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J. Indian Assoc. Child Adolesc. Ment. Health 2014; 10(1)47-68

Review Article

Determinants of psychological stress and suicidal behavior in Indian adolescents:

a literature review

Dr. Varun Kumar, Dr. Richa Talwar

Address for Correspondence: Varun Kumar, Post Graduate student, Department of

Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital,

New Delhi, India. Email: drvarunkumar17@gmail.com

Abstract

Adolescence can be a stressful time for children, parents and also all others who work

with them. School students in India have a high stress level and higher rate of deliberate

self-harm. Many recent studies have found relation between stress and suicidal ideas in

school children. Stress also results in increased likelihood of substance abuse among

adolescents. A social and public health response in addition to mental health response is

crucial to prevent suicidal behavior and creating awareness about substance abuse among

adolescents. Stress also positively correlates with maladaptive strategies adopted towards

schools, teachers, and parents, peers, opposite sex and also at a broader societal level.

Policy planning and implementation of preventive measures for adolescent suicide is

therefore, need of the hour. This review article focuses on determinants of psychological

stress and suicidal behavior in Indian adolescents and various psychosocial adjustments

adopted by them.

Key words: Indian adolescents, stress, suicidal behavior, psychosocial adjustments

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Introduction

The world is home to 1.2 billion individuals aged 10–19 years. Adolescents aged between

10 to 19 years account for more than one-fifth of the world’s population [1]. India has the

largest national population of adolescents (243 million), followed by China (207 million),

United States (44 million), Indonesia and Pakistan (both 41 million) [2]. In India, this age

group forms 21.4% of the total population. Adolescents are also entitled to enjoy basic

human rights- economic, political, social and cultural- but their inability to exercise these

rights places the onus on the policy makers and adults to implement separate measures to

ensure their rights. Moreover it is necessary to invest in adolescents as the future leaders

and guardians of nation’s development [3].

Adolescents face health challenges that pediatric and adult physicians alike are often ill-

equipped to handle. Rapid physical and emotional growth, as well as the frequently

conflicting and influential cultural messages they receive from the outside world, account

for the unique nature of their health concerns. Without proper education and support,

adolescents lack the knowledge and confidence to make decisions [4].

Adolescents are generally perceived as a healthy age group, and yet 20% of them, in any

given period, experience a mental health problem, most commonly depression or anxiety.

In many settings, suicide is among the leading cause of death in young people [5]. Mental

well-being is fundamental to good quality of life. Happy and confident adolescents are

most likely to grow into happy and confident adults, who in turn contribute to the health

and well-being of nations [3]. Mental health problems among

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adolescents carry high social and economic costs, as they often develop into more

disabling conditions later in life.

In this context, in India particularly, adolescents are put under pressure to perform well in

school examinations. For some students, the experience of academic stress leads to a

sense of distress, which is generally manifested in a variety of psychological and

behavioral problems. The experience of academic stress and adolescent distress has been

identified and explored by researchers in Korea and Japan [6]. It is relevant to mention

here that in India, in the year 2011 alone, 2381 children, or more than six children per

day, committed suicide because of failure in examinations [7].

Youth suicide, however, is only the tip of iceberg, which masks the generalized anxiety

and depression experienced by many students. If denied their rights to quality education,

health care, protection and participation, adolescents are very likely to remain or become

impoverished, excluded and disempowered – increasing, in turn, the risk that their

children will also be denied their rights. For these reasons, UNICEF (United Nations

International Children's Emergency Fund) has dedicated the 2011 edition of its flagship

report The State of the World’s Children to adolescents and adolescence [8].

At the international level, a number of instruments and agreements are in place to

promote the health and development of adolescents, most notably the Convention on the

Rights of the Child and the Convention on the Rights of Persons with Disabilities. The

integration of mental health into primary health-care systems is a major endeavor to

reduce the treatment gap for mental health problems. To that end, the WHO (World

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Health Organization) and its partners have developed the 4S Framework, which provides

a structure for national initiatives to gather and use strategic information; develop

supportive, evidence-informed policies; scale up the provision and utilization of health

services and commodities; and strengthen links with other government sectors. Such

integration will increase the accessibility of services and reduce the stigma attached to

mental disorders [9]. However in India, there are no such dedicated policies or programs

catering to this specific need of adolescents.

Magnitude of Problem

Today stress is a commonly used term. Stress is understood in relation to the stressors or

with the feelings associated with it. Stress is both a physical as well as a mental condition

that pushes a person to change, grow, fight or adapt. Palsane et al. (1986) also notes that

in contrast to the western psychology where stress is believed to be produced by

environmental events, in Indian psychology goals and expectations of the individuals

bring to the potentially stressful situation. Where stress enhances function (physical or

mental, such as through strength training or challenging work), it is considered as

eustress. Persistent stress that is not resolved through coping or adaptation leading to

anxiety, withdrawal behavior and depression is considered as distress [10].

The prevalence of stress among Indian adolescents varies from 13% to 45% among

different studies done after the year 2000 [11 – 17]. Despite little research,

epidemiological studies of the prevalence of adolescent stress show that such problems

51

are not uncommon. The studies reporting prevalence of stress among adolescents are

given in table 1. The results are similar to studies conducted in Saudi Arabia [18], Iran

[19], and Malaysia [20].

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Types of Stressors

Gender: Many studies [18, 19] done outside India highlighted the fact that girls are

under more stress than boys. But an Indian study by Dhuria M et al. [13] among students

in classes XI and XII in Delhi during 2009, found that psychological problems were

present more among boys than girls. Another study conducted by Sibnath Deb et al. [21]

also found boys to be more anxious than girls.

Age: Chabbra GS and Sodhi MK [16] in their study among 500 male adolescents aged 12

to 18 years in Amritsar during 2011 found that psychological problems were significantly

higher in middle adolescence (14-16 years). These adolescents with psychological

problems were having significantly more academic problems, family disputes, domestic

violence and lesser number of close friends.

Socio-economic status: A cross sectional study conducted by Sibnath Deb et al. [21] on

anxiety among high school students in Kolkata during 2010 found that adolescents

belonging to the middle socio-economic group were more anxious than those from both

high and low socio-economic groups and also adolescents with working mothers were

found to be more anxious.

Family structure: Singh H et al. [22] found that stress was more among adolescents

belonging to nuclear families. Chabbra GS and Sodhi MK [16] in their study reported

stress was more in large extended families (> 8 members). Krishnakumar P et al. [23]

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found sources of stress in the family can be death of a parent, conflicts with parents or

siblings, mental illness in the family, parental alcoholism and parental disharmony.

Academic achievement: In a study by Bhasin SK et al. [24] done in students belonging

to classes from ninth to twelfth in Delhi during 2010 it was found that stress levels were

significantly higher among the 'board classes' i.e., 10th and 12th as compared to the

classes 9th and 11th. Rajni Kumari et al. [25] found a positive correlation between stress

and academic achievement. Students with high and moderate stress performed better than

the students having less stress. Latha KS et al. [26] in their study have found that the

main sources of academic stress were getting up early in the morning, pressure to study,

having to concentrate for too long and long working hours. Verma S et al. [27] in their

study found that those who spent more time doing homework experienced lower average

emotional states and more internalizing problems, while those who spent more time in

leisure experienced more favorable states but also reported higher academic anxiety and

lower scholastic achievement.

Psychosocial stressors: A cross sectional study by Arun P and Chavan BS [13] in

Chandigarh during 2009 found a significant correlation between student’s perception of

life as a burden and the class they were studying and problems students experienced in

relation to study, their peers, future planning and with parents. Munni and Malhi [28]

reported that the adolescents exposed to violence had poorer school performance and

adjustment scores.

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Apart from the above mentioned risk factors identified as stressors, few other variables

like religion, ethnicity and number of siblings in the family are also mentioned in some

international studies. [29]

Factors Associated with Stress

Substance Use:

In DSM-IV (Diagnostic and Statistical manual of Mental disorders-IV), psychoactive

substance abuse is defined as a “maladaptive pattern of use indicated by continued use

despite knowledge of having a persistent or recurrent social, occupational, psychological

or physical problem that is caused or exacerbated by the use (or by) recurrent use in

situations in which it is physically hazardous”. [30] Suchday S et al. [31] in their study

found that stress had an association with chewing tobacco and alcohol use, and

psychosocial characteristics, such as hostility. Chabbra GS and Sodhi MK [16] also

reported a positive correlation between psychological problems and greater substance

abuse among 500 male adolescents aged between 12 to 18 years. Kaur S and Verma S

[32] in their study have found a high degree of negative correlation between abuse and

academic achievement of adolescents. Sharma A and Sharma J [33] came up with a

finding that adolescent smokers irrespective of gender and type of school were

significantly higher on anxiety, stress and family conflict. Mohan et al. [34] found that

low educational performance predict tobacco use among adolescent boys. A study

conducted in Australia also came up with similar findings [35].

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Suicidal behavior:

The average global suicide rate is 14.5 deaths per 100,000 people. But the suicide rate in

the 15-19 group adolescents reported in South India was 148 per 100,000 for girls and 58

per 100,000 for boys. [36]

In a study on the psychosocial and clinical factors associated with adolescent suicidal

attempts Kumar et al. [37] compared potential risk factors between adolescent and adult

suicide attempters and found that the adolescents had significantly higher levels of

depression, hopelessness, lethality of event, and stressful life events. Sharma et al. [38] in

their study on adolescent students found the prevalence of suicide risk behavior quite

high with almost 16% having suicide ideation and 5% having attempted suicide. Females

were seen as being more vulnerable.

Arun P and Chavan BS [13] in their school based study found that 6% of students had

suicidal ideas and 0.39% of students reported suicidal attempt. Daniel et al. [39] found

that suicidal tendency and school dropouts were strongly associated with each other.

Jena and Siddharta [40] reviewed articles on non fatal suicidal attempts of adolescents in

both Indian and international literature. They stated that non fatal suicidal behavior

among adolescents needs to be evaluated and managed effectively in order to reduce the

rates. They concluded that Indian studies in this area are very few and there is a great

need to conduct research in this area. The article also stresses upon the importance for

professionals like general practitioners, teachers, pediatricians and school counselors to

57

be trained to identify non fatal suicide behaviors in adolescents so as to facilitate referral

and effective management.

In a study conducted by Wilburn VR and Smith DE [41] in United States, results indicate

that both stressful life events and low self-esteem were significantly related to suicidal

ideation in adolescents and they insisted that social and public health response in addition

to mental health response is crucial to prevent suicidal behavior among adolescents.

Psychosocial adjustments:

The term, ‘psychosocial’ refers to the interconnection between psychological and social

processes and the fact that each continually interacts with and influences each other.

‘Psychological adjustment’ refers to the adaptive psychosocial response of an individual

to a significant life change. [42]

Takahiro Hasumi et al. [43] examined the association between parental involvement and

mental well-being among the 6721 school-going adolescents aged 13 to 15 years who

participated in India’s nationally-representative Global School-based Student Health

Survey (GSHS) in 2007. Parental involvement (homework checking, parental

understanding of their children’s problems, and parental knowledge of their children’s

free-time activities) was reported by students to decrease with age, while poor mental

health (loneliness, insomnia due to anxiety, and sadness and hopelessness) increased with

age. This study shows that mental health concerns, especially symptoms of

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depression, are common among Indian adolescents and increase with age. The study also

adds that adolescents who report high levels of parental involvement in their lives tend to

report lower levels of depression, loneliness, and anxiety.

Akbar Hussain et al. [44] found that the magnitude of academic stress was significantly

higher among the public schools students where as Government School students were

significantly better in terms of their levels of adjustment. A study done by Firdous D Var

et al. [45] indicates a negative correlation between self esteem and problem areas.

Warbha L et al. [46] in their study among 145 nursing students found that psychological

distress was significantly associated with psychosocial adjustment difficulties.

A study conducted by Adhikari SR et al. [47] in Nepal revealed that adolescents undergo

various stresses and adjustment and it depends upon their ability to cope with stress in

various places like home, school, peers and teachers. In another study by Flannery DJ et

al. [48] it was found that violent adolescents as compared to their less violent and non

violent peers employed more maladaptive coping strategies.

Social support:

Social support is considered as one of the most important way of coping with academic

stress. Social support may play an important role at two different points in the causal

chain linking stress to illness [49]. First of all support may intervene between the stressful

event (and expectation of that event) and stress reaction by attenuating or preventing a

stress appraisal response. Second, adequate support may intervene between the

experience of stress and the onset of the pathological outcome by reducing or

59

eliminating the stress reaction or by directly influencing physiological processes. There is

some evidence, however, that explained the main effect of support on major health

outcomes for the contrast between persons who are essentially social isolates (those with

very few or no social contacts) and persons with moderate or high level of support. [50]

The results of the study by Shadiya Baqutayan [51] indicate that there are significant

differences between the experimental group (provided classes on social support) and the

control group in relation to stress and social support. Eventually, the experimental group

proved to cope with academic stress better than the control group, and they were satisfied

with their academic performance during the experimentation.

Conclusion

After careful review of literature, it is observed that the risk factors for mental disorders

in adolescents include, but not limited to poverty, social exclusion, violence, peer

rejection, isolation and lack of family support. Protective factors for mental well-being

are linked to cohesion at the community level, family well-being, individual behavior and

skills, adolescent friendly social services including health services. Accumulated

evidences show that strengthening the protective factors in schools, homes and local

communities as well as improving quality of mental health care for adolescents, can make

important contributions to improving developmental outcomes of vulnerable young

people [52].

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Taking this into consideration Delhi government has launched a toll free YUVA help

line, 1800-11-6888 with the objective of providing support to adolescents, teachers

and parents. The YUVA Help line runs from 7.30 am to 7.00 pm on all working days

[53]. Besides these a Delhi based NGO called Viswa Yuvak Kendra provides vocational

and life skills training to orient youth towards the developmental process [54]. CBSE

(Central Board for Secondary Education) has also started a helpline number, 1800-11-

8004 for stress management and relieving tension among school students. While the

general queries are answered by the operators, students are connected to the principals or

counselors in case of exam related anxiety or stress. [55] ARSH (Adolescent

Reproductive and Sexual Health) program was implemented by the Government of India

under NRHM/RCH-II program which focuses on reorganizing the existing public health

system in order to meet the service demands of adolescents [56]. Apart from these, NASP

(National Association of School Psychologists) has a number of resources available to

assist families and educators in preventing youth suicide [57].

But the findings from the Atlas of Child and Adolescent Mental Health Resources [58]

suggest that governmental child and adolescent mental health policies are scarce

worldwide. Developing countries like India lack the policies to guide system

implementation, thus hampering service development, and undermining efforts to ensure

accountability for the manner in which resources for program development are allocated.

The UN (United Nations) resolution [59] on a World Fit for Children endorses

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the commitment that “every child has the right to develop his or her potential to the

maximum extent possible to become physically healthy, mentally alert, socially

competent, emotionally sound and ready to learn. However, evidences suggest that

endorsement of the Convention is not correlated with the development of specific policies

or programs to support child and adolescent mental health services.

Recommendations

The promotion of child and adolescent mental health is a worldwide challenge, but a

potentially rewarding one [60]. It is important that Adolescent Friendly Health Services

be made an integral part of the health system. A comparative study on utilization of

adolescent health services found that school based services were better utilized than

health facility based services [61] and parental involvement contributed to help seeking

behavior [62]. A holistic approach should be adopted which should focus on a broader

range of health issues and not just sexual and reproductive health. This would entail

convergence of all the appropriate medical specialties. Utilization of such services could

be improved by intensive information, education and communication (IEC) and involving

the parents or guardians.

Early interventions can provide long-term health and socioeconomic benefits by

prevention of the onset of mental health problems and their development into chronic

disorders. These issues are even more relevant in India, where the proportion of children

and adolescents in the population is high and the resources are scarce. India is currently

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going through a demographic transition, and intervention today is likely to result in a

decreased burden in future.

References

1. United Nations (UN): Department of Economic and Social Affairs, World

Population Prospects: The 2008 revision. Available from: URL:

http://www.un.org/esa/population/publications/wpp2008/wpp2008_highlights.pdf.

2. United Nations (UN): Department of Economic and Social Affairs, World

Population Prospects: The 2012 revision. Available from: URL:

http://esa.un.org/wpp/.

3. Rao M: Promoting children’s emotional well-being. J Public Health Med. 2001,

23(2):168.

4. Mates D, Allison KP: Sources of stress and coping responses among high school

students. Adolescence. 1992, 27(106):461-474.

5. World Health Organization (WHO) meeting report (Geneva 2003): Caring for

children and adolescents with mental illness, setting WHO directions. 1-4.

6. Lee M, Larson RW: The Korean Examination Hell: Long hours of studying,

distress, and depression. J Youth Adolescence. 2000, 29:249-272.

7. National Crime Records Bureau (NCRB): Ministry of Home Affairs, Government

of India. Available from: URL: http://www.ncrb.nic.in.

8. UNICEF global databases: Available from: URL: http://www.childinfo.org.

http://www.childinfo.org/

63

9. Adolescent Psychology and Psychological issues: Available from: URL:

http://www.knowledge-peak.com.

10. De Kloet R, Joels M, Holsboer F: Stress and the brain: from adaptation to disease.

Nat Rev Neurosci. 2005, 6(6):463-475.

11. Mishra A, Sharma AK: Clinico social study of psychiatric morbidity in 12 to 18

years school going girls in urban Delhi. Indian J Community Med. 2001,

26(2):71-82.

12. Bansal V, Goyal S, Srivastava K: Study of Prevalence of depression in adolescent

students of a public school in Pune. Indian J Psychiatry. 2009, 18(1):43-46.

13. Arun P, Chavan BS: Stress and suicidal ideas in adolescent students in

Chandigarh. Indian J Med Sci. 2009, 63(7):281-287.

14. Dhuria M, Sharma N, Taneja DK, Kumar R, Ingle GK: Assessment of mental

health status of senior secondary school children in Delhi. Asia-Pac J. Public

Health. 2009, 21(1):19-25.

15. Sahoo S, Khess CR: Prevalence of depression, anxiety, and stress among young

male adults in India: a dimensional and categorical diagnoses-based study. J Nerv

Ment Dis. 2010, 198(12):901-904.

16. Chhabra GS, Sodhi MK: Factors Contributing to Psycho-Social Ill-Health in

Male Adolescents. Online J Health Allied Scs. 2011, 10(3):2.

17. Salunkhe V, Sutrawe A, Goel R, Jadhav P: Health status of adolescents in Navi

Mumbai. Int J Med. Clinical Res. 2011, 2(1):14-19.

http://www.knowledge-peak.com/http://www.ncbi.nlm.nih.gov/pubmed?term=Sahoo%20S%5BAuthor%5D&cauthor=true&cauthor_uid=21135643http://www.ncbi.nlm.nih.gov/pubmed/21135643http://www.ncbi.nlm.nih.gov/pubmed/21135643

64

18. Al-Sughayr AM, Ferwana MS: Prevalence of mental disorders among high school

students in National Guard Housing, Riyadh, Saudi Arabia, J Fam Community

Med. 2012, 19(1):47-51.

19. Emami H, Ghazinour M, Rezaeishiraz H, Richter J: Mental health of adolescents

in Tehran, Iran, J Adolescent Health. 2007, 41(6):571-576.

20. Zulkefly NS, Baharudin R: Using GHQ-12 to assess psychological health of

Malaysian college students. Global J Health Science. 2010, 2(1):26-33.

21. Deb S, Walsh K: Anxiety among high school students in India. Aust J

Educational and Develepmental Psychology. 2010, 10:18- 31.

22. Singh H, Sofat R, Gill PJ, Soni RK, Kaur L: Adolescent girls' anxieties - role of

stressful life events. Indian J Matern Child Health. 1990, 1(4):142-143.

23. Krishnakumar P, Geeta MG, Riyaz A: Deliberate self harm in children. Indian

Pediatr. 2011, 48(5):367-371.

24. Bhasin SK, Sharma R, Saini NK: Depression, anxiety and stress among

adolescent students belonging to affluent families in Delhi. Indian J Pediatr. 2010,

77(2):161-165.

25. Kumari R, Garita R: Relationship between stress and academic achievement in

senior secondary school students. Asian J Multidimensional Research. 2012,

1(3):76-82.

26. Latha KS, Reddy H: Patterns of stress, coping styles and social support among

adolescents. J. Indian Assoc. Child Adolesc. Ment. Health. 2006, 3(1):5-10.

65

27. Verma S, Sharma D, Larson RW: School stress in India: Effect on time and daily

emotions. Int J Behav Dev. 2002, 26(6):500-508.

28. Munni R, Malhi P: Adolescent violence exposure, gender issues and impact.

Indian Paediatr. 2006, 43(7):607-612.

29. Kameel, Kamal M: Screening for psychiatric illness among students of the

University of West Indies, Trinidad. Int J Adolesc Med Health. 2011, 23(3):199-

203.

30. Substance abuse definition: Available from URL:

http://www.who.int/substance_abuse/terminology/abuse/en/.

31. Suchday S, Kapur S, Ewart CK, Friedberg JP: Urban stress and health in

developing countries. Behav Med 2006, 32(3):77-86.

32. Kaur S, Verma S: Corelates of abuse among Indian adolescents in rural Punjab,

Global J of Human social science 2010, 10(3):39-48.

33. Sharma A, Sharma J. Tobacco use in adolescents: the role of psychosocial factors.

Global J of Human social science 2011, 11(8):51-57.

34. Mohan S, Sharma SP, Thangappan KR: Access to pocket money and low

educational performance predict tobacco use among adolescent boys in Kerala.

Indian J Prev Med. 2005, 41(2):685-692.

35. Norris TF, Eyeson-Annan ML: Recent substance use and high levels of

psychological distress among secondary school students in New South Wales.

NSW Public Health Bull. 2007, 18:125-9.

66

36. Aaron R, Joseph A, Abraham S, Muliyil J, George K, Prasad J: Suicides in young

people in rural southern India. The Lancet 2004, 363(9415):1117-1118.

37. Kumar S, Chandrasekharan R: As study of psychosocial and clinical factors

associated with adolescent suicide attempts. Indian J Psychiatry 2000; 42:237–

242.

38. Sharma R, Vijay L, Chaturvedi S: Suicidal behavior amongst adolescent students

in South Delhi. Indian J Psychiatry. 2008, 50:30–33.

39. Daniel SS, Walsh AK, Goldston DB, Arnold EM, Reboussin BA, Wood FB:

Suicidability, school dropout and reading problems among adolescents. J Learn

Disabil. 2006, 39(6):507-514.

40. Jena S, Sidhartha T: Non-fatal suicidal behavior in adolescents. Indian J

Psychiatry. 2004, 46:310–318.

41. Wilburn VR, Smith DE: Stress, self-esteem, and suicidal ideation in late

adolescents. Adolescence 2005, 40(157):33-45.

42. Angold A, Costello EJ: Depressive co morbidity in children and adolescents:

Empirical, theoretical and methodological segues. Am J Psychiatry 1993,

150:1779-1791.

43. Hashumi T: Parental involvement and mental well being of Indian adolescents.

Asian J Multidimensional Research 2009, 1(3):36-44.

44. Hussain A, Kumar A, Husain A: Academic stress and adjustment among high

school students. J Indian Acad. Applied Psychology. 2008, 34:70-73.

67

45. Var FA, Paul MA, Kumar P, Shah SA: Self-esteem and psychosocial problems

among Kashmiri youth. Delhi psychiatry J. 2011, 2(3):24-29.

46. Warbah L, Sathiyaseelan M, Vijayakumar C, Vasantharaj B, Russell S, Jacob KS:

Psychological distress, personality and adjustments among nursing students.

Nurse Educ Today. 2007, 27(6):597-601.

47. Adhikari SR, Bhattari S: Evidence of stress and its consequences in Nepalese

adolescents. Health Renaissance 2013, 11(1):11-16.

48. Flannery DJ, Singer MI, Wester KL: Violence, coping and mental health in a

community sample of adolescents. Violence Vic. 2003, 18(4):403-418.

49. Cohen J: Statistical power analysis for the behavioral science. New Jersey:

Lawrence Enlbaum Associates; 1988.

50. House JS, Landies KR, Umberson F: Social relationships and health. Science.

1988, 241:540–550.

51. Baqutayan S: Stress and Social Support. Indian J Psychol Med. 2011, 33(1):29-

34.

52. Sameroff A, Gutman LM, Peck SC: Adaptation among youth facing multiple

risks. New York: Cambridge University press; 2003:364-391.

53. YUVA help line: Available from: URL:

http://delhi.gov.in/wps/wcm/connect/doit_scert/Scert+Delhi/Home/YUVA/Yuva+

Helpline.

54. Viswa Yuvak Kendra: Available from: URL:

http://vykdemo.bizarredesigns.com/our-vision.html.

http://vykdemo.bizarredesigns.com/our-vision.html

68

55. CBSE help line: Available from: URL: http://cbse.gov.in/helpline/final_2012.pdf.

56. Adolescent reproductive and Sexual Health (ARSH): Available from: URL:

http://www.mohfw.nic.in/NRHM/ARSH.html.

57. National Association of School Psychologists (NASP): Available from: URL:

http://www.nasponline.org/resources/crisis_safety/suicideprevention.aspx.

58. Shatkin J, Belfer M: The global absence of child and adolescent mental health

policy. Child Adolesc Ment Health. 2004, 9:104-108.

59. United Nations (UN) Convention on the Rights of the Child: Available from:

URL: http://www.unicef.org/crc.

60. Funk M, Minoletti A, Drew N, Taylor J, Saraceno B: Advocacy for mental health

roles for consumer and family organizations and governments. Health Promot Int.

2006, 21:70-75.

61. Santelli JS, Nystrom RJ, Brindis C, Jusczak L, Klien JD, Bearss N et al:

Reproductive Health in School based Health Centers: Findings from the 1998-99

Census of School based Health Centers. J Adolesc Health. 2003, 32:443-451.

62. Joshi BN, Chauhan LS, Donde UM, Tryambake VH, Gaikwad NS, Bhadoria V:

Reproductive problems and help seeking behavior among adolescents in urban

India. Indian J Pediatr. 2006, 73:509-513.

Dr. Varun Kumar, Post Graduate student, Dr. Richa Talwar, Professor, Department of

Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital,

New Delhi, India.

http://www.nasponline.org/resources/crisis_safety/suicideprevention.aspx