Stress is a condition of major public health concern, because of its high rate of prevalence and the high degree of dysfunction and suffering associated with it. Studies on stress in India are mostly based on the objective measures of stress and various causes of stress. Prevalence studies of stress in India have mostly been carried out in conjunction with prevalence of anxiety and depression. Daily hassles, academic pressure and career-related demands are the major causes of stress among Indian adolescents. According to Mehta (2000), majority of Indian adolescents experience mild to moderate levels of stress. Daily hassles are a significant cause of their stress. For many adolescents, examinations are a significant cause of emotional trauma and anxiety. Being labelled as “average” or “below average” may be extremely distressing and can lead to low self-esteem and poor academic concept. Even high achievers have high fears of failure and experience stress.

Figure 8.2 presents the prevalence rates of stress in adolescents in India.

Findings from other studies suggest that students in Government schools experience higher levels of stress than those in private schools. Students engage in higher use of avoidance coping (Augustine et al. 2011). Depression, anxiety and stress are higher among students in “board classes” (Bhasin et al. 2010). Findings from these studies reveal that managing stress among adolescents in India is the need of the hour.

Certain stressful situations are more likely to occur during particular developmental periods. Adolescent stress is an important, yet often overlooked, health issue. During this period, adolescents undergo a time of rapid body growth. It is also during this phase that they have to make crucial academic and professional decisions. Adolescence is also a period associated with identity development. The main causes of stress arising during adolescence have been highlighted in Table 8.1.

According to Selye (1978), the state of stress can be recognized only by its physiological manifestations. He defined stress as “an adaptive or defensive reaction to an event or stimulus” and labelled it as the General Adaptation Syndrome (G.A.S.), which occurs in three stages: the alarm reaction (A.R.), the alarm resistance (A.R.) and the stage of exhaustion (S.E.).

The alarm reaction is a physiological response made by the body for alerting the defensive forces within the individual. In this stage, blood is diverted towards the skeletal muscles in order to prepare them for action in response to a stressor.

If the stress exposure remains, the stage of resistance follows. In this stage, the body begins to restore balance, recover depleted body sources, and start renewal and repair. If the stressor still persists, the body starts adapting itself with continued effort in resistance. During this phase, the body continues to remain in a state of arousal. If an individual accepts that the stressor is a necessary part of life, it may persist indefinitely. In such a condition, the person becomes highly vulnerable to a wide range of stress-related problems and diseases.

With long-term stress exposure, the individual enters the third stage, the stage of exhaustion. During this stage, the risk of emotional and physical problems increases and the individual starts experiencing symptoms such as loss of morale and feelings of loss of control and may finally collapse.

The impact of maladaptive responses to stress can manifest in five main domains—physical, psychological, emotional, behavioural and social. The most common signs of stress seen in adolescents are highlighted in Fig. 8.3.

Adolescents may also experience certain types of thoughts that can precipitate, lead to, maintain or heighten the experience of stress. These thoughts generally represent certain dysfunctional styles in thinking and cognitive distortions. A list of cognitive distortions is provided in the Appendix.

Common examples of the thoughts experienced by adolescents during stress are included in Fig. 8.4.

While these thoughts can lead to experience of stress, they can also be seen as by-products of stress. The experience of these thoughts can prolong the effects of stress among adolescents. Cognitive behaviour therapy (explained in detail in subsequent sections) can serve as a promising treatment modality in dealing with these cognitions.

Stress can have numerous detrimental effects on adolescents. Stress generally elevates the production of cortisol, a stress hormone, which not only impairs memory but also general health. Between 50 and 80 % of all diseases, at least in part, have stress-related origins (Humphrey 2004). There is a strong correlation between an increase in stressful events and a decrease in health and psychological functioning (Newcomb et al. 1981). In the longer term, stress can have a very cumulative and wide-ranged effects on health (Table 8.2).

Effectively managing stress mainly involves taking charge over one’s thoughts and feelings and finding a way to deal with the problems. Adolescents can learn to become more resilient by changing how they think about their problems and life situations. Resilience can be defined as the ability to cope well with challenging situations and a context of positive adaptation in light of adversity. Resilient individuals generally use more effective coping strategies, have a realistic understanding of situations and have better tolerance and control over their feelings.

Thus, building resilience essentially involves learning to develop good coping skills. Two main types of coping styles have been widely reviewed—problem-focussed coping (approach oriented) and emotion-focussed coping (avoidance oriented).

Problem-focused coping (approach-oriented coping) aims at changing the source of the stress. For example, if a student is stressed about an upcoming exam, the problem-focused approach for the student would be to devote more time for studying. The student may also ask friends and teachers for help. Emotion-focussed coping (avoidance oriented) aims towards reducing or managing the emotional distress related to a situation. Examples include denial, avoidance, and procrastinating. Studies suggest that females generally use more emotion-focused coping strategies while males tend to use more problem-focussed strategies. Adolescents often use less effective coping strategies such as wishful thinking, self-blame, complaining, making excuses, not communicating, bullying, becoming withdrawn, smoking or drinking. While these coping strategies may temporarily reduce stress, they are counterproductive and may worsen the stress and cause more damage in the long term. Adolescents can learn healthier ways to manage stress by learning more effective and problem-focussed coping strategies. These may include developing problem-solving skills, developing positive thinking, developing more flexible styles of thinking, maintaining an optimistic outlook, learning better time management, developing a balance between work and leisure, engaging in regular physical exercise, practising relaxation exercises, spending time with friends, sharing problems with a friend or family member, expressing feelings instead of bottling them up, developing more effective communication skills, maintaining healthy eating and sleeping habits, maintaining a stress diary, indulging in a hobby, reading a novel or comics, watching a funny movie or videos, listening to music, doing something creative such as drawing or painting and playing with pets. These coping strategies are more problem focussed and help in building resilience to stress.

Stress is related to a wide range of health-related problems among adolescents. Chronic stress can cause hormonal imbalance and has emerged as a key risk factor in development of many physical and psychiatric illnesses and lifestyle-related diseases as seen in the previous section. Academic stress among adolescents is emerging as a leading problem which requires immediate concern. “Today stress levels among children and adolescents have been going up dangerously due to the pressure of their academic or cultural activities. Not all children can cope with such high levels of expectations and parents do not seem to realize or accept that their children are under severe pressure” says Elizabeth Vadakkekkara, a child psychologist and director of Thrani; a counselling centre in Kerala focussing on crisis intervention and suicide prevention (The Hindu 2003). Many adolescents believe that nothing can be done to avoid stress. Poor coping strategies used by adolescents can have significant short- and long-term consequences on their physical and emotional health. Stress management has thus become a need of the hour for adolescents in India. Teaching several coping strategies such as seeking social support, cognitive restructuring, positive self-talk, problem solving, relaxation, physical activity, sleep and diet regulation, cognitive restructuring and self-talk can serve to be successful in combating stress among adolescents and promising a healthy lifestyle.

The case illustration provided in Fig. 8.5 highlights the case of a 19-year-old female with significant body image issues and cognitive distortions experiencing significant amount of stress and developing a stress-related condition (Irritable Bowel syndrome).

Assessment of stress involves identification of signs of stress, the causes (stressor), and the present demands and resources of the individual. This can be carried out using detailed interviews, providing the adolescents with self-assessment records, and through structured questionnaires and inventories.