Addressing psychiatric and psychosocial issues related to children and adolescents
To be self-confident is to trust in one's self and abilities to succeed. Self-esteem is how an individual values him/herself (i.e., self-worth). Self-confidence and self-esteem do not always coincide. Many individuals can be highly self-confident and even successful yet have low self-esteem. Self-efficacy is an individual's belief in his/her ability to control how events affect his/her life. Self-confidence is a combination of self-efficacy and self-esteem. Self-esteem is vital for emotional well-being, whereas self-confidence is linked to feelings of achievement (Kay & Shipman, 2014).
The development of self-esteem and the building of self-confidence extend across the lifespan. Nevertheless, this complex interplay is particularly vulnerable during the teenage years. Adolescence is a challenging period of physical and mental growth and development. During the adolescent period, developing egocentrism and feelings of invulnerability and immortality can lead to risk-taking and behavioral experimentation (Burns et al., 2017). These risky behaviors can include smoking, drug and alcohol use, and engaging in sexual activity, which may result in pregnancy. Approximately 80% of teen pregnancies are unintended (Leftwich & Alves, 2017). Although the teen pregnancy rate in the United States has declined over the past 2 decades, 249,078 babies were born to adolescent females ages 15 to 19 in 2014 (U.S. Department of Health & Human Services, 2016).
The additional challenges of pregnancy and motherhood can negatively impact adolescent self-confidence and self-esteem (Babington, Malone, & Kelley, 2014). A research review of social support interventions for adolescent mothers revealed that, compared to non-parenting adolescents, adolescent mothers display more difficulties with trust, less autonomy, coping difficulties, and lower self-esteem (Letourneau, Stewart, & Barnfather, 2004). One way an individual's feeling of self-worth can be improved is by addressing deficits in self-efficacy and self-confidence (Wong, Lau, & Lee, 2012). Furthermore, children born to adolescent mothers are more likely to have impaired cognitive development, more behavioral problems, less education, and higher rates of unintended pregnancies. These additional problems create a heavy social burden, costing approximately $9 billion per year (Yonek & Hasnain-Wynia, 2011).
Programs to improve self-esteem, build confidence, and increase self-efficacy are needed to improve the overall mental health of adolescent mothers (Logsdon, Ziegler, Hertweck, & Pinto-Foltz, 2008; Mossman, Heaman, Dennis, & Morris, 2008; Sadler et al., 2007). To effectively implement a self-esteem building program, self-efficacy needs to be addressed. Confidence and self-efficacy are closely related. Confidence is a general strength or belief, whereas self-efficacy is an individual's belief in his/her ability to achieve something specific (Kay & Shipman, 2014). As self-efficacy increases with various tasks and challenges, it will positively contribute to an individual's overall self-esteem. Self-efficacy is an individual's belief in his/her capabilities and the strength of that belief, which can be increased through mastery experience, vicarious experience, regulating emotional states, and verbal persuasion (Bandura, 1997).
The school, where the current clinical project took place, has a school-based health center on site. An additional support system for students is offered through a bimonthly parenting support group led by university nursing faculty. The support group covers a wide range of infant, toddler, and maternal topics, including developmental milestones, safety, and nutrition. During interactions with students at the parenting support group sessions, it was observed that many struggled with low self-confidence and self-esteem. An initial needs assessment was performed to assess self-efficacy of the support group attendees using the General Self-Efficacy Scale (GSE) developed by Schwarzer and Jerusalem (1995), which revealed an overall low self-efficacy score of 3.096, correlating with research findings of low self-efficacy observed in adolescent mothers. The results of this initial needs assessment; the observations of low self-esteem at the bimonthly support group meetings; and a literature review regarding self-efficacy, self-esteem, and confidence in adolescent mothers led to the development of the current clinical project.
Bandura's (1997) social learning theory was used to guide the clinical project. The aim of the project was to explore how self-efficacy–focused activities provided in a school-based support group could improve self-efficacy and build self-confidence and to determine the feasibility of providing this service to adolescents.
The current project took place at an alternative public school for pregnant and/or parenting adolescent females located in a large metropolitan area. A total of 51 female students participated in the group sessions. Participants ranged in age from 13 to 19 years and were predominantly African American (81%, n = 33), as well as Hispanic/Latino (18%, n = 17) and White (1%, n = 1). The majority of enrolled students live in urban, high poverty areas, with 96% qualifying for free or reduced-price lunch programs. Institutional Review Board approval was obtained. Informed consent was obtained from all participants. Confidentiality was maintained throughout the study. In addition, all Health Insurance Portability and Accountability Act regulations were followed. Convenience sampling was used to select participants. Exclusion criteria were students who were serving in school detentions.
The GSE was used for the current project. The GSE is a 10-item, 4-point Likert scale, where 1 = not at all true, 2 = hardly true, 3 = moderately true, and 4 = exactly true (Schwarzer & Jerusalem, 1995). Each item is equally weighted. The GSE has a reported internal reliability Cronbach's alpha between 0.76 and 0.90. The total score is calculated by adding the sum of all items. Scores range from 10 to 40, with higher scores representing more self-efficacy. The reading level measures at the 7th grade level. In the current project, the GSE served as a pre- and post-test to measure improvements in participants' self-efficacy.
The project took place over 12 weeks with a total of four sessions focusing on fundamental components of self-efficacy. Each session lasted 30 minutes and was intentionally designed to stand-alone, as it was presumed most students would not be able to attend all four sessions due to maternity leave, school transfers, clinic appointments, or meetings with teachers. The sessions coincided with the bimonthly parenting support group meetings, which were already established. Four sessions were selected to determine feasibility with the intention of expanding the number of sessions in the future. Session content was developed from the Girl Scouts of America #BanBossy program (Girl Scouts, 2015). Constructing stand-alone sessions allowed students to experience each session fully without feeling as though they were behind. Participants completed a pre- and post-GSE at each session.
Session 1 focused on teaching general self-efficacy concepts. A Jeopardy!® game format was used to engage participants. For Session 2, a scenario about a young mother who worried about her child's development was presented. This scenario was used to generate discussion on particular worries participants have regarding parenting, academic achievement, and future goals. At this session, participants were also asked to share their own positive coping mechanisms. During Session 3, participants played a timed game of keep away. The G.I.R.L. problem-solving protocol from the Girl Scouts of America #BanBossy program served as the guide for this session. The acronym for the protocol stands for gather your choices (G), I choose (I), reasons are (R), and list the outcomes (L). Participants were asked to use the G.I.R.L. protocol to identify ways they could improve their time during the game.
Regulating emotional states was the focus for Session 4. Participants were divided into two groups and were timed to see which team could fill a pair of pantyhose quickest with balloons. Each balloon color was associated with a feeling or emotion (e.g., joy, sadness, envy, fear). The objective of the game was to illustrate that individuals experience many emotions during situations, especially challenging and stressful situations. Often individuals equate feeling fearful as failure (Bandura, 1997). To better achieve the objective, individuals with lower self-efficacy needed to learn how to regulate their feelings to motivate them and identify positive ways to cope with overwhelming emotions.
The overall score and per item GSE served as a pre- and post-test to measure whether the program improved participants' self-efficacy. Individual and group scores were analyzed using SPSS version 25 and two-tailed Pearson correlation. Statistical significance was set at p < 0.05. Descriptive statistics were used to describe and summarize overall data.
General Self-Efficacy Scale Scores Per Session
A slight increase trend was seen in mean group scores for Sessions 1, 3, and 4. Further analysis showed no statistical significance (p = 0.76, p = 0.84, and p = 0.38, respectively). A decrease was noted in the overall mean pre-test and post-test score (31.79 to 30.89) and the mean per item score from 3.18 to 3.10 for Session 2 (Table 1). This decrease in score is possibly due to challenging conversation on worry and control discussed at that session.
Group Mean Pre- and Post-Test General Self-Efficacy Scale Scores Per Session
Number of Sessions Attended and General Self-Efficacy Scale Score
A total of 34 students attended more than one self-efficacy activity session and 12 students completed all four sessions. Overall, GSE scores did not demonstrate a positive correlation between number of educational sessions attended and improved self-efficacy. Analysis identified item eight—“When I am confronted with a problem, I can usually find several solutions”—as having a moderate correlation between the number of sessions attended and improved score (r = 0.30, p < 0.08).
Due to variations in attendance, stand-alone sessions were required for the current project. This necessary design was limiting in that participants were not provided the opportunity to identify deficits in improving self-efficacy, specifically the content from Session 2. The decrease in mean group score for Session 2 may be attributed to the difficult conversation on worry and control. For future sessions, implementing a debriefing discussion should be considered. When addressing worries and anxieties within the principles of self-efficacy, guided mastery is necessary. With guided mastery, individuals confront fears and distance themselves from the situation when their emotions become too overwhelming. With guidance, individuals work on developing coping skills until they are able to effectively navigate their fears (Bandura, 1997). Mastery experience and overcoming anxieties takes time to develop; therefore, prospective analysis on the impact of the self-efficacy sessions would be beneficial to explore further.
By Session 3, participants reported feeling confident in their self-efficacy scale items knowledge and would rush to circle their responses. To avoid this issue with future sessions, only items pertaining to each session's specific content from the GSE should be administered for that session. To further explore the impact of the self-efficacy–focused activities, an online 1-minute paper would be a productive evaluation method to implement. A 1-minute paper is a simple, timely method to assess learning and feedback. The 1-minute paper asks participants to identify one thing they learned during the session and ask a question they may have regarding the session content. Advantages of the online 1-minute paper are responses tend to be more thoughtful and participants who are shy in the sessions may be less so online (Erickson & Erickson, 2013).
Social support influences self-efficacy and is more likely to be sustained if family and friends share a mutual belief in their loved one's capabilities. When an individual is confronted with family and friend doubts regarding their perceived capabilities, their self-efficacy often diminishes (Bandura, 1997). In the current project, participants who were most engaged in the sessions expressed greater family support, especially maternal support when discussing their future goals. Inversely, during the project period, there was an increase in students' reporting of domestic violence encounters to the school-based health center. It is difficult to determine if the increase was related to the self-efficacy–activity sessions fostering confidence to report domestic violence issues or if this was coincidental. Domestic violence and intimate partner violence negatively impact the ability to enhance self-efficacy (Shiles, 2011). Individuals who experience violence in the home are often isolated, which inhibits them from developing mastery and vicarious experiences. Further self-confidence research regarding perceived social support and domestic violence effects in this population is warranted.
Collectively, the four activity sessions offered during the current clinical project did not demonstrate significant improvement in self-efficacy. These results bring into question whether additional sessions would be beneficial. Although the GSE is a reliable measurement tool, other methods of evaluation could have been used to reveal changes in self-efficacy and self-confidence. A focus group at the completion of the four activity sessions would have been a valuable way to bring participants together to discuss their thoughts about the activities and to determine ways to improve sessions.
Overall, there were multiple feasibility challenges to this project. One of the main constraints was time. The sessions were limited to the lunch period due to scheduling conflicts. The lunch period was 30 minutes. By the time students picked up their lunch in the cafeteria and brought their meals to the activity room, there was approximately 20 minutes left to conduct the sessions. Furthermore, detentions were also served during lunch time, so this limited the number of students who were allowed to participate in the sessions. Detentions were often issued for being tardy. The majority of students had to manage childcare in the morning and take public transportation to school, which increased the likelihood of arriving late. These issues regarding time and attendance would need to be addressed further if the sessions were to continue. Increasing the length of each session and number of overall sessions provided has the potential to yield increased confidence and self-efficacy.
A self-efficacy program is one way to involve adolescents in improving their self-esteem and building self-confidence. Pregnancy and parenting are challenges that adolescents may encounter as they transition to adulthood and this added burden carries the potential to negatively affect self-esteem and self-confidence. Finding ways to foster positive mental health in the school setting, especially in at-risk groups, such as pregnant and parenting adolescents, needs to be further addressed and promoted.
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Group Mean Pre- and Post-Test General Self-Efficacy Scale Scores Per Session
|Session (No. of Attendees)||Pre-Test Mean Score||Pre-Test (Per Item)||Post-Test Mean Score||Post-Test (Per Item)||p Value|