Stress, and humans physiological and psychological

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1 Adolescent Male Health Stress and Stress Management Among Youth and Young Men American Journal of Men s Health Volume 2 Number 4 December Sage Publications / hosted at Dzung X. Vo, MD, and M. Jane Park, MPH Stress, and humans physiological and psychological responses to stressors, has a strong influence on health status (Cohen, Janicki- Deverts, & Miller, 2007; McEwen, 1998). A substantial body of research links stress to mental and physical health outcomes as well as behaviors that jeopardize health. The stress and stressors literature is vast and spans decades. Definitions and measurements of stress vary in this literature. Some research assesses physiological reaction to events or conditions considered stressful. Many studies examine psychosocial measures of stress, which can be broadly categorized as objective or subjective. Objective or environmental stressors may be acute (e.g., events such as natural disaster or the death of a relative) or chronic (e.g., poverty). Subjective measures assess individuals perceived stress (e.g., frequency of feeling stressed or self-reported ability to cope with life hassles). Some research investigates stress as a mediator (e.g., between socioeconomic status [SES] and health status); some research examines coping mechanisms as a mediator between stress and health outcomes. Adolescence presents a critical period to foster stress management skills. The second decade of life involves tremendous cognitive development that increases adolescents ability to think abstractly, reason, and plan (Halpern-Felsher, Millstein, & Irwin, 2002; Keating 1990). Inherent in this development is an emerging capacity to recognize stress and actively manage it. Stress research with adolescents has focused on outcomes that can be measured in youth, such as mental health problems and health-damaging behaviors. Stress research in adult populations has From The Division of Adolescent Medicine, University of California, San Francisco, California. Address correspondence to: M. Jane Park, Box 0503, LH245, San Francisco, CA ; examined a broader range of health issues. Thus, promoting effective stress management in adolescence has implications for health across the lifespan. Studies have also examined stressors that adolescents face, using both subjective and objective measures. Although researchers debate which method is better suited for adolescents (Grant et al., 2003), this literature has identified many sources of stress experienced by adolescents. Some researchers report on daily hassles common in adolescence, such as conflicts with family and peers and academic pressure (and consequent lack of free, child-driven play); other research examines less common chronic and acute stressors, such as chronic illness, parental divorce, poverty, natural disaster, exposure to violence in communities, and sexual abuse (Compas, Connor-Smith, Saltzman, Thomsen, & Wadsworth, 2001; Finkelstein, Kubzansky, Capitman, & Goodman, 2007; Ginsburg, 2007a; Rasmussen, Aber, & Bhana, 2004; Turyk et al., 2007). This column will review research on how stress influences health outcomes and how effective coping mechanisms and stress management can reduce the negative impact of stress. Implications for practice and interventions in clinical and community settings are discussed. Whereas most research in these areas focuses on adults, the column highlights findings related to adolescents. Also highlighted is the relatively small literature that examines gender differences in stress and coping. Although this column focuses primarily on stress and stress management among individuals, it is critical to note that environments significantly influence stress exposure. A large literature on resilience has examined factors that lead young people to thrive despite exposure to adverse circumstances and stressors that threaten healthy development. This field of research has evolved from a focus on individual traits of resilient youth to identifying 353

2 354 American Journal of Men s Health / Vol. 2, No. 4, December 2008 aspects of adaptive systems that protect youth from negative consequences. Protective aspects include a close relationship with parents, opportunities for mastery and learning, and relationships with positive adults (Masten, 2007). Although it is important to strengthen individuals capacity to cope with stress and adversity, it is also critical to develop social policies that reduce stressors in the environment. Although such policies, for example, policies to reduce poverty, maltreatment, and violence, are beyond the scope of this column, it is nonetheless critical to note their importance. The Role of Stress in Health Hans Selye s (1936) classic theory of stress described the physiological response to perceived threats, often simplified as the fight-or-flight response (McEwen, 2005). A widely cited extension of this theory holds that stressful events of daily life cause repeated cycles of physiological and psychological changes, which result in allostatic load, or wear and tear on the body and brain. This model holds that the body s responses to acute stress are potentially adaptive in the short term, but can lead to deleterious health effects on many systems of the body in the long term (McEwen, 1998; McEwen & Seeman, 1999). A substantial body of research has examined the effects of stress on mental health as well as cardiovascular disease, and immune, endocrine, and metabolic function. In addition, a growing literature has implicated psychosocial stress and psychological distress in the development of a variety of nonspecific and medically unexplained somatic symptoms, or functional disorders (Hatcher & Arroll, 2008). Stressors and Mental Health A large body of research implicates stress in various mental health disorders among youth and adults. Several large studies among adults have linked chronic work-related stress and mental disorders in adults. High job strain, increased psychological demands, and job insecurity are strongly associated with depression, particularly among men (Blackmore et al., 2007; Cohen et al., 2007; Virtanen et al., 2007; Wang, 2005; Wang, Lesage, Schmitz, & Drapeau, 2008). Current evidence supports the importance of acute and chronic life stressors in the development of psychopathology among adolescents, a relationship largely mediated by family-based variables (Grant et al., 2003; Grant, Compas, Thurm, McMahon, & Gipson, 2004; Grant et al., 2006). It is well-known that life stress and exposure to stressful life events is a risk factor for suicide in youth (Gould, Greenberg, Velting, & Shaffer, 2003). Other research has linked perceived stress and/or stressful life events in adolescents and young adults to tobacco smoking (Siqueira, Diab, Bodian, & Rolnitzky, 2000), drug and alcohol use (Broman, 2005), and marijuana use (Siqueira, Diab, Bodian, & Rolnitzky, 2001). These findings suggest a potential role of self-medication for stress and psychological symptoms among adolescents. Research suggests normal brain development may be particularly vulnerable to stress during adolescence and puberty (Romeo & McEwen, 2006), making adolescents vulnerable to developing depression (Andersen & Teicher, 2008) and bipolar spectrum disorder (Alloy, Abramson, Walshaw, Keyser, & Gerstein, 2006). Young, postpubertal males appear to be less vulnerable to developing these two disorders compared with their female counterparts, in part because of hormonal differences (Andersen & Teicher 2008) and a less negative and ruminative cognitive style (Alloy et al., 2006). Studies examining the effects of gender in stress and psychopathology in adolescents have reported that, compared with girls, boys are more likely to respond to stressors with externalizing symptoms (such as aggression); and that particular stressors including poverty, divorce, and abuse appear to be associated with higher risk for negative outcomes among boys (Grant et al., 2006). Cardiovascular Disease and Related Conditions Research also implicates chronic stress in the development of hypertension, atherosclerosis, and cardiovascular disease (CVD; Esch, Stefano, Fricchione, & Benson, 2002; Krantz & McCeney, 2002; Rozanski, Blumenthal, & Kaplan, 1999). This literature largely focuses on adults. Literature links several personality traits, including anger as a response to stress, to the development of CVD (Rozanski et al., 1999). A large prospective study of young men reported an association between self-reported anger reactions to stress and premature CVD and myocardial infarction (Chang, Ford, Meoni, Wang, & Klag, 2002). Other research has confirmed the role of anger in CVD (Kubzansky, Davidson, & Rozanski, 2005; Shah, White, White, & Littler, 2004).

3 Stress and Stress Management / Vo, Park 355 There is relatively less literature on the cardiovascular effects of stress during adolescence and young adulthood, in part because it is difficult to study endpoint CVD outcomes in youth. The relatively small studies to date mostly support the role of anger and chronic stressors in the development of hypertension in adolescents and suggest that young males are particularly vulnerable to this effect (Clark & Armstead, 2000; Johnson, Spielberger, Wordern, & Jacob, 1987; Weinrich et al., 2000). Researchers investigating possible mechanisms between chronic stress and CVD point to corticosteroid and catecholamine dysregulation and chronic vascular inflammation (Black, 2006; Rozanski et al., 1999; Shah et al., 2004), which is consistent with the allostatic load model of chronic stress. Stress and the Immune System Literature in psychoneuroimmunology, endocrinology, and related fields have provided insights to help understand how stress can alter the complex relationships between the brain, endocrine, and immune systems to contribute to the development of disease (Blalock & Smith, 2007; Kemeny & Schedlowski, 2007). Stress affects the functioning of the autonomic nervous system and the hypothalamic pituitary adrenal (HPA) axis, which in turn affects immune functioning via various immunomodulators including catecholamines (e.g., epinephrine, norepinephrine) and glucocorticoids (e.g., cortisol; see Figure 1; Padgett & Glaser, 2003; Ziemssen & Kern, 2007). Although research has demonstrated that acute stress enhances the immune system, there is persuasive evidence that chronic stress suppresses immunity (Dhabhar, 2002; Godbout & Glaser, 2006; Kemeny & Schedlowski, 2007). Persuasive evidence indicates that stress increases susceptibility to viral respiratory infections, a relationship mediated by cytokine and cortisol regulation; increased social support and higher SES may be protective (Cohen, 2005). Stress plays a role in the recurrence of viral infections such herpes simplex virus Types 1 and 2, Epstein Barr virus, and herpes zoster virus (Cohen et al., 2007; Godbout & Glaser, 2006; Ziemssen & Kern, 2007). A small literature examining links between stress and cancer has provided inconclusive evidence for stress contributing to the initiation and progression of cancer (Cohen et al., 2007; Godbout & Glaser, 2006; Reiche, Nunes, & Morimoto, 2004). Similarly, the evidence to date regarding the role of stress in autoimmune diseases is inconclusive (Kemeny & Schedulowski, 2007). Emerging research suggests that personality and coping style may influence immunologic Figure 1 The brain, the immune system, and stress. As part of the stress response, the hyopthalamus releases corticotropinreleasing hormone (CRH), which stimulates the pituitary gland to release adrenicorticotropin hormone (ACTH). ACTH acts on the adrenal glands to release the stress hormone cortisol, which acts on the immune system in complex ways. Source: Wein (2000), from the National Institutes of Health. responses to stressors (Kiecolt-Glaser, McGuire, Robles, & Glaser, 2002a). Stress and Metabolic Disorders Another body of literature suggests that chronic stress plays a role in the development of metabolic disorders including obesity, insulin resistance, and Type 2 diabetes mellitus (DM; Mietus-Snyder & Lustig, 2008; Tsatsoulis & Fountoulakis, 2006), which are increasingly serious public health problems among children and adolescents (Institute of Medicine, 2004). It is well-known that glucocorticoids and catecholamines, sometimes referred to as stress hormones or counter-regulatory hormones, oppose the action of insulin (Black, 2006; Brindley & Rolland, 1989). Emerging research supports the hypothesis that chronic stress leads to dysregulation of the HPA axis, causing chronic elevations of these hormones, contributing to the development of insulin resistance, Type 2 diabetes, visceral fat, and obesity (Black, 2006; Brindley & Rolland, 1989; Dallman et al., 2003). Research in animal models and human studies provides preliminary evidence supporting the hypothesis that chronic and acute stress causes increases in stress eating, and especially of calorie-dense comfort

4 356 American Journal of Men s Health / Vol. 2, No. 4, December 2008 foods, thereby contributing to obesity and insulin resistance (Dallman et al., 2003; Mietus-Snyder & Lustig, 2008; Pecoraro, Reyes, Gomez, Bhargava, & Dallman, 2004; Roemmich, Gurgol, & Epstein, 2003; Roemmich, Smith, Epstein, & Lambiase, 2007; Roemmich, Wright, & Epstein, 2002; Tsatsoulis & Fountoulakis, 2006). Gender Differences in Stress Responses Several studies have reported that, in response to a variety of stressors, women subjectively experience more stress and report more symptoms of stress than men and that perceived stress in women (but not men) is associated with health symptoms (Kudielka & Kirschbaum, 2005; Weekes, MacLean, & Berger, 2005). Research on gender differences in interpersonal relationships has reported that adolescent girls in general are more vulnerable to experiencing relationship stress and associated psychological distress; and that adolescent girls tend to find loss of closeness in relationship more stressful, whereas adolescent males tend to find loss of status in peer group more stressful (Rudolph, 2002). Some researchers have criticized the fight-or-flight model for inadequately describing stress responses in females and cite evidence that suggests that females are more likely to respond to stress by seeking social connection, caregiving, and nurturing behaviors, a response sometimes termed the tend-and-befriend response (Taylor et al., 2000). Recent research investigating HPA axis responses to stressors offers preliminary support for this view. Findings generally suggest that males experience higher cortisol responses to stress than women. Gender differences in stress response may be in part modulated by hormonal differences (Ennis, Kelly, & Lambert, 2001; Kajantie & Phillips, 2006; Kudielka & Kirschbaum, 2005; Taylor et al., 2000). Gender differences in HPA axis responses to stress are hypothesized to play a role in the observed gender disparities of stress-related diseases such as CVD and autoimmune diseases (Becker et al., 2007; Kudielka & Kirschbaum, 2005). Stress Management Strategies and Interventions Stress and Coping in Adolescents Although this section focuses on nonpharmacologic stress interventions, it should be noted that adolescents, like people of all ages, manage stress in a variety of ways. Definitions and measurement of coping in the literature vary, but coping generally refers to cognitive and behavioral efforts to manage stress (Bonica & Daniel, 2003; Compas et al., 2001). Various coping strategies and models have been described in youths. These include engagement or approach coping (which acknowledges stressful thoughts and emotions) versus disengagement or avoidance coping (which is oriented away from thoughts and emotions); and problem-focused coping (which emphasizes acting on the source of stress in the environment) versus emotion-focused coping (which emphasizes expressing one s emotional response to stress and seeking support; Bonica & Daniel, 2003; Compas et al., 2001). Although the relationships between stress, coping strategies, and resilience appear to be complex, the literature overall strongly suggests that coping is important in the psychological and physical health of youth, including adolescent health risk behaviors (Bonica & Daniel, 2003; Compas et al., 2001). There is some evidence that more active coping styles such as engagement and problem-focused coping are generally associated with better psychological functioning among adolescents (Clarke, 2006; Compas et al., 2001; Steiner, Erickson, Hernandez, & Pavelski, 2002). Accumulating evidence documents the beneficial effects of regular exercise in preventing or reducing the deleterious psychological, metabolic, and physiologic effects caused by chronic stress (Tsatsoulis & Fountoulakis, 2006). Healthy sleep patterns also affect mood regulation, coping, and mental health of adolescents; and psychosocial stress is known to disrupt normal sleep patterns, which can set up a vicious cycle of sleep and mood dysregulation (Dahl & Lewin, 2002; Graham, 2000). Mindfulness-Based Stress Reduction Mindfulness-based stress reduction (MBSR) is a strategy developed and initially implemented by Jon Kabat-Zinn at the University of Massachusetts Medical School in 1979 (Kabat-Zinn, 2003). Influenced by Eastern contemplative meditation practices, Kabat-Zinn (2003) has proposed an operational definition of mindfulness as... the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment (p. 145). This approach has been hypothesized to

5 Stress and Stress Management / Vo, Park 357 increase effective coping and behavioral change across a range of stressors by responding to stressful situations intentionally and effectively, rather than reacting with escalating panic or fear, thereby modulating the fight-or-flight and other psychological and physiological responses to stress (Miller, Fletcher, & Kabat-Zinn, 1995, p. 197). The standard MBSR curriculum is a skill-based and psychoeducational training program, consisting of 8 to 10 weekly group sessions that involve formal lectures, daily homework exercises, formal sitting meditation, body scan, walking meditation, and yoga (Baer, 2003; Proulx, 2003). A growing body of research has reported promising results of interventions using mindfulness-based interventions in patients with psychiatric illnesses. This includes studies of mindfulness-based cognitive therapy (MBCT), a variation of MBSR that incorporates theory and techniques of cognitive therapy. Several relatively small, uncontrolled studies of adults with generalized anxiety disorders have reported reduced anxiety and depressive symptoms after MBSR (Miller et al., 1995) or MBCT (Evans, et al., 2008). Several more recent randomized controlled trials in chronically depressed adults have reported that MBCT reduces residual depressive symptoms and dramatically reduces relapse rates of depression (Kingston, Dooley, Bates, Lawlor, & Malone, 2007; Ma & Teasdale, 2004; Teasdale et al., 2000; Williams, Russell, & Russell, 2008). Dialectical behavioral therapy, a form of individual psychotherapy that employs mindfulness training and cognitive-behavioral techniques, has been demonstrated in multiple well-controlled trials to be effective for the treatment borderline personality disorder; and preliminary evidence is emerging that supports the application of dialectical behavioral therapy in other psychiatric disorders including treatment-resistant depression and binge-eating disorder (Lynch, Trost, Salsman, & Linehan, 2007). Very preliminary evidence in adult populations also suggests that mindfulness-based interventions may be effective in the treatment of suicidality (Williams, Duggan, Crane, & Fennell, 2006), binge-eating disorder (Kristeller & Hallett, 1999), insomnia (Winbush, Gross, & Kreitzer, 2007; Yook et al., 2008), and bipolar disorder (Williams et al., 2008). Mindfulness training has been proposed for treating substance abuse as a skill for coping with negative thoughts, relapse triggers, and cravings (Bowen, Witkiewitz, Dillworth, & Marlatt, 2007; Marlatt & Chawla, 2007). Studies examining the impact of mindfulness meditation on substance abuse among high-risk adult populations have yielded promising, but mixed, results (Alterman, Koppenhaver, Mulholland, Ladden, & Baime, 2004; Bowen et al., 2006, 2007). There is also a growing literature examining mindfulness-based interventions in adults with medical illnesses. Several reviews of the literature have reported preliminary evidence that MBSR improves medical symptoms in a variety of conditions including chronic pain, psoriasis, and fibromyalgia (Baer, 2003; Bishop, 2002; Grossman, Niemann, Schmidt, & Walach, 2004; Proulx, 2003). Preliminary evidence also suggests that MBSR helps patients cope with the stress and physical symptoms related to a variety of psychological and medical conditions, suggesting a role for mindfulness strategies in coping with morbidity associated with chronic illness (Majumdar, Grossman, Dietz-Waschkowski, Kersig, & Walach, 2002; Reibel, Greeson, Brainard, & Rosenzweig, 2001). Two small, randomized, controlled trials of MBSR in nonclinical populations demonstrated decreased perceived stress and improved psychological functioning in the intervention groups (Astin, 1997; Williams, Kolar, Reger, & Pearson, 2001). Another body of literature has examined the role of mindfulness-based interventions in patients with cancer as a strategy to manage stress, promote relaxation, and alleviate physical discomfort and emotional distress. A randomized wait-list controlled study of adults with heterogeneous types and stages of cancer reported significantly lower symptoms of mood disturbance, anger, depression, confusion, stress, and physical symptoms in the intervention group (Carlson, Ursuliak, Goodey, Angen, & Speca, 2001; Speca, Carlson, Goodey, & Angen, 2000), findings consistent with other, mostly uncontrolled, studies of MBSR in cancer patients (Ott, Norris, & Bauer-Wu, 2006). Several studies reported improvements in psychological outcomes such as quality of life, symptoms of stress, sleep quality, and exercise in patients with breast and prostate cancer who underwent MBSR training (Carlson, Speca, Faris, & Patel, 2007; Carlson, Speca, Patel, & Goodey, 2003). These studies reported intriguing alterations in adrenal hormones, cortisol levels and secretion patterns, and decreased systolic blood pressure as well as a shift in immune cytokine patterns from a proinflammatory towards a more anti-inflammatory profile (Carlson et al., 2003, 2007; Carlson, Speca,

6 358 American Journal of Men s Health / Vol. 2, No. 4, December 2008 Patel, & Goodey, 2004). These findings raise the possibility that stress management interventions in cancer patients may affect not only reported coping and mood symptoms but also physiological parameters believed to play a role in health and disease. There is relatively less literature on MBSR among underserved populations and among youth. Several studies, mostly among Latino inner-city adults with heterogeneous medical issues, have reported evidence that MBSR improved medical and psychological symptoms, reduced chronic care medical visits, and was feasible and acceptable in this population (Roth & Creaser, 1997; Roth & Robbins, 2004; Roth & Stanley, 2002). A relatively small randomized wait-list control study of MBSR among premedical and medical students reported improved psychological distress and depression and increased empathy in the intervention group (Shapiro, Schwartz, & Bonner, 1998). Another randomized wait-list controlled trial of predominantly White female college undergraduates compared MBSR with another meditation-based stress management program. This study reported that both intervention groups had similar reductions of perceived stress and rumination, and that these improvements were mediated by higher scores on a mindfulness scale (Oman, Shapiro, Thoresen, Plante, & Flinders, 2008; Shapiro, Oman, Thoresen, Plante, & Flinders, 2008). Research on mindfulness-based interventions in children and adolescents is sparse (Ott, 2002). A pilot study of an intervention combining techniques from MBSR and Tai Chi at an inner-city middle school reported that such an intervention was feasible and acceptable in this age group and population. This report also underscored the importance of adapting mindfulness-based interventions for the developmental level of the participants (Wall, 2005). A randomized controlled study among healthy normotensive middle school students examined the effects of a simplified MBSR intervention on blood pressure and reported small but significant reductions in resting and ambulatory blood pressure and heart rate in the intervention group (Barnes, Davis, Murzynowski, & Treiber, 2004). Limitations of research on MBSR include methodological limitations, little research on cultural and racial/ethnic components of mindfulness, relatively few studies with youth subjects, and little discussion on gender-related aspects of mindfulness-based interventions. Despite these limitations, the literature to date offers promising evidence that mindfulness training can offer psychological and perhaps physiological benefits to patients with a range of psychiatric and medical illnesses. Further research should employ more rigorous methodology, investigate mindfulness interventions in youth populations, and examine possible gender differences in the intervention (Baer, 2003; Bishop, 2002; Grossman et al., 2004; Kabat-Zinn 2003; Proulx 2003). Mind Body Medicine and the Relaxation Response Other interventions employed to manage stress and the effects of stress on health include other forms of meditation (such as transcendental meditation), yoga, tai-chi, chi-gong, biofeedback, autogenic training (self-hypnosis), and progressive muscle relaxation. In the scientific literature, this heterogeneous group of interventions is sometimes broadly referred to as mind body techniques or grouped together under the umbrella of mind body medicine (Benson-Henry Institute for Mind Body Medicine; Esch, Fricchione, & Stefano, 2003; Vitetta, Anton, Cortizo, & Sali, 2005). The mind body medicine paradigm also emphasizes the importance of proper nutrition and exercise and reframing negative thinking patterns (Benson-Henry Institute for Mind Body Medicine; Jacobs, 2001a). This paradigm proposes that mind body interventions may be particularly useful to reduce stress from general psychosocial stressors and/or medical illness as well as an adjunctive strategy to treat stress-related illnesses (Jacobs, 2001b). These interventions are hypothesized to affect physiological responses to stress by inducing the relaxation response, an integrated pattern of physiological changes that opposes the fight-or-flight stress response, reduces sympathetic nervous system and autonomic nervous system activity, increases parasympathetic nervous system activity, and improves immune functioning (Benson, 1982; Deckro et al., 2002; Jacobs, 2001b). Although the scientific literatures on mind body medicine/relaxation response and mindfulness-based interventions are generally separate, the two models share certain major assumptions and often employ similar techniques, including yoga and sitting meditation (Baer, 2003; Wall, 2005). The literature on mind body medicine and the relaxation response is still developing and has methodological limitations. Several reviews of the literature have reported that mind body interventions and relaxation response techniques appear to be beneficial in headaches, certain autoimmune

7 Stress and Stress Management / Vo, Park 359 diseases, chronic pain, insomnia, anxiety and depression, and hypertension and CVD (Esch et al., 2003; Jacobs, 2001a). Research on the potential benefits of mind body interventions on immune functioning have reported overall promising, but mixed results (Kiecolt-Glaser, McGuire, Robles, & Glaser, 2002b). Relaxation training is widely used among patients with cancer. A randomized controlled trial of a group intervention that included stress management and relaxation training among adults with melanoma reported reduced distress, improved coping, alterations in variables associated with improved immune functioning, and improved medical and mortality outcomes in the intervention group (Fawzy, Canada, & Fawzy, 2003). Other controlled studies of similar interventions among patients with cancer have confirmed the benefits of these interventions on psychological functioning, but have reported mixed results with regards to survival and mortality benefits (Boesen et al., 2007). Several studies have examined the use of mind body interventions and relaxation response among youth populations. A randomized wait-list controlled study of a formal 6-week multicomponent mind body training intervention among college students reported significantly decreased psychological distress, anxiety, and perceived stress in the intervention group (Deckro et al., 2002). Another randomized controlled trial of a stress management program among college students employed cognitive behavioral techniques, social support, and psychoeducation and reported improved resilience and coping and lower perceived stress in the intervention group (Steinhardt & Dolbier, 2008). A randomized controlled trial of progressive muscle relaxation training among male adolescents in Germany who reported subjective stress and had high scores on an anger expression scale reported significantly decreased anger scores as well as decreased salivary cortisol concentrations in the intervention group (Nickel et al., 2005). A randomized controlled trial examined the effects of stress reduction on blood pressure among inner-city African American adolescents (approximately 70% of whom were overweight); it compared transcendental meditation to a health education control group in a high school setting and reported that subjects in the transcendental meditation group had significantly reduced systolic blood pressure at 4 months, with a decrease in daytime systolic blood pressure of about 3.9 mm Hg (Barnes, Treiber, & Johnson, 2004). Several studies have examined stress management interventions in youth with DM. A randomized controlled trial of a stress management curriculum among adolescents and young adults with Type 1 DM employing psychoeducation, progressive muscle relaxation, and counseling around diet and exercise, reported significantly improved coping as well as improved glycemic control in the intervention group (Attari, Sartippour, Amini, & Haghighi, 2006). Another randomized controlled trial of cognitive coping skills training intervention among adolescents with Type 1 DM also reported improved psychological functioning and glycemic control in the intervention group (Grey et al., 1998; Grey, Davidson, Boland, & Tamborlane, 2001). This literature suggests that stress management should be an integral part of chronic disease management. Health Realization Another paradigm for stress management is referred to as health realization. This model starts with the assumption that people have innate wellbeing and internal resiliency to psychosocial stressors and aims to promote or restore this innate psychological health by reversing negative or unhealthy thought processes (Kelley, 2003, 2004). Health realization based psychotherapy has shown promise in adults with a range of psychiatric diagnoses (Kelley, 2004). Educational and empowerment programs based on the health realization/innate health model have been implemented with high-risk youth in a variety of settings including violenceridden housing projects, youth development programs, schools, and juvenile justice centers. These projects have reported improvements in school and family functioning and in subjective psychological functioning (Kelley, 2003, 2004). Implications for Clinical Services and Programs Clinicians and service providers can play an important role in identifying and helping youth and young men cope with stress. Preventive health counseling should involve routine screening for stress-related problems and psychoeducation regarding the role of stress in health and disease (see Table 1). Youth with risk factors such as chronic health conditions, medically unexplained somatic symptoms, low SES, unstable family environments, or exposure to violence, may have special needs related to stress and stress management which should be explored.

8 360 American Journal of Men s Health / Vol. 2, No. 4, December 2008 Table 1 Stress Management Resources for Clinicians and Patients Screening and counseling methods for primary care clinicians HEEADSSS (Goldenring & Rosen, 2004) is a popular psychosocial interviewing method for youth. HEEADSSS stands for home, education, eating, activities, drugs, sexuality, suicide/depression, and safety. SHADESS (Ginsburg, 2007b) is a modification of the HEEADSSS interview, which underscores resiliency by opening with questions about strengths, before questioning about risks. SHADESS stands for school, home, activities, drugs/substance use, emotions/depression, sexuality, and safety. BATHE (Lieberman & Stuart, 1999) is a brief supportive interviewing technique, adapted from psychotherapy for the primary care setting, used to explore and counsel patients around behavioral and stress-related concerns. BATHE stands for background, affect, troubling, handling, empathy. Mindfulness. Interest in MBSR has increased rapidly, with over 240 hospitals and clinics now offering mindfulness-based stress reduction (MBSR) classes nationwide. Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School, offers a directory of MBSR classes nationwide as well as trainings for clinicians and educators, and scientific conferences. Clinicians can refer patients to MBSR classes ( Kabat-Zinn s (1990) widely read book contains an overview of mindfulness techniques as well as a description of the Stress Reduction Program at the University of Massachusetts. Suitable for clinicians and patients. Mind body medicine The Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital provides outpatient services as well as trainings for clinicians and policy makers. They also offer audio and video resources teaching relaxation techniques ( The National Institutes of Health maintains a Web site with an overview of mind-body medicine ( Schaffer and Yucha (2004) offer a practical, step-by-step description of how clinicians can apply relaxation response techniques in individual clinical settings. Stress management for teens. These tools have not been formally evaluated but were developed based on extensive clinical experience and what is known from the literature about stress and resilience in youth. The American Academy of Pediatrics Web site offers useful resources for clinicians and teens, including A Teen s Personalized Guide to Managing Stress (Ginsburg & Jablow, 2006; The National Institutes of Health Web site offers information and links to resources on stress management, including stress management in teens ( The Adolescent Health Working Group offers the Behavioral Health Toolkit, available for purchase or free download, which includes stress management handouts and exercises for teens ( Health realization The West Virginia Initiative for Innate Health at the Robert C. Byrd Health Sciences Center, West Virginia University, maintains a website with publications and resources related to the Health Realization/Innate Health model ( hsc.wvu.edu/wviih/) Clinicians can directly apply and teach stress management techniques, offer stress management exercises and handouts, and/or refer patients to stress management programs as appropriate (see Table 1). Counseling youth about stress and stress management can include encouraging youth to be aware of and decrease habitual negative thinking, encouraging youth to develop healthy and effective coping methods, and discussing risks and alternatives to unhealthy coping strategies such as substance use (American Academy of Child & Adolescent Psychiatry, 2005; American Academy of Family Physicians, 2006; Bonica & Daniel, 2003; Clarke, 2006). Counseling parents and families about stress in youth can include encouraging parents to monitor for physical and behavioral symptoms of stress in their teens and supporting a balanced academic, extracurricular, and play schedule (American Academy of Child & Adolescent Psychiatry, 2005; Ginsburg, 2007a). Routine preventive counseling and stress management counseling should also emphasize the importance of healthy nutrition, exercise, and sleep habits. At the community and policy level, stress reduction programs using strategies from mindfulness, relaxation, and health realization can be implemented in community settings including schools, youth development programs, and juvenile justice settings, to prevent and reduce youth risk behaviors outcomes associated with stress (Jacobs, 2001a; Kelley, 2003; Wall, 2005). Clinicians, health delivery organizations, and service providers working with youth should identify or develop local resources for stress management among the youth populations they serve. Clinical training

9 Stress and Stress Management / Vo, Park 361 programs should integrate a biopsychosocial model that describes how biological, psychological, and social factors interact and affect health and teach stress management and other behavioral and psychological interventions to promote health (Novack, et al., 2007). Conclusions It is well-recognized that the major sources of morbidity and mortality in youth are due to mental health and behavioral factors such as injury and violence, risky sexual behavior, substance use, and suicide (Irwin, Burg, & Uhler Cart, 2002), so the role of stress management in mental health and risk behaviors is particularly important in this age group. The literature demonstrates that chronic stress plays an important role in health and disease. Research in adults as well as some research in youth documents beneficial effects of various stress management strategies and interventions on a variety of psychological and health outcomes. Clinicians, youth service providers, and policy makers have an important role to play in identifying and helping youth manage the stress that is pervasive in the lives of many youth. Research on stress and stress management would benefit from more consistency in definition, conceptualization, and measurement of stress. More research is needed in the emerging area of stress management interventions among youth and young men in particular. Future research should investigate developmental, gender, socioeconomic, and cultural factors that affect stress and stress management in youth. Future research should also evaluate the effects of coping and stress management interventions on the most important behavioral and health outcomes in youth. Research on stress management interventions should employ rigorous scientific methodology when feasible, including appropriate control groups and longitudinal designs when possible. Last, but not least, researchers, clinicians, educators, and policy makers should attend not only to risks and negative health outcomes of stress and youth, but also maintain an emphasis on understanding and promoting positive youth development and resiliency, so that our youth can have achieve physical and emotional well-being. Acknowledgments The development of this article was supported in part by grants from the Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services (U45MC and T71MC00003). References Alloy, L. B., Abramson, L. Y., Walshaw, P. D., Keyser, J., & Gerstein, R. K. (2006). A cognitive vulnerability-stress perspective on bipolar spectrum disorders in a normative adolescent brain, cognitive, and emotional development context. Development and Psychopathology, 18, Alterman, A. I., Koppenhaver, J. M., Mulholland, E., Ladden, L. J., & Baime, M. J. (2004). Pilot trial of effectiveness of mindfulness meditation for substance abuse patients. Journal of Substance Use, 9, American Academy of Child & Adolescent Psychiatry. (2005, May). Helping teenagers with stress. Retrieved July 24, 2008, from With+Stress&section=Facts+for+Families American Academy of Family Physicians. (2006, January). Teens and stress: Who has time for it? Retrieved July 24, 2008, from home/children/teens/prevention/278.printerview.html Andersen, S. L., & Teicher, M. H. (2008). Stress, sensitive periods and maturational events in adolescent depression. Trends in Neurosciences, 31, Astin, J. A. (1997). Stress reduction through mindfulness meditation. Effects on psychological symptomatology, sense of control, and spiritual experiences. Psychotherapy and Psychosomatics, 66, Attari, A., Sartippour, M., Amini, M., & Haghighi, S. (2006). Effect of stress management training on glycemic control in patients with type 1 diabetes. Diabetes Research and Clinical Practice, 73, Baer, R. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10, Barnes, V. A., Treiber, F. A., & Johnson, M. H. (2004). Impact of transcendental meditation on ambulatory blood pressure in African-American adolescents. American Journal of Hypertension, 17, Barnes, V. A., Davis, H. C., Murzynowski, J. B., & Treiber, F. A. (2004). Impact of meditation on resting and ambulatory blood pressure and heart rate in youth. Psychosomatic Medicine, 66, Becker, J. B., Monteggia, L. M., Perrot-Sinal, T. S., Romeo, R. D., Taylor, J. R., Yehuda, R., et al. (2007). Stress and disease: Is being female a predisposing factor? Journal of Neuroscience, 27, Benson, H. (1982). The relaxation response: History, physiological basis and clinical usefulness. Acta Medica Scandinavica Supplementum, 660, Benson-Henry Institute for Mind-Body Medicine, Massachusetts General Hospital. History/Mission. Retrieved July 15, 2008, from

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