Stressors and Coping Strategies of Institutionalized Adolescents at Minia Governorate

Introduction

Adolescence is defined as the period in development that begins with 12 years of age, terminating with 17 years of age (1). There is no definite age when it begins and no definite age when it ends, but it is often thought to begin around the age of 10 years and end between the ages of 20 and 24 years. The age range of adolescence can vary with cultural and historical circumstances (2). During this period, the individual undergoes extensive physical, psychological, emotional and personality changes (3).

The terms ‘institution’ and ‘institutional care’ refer to sort of residential care without a parent or guardian for longer than three months providing care for large numbers of children in a building often referred to as a ‘children’s home’ (4). Orphanage has been described as a form of institution (5-6). Children  and adolescents are  institutionalized  with  a  major  reason  that  the  parent  or  the  family  is  not  equipped  to  provide enough  care  and  support  for  wide  range  of  situations include death  of  one  parent,  presence  of domestic  violence,  substance  abuse  by  one  or  both  parent,  separated  parent,  physical  or mental illness of parent, illegal relationship, and extra marital relationship (7). Despite the evidence favoring the aspects of institutional care as a controlled and structured environment, images of negative experiences of total institutions leaves a little room for perceiving institutional care in a positive way (8).

Institutionalized adolescents experience numerous traumatic stressors and damaging events. They may be particularly vulnerable to stressful events prior to institutionalization such as removal from the home, separation from familiar social circles, and constant transitions to different homes and schools (9-10). While living in institutions, the adolescents are often deprived of basic care and support and are exposed to unhealthy living conditions and harsh disciplining practices (11). Stressful experiences within the institutional care system affect adolescents’ engagement in school activities, their sibling ties, and their relationships with family members and caregivers which in turn result in avoidance of others due to fear of rejection (12-13-14). The way these difficulties show themselves will vary with respect to the intensity of the experiences and the circumstances that follow the events. The outcome will depend on children’s psychological coping (15). 

Coping strategies refer to the efforts made to “master, reduce or tolerate the demands created by stress” (16). Institutionalized adolescents utilize different coping strategies than their counterparts who are residing with their biological families and are at higher risk of forming maladaptive coping methods that are unique to the stressors experienced. They engage in more self-protection coping methods to handle the stress related to feelings of low self-esteem resulted from an undesirable institutional care placement (17).

Nurses' role should include an assessment of each adolescent’s stressors and coping strategies in providing care to the institutionalized adolescents. Mental health nurse should make time every day to talk with the institutionalized adolescents and do activities together. It is important to look at the different factors of stress to help adolescents identify their stressors, learn to communicate with adults and peers, and gain awareness that they are not alone in their struggles (18-19).

Based on the assessment, nurses can work with the institutionalized adolescents to reinforce the use of existing effective coping strategies and develop some new coping strategies that may lead to positive outcomes. Another important role for the mental health nurse is to teach them appropriate stress management strategies to cope with different stressors such as reading, exercise, sports, games, music therapy, and other relaxation techniques to increase their sense of control and allay stress (20). By doing this, nurses are able to assist the institutionalized adolescents deal more effectively with stressors.

Significance of the study

Institutionalized adolescents have received minimal attention from researchers. Despite of the rapidly growing burden of institutionalized adolescents, stressors and coping strategies of these adolescents in institutions are not well researched. International statistics suggest that the number of institutionalized adolescents is increasing throughout the world. According to an official census issued by the Central Agency for Public Mobilization and Statistics, Egypt has 473 foster care institutions, accommodating about 10,000 children until the age of 18, compared with 9,000 others living in other alternative organizations, while the total number of Egyptian children 18 years old accounted for one third of the total population (21-22). Institutionalized adolescents constitute one of the most underserved and vulnerable groups that face a variety of stressors and problems. Entering the institutional system itself presents a significant psychological stresses; which in return play a detrimental role in their development and in the establishment of interpersonal relationships and skills necessary for adult life. In addition, institutionalized adolescents exhibit more psychiatric disorders and more difficulty in life demands when compared with adolescents who reside with their families. They are a (2-5) time higher rate of referral for clinical mental health services. Institutionalized adolescents must cope with the effects of traumatic events precipitating their entry into institutional care, face a temporary or permanent loss of their parents, and adjust to new people and living situations in the institutions. They revert to different coping strategies, harmful as well as constructive. Stress reduction and adopting a healthier lifestyle have been major concerns of the adolescents.

At Minia governorate, no research studies were conducted in this respect, so an in depth research is needed to clarify the magnitude of the problem as to emphasize whether these stressors are mostly related to institutionalization and how the institutionalized adolescents cope with these stressors. This research will detect the stressors and coping strategies of institutionalized adolescents, the matter which provide knowledge base for mental health nurses to promote coping with these stressors in the future, also providing empirical knowledge in this area of research which may be used after that in other future researches related to institutionalized adolescents. 

Aim of the study

The aim of the present study was to investigate the stressors and coping strategies among institutionalized adolescents.

Research Questions

Q1: What are the stressors experienced by the institutionalized adolescents?

Q2: What are the coping strategies used by the institutionalized adolescents?

Q3: Is there a relationship between stressors and coping strategies among institutionalized adolescents?

Subjects and Methods

Research Design:

A descriptive correlational research design was used in the current study.

Setting:

The current study was carried out in nine foster care institutions at Minia governorate distributed in four cities. They are divided into governmental and non-governmental institutions. These cities are: Minia city includes three foster care institutions (Minia Institution for Muslim Boys, Minia Institution for Muslim Girls, and Institution of Genoud Al Masieh for Christian Boys) & Abo Korkas city includes one foster care institution (Institution of Al-Nahda Al-Rohiea for Christian Boys) &  Malawy city includes four foster care institutions (Institution of Al-Rahma for Muslim Girls, Institution of Al Ber & Al-Ehsan for Muslim Boys, Institution of Al-Salam Al Kebtiea for Christian Boys, and Institution of Marri Mourkas for Christian Girls) & Samalout city includes one foster care institution (Institution of Al-Nashat Al-Rohie for Christian Boys).

Subjects:

A convenience sample consists of (80) institutionalized adolescents at Minia foster care institutions were included in the study. The sample included in the study was the institutionalized adolescents at Minia foster care institutions with a number of (35) for females and (45) for male adolescents. The age of adolescents ranged from 12 to 20 years old.

Inclusion criteria:

• The sample included those adolescents who are institutionalized as a result of:
• Inadequate parental socio-economic status resulting from poverty.
• Parental loss, either through death or abandonment.
• Family conflict, such as that which results in divorce.
• Parental problems that might have genetic or behavioral implications for the child, such as parental mental illness, parental incarceration, drug or alcohol abuse.
• The loss of parental right to children.
• Wide range of situations as illegal relationship, extra marital relationship, and broken family.
• The experience of violence or abuse.
• Both genders (male and female).
• Adolescents aged between (12-20) years old.

Exclusion criteria:

• Adolescents who subject to a criminal justice.
• Adolescents who displayed anti-social behavior.
• Adolescents who are suffering from terminal diseases, mentally/ physically challenged and with no support.

Tools of data collection:

Three tools were used to collect data pertinent for this current study. These tools are:

 1:Demographic characteristics of the institutionalized adolescents sheet: This tool was developed and constructed by the researcher and it was used to assess the following:( age, gender, educational level, residence, reasons for entry to foster care institutions, duration of stay in it and number of relatives visits.

2: The Adolescent Stress Questionnaire (ASQ); It was developed by (23) and used to measure common stressors that adolescents may experience in their lives. The tool was translated into Arabic language by the researcher and back translation was done and then tested for content validity and reviewed for its clarity by a panel of   five experts in the field of psychiatry and psychiatric nursing and their modifications were done accordingly. The ASQ is consisted of 56 items covering broad range of perceived adolescent stresses. The items were attributed to 10 components or dimensions of adolescent stressor experiences (stress of home life, school performance, school attendance, romantic relationships, peer pressure, teacher interaction, future uncertainty, school/leisure conflict, financial pressure and emerging adult responsibility). Each stressor item was rated on a five-point Likert scale where the respondents were self-reported individual stressor appraisal as: 1 = not at all stressful or is irrelevant to me & 2 = a little stressful & 3 = moderately stressful & 4 = quite stressful & and 5 = very stressful. The total scores for The Adolescent Stress Questionnaire ranged from 56 to 280. High scores indicated that institutionalized adolescent's stressor was very stressful. Scoring system was calculated as following:

• Score less than or equal 56 = not at all stressful.
• Score ranged from 57 to 112 = a little stressful.
• Score ranged from 113 to 168 = moderate stressful.
• Score ranged from 169 to 224 = quite stressful.
• Score more than 224 = very stressful.

3: The Coping Strategies Inventory (CSI); It is adapted from (24) (Ways of Coping Questionnaire) to assess the adolescent's coping thoughts and behaviors in response to a specific stressor. The tool was translated into Arabic language by the researcher and back translation was done and then tested for content validity and reviewed for its clarity by a panel of   five experts in the field of psychiatry and psychiatric nursing and their modifications were done accordingly. The CSI consisted of 72 items under four domains (8) subscales consist of specific coping strategies that adolescents use in response to stressful events. These include problem solving, cognitive restructuring, social support, express emotions, problem avoidance, wishful thinking, self-criticism, and social withdrawal. There are (9) items in each subscale as:

Each item was rated on a five-point Likert scale where the respondents determine the extent to which they use these coping strategies as 1 = not at all & 2 = a little & 3 = somewhat & 4 = much & and 5 = very much. Total scores ranged from 72 to 360.  High scores indicated that institutionalized adolescents used the coping strategies very much. Scoring system was calculated as following:

• Score less than or equal 72 = not at all.
• Score ranged from 73- to 144 = a little.
• Score ranged from 145 to 216 = somewhat.
• Score ranged from 217 to 288 = much.
• Score more than 288 = very much.

Validity of tools

Tools content validity was done to identify the degree to which the used tools measure what was supposed to be measured. The translated tools were examined by a panel of five experts in the field of the study (Minia University, Assiut University, and Cairo University - Faculty of Nursing, Psychiatric Mental Health Nursing Department). All Jury member (100%) agree that current study translated tools were valid and relevant with the aim of the study.

Pilot study

A pilot study was carried out on 8 adolescents (10%) of the total sample to test feasibility, objectivity, and applicability of the tools. Results of the pilot study illustrated that no any refinements and modifications were needed so the subjects were included to the actual sample.

Reliability of tools

Internal consistency was measured to identify the extent to which the items of tools measure the same concept and the extent to which the items are correlated with each other. Internal consistency estimated reliability by Cronbach's alpha for reliability testing performed for adolescent stress questionnaire and coping strategies inventory were .90 and .85 respectively.

Ethical Consideration

First, primary approval was obtained from the ethics and research committee of the Faculty of Nursing, Minia University. Then, an official permission was obtained from the concerned authority (director of foster care center). The ethical rules of research are guaranteed for each participant in order not to refrain. The adolescent was assured that the data are confidential and used only for research purposes. The researcher arranged time with each director of the foster center to   meet adolescent on planned time.  Researcher made full description of the study aim and procedures, written informed consents were introduced by the adolescent who agreed to participate. Anonymity, confidentiality and privacy were assured. Researcher assured adolescents that no harm will affect them if they express their opinion regarding stressors.  Each tool for data collection coded and subjects' names didn't appear on the sheets for the purpose of anonymity and confidentiality. Subjects were free to withdraw from the study at any time.

Procedure

An official permission was sent from the dean of the Faculty of Nursing, Minia University, to the Undersecretary of the Ministry of Social Solidarity in order to carry out the study. The investigator conducted visits to the foster care institutions in four cities in Minia Governorate to explain the aim of the study to the institutionalized adolescents to gain their cooperation and consent to share in the study. After oral explanation, an oral consent was obtained from every subject who accepted to participate in the study. The total data were collected over a period of nine months starting from January 2016 to September 2016. The tools were filled by the investigator through an interview with the institutionalized adolescents at each foster care institution two day/week from 9 Am: 2 Pm.   The time spent to fill the tools ranged between 20 to 30 minutes according to the needed explanation. Some participants were visited twice to complete the data needed for the study. Voluntary participation, confidentiality and anonymity were assured.

Limitation of the study      

Several limitations were identified in the study. Institutional environment is not ideal for interviews because of noise and frequent interruptions. When the meeting room was occupied, the investigator interviewed the children at places such as a corner outside of the institution or other place in the institution. These places were not ideal for interviews.

Also, in gathering data for this study, the major challenge faced was obtaining permission from foster care authorities due to security and other reasons. They asked many questions and requested many formal consents and this was time consuming. In addition, in this study, the experiences of stressful events were measured by interviewing the institutionalized adolescents and thus capturing their viewpoints. Stressors and coping strategies of the studied subjects couldn’t be observed directly as they were occurred at different too late or early times, therefore these items were asked to the studied subjects and their reports were recorded.

Statistical analysis of data

Data were scored, tabulated, and analyzed by computer using “the statistical package for social science” (SPSS) version (20). Descriptive data were expressed as number and percentage. Quantitative data were presented by mean and standard deviation. Correlation was calculated between stressors and coping strategies using Pearson correlation test.  Probability (p-value) less than 0.05 was considered significant in tests of relationships.

Results

Table (1) Demographic characteristics of the institutionalized adolescents (n= 80).

Table (1) describes the demographic data of institutionalized adolescents namely gender, age, level of education and place of residence. More than half of the institutionalized adolescents (n=45, 56.2%) were males. As regards to age group, the same table indicates that, more than two thirds of the institutionalized adolescents (n=58, 72.5%) were in the age group 17 – 21 years. Concerning institutionalized adolescents' level of education, table (1) shows that, about two thirds of institutionalized adolescents (n=52, 65.1%) were in primary and preparatory school. Regarding place of residence table (1) indicates that, more than two thirds of the institutionalized adolescents (n=54, 67.5%) were from urban areas.

Table (2): Data about living in care institutions (n= 80).

Table (2):  presents the data about institutionalized adolescents' living in foster care institutions, there were over half of adolescents (n=41, 51.2%) were institutionalized due to orphanhood, sixteen adolescents (20 %) were institutionalized due to poverty, fourteen adolescents (17.5 %) were institutionalized due to broken family, and nine adolescents (11.3 %) were institutionalized due to illegitimacy. In relation to number of relative visits, the same table indicates that, more than half of institutionalized adolescents (n=47, 58.2%) receive two visits a week.  Concerning the period of stay in care institution, table (2) indicates that, more than half of institutionalized adolescents (n=41, 51.3%) stay in care institution for (7-12) years.

Table (3) Institutionalized adolescents' stressors (n= 80).

Table (3) presents institutionalized adolescents' stressors. It shows that future uncertainty, school performance, emerge adult responsibility, school leisure conflict, were considered very stressful for institutionalized adolescents with percent (89, 88, 84, 83 %) respectively). Financial pressure, teacher interaction stressors, and peer pressure were considered quite stressful for institutionalized adolescents with percent (79, 71, 69 %). More than half of institutionalized adolescents (58 %) reported stressors related to school attendance stressors. Romantic relations were considered a little stressful (40 %).

Table (4) Institutionalized adolescents' coping strategies (n= 80).

Table (4) presents institutionalized adolescents' coping strategies. It shows that that the most common coping strategies used by the institutionalized adolescents were problem solving, cognitive restructuring, express emotion, wishful thinking, social support with percent (88, 86, 78, 75, and 73 %) respectively) which indicate high coping. More than half of institutionalized adolescents reported using self-criticism and social withdrawal strategies with percent (58, and 53 % respectively). Only (29 %) of them reported using problem avoidance which indicate low coping.

Table (5) Difference between adolescent's stressors and gender (n= 80).

S= not statistical significant difference * Statistical significant difference at p < 0.05

Table (5) showed the differences between adolescent's stressors and gender and revealed that, there was a statistically significant difference between the total of adolescent's stressors and gender. Male adolescents reported significant higher mean scores on stressors related to teacher interaction, school leisure conflicts, and financial pressure than female adolescents.

Table (6) Difference between adolescent's stressors and place of residence before institutionalization (n= 80).

NS= not statistical significant difference * Statistical significant difference at p < 0.05

Table (6) illustrated the differences between adolescent's stressors and type of residence and showed that, institutionalized urban adolescents were significantly higher as regard romantic relation stressors, peer pressure, teacher interaction stressors, financial pressure and totally stressors than rural adolescent with mean score of (11.8 ± 9.3 vs. 5.8 ± 5.3); (20.1 ± 7.2 vs 15.8 ± 5.9); (20.9 ± 7.8 vs 16.9 ± 4.8); (14.3 ± 4.4 vs 9.5 ±3.4) and (155.6 ± 38.6 vs 135.6 ± 27.4) respectively. While rural adolescents were significantly higher as regard school attendance stressors than urban adolescents with mean score of (9.8 ± 3.9 vs. 7.5 ± 4.4) with statistically significant differences.

Table (7) Difference between adolescent's coping and gender (n= 80)

NS= not statistical significant difference * Statistical significant difference at p < 0.05

Table (7) demonstrated differences between adolescent's coping and gender and showed that, there were statistically significant differences between institutionalized adolescents' gender and coping strategies. Male adolescents were higher as regard problem solving, cognitive restructuring and total coping scale than female adolescents with mean scores of (38.2 ± 5.5 vs. 31.9 ± 5.7), (34.3 ± 5.5 vs. 30.7 ± 3.6), and (248.3 ± 28.9 vs. 236.1 ± 27.5) respectively.

Table (8): Difference between adolescent's coping and type of residence before institutionalization (n= 80)

NS= not statistical significant difference * Statistical significant difference at p < 0.05

Table (8) described the differences between adolescent's coping and type of residence and showed that there were statistically significant residence differences as regards to coping strategies of the institutionalized adolescents. The institutionalized urban adolescents had higher mean scores as regard problem solving, cognitive restructuring, problem avoidance, wishful thinking, self-criticism, social withdrawal and totally coping than rural adolescents.

Table (9) Correlation between institutionalized adolescent's stressors and coping strategies (n= 80).

** Correlation IS significant at the 0.01 level (2-tmled). *Correlation is significant at the 0.05 level (2-tailed).

Table (10) Table (31) demonstrated the correlation between coping strategies and stressors of the institutionalized adolescents.  It indicated that, there were statistically significant positive correlations between problem solving strategy and stressors of (future uncertain, financial pressure, emerge in adult, and total adolescent stressors). As regard cognitive restructuring strategy, there were statistical significant positive correlations with stressors of (school performance, school attendance, teacher interaction, and financial pressure). Concerning to express emotions strategy, there were statistical significant positive correlations with stressors of (financial pressure and emerge in adult responsibility). Also, the same table showed that, there was statistical significant positive correlation between social support strategy and school attendance stressors.

The same table illustrated that there was statistically significant positive correlation between problem avoidance coping strategy and school performance stressor. As regard wishful thinking, there were statistical significant positive correlations with stressors of (peer pressure, teacher interaction, financial pressure, and total adolescent stressors). With respect to self-criticisms coping, there were statistical significant positive correlations with stressors of (school attendance, romantic relation, teacher interaction, and financial pressure). The same table demonstrated that, there were statistical significant correlations between social withdrawal coping and stressors of (school stressor and future uncertainty).