A Brief Introduction to Stress Mitigation in Children

Abstract

This paper presents a brief introduction to stress-mitigation in children by addressing stress assessment considerations specific to working with children and the use of behavioral interventions. Of behavioral intervention studies reviewed: biofeedback cases outline positive results in children with tension-type headaches and those with trauma; guided imagery and progressive muscle relaxation yield variable results; studies discussing the use of yoga show positive results with little negative side-effects, slow-paced diaphragmatic respiration training proves to be a valuable tool in teaching children how to relax and hypnosis could potentially positively inform other interventions. Future papers would benefit from specifying their review, honing in on one modality so as to better ascertain its clinical utility.  

Keywords: stress, children, relaxation training 

In children, stress can lead to somatic symptoms (Lohaus & Klein-Hessling, 2003; Pop-Jordanova & Zorcec, 2009), difficulty with self-regulation (Pop-Jordanova & Zorcec, 2009), and can precipitate health concerns later in life.  Early attachment to primary caregivers can set the stage for how children perceive and respond to stressful events later in life. Children with insecure attachment styles are more likely to have difficulty with self-regulation, a heightened stress response and are more likely to develop Post-Traumatic Stress Disorder (PTSD) (Gunnar & Cheatham, 2003; Pop-Jordanova & Zorcec, 2004). Disruption in developing a secure attachment bond has been shown to impact the right orbitofrontal cortex (ROFC) which has been implicated in both emotional and autonomic nervous system (ANS) regulation (Pop-Jordanova & Zorcec, 2004). Regardless of a child’s care-giver attachment, relaxation training and psychophysiological interventions can help resource the child (Lohaua & Klein-Hessling, 2003)  and lessen the long-term impacts of stress.  

Pop-Jordanova and Zorcec (2004) discuss that stress can be measured in clinical settings using psychophysiological recording devices and psychometric instrumentation. Quas (2011) notes a few considerations to take into account when measuring stress in children: the term ‘stress’ is often used to describe a complex systemic response and often lacks a concrete definition; there are many physiological mechanisms at play when an individual is experiencing stress, therefore it is limiting to rely on only one system of measurement; lastly, it is important to note: an individual’s stress response is dependent on their developmental stage and what is most adaptive to their environmental conditions. Few studies discuss stress symptomology in children (Sharrer & Ryan-Wenger, 2002) and few studies have utilized physiological instrumentation to measure stress in children (Quas, 2011).  

Physiological recordings can be difficult to obtain from young children because they have a hard time sitting still for long periods of time (Quas, 2011). Subjective assessments can be used to assess a child’s affective response to stress (Sharrer & Ryan-Wenger, 2002). However, when working with children: observer-report assessments, usually completed by caregivers, are susceptible to false/minimized reporting and do not accurately capture a child’s stress level (Sharrer & Ryan-Wenger, 2002). Further, children may not be able to understand self-report scales and results might be limiting due to a child’s ability to assess, remember, and report their experience of stress. A benefit to utilizing physiological recording equipment is that it can accurately depict a child’s level of physiological arousal, i.e their stress level (Quas, 2011). Sharrer & Ryan-Wenger (2002) found that children ages seven to twelve could easily asses and report their stress symptomology through a self-assessment inventory.  

Pop-Jordanova and Zorcec  (2004; 2009)  found that biofeedback interventions provide non-negligible changes in children’s physiological stress response.  Electrodermal (EDR) and electroencephalography sensory motor-rhythm (EEG-SMR) biofeedback training coupled with cognitive behavioral therapy has been shown to alleviate symptoms of PTSD in children with insecure attachment styles (Pop-Jordanova & Zorcec, 2004). Electrodermal (EDR) and electromyography (EMG) biofeedback have been shown to be helpful in treating tension-type headaches in children (Pop-Jordanova & Zorcec, 2009).  

Progressive muscle relaxation (PMR) and guided imagery have been shown to result in marginal, short-term stress reduction in moderately to highly anxious children (Hashim & Zainol, 2015). Lohaus & Klein-Hessling (2003) found that healthy childrens’ physiological response to PMR was comparable to being left alone in a low-stimulation environment while being told a neutral story and that training sessions had little impact on the childrens’ stress response in other situations. The results emphasized the importance of context within which relaxation techniques are taught. Hashim and Zainol (2015) found that twelve sessions of progressive muscle relaxation training showed only marginal to no improvement in moderate to highly anxious childrens’ cognitive appraisal of stress-inducing situations and attention span. But did find that 12 sessions of PMR had positive impacts on short-term memory. Both studies found no significant benefits to doing more or longer relaxation training sessions (Hashim & Zainol, 2015; Lohaus & Klein-Hessling, 2003).  

A scant amount of literature exists explicitly discussing hypnosis’ use and efficacy in children. But of that available: children generally demonstrate an easier time reaching a trance state with their peak of hypnotic talent being between ages eight and twelve. Hypnosis can be used as an adjunct to other treatments for a wide array of stress-inducing phenomena (Kohen & Olness, 2011). An understanding of a trance state, hetero-hypnosis procedures, hypnotic suggestibility, and hypnotic talent might be beneficial to consider when doing relaxation training, guided imagery and PMR with  children.  

Terai, Shimo, & Umezawa (2014) measured the effects of teaching children slow-paced, diaphragmatic breathing in an elementary-school setting. The authors measured respiration rate with a respiratory inductive plethysmography, cardiac intervals through a finger photo-plethysmography, and subjective experience with the State-Trait Anxiety Inventory for Children (STAIC). A limitation of this study is that the authors do not specify whether participants were relatively healthy or struggling with anxiety/stress. The study found that the childrens’ breath rate and overall anxiety levels, based of pre/post STAIC scores, were reduced after three training sessions. Findings suggest a correlation amongst subjects’ counted breath rate and actual breath rate. Suggesting that teaching slow-diaphragmatic breathing can be an effective tool to help mitigate anxiety and slow breathing rate.  

Yoga is the amalgamation of slow breathing, body movement, and being aware of one’s thoughts. The quality of studies discussing the use of yoga with children is variable. Most studies lack a control group, vary in quality of study design, and grapple with the many confounding variables inherent in working with children. Generally, yoga seems to yield positive results with negligible side effects. Improving vagal activation, subjective reports of well-being, decreasing cortisol levels, and can increase serotonin and endorphins (McClafferty, 2018). 

Of the modalities and studies reviewed, biofeedback and slow-paced diaphragmatic respiration training show clinical efficacy in mitigating stress in children. Further study is needed to assess the complex phenomena of a hypnotic trance when working with children. And those utilizing guided imagery techniques and PMR might benefit from understanding hypnotic phenomena. Yoga seems to yield positive results with no negative effects. However, stronger study design is needed to better understand its clinical utility. While this paper provides a brief introduction to stress-mitigation in children there is much to be investigated in how to better support children in self-regulation, relaxation training, stress-mitigation and understanding stress symptomatology.

References 

Gunnar, M & Cheatham, C. (2003). Brain and behavior interface: Stress and the developing brain. Infant Mental Health Journal, 24(3), 195. 

Hashim, H. A., & Zainol, N. A. (2015). Changes in emotional distress, short term memory, and sustained attention following 6 and 12 sessions of progressive muscle relaxation training in 10–11 years old primary school children. Psychology, Health & Medicine, 20(5), 623–628. 

Lohaus, A., & Klein-Hessling, J. (2003).  Relaxation in Children: Effects of Extended and Intensified Training 18(2), 237–249. 

McClafferty, H. (2018). Mind-Body Therapies in Pediatrics. Alternative & Complementary Therapies, 24(1), 29–31. Retrieved from https://doi-org.tcsedsystem.idm.oclc.org/10.1089/act.2017.29143.hmc 

Kohen, D. & Olness, K. (2011). Hypnosis and hypnotherapy with children (4h ed). Routledge: New York & London 

 Pop-Jordanova, N., & Zorcec, T. (2009). Psychological Assessment and Biofeedback Mitigation of Tension-Type Headaches in Children. Contributions of Macedonian Academy of Sciences & Arts, 30(1), 155–166. 

Pop-Jordanova, N., & Zorcec, T. (2004). Child trauma, attachment and biofeedback mitigation. Contributions, Sec. Biol. Med. Sci., MASA, XXV, 1-2, 103–114. 

Quas, J. (2011). Measuring Physiological Stress Responses in Children: Lessons From a Novice. Journal of Cognition & Development, 12(3), 261–274. 

 Sharrer, V. W., & Ryan-Wenger, N. A. (2002). School-age Children’s Self-Reported Stress Symptoms. Pediatric Nursing, 28(1), 21. 

Terai, K. , Shimo, T., & Umezawa, A. (2014).  Slow diaphragmatic breathing as a relaxation skill for elementary school children: A psychophysiological assessment. International Journal of Psychophysiology (94) 2, 29. DOI 10.1016/j.ijpsycho.2014.08.897

This paper was written by Madeline Stein © for a class at Saybrook University during Fall Semester 2019