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Adolescent stress through the eyes of high-risk teens

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 Adolescent Stress through
The Eyes of High-Risk
Continuing
Nursing Teens
Education
Series Denise E. LaRue
Adults often under-estimate the levels of stress in adolescents; however, stressors experienced by teens are
valid and have been described in both lay and professional literature. This article presents a thorough liter-
ature review as well as study results that explore teen perceptions about the stressors they face.
am stressed out” is a phrase
“I that has been echoed by
teens down through the
ages. The level of stress
experienced by teens on a daily basis
has been described in lay and profes-
sional literature. Adults often under-
estimate this level of stress and may
not always be cognizant of the poten-
tial consequences of stress on teens
and young adults. This lack of appre-
ciation of the stress experienced by
adolescents may be partially related
to a lack of awareness of the sources
of stress in teen life, the changing
nature of stressors through time, the
ever-evolving complexities of adoles-
cent life, and the tendency for adults
to minimize their own personal stress
during the teen years or compare their
teen years to the experiences of oth-
ers. Physiological development, cog-
nitive differences, pubertal changes,
immature coping mechanisms, slower
recovery from stressful events, and
lack of experience in dealing with
stress may intensify the stressful
events experienced by adolescents
(Herrman, 2005).
The purpose of this study was to
determine teen perceptions about the
Denise E. LaRue, RN, is a Graduate of the
University of Delaware, School of Nursing,
Newark, DE.
Judith W. Herrman, PhD, RN, is the
Assistant Director and an Assistant
Professor, University of Delaware, Newark,
DE.
Objectives, the CNE
posttest, and disclosure
statements can be found
on pages 395-396.
PEDIATRIC NURSING/September-October 2008/Vol. 34/No. 5
Judith W. Herrman
stressors they face, offering an adoles-
cent perspective to the literature relat-
ed to teen stress. According to Lau
(2002), teens “can experience a spec-
trum of stresses ranging from ordinary
to severe” (p. 238). Stress has been
associated with a variety of high-risk
behaviors, including smoking, suicide,
depression, drug abuse, behavioral
problems, and participating in high-
risk sexual behaviors (Finkelstein,
Kubzansky, Capitman, & Goodman,
2007; Finkelstein, Kubansky, &
Goodman, 2006; Goodman, McEwan,
Dolan, Schafer-Kalkhoff, & Adler,
2005). In addition, long-term expo-
sure to stress is associated with a vari-
ety of chronic psychological and
physical illnesses (Goodman et al.,
2005). High-risk teens, or those who
live in social disadvantage, may be at
increased risk for illness related to
chronic exposure to stress, discrimi-
nation, stigma, and a “harsh social
environment” (Goodman et al., 2005,
p. 485). Chandra and Batada (2006)
purported that assessing adolescent
stressors and “the impact of stress is
the first step in the prevention and
treatment of its associated chronic
diseases” (p. 2). Understanding teen
stressors may assist pediatric nurses
working with adolescents by helping
teens develop resilience to stress,
thereby increasing teens’ levels of
health (Tussaie, Puskar, & Sereika,
2007).
Review of the Literature
The word stress has emerged as a
part of current daily vocabulary and is
not always well defined as a concept
or uniformly understood. Several
authorities have defined stress as it
relates specifically to teens. According
to Goodman et al. (2005), stress
refers to a stimulus generating psy-
chosocial and physiologic demands,
and requiring action on the part of the
individual. Finkelstein et al. (2007)
differentiate stress in the adolescent
period as having both environmental
(objective assessments of conditions)
and psychological (subjective evalua-
tions) perspectives of stressful events.
The psychosocial perspective views
stress from the experience of the indi-
vidual and dictates that stress is
assessed from a variety of dimen-
sions, including the personal meaning
of the stressor, the magnitude of the
stressor, the demands placed by the
stressor, and the coping mechanisms
available to react to the stimulus
(Finkelstein et al., 2007). The current
study is informed by this psychologi-
cal, or personal subjective assess-
ment, of the stress experience and
how stress is interpreted on the indi-
vidual level.
Chandra and Batada (2006) asked
teens to use their own words to define
stress. One of the teens described his
stress as “a great deal of pain that’s
inside your body that you can’t get
out…and makes you feel bad”
(Chandra & Batada, 2006, p. 4).
Another stated stress was character-
ized by “worrying, keeping secrets,
gray hair, problems, anger, being
tense” (Chandra & Batada, 2006, p.
4). These definitions of stress led to an
exploration of adolescent perceptions
on the origins of stress. The research
related to stress has identified several
key sources of stressors having an
impact on teens, including school,
family and home life, social disadvan-
tage. and other stressors.
School stressors. Pressures in the
school setting were frequently cited as
stressful by adolescents. Using a pile-
sort activity, participants in a study by
Chandra and Batada (2006) identified
school work “as the most frequent and
important source of stress” in their
lives (p. 5). The 9th graders stated
that the sudden increase in homework
375
was a main stressor for them, along
with “worrying about exams and
grades” (Chandra & Batada, 2006, p.
5). Green, Holohan, and Feldheim
(2003) identified that for even the
most confident teen, schoolwork is
“often the first area to fall apart under
duress” (p. 4). Homework, tests,
needing to keep up with daily materi-
al, the presence of a learning disabili-
ty, a conflict with a teacher, problems
with other students, or simply a dislike
of the school experience represented
common areas of stress for the school
setting (Green et al., 2003).
According to Lau (2002), there
were three main clusters of stress
associated with school that included
“fear of success or failure, test or per-
formance anxiety, and fears associat-
ed with the school setting” (p. 241). In
addition, teens with a low self-esteem
were reported to seek “acknowledg-
ment and acceptance by teachers and
peers,” which was also extremely
stressful (Lau, 2002, p. 241). Often,
“a perceived lack of respect from
teachers as well as general conflicts”
with teachers stressed teens within the
school setting and inhibited “their aca-
demic performance and school func-
tioning” (Chandra & Batada, 2006, p.
5). Poor student-teacher relationships
were noted to have a profound impact
on learning, success in school, and
overall stress levels (Chandra &
Batada, 2006). Finally, teens’ tenden-
cy to look toward the future after the
school experience proved stressful as
well (National Campaign to Prevent
Teen Pregnancy, 1999). In focus
groups, participants disclosed finding
school and education as primary con-
cerns in life, and students pointed out
that they were determined to get “an
education to get somewhere in life”
(National Campaign to Prevent Teen
Pregnancy, 1999, p. 6).
Family and home life stressors.
Rather than serving as a source of sup-
port, families and the home environ-
ment were often cited as major stres-
sors in teens’ lives (Tarrant & Woon,
1995). One study cited four of the nine
major domains adolescents compiled
as life stressors, including the teen’s
home, parents, siblings, and extended
family members (Moos, 2002). The
teens involved in Chandra and
Batada’s (2006) study “noted that fam-
ily conflicts usually involved doing their
homework, cleaning their room, and
doing chores” (p. 4). In addition, teens
described family stress as including
“worrying about the well being of fami-
ly members,” “being nagged,” and
“conflict over family responsibilities with
siblings” (Chandra & Batada, 2006, p.
376
4). Many boys discussed the stress “of
being the only male in the household,”
and therefore, feeling the need to
“defend the home” or to protect the
family (Chandra & Batada, 2006, pp.
4-5).
Teens noted that not getting along
with a sibling or parents were indicators
of family stress. Teens also cited that
hearing or seeing their parents fight
with each other and worrying about the
general outcome of these altercations
was a frequent stressor (Lau, 2002).
Customary methods families and par-
ents use to deal with current stressors
and conflict, including arguing, yelling,
or physical fighting, may affect the
level of stress perceived by the teen
(Tarrant & Woon, 1995). According to
Lau (2002), the sibling stress that teens
mention often started with the birth of a
younger sibling and then continued
through the years with a sibling rivalry.
Problems, such as “divorce or the
death of a family member, are more
serious than others” (Green et al.,
2003, p. 3). Divorce may have other
effects on the family as well, such as
lowering the income or changing the
living arrangements, which in turn
could have negative effects on the
child’s “health, well-being, and school
achievement” (Lau, 2002, p. 239).
Social disadvantage stressors.
Social disadvantage, whether real or
perceived, may be related to race,
community, ethnicity, or socioeconom-
ic status. Potential stressors associated
with social disadvantage in the inner-
city environment may include violence,
drug use, or poor housing, all of which
can contribute negatively to the devel-
opment of the adolescents living in
these areas (Miller, Webster, &
MacIntosh, 2002). The Urban Hassles
Scale was created to rate how frequent-
ly participants confronted each stres-
sor. The most frequently cited stressors
were found to be “being pressured to
join a gang and offered sex by drug
addicts for money” (Miller et al., 2002,
p. 383).
Neighborhood stress was common-
ly reported as a source of stress. Urban
African-American adolescents cited
“drug dealing and litter on the streets”
as two of the top neighborhood stress-
es, which was also accompanied by
many girls voicing “concerns about
men” (Chandra & Batada, 2006, p. 6).
These teens expressed fear of living in
their neighborhoods and worrying
about going out on the streets. Drug
dealers, older boys hassling girls, and
gang violence were identified as causes
of stress (Chandra & Batada, 2006).
Lau (2002) noted that “poor children
are being exposed to increasing levels
PEDIATRIC NURSING/September-October 2008/Vol. 34/No. 5
of violence in their homes, their
schools, and on the streets” as well as
the fact that “poverty is also associated
with serious mental disorders” (p. 240).
An adolescent living in social disadvan-
tage may encounter multiple and inter-
related stressors creating a complex
environment for adolescent growth and
development.
Other stressors. Other stressors
have been identified as posing threats
to teens. For most adolescents, being
hospitalized would increase stress lev-
els. Sources of anxiety may include the
“threat of physical harm, separation
from parents, and fear of the unknown
and uncertainty about acceptable
behaviors” (Lau, 2002, p. 243). Puskar
and Rohay (1999) found that “geo-
graphic relocation may compromise or
retard the adolescent developmentally.
With a limited repertoire of coping skills
and an unfamiliar peer group, teens
may find the transition associated with
relocation particularly stressful” (p.
16). Ethier et al. (2006) discovered
that stress manifested by depressive
symptoms, anxiety, or hostility was
associated with “pregnancy, to have
had unprotected vaginal sex, to have
nonmonogamous sex partners, and to
not use any form of contraception” and
further added to the stress (p. 269).
Other adolescent stressors included
obtaining or holding a job, money,
body image, relationships, and abuse
(Puskar & Rohay, 1999). Adolescents
have also identified major stressors
associated with war, natural disasters,
or community disasters. Tarrant and
Woon (1995) commented that “the
escalating threat and damage to the
environment and constant world con-
flict which is graphically brought into
the home on a daily basis, questions
one’s safety and security” (p. 26).
A newer phenomenon associated
with teen stress has been the act of
“cutting” (Derouin & Bravender, 2004,
p. 13). The authors noted that “adoles-
cents who have low impulse control
and a high desire to be popular may be
unable to manage this mass influx of
information in a healthy way, and may
direct the violence expressed in the
news and media against themselves”
(Derouin & Bravender, 2004, p. 15).
These acts of self-mutilation may be
used by teens as a coping mechanism
for managing their stress. To those who
participate in self-mutilating acts, the
episodes are “depersonalizing events
occurring during periods of extreme
stress or marked anxiety” (Derouin &
Bravender, 2004, p. 13). These events
may actually serve to escalate levels of
anxiety and provide an additional
source of stress for teens.

These studies demonstrate the wide
variety of the sources of stress impact-
ing adolescents. Though Chandra and
Batada’s (2006) study included teens’
own words, most of the research was
quantitative in nature, using estab-
lished measures of stress and adult per-
spectives in the analysis of results. The
current study provides a new perspec-
tive by using teens’ own words to
describe their levels of stress and those
stimuli that are associated with the
greatest levels of adolescent stress.
Materials and Methods
This qualitative study stemmed
from a focus group descriptive study
exploring teens’ perspectives of sex,
pregnancy, and teen births (Herrman,
2008). Rich and Ginsburg (1999)
addressed the benefits of gathering a
focus group for information, explaining
that it is a natural setting “where ques-
tions are asked of groups that create
the give-and-take atmosphere in which
opinions naturally form” (p. 373).
The qualitative format used in this
study was effective in allowing teens to
open up about their lives and eliciting
teens’ responses related to stress. The
facilitator asked questions, and the
teens would discuss their personal
responses, interact with other teens,
and share insights related to the per-
spectives of others in the group.
Quantitative methods are helpful in
“identifying the sources and impact of
youth stress,” but “qualitative tools
would add a unique perspective on how
young people themselves discuss and
prioritize issues” (Chandra & Batada,
2006, p. 2). Qualitative methods pro-
vided a mechanism to determine teens’
stressors and examine causal factors
from the adolescents’ own perspective,
allowing adults an informed glimpse
into some of the realities of teen life.
Approval for this study was
received from the Institutional Review
Board (IRB) at the local academic insti-
tution. Due to the sensitive nature of the
material and the vulnerability of youth,
careful attention was paid to the
recruitment of the teens and to the con-
sent/assent processes. High-risk youth
in the state of study were the popula-
tion for this study, selected to inform
nursing and policy interventions and
glean new information about teen per-
ceptions of the stress experienced by
this cohort. Focus group participants
were solicited from school-based well-
ness centers, health services, churches,
teen support groups, and non-profit ado-
lescent programs. These sites served
teens considered at risk for negative
behaviors, whether by self-report,
demographics, or referral due to previ-
PEDIATRIC NURSING/September-October 2008/Vol. 34/No. 5
Adolescent Stress through The Eyes of High-Risk Teens
Figure 1.
Life Stressors of Teens
Miscellaneous
Graduation
College
Friends
Violence/fighting
Time (lack of)
STD’s/AIDS
Becoming pregnant
Sex
Job
Being a mother
Parents
Relationships
Money
School/Grades
5 10 15
ous high-risk behaviors. Agency per-
sonnel were responsible for identifying
and recruiting study participants, dis-
tributing packets, and collecting com-
pleted assent and consent forms.
Employees and volunteers from the
advocacy groups were asked to identi-
fy youth who may take part in the focus
groups based on their participation in a
variety of teen support efforts, includ-
ing programs focused on preventing
teen pregnancy, assisting teens to deal
with social disadvantage, and delaying
high-risk behaviors. The final purpo-
sive, non-random sample included 120
youths from throughout the state,
including 72 females and 48 males
ranging in age from 12 to 19 years. The
mean age of the participants was 16.1
years, with 68% of the youths identify-
ing themselves as African American,
19% as Caucasian, 11% as Hispanic,
and 2% as another ethnic origin.
Seventeen focus groups were con-
ducted over a span of six weeks. Each
group had 3 to 15 participants, and the
interviews averaged 40 minutes in
length. One focus group included preg-
nant girls, 1 included teen fathers, 3
had teen mothers, and 12 were com-
posed of non-parenting teens. The
non-parenting groups included 4
female groups, 2 male groups, and 6
with boys and girls. The focus groups
were conducted in private conference
rooms and were recorded using a
handheld digital recorder, saved to a
CD-ROM, and transcribed verbatim.
The interviews included ice-breaker
questions, including “Tell me about
your life as a teen right now,” and
“What are some of your concerns as a
teen?” These prompts led to various
probing questions about stress and
20 25 30 35 40
OccurRence
angst in their daily lives, and resulted in
the group discussing the sources of
stress.
The Principal Investigator conduct-
ed all interviews, and made marginal
and observational notes during and fol-
lowing each interview. Summaries at
the end of each interview provided a
mechanism for “member checking” or
reviewing and validating data with each
group participant (Rich & Ginsburg,
1999). Saturation of the data was
achieved in the final interviews, when
no new information was solicited. Each
transcription was checked against the
audio-recording for accuracy. The data
were coded and analyzed using the
Ethnograph v 5.08. The teens’ most
common stressors were then ranked
from the most commonly found to the
least commonly found. Marginal notes,
transcripts, and audiotapes were used
to determine the intensity of responses
related to stressors in addition to the
frequency of responses.
Results
In qualitative research, the results
are often best understood through the
words of the participants, in this case,
the teenagers themselves. The stress-
ful aspects of the teens’ lives emerged
as themes from the data. Each of the
stressors was ranked from most com-
mon to least common using Microsoft
Excel®. The frequency of the most
commonly noted stressors is found in
Figure 1. The most frequently noted
stressor was school, followed by
money, relationships, and parents.
The following is a discussion of these
stressors with exemplary quotes.
School. The greatest stressor dis-
covered in this study was school and
377
its related components. Maintaining
good grades, passing their classes,
making it to graduation, and being
accepted into college were all worries
that the students cited as stressors.
One student admitted to “stressing
over like whether I’m gonna pass or
not, or your grades.” For some, this
stress existed because they found
school challenging on a normal basis,
while for others it was because they
took on increased challenges. For
example, one student mentioned that
things in school were more difficult
because of the fact that he “took a lot
of harder classes this year, so it’s
hard.”
Seniors taking part in this study
had an additional group of stressors
than the rest of the participants. They
cited the increased pressure of keep-
ing up with school and graduating,
stating that it adds “a lot of pressure
your senior year ‘cause you wanna
graduate with your class…you don’t
wanna be left behind.” At this point in
time, the seniors also “have to think
about – getting scholarships, looking
for colleges, [and] start writing your
resumes and stuff.” Another student
said it best when stating that senior
year was “the time to act right” if you
have not in the previous three years.
“Pulling themselves together” and
“staying on track” in order to graduate
were very important to many of the
students. In the interviews, students
also brought up the fact that depend-
ing on one’s job, “it’s hard to make
money, even with a bachelor’s degree
today,” so with just “a high school
diploma, you ain’t making nothing.”
The discussion of school and later
work success led into a discussion of
money.
Money. The teens’ financial status
was an issue in their lives. Depending
on whether they had a baby to sup-
port, were planning to put themselves
through college in the upcoming
years, or just wanted extra spending
money, obtaining money to meet their
needs was perceived as difficult.
Adolescents verbalized the fear of debt
if they did not learn sound budgeting
skills. Some teens were able to work
and manage school, but were still find-
ing themselves low on cash due to the
many demands for money in their
lives. For example, respondents noted
“every paycheck that is coming in
right now, I am saving it, and it already
has an owner” and “It’s going right
back out.” Some of the teens shared
that they were in search of money to
pay for common high school memo-
rabilia, activities, and other necessi-
ties. For instance, a class ring, school
378
pictures, class dues, SATs, prom tick-
ets, tuxedo rental, and a prom dress
were all listed as adding to their stress.
With these expenses in mind, the
overall biggest complaint heard
repeatedly was “how to get it.” This
was especially true of young parents
who suddenly found themselves need-
ing to pay for daycare and to purchase
diapers, wipes, formula, and other
miscellaneous items that were neces-
sary for raising a baby. For example,
one young mother stated, “Today I
just found out that my daycare bill is
$120.93, and I’m like, how am I gonna
pay that?” As is evidenced by the ado-
lescents’ statements, money caused a
large amount of stress in their lives,
which is then compounded even fur-
ther for some by parenting.
Relationships. Participants dis-
cussed the troubles they were having
both with their friends and significant
others. Many females seemed to have
problems with young men either
“cheating on them” or “lying” to them.
For instance one girl noted that “they
say that you’re the only one they
messing with and then they’re lying,
[you] find out they mess with some-
body else.” Another comment indicat-
ed that “guys will tell you one thing,
then it’s another thing.” Many of the
girls demonstrated signs of stress
when merely speaking about these
relationships and the young men’s
behavior. Two young women men-
tioned trouble from guys “trying to
pressure you” and who “just don’t
know when to stop.” Conversely,
young men stated that “relationships”
were stressful when asked about their
life stressors. More specifically, “girl-
friends get on my nerves” said one
boy. The overall feeling among the
males regarding relationships was
best stated by one young man, who
said that girls were “nothing but in the
way sometimes.” Topping off the dis-
cussion on relationships was one male
who stated, “Girls ain’t worth my trou-
ble or my time.”
Parents. Several participants re-
ferred to parents as sources of stress.
One teen discussed her father, stating,
“He don’t realize how much pressure
he puts on me.” A second girl
expressed stress about her mom, stat-
ing, “I’m scared of my mom.” Another
teen commented that her parents
“make me sick sometimes.” One par-
ticipant explained that her parents’
daily after-school request of her to
“fold up the clothes, and clean the
bathroom, and make sure that every-
thing’s cleaned before they get home
at like 4:00 or 5:00, and if it’s not
done…oh my, you’re in trouble” posed
PEDIATRIC NURSING/September-October 2008/Vol. 34/No. 5
significant stress in her life. Demands
like these were interpreted as difficult
by several teens given that they got up
early in the morning, went to school
all day, and then came home and were
asked to do chores. This was a prime
example of how various stressors tie
into one another in which schoolwork,
cleaning the house, and fatigue all
created a difficult situation.
Discussion
The teens involved in the focus
groups ranked school as their number
one stressor in life. This held true for
all grade levels and both genders,
demonstrating that school, along with
its associated workload and worries,
caused stress for these teens. These
results coincided with the literature as
school being teens’ main stressor
(Chandra & Batada, 2006; Miller et
al., 2002; National Campaign to
Prevent Teen Pregnancy, 1999). In
addition, several of the other stressors,
including money, relationships, and
parents, were in concert with those
identified in the literature (Chandra &
Batada, 2006; Green et al. 2003; Lau
et al, 2002, Miller et al., 2002). Being
a mother also ranked highly as a
stressor, validating the stressors antic-
ipated associated with being a young
mother (Herrman, 2008).
The participants often used the
term “pressure” to describe their
stress. This referred to “pressure”
from parents to complete chores or
get good grades, from teachers to
hand in assignments, from friends to
always be available on request, or
from significant others. Ethier et al.
(2006) noted that the word “pressure”
was used by teens when describing
the duress placed on teens to partici-
pate in sexual activity or to describe
the need to compare one’s personal
behavior to peers. “Pressure” was a
word that was consistently cited in
other resources; this theme pervaded
the adolescents’ expressions of stress
both in this study and in the literature
(Chandra & Batada, 2006; Miller et
al., 2002).
Another noticeable trend among
the answers given by the teens were
references to the emotions inherent in
their daily lives. For example the teens
often spoke of being “worried” about
exams or grades, graduation, college,
getting pregnant, or simply the future.
Some voiced concerns of doubt, while
others talked about being “upset” or
“mad.” For instance, to sum up the
stressors experienced in the relation-
ship with her parents, one girl stated,
“Oh my gosh, that makes me so
mad!” Comments the teens gave

expressing their emotions of fear or
disdain when discussing their families
included, “I’m scared of my mom,”
“To me, family is foul,” and “They
make me sick sometimes.” As was
seen here, the focus group format
allowed the teens to be open and say
what they truly felt without needing to
hold back. This was also evident in the
teens’ enthusiasm, with many of the
students jumping in with answers to
questions before the entire question
had even been asked. The comments
they then made were often times very
emphatic in nature. For example,
when one girl quickly exclaimed that
“boys!” were a stressor, the next cou-
ple responded with “Yes! Oh my
[gosh]!” and “Yeah, that is stressful.”
Responses like these were seen fre-
quently throughout the interviews.
Despite the fact that the data on
stress found here were taken from a
teen pregnancy prevention study, it
provided insight into the lives of teens
and the daily stressors they face. The
teens’ stressors built upon each other,
causing greater cumulative stress in
their lives. Teenagers expressed feel-
ing overwhelmed by their studies and
schoolwork. They were distracted by
troubles with their friends and signifi-
cant others while attending school.
Upon being dismissed from school,
they returned home to complete all of
the required tasks assigned by their
parents, while putting off studying and
homework. Some teens also had to
juggle a job in order to manage the
costs of a new baby or simply the
costs of living.
Limitations
The sample of this study repre-
sents teens considered to be at risk for
both negative youth behaviors and
pregnancy, and all participants were
from a single state, limiting its gener-
alizability. The timing of the study was
during the last month of the school
year in finals week with graduation on
the horizon, which may have con-
tributed to the emphasis on school as
the highest priority stressor. Although
it is not known whether school was
truly paramount or if the time of
intense emphasis on studying influ-
enced school’s high ranking, much of
the research in the literature cited
school as a major source of stress in
adolescents’ lives (Chandra & Batada,
2006; Green et al., 2003, Lau, 2002;
Miller et al., 2002). The qualitative
nature of this study limits the ability to
generalize findings to a different popu-
lation but does offer insights to the
unique perspectives of teens identified
as high risk.
PEDIATRIC NURSING/September-October 2008/Vol. 34/No. 5
Adolescent Stress through The Eyes of High-Risk Teens
Clinical Implications
Appreciating what teens reported
regarding the stress in their lives leads
to numerous measures that can be
taken to aid them in dealing with those
stressors. First and foremost, adults
need to be aware of the stresses that
confront teens. This study provided
important data related to the teens’
urses, as well as other adults, may make a
N difference by encouraging all teens, no
matter their level of stress, to seek out and talk
to their parents or another adult role model
with whom they are comfortable.
own perception of the stress experi-
ence and the sources of stress they
encounter. Many adults feel that since
the teens have not yet entered adult-
hood, their lives are stress-free. The
realization that teens experience stress
and the origins of those stressors may
assist adults to empathize with teens
and enhance communication between
adults and teens. For many teens,
adults contribute to the high-stress
levels experienced. Disseminating
information about common stresses
and their causes to teens, youth advo-
cates, and families with adolescents is
of prime importance. Because stres-
sors are believed to lead to chronic ill-
ness and due to the potential for ado-
lescents to live long lives, adults need
to be attentive to teen levels of stress
and means to assist adolescent cop-
ing (Goodman et al., 2005).
The key sources of stress offer
insight into the world of teens and the
means to intervene with teens about
the stress experience. It is important to
recognize the role of school in a teen’s
life, as several other sources also iden-
tify school as a major stressor in their
lives (Chandra & Batada, 2006; Green
et al., 2003, Lau, 2002; Miller et al.,
2002). Intervention is necessary to
address these stressors, and adults
should assist teens to cope with school
and its associated stressors.
It may be extremely beneficial for
teens to have access to stress man-
agement programs. Developing such
programs in their schools, recreation
centers, and/or churches, or with the
help of pediatric nurses in hospitals,
would be a valuable resource to aid
them in learning to manage their
stress. Constructing a stress manage-
ment program based on teen percep-
tions of stress may lend validity to the
program content and enhance the
effectiveness of youth-based initia-
tives. Stress management programs
to enhance coping, increase resiliency
resources, increase optimism, and for-
tify community supports may be
effective in assisting teens to deal with
stress (Tussaie et al., 2007).
Simply convening youth to specif-
ically deal with stress or facilitating the
discussion of stress in already estab-
lished group meetings may provide
the opportunity for teens to ventilate
concerns, receive peer and adult
leader support, and pursue healthy
coping mechanisms to manage the
stress inherent of teen life. Support
groups designed to assist teens to deal
with a variety of issues, including loss,
substance abuse, chronic illness, or
violent behaviors, may benefit from
discussions framed within the context
of the universal nature of stress, the
recognition of the teen years as stress-
ful, and the need to learn ways to cope
with stress on a progressive and
developmental basis (Tussaie et al.,
2007). Methods to enhance stress
resilience, including assisting teens to
use cognitive reframing to interpret
stressful stimuli, informing parents of
their need to provide support to teens
during stressful times, and the provi-
sion of psychological counseling as
needed, should be employed to
reduce the stress experience (Tussaie
et al., 2007).
Researchers have explored the
relationship of optimism with increased
abilities to deal with the stressors con-
fronted in daily life (Finkelstein et al.,
2007; Tussaie et al., 2007). Assisting
teens to identify positive aspects of
their lives, providing role models who
have surmounted similar challenges
of social disadvantage, and offering
opportunities for success and happi-
ness may help teens develop the
resilience to handle life stressors
(Finkelstein et al., 2007).
Nurses, as well as other adults,
may make a difference by encourag-
ing all teens, no matter their level of
stress, to seek out and talk to their
parents or another adult role model
with whom they are comfortable.
Having a role model to talk to and
379
confide in during the teen years has ease prevention (Herrman, 2008). Derouin, A., & Bravender, T. (2004). Living on
positive benefits (Tussaie et al., Further studies should be done to the edge: The current phenomenon of
2007). Pediatric nurses may have an compare a larger and more diverse self-mutilation in adolescents. MCN The
impact on a young person’s life sample of high-risk and low-risk teens American Journal of Maternal Child
Nursing, 29(1), 12-20.
through counseling teens and their to explore their array of stressors. Ethier, K.A., Kershaw, T.S., Lewis, J.B., Milan,
families on the value of a mentor. Youth stressors should be examined S., Niccolai, L.M., & Ickovics, J.R. (2006).
They can also help adults build rela- for their role in high-risk behaviors, Self-esteem, emotional distress, and
tionships with teens based on adoles- such as substance abuse, violence, sexual behavior among adolescent
cents’ needs, developmental norms, sexual behavior, and defiance of rules females: Inter-relationships and temporal
and associated stressors. Teens may and laws (Finkelstein et al., 2006). effects. Journal of Adolescent Health, 38,
find that when working with a nurse, They should also be investigated for 268-274.
as someone they can trust, they can their relationship to adolescent mental Finkelstein, D.M., Kubzansky, L.D., Capitman,
become better able to deal with the health issues, including suicide, J., & Goodman, E. (2007). Socioeco-
nomic differences in adolescent stress:
stress in their lives. In their roles as depression, self-mutilation, and anxi- The role of psychological resources.
youth advocates and parent/teen edu- ety. The impact of stress on sleep, Journal of Adolescent Health, 40(2),
cators, pediatric nurses may commu- nutrition, dealing with peer pressure, 127-134.
nicate common stressors to parents school performance, and quality of life Finkelstein, D.M., Kubzansky, L.D., &
as a means to enhance communica- should be topics of research. Future Goodman, E. (2006). Social status,
tion and parents’ capacities to serve research to discover effective coping stress, and adolescent smoking. Journal
as youth role models (Herrman, mechanisms used by teens and the of Adolescent Health, 39(5), 678-675.
2005). means to enhance coping in teens Goodman, E., McEwen, B.S., Dolan, L.M.,
Teens also need to be told the with varying levels of stress and con- Schafer-Kalkhoff, T., & Adler, N.E.
(2005). Social disadvantage and adoles-
importance of being assertive with current manifestations of stress on cent stress. Journal of Adolescent
boyfriends or girlfriends when they their lives should be priorities for pedi- Health, 37, 484-492.
start feeling pressured to engage in atric nurses. Above all, nurses, adult Green, S.E., Holohan, E., & Feldheim, A.
any activity, including sexual behavior, role models, and parents should con- (2003). Stress in the family. Retrieved
for which they may not be ready. sider the stress levels experienced by August 26, 2008, from http://www.ecb.
Discussions related to gender identity, teens, develop ways to reduce those org/guides/pdf/CE_68_05.pdf
difficulties with relationships, personal stress levels, continue to explore the Herrman, J. (2005). The teen brain as a work
attitudes and activities, and high-risk impact of stress on today’s youth, and in progress: Implications for pediatric
behaviors may be initiated from the design interventions to assist teens to nurses. Pediatric Nursing, 31(2), 144-
148.
disclosure of these research findings cope with a complex world. Herrman, J. (2008). Adolescent perceptions of
of the common stressors of adoles- teen births. Journal of Obstetrical,
cents. Stressors associated with sexu- Gynecological, and Neonatal Nursing,
al activity and decision making may 37(1), 42-50.
provide the springboard for further References Lau, B.W.K. (2002). Does the stress of child-
discussion of responsible sexual Chandra, A., & Batada, A. (2006). Exploring hood and adolescence matter? A psy-
behavior, the role of relationships in stress and coping among urban African- chological perspective. The Journal of
American adolescents: The shifting the the Royal Society for the Promotion of
sexual activity, abstinence, compre- lens study. Preventing Chronic Disease:
hensive sexuality education, and teen Health, 122(4), 238-244.
Public Health Research, Practice, and Miller, D.B., Webster, S.E., & MacIntosh, R.
pregnancy/sexually transmitted dis- Policy, 3(2), 1-10. (2002). What’s there and what’s not:
Measuring daily hassles in urban African-
American adolescents. Research on
Social Work Practice, 12(3), 375-388.
Moos, R.H. (2002). Life stressors, social
Adolescence: A Select
ion of Issues resources, and coping skills in youth:
nursing education (CNE)
The purpose of this continuingunderstanding about a selection of
nurse’s
series is

1. Discuss the importance

OBJECTIVES
of maintaining a basic
understanding
Applications to adolescents with chronic
to increase the pediatric

disorders. Journal of Adolescent Health,

adolescence. today’s adolescent.
issues of importance in fraught with change,
a transition of the issues affecting a group of high-risk
Adolescence is a period issues in adoles- common stressors for
adulthood. Although many others, such as 2. List the three most
between childhood and years, adolescents.
the same throughout the with overweight for rural
adoles-
cence have remained the number of over- 3. List three factors associated
the enormous increase in

34, 22-29.
the need to address become a pri-
have only in recent years cents. al deter-
weight or obese teenagers, issues that affect adolescents can help social-cultural, and environment
on 4. Describe behavioral,
ority. Keeping updated
adolescents through
this exciting but often individuals among adolescent
minants of overweight
pediatric nurses guide
Latino/Hispanics. ion of Issues
Adolesence: A Select
stormy time. adoles- keep current on
of three articles that address for pediatric nurses to
This CNE series consists
cent issues. The first
ined adolescent stress
second article reports
article presents findings from
through the eyes of high-risk
the results of a study
a study that exam-
teenagers.
that sought to determine
demographic vari-
The
5. Identify opportunities
adolescent issues.

for X.X contact

c. Acculturation
This offering
is provided by Anthony
to the subtle
refers hours
J.
b. Private health insurance can have
protective effect on the incidence
a
of
National Campaign to Prevent Teen
overweight and obesity, following referrals is an
the association between

weight in Latino/Hispa
nic adolescentsthe
Which of of
11. frequency
and
ables, elevated blood pressure, articleillustration
in rural adolescents. The
third reviews the
and
this healtha.matter
thehealth carestatements

offers
Latino
most
cultural perceptions
of literature
potential strategies
population?
efficaciously
is the
.
Jannetti, Inc.
on over- with Anthony J. Jannetti,
nursing education
accepted language Commission d.
process of change
thinking through
the American
surebywith another
on Accreditationabove
All of theInc.
in behavior and

culture.
(ANCC-COA).
as a provider of continuing
contact and expo-
Inc is accredited
Nurses Credentialing
of continuing edu-
overweight.

income, and adverse health

can all work synergisticall
low-
c. Higher rates of overweight, effects
Center's

y to the dis-
Pregnancy. (1999). What about the
nurses can use to address
Spanish is an approved provider
spoken in most homes.
b. Chubby children are a
Anthony J. Jannetti,
e. None the above
ofBoard of Registered Nursing, CEP No. 5387. advantage of the individual.
sign of health cation by the California publication in the continuing education series
teens? Research on what teens say
Take the CNE
Articles accepted for d. All of the above
ASSIGNMENT in the standard Pediatric
used screening
are reviewed
and prosperity. 13. What that widely
is the most
manuscripts e. None of the above
a sign of are refereed
foods arethe otherchildren
with and to identifyin the journal. RN,
articles appearing
c. Highly saturated
J. (2008). Adolescent
stress through Nursing review for teens
toolprocess Rollins, PhD,
and edited by Judy A.
LaRue, D., & Herrmann, Pediatric Nursing,
eyes of high-risk teens.
Adams, M., Carter, T.,
Lammon, C., Judd,
(2008). Obesity and blood
wealth.34(5), 375-380.
d. Public
pressure tion
Nursing, e.
J., & Wheat,
health insurance
A., Leeper,
in rural adolescents
of prestige.
trends
(5), 381-386.
34None of the above
J. indica-
is an
Pediatric Nursing
FAAN, Pediatric
was reviewed
This testweight concerns?
associate editor, and Veronica
a. Skin foldseditor.
Nursing
b. Waist circumference
and gender
D. Feeg,15. is important to intervene
PhD,It RN,
tions for overweight in
Environmentally, what factors
indirectly contribute to this
in predisposi-
Latino children.
directly or
tendency?
about teen pregnancy: A focus group
Earn X.X Contact Hours
over a decade. Pediatric c. BMI for age

report. Washington, DC: Author.

nic adolescents: of screen time
Overweight in Latino/Hispa a. Less than 2 hours/day
Harrington, S. (2008). and implications.
nursingstatement
Pediatricthe term
defines d. Insulin levels drop-out rate
Scope of the problem 12. What best b. Elevated high school
e. Fasting blood sugars activity and energy
acculturation? c. Increased physical

posttest on
Nursing, 34(5), 389-394.
of behaviors
a. Acculturation is a group QUESTIO ic status is a thread that
practices of NS 14. Socioeconom
expenditure

1. According to this
study, adolescents
that speak to the cultural
a population. One way teens may deal with stress
4. a private the
b. Acculturation isthrough
members
experience
influences
is
many The
8.
health status. Which
practice of “cutting.”
of a partic- statements
a cop-
decisions
current
related toof Adams
analysis
of the following
leagues’ study was based
are true?
the following information?
d. and
e. which
on
the above
All ofcol-
None of the above
Puskar, K.R., & Rohay, J.M. (1999). School
cited several stressors
as particularlyamongst familyExperts believe teens use this as a. Economic insecurity can detrimentally
a. Ten years of observations
intense during the
the following stressors
from this study cite as
teen years. Which
did the teens
their number
of culture.
ular
one
ing mechanism because
a. Allows individuals to
b. Satisfies a need to feel
cutting:
express anger.
pain.
impact food choices.
b. Kindergarten through
dents
c. Repeated cross sectional
12th grade stu-

design PED J806 relocation and stress in teens. Journal of

pages 395 and 396
stressor? to respond to
of Issues
A Selection
the individual design
a. Parents
b. School
c. Relationships
Answer Form: Adolescen
Check the box next to
1. I A 2. I A 3.
c. Helpsce:

d. the
IA
anxiety.
correct
Provides
answer. for past mis-
a punishment
4. I A 5. I A 6.
takes.
I
I A 7. I A 8. I A
I B I B 9. I
d. Traditional longitudinal
e. a and c

B
9. I A 10. I A 11.
According
I A 12. I A 13. I A
I B Baur,Iand
ItoB Lobstein,
I
B UauyI B
C I C
IB
IC
14. I A 15. I A
IB
IC
IB
IC
School Nursing, 15(1), 16-22.
e.I BNone ofIthe B above. B I Cis theIprevalence of being
C ID ID
d. Money IB I ID

Rich, M., & Ginsburg, K.R. (1999). The reason

IB IC C what
IC (2004), ofD5 to 17I
I I Drange I D
e. Job IC IC IC I I inD the age IE IE
IC I D from I D D
overweight IE IE IE
ID
I D demonstrate slower recovery I IE IE
ID I D5. Teens IE IE E worldwide?
years
to this study, which of the fol- I E I E
stressful IE
events.
2. According IE a. 5% TIONS
lowing words do teens
most commonly POSTTEST INSTRUC
a. True ING: b. 6%
and rhyme of qualitative research: Why,
and earn 2.0
for “stress?” E THE FOLLOW
use as a synonym b.COMPLET
False and check the
by others.
c. 10% 1. Select the best answer answer form.
a. Worry
This test may be copied for usehave d. 12% correspond ing box on the
2004, how much as your
b. Hassle 6. Between 1980 and increased? ____________________
e. 15% __
Retain the test questions

when, and how to use qualitative meth-

__________
obesity rates
__________
c. Anxiety Name: ____________________ the adolescent record.
d. Pressure 5.0% to 17.4% ____________________ results are cor-
a.__________ ____________________ 10. Which of the following betweenthe information requested in
e. Strain Address: __________b. 5.0% to 13.9% rect related to the association
__________ 2. Complete
__________ characteris-
6.5% to 18.8%
c.__________ ____________________ obesity and demographic the space provided.
__________
3. A nurse is designing
ment program for teens
a stress manage-
and plans the
____________________
d. 6.7% to 18.8%
_______________State:
________ Zip: tics? ___________
the answer form or a copy
greater risks
adolescents are3.at Detach
of the
Pediatric ods in the study of adolescent health.
contact hours.
City: e. 7.0% to 19.1% a. Older and mail to:
intervention with the knowledge
that: Strongly
of being overweight.
answer form
Strongly Jannetti Pub-
discuss their agree higher, CNE Series,
Nursing
a. Teens are reluctant to 7. According to the
literature, becoming
disagree b. Females have a significantly Inc.; East Holly Avenue
Box
stress and coping mechanisms.
b. Teens do not find adult
effective in learning to deal
Evaluation
role models
1. The objectives relate
with
purpose/goals of the
obese in adolescence
onetoto thewhich
education activity.
problems?
can predispose
overall of the following health
1 2 3 5 being overweight.lications
4risk of
c. Nonwhites are at greater
overweight.
being NJ 08071-005
risk ofPitman,
56;
check or money order for $XX.00
Jannetti
income increases, over- Publications Inc.
6 with a
payable to Journal of Adolescent Health, 25, 371-
stress. The activity met the stated objectives. 3 d. 4As family
5 (nonsubscriber).
a. Hypertension a basic 2
(subscriber) or $XX.00
378.
2.
means 1
c. Teens prefer to use unhealthy a. Discuss the importance b.
of maintaining
Dyslipidemia today’s weight increases.
to deal with stress. the issues affecting e. All of the above. be postmarked by
e the levelunderstanding of c. Pneumonia 4. Test returns must pass the test
d. Adults often underestimat adolescent. resistance
d. Insulin stressors 1 2 3 4 5
October 31, 2010. If you
of stress teens experience. b. List the three most common for a group for X.X
e. a, b, and d (70% or better), a certificate
e. a and b.
c.
of high-risk adolescents.
List three factors associated
rural adolescents.
with overweight for

1
1

2
2

3
3

4
4

5
5
contact hours will be
Anthony395J. Jannetti, Inc.
awarded by

for processing.
Tarrant, B., & Woon, A. (1995). Adolescent sui-
2008/Vol.
Describe behavioral, 34/No.and
social-cultural, 5 environmental Please allow 6-8 weeks the date that
cide: An overview. Australian Journal of
d. r-October
Septembe individuals among adolescent For recertification purposes,will reflect the
PEDIATRIC NURSING/ determinants of overweight
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keep current 1
f. Identify opportunities
for pediatric nurses to date of processing.
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Emergency Care, 2(1), 26-30.

1 2
3. Home study format
was appropriate.
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relevant to my practice. 1 2 3 4
4. The content was needs.
5. The content met my used to complete reading
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Nonsubscriber
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PEDIATRIC NURSING/
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A predictive and moderating model of
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380 PEDIATRIC NURSING/September-October 2008/Vol. 34/No. 5

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