Suicide accounts for 42.3% of the leading causes of death among teenagers, with 7.2 teenagers per 100,000 people dying by suicide(Korean Statistical Information Service, 2023).
In 2015, 1.4% of elementary school students (n=19,123) had suicidal problems, including suicide ideation, suicide plans, and suicide attempts (Hwang, Kim, Kang, Son, Kim, 2016). In addition, a study reported that 192 (29.2%) of 657 6th graders in four elementary schools had experienced suicide ideation in the past year (Hong et al., 2014).
Suicide ideation refers to thoughts closely related to suicide that frequently occur before the actual act of suicide (O’Carroll et al., 1998). Suicide ideation is correlated with various psychological factors (O’Connor & Nock, 2014), and variables such as depression(Kim & Kim, 2008; Song et al., 2003), hopelessness, and impulsivity have been identified as predictors of suicide ideation (Klonsky, May, & Saffer, 2016; O’Connor & Nock, 2014). and Seo (2019) reported an association between pain tolerance (PT) and suicide ideation.
Children and Adolescents’ Mental Disorders and Sensory Abilities
Green et al. (2013) compared brain responses of adolescents with Autism Spectrum Disorders (ASD) and those of typically developing adolescents. Individuals with ASD often respond to sensory stimuli in unusual ways and may experience sensory overload or sensory-seeking behaviors due to difficulties in processing sensory information (Freeman, Ritvo, & Schroth, 1984). Green et al. (2013) reported that the brains of adolescents with ASD showed greater activation in the amygdala, hippocampus, and the Orbital-Frontal Cortex (OFC), as well as in the primary sensory cortex, compared to the brains of control adolescents group. In addition, neurological evidence has been reported for a link between sensory abilities and emotional areas of the brain, such as the amygdala(Dalton et al., 2005; Weng et al., 2011; Posner et al., 2011).
Studies linking reduced olfactory abilities and depression (Atanasova et al., 2010; Croy et al., 2014) have also described connections between olfactory pathways and brain regions related to emotional processing (Brand & Schaal, 2016). Negoias et al. (2010) reported a negative correlation between the volume of the olfactory cortex and depression severity in depression patients. Additionally, individuals with visual and auditory impairments are twice as likely to have suicide ideation and more than three times as likely to have suicide attempts in the past year compared to individuals without disabilities (Khurana, Shoham, Cooper, & Pitman, 2021), and late-life visual and auditory impairments increased the risk of suicide ideation (Cosh et al., 2019).
Sensory ability deficits or impairments appear to be associated with mental disorders such as depression, anxiety, and suicide ideation (Negoias et al., 2010; Atanasova et al., 2010; Croy et al., 2014; Khurana et al., 2021; Cosh et al., 2019).
Sadowski and Kelly (1993) reported that adolescent suicide attempters exhibited maladaptive cognitive-emotional-behavioral responses compared to both the control group and the mental ill group.
Sensory processing abilities and Maladaptive Cognitive-Emotional-Behavioral Responses
Brown and Dunn (2002) conducted research on the relationship between maladaptive cognitive-emotional-behavioral responses in children and adolescents and their sensory processing abilities. Adolescent/Adult Sensory Profile (AASP), based on Dunn’s sensory processing model, is the leading tool for assessing sensory processing abilities in children and adolescents (Dunn, 1997; Brown & Dunn, 2002).
The Sensory Processing Model focuses on the relationship between neurological thresholds and behavioral responses. Neurological thresholds are divided into ‘high’ and ‘low’, and behavioral responses are divided into ‘active’ and ‘passive’. People with low neurological thresholds respond quickly to weak stimuli, while people with high neurological thresholds respond passively even to strong stimuli.
Active response means that a person with low neurological thresholds reacts quickly, while passive response means that the person does the opposite of the neurological threshold. In the sensory processing model, sensory processing patterns are categorized into four quadrants: Low Registration, Sensory Seeking, Sensory Sensitivity, and Sensory Avoiding (Dunn, 1997).
Higher levels of depression in adolescents (aged 15-17; 166 males and 122 females), were associated with higher scores in sensory avoiding and low registration (Kim, Kim, Park, Jeon, & Jang, 2013).
Engel-Yeger et al (2016) reported a pattern of association between sensory processing ability scores and depression.
Children who have problems with sensory processing can have difficulty in everyday life and may experience emotional or academic difficulties (Dunn, 2002).
Children with a high Low Registration Score have difficulty recognizing things that others easily recognize due to their high neurological thresholds.
Children with high Low Registration Scores use passive self-regulation strategies, which can make them less likely to notice additional inputs, leading to more confusing situations (Dunn, 2007).
In addition, over 90% of children with ASD suffer from sensory abnormalities (Leekam, Nieto, Libby, Wing, & Gould, 2007). Low Registration score was associated with emotional instability (r=.597) and aggression (r=.526) (Choi, Kim, Baek, Hong, Jung, 2015) Jerome and Liss (2005) reported that Low Registration scores in adolescents were associated with relationship anxiety (r=.248) and relationship avoidance (r=.224). Aggression, depression, anxiety, and self-regulatory failure have been noted as factors in suicidal behavior (Kim & Jeon, 2012; Park, 2009).
A meta-analysis of 33 studies (N = 2008) that used AASP as a measurement tool found that patients with various types of psychiatric disorders had a high score of low registration, sensory sensitivity, sensory avoiding and a low score of sensory seeking. These patterns indicate that sensory processing difficulties can be seen as a broad phenotype associated with various mental disorders (van den Boogert et al., 2022).
Sensory processing abilities and Sandplay Therapy
Sandplay Therapy (SPT) began when Lowenfeld initially introduced the World Technique which utilizes sand, water, toys, and a sand tray for children (Lowenfeld, 1931/1939). Lowenfeld sought to develop a therapeutic tool that incorporated sensory elements, such as visual and tactile, while allowing children to freely express their fluid, multidimensional thoughts and emotions (Lowenfeld, 1993/2007, pp. 3-4).
SPT further evolved under Kalff, who integrated Jung’s analytical psychology and Buddhist meditation, naming it ‘sandspiel’ (Kalff, 1991). SPT has gained wide acceptance in Western, Asian, and Latin American and has been effectively applied to a variety of mental health issues in children and adolescents (Roesler, 2019). SPT has been effectively used in diverse clinical settings, such as disaster-stricken areas, schools, and hospitals, addressing various mental health issues in children and adolescents(Roesler, 2019; Flahive & Ray, 2007; Rousseau, Benoit, Laconix, & Gauthier, 2009; Shen & Armstrong, 2008; Kwak, Ahn, & Lim, 2020).
SPT is a technique that utilizes sand and symbolic objects to help individuals express their inner worlds, heal psychological wounds, and activate their developmental potential (Turner, 2005).
Freedle (2007) conceptualized the core experience of SPT - seeing, touching, and doing - as the ‘Sensory Feedback Loop’. The Sensory Feedback Loop occurs in psychological interaction between the patient and the therapist.
SPT allows patients to express their experiences using all their senses, while the diverse sensory environment in the SPT therapy room offers participants a corrective sensory information processing experience. (Freedle, 2007)
Freedle (2017) argued that the multisensory experience in SPT can facilitate neurointegration processes.
Sensory Therapeutic Factors of SPT and Neurointegration
Sensory Integration (SI) is the neurological process of organizing sensory information from the environment and the body to efficiently use the body (Ayres, 2005). SI manifests as behavioral patterns of modulation and praxis (Bundy & Murray, 2002).
To enhance basic processes such as learning, brain maturation, and neural organization for self-regulation, it is crucial to actively engage with sensory experiences (Derryberry & Reed, 1996; Ryan, Kuhl, & Deci, 1997; Schore, 1996).
Early sensory experiences play a significant role in shaping brain patterns and sensory processing areas (Davidson, 1994).
Sensory functions are linked to control and organization of the nervous system, and neuroscientific SPT researchers have shown how SPT promotes sensory integration through neural circuits and investigate outcomes linked to the multisensory aspects of SPT (Akimoto, Furukawa, & Ito, 2018; Foo, Freedle, Sani, & Fonda, 2020; Freedle, 2017; Turner, 2005).
Foo et al. (2020) used Magnetic Resonance Spectroscopy (MRS) to examine sensory input processing in the amygdala and thalamus, which are linked to the limbic system, and found that SPT effectively reduced anxiety symptoms by activating the thalamic-limbic neural circuit.
Akimoto et al. (2018) used Near Infrared Spectroscopy (NIRS) to examine the brain activity of both therapists and clients during SPT sessions. And found that for both therapists and clients, there was active interconnection in several areas between the bilateral hemispheres of the brain, and enhanced activity connectivity in the prefrontal and temporal lobe areas.
Lowenfeld (1993/2007) initially devised SPT as a therapeutic method facilitating the dynamic and multidimensional expression of a child’s thoughts and emotions, incorporating sensory modalities like vision and touch. And neuroscientific SPT studies have commenced exploring the neurointegration aspects of SPT (Freedle, 2017; Foo et al., 2020; Akimoto et al., 2018). Nonetheless, the Review Studies of SPT found no research concerning the influence of the sensory factors within SPT on clients’ sensory processing abilities. Furthermore, There is no research on the sensory components of sandplay as a therapeutic element within SPT (Roesler, 2019; Ahn, Lee, Lee, & Jang, 2020; Wiersma, Freedle, McRoberts, & Solberg, 2022).
Ahn (2021) suggested elements like ‘play, transference, symbolic experiences, and meditation’ as therapeutic factors of SPT. However, there has been a lack of interest in the impact of SPT on the sensory functioning of clients or sensory utilization as a therapeutic factor.
Therefore, this study, aims to investigate how school sandplay group counseling impacts the sensory processing abilities of elementary school students with suicide ideation and presents the following research hypothesis:
<Hypothesis> School sandplay group counseling will lead to significant changes in the sensory processing abilities of elementary school students who report suicide ideation.
Methods
This study was conducted in a local elementary school to investigate the impact of sandplay group counseling on sensory processing abilities and suicide ideation in elementary students with suicide ideation.
The average age of the participants was 11.74 years (range 11.25-12.15, SD .30), and there were 10 males and 10 females.
The research team informed school counselers to several elementary schools in Chungcheongbuk-do about the purpose and methods of the study. The research team selected one school from the applicants.
Through the school counselor of the selected school, the research team informed the teachers’ and parents’ associations about the study’s purpose and methods.
Through meetings, the research team selected 170 students from 7 classes of the 6th grade, who were in agreement with the research goals. The research team conveyed the study’s purpose and methods to all 6th-grade parents by means of a parental communication letter. To screen students with suicide ideation, the Korean version of the Suicidal Ideation Questionnaire-Junior (SIQ-JR) was administered to all 170 6th-grade students during the ethics class. Excluding 8 students (3 students who were absent on the day, 4 students with intellectual disabilities, and 1 student who did not want to be tested), 162 students responded to the test. The research team selected 36 of the 162 participants for the study based on SIQ-JR raw scores of 20 points or higher.
The research team included 4 students in the study, even if their SIQ-JR score was below 20, if they checked questions on the survey, “I thought about how I would kill myself,” for a specific method, and “I thought about when I would kill myself,” for a specific time.
These 40 selected students underwent individual interviews with the school counselor. And the research team individually informed the parents of the selected students about the student’s psychological condition, and implemented protective measures.
The research team informed 40 selected individuals about the study, and 20 students who agreed to participate in the study were selected as the final study subjects.
The process, from the selection of the target school to the sandplay group counseling, is presented in Table 1.
Sandplay group counseling was conducted in 5 groups, with 4 children and 1 counselor per group. The sandplay group counseling was conducted simultaneously in five groups of 20 people, and the composition of the counseling site is shown in Picture 1. The counselors consisted of two senior counselors with over 3,000 clinical hours of sandplay and three specialist counselors with over 1,000 clinical hours of sandplay.
Each group’s members showed their individual sandboxes, to the other members of the group and shared stories about the box. The process of the sandplay group counseling is shown in Picture 2.
The design for this study is field-based and focuses on elementary school students with suicide ideation identified through a school-wide psychological assessment. Considering the research environment’s characteristics and ethical considerations, single-group without a control group pretest-posttest design was employed.
The study consisted of a pretest, eight sessions of school sandplay group counseling, and a posttest, for a total of 10 sessions.
The school sandplay program can also organize a structured program based on the ‘Program Construction Principles for School Sandplay Group Counseling’ by Kwak, Ahn, Han, & Im (2018).
However, in this study, a non-structured approach was adopted, involving 4 participants and 1 counselor.
This choice aimed to minimize the influence of structured program’s symbolic themes on the research.
Each session lasted 40 minutes, with an introduction(5min), activity(15-25min), and sharing(10-20min) phase. During the introductory phase of the first session, the counselor educated and explained SPT to the participants.
In all the introductory stages from the first to the eighth session, a treatment contract for SPT was established by setting rules for creating a secure group counseling atmosphere and organizing information protection commitments such as “keeping each other’s secrets’.
During the activity phase, the group spent 3-5 minutes each session meditating in the sand, then explored the cabinet to create their own sandboxes.
In the sharing phase, participants admired the boxes together, introduced themselves and shared positive comments about each other’s boxes.
Suicidal Ideation Questionnaire-Junior(SIQ-JR). The SIQ-JR has been used to assess suicide ideation. This study used the SIQ-JR adapted for Korean adolescents by Lee, Seo, Yang, & Lee (2004). The SIQ-JR includes items that do not follow a specific order or level of severity of suicide ideation. The SIQ-JR covers various aspects of suicide ideation, ranging from general thoughts about death to more specific and severe thoughts.
The SIQ-JR comprises 15 items designed to measure suicide ideation. Participants rate the frequency of their suicidal thoughts using a 7-point Likert scale, which ranges from 0 (absent) to 6 (very often). The potential total score on this questionnaire ranges from 0 to 90.
The SIQ-JR has undergone testing for reliability and validity with Korean adolescents, with reported Cronbach’s alpha values ranging from 0.68 to 0.78 (Lee et al., 2004).
This was a field-based study aimed at preventing suicidal behavior among students in a school setting, which had limitations. The nature of the school site precluded the use of additional mental status assessment tools for lower grade students.
Therefore, the SIQ-JR, a participant screening tool, was included in the pretest and posttest to measure suicidal ideation.
Korean Adolescent/Adult Sensory Profile(AASP). The AASP has been used to assess sensory processing abilities. The AASP is originally developed by Brown and Dunn (2002), which is based on Dunn’s Sensory Processing Model (1997).
The K-AASP used in this study is a version of the original AASP developed by Jung (2016), reviewed by Korean experts, back-translated by translation experts, and validated for reliability and validity with a sample of 1,264 participants. The Korean version of AASP retained the same 60 items as the original version.
Each item is rated on a Likert scale, ranging from 1 (definitely does not respond that way) to 5 (definitely responds that way).
In the AASP, a test taker’s Sensory Processing Abilities score is interpreted in one of five categories : (much) less than most people, similarly to most people, or (much) more than most people. These interpretations are derived from the description of an individual’s score in relation to a normal distribution, providing an estimate of how individuals compare to others in their age group within specific quadrants (Dunn, 2002). The Korean version of AASP reported an interrater reliability of 0.89 for the original-back-translated items, test-retest reliability in the range of 0.806 to 0.909, and Cronbach’s alpha reliability coefficients ranging from 0.660 to 0.804 (Jung, 2016).
Data analysis was performed using the SPSS 29.0 for MAC software. Descriptive statistical analysis was performed to evaluate the demographic characteristics of the participants.
To ascertain the effectiveness of school sandplay group counseling, the paired-sample t-test, was performed. And to ascertain the effect size of school sandplay group counseling Cohen’s d value was calculated.
Results
This study utilized the paired-sample t-Test to examine the influence of the school sandplay group counseling program on the sensory processing abilities of elementary school students with suicide ideation.
The mean scores, mean differences, and Cohen’s d value before and after counseling, and the results of the paired-sample t-Test are presented in Table 2.
The results of the paired-sample t-Tests revealed statistically significant differences in suicide ideation (t = -2.610, p = .017) and low registration (t = -2.429, p = .025).
Cohen’s d-value analysis showed a small effect sizes for Low Registration(Cohen’s d = -.202) and Sensory Avoiding(Cohen’s d = -.247) in the AASP quadrants and a medium effect size for Suicide Ideation (Cohen’s d = -.599), while Sensory Seeking(Cohen’s d = -.064) and Sensory Sensitivity(Cohen’s d = -.042) showed no significant effects.
Discussion
This study aimed to investigate the effects of school sandplay group counseling on the sensory processing of elementary students experiencing suicide ideation. Lowenfeld (1993/2007), the founder of SPT, developed SPT as a therapeutic approach that allows children to express thoughts and emotions using senses like vision and touch. there has been a lack of research, on both nationally and internationally, examining the impact of SPT on sensory processing abilities as variables (Roesler, 2019; Ahn, Kwak, Kim, 2021; Ahn, 2021; Wiersma et al., 2022; Kang, Lee, 2010; Ahn et al., 2021).
Therefore, this preliminary study is significant as it represents the initial effort to investigate the clinical impacts of SPT on sensory processing abilities.
This study was a single-group design without a control group, and a total of 10 sandplay group counseling sessions were conducted, including a pretest and posttest.
The baseline score for the participants resembled the average scores reported for Korean adolescents with moderate depression (M = 34.25, SD = 8.39) (Kim et al., 2013) and patients with schizophrenia (M = 31.94, SD = 8.92) (Jung, 2016). This comparison indicates that the participants may be facing challenges related to sensory processing issues.
After eight sessions of sandplay group counseling, there was a statistically significant change in the low registration. These results suggest that school sandplay group counseling had a positive impact on the participants’ sensory processing abilities.
The debate about sensory integration is still ongoing. Theoretical underpinnings, existence as a unique disorder, and the effectiveness of theory-based treatment approaches are still being debated (Pollock, 2009).
Nevertheless, in order to consider the reasons for the improvements in sensory processing abilities that occurred during the sandplay group counseling, it is reasonable to consider the variables of sensory integration therapy (SIT) that have been studied.
Kim & Kim (2009) studied the effects of group SIT on play by conducting SIT twice a week, 50 minutes per session for 6 months. Comparisons before and after the treatment period showed that play and socialization improved along with sensory processing abilities.
The results of improved socialization after SIT are consistent with improvements in peer relationships (Lee & Cha, 2011) and peer interaction and socialization (Lee & Han, 2014) after sandplay group therapy.
Kim & Kim (2009) used the Revised Knox Preschool Play Scale (RKPPS) to measure children’s play levels
The RKPPS measures children on four dimensions: space management, material management, pretense/symbolic, and participation.
In sandplay group counseling, participants’ appreciation of the process of making sand artwork and the image of sand artwork together, as well as group members’ acceptance of the theme of the series of artwork, are variables that affect the therapeutic effect in the treatment process (Ahn, Kwak, Kim, 2021).
In conclusion, the four dimensions of play in the RKPPS scale are similar to some elements of sand play group counseling.
During the eight sessions of SPT, The children participating in the study experienced the core experiences of SPT, as proposed by Freedle (2007) : ‘seeing,’ ‘touching,’ and ‘doing’.
The children in the study placed food props such as fruit or cake, in a box. And said to therapists and peers, treating the props as real and expressed expressions like this, ‘It looks delicious. Smell it.’. They expressed not only vision and touch but also imaginative senses of taste and smell. The expression of sensory experiences through hands and eyes, along with the exploration of senses through imagination may have helped improve participants’ behavioral responses to sensory experiences.
Following eight sessions of sandplay group therapy, significant changes were observed in participants’ low registration as well as suicide ideation.
These findings align with a study conducted SPT on 22 adolescents who experienced suicidal events(Ahn & Kwak, 2022), and a study conducted SPT with elementary students (Jeon, Lee, & Ahn, 2023), and a Japanese study conducted SPT with 80 college students with comorbid anxiety (Kaoru, 2012).
This suggests that school sandplay group counseling has a significant clinical effect not only on the sensory processing abilities of children with suicidal thoughts but also on the reduction of suicide ideation. Previous studies have proposed various therapeutic factors, such as symbolic experiences in SPT, the positive transfer of ‘Mother-Son Unity,’ play, and meditation, as variables contributing to the improvement of self-concept and a reduction in self-harm and suicide ideation (Jeon et al., 2023; Ahn, & Kwak, 2022). And other SPT studies have also suggested that addressing imbalances in adolescent brain development, trauma, and improving negative attachment can lead to a reduction in suicidal behavior (Ahn & Kwak, 2022) and a decrease in anxiety, further improving self-harming behaviors (Kaoru, 2012). However, research investigating the sensory elements or sensory processing changes in SPT, as proposed by Lowenfeld (1993/2007), has not been presented.
1. the relatively small sample size (n = 20) makes it difficult to generalize the research findings. Therefore, larger-scale studies are necessary to validate the results more reliably, incorporating children of various age groups and grades.
2. This study is a preliminary study to verify the effectiveness of school sand play group counseling on sensory processing abilities in a single group, which is the lowest level of therapeutic research. Therefore, it is difficult to generalize the results of this study to the effects of school sand play group counseling. In future studies, it is necessary to improve the quality of the study by setting up a control group to ensure reliability.
3. due to the short duration of the study, it is challenging to assess the sustainability and long-term effects of the intervention. Future research should delve into the long-term impact of school sandplay group counseling and the changes in children’s sensory processing abilities in more detail.
4. it is difficult to define a clear mechanism or reason for the significant decrease in the Low Registration score after SPT and the non-significant changes in the Sensory Seeking, Sensory Sensitivity, and Sensory Avoiding scores after SPT. This is because there is a lack of published research on mechanisms, and this study did not measure neurological thresholds or behavioral responses. Neurophysiological follow-up studies measuring neurological thresholds or behavioral responses to SPT should be conducted.
This is a preliminary study to investigate the clinical effects of School Sandplay group counseling on sensory processing abilities of 20 elementary school students with suicide ideation.
The outcomes of this study are significant in providing a new perspective on the application of school sandplay group counseling programs in the field and offer directions for future research.
