Stress and psychopathology in children and adolescents

Stress is defined as the non specific response of the body to a demand and psychopathology is the study of abnormal experience, cognition and behaviour.

Types of stress

Life events e.g. a child going to school for the first time.

Chronic stress e.g. daily fights between a child’s parents at home.

Daily hassles of life e.g. transportation difficulty, bandhs.

Developmental stress e.g. transition from childhood to adolescence.

Accidental stress e.g. unexpected injury resulting in fracture of hand.

Eustress: Pleasant events e.g. child standing first in class.

Dystress: Unpleasant events e.g. a child failing to pass an exam.

Some causes of stress in child and adolescent population

There may be different causes for stress in this group like: Loss of a parent early in life, divorce of parents, physical abuse of child, sexual abuse of child, severe physical illness, disasters e.g. tsunami/earthquake, examination stress in an increasingly competitive environment, high performance expectations by parents/peers, poverty , hunger and deprivation, exposure to violence e.g. war.

Factors which may mediate effect or be protective against stress in children and adolescents

Level of exposure to stress: More severe stress is likely to lead to more symptoms.

Age: Preschool children may display withdrawal, school age children may show aggression.

Family support: A child with a supportive family is likely to cope better with stress than a child without one.

Friends: Children with a good peer group may adjust better to stress.

Others: A caring school, a well knit social community, and timely help from teachers or professionals may be helpful in reducing effects of stress.

Common stress related clinical conditions in children and adolescents

Depression may result from prolonged stress: The subject may show low mood, irritability and aggression, school refusal, poor academic performance, poor appetite, disturbed sleep (less sleep or more sleep), physical complaints (e.g. headache, body pain), lethargy and tiredness.

Separation anxiety disorder: Child may show persistent refusal to attend school, may have physical complaints, fear he/she will get lost, or parent may be harmed.

Acute stress reaction/posttraumatic stress disorder: After exposure to a trauma, child may show intense fear/helplessness/horror. Child may also have avoidance of reminders of trauma, poor academic performance, have “flashbacks” of the traumatic event, get poor sleep, irritable mood, poor concentration and increased “startle” response.

Substance use disorders: Commonly used by adolescents with high family stress are inhalants (e.g. dendrite), tobacco, cannabis (bhang/ganja), sedatives (valium), cough syrups (e.g. corex), brown sugar and also alcohol. There may be repeated/daily use leading to difficulty in studies, irregular school attendance, legal problems (accidents/arrest by police), physical illness (e.g. infection due to needle use), lying, stealing/borrowing money, aggressive behaviour.

Conduct disorder: May involve aggression to people, property or animals; theft, violation of rules, truancy from school, running away from home, telling lies, encounters with police, getting arrested/jailed.

High risk behaviour: Like driving motorcycle/car at dangerously high speed, risky sexual behaviour may be associated with underlying stress and substance use, even suicidal thinking at times. Self-harming behaviour may be present in children and adolescents with high levels of stress.

Age wise distribution of stress and trauma related symptoms

Three to eight years: Helplessness, generalised fear, difficulty identifying feelings, sleep problems, separation anxiety, anxiety about death.

Nine to 12 years: Feelings of guilt, strong emotions, difficulty in concentrating, sleep difficulty, concerns for safety, physical complaints, behavioural changes.

Twelve to 18 years: Detachment, shame and guilt feelings, sudden change in relationships, desire for revenge, intense anger, change in attitude towards life.

The red flags of stress in children and adolescents

Sleep problems, enuresis (inappropriate passing of urine), encopresis (inappropriate passing of stool), physical complaints, new fears, aggression and oppositionality, school difficulties, problems with peers, depressed or irritable mood, anxiety or restlessness, poor concentration, disturbed appetite.

Risk for self-harm in adolescents: what teachers need to know

A: Availability of arms/other methods (e.g. poison)

D: Discord in family

O: Organised plan/intention

L: Lack of social support

E: Earlier suicidal attempt/attempts

S: Substance dependence/abuse

C: Cognitive distortions (hopelessness)

E: Exposure to others’ suicidality

N: Not agreeing to a ‘no suicide’ contract

T: Temper/aggression

Risk factors for potential aggression/violence in school going children

Regular use of abusive language, use of violent threats regularly, bringing weapons to school, history of substance use, past record of disciplinary problems in school/community, displays cruelty to animals, has been bullied at school/abused at home, prefers TV shows/books/games with violent themes, involved in gang/antisocial behavior, has threatened/attempted suicide.

Role of school teachers in identifying stress in students

Observant teachers may be able to recognise signs of stress or stress related psychiatric problems earlier in school children than family/friends may be able to. Appropriate communication with the student/parents may help to solve some of the issues. Prompt referral to a mental health professional can help to identify and treat those conditions where delay may cause significant suffering (and occasionally mortality).