The study of stress and coping in children encompasses a remarkable variety of subjects, including the stressfulness of the pediatric hospital environment, separation anxiety in infancy, the impact of divorce on millions of American children, the role of stressful life events in episodes of chronic illness, and the nature of stress-resistant children. The common denominator of this diverse array is a concern with the process of adaptation under relatively difficult conditions, particularly as it relates to development. The overarching goal is to improve our efforts at intervention, to prevent or ameliorate the adverse consequences of stress on the health and well-being of children.
Although the concept of stress continues to be tangled in controversy, the prevailing view is an interactional one in which stress refers to an imbalance between environmental demands and a person's coping resources that at some level disrupts the equilibrium of the person. 1^ The disequilibrium may be observed or perceived in different systems: 1) physiologically, as in the General Adaptation Syndrome described by Selye;4 2) subjectively, in adverse feelings of distress; and 3) behaviorally, in disturbed interpersonal functioning or performance. Stressors are events that usually (in most people) induce stress, significantly interfering with normal functioning in one or more systems. Coping refers to the process involved in adapting to these effects or attempting to restore equilibrium.
Adaptation is a developmental process, and in children the role of development is paramount in the struggle to reach a better understanding of stress and coping. A developmental perspective calls attention to the role of age and sex and cognitive or socioemotional maturity in the perception of stress by the child, as well as in the child's coping resources. A visit to the doctor's office elicits far different reactions in the 2month-old, the 10-month-old and the 8-year-old. Similarly, the stressfulness of separations required by hospital care differs for children at different stages in development. Separation is more stressful for children in the period of greatest separation anxiety, approximately 6 months to 4 years.5
There are currently three major approaches to the study of stress and coping in children:
1) studies of children "at-risk" due to a variety of individual or environmental factors associated with risk to healthy development, such as prematurity, socioeconomic disadvantage, or having a parent with a major mental disorder;
2) studies focusing on one specific stressor such as illness, trauma or divorce; and
3) studies linking composites of stressful life events to outcomes such as physical illness or maladjustment.
CHILDREN AT RISK: THE EXAMPLE OF PREMATURITY
Risk, an epidemiological concept, refers to a higher probability for negative outcome. For example, children with a parent who has schizophrenia are at risk because the probability of them developing this severe mental disorder in their lifetime is 8 or 10 times higher than it is for the general population.
There is a large literature on infants at risk due to perinatal complications.6 This literature illustrates the importance of both medical risk factors and environmental stress-related factors in predicting long-term consequences of perinatal complications. For example, risks associated with socioeconomic disadvantage often may outweigh the risks associated with prematurity itself; the co-occurrence of these factors significantly heightens overall risk for the infant.
The study of prematurity also highlights the role of stress in the adaptation of the infant. Along with the extraordinary advances in medical technology, there has been great attention to the psychosocial care of the infant and family. Prematurity creates a plethora of stressful events for infant, parents, and medical personnel. Interventions have been generated to reduce the stressfulness of the environment and to enhance the quality of interactions between infant and parents.7 Undoubtedly, these efforts will be improved as more is known about the relations among risk and protective factors, stress and coping in these infants and their families. Recent studies have focused particularly on the transactional relationship between the high-risk infant and caregivers.8 More research is needed to identify potential modifiers of biological risk, particularly protective factors that can be mobilized on behalf of a child at risk.9
STRESSORS: THE EXAMPLE OF DIVORCE
Another approach focuses intensively on a single stressor. A wide variety of specific stressors are under investigation, including divorce, bereavement, birth of a sibling, kidnapping, acute or chronic illness, and abuse. 10
Divorce, one of the major stressors of our time, illustrates several important points about stress and coping in children.3,11 First, a stressful event rarely occurs in isolation. Divorce is not a single event but a series of related events embedded in the ongoing lives of a group of people. It often occurs in the context of extreme family conflict and economic crisis. It can precipitate recurrent financial problems and separations, custodial conflicts, changes of school, home and daily routine. Above all, divorce can be so devastating to the parents that the children temporarily lose the most important protective factor in their lives, a healthy, well-functioning caregiver.
Second, characteristics of the stressor and the people involved can vary tremendously, complicating the search for answers about the impact of divorce and the most effective interventions.
Third, divorce research demonstrates the importance of a developmental perspective. Wallerstein and Kelly have followed the course of 60 divorced families over more than 10 years, charting the response of children at four different age levels.11,12 Preschoolers, for example, were very distressed at the time of divorce and appeared to be in worse shape than older children. However, 10 years later, these same preschoolers appeared to have fewer problems related to the divorce than older children. Their memories of the events surrounding the divorce were less intense and their views of the future were more optimistic. These results suggest that the immaturity of the preschoolers mayhave functioned like a protective factor with regard to long mn sequelae although it may have increased their vulnerability for distress in the short run.
Fourth, resilience is evident in the coping responses of children to divorce. In Wallerstein's study, children who were doing reasonably well after the initial crisis of separation were described as more intelligent, perceptive, and courageous. Their environments were more stable, organized, and supportive. Their parents avoided engaging their children in conflicts and did not desert their children physically or emotionally.
Current work on abused and neglected preschoolers suggests dire short-term effects.13 It will be important to see the longitudinal picture, particularly given positive changes in the environment. As children grow and change, the impact of past and current stressors will change as a reflection of their maturing comprehension, new competencies, and new relationships.
The "life events" method has been employed in countless studies of adults and with increasing frequency in studies of children. Diverse stressors, or life events, are typically composited into a single index of stress which is then correlated with the incidence of illness, symptoms, or other outcomes. The question addressed by this method is whether "stress" in the form of cumulative life events is associated with risk to health or adjustment.
The first life events scale for use with children was developed by Coddington. 14,15 It was modeled on the widely used Social Readjustment Rating Scale for Adults.16 Coddington selected events on a rational basts, then had a large number of professionals who work with children (such as physicians, teachers, and therapists) rate them according to the social readjustment required by such events for four different age groups. Rated as highly stressful were such items as death of parent or divorce. Usually the parent fills out the life events questionnaire, indicating which events have occurred during a specified time period, most often the past 12 months. The total number of events is summed or a weighted sum is derived according to the potential stressfulness of the events endorsed.
Greater frequency of stressful life events in children and their families has been linked to the incidence of physical illnesses (ranging from streptococcal infectiom to cancer), rate of visits to the doctor, psychiatric illness or maladaptive behavior, accidents, and injuries.17 There is also suggestive (though sparse) evidence of an association between life stress and episodes of chronic illnesses such as asthma, diabetes, and hemophilia. 17
The correlations obtained in such studies are usually quite low, although consistent. Therefore, recent research has increasingly turned to the study of potential modifiers and mediators of the relations between stressful life events and outcomes, including personal characteristics such as sex, IQ, or immunologic response, and environmental factors such as social support, or parental competence. An interesting recent example is provided by Fergusson, Hons, Horwood, and Shannon, who argued with suggestive empirical support that the relation of family life events to child-rearing problems is due to the mediating role of maternal depression.18
There are many conceptual and methodological problems with the studies of life events.10,17 Major problems include the following:
1. Methodological problems abound. There has been a proliferation of life event scales with little data on their reliability or validity, and an excess of poorly controlled, retrospective studies. For example, the distressed parent of a disturbed or sick child may recall more negative events than a parent whose child is flourishing.
2. Life events and symptoms may be confounded. Some life events can be the result, rather than the cause, of illness or maladjustment. For example, some life event scales include events such as "increased arguments between parent and child" or accidents, events that to some degree may be under the control of the child and directly related to symptoms such as depression, irritability, fatigue, or delusions. One way to reduce this problem is to count only events beyond the control of the child or family.
3. There are conceptual problems, such as how to interpret global "stress" scores when the events differ for each family. Similarly, it is difficult to interpret a significant relation between the number of life events and a specific illness without considering all the individual and environmental variables related to the illness and its context.
4. Developmental issues often have been ignored, such as by combining data from wide-ranging ages.
Further advancement using the life events approach requires closer attention to these issues and more prospective, longitudinal research designs which consider important stress-moderators.
THE STRESS-RESISTANT CHILD
Recently, a great deal of attention has been focused on the idea of "invulnerable" or stress-resistant children. This interest was generated from the observations by physicians, parents, psychologists, educators, and others that some children manage to survive and even flourish in spite of extremely stressful life events. 3 Studies of outcome for high-risk infants as well as for children exposed to many different stressors provide ample support for the concept of stress-resistance. In fact, resilience is usually the norm, not the exception.
The overwhelming general evidence for resilience, however, does not clearly differentiate the characteristics of the stress-resistant child or elucidate the process through which stress-resistance is manifested. What one can address at this early point in the empirical study of resilience is this basic question: What can be gleaned from a diverse and scattered literature to at least identify the important factors associated with stress-resistance in children? These are major contenders:3
1. Age: Children at different ages or stages of development respond differently both in the short run and in the long run to the same stressor.
2. Sex: Boys and girls often respond differently to stressors. Usually boys appear to be more vulnerable, although the reasons are unclear. Girls may have biological or social advantages that buffer them more effectively. For example, because of differing socialization or cultural expectations, female children under stress may receive more social support than their male peers.
3. Personal resources: There appear to be a number of individual differences associated with resilience, many involving a favorable genetic endowment. For example, children who cope well appear to be more intelligent, more reflective in cognitive style, have a more internal locus of control, and an "easier" temperament.
4. Interpersonal resources: The social environment of resilient children appears to have at least one and often more competent adults who provide warmth and structure. Whether the stressor is war or divorce, resilience is often characterized by the presence of stable family members, teachers, or others who consistently provide a model of competence and secure islands of affection and organization in the lives of the children. Of particular importance in current research is the study of attachment in infancy as it relates to later resilience.
5. Socioeconomic resources: just as socioeconomic disadvantage is a pervasive risk factor, socioeconomic advantage appears to be a general protective factor, although the explicit nature of this buffering effect is unclear. High socioeconomic status is related to less exposure to stressful events, higher income, better health care, more parental education, family stability, and other positive family attributes. Hopefully, further research will tease out the important aspects of this powerful correlate of resilience.
IMPLICATIONS FOR CHILDREN'S HEALTH
In spite of all the shortcomings and complexities of the research concerned with stress and coping in children, there is considerable evidence that the health and well-being of children is profoundly related to stress. At the present time the processes by which risk, stress, or protective factors operate are often poorly understood. Nonetheless, one can observe striking examples of how some understanding of stress and coping, particularly in a developmental context, has improved the way in which health-related services are delivered. For example, the hospital environment can be viewed as a complex system of both stressors and protective factors. Children's hospitals now routinely attempt to reduce the stress of separations by providing families with rooming-in or opportunities for contact even with infants in critical condition. "Stress prevention" efforts in hospitals range from preparation and training courses for children and parents to changes in uniforms, decor, or routines. 19
Similarly, institutional care has changed dramatically with increasing awareness of risk and protective factors in the environment. At the turn of the century, most infants died if they were institutionalized in socalled "foundling" homes.20 Subsequently, even if institutions were immaculate and nutritionally adequate, many children still failed to thrive. Then research clinicians such as Rene Spitz generated widespread recognition that there is more to nurturing than room and board.21 The "TLC" factor embodied in a warm, stable caregiver is as vital to healthy development as food and medical care.
Further research on stress and coping will have direct implications for intervention and prevention. We need to know which children at what developmental stages in which environments are at greatest risk, because intervention must be targeted to be cost-effective. We need to know what the major risk and protective factors are, particularly those that can be changed, prevented, or counteracted. Similarly, we want to know what can be done to reduce risk and to ameliorate stress for the vulnerable child - what medical, psychosocial, and educational interventions. For these goals of prevention and early intervention, parent, teacher, and physician are key figures.
THE PEDIATRICIAN AND NURSE AS PROTECTIVE FACTORS
Favorable genetic endowment and effective parenting are the cornerstones of stress-resistant development; however, the health care provider may also be of crucial importance. Physicians and nurses play an important role on four fronts of intervention: primary care, research, teaching, and public policy-making. Pediatricians are particularly important for prevention and early intervention efforts since they see children from birth onward on a routine basis as well as during health crises. They often serve as consultant or facilitator to meet socio-emotionai as well as medical needs of children and their parents. A pediatrician, for example, may mobilize or enhance the effectiveness of the child's potentially most powerful protective factor - a competent caregiver - by relieving the anxieties of a parent, whether it be through physical treatments of the child or advice, reassurance, or even just availability to the parent. In countless ways, the pediatric team serves to mediate the health of children by reducing stress and promoting coping. The effectiveness of their role as protective factor will be enhanced by greater understanding of stress and coping processes.
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