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CS, 2011, 6(4), 23-28
http:// journals.tbzmed.ac.ir
* Corresponding Author: Mahni Rahkar Farshi (MSc), E-mail: mahni_farshi@yahoo.com
This article was derived from MSc thesis in the Tabriz University of Medical Sciences, No: 255.
Copyright © 2011 by Tabriz University of Medical Sciences
Investigation of Stress Symptoms among Primary School Children
Leila Valizadeh1, Alireza Farnam2, Mahni Rahkar Farshi3*
1 PhD, Assistant Professor, Department of Pediatrics, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences,
Tabriz, Iran
2 MD, Associate Professor, Department of Psychiatry, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
3 MSc, Department of Pediatrics, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
ARTICLE INFO ABSTRACT
Article type:
Original Article
Introduction: Experience of chronic stress in children plays an important role in enhanc-
ing future physical, mental and social problems. It is very essential and vital that fami-
lies, teachers and professional groups possess necessary abilities to diagnose stress
symptoms in children. According to the statistics of Education Ministry, there were al-
most 5.5 million primary school students in Iran in 2008-2009. However, there are very
limited studies about stress in 7 to 12-year-old children. The present study aimed to re-
view stress symptoms in school-aged children. Methods: In a descriptive study, 839
third to fifth grade students were selected from five randomly chosen districts of Tabriz
using random sampling method in the schools. The data were collected by means of
children’s stress symptom scale (CSSS) through interviewing by children. Accuracy of
translation was checked and content validity and reliability were confirmed using test
retest method. Results: The entire twenty-six items of the questionnaire were reported as
stress symptoms. More than half of the study subjects reported worry, fast heart beating,
being afraid, chills and feeling sad as their signs of stress. Headache (46.6%) and tired-
ness (41.8%) were also reported. In examining every stress symptoms, there was a statis-
tically significant correlation between some symptoms with age, grade and type of
school. Conclusion: Children showed a wide range of symptoms in facing with stressful
events. Accurate identification of symptoms can inform parents, teachers and profes-
sional health staff about physical and mental status of school-aged children and result in
interventions to reduce their stress.
Article History:
Received: 2 Apr. 2011
Accepted: 25 July. 2011
Keywords:
Stress
School age
Symptoms
Child
Introduction
Stress is caused when requirements of a posi-
tion are more than individual’s ability to cope
with them.1, 2 In fact, stress is a reaction that
occurs against stressor agents.3 Response to the
stressful events has three components: emo-
tional and physical responses, coping strate-
gies and defense mechanisms.
The first component is physical response that
cause some symptoms by arousing autonomic
responses,4 and is related to stimulation and
response in hypothalamic pituitary adrenal axis
that ultimately leads to mineralocorticoids and
glucocorticoids secretion from the adrenal
gland and prepares body for fight-escape reac-
tions.5-7 Many health care providers and adults
believe childhood is the period that human is
free from any pressure and problem, children’s
world is full of games and cheers away from sor-
row, sadness and they pass this era without any
responsibility.1, 8 However, children might also
feel mental and emotional pressure due to envi-
ronmental situations and certain individuals.2
Approximately 35 percent of American
children experience stress-related health prob-
lems.1 According to many psychologists, pe-
diatricians and health care providers, expe-
Valizadeh et al.
24 | JCS, Autumn 2011; l6 (4), 23-28 Copyright © 2011 by Tabriz University of Medical Sciences
riencing stress in children plays a major role in
increasing physical, mental and social prob-
lems.1,9 On the other hand, today there are
many other issues in families and children’s
life which are considered as stressors. Nowa-
days, moving to other places and displacement
are much more common that cause school and
friend replacement and separating from them.
It possibly may not be considered by parents
very much. Moreover, the structure of families
has changed. Extensive and multi-member
families have altered into nuclear families. To
make a living, both parents need to work out-
side in some families and children have to stay
home alone long after they return from school.1
All these changes are growing in developing
communities as well as in our community and
children are the most vulnerable group af-
fected by these changes. The studies about
stress symptom in school-aged children have
shown that psychological and physical com-
plaints in the past decade among school-aged
children had an upward trend.10,11 Nowadays,
health educators in schools as well as family
counselors are considered as the most impor-
tant elements of health and must have ade-
quate information on common stress symp-
toms in children. That is to say that education-
al role of nurse appears to be more highlighted
as a health care provider so that nurse teaches
the related issues to school educators and par-
ents or acts as a child’s health counselor. Most
of the mentioned studies related to childhood
stress have been done in other countries and
there are very limited studies in Iran on the
stress in primary school children. According to
statistics of Education Ministry, there were al-
most 5.5 million primary school students in
Iran in 2008-2009. However, there is no accu-
rate estimate of psychiatric12 and psychosomat-
ic disorders in children. Therefore, conducting
a study aiming to review the stress symptoms
in elementary school children seems necessary.
Materials and methods
In a descriptive study, all students studying in
the third to fifth grade of primary school in
Tabriz were considered as study population.
Three people in each grade (9 people from
each school), from one male public school, one
female public school, a male and a female non-
public school were randomly selected that re-
sulted in 180 students enrolled in the pilot
study. After calculation of ICC = 0.02 in SPSS
software, the effect size was estimated 1.52.
The main sample size was estimated approx-
imately 600 students using ESS = Mk/DE for-
mula. In order to prevent from sample loss,
this amount was increased 20-25 percent. They
could be excluded from the study provided
that a student had a known physical and men-
tal disease or his/her age was less than 9 or
higher than 12 years or could not understand
Persian language. Finally, a sample size of 839
people was collected.
After obtaining permission from the five
Education districts, in each school (cluster) and
from each grade 10 students (30 students in
each cluster) were selected using random sam-
pling method. Thereafter, they were given data
collection form of demographics as well as
consent form that they took home and their
parents sign the consent form and answered
the demographic characteristics questions.
Moreover, the students and parents were in-
formed about the voluntary nature of partici-
pation in the study. The children who returned
demographic characteristics and consent forms
were enrolled in the study.
The data were collected through the 24-item
self-report questionnaire of children’s stress
symptom scale designed by Sharrer and Ryan-
Wenger.3 This questionnaire assesses the expe-
riences of stress in 7 to 12-year-old children
using eleven cognitive-emotional symptoms
and thirteen physical signs. Presence of a
symptom scored with 1 yes = 1 and lack of
symptom with zero no = 0. Two items of “nau-
sea-vomiting” and “feeling sad” were added to
other items after studying other literatures and
totally 26 items were questioned. The range of
obtained scores to the stress-related symptoms
was from zero to 26 and stress symptoms were
reported in three low, moderate and high le-
vels. The questionnaire was translated by the
researcher and translation accuracy was
Stress in primary school children
Copyright © 2011 by Tabriz University of Medical Sciences JCS, Autumn 2011; l6 (4), 23-28 | 25
checked and content validity were determined.
The reliability of the CSSS in the study of Sky-
bo and Buck11 was obtained as 0.88 (Cron-
bach’s alpha). The reliability of this scale in the
present study was also determined 0.76 corre-
lation coefficient using test re-test method. The
data then were collected in a quiet room of
school through interviewing with children in
non-education hours. Data analysis was done
using descriptive statistics by absolute num-
bers and percentages. Moreover, chi-square
test was used to obtain the correlation between
the variables. The analyses were done in SPSS
software.
Results
There were 470 female students (56%) and 369
male students (44%). The students’ average age
was 10.46 ± 1.02 years (mean ± SD). The age
distribution of participants was 182(21.8%)
nine-years-old children, 238 (28.5%) ten-years-
old, 262 (31.4%) eleven-years-old and 153
(18.3%) twelve-years-old children.
809 children (96.4%) lived with their both
parents; 21 children (2.5%) with mother, 4
children (0.5%) with father and 5 children
(0.6%) with other family members. The most
important events occurred for children during
last year were “moving” (12.5%), “death of a
close relative” (9.7%), “car accident” 4.1% and
“birth of a new brother or sister” (3.7%). Al-
most three percent of children [24(2.9%)]
pointed out many symptoms (more than 18
items), 50.4 percent (423 children) had average
number of symptoms (between 9 to 17 items)
and 46.7 percent (394 children) had a low
number of symptoms (less than 8 items).
The entire 26 items of the questionnaire
were mentioned by the study subjects as the
stress symptoms. Out of these 26 items, worry,
“being afraid”, “fast heart beating”, “chills”
and “feeling sad” were reported in more than
fifty percent of children. Moreover, “head-
ache” was reported by 46.6 percent of them.
The most common stress symptoms in children
are given in Table 1. It should be noted that
“worry”, “being afraid” and “feeling sad” are
part of cognitive emotional stress symptoms
and “tachycardia”, “chills” and “headache” are
part of physical stress symptoms. The lowest
reported stress symptoms were “bad temper”
(16.1%), “skin rash” (17.1%), “desire to hit
someone” (17.6%), “nausea and vomiting”
(18.6%) and “muscle stiffness” (23.4%). Fur-
thermore, distribution of stress symptoms is
given in Table 2 based on gender, grade and
public and non-public schools. As indicated in
this table, there was a significant correlation
between these symptoms and some demo-
graphic factors (p < 0.05).
Table 1. Most common stress symptoms in primary school children of Tabriz
Stress symptom* No stress symptom* Unresponsive** Total**
Worry 580 (69.4) 256 (30.6) 3 839
Fast heart beating 458 (55.4) 369 (44.6) 12 839
Afraid 461 (55.3) 372 (44.7) 6 839
Chills 422 (50.8) 408 (49.2) 9 839
Feeling sad 418 (50.3) 413 (49.7) 8 839
Headache 384 (46.4) 444 (53.6) 11 839
Tiredness 347 (41.8) 483 (58.2) 9 839
Shame and embarrassment 340 (40.9) 491 (59.1) 8 839
Hunger 326 (39.2) 505 (60.8) 8 839
Sweating 324 (39.2) 502 (60.8) 13 839
* The data are given as n (%)
**The data are given as n
Valizadeh et al.
26 | JCS, Autumn 2011; l6 (4), 23-28 Copyright © 2011 by Tabriz University of Medical Sciences
Table 2. Perecentage of stress symptoms by sex and grade of students, and
type of schools in primary school children in Tabriz
Items
Gender Grade School type
Female Male P-value 3rd 4
th 5
th P-value Public Non-public P-value
Madness 20.3 31.5 < 0.001 19.4 22.7 33.1 < 0.001 24.9 26.1 0.71
Worry 72.3 65.6 0.04 64 71.2 73 0.04 67.1 75.3 0.02
Crying 29.2 27.1 0.53 29.2 24.4 31 0.22 29.8 24.4 0.14
Early agitation 25.8 30.2 0.18 24 25.6 33.3 0.03 27.2 29.3 0.54
Being afraid 64.6 43.6 < 0.001 53.5 55 57.4 0.63 53.6 59.3 0.11
Bad temper 14.6 18.1 0.18 15.2 14.6 18.2 0.46 16.7 14.5 0.46
No clear thought 24.7 27.4 0.29 23.2 28.3 27.2 0.36 26.6 25.2 0.72
Thinking about death 22.9 27.1 0.16 18.6 23.8 31.6 0.002 25.2 23.7 0.71
Desire to hit someone 15.1 20.7 0.04 11.6 15.4 25.4 < 0.001 18.2 16 0.53
Embarrassment and
shame 43.1 38.1 0.15 38.3 41.8 42.7 0.53 39.1 45.7 0.09
Feeling weird 20.4 36.4 < 0.001 26.4 26 29.8 0.53 24.9 34.2 0.009
Feeling sad 52.8 47.1 0.1 44.3 49.2 57.1 0.08 49.4 52.6 0.43
Headache 47.6 44.8 0.44 48 43.8 47.1 0.59 46.2 46.9 0.87
Stomachache 39.1 26.4 < 0.001 30.1 35.6 34.8 0.33 33.7 33 0.93
Sweating 36.4 42.7 0.07 40.4 41.9 35.7 0.29 38.8 40.4 0.69
Fast heart beating 60.5 48.9 0.001 47.5 57.1 61.5 0.003 53.3 61 0.05
Feeling unwell 30.3 28.7 0.64 32.3 30.6 26 0.23 28.6 32.2 0.3
Chills 57.5 42.3 < 0.001 50 48.9 53.4 0.52 49.1 55.5 0.1
Tiredness 39.8 44.4 0.2 39.6 45 41 0.42 41.7 42.1 0.93
Muscle stiffness 19.2 28.9 0.002 23.1 19.4 27.5 0.08 22.4 26.2 0.26
Face blushing and
warmness 39.7 35 0.17 34.9 32.4 45.1 0.005 37.5 38 0.93
Weakness 34.8 31 0.26 28.4 34.7 36.3 0.11 31 38.6 0.04
Skin rash 16.2 18.3 0.45 19.8 15.4 16.1 0.33 17 17.5 0.91
Feeling cold 38.2 31 0.03 32.3 36.6 36.2 0.49 35.5 33.8 0.68
Hunger 33.5 46.6 < 0.001 38.9 39.9 38.9 0.96 40.8 35.2 0.15
Nausea and vomiting 18.7 18.5 1 24.9 15.6 15.2 0.004 18.9 17.7 0.76
Total 470 369 - 284 264 291 - 608 231 -
Discussion
This study aimed to investigate the stress
symptoms in primary school children in Ta-
briz. Accordingly, the children showed a
wide range of cognitive-emotional and phys-
ical symptoms in confrontation with stressful
events. The entire twenty-six items of the
questionnaire was mentioned as stress symp-
toms by the third to fifth grade students.
More than fifty percent of children had 9 or
more stress symptoms. Among cognitive-
emotional symptoms of stress, worry, being
afraid and feeling sad and among physical
symptoms tachycardia, chills and headache
were reported by the majority of children.
There was a significant difference between
male and female students in following items;
madness, desire to hit someone, feeling
weird, muscle stiffness and hunger which
were more in males than in females. Worry,
being afraid, stomachache, tachycardia, chills
and feeling cold were more in females. In re-
searcher’s view, the differences between male
and female students probably might be due
to gender nature and characteristics.
Stress in primary school children
Copyright © 2011 by Tabriz University of Medical Sciences JCS, Autumn 2011; l6 (4), 23-28 | 27
Furthermore, there was a significant dif-
ference between grades in terms of stress
symptoms. The items of madness, worry, ta-
chycardia, thinking about death, desire to hit
someone, feeling sad and early agitation,
nausea and vomiting were more reported
when students’ grade increased. Moreover,
face blush and warmness was higher in fifth
grade while lower in fourth grade. The re-
searcher believes the difference related to
concern, thinking about death and sorrow
was due to higher cognitive development of
fifth grade students rather than third and
fourth grades. However, conducting a com-
parative study is recommended for further
investigation about these differences. Like-
wise, Students in non-public schools reported
higher levels of “worry”, “feeling weird”,
“fast heart beating” and “weakness” than
public schools. Conducting more compara-
tive studies also is recommended to evaluate
these differences.
The findings of this study to some extent
were in accordance with those of Sharrer and
Ryan-Wenger3 and Skybo and Buck11 but had
some differences with the study of Hjern et
al.10 In the study of Sharrer and Ryan-Wenger
on 7 to 12-year-old American children, con-
cern, unwell and fear were the highest cogni-
tive-emotional symptoms and headache,
stomachache, sweating and tachycardia were
the highest physical symptoms.3 However, in
Sharrer and Ryan-Wenger study, the items of
rage and irritability considered as the highest
stress symptoms but reported lesser in the
present study. Skybo and Buck in their study
on fourth grade primary school children in
Ohio, United States, found that hunger,
headache and irritability were the highest
stress symptoms.11 In addition, the item of
“desire to hit someone” in their study was a
frequently mentioned item; while in the
present study, this item was one of the least
reported items. In the study of Hjern et al. on
10 to 18-year old Sweden children, physical
symptoms of headache, abdominal pains and
other complaints such as feeling unwell, irri-
tability and rage were the most common
stress symptoms.10 Hesketh et al.13 confirmed
the prevalence of physical symptoms re-
sulted from stress. Laessle and Lindel14 also
surveyed the stress symptoms in depressed
children; they also found physical symptoms
of stress and subjective conception of stress
feeling. Generally, in most of the mentioned
studies, headache and stomachache were
considered as the most common stress symp-
toms in school-aged children. In the present
study headache was also reported in nearly
half of the children and stomachache was re-
ported in nearly one third of students.
The present study had some limitations
similar to other studies as follows. Individual
differences may affect on quality of respond-
ing in different ages. The subjects might not
provide their real information to the re-
searcher through the questionnaire. This
problem was tried to be solved to some ex-
tent with ensuring about confidentiality of
information.
Conclusion
The present study aimed to determine stress
symptoms in 9 to 12-year-old children. By re-
viewing the obtained results of this study and
other studies, we have come to realize that
health educators and nurses in schools should
have the necessary abilities to recognize emo-
tional stresses symptoms and be able to pro-
vide required facilities and tools to prevent
and control high-stressful situations for child-
ren and parents.2 Children nurses teach child-
ren how to deal with the physical needs. Giv-
en that child’s health would not be met only
through biological factors and complex mental
and social relations also are highly involved in
children’s health, nurses’ functional areas
would be extended from physical to social
dimension and therefore social environment
and schools are also included. Professional
health staff must identify emotional and phys-
ical needs of children and reflect them to par-
ents and teachers.1, 2, 15 Giving notice about the
stress symptoms can inform parents, teachers
and professional health staff about physical
and mental status of children and leads to
Valizadeh et al.
28 | JCS, Autumn 2011; l6 (4), 23-28 Copyright © 2011 by Tabriz University of Medical Sciences
stress reduction and its physical and mental
signs.11 The results of this study confirmed the
presence of stress symptoms in children aged
9-12 years. Identifying these cases and future
measures would be useful in order to improve
children’s health in these ages. On the other
hand, identification of common stress symp-
toms can be effective in order to design
school-based or family-based interventions
and programs to identify common symptoms
that cause many physical and behavioral
problems of school-age children.16 Therefore,
conducting further studies in this field and in
a wider age range is recommended.
Ethical issues
None to be declared.
Conflict of interest
The authors declare no conflict of interest in
this study.
Acknowledgments
Hereby, thanks go to the officials of Adminis-
tration of Education and five education dis-
tricts in Tabriz city and also head teachers
and teachers of schools that participated in
this study. Furthermore, we would appre-
ciate primary school children of Tabriz, their
parents and all the facilitators who heartily
cooperated with us.
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