Pediatric Annals

EDITORIAL 

A Pediatrician's View: Stress: Also a Pediatric Problem

Milton I Levine, MD

Abstract

It was George Bernard Shaw who, in his sardonic way, maintained that "Youth is a wonderful thing. What a crime to waste it on children." Most adults are apt to smile at this statement and might even agree with the sentiments expressed by the poet Elizabeth A. Allen "Backward, turn backward, O time in your flight." But many of us who are closely involved with the lives and development of the growing child are ready to argue that the Shavian theory is not completely realistic.

No one can argue with the fact that the lives of many adults are replete with frequent periods of stress and tension. We are involved in problems of family life, in our attempts to gain financial and domestic security, in local, national and international political and social problems and in later years with the physical problems often associated with aging. And of course, we worry about tomorrow.

The child lives in a different world - but a world with its own stresses and tension. He or she is affected and restricted by the need to adjust to adult mores and frequently has cause to suffer directly or indirectly from the tensions reflected by parents or other adults.

Then, too, there are many stressful situations in the lives of children that we have all observed. There are children suffering from the stress of sibling rivalry; there are the tensions of separation from parents, so frequently seen in younger children, and very evident in cases of school phobia; there is the stress of being exposed to family strife, and only too often to the devastating experience of divorce or a parent's death. Annually in the US there are over 1,200,000 divorces; and it is estimated that each year there are several million additional children affected by divorced or separated parents.

Add to these concerns the fear of kidnapping repeatedly impressed on young children by parents, news media, and others.

As the child grows, new stresses arise. During prepuberty and adolescence there is the pressure of peer acceptance. Furthermore, the older child becomes sensitive to international tension and the fear of nuclear warfare. On top of all of these are the stresses of poverty, and race and religious discrimination.

Have I given sufficient examples to emphasize that a child's life is for from a period of unbounded happiness - a period free of cares?

All of us realize just how deeply the presence of stress affects children. But how much is known of the physical effects? It is generally accepted that adults under stress can react somatically with such symptoms as diarrhea, headache, abdominal pain or asthma. What do we know of the reactions of children?

As Guest Editor on this subject we have turned to Dr. W. Thomas Boyce of the Department of Pediatrics at the Medical College of the University of Arizona, Tucson. Dr. Boyce has had a deep interest in this area for many years and has written on it and discussed it before meetings of the American Academy of Pediatrics.

He opens the symposium with an overview of the subject of stress and child health, presenting the recent research on stress, social support and child health. How much is really known on this subject and what is yet to be learned?

First, Dr. Boyce notes the heavy exposure of children to psychosocial stress and presents the results in the literature of five studies on the prevalence of behavioral, educational or social problems in over 70,000 children. He then goes on to discuss the facts suggesting that children under great stress are at greater risk…

It was George Bernard Shaw who, in his sardonic way, maintained that "Youth is a wonderful thing. What a crime to waste it on children." Most adults are apt to smile at this statement and might even agree with the sentiments expressed by the poet Elizabeth A. Allen "Backward, turn backward, O time in your flight." But many of us who are closely involved with the lives and development of the growing child are ready to argue that the Shavian theory is not completely realistic.

No one can argue with the fact that the lives of many adults are replete with frequent periods of stress and tension. We are involved in problems of family life, in our attempts to gain financial and domestic security, in local, national and international political and social problems and in later years with the physical problems often associated with aging. And of course, we worry about tomorrow.

The child lives in a different world - but a world with its own stresses and tension. He or she is affected and restricted by the need to adjust to adult mores and frequently has cause to suffer directly or indirectly from the tensions reflected by parents or other adults.

Then, too, there are many stressful situations in the lives of children that we have all observed. There are children suffering from the stress of sibling rivalry; there are the tensions of separation from parents, so frequently seen in younger children, and very evident in cases of school phobia; there is the stress of being exposed to family strife, and only too often to the devastating experience of divorce or a parent's death. Annually in the US there are over 1,200,000 divorces; and it is estimated that each year there are several million additional children affected by divorced or separated parents.

Add to these concerns the fear of kidnapping repeatedly impressed on young children by parents, news media, and others.

As the child grows, new stresses arise. During prepuberty and adolescence there is the pressure of peer acceptance. Furthermore, the older child becomes sensitive to international tension and the fear of nuclear warfare. On top of all of these are the stresses of poverty, and race and religious discrimination.

Have I given sufficient examples to emphasize that a child's life is for from a period of unbounded happiness - a period free of cares?

All of us realize just how deeply the presence of stress affects children. But how much is known of the physical effects? It is generally accepted that adults under stress can react somatically with such symptoms as diarrhea, headache, abdominal pain or asthma. What do we know of the reactions of children?

As Guest Editor on this subject we have turned to Dr. W. Thomas Boyce of the Department of Pediatrics at the Medical College of the University of Arizona, Tucson. Dr. Boyce has had a deep interest in this area for many years and has written on it and discussed it before meetings of the American Academy of Pediatrics.

He opens the symposium with an overview of the subject of stress and child health, presenting the recent research on stress, social support and child health. How much is really known on this subject and what is yet to be learned?

First, Dr. Boyce notes the heavy exposure of children to psychosocial stress and presents the results in the literature of five studies on the prevalence of behavioral, educational or social problems in over 70,000 children. He then goes on to discuss the facts suggesting that children under great stress are at greater risk for health problems. Also cited are interesting studies showing that young mothers with low social support have four times the neonatal complications than mothers with high social support. The difference is also noted in studies of maternal- infant attachment. In discussing the child's reaction to stress Dr. Boyce notes, as many of us have long recognized, that there are certain children who appear to be resilient and have a strong inner core. Why this occurs is not as yet known, although he suggests that the whole relationship between stress and illness may be on an immunological and neuroendocrine basis.

The second article entitled, "Stress, Coping and Children's Health" is written by Dr. Ann S. Masten of the Department of Psychology of the University of Minnesota, Minneapolis, Minnesota.

In this very interesting paper, Dr. Masten first defines stress as it may be expressed physiologically, subjectively in adverse feelings of distress, and behaviorally in performance or functionings. Coping is the "process involved in adapting to these effects or attempting to restore equilibrium." The author points out that there are certain children at risk, such as those born to parents with schizophrenia. Following this she discusses stressors and uses divorce for a careful study of the response of children. As in the previous paper by Dr. Boyce, she brings up problems of studying stress including the stressresistant child. She concludes by noting the importance of the pediatrician in reducing stress and promoting coping.

The third contribution to this symposium, "Social Support and Vulnerability to Stress - A Pediatric Perspective," is presented by Dr. Jack P. Shonkoff, Associate Professor of Pediatrics, and Co- Director of the Child Development Service of the University of Massachusetts Medical Center, Worcester, Massachusetts.

Dr. Shonkoff emphasizes the importance of the pediatrician in the social support of the child under severe stress. Such a child needs to feel that he or she is loved, cared for, and "esteemed." The child, or adult for that matter, who has limited access to supportive resources is considered vulnerable to the adverse effects of stressful life events. Dr. Shonkoff differentiates between the normative or expected stresses, such as sibling rivalry and starting school, and the unanticipated or crisis-oriented stressors, such as divorce, death of a family member, or sexual abuse. He emphasizes the effects of social support as an "immunization" against vulnerability and suggests that this support influences parental attitudes and behavior resulting in both direct and indirect effects on the child's development. He concludes that a pediatrician can be a critical source of social support for children and their families.

The fourth article, "Psychological Distress and Children's Use of Health Services" comes from the UCLA School of Medicine in Los Angeles and is authored by Dr. Mary Ann Lewis, Adjunct Associate Professor, Department of Medicine, School of Nursing, and Dr. Charles E. Lewis, Professor of Medicine.

They first emphasize the reported relationship between stressful events and the occurrence of disease. Then they define stress and make a differentiation between "stress" which involves physiological reactions to unpleasant or unexpected phenomena, and "psychological distress" where the primary effect is on emotional or mental health. The authors report on their interesting studies on children in school, where the most common stress symptom in those under 7 years was stomachache, while those over 7 years complained of headaches. The authors also found that the children themselves were the best source of information about things that concerned them. They report on their findings and suggest treatment and discuss the implications for the practicing pediatrician.

The final article deals with an important and basic problem, the "Biological Mechanism in the Relationship of Stress to Illness." It has been contributed by Dr. S. Michael Plaut, Associate Professor of Psychiatry and Pediatrics, University of Maryland, and Dr. Stanford B. Friedman, Professor of Pediatrics and Head of the Division of Behavioral Pediatrics, Department of Pediatrics, University of Maryland School of Medicine, Baltimore.

All of us are aware of the studies in psychosomatic medicine relative to ulcerative colitis, bronchial asthma, peptic ulcer and essential hypertension. But what is the biological mechanism responsible for these conditions as well as for the growing evidence that psychosocial conditions can alter a child's resistance to infection? The authors note that stress can cause alternatives in a great many hormones and neurotransmitters such as growth hormone, insulin, testosterone, epinephrine and norepinephrine. They add that in the last 10 years there has been increased attention to immune mechanisms of psychosocial influences on disease. Such studies have involved neutrophile phagocytosis, IgA, antibody titers, and lymphocyte cytotoxicity. The article concludes with guidelines for pediatricians. Among these are the statements that children who are frequently ill tend to have a variety of diseases and problems. In such cases diseases should not be thought of as either organic or psychosomatic; psychosocial factors can either increase or decrease a patient's resistance to disease; and the enhancement of a patient's ability to cope with relevant life events is more likely to be productive in the long run. This is a most interesting article which directs our understanding of an important area of psychosomatic pediatrics.

10.3928/0090-4481-19850801-04

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