Effectiveness of the Group Play Therapy on the Insecure Attachment and Social Skills of Orphans in Ahvaz City

This study aimed to determine the effectiveness of the group play therapy on the insecure attachment and social skills of orphans in Ahvaz city. Statistical population included all orphans in Ahvaz city, of whom 30 students were selected whose scores in insecure attachment and in social skills were one standard deviation higher and one standard deviation lower than the mean, respectively and they were randomly divided into two treatment (15 persons) and control (15 persons) groups. The research tools included Randolph Attachment Disorder Questionnaire (2000) (RADQ) and Social Skills Rating System (SSRS) questionnaire (Gresham and Elliot, 1990). This is an experimental study with pretest, posttest, and follow-up by the control group. Firstly, pretest was implemented for both groups, and then experimental intervention (play therapy) was carried out for the treatment group during 10 sessions. After the therapeutic program, the posttest and two months later follow-up were implemented. The results obtained using the statistical method of multivariate covariance analysis showed that group play therapy reduces the insecure attachment and increases the social skills at P < 0.001 during the stages of posttest and follow-up in the treatment group compared to the control group. Results also indicated that there is a significant difference between posttest and follow-up of the treatment and control group in terms of the components of social skills (collaboration, assertiveness, and self-control).


Introduction
Emotional and receiving interactions at the birth and during the childhood have been the most beautiful mother-child relationship throughout the all ages.These primary mother-child interactions lay the foundation for the personality development, behavior and future excitements of the child and all different psychological and behavioral sciences approaches have paid special attention to this period of life.But, due to the particular transformations and their certain effect on the family, there are an increasing number of the children who are deprived of these emotional and cognitive interactions with their mothers and some of them grow up usually in very cold and fragile emotional conditions.These children known as the "orphans" are kept in the boarding facilities, orphanages, charity centers, and correction and rehabilitation centers.A number of studies (Balurka et al., 2014;Kameli et al., 2011) showed that due to lack of the emotional bond with mothers and early separation from the family, these children suffer from a lot of emotional disorders such as the social inconsistencies, suspicion and pessimism, withdrawal, insecurity, aggression, anxiety and depression.Within the wide range of orphans problems, weak social skills and insecurity as well as insecure attachment resulting from the past misbehavior are mostly taken into account (Murphy et al., 2014).Weak social skills and social inconsistencies of the children are due to undesired relationships with parents.Those children who have been deprived of the guidance and encouragement due to their parents' separation or due to the negligence and carelessness to upbringing them, obtain misconceptions from the world, and may develop a hostile attitude towards the society in their adulthood.Separating the children from their parents, notably their mothers, makes the children incapable to establish a healthy and correct emotional relationship during their childhood and maturity (Kaskak & Mary, 2012).
Most social skills, including the skills of collaboration, assertiveness, self-control, and self-efficiency are observable learned behaviors, which enable the persons to interact effectively with others and prevent the social unreasonable reactions (Crawford & Mansis, 2011).On the other hand, according to the attachment theory, there is a relationship between the human mental health and his or her relationship with the attachment pictures.Bowlby (1980) believes that attachment is a kind of relationship in which the mother plays a key role and therefore, she affects the quality of this kind of relationship.Theorists like Bowlby (1980), Freud (1933), and Klein (1950) believe that the children's earliest notably contribute to their future development so that children's deprivation of this kind of relationship, for example, may lead to the neuroticism and personality disorders (Quoted from Michel & Birchwood, 2014).
According to the Bowlby theory, Simpson and Rolz (2012) believe that orphans usually face the behavioral problems and insecure attachment because of experiencing the failure and lack of a warm relationship with their mothers and these destructive consequences are mostly stable.For this reason, methods and solutions, which are able to alleviate the effect of these events, are required.These children usually are interested in the projective methods and rehabilitation tools, which facilitate their problems' occurrence.Hence, play therapy-based methods for establishing the connection and diagnosing and treating the behavioral problems as well as the emotional disorders among the children have obtained special setting (Crenshaw, 2014).Play therapy is one of the most important methods used for training the social skills to the children.For example, psychoanalysts like Freud, Anna Freud and Klein have used the play therapy theories on children as a therapeutic method (Nonteni, 2012).Play is a structured and treatment theory-based approach, which lay the foundations for learning processes and natural and normal children's relationships.Therefore, this study determines the effectiveness of the play therapy on the social skills and insecure attachment among the orphans of Ahvaz City.

Method
The statistical population of the present study includes all 6-10 years-old orphans (both boys and girls) who are kept in the Javad-al-A'emeh Orphanage (the only orphanage 6-10 years-old boys and girls in Ahvaz City).Reception and Servicing Office of the Orphanage reports their total as 60 persons (27 girls and 33 boys).Due to a small research group, the whole population was selected as the statistical sample.To this end, firstly, the questionnaires of Social Skills and Insecure Attachment disorder were distributed to the instructors of the children and on the basis of their knowledge from each of children, the instructors completed the separate questionnaires for them.After the primary analysis, all children whose scores in the insecure attachment were higher than the cutting point and in social skills, the scores were one standard deviation lower than the mean of total scores, total of which were 43 persons.Then, from among these 43 children, 30 persons were selected as the research sample using the simple random sampling method and then they were divided into two treatment (15 persons including 8 girls and 7 boys) and control (15 persons including 8 girls and 7 boys) groups.The similarity between the treatment and control groups was taken into account based on subjects' gender.

Sicoal Skills Rating System (SSRS) Questionnaire
In the present study, Social Skills Rating System (SSRS) questionnaire (Gresham and Elliot, 1990), teacher form, was used for measuring the social skills.This scale includes three forms of parent, teacher, and student and consists of two main parts of social skills and behavioral problems.Social skills include the subscales of collaboration, assertiveness and self-control and behavioral problems include the internalized, externalized and hyperactivity problems.Teacher form of this scale consists of 48 items of three-degree Likert type which has been scored as follows: never: 0, sometimes: 1, most often: 2. Range of this questionnaire's scores is between 0 to 96 in which the lower scores indicate the weak social skills and the high scores show enjoying the appropriate social skills.Gresham and Elliot (1990) reported the reliability of this scale using the retest and Cronbach alpha as 0.94.Balurka et al. (2014) reported the Cronbach alpha for social skills and behavioral problems were reported as 0.84 and 0.79, respectively.In the current study, the reliability coefficient of subscale of social skills by Cronbach alpha and halving method was obtained 0.89 and 0.83, respectively.

Randolph Attachment Disorder Questionnaire (2000) (RADQ)
This questionnaire, which was developed by Randolph (2000), consists of a 25-item checklist for 5-18 years-old children that should be completed by the parents or the child's caretaker.This questionnaire has been developed in a Likert scale in which each item has 0 to 4 scores.The Score range is between 0 to 100 and scores higher than 30 indicate the existence of the children's attachment problems and insecure attachment disorders.Psychometric properties of the attachment disorder questionnaire in Iran were normalized and investigated by Movahed-Abtahi et al. (2012).Movahed-Abtahi et al. (2012) used the sensitivity and specificity method for examining the diagnostic validity of the questionnaire and the questionnaire's sensitivity and specificity were obtained 100% and 90%, respectively.In other words, using this questionnaire, the 100% of the patients, and 90% of the healthy people are identified.In this study, reliability of the attachment disorder questionnaire using the Cronbach alpha and Halving method was calculated as 0.81 and 0.84, respectively, which indicates the reliability of this tool.

Findings
In Table 1, the indicators related to the descriptive statistics for the research sample including the mean and standard deviation for the research variables are reported.2 shows the results of the Levene test on the variables of collaboration (F = 0.83 & p = 0.33), assertiveness (F = 0.64 & p = 0.49) and self-control (F = 0.71 & p = .43)and insecure attachment variable (F = 0.79 & p = 0.45) are not significant.Therefore, variances of both the control and treatment groups are not significant on the variables of collaboration, assertiveness, self-control, and insecure attachment and therefore, hypothesis of variances' homogeneity is approved.
First Hypothesis: Group training of the play therapy affects the insecure attachment and social skills (collaboration, assertiveness, and self-control) of orphans.
Table 3 shows the results of the multivariate covariance analysis on the posttest and follow-up scores by controlling the pretests.3 show that there is a significant difference between the control and treatment groups, in terms of at least one of the variables of insecure attachment, collaboration, assertiveness, and self-control.For examining the difference point, one-way covariance analysis in MANCOVA context on insecure attachment and variables of collaboration, assertiveness, and self-control was carried out.Results of this analysis are reported in table 4. Table 4 shows the results of one-way covariance analysis in MANCOVA context for comparing the posttests of insecure attachment and variables of collaboration, assertiveness, and self-control by controlling over the pretests in both control and treatment groups.
Second Hypothesis: Play therapy affects the insecure attachment of the orphans.
p < 0.001) and in the follow-up stage (F = 46.11& p < 0.001) is significant.Therefore, the fifth hypothesis is confirmed.

Discussion and Conclusion
Findings of this study indicate that the group play therapy is effective and satisfactory on the insecure attachment and subscales of social skills including collaboration, assertiveness, and self-control.MANCOVA results show that the first hypothesis is confirmed (p<0.001).Results of the present study are consistent with those of Khaledian (2014), Gharaei andFathabadi (2013), Seyyedmousvai et al. (2013), Tabaeian et al (2009), Bowth and Jerenberg (2010), Kernshaw (2014) and Balurka et al. (2014).
Now the effectiveness of group play therapy on reducing the insecure attachment of orphans is explained.Fear of rejection and unpredictable social situations cause the insecure attachment.Group behavioral -cognitive play therapy that emphasizes on accepting the reality, increasing the self-awareness, self-regulating the ability, autonomy, and facing the mental pressure, improves the self-esteem and group attachment.In fact, sense of being accepted in the group and stress management entails using a wide range of confrontation strategies such as emotion regulation, constructive thinking, action control, and environmental behavior in order to reduce the stresses.All of these intra-structure processes are considered as confrontation strategies that are used for reducing the insecure attachment and increasing the group security, attachment and reception by the instructor and group members (Bowth & Jerenberg, 2010).
As said by Galager et al. ( 2004), fear of negative assessment is the main cause of most children's anxieties with weak social skills and insecure attachment.In other words, a number of children are afraid of others' negative assessment.One the main characteristic of these children is their continuous fear of one or several social situations in which they face unknown people that the children are curious to know them.These children fear that they behave in such a way that they are rejected, ridiculed, humiliated, or embarrassed.In such conditions, using the group play therapy, self-confidence, self-efficiency, competency, being useful, and group attachment are increased and this may provide an appropriate background for raising the secure attachment and social skills of children.The research findings indicate that play therapy is effective and satisfactory on reducing the insecure attachment of orphans.With regard to the results of MANCOVA analysis, the second hypothesis is confirmed (p < 0.001).Results of the present study are consistent with those of Khaledian ( 2014 Now, the effectiveness of group play therapy on reducing the insecure attachment among the orphans is explained.According to the Lenderth' (2002) point of view, therapeutic objectives for all children help them to face the painful emotional issues, enjoy the self-feeling of the self and others, change the inconsistent behaviors and create the secure environment for flowing out the child emotions.Play therapy as one of the main therapeutic approaches, by creating secure environment for the children, helps them to try their abilities, assert themselves, participate with others, and trust them.Therefore, orphans who have insecure attachment due to the lack of positive relationship with their mothers suffer from the weak emotional self-awareness, they do not trust themselves or others, therefore, and they can change negative emotions into positive ones via group plays.
Of the characteristics of orphans with the insecure attachment is the deep sense of mistrust their and others' capabilities that is the main cause of most withdrawals and preventing behaviors.The play therapy techniques focus on creating a background for social interactions, friendships and interactions among the group members.In this way, these children achieve a sense of self-exposure and empathy and can trust others.In such cases, unfavorable feelings of mistrust is gradually faded and is replaced by a sense of confidence and self-belief and children try to participate in the social situations and establish relationships with others as an opportunity for personal development and self-esteem promotion rather than consider it as a threat (Simpson & Rolz, 2012).
One of the other findings of this study is that group play therapy is effective and satisfactory on increasing the collaboration of the orphans.The results of MANCOVA analysis confirm the third hypothesis (p < 0.001).
In explaining the effectiveness of group play therapy on increasing the collaboration as one of the important dimensions of social skills of orphans, it can be said that play therapists have classified the play objectives as follow: self-development, maturation, communication development and developing the participation skills level.
In the field of self-development, children use play for expressing their feelings and thoughts, exploring their interests, and achieving the control over environment.By developing this kind of skills, they promote self-awareness, self-scrutiny, empathy, and finally taking measures for group and social life.About the processes of maturity, communication development and developing the participation skills level, play can be used for raising and developing the motor skills, cognitive skills, language skills, problem-solving, knowing the emotions and excitements and logical solutions.This provides the children with an opportunity to become aware of their environment, know the people who surround them, recognize the environmental limitations and efficient consistency, and finally develop the viewpoint of participation and collaboration to cope with the group limitations.Therefore, the play therapy mainly aims to identify and change the inconsistent thoughts related to the behaviors and emotional problems of children as one of the main limitations of the group activities and cooperation (Lendert, 2002).Additionally, findings of this research indicate that the group play therapy is effective and satisfactory on increasing the assertiveness of the orphans.Results of MANCOVA analysis confirm the fourth hypothesis (p < 0.001).Results of the present study are consistent with those of Gharaei and Fathabadi (2013), Tabaeian et al. (2009), Walton (2009) and Kernshaw (2014).
In explaining this finding, it can be said that the reason for success of play therapy in increasing the assertiveness is the comprehensive property and extension of processes and its techniques.Group behavioral-cognitive play therapy is a combination of self-awareness, self-regulating, anger and stress management, assertion, expression of feelings, active listening, feedback and reflection, emotion management and the way of interaction and connection.For example, training the empathy skill using the puppet plays the includes using the techniques of the verbal communication (speaking and listening), non-verbal communication, body language, listening skills, emotional acceptance and skill of refusal and rejection of a proposal‫و‬ all of which may be trained in the form of the play.In addition, group membership and self-expression create social network and group support and reduce the withdrawal and social isolation of orphans (Kernshaw, 2014).
Additionally, findings of this research indicate that group play therapy is effective and satisfactory on increasing the self-control of orphans.The results of MANCOVA analysis confirm the fifth hypothesis (p < 0.001).Results of the present study are consistent with those of Gharaei and Fathabadi (2013), Tabaeian et al. (2009), Walton (2009), and Kernshaw (2014).
Now the effectiveness of group play therapy on self-control as one of the important dimensions of orphans' social skills is explained.Training the self-control skills including verbal skill, decisiveness, participation, emotional awareness, respecting the social regulations and others' opinions, thinking before taking action using the play increase the self-respect, self-awareness and self-control in different situations that make the self-control of treatment group differs from that of the control group.According to Lendert (2002), playing is the most suitable method for training the new skills to the children and it includes all techniques of behavior changes for example the change in role and a high number of new skills can be trained in this way.Mohammad-Esmaeil (2010) states that playing helps the children to assess their social skills, self-awareness, exercise and learn the adequate and complementary behaviors.

Table 1 .
Descriptive indicators of research variablesTable2shows the results of Levene variance homogeneity test between the dependent variables of the study; i.e. variables of collaboration, assertiveness and self-control and insecure attachment, as well.

Table 2 .
Results of the Levene variance homogeneity test between the dependent variables of collaboration, assertiveness, and self-control and insecure attachment as well in both control and treatment groups

Table 3 .
A summary of the results of the multivariate covariance analysis for comparing the means of insecure attachment tests and variables of collaboration, assertiveness and self-control by controlling over the pretests in both control and treatment groups