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The Effectiveness of Adlerian Group Play Therapy-based Counseling Intervention on the Holistic Wellness of Neglected Children

Childhood is regarded as a highly crucial developmental stage for humans, whereby it is believed to be the most appropriate time to administer important interventions for the purpose of improving the holistic wellness of individuals. Hence, the aim of this study was to examine the effectiveness of the Adlerian Group Play Therapy in improving the holistic wellness of neglected children. The study design was quasi experimental which was performed by measuring the preand post-test wellness scores for the control and interventional groups. A total of 83 children between the age of 10 and 12 years were purposively selected from the children’s homes. In this case, only a total of 66 children were included as the participants of this study after the initial administration of the Five Factor Wellness Inventory – Elementary School Age version (FFWEL-E) as they managed to score less than one standard deviation which was below the mean. Meanwhile, paired random sampling was carried out to equally divide them into the control and treatment groups with 33 participants each. In addition, all participants of the treatment group were further divided into eleven small groups of three to enable the conduct of nine weekly counseling sessions in total that lasted 90 minutes each. The data of this study was evaluated using the analysis of variance (ANOVA). The findings showed significant differences between the pre and post-test wellness scores of the control and treatment groups [F (1, 64) = 78.942, p < .01, α = .00]. On top of that, the mean post-test score of the treatment group was significantly increased compared to the control group. Overall, it can be concluded that the Adlerian Group Play Therapy is suitable to be incorporated into counseling sessions involving children considering that this therapy can effectively improve the holistic wellness of neglected children.


Introduction
Holistic wellness is important for the development of human capital as well as the improvement of individuals' quality of life to enable them to conduct their daily activities without any limitations. According to Rohany and Fatimah (2006), life satisfaction can be achieved when a person is happy and has no negative feelings. Meanwhile, Myers and Sweeney (2014) introduced a holistic model of wellness known as the Indivisible Self Model that covers not only the physical and mental aspects of individuals, but also the spiritual aspect. On top of that, it can also be used to describe how the environmental factors contribute to healthy lifestyles. Overall, all of these is able to enhance the understanding of human being in a more holistic manner.
Moreover, the Indivisible Self Model by Myers & Sweeney comprises of five aspects, namely essential self, social self, coping self, physical self, and creative self. Essential self is composed of several sub-domains such as gender, culture, aspects such as thoughts, feelings, control, emotions, humor, and work. Finally, coping self consists of the sub-domains of leisure, stress, self-worth and realistic beliefs. More importantly, it should be noted that each factor is related to and dependent on the others. On a more interesting note, these domains commonly interact with the environment in the local, institutional, global, and chronometrical contexts. The local context refers to a system that is normally lived by an individual which is composed of families, neighborhoods, and communities. On the other hand, the institutional context is made up of politics, cultures, global events, and environmental factors that have the ability to connect individuals all around the world in a chronometrical (time-based) manner. Evidently, this model is in line with the objectives of the Malaysia Education Blueprint (2013-2025) with the aim of ensuring that children are able to grow well physically, emotionally, spiritually, intellectually and socially. Moreover, holistic wellness provides the opportunity for children to lead productive and enjoyable lives (Hollingsworth, 2009(Hollingsworth, , 2010. In addition, a greater focus on the promotion of wellness in children will enhance their academic achievements and reduce social problems (Hollingsworth, 2009).
In the current 21st century, Malaysia is shown to be gearing towards the status of a developed country. However, issues regarding holistic wellness of children in Malaysia are still prevalent, especially in those who are neglected. "Neglect" is described as the failure to meet the children's needs for holistic wellness. More specifically, it should be acknowledged that maltreatment tend to occur in many forms such as physical and emotional neglected as well as deprivation of education, nutrition, and supervision (Allin, Wathen, & MacMillan, 2005;Mohd Yusof, 2010;Stoltenborgh, Bakermans-Kranenburg, & Van Ijzendoorn, 2013). On top of that, it is even more unfortunate that these groups of children are often mistreated, especially by their parents or the most significant people in their lives. Moreover, neglected children include those who are constantly exposed to drug abuse and domestic violence in the family (Kantor et al., 2004). Hence, failure to monitor children's behaviors will lead them to be involved in negative activities (Goodvin, Johnson, Hardy, Graef, & Chamber, 2007;Kantor et al., 2004;Slack et al., 2011), particularly those who seek attention, power, proving inadequacy and revenge (Kottman & Meany-Walen, 2016;Meany-walen, 2010;Meany-walen, Bratton, & Kottman, 2015).
Generally, it cannot be denied that children are naïve. Hence, all of them who are neglected tend to be very vulnerable to all forms of violence or abuse. Meanwhile, Thompson et al., (2016) states that maltreatment has been recognized as an important predictor of risky sexual behavior among children. Nevertheless, it is undeniable that the victims of neglect still have the potential to develop into a normal human being. Hence, it is very important to determine their wellness levels for the purpose of developing the interventions that can adhere to their needs. In this case, early intervention that is important for the psychological health of children, should take place when they are still able to adapt to their social lives or before their mental health deteriorates (Meany-Walen, Bratton, & Kottman, 2014a) . On a more important note, the impact of unresolved neglect is severe which will adversely affect many areas of child development, thus resulting in serious, immediate, and long-term consequences for the children and their future generations. Moreover, chronic neglect tends to occur over a prolonged period which will turn into an intergenerational problem.
Counseling is a professional service that aims to support and enhance the wellness of individuals, including children. Conventionally, counseling for adults involves verbal communication of the issues or concerns that are commonly related to themselves. However, children are not able to communicate like the adults considering their cognitive limitations and difficulties in expressing their emotions in words which are part of their normal developmental processes (T Kottman & Meany-Walen, 2016) and traumatic events (Rosanida Anang, 2012). Hence, counselors have implemented play therapies as part of child counseling sessions due to the fact that play is the natural "language' in children (Kottman & Meany-Walen, 2016;Landreth, 2012). In addition, play has a therapeutic role that can help counselors to interact with children in the counseling setting. On top of that, toys such as puppets, drawings, miniature, sand trays, and their ilk can be used as a means to communicate with the children. In other words, children can express their feelings, thoughts, and experiences through play. Therefore, play therapies enable counselors to tap into the children's internal worlds and address their concerns in the process.
In relation to this, most of the established studies have recognized the higher efficacy of play therapy over other interventions for neglected children (Allin et al., 2005). The overall conclusion is that play therapy involves resilient peer treatment are found to evidently produce positive outcomes for children who have been experiencing neglect (Udwin, 1983). In addition, many studies have also concurred that play therapy is an effective therapeutic intervention in children counseling sessions (Blanco, Muro, & Stickley, 2014;Blanco, Ray, & Holliman, 2012;Lin & Bratton, 2015;Ray, Schottelkorb, & Tsai, 2007;Stickley, Muro, & Blanco, 2013). The establishment of play therapy in Malaysia is still at an early phase; hence, they are limited studies in this field (Ku Suhaila Ku Johari, Bruce, & Mohamad Isa Amat, 2014; Rafidah Kastawi, 2013;Rosli Busu, 2011). A research carried out by Ku Suhaila, Bruce and Muhammad Isa (2014) on the effectiveness of play therapy training among mental health professionals in Malaysia showed that the usage of this method in counseling has successfully helped children to get better.
The Adlerian Play Therapy approach emphasizes the social context and holistic understanding of human beings. Kottman & Meany-Walen, (2016) state that several studies have highlighted the efficacy of the Adlerian Play Therapy in counseling. The positive outcomes of this approach include the reduction of externalized and destructive behaviors during intervention and follow-up phases, including the improvement of social skills (Meany-Walen & Teeling, 2016).
However, the existing study on the effectiveness of Adlerian Group Play Therapy is still limited despite the empirical evidence that show the effectiveness of this approach for children counseling sessions (Kottman & Meany-Walen, 2016). Nevertheless, there has been a lack of interventional researches on the effectiveness of Adlerian Group Play Therapy in enhancing the wellness of neglected children despite the knowledge on the severity of the consequences of serious and chronic neglect. Therefore, this study aims to determine the effectiveness of the Adlerian Group Play Therapy with respect to the five domains of wellness mentioned earlier, namely essential self, social self, creative self, coping self, and physical self.

Literature Review
Adlerian Group Play Therapy is a counseling approach which is grounded to the tenets of Adler's Theory of Individual Psychology (Kottman & Meany-Walen, 2016). More importantly, human beings can be understood in a holistic and social manner through this theory. In addition, the Adlerian Play Therapy was first developed by Kottman in 1987 by integrating the Adler's Theory of Individual Psychology with the play techniques that befitted the natural development of children in order for the purpose of ensuring the success of the intervention.
In relation to this, it should be noted that the above mentioned holistic model of wellness was developed based on the Adlerian Counseling Theory (Myers & Sweeney, 2014;Myers, Sweeney, & Witmer, 2000). In this case, play therapy has been used as a tool to enhance the holistic wellness of neglected children in order to ensure the practicality. Most established studies on holistic wellness only focused on adults and teenagers, thus explaining the need of conducting more studies on children. Meanwhile, Hollingsworth, (2009) examined the correlation between the wellness of children and their academic achievements, and it was found that children with good holistic wellness will be able to obtain better academic achievement. Hence, the present study aims to test the effectiveness of Adlerian Group Play Therapy in terms of the five domains of holistic wellness based on the information provided in this section.

Methods
The present study employed the quasi-experimental design in order to compare the effects of counseling (based on the Adlerian Group Play Therapy) on the five domains of holistic wellness. The participants were further divided into two experimental groups, namely one that receives the treatment and one control group with no treatment.

Participants
The participants for this study consisted of a total of 83 neglected children who were selected from the children homes. In the case of this study, the participants were selected based on the following criteria: (a) neglected children living in children's homes (b) children with the age between 10 and 12 years and (c) informed consent from the neglected children that must be obtained prior to the commencement of data collection.
On top of that, the researchers distributed the Five Factor Wellness Inventory -Elementary School Age version (FFWEL-E) to the children's homes with the help of the facilitators that was also known as the in-house counselors. These children were gathered in air-conditioned rooms such as libraries, halls, and meeting rooms, followed by a briefing session on the FFWEL-E provided by the researches. More specifically, all the items in the questionnaire were read aloud to the children to make it easy for them to provide their responses to the questionnaire. According to the manual of FFWEL-E, the suggested duration for the conduction of data collection is between 10 and 20 minutes and should be carried out under the proctoring of an adult (Myers & Sweeney 2005;.
Hence, children with the lowest mean wellness scores were selected as the respondents of this study with a total of 66 students found to be qualified for the present study. Next, the selected respondents were randomly assigned to the experimental or control group with 33 participants for each group. Moreover, the experimental group was subjected to nine weekly sessions of counseling that lasted for 90 minutes. Adlerian Group Play Therapy sessions was conducted using Adlerian Play Therapy Manual Treatment by Terry Kottman. On the other hand, the control group required no treatment. Therefore, data was again collected from both groups via the FFWEL-E after the nine sessions.

The Reliability and Validity of the Instruments
The FFWEL-E was initially developed by Myers and Sweeney in 2005 and then revised in 2014. In relation to this, the structural equation modeling was employed to devise the FFWEL through the analysis of Adler's Theory of Individual Psychology. Moreover, it is important to note that there are three versions of FFWEL that were respectively developed for adults, adolescents, and elementary school children. However, the present study adopted the English version of FFWEL-E that was translated from English to Malay with the permission obtained from Mind Garden Inc. In addition, the translation process involved both forward and backward translations (Brislin, 1976).
In this study, a four-point Likert scale was adopted with each item in the FFWEL-E represented in the form of a statement that requires the participants to provide responses in the range of "strongly agree", "agree", "disagree", and "strongly disagree". On top of that, all the items had been worded positively except for the realistic beliefs scale as well as one of the items in the safety scale. More importantly, these items have been reverse-scored to maintain an internal consistency when they are reported with other scales.
Nevertheless, a considerable amount of studies has evaluated the reliability and validity of this instrument. Hattie, Myers, and Sweeney (2004) reported that the alpha coefficients for the five-second order factors were .93 (creative self), .92 (coping self), .94 (social self), .91 (essential self), .90 (physical self), and .94 (total wellness). Furthermore, a research conducted by Hollingsworth (2009) showed that the alpha coefficients for the other five wellness composites are .721 (essential self), .764 (creative self), .719 (social self), .664 (physical self), and .588 (coping self). The overall Cronbach's alpha for this study was 0.91 which indicates a high level of reliability because it exceeded the value of 0.8 (Cohen, Manion, & Morrison, 2018).

Data Analysis
The pre-and post-test data that have been analysed will be utilized in this section for the purpose of comparing the effects of Adlerian Group Play Therapy on the holistic wellness of children in both the intervention and control groups. Meanwhile, the split-plot analysis of variance (ANOVA) was conducted for each dependent variable (of wellness) using SPSS in order to analyse the differences between the groups and confirm the presence of interaction effects on group membership that is considered as part of the particular interest in this research. Hence, the scores for all 66 participants from the analyses of the FFWEL-E are provided in this section. Table 1 shows that 50.6% of the respondents are males, while 49.4% are females. In this case, the somewhat equal male/female ratio indicates the absence of significant standard error differences between both groups (males and females). In terms of ethnicity, there are 74 (89.2%) Malays, 1 (1.2%) Chinese, 6 (7.2%) Indians, and 2 (2.4%) others. The descriptive statistics (means and standard deviations) were used to evaluate the pre-and post-test scores of the control and treatment groups as shown in Tables 2 and 3 below: According to Table 2, the differences in the mean pre-test scores between both groups are low in the range of 0.033 -0.134. As can be observed in Table 3, the differences in the mean post-test scores between both groups are high in the range of 0.667 -2.090. It is crucial to note that higher scores in the FFWEL-E scales indicates better holistic wellness. Meanwhile, Table 4 shows that the variances of the wellness are equal across groups (p > .05).  Table 5 illustrates that the variances of the domains are equal across groups (p > .05).  Table 6 indicates that the play therapy has a significant positive effect (p < .01) on holistic wellness with the efficacy of the intervention recorded as 0.925 (ƞ² = .925).  Table 7 shows that play therapy has a significant positive effect (p < 0.01) on each domain with the efficacy rates (ƞ²) ranging between 0.376 and 0.908.

Limitations
The current research was an initial investigation of the effectiveness of Adlerian Group Play Therapy on the holistic wellness of children. The results cannot be generalized to the entire population of neglected children in Malaysia because of the sampel size is small and considered adequate for experimental studies.

Discussion and Conclusion
The findings of this study showed that Adlerian Group Play Therapy-based counseling sessions managed to significantly increase the levels of all five domains of holistic wellness, namely essential self, social self, coping self, creative self, and physical self. The results obtained in this study are consistent with the finding of Adlerian Group Play Therapy-based counseling sessions that can reduce destructive behavior (Meany-Walen et al., 2014b) and improve social skills (Meany-Walen & Teeling, 2016).
Unwellness in children is associated with negative long-term consequences. More importantly, the statistical, practical, and clinical significance of the present study supports the notion that Adlerian Group Play Therapy is a promising intervention in enhancing holistic wellness. Apart from that, early intervention also has the potential to break the cycle of negative behavior which arises from unwellness, thus preventing future occurrences of intergenerational neglect.
In the Adlerian Group Play Therapy, children are provided with playing materials that allow them to express a wide range of emotions, promote a sense of control and mastery, and provide opportunities to practice socially-acceptable behaviors during counseling sessions. Moreover, it is also plausible that children who undergo the Adlerian Group Play Therapy tend to experience a sense of confidence and control when they are given encouragement and support by their counselors.
In addition, the Adlerian Group Play Therapy indirectly changes the experience of the children and enhances their coping self attributes, namely self-esteem, stress-management abilities, and reality beliefs which are able to create pleasant and desirable experiences. Apart from that, it has also been reported that children are able to attain a sense of empowerment post-therapy as well as demonstrate improvements in their social selves and social skills.
Overall, these findings indicate that institutionalized counselors can utilize the Adlerian Group Play Therapy to effectively increase the holistic wellness of children. Moreover, this study provides an impetus for counselors to identify neglected children at an early stage and take the necessary steps to ensure that these children receive Adlerian Group Play Therapy-based counseling services that can improve their overall wellness and prevent any problems which may be resulted by the adjournment or deficiency of treatment. Other than that, it was also demonstrated that the Adlerian Group Play Therapy is an effective intervention that can enhance holistic wellness and be delivered to children in institutional care settings.