.2) | 20 (29.9) | |
| Morning and evening | 18 (54.5) | 14 (41.2) | 32 (47.8) | |
| rotation | 8 (24.2) | 9 (20.6) | 15 (22.4) | |
| Babysitting during parent shift | P = 0.099; χ2 = 7.444 | |||
| Another parent | 5 (15.2) | 9 (26.5) | 14 (20.9) | |
| Other family | 10 (30.3) | 14 (41.2) | 24 (35.8) | |
| Hospital kindergarten | 1 (0.3) | 4 (11.8) | 5 (7.5) | |
| Other kindergarten | 8 (24.2) | 3 (8.8) | 11 (16.4) | |
| Other | 9 (27.3) | 4 (11.8) | 13 (19.4) |
a Value are expressed as No. (%).
The mean and standard deviation of the intervention and control groups in pre-test and post-test, and also analyzing the effect of parent-child interaction therapy on separation anxiety at pre and post-test are presented in Table 3 based on ANCOVA test. As shown in Table 3, the mean of separation anxiety decreased from 10.82 ± 0.62 to 7.69 ± 0.52 in the intervention group (P = 0.0006).
Table 3.Comparison of Mean Separation Anxiety Score Between the Intervention and Control Groups Before and After the Intervention Using ANCOVA Test a
| Intervention | Control | ANCOVA | |
|---|---|---|---|
| Before intervention | 10.82 ± 0.62 | 9.35 ± 0.40 | P = 0.0006; 12.9 |
| After intervention | 7.69 ± 0.52 | 10.26 ± 0.40 |
a Values are expressed as mean ± SD.
Since each type of anxiety disorder in the questionnaire could affect separation anxiety disorder, the effect of each one of these variables was adjusted in the final analysis. As the results show, there was a significant difference in the separation anxiety scores between these two groups. In this regard, it was shown that, parent-child interaction therapy had a significant effect on separation anxiety, and the post-test group participants' scores significantly dropped. (P < 0.001).
4. Discussion
The purpose of this study was to determine the effect of parent-child interaction on reducing the symptoms of separation anxiety disorder in 3-6-year-old children of Qazvin nurses. The symptoms of separation anxiety had decreased in the intervention group compared to the control group. The findings also showed that, parent-child interaction therapy significantly reduced the symptoms of separation anxiety disorder in the subjects at the post test stage compared to the control group.
Several studies have shown that, the parents of anxious children inadvertently facilitate anxious responses in the child by fear or avoidance modeling, attempting to control the child's behavior, over-supporting the child or facilitating their avoidant responses (24).
Positive and negative reinforcement patterns during separation can reinforce fear in the child. Studies have also emphasized on the role of parents and have emphasized that, when parents are aware of the importance and nature of anxiety problems, they can act as "educators" in their child's treatment using encouraging approaches. Since the goal of therapeutic interaction is to increase warmth, acceptance, and positive parent-child interactions, by considering a specific time to play with the child, paying attention to positive behaviors, and ignoring the negative behaviors; the likelihood of secure attachment is improved between the parents and children. This improvement helps the child feeling more secure with less distress from the parents (25).
Therefore, improving parental relationships with children can help in reduction of the symptoms of separation anxiety in children. The results from previous research such as Pincus et al., Eyberg et al., and Comer et al., also showed that, parent-child interaction therapy had a positive effect on child separation anxiety, and intervention has led to a decrease in the symptoms (2, 19, 26, 27). Research on Iranian children has also shown the effect of parent-child interaction therapy on the reduction of the symptoms of separation anxiety disorder (24, 28). Other studies have been conducted in this field in which either the sample size was small (4), or the generalizability of the results was limited due to the consideration of only one gender group (29). Also, some studies are not comparable to the present study because the tools used were not suitable for the age of the studied samples (27) or the study was performed on other populations (2).
Mohajeri et al., in a study performed on the effect of parent-child interaction therapy on parenting self-efficacy in five mothers with the children of high-functioning autistic disorders selected from the Center for the Treatment and Rehabilitation of Autistic Disorders, showed that, the parent-child interaction therapy can gradually improve the self-efficacy of mothers of children with high-functioning autism from poor to moderate (30). This mild to moderate effect can be attributed to the fact that the sense of efficiency is a complex construct that is likely influenced by other factors such as the type and severity of illness, social and economic support and improvement of children’s status, and cannot by itself lead to the increased self-efficacy (30).
Another result of this study was that, child-centered learning skills lead to a positive interaction between the child and the parent. In this treatment, the parents at first improve their relationship with the children step by step, and this may restore the child's sense of confidence that may have been impaired by inappropriate parenting.
In this treatment, parents first gradually improve their relationship with their child and then restore the sense of trust that may have been damaged as a result of improper and irresponsible parenting. On the other hand, the child will understand this behavioral change and shows a positive behavior. In this intervention, the parents were instructed to develop their relationships in some ways such as empathy with the child, reinforcing positive behaviors, unconditional acceptance, and giving the child an active role in play to increase children's confidence. Also, availability is another feature of this therapeutic model. The process of implementing this plan is that, mothers have to spend a certain amount of time a day with their child, and this increased contact creates a sense of mother's availability to the child and reducing the levels of separation anxiety can be explained by the relationship and sense of parental availability. The findings of follow ups performed immediately after the intervention indicated that, these results were in line with the results of Eyberg and Funderburk (31).
Attention to the specific job characteristics of nurses such as circular shifts, excessive working hours and job stress as well as the importance of nurses' health as one of the main pillars of the country's health system and since nurses' health is directly related to the quality of patient care and their family role, highlights the importance of this research.
4.1. Conclusions
Given the significant individual and social costs associated with anxiety disorders, the treatment of anxiety at an early age is an issue that has great importance to public health. In general, it can be concluded that, this study supported the role of the parents as well as this treatment plan in the treatment of separation anxiety disorder. Children in elementary school are not cognitively able enough to reason independently, and also to have a great impact on their peers. Parents at no other time in their childhood or adolescence are able to affect them as they are in the pre-school. In this way, by educating the parents, in addition to detecting separation anxiety disorder at an early age, we can reduce the level of disorder in the child by establishing some educational and therapeutic sessions on one hand, and on the other hand, we can reduce psychological stress in the parents. Analysis of the results of this study showed that this treatment is effective in reducing the symptoms of separation anxiety in children participating in the intervention group. This study attempted to reduce confounding variables and probable bias by randomly assigning the subjects to the intervention and control groups. Based on the findings of this study, it can be concluded that, this therapy can be effective on preventing the emergence and treatment of anxiety problems among the preschool children. This intervention, helped to reduce separation anxiety disorder in children by leaving an active role to the parents and creating a warm relationship between the child and the parents. In this study, given the effectiveness of this intervention on reducing the separation anxiety of children, it seems that, this treatment can be used to reduce the problems associated with separation anxiety in children.
4.2. Limitations
Limitations of this study was unwillingness of some individuals to participate in the study. This problem was solved when we explained the benefits of treatment for the children and parents to them. The follow-up of this study was also performed immediately after training, and this limitation should be removed in subsequent studies.
