Stress in children and adolescents

By

Dr Abang Bennett Taha

Specialist Psychiatrist (Child and Adolescent)

RIPAS Hospital, Bandar Seri Begawan

A Palestinian student looks out the window of a classroom. At school, factors that may cause stress include starting school, change of school, high expectations, bullying by peers or other schoolmates, and punishment by teachers. Pressure from studying is the most common cause of stress in children and adolescents. epa

In modern society stress is inevitable. Stress arises when an individual perceives that he cannot adequately cope with the demands being made of him or when his well-being is threatened.

The worst possible way to cope is to run away from it or avoid dealing with it. If an individual is constantly stressed, he will be in danger of developing long-term stress-related physical illness or more importantly it could trigger a mental breakdown.

This article will initially discuss stress in general and then specifically focus on stress in children and adolescents. We will then deal with approaches for both parents and teachers to help their children or students who are stressed.

Is stress bad?
The answer is both 'yes' and 'no.'

If we have no stress in our lives, we would probably be dead. With little or no stress, we would not be motivated to perform. As stress increases, our performance will also increase until it reaches an optimum level of functioning.

Further increase in stress after this optimum level will not, however, increase the performance but will plateau off until the stress level becomes distress.

At this point, further increase in stress level will cause the performance to decline. Stress is therefore both useful and bad depending on the intensity of the stress experienced.

What causes an individual to feel stress may not affect another. A lot depends on the personality, attitude and expectation of life. The challenge is for the individual to determine what level of stress he needs to function at his optimal level.

Can children and adolescents experience stress?
The adolescence period is the most stressful time in a young person's life. This is the time when children change or grow up into adults. They are going through puberty, meeting the changing expectations of others and coping with feelings that may be new to them. Children too cannot avoid stress. The sources of stress may be personal, from the home, and the school.

Personal sources
Personal sources include high hopes, unrealistic values, fear of failure and comparing himself to his siblings or other children.

Children and adolescents who have impaired intellectual ability, especially mild intellectual impairment, are vulnerable to experiencing stress when their disability is not recognised by their parents or teachers.

Home
At home, entry and exit events can be very stressful to both children and adolescents. The birth of a sibling is very stressful to a child or even an adolescent, which may lead to emotional or behavioral problems.

To a young child, the younger sibling is his rival. An adolescent may feel ashamed when his mother gives birth to a sibling.

Parental conflict, where there are lots of quarrel and violence at home, is the worst stressors that a child or adolescent can experience. Divorce by itself is harmless but becomes stressful when there is a fight for custody of the children or when the parent who has custody is neglecting the child.

A divorce may help young people recover from the 'trauma' of being caught in the dysfunctional family environment. An intact family with calm environment is the best environment for young people to nurture and this is what we should achieve.

Not being able to fulfil the demands of parents is another source of stress at home. Please remember that young people have their limits and each individual is different. Expecting all young people to respond to our demands in the same manner can lead to disaster.

School
At school, factors that may cause stress include starting school, change of school, high expectations, bullying by peers or other schoolmates, and punishment by teachers. Pressure from studying is the most common cause of stress in children and adolescents.

Teachers should be able to recognise the early signs of stress in young people. They and the school management should provide a suitable environment for young people to learn and nurture rather than expecting young people to 'digest' whatever has been taught, or at the other extreme, ignoring young people when they cannot learn as expected.

Young people with special needs can go into 'catastrophic reaction' if they are stressed in the mainstream environment. They should not be ignored but should instead be given the support throughout the time they are at school.

Young people with borderline problems (ie those who appear normal but just cannot learn as much as their peers) are the most stressed individuals in the school scene. They are usually labeled as lazy or their parents are considered to be paying no attention to their educational needs.

Reaction to stress in children and adolescents
This depends on the developmental stage of the child, ability to handle stress, duration and intensity of the stress and support that is given. In early childhood, they may feel unloved, becoming clingy and demonstrating a dependent behavior.

Children in the middle childhood stage may show fearfulness, defiant behaviour, complain of headaches and sleep problems or observed to have poor concentration at school.

Adolescents on the other hand will demonstrate it with anger, hysterical behavior, disappointment, low self esteem and loss of faith in adults. In extreme cases, adolescents may indulge in health risk behaviours such as deliberate self-harm, violence, substance use, risky sexual behaviour and unhealthy dietary behavior.

Before we discuss the approaches to handling stress, let us examine the following cases.

Case 1
Armah was actually the kind of daughter any parent would be proud of. She studied hard, was obedient and a devout Muslim. She had a few friends and spent all her free time looking after her younger siblings.

Her father had very high expectation of her, wanting her to excel in her 'O' Level examinations. Armah felt so pressured to do well in her examination that when the day arrived, her mind was a blank.

She had so wanted to make her parents proud. She was devastated when she failed the exam. Her father was angry, blaming her for not studying hard. She felt worthless and a disgrace to her family. Impulsively she took 20 Panadol tablets.

Case 2
Ali, a Primary I pupil, cries when he wakes up in the morning, complaining of stomach ache and refusing to go to school. This happens everyday, consecutively. The doctor who treated him could not find any physical causes for the problem.

Earlier, his mother had spent a lot of time forcing him to focus on his 'Spelling' subject as she was expecting him to score 100%.

He scored poorly and was admonished by his teacher. When he returned home, his mother also scolded him.

Case 3
A Form III girl was punished by her teacher in the presence of her classmates for not handing in her assignment according to the required format.

She had told her father to buy the materials from the shop earlier but he could not effort to buy them. The next day she was not her normal self and started to scream and going berserk when she was in the toilet.

The other students nearby attempted to calm her down but she was strong. One of the students who tried to help her also started to scream.

These three cases show the various types of reaction to stressful situation. All the situations depicted above happen in our real life and the experiences encountered by the children are perceived as stressful leading to maladaptive reactions.

Children and adolescents should enjoy studying rather than pressured to do so. Sometimes children have limit to their learning ability, therefore parents and teachers should have realistic expectations regarding their ability.

In case 3, it was the family's financial difficulties that caused the girl not adhering to the regulation.

In this situation simple financial help and the teacher's understanding of the girl's problems removed the maladaptive behaviour. We must always remember that social problems in our community are the reactions of young people to stressful situation that occur at home, at school or both.

How can we help stressful young people?
Keep talking to them: Everyone needs to be able to talk and listen to others. If it stops happening, problems and misunderstanding creep in. Keep the communication lines open.

Listen to them: Being able to listen is a key aspect of good communication.

Good listening means:
- showing you are attentive
- trying to understand what they are saying to you
- taking time to find out about their views and feelings without arguing with them
- not insisting on our views being heard all the time; listen to their views as well.

Put ourselves in their shoes

It will help if we can show that we do understand what it's like for them. It means showing them that we are sensitive to their problem. We have to try to look at the world through their eyes.

Be there and be available
It is important that young people know the door is always open for them to talk to us. They want to feel we are always interested in them. Sometimes, unfortunately, we are physically, but not emotionally present.

Be firm but consistent
Make sure our views and feelings are known and that we want them to respect our views. Be consistent as well. Do not keep changing your mind or making threats that you won't carry out. We must differentiate firmness from anger.

Remember young people are unique
Children have strengths and they all need to feel valued and good about themselves. When they feel they can achieve something, and that we recognise what they have done, it helps to build their self esteem.

What to do when the above approach is not helpful?
When the above approach is not helping young people or when the stress led to serious psychiatric complications it is important that the child or adolescent is referred to the mental health professionals.

Who are the mental health professionals who can help them? A child and adolescent psychiatrist or a clinical psychologist may be able to help.

A child and adolescent psychiatrist is a medical doctor who has further training in the diagnosis and treatment of mental health problems in young people.

They use both medicine and psychological techniques in helping these young people.

Clinical psychologist is not a medical doctor but they learn about both normal and abnormal human behavior. In addition they have further clinical training in the treatment of people with mental health problems using psychological techniques.

Sometimes we use antidepressant if young people become depress. For the very young psychological methods are best.

These include parents' management training, behavior modification, cognitive behavior therapy and workshop for teachers.

Source: Weekend, 18 April 2009