Table of Contents

STRESS AND DEPRESSION AMONG THE OLDEST...........................................................................1

IDENTIFYING SIGNS OF STRESS IN YOUR CHILDREN.......................................................................5

THE IMPACT OF STRESS ON STUDENT...........................................................................................7

REFERENCES.................................................................................................................................13

I
STRESS AND DEPRESSION AMONG THE OLDEST

Elders aged 85 and older are more vulnerable to stress and depression than other age groups
(Blazer 2000; Dunkle, Roberts, and Haug 2001) due to increasing stressors with age resulting
from declining health and dwindling social relationships (Borson et al. 2001). Diminishing
psychosocial resources with increasing age further contribute to increasing depression
(Dunkle et al. 2001; Long and Martin 2000). This is an important consideration as
psychological and social resources act as protective factors to depression by contributing to
decreasing depression directly or mediating the impact of stress on depression (Hobfoll et al.
2003; Holahan et al. 1999; Lazarus and Folkman 1984; Pearlin 1989). Researchers suggest
that there are significant individual differences in available psychosocial resources that
influence the relationship between stress and depression. Some individuals have greater
resources than others, and these may fluctuate over time. Yet, little is known about the
stressors the oldest-old face, what resources they have, and how these influence their
depression. Furthermore, there is not much known about how these relationships fluctuate
over time.

One theoretical perspective that aids our understanding of how stressors and resources are
associated with depression is the stress process model. The stress process model consists of
three key factors: stress, psychosocial resources, and outcome variables (e.g., depression).
This model proposes that psychosocial resources directly influence depressive symptoms. By
contrast, the indirect effect (i.e., mediating effect) in the stress process suggests that the effect
of the stress on depressive symptoms is mediated by psychosocial resources (George
1989; Pearlin 1989; Pearlin et al. 1981). To date, the changing role of psychosocial resources
in the stress process among the oldest-old has not been addressed (Hobfoll 1998).

While the stress process model examines the crucial role of psychosocial resources in stress
research, several issues have not been addressed adequately that are particularly relevant to
the oldest-old. First, most studies have paid little attention to possible variations in the types
of stress experienced by different age groups, with little work on stress with the very old.
With advancing age, elders experience certain types of stressors such as death and health
problems more often than younger people. Hassles are also significant stressors for the very
old and are strongly associated with depressive symptoms (Dunkle et al. 2001; Roberts,
Dunkle, and Haug 1994). Recognizing that stress is multidimensional, this study included
multiple stress variables and allows examination of a variety of types of stressors among
elders in this very old age group. Knowing what stressors are prevalent in this age group can
facilitate mental health intervention.

Second, the dynamics of change in stress and psychosocial resources in relation to change in
depressive symptoms have been overlooked in most research on stress and depression
(e.g., Glass, Kasl, and Berkman 1997; Jang et al. 2002; Roberts et al. 1994). Due to limited
research on the central role of psychosocial resources using longitudinal data, little is known
about how changes in stress and resources are associated with changes in depressive
symptoms in later life. Few studies have employed appropriate research methodology such as
multilevel modeling analysis to address how changes in stress and resources affect depressive

1
symptoms. Understanding how stress and resources affect depressive symptoms would
facilitate mental health intervention.

While there are a few longitudinal studies on the relationships among stress, psychosocial
resources, and depression among the oldest-old (e.g., Dunkle et al. 2001; Johnson and Barer
1997; Roberts et al. 1994), these studies did not examine the association at the individual
level. Individuals differ in the ways they handle the stressors in their lives (Turner and
Roszell 1994) and chronological age may be a significant factor. For instance, the oldest-old
show poorer physical health than do younger age people (Kulminski et al. 2007). Baltes and
Smith (2003) found a high prevalence of dysfunction and a reduced capacity for
improvement among people 85 year of age and older; a state that makes them very different
than all other age groups. Examining these unique qualities of people in this age group is
important in understanding the relationship of stress and depression.

Third, existing studies have paid little attention to the psychosocial resources of the oldest-
old. Psychosocial resources vary depending on the individual and the conditions of life that
the person has experienced (Turner and Roszell 1994). Many cross-sectional studies found
that older adults experience decline in psychosocial resources (Ajrouch, Antonucci, and
Janevic 2001; Ben-Zur 2002; Shaw and Krause 2001), and it is a general notion that this
decreasing trend in psychosocial resources will continue in the very late life stage. The
oldest-old population, however, is not included or folded in with those participants 65 years
of age or older in the majority of research studies examining the change in psychosocial
resources and its underlying mechanism in the stress process. In addition, the physiological as
well as psychological resources of the oldest-old differ in some respects from the younger old
(Baltes and Smith 2003). Whether the findings from the previous research generalize to the
oldest-old is not clear and requires further investigation.
Various meanings of stress have been measured in different ways, for example, major life
events including both negative life events and positive life events (Holmes and Rahe 1967)
and daily hassles (Kanner et al. 1981; Lazarus and Folkman 1984). Although life events
inventories measure stressful situations objectively by asking respondents to indicate whether
a specific event occurred during a certain period of time, the life events scale has been
criticized for not taking into account the individual’s appraisal in determining whether or not
the situation is stressful (Aldwin 1994; Lazarus and Folkman 1984). Measures of hassles are
more likely to emphasize individual variations in perceiving stress (Lazarus and Folkman
1984). Hassles are defined as the irritating or frustrating demands that frequently happen in
an individual’s everyday transactions with their environment (Kanner et al. 1981).
Researchers who focused on negative life events to predict depression (Glass et al. 1997)
found that these events (e.g., as loss of friends due to a move, death of a close
relative/friends, illness of a close relative, loss of a hobby, victimization in a crime, admission
to a nursing home, and hospitalization) are significantly related to increased depressive
symptoms among noninstitutionalized elders aged 65 and older. De Beurs and colleagues
(2001) also found that negative life events (e.g., death of a partner or other relatives, illness of
one’s partner, a major conflict with others, income loss, being a victim of crime and
relocation) were closely related to the onset of depressive symptoms among community-
dwelling elders aged 55 and older. Although these two studies included longitudinal data,
they only assessed between-person differences in the associations between stress and
depression, which limited understanding of the long-term patterns within individuals.

2
Examining another type of stress, daily hassles, Catanzaro, Horaney, and Creasey
(1995) found that these were associated with higher levels of depressive symptoms among
community-living older adults aged 55 and older. Even though the authors examined the
impact of minor stress on depression, the findings were limited by using predominantly
young-old participants in a cross-sectional analysis. Kraaji, Arensman, and Spinhoven
(2002) examined daily hassles as well as negative life events, finding a strong association
with depressive symptoms among the older populations for both types of stressors. One
recent study found that hassles were significantly related to depression among the oldest-old
using longitudinal data (Jeon, Dunkle, and Roberts 2006). This study, however, failed to
examine longitudinal associations on the individual level. Thus, it is not known about the
long-term change in the associations between daily hassles and depression among the oldest-
old. By contrast, another type of stress, positive life events, has received limited attention by
gerontologists. One study by Krause (1988) found that positive life events were significantly
associated with depressive symptoms among older adults. Many researchers found that both
life events and daily hassles are associated with negative mental health outcomes, especially
depression, for older people (Catanzaro et al. 1995; De Beurs et al. 2001; Glass et al.
1997; Jeon et al. 2006).
To look at longitudinal characteristics of stress in existing literature, it is helpful to examine
the relationship between age and stress. In terms of the associations between age and stress,
even though the nature and types of stressors vary depending on age and life course stage
(Pearlin and Skaff 1996), substantial evidence shows that older adults experience fewer life
events and appraise them as less stressful than younger age groups (Aldwin et al.
1996; Folkman et al. 1987; Murrell, Norris, and Grote 1988). Because these studies have
been conducted at the between-person level, longitudinal within-person variability of
stressors among the oldest-old is not known.
For change over time in depression, a number of researchers have examined the relationship
between age and depression, but the findings are inconsistent. Some researchers found a
curvilinear relationship between age and depression, showing that the youngest age groups
and the oldest age group reported greater depressive symptoms than other age groups (Gatz
and Hurwicz 1990; Kessler et al. 1992; Newmann 1989). Including only older adults, Haynie
and colleagues (2001) found that depressive symptoms were negatively associated with age
in very late life. By contrast, other research found that the old-old tended to have higher
levels of depressive symptoms than the young-old (Blazer et al. 1991; Stallones, Marx, and
Garrity 1990), indicating that depressive symptoms are positively associated with age in later
life. Even though many studies examining the relationship between depressive symptoms and
age have been conducted, little is known about the trajectory of depressive symptoms among
the oldest-old.
In summary, although there is abundant research on stress among older adults, the oldest-old
have not received much attention. In addition, gerontologists tend to use only one type of
stressor at a time. Given that stress is multidimensional, this study included multiple stress
variables, negative life events, positive events, and hassles using a sample of very old elders.
In addition, this study examines the relationship of stress and depression over time.
Psychosocial resources are defined as the factors in the internal and external environment that
directly deter negative outcomes or mediate the impact of stress on the outcome (Ensel and
Lin 1991). Mastery and social support have been considered as crucial types of psychosocial
resources (Ensel and Lin 1991; Hobfoll 1998; Pearlin et al. 1981). Psychosocial resources
such as mastery and social support have been considered protective factors against depression
(Badger 2001; Dunkle et al. 2001; Jang et al. 2002; Pearlin et al. 1981). In a study by Jang et

3
al. (2002), elders aged 60 to 84 with a higher level of mastery reported lower levels of
depressive symptoms. Badger (2001) found that mastery was significantly related to lower
depression among community-dwelling elders aged older than 75. These researchers divided
their sample of elders into two groups, mildly depressed and severely depressed. Results
showed that severely depressed elders reported lower levels of mastery than their mildly
depressed counterparts. In addition to mastery, social support was also associated with
depressive symptoms (e.g., Antonucci, Fuhrer, and Dartigues 1997; Taylor and Lynch
2004). Antonucci and colleagues (1997) in a cross-sectional study of French elders (mean age
= 75) found that those with extensive social networks who were satisfied with their quality of
support reported lower levels of depressive symptoms. By using a random coefficient
(growth) model, Taylor and Lynch (2004) found that the trajectory of perceived social
support was significantly associated with the trajectory of depressive symptoms among older
adults. This study, however, showed long-term change in social support and depressive
symptoms among elders aged 65 and older, thus limiting the understanding for the oldest-old
population.
A few researchers have examined how psychosocial resources have changed over the life
span and the associations with other outcome variables (e.g., depression). Regarding change
over time in psychosocial resources, a number of studies showed that mastery and social
network size declined with age (Ajrouch et al. 2001; Ben-Zur 2002; Shaw and Krause 2001).
Although the studies contributed to understanding of psychosocial resources in later life, it
should be noted that most studies have been conducted cross-sectionally. More recently, even
though longitudinal studies were conducted (e.g., Shaw et al. 2007; Wolinsky et al. 2003), the
findings were drawn based on either cross-sectional analysis or used predominantly young-
old as participant. Accordingly, little is known about longitudinal intraindividual changes
over time in psychosocial resources among the oldest-old.
Many studies have examined the mediating model of psychosocial resources in the
relationship between stress and depression and helped to identify the mechanisms through
which stress affects depressive symptoms (George 1989; Hobfoll et al. 2003; Pearlin et al.
1981). For example, Hobfoll and colleagues (2003) found that loss of mastery and social
support mediated the impact of stress on depressive mood among single parents in young
adulthood. Similarly, people aged 18 to 65 reported that life events had a less negative impact
on depressive symptoms when they had a high sense of mastery (Pearlin et al. 1981). To date,
no one has examined this mediating relationship between stress and depression among elders
older than age 85. Our study examines the mediating effect of psychosocial resources on the
relationship between stress and depression (Hobfoll et al. 2003; Pearlin et al. 1981) among an
oldest-old population and the mediating effect of changes in psychosocial resources on the
relationship between trajectories of stress and depression.
In sum, despite numerous studies on stress and mental health among older adults, there are
several gaps to be addressed. First, previous research has paid little attention to the influence
of stress and depression among the oldest-old. Second, many previous studies have employed
between-person and cross-sectional research designs, thus limiting the understanding of the
nature of long-term change in the stress process. Third, stress as a multidimensional factor is
not reflected in previous research. To address these limitations, our study aims to address the
following research questions:

4
IDENTIFYING SIGNS OF STRESS IN YOUR CHILDREN
Young people, like adults, experience stress. It can come from a variety of sources including
doing well in school, making and sustaining friendships, or managing perceived expectations
from their parents, teachers or coaches. Some stress can be positive in that it provides the
energy to tackle a big test, presentation or sports event. Too much stress, however, can create
unnecessary hardship and challenge. Adults can sometimes be unaware when their children
or teens are experiencing overwhelming feelings of stress. Tuning into emotional or
behavioral cues is important in identifying potential problems and working with your young
person to provide guidance and support to successfully work through difficult times.
Youth of all ages, but especially younger children, may find it difficult to recognize and
verbalize when they are experiencing stress. For children, stress can manifest itself through
changes in behavior. Common changes can include acting irritable or moody, withdrawing
from activities that used to give them pleasure, routinely expressing worries, complaining
more than usual about school, crying, displaying surprising fearful reactions, clinging to a
parent or teacher, sleeping too much or too little, or eating too much or too little. With teens,
while spending more time with and confiding in peers is a normal part of growing up,
significantly avoiding parents, abandoning long-time friendships for a new set of peers or
expressing excessive hostility toward family members, may indicate that the teen is
experiencing significant stress. While negative behavior is not always linked to excessive
stress, negative changes in behavior are almost always a clear indication that something is
wrong. Adults will want to pay attention to these behaviors and determine an appropriate
response or intervention.
Stress can also appear in physical symptoms such as stomach aches and headaches. If a
child makes excessive trips to the school nurse or complains of frequent stomachaches or
headaches (when they have been given a clean bill of health by their physician), or if these
complaints increase in certain situations (e.g., before a big test) that child may be
experiencing significant stress.
Sometimes a child may seem like his or her usual self at home but be acting out in unusual
ways in other settings. It is important for parents to network with one another so that they can
come to know how child or teen is doing in the world around them. In addition to
communicating with other parents, being in contact with teachers, school administrators and
leaders of extracurricular activities can help parents tap into their child or teen’s thoughts,
feelings and behaviors, and be aware of any sources of concern.
Because children are often not familiar with the word stress and its meaning, they may
express feelings of distress through other words such as “worried,” “confused,” “annoyed”
and “angry.” Children and teens may also express feelings of stress by saying negative things
about themselves, others, or the world around them (e.g. “No one likes me,” “I’m stupid,”
“Nothing is fun.”). It is important for parents to listen for these words and statements and try
to figure out why your child is saying them and whether they seem to indicate a source or
sources of stress.
Parents, children and teens do not need to tackle overwhelming stress on their own. If a
parent is concerned that his or her child or teen is experiencing significant symptoms of stress
on a regular basis, including, but not limited to those described above, it can be helpful to
work with a licensed mental health professional, such as a psychologist. Psychologists have

5
special training to help people identify problems and develop effective strategies to resolve
overwhelming feelings of stress.

6
THE IMPACT OF STRESS ON STUDENT

Students in secondary and tertiary education settings face a wide range of ongoing stressors
related to academic demands. Previous research indicates that academic-related stress can
reduce academic achievement, decrease motivation and increase the risk of school dropout.
The longer-term impacts, which include reduced likelihood of sustainable employment, cost
Governments billions of dollars each year. This narrative review presents the most recent
research concerning the impact of academic-related stress, including discussion of the impact
on students’ learning capacity and academic performance, mental health problems, such as
depression and anxiety, sleep disturbances and substance use.

Students in secondary and tertiary education settings face a wide range of ongoing normative
stressors, which can be defined as normal day to day hassles such as ongoing academic
demands. Accordingly, secondary/high school (defined here as junior/lower secondary
education and senior/upper secondary education)] (UNESCO, 2012) and tertiary (defined
here as post-secondary education) (UNESCO, 2012) students commonly self-report
experiencing ongoing stress relating to their education, which we refer to as academic-related
stress, such as pressure to achieve high marks and concerns about receiving poor grades. For
example, the Organisation for Economic Co-operation and Development (OECD) recently
conducted a survey involving 72 countries and consisting of 540,000 student respondents
aged 15–16 years. On average across OECD countries, 66% of students reported feeling
stressed about poor grades and 59% reported that they often worry that taking a test will be
difficult. The OECD further found that 55% of students feel very anxious about school
testing, even when they are well prepared. As many 37% of students reported feeling very
tense when studying, with girls consistently reporting greater anxiety relating to schoolwork
compared to boys (OECD, 2017). This data demonstrates that education and academic
performance are a significant source of stress to students. The impact of this ongoing
academic-related stress to student outcomes and well-being has not been comprehensibly
explored. Therefore, the current narrative review explores the impact of academic-related
stress on students’ academic performance, mental health and well-being.

A single author (MP) searched PubMed and Google Scholar for peer-reviewed articles
published at any time in English. Search terms included academic, school, university, stress,
mental health, depression, anxiety, youth, young people, resilience, stress management, stress
education, substance use, sleep, drop-out, physical health with a combination of any and/or
all of the preceding terms. A snowball strategy allowed for examination of references in
identified articles, and inclusion of additional articles as appropriate. The author reviewed all
potential articles for inclusion. Articles from all countries were included in this narrative
review, if a school based (secondary [as defined at grade 7 or higher] or university)
population was included and the study assessed the impact of stress on student mental health,
substance use, sleep, dropout rates, physical activity or academic outcomes. Articles were
included regardless of study design.

Previous research indicates that self-reported stress is associated with the presentation of
anxious states and lower well-being (Carter, Garber, Ciesla, & Cole, 2006; Kessler, 1997;
Robotham & Julian, 2006). The recent above-mentioned OECD survey reports that secondary
students who self-report higher levels of academic-related stress also report lower well-being,
measured using psychological, social, cognitive and physical components (OECD, 2015). A
systematic review of 13 studies showed that in individuals undertaking higher education, self-
reported levels of stress are associated with poorer quality of life and well-being (Ribeiro et
al., 2017). Ongoing stress also precipitates the development of more serious mental health
issues such as anxiety and depression (Kessler, 1997; Moylan, Maes, Wray, & Berk, 2013).
The prevalence of anxiety is as high as 35% in tertiary students (Bayram & Bilgel, 2008;
Eisenberg, Gollust, Golberstein, & Hefner, 2007; Ozen, Ercan, Irgil, & Sigirli, 2010) and the
prevalence of depression is 30% (Ibrahim, Kelly, Adams, & Glazebrook, 2013). The
reciprocal relationship between stress and depression and anxiety is well established
(Dantzer, 2012; Dantzer, O’Connor, Lawson, & Kelley, 2011; Maes, 2008). Indeed, major
stressful life events are one of the best predictors of the onset of depression (Kendler et
al., 1995; Kessler, 1997). Accordingly, in young people the first onset of depression is often
preceded by major life stressors (Lewinsohn, Allen, Seeley, & Gotlib, 1999).

Aside from impairing overall health and well-being, depression and anxiety symptoms can
further adversely affect academic achievement (Bernal-Morales, Rodríguez-Landa, & Pulido-
Criollo, 2015). In undergraduate university students from the United States, those with higher
self-reported anxiety and depression symptoms were found to achieve poorer grades on
examinations (Chapell et al., 2005; Hysenbegasi, Hass, & Rowland, 2005). A longitudinal
study of Hawaiian secondary school students showed that self-reported depressive symptoms
resulted in subsequent poor academic achievement (Kessler, 2012; McArdle, Hamagami,
Chang, & Hishinuma, 2014). This is consistent with the findings of Humensky et al. (2010)
who found that self-reported depressive symptoms were associated with concentration
difficulties and trouble with completing school tasks, in 83 students from the United States
between the ages of 14–21, and at-risk for major depression (Humensky et al., 2010). In a
sample of Finnish students aged 13–17, self-reported depression severity was associated with
concentration difficulties, and poorer social relationships, self-learning, poorer academic
performance, and worse reading and writing outcomes (Fröjd et al., 2008). Therefore, it is not
surprising that young people with depression, particularly males, are less likely to undertake
higher education, as shown in a 15-year longitudinal study of Swedish adolescents (Jonsson
et al., 2010). Importantly, adolescent depression can also result in longer-term poor
employment outcomes, as demonstrated by a 25-year longitudinal study of New Zealand
children (n= 982). This study found that people who had depression at ages 16–21 had greater
rates of welfare dependence and unemployment, demonstrating that the impact of poor
mental health in adolescence can have long-lasting impacts (Fergusson, Boden, &
Horwood, 2007). Enhancing support in the education setting may improve the mental health
of young people. A national telephone survey of United States households showed that the
incidence of depression in college students decreases if students have positive adjustments to
academic life as well as adequate social support (Ross & Mirowsky, 2006). Indeed, an
Australian randomised control trial reported that a gamified online cognitive behaviour
therapy intervention was effective in reducing depressive symptoms in 540 final year
secondary students (Perry et al., 2017). This study demonstrates the potential of education
settings in mediating the impacts of academic-related stress on young people’s mental health.

The health and risk behaviours of young people, including substance use and abuse, are all
important determinants of their current and future health and well-being status (Tountas &
Dimitrakaki, 2006; World Health Organisation, 2004). Academic-related stress can increase
substance use among young people. In a survey study of 128 Grade 11 students attending
competitive private schools in the United States, students who reported experiencing high
ongoing stress, particularly in relation to academic achievement and the tertiary education
admissions process, also reported high rates of drug and alcohol use (Leonard et al., 2015).
The authors report that substance use was associated with a greater desire for academic
achievement, higher perceived stress, less effective coping strategies, and less closeness with
parents (Leonard et al., 2015). In 7th and 8th Grade students from the United States, self-
perceived stress has similarly been reported to be related to substance use. In these students,
coping strategies that included information gathering, problem solving and having a positive
outlook, as well as adult social support and relaxation were inversely related to substance use
(Wills, 1986). This study demonstrates the importance of protective social factors in
mediating the effects of academic-related stress. In a cross-sectional study of tertiary nursing
students from the United States, those with higher self-reported stress had higher incidence of
substance use. Students who had higher perceptions of faculty support used fewer stimulants
to assist them while studying, further demonstrating the proactive role of social factors
(Boulton & O’Connell, 2017). Finally, The Canadian Institute for Health reports that young
people aged 12–19 who feel connected to their school report less anxiety and less risky
behaviours, such as smoking and drinking alcohol, compared to those who do not feel
connected to their schools (Canadian Institute for Health, 2005). Collectively, the above
discussed findings indicate that increased stress is associated with substance use among
students and that perceived social support, including from within the education environment,
may positively mediate this relationship.

Insufficient sleep in adolescents is recognised as a serious health risk by the American

Medical Association and the American Academy of Sleep Medicine, who report that many
young people do not get enough hours of sleep (Owens, 2014). Stress is a contributing factor
to poor sleep in young people (Bernert, Merrill, Braithwaite, Van Orden, & Joiner, 2007;
Curcio, Ferrara, & De, 2006). Noland et al., found that 42% of 9–12th Grade students report
that stress is an impediment to good sleep, in 384 students surveyed (Noland, Price, Dake, &
Telljohann, 2009). Self-perceived stress has been shown to result in poorer sleep in female
university students from the United States (Lee, Wuertz, Rogers, & Chen, 2013; Wallace,
Boynton, & Lytle, 2017), medical students from Saudi Arabia (Almojali, Almalki, Alothman,
Masuadi, & Alaqeel, 2017), university students from Portugal (Amaral et al., 2017) and
Pakistani medical school students (Waqas, Khan, Sharif, Khalid, & Ali, 2015), demonstrating
the cross cultural impacts of stress on sleep quality and quantity tertiary education students.
In a study from the United States, over 90% of 9–12 th Grade students reported that they have
an inadequate number of hours of sleep on most school nights. These young people report
that the impact of the loss of sleep is difficulty paying attention, lower grades, higher stress,
and trouble getting along with other people. Some students reported problematic coping
strategies such as taking sleeping pills, smoking cigarettes and drinking alcohol to help them
sleep (Noland et al., 2009). Sleep quality and quantity has been shown to be closely related to
student learning capability and academic performance (Curcio et al., 2006). Loss of sleep is
frequently associated with poor learning (Curcio et al., 2006). Therefore, stress-related
disruption to sleep quality and quantity is an important factor contributing to poor learning
and well-being among students.

The experience of high levels of academic-related stress increases the risk of young people
developing preventable physical health problems later in life. A systematic review of
prospective studies found that people who were stressed, such as during examination periods,
were less likely to be physically active, the impact of which is associated with a plethora of
potentially inter-related poor physical health outcomes (Stults-Kolehmainen & Sinha, 2014).
Stress may also lead to the development of non-communicable diseases, including metabolic
syndrome, obesity and reduced insulin sensitivity, resulting from unhealthy lifestyle habits
and stress system dysregulation (Pervanidou & Chrousos, 2012). Similarly, stress has been
shown to be associated with increased appetite (Dallman et al., 1993) and higher body weight
(Stephens et al., 1995). Therefore, academic-related stress can contribute to the development
of health issues, including chronic non-communicable diseases, due to decreases in physical
activity and increases in unhealthy lifestyle habits.

The World Health Organisation (1996) states that students must be healthy and emotionally
secure to fully participate in education (World Health Organisation, 1996). Indeed, the
abovementioned OECD survey reports that anxiety about schoolwork, homework and tests
has a negative impact on students’ academic performance in science, mathematics and
reading. The survey highlights that top-performing girls report that the fear of making
mistakes often disrupts their test performance (OECD, 2015). Students in the bottom quarter
of academic performance report feeling far more stressed compared to those in the top quarter
of academic performance. As many as 63% of students in the bottom quarter of science
performance report feeling anxious about tests no matter how well prepared they are, while
46% of students in the top quarter report feeling anxious (OECD, 2015). This demonstrates
that higher perceived stress levels are associated with poorer academic performance.

Previous research shows that the experience of positive and negative emotions are directly
related to levels of student engagement (Reschly, Huebner, Appleton, & Antaramian, 2008).
In 293 students in Grades 7–10 from the United States, the frequency of positive emotions
during classes was associated with higher student engagement. Conversely, the frequency of
negative emotions was associated with lower engagement (Reschly et al., 2008). This finding
is important as engagement in learning is necessary for achievement, as illustrated by the
findings of a survey conducted by the National Union of Students. This survey reported that
the main factors affecting the tertiary studies of Australian university students aged 17–25
was stress (Rickwood, Telford, O’Sullivan, Crisp, & Magyar, 2016). In an observational
study of 456 German undergraduate medical students, higher perceived academic-related
stress was found to predict poor academic performance (Kotter, Wagner, Bruheim, &
Voltmer, 2017). In another study of 121 medical students from Hong Kong, high self-
reported stress levels were similarly related to poorer academic performance (Stewart, Lam,
Betson, Wong, & Wong, 1999). The above findings demonstrate that the academic-related
stress that secondary and tertiary students experience constitutes a major factor affecting their
academic achievement. Students with higher perceived stress are likely to have lower
academic achievement.

Academic-related stress and burnout includes exhaustion, depersonalization, cynicism and

inefficacy or reduced accomplishment (Walburg, 2014). Academic-related stress is strongly
related to decreased student academic motivation (Liu, 2015; Liu & Lu, 2011; Shinto, 1998)
and academic disengagement (National Centre on Addiction and Substance Abuse at
Columbia University (CASA) United States of America, 2003). The relationship between
academic-related stress, motivation and dropout does not appear to be culturally specific,
with similar findings shown from a number of international studies (Liu, 2015; Liu &
Lu, 2011; Shinto, 1998; Walburg, 2014). In 298 Chinese secondary school students,
academic-related stress in Grade 10 negatively predicted intrinsic academic motivation and
positively predicted lack of motivation in Grade 12. This indicates that decreasing academic-
related stress might preserve students’ ongoing intrinsic academic motivation (Liu, 2015; Liu
& Lu, 2011). Similarly, in 495 Japanese students in junior secondary school, self-reported
academic-related stress was found to negatively relate to feelings of self-growth and
academic motivation (Shinto, 1998). A recent literature review highlights how stress and
burnout can also affect academic achievement by increasing the risk for school dropout
(Walburg, 2014). This was particularly true for students who experience more stressful life
events of a more severe nature, as well as students who do not seek support from their parents
or other family members as well as students from ethnically diverse groups (Hess &
Copeland, 2001).

School dropout is associated with a lifelong reduction in earning capacity and secure
employment (Lamb & Huo, 2017). Individuals with lower education levels report having
poorer mental health and more illness than those with higher levels of education (Turrell,
Stanley, de Looper, & Oldenburg, 2006). Early dropout from school has also been reported to
contribute to inter-generational issues including unemployment, poverty and less academic
achievement (Black, 2007; Lamb & Huo, 2017; Muir, Family, Maguire, Slack-Smith, &
Murray, 2003). Academic achievement and completion of secondary school leads to greater
employability, less reliance on social welfare support and a higher likelihood of participation
in further education (Noble, Wyatt, McGrath, Roffey, & Rowling, 2008). These outcomes in
turn increase the likelihood of sustainable employment, adequate income and self-sufficiency
(Noble et al., 2008), which can save Governments hundreds of millions of dollars every year
(Lamb & Huo, 2017).

The current narrative review highlights that students commonly report high levels of
academic-related stress, cross-culturally. The academic-related stress experienced by
secondary and tertiary students’ impacts their mental and physical health and leads to a range
of academic problems. Good stress-management skills have the potential to benefit young
people in an ongoing manner throughout their lives, given that many long-term health-related
behaviours and patterns, both positive and negative, are established during adolescence and
early adulthood (Sawyer et al., 2012). Therefore, providing opportunities to improve young
people’s academic stress-related coping abilities during this highly stressful, crucial period of
development is an important target (OECD, 2015).

The OECD highlights that education settings are places where young people develop many of
the social and emotional skills needed to become resilient and thrive (OECD, 2015).
Therefore, education settings can work to improve student academic related stress through
the provision of programmes shown to decrease stress and increase stress management and
coping. Discussion regarding the efficacy of particular school based stress management
programmes to teach students to cope with stress is beyond the scope of the current review. It
worth noting, however, that education-based initiatives that focus on increasing students
skills and ability to cope with stress have been previously demonstrated to directly and
positively influence educational achievement and decrease health risks (Hanson &
Austin, 2002; Perry et al., 2017; Weare & Gray, 2003). For example, a meta-analysis of 19
randomised controlled trials or quasi-experimental studies found that school programmes
targeting stress management or coping skills reduced stress symptoms and improved coping
skills among students (Kraag, Zeegers, Kok, Hosman, & Abu-Saad, 2006). Schools provide
access to a large number of young people, across a diverse range of backgrounds, during a
formative developmental period (Sawyer et al., 2012). As such, even if modestly effective,
the population level implementation of stress management and coping skills programmes
would help young people to develop healthy coping strategies in order to deal with the
inevitable stressors of life. Understanding and addressing the barriers and enablers to
implementation of stress management programmes in schools would support the development
of effective implementation strategies (Albers & Pattuwage, 2017; Domitrovich et al., 2008),
resulting in significant health, economic and social benefits for large numbers of young
people, their families and the community.
A strength of the current review is that we have discussed studies from many countries,
indicating that the academic-related stress experienced by students in education is cross-
cultural and wide spread and is of international concern. We reviewed studies that
demonstrated a range of negative effects of academic-related stress, highlighting the potential
broad spectrum of benefits that may result from the implementation of stress-management
interventions. A limitation of the current study is that we have not delineated between studies
that have assessed the impact of academic-related stress during different phases of secondary
and tertiary education. It is more than likely that the needs and therefore the most beneficial
coping strategies may vary throughout the life span. Therefore, the most appropriate stress-
management education approaches may differ between the early high school and tertiary
education years.

This narrative review highlights that academic-related stress is a major concern for secondary
and tertiary students. The ongoing stress relating to education has demonstrated negative
impact on students’ learning capacity, academic performance, education and employment
attainment, sleep quality and quantity, physical health, mental health and substance use
outcomes. Increasing students’ stress-management skills and abilities is an important target
for change.
REFERENCES

1. https://www.tandfonline.com/doi/full
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3092309/
3. https://www.apa.org/topics/stress-children