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Preventing Disease with Stress Management in Elementary Schools.

The link between stress and disease was first noted by Seyle in the 1930s.[1] Since that time, the physiologic mechanisms of the stress response and its ramifications on health status have been researched within a variety of disciplines including psychology, neurology, endocrinology, and immunology.[2,3] Heightened awareness regarding the detrimental effects of stress gave rise to a variety of stress reduction and stress management programs. However, these programs often target adult audiences despite the large number of children who experience illness associated with chronic stress.[4-6]

Knowing that chronic stimulation of the stress response can influence disease states, it seems logical that stress management programs should begin during childhood, a time when lifelong behaviors are developed.[7] Including stress management education in the curricula for all elementary school children represents an important step toward reducing the incidence and severity of childhood morbidity. Further, implementing stress reduction programs may facilitate attainment of some health status objectives outlined in Healthy People 2000, a document describing national health goals.[8]

Many stress management programs for children are described in the literature, but they frequently focus on classroom behavior, achievement levels, and self-concepts.[5,6,9-11] Though results from these studies were favorable, they did not address effects of stress management on overall health. Results have not generated sufficient enthusiasm to prompt nationwide implementation of stress management programs in elementary schools.


Multiple factors contribute to development of disease including genetic predisposition, environmental exposure, and risk-taking behaviors.[2] Chronic activation of the stress response also constitutes a major risk factor in the development of disease due to its physiologic effects in the body.[1,3]

When an individual encounters a stressor, the physiological response includes activation of the hypothalamicpituitary-adrenal system and production of stress hormones known as catecholimines (adrenaline and noradrenaline) and glucocorticoids.[3] These hormones are secreted by the adrenal gland to promote lipolysis and glucogenesis. Lipolysis and glucogenesis create energy sources for cells such as free fatty acids, triglycerides, and glucose, enabling the body to respond appropriately to stressful situations.[1,3] Unfortunately, if the energy sources are not used, as with many psychological stressors, the risk for developing disease increases. For instance, high levels of free fatty acids, triglycerides, and cholesterol levels in the bloodstream generated from the stress response can contribute to development of atherogenesis and subsequent heart disease.[3]

Diabetes is another chronic health condition linked to the stress response.[2] The increase in blood glucose levels produced during glycolysis causes the pancreas to secrete insulin. However, the glucocorticoids, also secreted during the stress response, decrease effectiveness of insulin so the pancreas must release greater quantities of insulin for glucose to be taken up by the cells. As a result, insulin receptors down-regulate, or become less sensitive to insulin, making it more difficult for glucose to enter the cells even when there are no stessors. Thus hyperglycemia results due to insufficient amounts of circulating insulin, a condition associated with diabetes.[2] Given this response, it is not surprising that psychological stressors, such as divorce, often are associated in the onset or worsening of diabetic conditions in children.[5]

Depression and obesity are other stress-related health concerns affecting young children. This situation may be due to the fact that the stress response reduces the amount of neurotransmitters, such as of noradrenaline, serotonin, and dopamine, available to brain cells thereby affecting mood, affect, and behavior.[2] During periods of stress and depression, individuals tend to increase fat intake by as much as 30%, due partly due to an increased craving for carbohydrates. Carbohydrates increase blood glucose and stimulate insulin which increases uptake of tryptophan. Tryptophan is a precursor for serotonin, one of the neurotransmitters that helps to elevate mood. Since serotonin is often decreased in depressed individuals, one may actually "self-medicate" with food. Further, obesity and depression are considered health risks for developing other conditions including heart disease and diabetes which suggests a great deal of overlap of stress-induced responses.[3]

Finally, the immune system becomes compromised during periods of stress and increases susceptibility to disease.[2] Release of glucocorticoids during stress inhibits effects of cytokins, a protective hormone released during the immune response, and suppresses immune and inflammatory reactions.[2] Thus children with behavioral, educational, family, and social problems are more likely to visit the school nurse or seek health care at community clinics.[5,11]

Effects of the stress response described in this section addresses only a few ways in which chronic exposure to stressors may contribute to development of disease. Other conditions associated with increased stimulation of the stress response include growth retardation, reproductive dysfunction, psychiatric disorders, autoimmune disease, thyroid dysfunction, and substance addiction. Stress is not the sole reason for development of disease, but these examples demonstrate how stress can increase a child's risk for development of common disease states.


Many of the chronic illnesses reviewed in the previous section are targeted in the objectives of Healthy People 2000. For example, one of the nation's health objectives is to decrease the suicide rate in children ages 15-19, a rate that has tripled during the past 40 years. This dramatic increase has been partially attributed to severe stress in school and family life.[8,12] Other health objectives include reducing obesity by 15% among children 12-19 years old, decreasing the number of coronary heart disease deaths, reducing the incidence of diabetes, and reducing the number of individuals who experience adverse health effects from stress by 35%.[8]

Services employed to meet these objectives include increasing the accessibility of stress reduction services, in whatever ways these services are specifically directed toward individuals over 18 years of age.[8] Given what is known about links between the cumulative effects of stress response and disease over the life span,[3] stress reduction strategies for children during elementary school should be more effective in meeting these health care objectives.


The role of school and community health nurses includes health promotion and disease prevention.[7] Nurses working with the school need to be advocates for stress management programs and educate teachers and parents about short- and long-term benefits. The diverse background of nurses allows them to consider physiological implications of stress in conjunction with the developmental, psychosocial, and physical needs of the children.[7] Nurses need to be involved in the selection and implementation of stress management programs that best meet the needs of children in the community. A variety of successful stress management programs for progressive relaxation, deep breathing, biofeedback,[6,13] and even educational television[14] have been successful at all educational levels.

Nurses also must realize that stress management programs will complement other beneficial school health programs such as those targeting nutrition, exercise, and cardiovascular health. For example, use of stress-reducing techniques may help decrease fat and carbohydrate cravings associated with periods of increased stress so healthier decisions regarding nutrition and exercise are easier for children to make.


Knowledge regarding the link between the stress response and disease provides a rationale for stress management interventions in elementary schools. Incorporating brief periods of stress management into educational curricula could instill life-long habits in children and decrease their risk factors for developing poor health conditions. School nurses play an important role in disease prevention by recognizing stress management as a necessary program for school health promotion and advocating for its implementation in elementary schools. Stress management may be essential for preventive health care in our nation's children.


[1.] Seyle H. The Stress of Life. New York, NY: McGraw-Hill Book Co, Inc; 1956.

[2.] Stratakis CA, Chrousos GP. Neurodendocrinology and pathophysiology of the stress system. In: Chrousos GP, McCarty R, Pacak K, Cizza G, Sternberg E, Gold PW, Kvetnansky R, eds. Stress: Basic Mechanisms and Clinical Implications. New York, NY: The New York Academy of Sciences; 1995;771:1-8.

[3.] Chrousos GP, Gold PW. The concepts of stress and stress system disorders: overview of physical and behavioral homeostasis. JAMA. 1992;267:1244-1252.

[4.] Grey M. Stressors and children's health. J Pediatr Nurs. 1993;8:85-91.

[5.] Johnson JH. Life events and physical health. In: Life Events as Stressors in Childhood and Adolescence. Beverly Hills, Calif: Sage Publications, Inc; 1986;57-72.

[6.] Humphrey JH. Teaching Children to Relax. Springfield, Ill: Charles C. Thomas Publisher; 1988.

[7.] Bartfay W. Reading, writing, and health. Can Nuts. 1994;90:29-31.

[8.] Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: USDHHS, Public Health Service; 1991.

[9.] Shinke SP, Schilling RF, Snow WH. Stress management with adolescents at the junior high transition: an outcome evaluation of coping skills intervention. J Human Stress. 1987;13:16-22.

[10.] Thoben KA. The effects of a stress management program upon academic achievement, self-concept, and anxiety levels of elementary school children. Dis Abs Int. 1989;50A:1610.

[11.] Nadar PR, Ray L, Brink S. The new morbidity: use of school and community health care resources for behavioral, educational, and social-family problems. Pediatrics. 1981;67:53-60.

[12.] Lamarine RL. Child and adolescent depression. J Sch Health. 1995;65:390-393.

[13.] Zaichkowsky LB, Zaichkowsky LD, The effects of a school-based relaxation training program on fourth grade children. J Clin Child Psychol. 1984;13:81-85.

[14.] Mramor NL. Stress management for children through educational television. Diss Abst Int. 1991;52A;2028.

Mary Alice S. Dombrowski, BA, RN, 2329 Grandview Ave., Cleveland Heights, OH 44106, or <>. This article was submitted September 25, 1998, and accepted for publication December 18, 1998.
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Author:Dombrowski, Mary Alice S.
Publication:Journal of School Health
Date:Mar 1, 1999
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