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Adolescence is a period of many critical transitions

Adolescence is a period of many critical transitions - physical, psychological, economic and social. Adolescents are full of energy, have significant drive and new ideas. They are a positive force for a nation and are responsible for its future productivity provided they develop in a healthy manner.

Many mental health problems emerge in late childhood and early adolescence. Enhancing social skills, problem solving skills and self confidence can help prevent mental health problems such as conduct disorders, anxiety, depression, and eating disorders as well as other risk behaviors. Health workers need to have the competencies to relate to young people, to detect mental health problems early, and to provide treatment which include counseling, cognitive behavioral therapy and where appropriate, psychotropic medication (WHO 2003)

Anxiety disorders are among the most common mental, emotional and behavioral problems to occur during childhood and adolescence. In a social setting, anxious teenagers may appear dependent, withdrawn or uneasy. They seem either overly restrained or overly emotional. They may be preoccupied with worries about losing control or unrealistic concerns about social competence.

Teenagers who suffer from excessive anxiety regularly experience a range of physical symptoms as well. They may complain about muscle tension and cramps, stomachaches, headaches, pain in the limbs & back, fatigue or discomfort associated with pubertal changes.

Anxiety during adolescence typically centers on changes in the way the adolescent’s body looks and feels, social acceptance, and conflicts about independence. When flooded with anxiety, adolescents may appear extremely shy. They may avoid engaging in new experiences. They may protest whenever they are apart from friends, or in an attempt to diminish or deny their fears and worries, they may engage in risky behaviors, drug experimentation, or impulsive sexual behavior.

The last few years have brought exciting break through in the areas of anxiety disorders in youth. Anxiety disorders in children and adolescents have been recognized as one of the most common areas of pediatric psychopathology. These advances are of great importance because anxiety disorders in children are associated with negative outcomes including peer relationship difficulties, academic failure and later onset of co morbid disorders including major depression and alcohol abuse.

The treatment advances have been dramatic! Studies document that individual cognitive behavioral therapy (CBT) and group CBT are efficacious in treating youth with separation anxiety disorder, social phobia, and / or generalized anxiety disorder.

Positive psychology is sometimes brought up when addressing adolescent psychology as well. This approach towards adolescents refers to providing them with motivation to become socially acceptable and notable individuals, since many adolescents find themselves bored, indecisive and / or unmotivated.

Dance therapy is a type of psychotherapy that uses movement to further the social, cognitive, emotional and physical development of the individual. Dance therapy is often an easy way for a person to express emotions, even when his/her experience is so traumatic he or she can’t talk about it (American Dance Therapy Association).

Body positions and gestures relate to emotional states. For example, when one is angry, automatically the muscular response is tension, and is relaxation when one is at ease and peaceful. The direct relationship between the mind and body therefore indicates that if there is a psychological change, there will be a movement change and also, that through movement change it will be possible to bring about a psychological change. Dance therapy provides the structure for developing body senses and brings out further individual responses related to emotion and memory. When this happens, in case a feeling has been blocked or disguised in the individual, it finds scope for release. Dance movement therapy uses the body and its movement as tools that work towards the awareness of the self (Ambika kaneswar, 1998)

Research is proving that dance therapy has a part to play in the treatment of psychological and mental health problems. Dance exercise lifts mood more than exercise by it self.

SIGNIFICANCE AND NEED FOR THE STUDY

The largest generation of adolescents in history, 1.2 million is preparing to enter adulthood in this rapidly changing world. Their educational and health status, their readiness to take on adult roles and responsibilities and the support they receive from their families, communities and government will determine their own future and the future of their countries.

Nearly half of all people are under the age of 25, the largest youth generation in history. The state of world population 2003 report examines the challenges and risks faced by this generation that has an impact directly on their physical, emotional and mental well being.

India is the second most populous country in the world with total population of over 1081 million. Adolescents (10-19 years) form a large section population about 22.5% that is about 225 million. They are living in diverse circumstances and have diverse health needs. The total population of young people (10-24 years) is approximately 331 million comprising nearly 30% of the total population of India (Census 2001).

Complementary actions are needed to promote healthy development in adolescents to prevent health problems or problem behaviors, and to respond to them if and when they arise. They need interventions to decrease and to mitigate their vulnerability. These include information and skills, a safe and supportive environment, and appropriate and accessible health and counseling services (India Development Gateway)

During adolescence, boys and girls face several challenges such as forming bonds with peers, differentiating themselves from their family members and establishing their adult identities (De Minzi, 2003).

Anxiety disorders are among the most common mental, emotional and behavioral problems to occur during childhood and adolescence. About 13 of every 100 children and adolescents aged 9-17 years experience some kind of anxiety disorders; girls are affected more than boys. One about half of children and adolescents with anxiety disorders have a second anxiety disorder or other mental or behavioral disorder, such as depression. In addition, anxiety disorders may exist with physical health conditions requiring treatment. (American Academy of Pediarics, 2003).

No one knows exactly how prevalent anxiety disorders are among adolescents. But as with depression, anxiety can be provoked by factors ranging from the modern stresses on families to the break up of the family unit. If a teenagers family has been split by divorce, or if there are serious economic pressure in the household, anxiety may be one way in which he will react. Some adolescent anxiety is associated with growing up, leaving home and separating from mother and father. The challenge of being independent is too much for some teenagers to bear, and they may panic at the mere thought of it (American Academy of Pediatrics, 2003).

Anxiety disorders vary from teenager to teenager. Symptoms generally include excessive fears and worries, feelings of inner restlessness, and a tendency to be excessively wary and vigilant. A worried teenager performs less well in school, sports and social interactions. Too much worry can also result in a teenager’s failing to achieve to his potential. A teen who experiences a great deal of anxiety may be overly conforming, perfectionistic, and unsure of himself. In attempting to gain approval or avoid disapproval, he may redo tasks or procrastinate. The anxious youngster often seeks excessive reassurance about his identity and whether he is good enough.

Some teenagers with anxiety disorders can also develop mood disorders or eating disorders. In some teenagers who experience persistent anxiety may also develop suicidal feelings or engage in self-destructive behaviors. Anxious teens may also use alcohol and drugs to self-medicate or self-soothe or develop rituals in an effort to reduce or prevent anxiety. These situations require immediate attention and treatment (Harper Collins 2008).

The term alternative medicine refers to the various disease treating or preventing practices whose methods and efficiency differ from traditional or conventional biochemical knowledge (K.Lalitha.2008). Alternative medicine covers a broad range of healing philosophies, approaches and therapies. It generally is defined as those treatments and health care practices not taught widely in medical schools, not generally used in hospitals and not usually reimbursed by medical insurance companies (Ruth.N.Grendel 2000).

Terms such as harmony and balance are often associated with complementary care. In fact, restoring harmony and balance between body and mind is often the goal of complementary health care approaches (Credit, Hartunian, & Nowak, 1998).

“The body and mind are inseparable” this is the theory of dance movement therapy. Through the unity of the body, mind and spirit, dance movement therapy provides a sense of wholeness to all individuals. Dance therapy can be helpful to a wide range of patients from psychiatric patients to those with cancer to lonely elderly people (American Dance Therapy Association).

Dance therapy is often an easy way for a person to express emotions, even when his or her experience is so traumatic. It can also help people with physical deficits improve their self-esteem and learn balance and coordination. Dance therapists also work with people who have chronic illnesses and life threatening diseases to help them deal with pain, fear of death, and changes in their body image. Many people with such illnesses find dance therapy classes to be a way to relax, get away from their pain and emotional difficulties for a while, and express feelings about taboo subjects such as impending death. Dance therapy is suitable even for people who are not accomplished dancers. The emphasis in dance therapy is on free movement, not restrictive steps, and expressing one’s true emotions to be free from worries. (American Dance Therapy Association).

Goodill.et.al (1999) conducted a pilot study among 21 University students showed that those who took a series of four to five groups dance therapy sessions in a period of two weeks significantly reduced their test anxiety as measured by a well known exam called the test anxiety inventory. Afterwards, the subjects reported that their dance movement experience was positive and provided them with psychological insight. The researchers concluded that dance therapy could be an available method of treatment for students who suffer from over whelming test anxiety, and should be researched further.

Leste and Rust (1990) investigated the effects of modern dance on anxiety. State anxiety was assessed before and after a 3 month education programme, using the Spielberger State – Test Anxiety Inventory. The target group followed a class in modern dance. Control group were (1) a physical education group to control for the effects of exercise, (2) a music group to control for aesthetic sensitivity training and (3) a mathematics group. Several concomitant variables were measured like age, sex, attitude towards dance and previous experience in sport, dance and relaxation. Dance training significantly reduced anxiety, but no control activities did so.

Robyn price(2005) did a pilot study to test the potential of a dance / movement therapy program as a treatment for anxiety. The program was developed by drawing from the approaches of Kierr (1995) and Bourne (2000) and incorporating elements from psychodynamic, developmental, self psychology and cognitive behavioral approaches. Ten self selected adults joined a community based dance movement therapy program for a ten week series of sessions. Assessment tools included a client interview, Zung SAS questionnaire, movement analysis using the Samuels and Chaiklin Movement Observation Scale, and client feed back form. Eight out of the ten clients experienced a reduction in anxiety. This study provides support for further investigation into the use of Dance Movement Therapy interventions to treat anxiety.

The Dance Movement Therapy will have the potential benefit of avoiding side effects of pharmacological medications. Because of all these advantages the researcher has introduced dance movement therapy as an effective non-pharmacological management in treatment of anxiety. So researcher wanted to find out the effectiveness of dance/movement therapy on anxiety among adolescent girls and has undertaken this study.

Statement of the Problem:

A quasiexperimental study to assess the prevalence of anxiety and to evaluate the effectiveness of Dance Movement Therapy (DMT) on anxiety among adolescent girls in selected schools of Madurai.

Objectives of the Study

To assess the prevalence of anxiety among adolescent girls in selected schools of Madurai.

To assess the pre test and post test level of anxiety among adolescent girls in the experimental group

To assess the pre test and pos test level of anxiety among adolescent girls in the control group.

To compare the pre test anxiety level with post test anxiety level among adolescent girls in experimental group.

To evaluate the effectiveness of dance movement therapy on anxiety among adolescent girls.

To associate the post test anxiety levels of adolescent girls in the experimental group with their selected demographic variables ( education of parents, occupation of parents, family income, religion, order of birth and number of siblings)

Hypothesis

All hypotheses will be tested at 0.05 level of significance.

The mean post test anxiety score of the adolescent girls will be significantly lesser than the mean pre test anxiety score in the experimental group

The mean post test anxiety score of the experimental group will be lesser than the mean post test anxiety score of control group.

There will be a significant association between the post test anxiety level of adolescent girls in the experimental group and their selected demographic variables.

Operational Definitions

Adolescent Girls:

It refers to girls who were in the age group of 13-17 years studying in selected schools of Madurai district.

Anxiety:

It is a natural and important emotion experienced by adolescent girls, signaling through sense of worry, apprehension, fear, shy, &distress which alarm that a danger or a sudden threatening change is near which is parallel to a score >25 in Screen for Child Anxiety Related Disorders (SCARD).

Dance Movement Therapy:

Dance movement therapy is an art therapy in which people can use every day movements as improvised dance and natural rhythms to communicate and make personal statements about their thoughts and feelings.

It refers to movements which will be implemented through individual and group sessions and progress through four phases like preparation, incubation, illumination & evaluation.

Effectiveness:

It is the outcome of the dance movement therapy which will be appraised and validated by a decrease in the anxiety level among adolescent girls.

Assumption:

Adolescent period is one of flux filled with anxiety, frustration, indecisiveness, identity crisis, looking out for support and struggle.

Many adolescents are affected by mental health problems

Body and mind interact, so that a change in movement will affect total functioning and is an easy way for a person to express emotions.

Adolescents like to dance.

Delimitations:

The study was delimited to the adolescent girls studying in selected schools of Madurai.

The data collection period was limited to six weeks.

Projected Outcome:

This study was proposed to evaluate the effectiveness of dance movement therapy in reduction of anxiety among adolescent girls. The findings of the study will elicit the level of anxiety among adolescents. The study report will help to arrange dance movement therapy sessions inorder to manage anxiety among adolescents.

CONCEPTUAL FRAME WORK

This study is based upon Wiedenbach’s helping art of clinical nursing theory. Widenbach first published her ideas in 1964 in clinical nursing. She further refined her theory in “nursing wisdom in nursing theory” published in 1970.

Widenbach views nursing as an art based on goal directed care. Factual and speculative knowledge, judgment, and skills are necessary for effective nursing practice.

Widenbach’s vision of nursing practice closely parallels assessment, implementation and evaluation steps of nursing process.

According to Widenbach, nursing practice consists of identifying a patient’s need for help, ministering the needed help and validating that the need for help was met.

The main concepts of this study are,

Identifying a need for help

Ministering needed help

Validating that need for help was met.

Identifying a Need for Help:

Here the individual is considered as a unique experience person. Person needs are determined and seen whether the person realizes the need and what prevents the person from meeting the need. In this study it refers to the assessment of anxiety level among adolescent girls before dance movement therapy.

Ministering the needed help:

It measures to meet the need of the individual who needs help. In this study it refers to ministering dance movement therapy to the adolescent girls with anxiety.

Validating that a need for help was met:

It is to evaluate and show that individual need have been met and his functional ability has been returned as a direct result of the nurse action. In this study it refers to post assessment of level of anxiety after dance movement therapy. There will be a reduction in the level of anxiety.

FIGURE – 1: CONCEPTUAL FRAMEWORK

Validating that a need for help was met

Ministering the needed help

Identifying a need for help

Assessment of level of

anxiety among the

adolescent girls in selected

schools.

Frightening

Fear

Lack of sleep

Worry

Nightmares

Scare

Shy

Afraid

Time: 45 minutes / session

Preparation phase (warm up)

Incubation phase (use of props)

Illumination phase (movements)

Evaluation phase (wrap up)

Week 2: Week 3:

(Individual session) (Group session)

Guided movements Mirroring

Week 4: Week 5:

(Individual Session) (Group session)

Spontaneous Creative imaging

movements

Assessment of level of anxiety among the adolescent girls.

Shows interest

Ability to experience pleasure

Feels worthy

Increased energy level

Relaxed

Experimental Group

Administration of dance movement therapy

Validation of dance movement therapy

Construction of dance movement therapy

Control Group

Ineffective response and no anxiety reduction on assessment

No Dance Movement Therapy

FEED BACK

CHAPTER III

RESEARCH METHODOLOGY:

The methodology of research indicates the general pattern of organizing the procedure for gathering valid and reliable data for investigation. This chapter provides a brief description of the method to be adopted by the investigator in this study. It includes the research approach, research design, setting, sample size, sampling technique, description of the tool, pilot study, data collection procedure and plan for data analysis.

Research Approach:

Two approaches were used in this study.

Phase I:

Descriptive survey was used to assess the level of anxiety among the adolescent girls in the selected schools at Madurai.

Phase II:

Experimental approach was used to determine the effectiveness of dance movement therapy in terms of reducing anxiety among adolescent girls in the selected schools at Madurai.

Research Design:

Non equivalent control group pre test post test design, a type of quasi experimental design was used in the study.

Group

Pre test

Intervention

Post test

Experimental Group (E)

Control group (C)

O1

O1

X

-

O2

O2

E - Experimental group

C - Control group

O1 - Pre test group

O2 - Post test group

X - Dance movement therapy

Variables:

Dependent variable – Anxiety

Independent variable – Dance movement therapy.

Setting of the Study:

The study was conducted in two Govt.girls higher secondary schools in and around Madurai.The two schools are namely Govt Girls Higher Secondary School, Mapalayam and Govt.Girls Higher Secondary School Sozhavandan. They are located at a distance of 8km & 15km respectively from Sacred Heart Nursing College

Strength of the School:

1. Government Girls Higher Secondary School Mapalayam

Total Strength - 550

From VIIIth std to Xth std

2. Government Girls Higher Secondary School, Sozhavandan

Total Strength - 500

From VIIIth std to Xth std

Infrastructure:

Govt Girls Higher secondary School, Mapalayam is located at the center of the city. Each standard has sections from A to C. This school has good physical facilities like play ground, drinking water supply and toilet facilities. Class rooms are well ventilated and are under close supervision of the teachers.

Government Girls Higher Secondary School, Sozhavandan is similar to that of Government Girls Higher Secondary School Mapalayam.

Population:

The population of the study was the adolescent girls in the age group of 13-17 years studying in selected schools of Madurai district.

Sample:

Samples were the adolescent girls in the age group of 13-17, who fit into the inclusion criteria.

Sample Size:

Sample size was 30 adolescent girls with anxiety in experimental group and 30 adolescent girls with anxiety in control group.

Sampling technique:

Purposive sampling was used for the selection of schools. Total enumerative sampling was used for the screening of adolescent girls with anxiety. Out of all students with anxiety simple random method (lottery technique) was used for selecting a sample size of 60.

Criteria for Sample Selection:

The sample were selected based on following criteria

Inclusion Criteria:

Adolescent girls studying in selected schools of Madurai district.

Adolescent girls in the age group of 13-17 years.

Adolescent girls who can read Tamil/English.

Adolescent girls who score >25 in the SCARED scale

Exclusion Criteria:

Those who were not willing to participate

Research tool and technique

Description of the Tool:

The research tool had two sections

Part I:

This part consisted of demographic variables such as name, age, education, family income, area of residency, education of parents, occupation of parents, order of birth and number of siblings.

Part II:

Screen for Child Anxiety Related Disorders (SCARD) was used to detect the anxiety among adolescent girls. It consisted of 41 statements. Each item had 3 options; not true, some what true and very true. Scoring for each response is as follows:

-Not true-0

-Some what true-1

-Very true-2

Interpretation of the Score:

A total score of >25 indicated the presence of an anxiety disorder.

A total score of<25 indicated the absence of anxiety disorder.

Testing of the Tool:

Validity:

Validity refers to the degree with which an instrument measures what it is supposed to be measuring. (Polit and Hungler 2001)

Since it is a standardized tool further standardization was not required. The tool was translated into Tamil and retranslated into English by language experts.

Reliability.

Screen for Child Anxiety Related Disorders had demonstrated a good internal consistency (alpha =.89) and split half reliability of .88.Stability of the scale was very good, with a test retest correlation of 0.85 over one week.

Intervention

Definition

Dance movement therapy is a type of psychotherapy that uses daily

movement to further the social, cognitive, emotional, and physical development of the individual.

Aims

Aims of dance movement therapy sessions would include;

Building up an awareness of one’s own movement potential

Improvisation of movements

Establish relationships

Willingness to take risks, problem solving capacity

Helps in expression of emotions

Make the person relax and free from anxiety.

Steps

Dance movement therapy will be implemented through 4 sessions which include 2 group sessions and 2 individual sessions. Each session will progress through 4 phases:

Preparation phase

Incubation phase

Illumination phase

Evaluation phase

Preparation phase (6minutes)

Every session will begin with breathing exercises. Students will be asked to take deep breath, hold it for a count of 1, 2, 3 and then exhale. This will be repeated for 10 times.

☻ This phase is designed to improve lymphatic drainage. Preparation will help an individual to adapt to the following phases.

Incubation phase (10minutes)

This phase will motivate the group to move with the help of props like ball, bands, and balloons. Students will be asked to use one prop for one day.

1st day-(balloon) - Each student will be given with a balloon and asked to bounce the balloon in the air. They will follow the balloon in all directions.

2nd day-(ball) - A ball will be given to the group of students and asked to play with that. Every one will actively concentrate on the ball.

3rd day-(stretching a band) - Students will be asked to hold the edges of a stretching band. Then they will be allowed to stretch it in any direction. As a group they will stretch it in different directions.

☻ These activities will remove the hesitation to move. This will motivate the students to take part in the next session of the therapy.

Illumination phase [(Dance movements)(25 minutes)]

This phase consists of different types of therapeutic movements. It consists of two group movements and two individual movements.

# Guided movements (Individual session):

In this the individuals in the group will be asked to follow the movements performed by the therapist. Simple dance movements will be used for this session. Movements will be simple and designed for adolescent girls with no dance experience. Initially simple movements will be teaching and repeated several times as a routine. As the girls learned a repertoire of familiar dance movements they will be able to follow the therapist’s lead in a more spontaneous flowing dance.

☻ This will improve their ability to follow instructions, concentration and co-ordination of body parts.

#Mirroring (Group session):

This is a group session which needs students pair up to perform it. During this, each student will be allowed to select their pair from the group. Then one student from each pair will follow the movements of the therapist and at the same time the other individual will give the mirror image of the movements. Then the students will exchange their positions. It repeated for the opposite pair also. The students were able to follow the movements easily.

☻ This will increase the awareness of nervous system regarding space, position and sides. This will also help to have a control over body movements.

#Spontaneous movements (Individual session):

This session will be given with the help of music. Mild instrumental music will be used for this session. This is an individual session in which each student will be asked to make spontaneous movements according to the music. They will be allowed to give any movements according to their wish.

☻ This will improve their creativity and increase the confidence in them. It will also help to increase their co-ordination skills.

#Creative imagery (Group session):

In this each individual will be asked to follow the movements performed by the therapist and then they have to add some movements on their own according to the music. They will be encouraged to make interesting stills according to the music.

☻ This will help to know about their own abilities and body movements. This improves their co-ordination, self confidence and self esteem.

Evaluation phase [(wrap up)(4 minutes)]

Each session will close with a gentle stretching and meditative movements. The students will be seated in a circle and ask to express their feelings and emotions.

Validity of the procedure

The intervention was validated by a psychiatrist, a dance movement therapist, an alternative therapy expert, and nursing experts.

Pre test

Week I

Pre test experimental group and control group

Dance movement therapy

Week II

Group

Phases

Therapy

Group 1

Group 2

Group 3

Preparation

Incubation

Illumination

Evaluation

Individual movements

Guided movements

Week III

Group 1

Group 2

Group 3

Preparation

Incubation

Illumination

Evaluation

Group movements

Mirroring

Week IV

Group 1

Group 2

Group 3

Preparation

Incubation

Illumination

Evaluation

Individual movements

Spontaneous movements

Week V

Group 1

Group 2

Group 3

Preparation

Incubation

Illumination

Evaluation

Group movements

Creative imaging

Post test

Week VI

Post test for experimental & control group

Figure: 2

Schematic representation of the data collection procedure

Pilot study:

In order to test the feasibility, relevance and practicability of the study, a pilot study was conducted among 6 adolescent girls with anxiety in a high school at Madurai.The study was conducted in a manner in which the final study would be done. It revealed that the study was feasible.

Data were analyzed to find out the suitability of the statistical method.

Data Collection Procedure:

The data collection was done for six weeks in 2 selected schools of Madurai district. Before conducting the study researcher obtained a formal permission from the District Educational Officer (DEO) and the head of the institutions. Purposive sampling was used for the selection of schools. Screen for Child Anxiety Related Disorders(SCARD) was used to assess the level of anxiety among adolescent girls. Total enumerative sampling was used for the screening of adolescent girls with anxiety. Out of all students with anxiety simple random method (lottery technique) was used for selecting a sample size of 60. Approximately 20 minutes was taken to complete the assessment on each individual. Samples in the experimental group were divided into 3 groups consisting of 10 samples in each group. There were 4 sessions (2 individual sessions and 2 group sessions) which included in dance movement therapy. Each session progressed through four phases. Nearly 45 minutes had been taken for the completion of each session. After 4 weeks of intervention post test was conducted. For both experimental group and control group post test had been done on the 6th week as like pre test

Plan for Data Analysis:

Data analysis was done according to the objectives of the study. Both descriptive and inferential statistics were used.

Descriptive Statistics:

Frequency, percentage and mean were used for the analysis of the pre test and post test.

Inferential Statistics:

Paired‘t’ test was used to determine the difference between pre test and post test score in experimental group.

Independent‘t’ test was used to determine the post test score difference between experimental group and control group.

Chi square was used to determine the association between selected demographic variables and post test scores in experimental group.

Protection of Human Rights:

The proposed study was conducted after the approval of dissertation committee of the college of Nursing. Permission was obtained from the Correspondent and the Principal of the Sacred Heart Nursing College. Formal permission obtained from the District Educational Officer (DEO)and the head of the institution. Oral consent of each subject was obtained before starting the data collection and assurance was given to them that the anonymity of each individual would be maintained.

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