SECTION II Literature Review
4.2. Relevance of stress to psychosocial models of adaptation
Despite widespread usage, the term stress is too nebulous to have scientific meaning (Rutter, 1983, in Trad & Greenblatt, 1990, p. 24). Stress may be a physical, emotional, cognitive or chemical factor that exerts significant pressure on an individual's ability to function adaptively (Trad & Greenblatt,
1990), and so it usually demands that the individual makes some adaptation to accommodate the pressure. The adaptation may be adequate or inadequate, with the adequacy being determined by (i) decreased stress levels; (ii) social appropriateness; or (iii) healthier functioning within the individual in either the long or short term (Dawes, 2000). The distinctions between these various forms of adaptation are complex and can be highly problematic. Consider a child who is stressed through living in extreme poverty and perpetual hunger: he may sniff glue to blot out the hunger pangs and thereby decrease his stress levels; he may steal food from neighbours - a response, though not
socially appropriate that would decrease the hunger pangs; or he may have to tolerate hunger pangs and perhaps develop physical and other complications, until he has been 'processed' through various government departments and a social grant has been accessed by his primary caregivers to gain food security. The concept of adaptation raises many ethical and practical issues, especially in terms of its applicability to vulnerable children and the context of HIV/AIDS.
Stress can be understood as either a stimulus, a response or an interaction between stimulus and response:
• It can be a manifest stimulus event that necessitates adaptation (Garmezy & Masten, 1990).
Some events are regarded as being inherently stressful (such as the death of a parent or being diagnosed with a terminal illness). The risk literature largely adheres to this paradigmatic approach and focusses on the impact of life events or experiences that are considered to be intrinsically stressful.
• It may be regarded as a syndrome of psychological and physiological responses, involving neuro-hormonal and psychoneuroimmunological reactions to disequilibrium (Burns &
Arnold, 1999). This conception of stress has found acceptance among those who advocate stress management techniques, such as life style adaptations and relaxation training as a means to decrease the recurrence of stress-related conditions and to decrease the suppression of the immune system (Burnette, Koehn, Kenyon-Jump, Hutton & Stark, 1991). HIV/AIDS is a disease of the immune system that is directly affected by stress (Cohen & Herbert, 1996).
One of the major principles of "living positively" (once diagnosed HIV+, the procedures that can be adopted to manage the repercussions of the virus and prolong one's life) is to decrease or actively manage stress levels.
• It can be an interaction between both stimulus and response, with an intervening subjective, experiential appraisal. This perspective recognises that one cognitively assesses an event or situation to evaluate if it is threatening or exceeds one's capacity to cope (Lazarus, 1991;
Tomaka, Blascovich, Kibler & Ernst, 1997). If the event is considered to be too demanding, a stress-induced activation of the sympathetic nervous system follows (Naime, 2000). If the individual perceives it to be within his or her coping capacity, various coping strategies are used. The cognitive appraisal takes place in the 'here and now', taking into consideration the current context. Therefore, a particular stimulus might activate a stress response at one point, a coping strategy at another and minimal response at yet another time. The cognitive appraisal of the interaction of the stimulus determines the response creating variations in
response across time and person (Lazarus, 1991).
The coping literature largely complies with this third mode of conceptualising stress. Coping is thus conceived as a bio-psycho-social interactional model of stress. Coping, from this perspective, adheres to a "goodness-of-fit" model since psychosocial adaptation is regarded as a match between the demands of a situation or event and the capacities, including the cognitive appraisal, of an individual within a specific environmental context (Aldwin, 1994). There is empirical support for the effectiveness of managing stress reactions through altering the cognitive attributions to significantly enhance quality of life (Lazarus, 1991; Nairne, 2000; Smith & Carlson, 1997).
In considering stress as a stimulus, there are various ways in which the nature of stress could be categorised: (i) internal or external in source; (ii) acute or chronic in duration; and (iii) multi- dimensional; and (iv) developmental perspective:
• External or internal sources: Stress can be regarded as a stimulus event/s that arises primarily from external or internal sources (Horowitz, 1992; Nairne, 2000). External sources of stress include: (i) significant life events that are defined as major events, either positive (securing a good albeit challenging job) or negative (death of a loved one) that are associated with changes in a person's day-to-day functioning and activities; (ii) daily hassles are the regular irritations and difficulties of life (Aldwin, 1994) such as concerns about one's appearance or health (Nairne, 2000), having to carry heavy buckets of water, collect firewood, stand in long queues, endure unpredictable transport facilities, etc.; or (iii) environmental factors that are present in an individual's environment such as poverty, over- crowding, dust, frequent deaths and bereavement, drought, etc. These external sources of stress are considered to be particularly persistent in the lives of the children within the current research context.
Internal sources of stress include: (i) various aspects of attributional styles such as (a) the amount of control that an individual perceives him/herself to have over a situation, such that perceived control over an event is associated with decreased stress (Horowitz, 1992); or (b) the typical explanatory style of an individual: for example, people who make internal, stable and/or global attributions of negative events are more likely to suffer stress-related health problems (Nairne, 2000); or (c) personality and temperamental characteristics of the individual: for example, optimism reduces stress; Type A (hard-driving, ambitious, easily
annoyed) personalities have elevated stress levels and increased risk of health problems (Horowitz, 1992); and (iv) genetic or physical in origin which takes into account the various stress factors that arise from genetic abnormalities or physical dysfunction or even less than optimal physical functioning.
Acute-chronic duration: Stress could also be categorised along an acute-chronic dimension (Horowitz, 1992; Smith & Carlson, 1997). Acute stressors demand changes in the existing circumstances and a disruption of the status quo. They may be severe in nature, such as sexual abuse or floods, or they could be less severe (for example, a domestic or peer dispute).
Chronic stressors are on-going aspects of the internal or external environment that undermine an individual's ability to cope (Compas, Malcarne & Fondacarco, 1988; Horowitz, 1992) and deplete one's physical and emotional resources. Chronic stressors include the predictable stressors and daily hassles that form a persistently adverse theme in one's life: e.g. poverty, discrimination and limited access to resources. In some situations, acute events may become chronic if the individual is unable to cope adaptively or if the stressful events persist over a prolonged period of time (Gibson, Swartz & Sandenbergh, 2002). Neutral stressors fall midway, are less calamitous, more mundane, and even though they create pressure, are not usually associated with maladaptive responses (Trad & Greenblatt, 1990).
Multi-dimensional: The integrated, multi-dimensional model for categorising stressors (Aldwin, 1994) conceptualises stress along three axes: (i) the duration of a stressor can be acute or chronic; (ii) the severity of a stressor with traumatic stress placed at one extreme and daily hassles are equated to relatively minor stressors at the other end of this axis; (iii) the cognitive appraisal of one's own capacity to cope, in combination with various other factors that moderate the impact of a stressor. While Aldwin's (1994) integrated model enhances understanding of the multi-dimensional nature of stress, the source of stress is considered to be especially relevant within the current research context, whereas she does not include this as a dimension for consideration. The advantage of this integrative approach is that it takes into account the reality that stressors tend to co-occur and interact with one another, acting additively and synergistically (Aldwin, 1994; Arnold, 1990; Baylis, 2002; Masten, 2001). For example, poverty creates stress through malnutrition, poor environmental circumstances, discrimination, inadequate parenting due to worry and pre-occupation, discouragement and resentment at one's social status (Arnold, 1990).
• The developmental perspective: This perspective takes into account children's reactions and the specific vulnerabilities that they face at different stages of development. Arnold (1990) hypothesised that there are developmental feedback loops in which the effects of stress can affect, either beneficially or detrimentally, any of the developmental parameters.
In turn, these impact on the child's future ability to tolerate or master stressful circumstances.
For example, the impact of a stressful event in early childhood may differ from the impact of the same event on an older child. Young children have the advantage of securing some protection from stressful events by virtue of their lack of understanding of an event in combination with the active role of their primary attachment figures (Trad & Greenblatt, 1990). The meaning that they attribute to the event is unlikely to be well developed and may reflect egocentric thinking (Killian & Perrott, 1994). Older children may not have the advantage of similar buffering effects, but may have benefited from previous life experiences that have assisted adaptive coping (Luthar & Cicchetti, 2000) and they may be better equipped to accurately appraise the nature of a stressful event.
In addition, the epistemological stage theory approach adopted in many theories of child development suggest that children may be exposed to stressors that are unique to their specific psychosocial developmental stage. For example, a child in the psychosocial stage of industry verse inferiority (Erikson, 1963) may not have the opportunities to develop a sense of mastery during this stage of development and so his or her future development may be compromised.
The heterogeneity in models used to conceptualise and categorise stress create difficulties in terms of measuring the degree of stress to which an individual has been exposed. Strategies to measure stress in children have typically relied on parent or educator perceptions of stress, even though it is known that the presumably objective reports of educators and parents do not correlate well with children's own reports of stress (Compas et al., 1988; Conners, Parker, Sitarenios & Epstein, 1998).
Adults, for example, regard major life events as a primary source of stress, whereas children are more likely to regard daily hassles as being stressful (Compas et al., 1988; Lazarus & Folkman, 1984; Nairne, 2000; Smith & Carlson, 1997). Nevertheless, child stress inventories are generally modelled on their adult equivalents with a focus on stressful events. Questionnaires list and rank order stressful events in terms of the exposure and/or intensity of various stressors that a child may
have experienced over a given period of time. However, this assessment technique fails to take into account either the child's subjective experience of the stressor (Howard & Dryden, 1999; Smith &
Carlson, 1997), or the child's appraisal of the event and his or her perceived ability to cope with the event (Horowitz, 1992; Lazarus & Folkman, 1984). One advantage of this approach is that it is consistent with the risk literature. While some events such as parental death may be regarded as being inherently stressful, the child's appraisal of the situation is of critical importance. For example, even an event as seemingly catastrophic as parental death can give rise to a variety of negative and positive emotions: relief that the parent no longer requires daily HBC and is no longer in pain, pleasure at having more time to play and study, sadness at the parent's death and worry about impending changes in one's own daily life (Killian et al., 2002). Only a limited understanding of a child's experience is gathered by listing the acute and chronic stressors to which s/he has been exposed. This checklist approach needs to supplemented by considering the child's subjective experience of the stressors.
The vulnerable children who are the subject of this research have probably been exposed to various forms of stress from both external and internal sources, that are acute and chronic in nature and are severe and/or debilitating in impact. The onslaught of difficulties that they and those who form their social support systems have faced may have compromised their cognitive appraisal of these stressors.
Given these stressful living circumstances, one can regard the children as vulnerable to developing various emotional and social problems.