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Stress
in Childhood
and Adolescence
Management Techniques
Relaxation
Many childhood
psychophysiological compodysfunction.
psychosocial evaluation, the clinician may identify many patients who are
application of stress reduction techniques such as progressive muscular
relaxation, meditation, biofeedback, and relaxation/mental imagery (self-hypnosis). This review describes these techniques and their application with selected children and adolescents.
CHILDREN
AND ADOLESCENTS often manifest symptoms that appear to have a strong psychophysiological component. It has become popular to
refer to predisposing conditions that precipitate such
symptoms
as
&dquo;stress.&dquo;1
reflecting
both
voluntary
and autonomic
nervous
Some diagnoses such as a major depressive disorder or sexual abuse require referral to a mental
health or social service professional. Often, however,
the clinician may determine that stress-related symptoms are not associated with major psychosocial disorder and may appropriately be managed in the
primary care setting. Examples of the latter might
include muscle contraction headaches in an overachieving child, recurrent abdominal pain in a child
of a family undergoing divorce or frequent chest
pain in an adolescent with anxiety related to school
581
problems. In these situations, brief supportive counseling by the primary care clinician coupled with instruction in stress reduction techniques may provide
appropriate cost-effective treatment. This paper is
intended to review the use of stress reduction techniques in children and adolescents.
Stress
Hypothesis
It is often
possible
to
582
treatment
Training
aware
muscular tension to relaxation. The process is repeated with successive muscle groups throughout the
body until deep muscular relaxation is achieved. Abbreviated versions of Jacobsons original technique
have been developed that can be completed in approximately 15 minutes.lO,1l
The progressive muscular relaxation technique
does not require mental imagery or special equipment and the rationale for its use is understood by
most patients. The following case illustrates the use
of the progressive muscular relaxation technique.
A 15-year-old girl undergoing chemotherapy for
a
lymphoma began
to
experience
extreme
anxiety
Hypnosis
Clinical hypnosis usually involves relaxation and
the use of mental imagery. For this reason, and because of the stigma attached to the word, hypnosis
has been termed relaxation-mental imagery by some
authors.&dquo; Gardner has aptly defined hypnosis as &dquo;a
state of heightened concentration in which the patient who is willing and motivated may experience
alterations in sensations and perceptions and may be
more responsive to suggestions from the
therapist
which are consistent with the patients own
wishes.&dquo;17 In hypnosis there is a general decrease in
critical cognitive function resulting in what Hilgard
has defined
as
&dquo;subsidence of the
planning
func-
tion.&dquo;18
The subject who is receptive to hypnosis focuses
attention on an alternate state of awareness that
allows the acceptance of suggestions promoting perception or behavior which is ultimately compatible
with the subjects desires. During hypnosis, the child
or adolescent may achieve relief from symptoms and
additionally receive post-hypnotic suggestions allowing continued improvement or relief from symptoms
to carry over into the normal waking state. Although
not all children and adolescents are good hypnotic
subjects, most receive some benefit from the state of
deep relaxation that can be achieved. Hypnotic ability (suggestibility) peaks in the pre-adolescent years
and remains at somewhat lower levels throughout
adolescence.9
The clinical use of hypnosis requires some training
and experience. Confidence, enthusiasm, and rapport generated by the therapist are important in
achieving clinical states of hypnosis. The clinical application of hypnosis is truly an art and there are
genuine masters of this technique. The interested
clinician, however, can achieve adequate competency
in hypnosis by participating in a workshop presented
by a reputable organization such as The American
Society of Clinical Hypnosis or the Society for Clinical and Experimental Hypnosis.
A 9-year-old boy experienced weekly common
migraine headaches for 3 years. A complete medical
evaluation was normal and the family history was
positive for migraine. He was motivated and receptive to instruction in self-hypnosis techniques. Following an eye-roll induction technique he visualized
himself walking through a pile of leaves which was
being blown away by the wind as he counted from
ten down to zero. He then imagined various scenarios (e.g., good &dquo;Transformers&dquo; subduing the evil
ones) that enhanced his sense of mastery and control
over headache mechanisms. After 4 weeks of practice for 15 minutes twice daily, the frequency of his
headaches decreased markedly. After 2 months of
practice he experienced only infrequent mild headaches, and at a 6 month follow-up visit he was headache free.
Biofeedback
583
specificity of biofeedback training is debatable.2~24 Certainly biofeedback may be used to augment relaxation training and the electronic instruThe
mentation is often attractive to children and adolescents who may be less receptive to simple relaxation
or
tacks. With
584
Conclusion
another, although
References
1.
2.
1984;5:21-5.
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relaxation response training in the treatment of pediatric
migraine. Dev Med Child Neurol 1986;28:139-46.
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Chicago Press, 1929.
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a manual for the helping professional. Champaign, IL. Research Press, 1973.
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chiatry 1982;139:267-74.
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state.
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585