the complexity of stress in mid-adolescent girls and boys

The Complexity of Stress in Mid-AdolescentGirls and BoysFindings from the Multiple Methods School Stress and SupportStudy

Viveca Östberg & Ylva B Almquist & Lisa Folkesson &

Sara Brolin Låftman & Bitte Modin & Petra Lindfors

Accepted: 1 April 2014# Springer Science+Business Media Dordrecht 2014

Abstract In many Western countries adolescents, especially girls, report high levels ofstress and stress-related health complaints. In this study we investigate the concept ofstress in a group of 14–15 year-olds (grade 8 in two Stockholm schools) using amultiple methods approach. The aim is to analyse stress, and gender differences instress, as indicated by a measure of perceived stress (questionnaires, n=212), thediurnal variation in the biomarker cortisol (saliva samples, n=108) and the students’own accounts of stress (semi-structured interviews, n=49). The results were generatedwithin the traditional framework of each method and integrated at the point ofinterpretation. The hypothesis that adolescent girls experience more stress than boyswas confirmed by all methods used. In the questionnaire, the most commonly experi-enced aspects of perceived stress were the same among girls and boys, but girlsconsistently reported higher frequencies. The saliva samples showed that girls hadgreater cortisol output in the morning. In the individual semi-structured interviews, girlsand boys discussed stress in similar ways but both acknowledged a gender gap to thedisadvantage of girls. The results as a whole suggests an interpretation of genderdifferences that focuses girls’ attitudes, perceived expectations and coping strategiesin relation to school performance, with their focus on achievement, marks, hard work,and worries about the future. The findings point to a need of an increased awarenessabout the role of perceived expectations in the stress process, and that these expecta-tions and their impact on stress may differ by the gender of the student.

Child Ind ResDOI 10.1007/s12187-014-9245-7

V. Östberg (*) :Y. B. Almquist : L. Folkesson : S. B. Låftman : B. ModinCentre for Health Equity Studies (CHESS), Stockholm University/Karolinska Institutet,106 91 Stockholm, Swedene-mail: [email protected]

L. Folkesson : P. LindforsDepartment of Psychology, Stockholm University, 106 91 Stockholm, Sweden

Keywords Mid-adolescence . Gender . Stress . Cortisol . Multiple methods . Datacollection

1 Introduction

Stress among young people is increasingly regarded an issue of great concern. InSweden and other Western countries a large share of adolescents, especially girls, reporthigh levels of perceived stress and stress-related health complaints (SOU 2006:77;Schraml et al. 2011; Ravens-Sieberer et al. 2009). High stress levels in adolescence areperhaps not surprising given that this life phase involves major physiological, psycho-logical and social changes and challenges (Arnett 1999). However, the reporting ofstress has increased over time (SOU 2006:77; Hagquist 2009; Sweeting et al. 2009),suggesting that social context and circumstances matter. While stress can emanate frommany areas of life, Swedish girls and boys commonly identify school as the origin oftheir stress (SOU 2006:77).

The general picture of adolescent stress is largely based on self-reports inlarge-scale surveys. Given the limitations of this research method, it has beenquestioned whether girls’ higher stress levels may be due to factors such asgender differences in the reporting and/or views of stress. The present study aimsto achieve a deeper understanding of stress in adolescent girls and boys by usinga multiple methods approach in which the data comprises stress measurementsobtained from three sources, namely questionnaires, saliva samples and semi-structured interviews. In the following we discuss stress perspectives, the role ofschool and gender for stress, and outline the purpose of the study in greaterdetail.

1.1 Perspectives on Stress

Stress is commonly defined as the imbalance between experienced demands or chal-lenges and an individual’s possibility to deal with these demands or challenges. Stressthus arises either when demands exceed the capacity to cope or when the demands aretoo low and result in understimulation (Frankenhaeuser 1986). Along with the focus onimbalance, stress is often conceptualized as part of a process. The individual experi-ences an event or a more chronic situation that may act as a stressor, influencing orchallenging the individual’s physiological and psychological stability (or relativestability). Whether or not an event or situation does in fact act as a stressor dependson the individual’s interpretation of the situation. This underscores the importance ofcognitive factors as a link between the stressor and the activation of stress (Karatoreousand McEwen 2013; Lazarus and Folkman 1984). The individual’s interpretationdepends on factors such as earlier experiences, genetics, education and resources.Individual efforts to resolve the situation are commonly described in terms of coping,and the success in handling stressors is affected by the individual’s coping strategiesand coping resources (Folkman and Lazarus 1985; Compas et al. 2001). Many types ofresources are seen as useful for the individual’s ability to cope with stressors, forexample social support (Cohen et al. 2000; Grant et al. 2006; Hostinar and Gunnar2013). Short-term or acute stress is typically not regarded as a problem for health

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whereas long-term or chronic stress is known to have detrimental effects on psycholog-ical and physical health (McEwen 1998).

Thus, we can identify a number of the key components involved in stress, namely astressor, interpretations/cognitions, an imbalance, coping strategies and coping re-sources. The process also comprises psychological and physiological consequences.In empirical studies, one or several of these components may be used to define andmeasure the concept of stress. It has been argued that this conceptual ambiguity is aproblem, which is often reflected in the stress measures for children (Lindblad et al.2008). Self-report measures of adolescent stress tend to focus on perceived stressors(see e.g. Byrne et al. 2007; De Vriendt et al. 2011) or on a number of the componentsinvolved in the stress process (see e.g. Osika et al. 2007). However, in those instanceswhere the research aim includes the empirical investigation of the linkagesbetween, for example, specific stressors and stress, stress and health, or themodifying role of social support, stress measures including several or all of thesecomponents are difficult to use. To address this problem, Lindblad et al. (2008)have developed a stress scale that focuses on perceived stress reactions and agenerally formulated level of demands in order to keep the measurement of stressclose to its conceptual origin.

While the psychological aspects of stress can be identified by means of question-naires and interviews, its physiological aspects are investigated by means of bio-markers. The physiological reaction to stress involves a number of bodily systems,such as the endocrine, cardiovascular, metabolic and immune systems. The body’sability to immediately activate physiological systems is central to survival and enablesus to adapt immediately to new situations. However, while the acute reaction isadaptive, chronic stress involving constant adaptation and lack of rest and restoration,will over time result in an over- or underactivation of bodily systems and give rise toallostatic load (allostasis meaning the maintaining of stability through change).Allostatic load increases the wear and tear on bodily systems and is related to variousphysical and psychological health problems (McEwen 1998; McEwan and Seeman1999). One of the key systems involved in overall bodily functioning is thehypothalamic-pituitary-adrenocortical (HPA) axis and its regulation of cortisol. Sinceit reflects the activity of the HPA-axis, salivary cortisol is used as a biomarkerof stress-related activation. Cortisol levels normally peak in the morning anddecrease throughout the day (Fries et al. 2009). Previous research has identifiedmorning cortisol, and profiles of diurnal variations of cortisol output as importantmeasures (Kristenson et al. 2012).

We know less about normal cortisol profiles for adolescents than for the adultpopulation. According to a review by Jessop and Turner-Cobb (2008), evidencesuggests that salivary cortisol may vary with gender and age (including pubertalstage) during childhood and adolescence, but the results are inconclusive. Somestudies have been unable to detect gender differences (e.g. Tornhage and Alfven2006) while other studies have found higher cortisol levels in girls than boys(e.g. Kelly et al. 2008; Rotenberg et al. 2012). The cortisol levels amongchildren and adolescents are, nevertheless, similar to those of adults; they areinfluenced by external conditions, and the diurnal cortisol curves are assumedto reflect long-term adjustment and chronic stress-related HPA-axis functioning(Peters et al. 2011).

The Complexity of Stress in Mid-Adolescent Girls and Boys

1.2 School, Gender and Stress

There are many reasons why it is useful to look at school when seeking to improve ourunderstanding of stress in adolescence. School is a long-term environment for youngpeople in terms of the number of years and hours per day they spend there. School isboth a work environment and a social arena. As a work environment the school makesdemands of and challenges students and assists them in their efforts to learn. Whileboth extrinsic demands and intrinsic efforts promote school performance they may alsoserve as sources of stress and poor health (Gillander-Gådin 2002; Modin and Östberg2007; Li et al. 2010; Fukuda et al. 2010; Låftman and Modin 2011). The grading ofschool performance also creates an educational hierarchy that may impact on feelingsof worth, identity and stress (Elstad 2010). As a social arena school is characterized byrelational work among same-aged peers, often revolving around friendship, groupings,status hierarchies, and sometimes marginalization and harassment. Where stress andhealth are concerned, relational work represents both risks and resources. Havingfriends at school is an important source of social support - a well-established healthpromoter and stress reliever (Almquist 2011; Due et al. 2003; Låftman and Östberg2006), while exposure to harassment or bullying, is perhaps the greatest school-stressorof all and closely linked to health problems (Craig et al. 2009; Alfvén et al. 2008).

It is well known that girls report higher levels of perceived stress and stress-relatedhealth complaints than boys – a gender difference that emerges in adolescence(MacLean et al. 2013; SOU 2006:77). The reasons behind the gender gap are less wellunderstood. In addition to there being a gender bias in reporting and gender differencesin ways of expressing emotions (SOU 2006:77), the explanations suggested includepotential differences in every part of the stress process. Thus, gender differences mayexist in the amount or types of stressors, in the interpretation of a stimulus as a stressoror the stress reactivity, in the coping resources or the coping strategies employed (e.g.SOU 2006:77; Wiklund et al. 2012; Taylor et al. 2000; Grant et al. 2006; Rose andRudolph 2006). In addition, the explanations focus on different levels, ranging frombiological sex differences (SOU 2006:77), to the gender order of societies (Wiklundet al. 2010).

With regard to school, both aspects of the work environment and the social arenamay give rise to gender differences in stress. It has been hypothesised that men reactmore strongly to achievement challenges, while women show greater stress responsesto social rejection stressors (Stroud et al. 2002). In line with this, Rudolph (2002)argues that girls are more sensitive to relational stress than boys, because girls investmore in interpersonal relations. However, a study by Murberg and Bru (2004) foundthat girls experienced more stress related to school achievement while boys experiencedmore stress from relational conflicts with teachers, parents and peers at school.

1.3 The Aim of the Study

This study will investigate the concept of stress in a population of mid-adolescents(aged 14–15, grade 8) by means of a multiple methods approach. The aim is to analysestress, and gender differences in stress, using three different methods, namely class-room questionnaires, saliva sampling and semi-structured interviews. Thus, stress willbe considered in terms of a self-report scale of perceived stress, as the biomarker

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cortisol and its diurnal variation, and as students’ own accounts of stress. The extensive,multiple methods data collection will also be described in greater detail.

Different methods represent diverse perspectives on the subject of research. Trian-gulation can be used to check the consistency of findings across data collectionmethods. If the findings are consistent it strengthens the credibility of the conclusions,especially since different methods have their own specific biases and weaknesses.However, since each method also reveals various dimensions of the subject it is notself-evident that a certain method should be given priority in cases of inconsistencies(cf. Patton 2002, p. 555). The point of departure for the present study is that eachmethod reveals different and complementary aspects of the complex and multifacetedstress concept. Accordingly, each type of data will be treated and analysed within itsown traditional framework. The findings will subsequently be combined and integratedat the stage of interpretation (cf. Moran-Ellis et al. 2006) in order to achieve a morecomprehensive understanding of stress in mid-adolescent girls and boys.

2 Material and Methods

The overall aim of the School Stress and Support study (TriSSS) was to improve ourunderstanding of school as an institution which influences students’ health and experi-ence of stress. By using a small-scale sample we aimed for a multiple methods datacollection in which important information was collected from one and the same popu-lation, namely grades 8 and 9 at two Stockholm schools. The study involved threedifferent types of data collection, all of which include stress. Because the interviewswere only carried out in two grade 8 classes the present study will use a subsample, i.e.data from grade 8. All data were collected in naturalistic settings familiar to the students.

2.1 The Study Population and the Data Collection Procedure

The total study population of all students in the 8th and 9th grades (ages 14–16) wasdistributed over 19 school classes in two elementary schools in Stockholm, Sweden(n=545). The selection of schools was based on the willingness of principals andschool staffs to participate. Schools with different characteristics were targeted in orderto achieve greater diversity. One school is located in the city centre of Stockholm, whilethe other is a suburban school. The city school has particularly high–performingstudents with a very high share of parents with tertiary education, while the suburbanschool has a somewhat lower performance and a lower proportion of parents withtertiary education (although still above the national average). The share of students withforeign background (defined as being born abroad or having two foreign-born parents)was similar in both schools and somewhat lower than in the country as a whole(statistics from the database SIRIS, www.siris.skolverket.se). Furthermore, the cityschool has a broad catchment area, meaning that many students had quite a longjourney to school and did not necessarily live in the same neighborhood as theirclassmates. The suburban school had a local catchment area.

The data collection took place in the spring of 2010. Members of the research teambegan by holding information meetings for staff and parent representatives at bothschools. Parental consent was required for participation. The parents received a letter at


http://www.siris.skolverket.se/

home containing information about the study and a form for parental consent. Parentswho did not return the consent form after a reminder were also contacted by phone. Inthis way all but 39 parents were reached and informed parental consent was success-fully obtained for 83 % of the students (n=455). The parents were also asked to answera short questionnaire (with 12 questions) about the family’s socio-demographic char-acteristics, although the number who provided this information was relatively small(n=178). The students with parental consent were asked to participate in one or more ofthe following parts of the data collection: class room questionnaire, saliva sampling,and semi-structured interview. The students were given oral and written informationabout the study in the classroom, and were informed that participation was voluntaryfor each part and that they had the right to withdraw from further participation at anypoint without having to explain why. However, participation in the first part (i.e. thequestionnaire) and signed student assent was required for participation in the other twoparts. The study was approved by the Regional Ethics Committee of Stockholm (EPN).Table 1 presents descriptive statistics of the total study population.

Table 1 Description of the total study population and participation in the classroom questionnaire, salivasampling and parental questionnaire by school, grade and gender

Study population(SP)

Classroomquestionnaire(CQ)

Saliva samples,Day 1a

Saliva samples,Day 2a

Parentalquestionnaire

City school 365 290 144 128 144

79.5 % of SP 39.5 % of SP 35.1 % of SP 39.5 % of SP

49.7 % of CQ 44.1 % of CQ

Suburban school 180 123 46 38 64


37.4 % of CQ 30.9 % of CQ

Grade 8 261 213 108 100 90


50.7 % of CQ 43.3 % of CQ

Grade 9 284 200 82 66 88


41.0 % of CQ 33.0 % of CQ

Girls 314 246 129 115 110


52.4 % of CQ 46.7 % of CQ

Boys 231 167 61 51 68


36.5 % of CQ 30.5 % of CQ

All 545 413 190 166 178


46.0 % of CQ 40.2 % of CQ

a Students delivering reliable saliva samples and time reports in diary for all five time points during one day(i.e. approximately 2/3 of all persons delivering saliva samples)

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2.2 Part I: Classroom Questionnaire

The classroom questionnaire was carried out by the research team. It included 106questions (including scale items) with fixed response alternatives.1 It was completedduring one lesson and returned to the researcher present in the classroom. Of the 455students with parental consent, 413 completed the questionnaire (32 students wereabsent on the day of data collection and 10 declined to participate). This equals 76 % ofthe total study population. The response rate was higher in the city school than in thesuburban school; it was also higher in grade 8 than 9, and higher among girls than boys.The internal attrition was low and varies between 0 and 4% for single questions.

The questionnaire contained eleven subject areas2 which aimed to capture school asa work environment and as a social arena as well as obtain information about stress andhealth complaints. The self-report measure of stress, using the perceived stress scaledeveloped by Lindblad et al. (2008), is of particular interest in this study. The scale isconstructed in order to measure perceived stress reactions and general demands, i.e. theexperience of non-specific demands without any links to specific stressors. The reasonfor this is that the scale as far as possible should be free of cultural bias and shouldmeasure stress similarly in subgroups defined by, for example, gender, ethnicity andsocio-economic circumstances. It also tries to avoid possible age-sensitive items, suchas the word stress itself. The scale includes two distinct dimensions that relate todifferent aspects of stress, namely Activation (measured by four items) and Pressure(seven items). (The wording of items is shown in ‘section 3’).

2.3 Part II: Saliva Sampling and Diary Information

In the second part of the data collection, all students who answered the questionnairewere asked to participate in the measurement of the stress hormone cortisol. Cortisol isgenerally measured in saliva since salivary measurements are performed easily withoutcausing pain or harm, or interfering with participants’ daily lives (cf. Kristenson et al.2012). To get a proper measure of the individual cortisol output, all study participantswere asked to sample saliva on five occasions on two separate schooldays. Saliva wassampled immediately upon waking, 30 min after waking, 60 min after waking, onarrival at school and finally at 8.00 pm. The sampling was done by the students

1 The full questionnaire was pre-tested in a pilot study in autumn 2009 in one class in a different school.2 The questionnaire contained the following subject areas: schoolwork characteristics (demands, effort,control, reward, teacher support); school performance (marks the previous term in the core subjects, satisfac-tion with school performance and marks); social relations (friendship quality, social support from same-agedpeers, experience of various types of harassment and involvement in bullying, school class climate); stressscale; global self-esteem scale; self-rated health and health complaints (i.e. psychological, somatic and sleepcomplaints); health-related behaviors (e.g. smoking, moist snuff, alcohol consumption, exercise); height andweight; material and economic resources; parental relations and support; family composition and livingarrangements. For social relations, the procedure of sociometric nomination was also utilized in order tovisualize the patterns of social relations. All students were asked to name which three classmates they a)preferred working with, b) liked the best, and c) thought were the most popular in the class. In addition, thestudents were asked about their own self-perceived level of popularity. Several questions posed in thequestionnaire have been used earlier in large-scale surveys (e.g. Health Behaviour in School-aged Children,The Swedish Welfare surveys for children) or are items in instruments developed and tested in earlierresearch (e.g. the stress scale; the global self-esteem scale), while a number of questions were developedfor this study specifically.


themselves and they received both verbal and written instructions on how to performthe sampling. They were given two plastic-packs with test-tubes, Salivette® (SarstedtInc., Rommelsdorf, Germany). The Salivette is a sterilized cotton swab in a plastic tube.Participants sampled saliva by chewing on a cotton wool swab, which is then placed inthe tube after approximately two minutes of chewing. It is also possible to spit directlyinto the test-tube. All saliva samples were kept in small plastic bags and returned to theresearch team on the following school day.3 Each student kept a sampling diary foreach day and returned it along with the test tubes. In the diary they noted the exact timeof sampling along with any information about discrepancies to the sampling protocol,such as having eaten, consumed caffeine, smoked or exercised close to sampling saliva.In the diary they also answered questions about medication and chronic diseases,menstruation, and stressful events during the previous year and month. When returnedto the research team, all saliva samples were transported to a laboratory and stored in afreezer (−20 ° C) until analysed. The assay used for the determination of cortisol insaliva was a competitive radioimmunoassay (Spectria Cortisol RIA, Orion Diagnostica,Espoo, Finland; intra-assay precision <5 %, 1.7–4.1 %, inter-assay precision <10 %,4.3–9.0 %). All samples were analysed twice and in randomized order.

The number of students who delivered saliva samples for the first day of testing was272, and for the second day 255. Of these, some two thirds provided reliable measure-ments for all five time points during each day. Thus the number of students for whomthere were complete cortisol measurements was 190 for day 1 and 166 for day 2, themajority of whom were girls in grade 8 at the city school. The present study is based onsamples from grade 8 for day 1.

2.4 Part III: Individual Semi-Structured Interviews with Students in Two SchoolClasses

A case study design was chosen for the semi-structured interviews, with the caseequaling the school class. This choice reflected our interest in studying the class as aunit in which all individual views on the same social entity can be taken into account.The school class is an important social context during the school years and theindividual’s position and relations within this group are of great significance in manyways, including stress and social support. This also means that it is essential to obtaininformation from as many individuals as possible within the group. A high share ofrespondents in the class therefore represents a ‘purposeful sampling’, that is selectingcases rich in information, variety and depth in order to learn as much as possible aboutthe case (Patton 2002, pp. 45–46). The two school classes with the highest participationrates for the student questionnaire (97 % and 90 %, respectively) were selected forinterview. Selecting two classes rather than just one enabled us to make comparisons.The two classes in question were at the same school, namely the city school. Theseclasses were selected because the type of variation the study was looking for is notprimarily associated with differences between schools but rather with differences

3 Saliva samples can be stored at room temperature for several weeks but must be frozen if stored for longerperiods. On the first day of testing participants gave one sample at each given time, while on the second dayparticipants left two samples on each occasion. The second sample will be used to analyse another biomarker,namely alpha-amylase, reflecting functioning with a system activated during the stress process.

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between the individuals who make up the group. The selection took place only in grade8. Grade 9 was not chosen because this school year is busy with national tests andapplications for upper secondary school, especially during the spring. All students whoanswered the questionnaire and had obtained parental consent were invited to partic-ipate. Forty-nine of 62 students agreed to be interviewed. There were more girls thanboys in the school at large, including the two classes chosen for the interviews. In oneof the classes (class B) a greater proportion of girls than boys also agreed to beinterviewed; in the other class (class A) there was no gender difference in willingnessto participate. Descriptive statistics of the interviews can be seen in Table 2.

The interviews were conducted by two members of the research team (with oneinterviewer and one respondent at a time); both were women of Swedish native origin(26 and 35 years old). The interviewers made efforts to minimize potential feelings ofpower asymmetry by demonstrating that the respondents were being taken seriouslyand regarded as experts. The students could choose to be interviewed during the lunchbreak, a free period, or after school. The majority of the interviews took place in roomswhich had been made available by the school. In order not to confuse potentialinterviewer bias with differences between the classes, each interviewer conducted halfof the interviews with each class.

The interviews were semi-structured and explored two main themes: social relationsin the class and stress. A thematic interview guide was used which had previously beentested in three pilot interviews.4 The section of the interviews which dealt with stress

Table 2 Description of interview participation in the two 8th grade classes in the city school

Class A Class B Class A+B

Number of students 31 31 62

Proportion of girls 58 % 68 % 63 %

Number interviewed 25 24 49

Proportion interviewed 81 % 77 % 79 %

Prop. girls interviewed 83 % 95 % 90 %

Prop. boys interviewed 77 % 40 % 61 %

Mean length 53.4 min. 46.0 min. 49.8 min.

Mean length, girls 53.4 min. 46.4 min. 49.4 min.

Mean length, boys 53.5 min. 44.3 min. 50.9 min.

4 The interviews began with a number of background questions about where the students lived, their journeyto school, and how long they had attended this particular school and been in this particular class. A peer-reportmethod called “The Social Cognitive Map” (SCM) was used to address social relations. The purpose of SCMis to let the young people themselves identify their own group as well as other groupings in the school class(Cairns et al. 1985). In addition to the usual question: “Are there any people in your class who hang aroundtogether?”, in the present study a ‘deck of cards’ containing the names of all students in the class was used.The respondent was instructed to lay out the cards on the table according to how he/she identified the socialgroupings in the class. The main reasons for using the cards were, firstly, to minimise the risk of the respondentforgetting any classmates and, secondly, to make it easier for the interviewers to ask follow-up questions aboutthe groupings. The subsequent themes of the interviews concerned these social groupings and their charac-teristics, the pros and cons of group membership, changeability of and conflicts within and between groups,friendships and best friends, the meaning and presence of popularity, likeability, social strategies, respect andmarginalisation. The second theme was stress, and a concluding section inquired about leisure time activities.


was initiated by a general question about what the students thought of when they heardthe word “stress”, the meaning of stress and how stress feels. Subsequent themesconcerned the presence, nature and experience of stressors in relation to school,especially school-related demands, and whether or not classmates were of any rele-vance for the experience and meaning of stress. The themes also dealt with therespondent’s ability to influence his/her situation, strategies for coping, presence ofemotional and instrumental support, the respondent’s view of his/her school perfor-mance and whether this view is determined by comparisons with classmates.

Each interview was digitally recorded and transcribed verbatim (in NVivo). Themean interview length was 50 min (min: 31 min; max: 91 min). The interview lengthdid not differ in any systematic way between boys and girls, nor did it depend on whenthe interview was carried out.

2.5 Analysis

The first two sources of information use a pre-determined conceptualization of stress.In the questionnaire data, the mean values for the two dimensions of the stress scale(activation and pressure) were calculated for girls and boys separately. The mean valuefor each individual statement making up the scales is presented together with thepercentage share of those who answered that the statement “always” applied. For thesaliva measurements, the mean values of cortisol concentration (in nmol/l) over fivetime points during the day were computed for girls and boys separately. The analysisuses all students for whom there are reliable measurements. It should be noted that theexclusion of the small share of pre-menstrual girls would not have altered the mainfindings (data not presented). The tests for statistical significance were conducted usinganalyses of variance (ANOVAs). All statistical analysis were made using SPSS forWindows (version 19, Chicago, IL, USA).

In the semi-structured interviews, the conceptualization of stress is handed over tothe responding students. The interview transcripts were analyzed by means of qualita-tive content analysis in order to illustrate the variation in the data (Graneheim andLundman 2004). Qualitative content analysis focuses on manifest content, i.e. visibleand obvious components of the text, or latent content, i.e. the underlying meaning ofthe text. Both manifest and latent content require interpretation by the researcher, butinterpretations vary in depth and level of abstraction (ibid.). The present study concen-trates on manifest content, presented as four categories and a number of sub categories.Three of the co-authors have held joint discussions about content and interpretation.Transcripts from both school classes are presented together, since few differencesbetween the classes emerged in the reading or the analysis. The students’ accountsand the quotations are, however, contextualized in each class, with own school classbeing the respondents’ frame of reference.

At the final stage of the research process, the findings generated by each methodwere combined and integrated, so-called ‘interpretive integration’ (see Moran-Elliset al. 2006). Here, the existence and understanding of a gender gap in stress is at focus.The explanations typically put forward, building on the shortcomings of each method,are discussed in the light of the results produced by the other methods. Furthermore, wediscuss whether the findings generated by multiple methods taken together can provideany guidance regarding the understanding of gender differences in stress.

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3 Results

3.1 Perceived Stress in the Questionnaire

Table 3 presents the results of the classroom questionnaire. Girls consistently reporthigher levels of perceived stress, both for activation and pressure. The mean score forgirls on activation is 3.11 and for boys 2.51, while the mean score for girls on pressureis 3.33 and for boys 2.62. These gender differences are statistically significant.

Table 3 also shows the results for each item making up the stress scales. The mostcommon stress-inducing experiences seem to have a similar ranking among girls andboys. Among both, the most common aspects of stress are feeling under pressure fromone’s own inner demands, feeling under pressure from demands made by school andthe pressure to do many things at the same time. However, the gender gap is pro-nounced, with a much larger share of girls reporting these pressures. For example,school demands has a mean value among girls of 3.90 and the share answering“Always” is 32 %. Among the boys the equivalent figures are 2.97 and 12 %. Otheraspects of stress that seem relatively common among the girls are never feeling reallyfree and finding it difficult to relax. Only two items revealed no statistically significantgender difference, namely the tendency to eat rapidly and the feeling of pressure fromdemands at home.

Table 3 Self-reported experience of stress measured in the questionnaire. Items for activation, pressure andgeneral stress. Girls and boys in grade 8. N=212

Mean (1–5) % Always

Girls Boys Diff., p Girls Boys

Activationa

I rush even if I don’t have to 3.01 2.43 0.000 7.3 4.5

I eat rapidly even if I don’t have to 3.06 2.82 0.153 10.4 11.5

I keep a high speed all the day in school 3.07 2.38 0.000 5.7 4.6

I find it difficult to relax 3.33 2.40 0.000 16.0 4.5

Activation scale (4 items) 3.11 2.51 0.000 – –

Pressurea

I do too many things at the same time 3.73 3.00 0.000 16.8 6.8

I do not have time enough 3.21 2.78 0.001 4.0 4.5

I feel under pressure from school demands 3.90 2.97 0.000 32.0 12.5

I feel under pressure from demands at home 2.53 2.24 0.087 8.8 3.4

I feel under pressure from my inner demands 3.91 2.94 0.000 37.6 9.1

I feel helpless 2.42 1.60 0.000 4.8 0.0

I never feel really free 3.61 2.78 0.000 23.2 4.5

Pressure scale (7 items) 3.33 2.62 0.000 – –

a The question concerns how often each statement has applied to the individual during the last few weeks.Response alternatives: Never; Rarely; Sometimes; Often; Always. Mean values calculated for each itemseparately, and for the scales for activation (7 items) and pressure (4 items) respectively, with values rangingbetween 1 (lowest possible stress) and 5 (highest possible stress). Scale from Lindblad et al. 2008


3.2 Salivary Cortisol

Figure 1 presents mean values of salivary cortisol (in nmol/l) for girls and boysthroughout the day. It shows the diurnal curve with a characteristic increase in themorning and subsequent decline throughout the day. Girls have higher cortisol levelson waking and 30 min after waking. The difference between girls and boys at boththese time points is statistically significant. One hour after waking up, the differencebetween girls and boys evens out. There were no statistically significant differencesbetween girls and boys in the decline in cortisol levels between 60 min after wakingand 8 pm.

3.3 Students’ Experience of Stress in the Semi-Structured Interviews

The section of the interview which addresses stress starts with a general question aboutwhat the students thought of when they heard the word “stress”. Many students claimedthat they were experiencing stress, although there were also students who said that theyhad very limited experience of stress. However, the latter students acknowledged thatthey had classmates who appeared to be under stress.

The interviews revealed four major recurrent and inter-related categories: timepressure, schoolwork, reconciling schoolwork and leisure, and manifestations of stress(Table 4). These categories were also identifiable from the students’ initial responses tothe word “stress”.

3.3.1 Four Inter-Related Categories

Stress as time pressure is reported by both boys and girls. It can refer to having toomuch to do all at the same time or being late with something, for example revising for atest late the night before. Some students acknowledge that stress related to timeconstraints is a consequence of their own deficient planning or prioritizing. Laggingbehind at school because of illness and absence from school is also mentioned. Stress is

*p< 0.05; **p< 0.01

0

5

10

15

20

25

30

Awakening (+30 min.) (+60 min.) Arrival at school Evening (8 pm)

Boys Girls

**

*

**

*

Fig. 1 Mean values of salivary cortisol (nmol/l) from morning to evening for girls and boys in grade 8.N=108

V. Östberg et al.

perceived by some students as a facet of everyday life, for instance, being in a hurry toget to school in the morning. The notion of having too much to do is often combinedwith the feeling of not being able to get it all done.

‘If I have a test and I sit there revising the day before and don’t feel I can make itin time. That can get you really stressed. I can almost be ready to cry. Just: “Shit,I’m not going to make it!” That’s a stressful thing. Stress can also be the busleaving in two minutes and I still have to brush my teeth and get dressed. Thatdoesn’t work. Then I have to dash and that’s really annoying. That’s stress to me.’(Boy, Class A)

Schoolwork is perceived as stressful in a variety of ways. The large amount ofschoolwork in general and homework in particular, is a source of stress for manystudents. Tests are also stressful. One girl says: ‘Well homework in particular I findvery very stressful. […] The teachers can’t give us so many tests. But homework, theycan give as much as possible and it depends on how people have been doing in class,how much you’re behind in maths, just anything, then it’s: “Do this for homework.”’(Girl, Class A). The clustering of homework and tests in certain weeks is also seen asstressful: ‘… one week we may be completely free and have almost no homework andno tests. And then next week there are three tests and eight essays and everything has tohappen that week.’ (Girl, Class B)

Several students mention the difficulty of reconciling schoolwork and leisure.Examples of leisure time activities that have to be fitted in are helping out at home,picking up younger siblings, and pursuing own activities of personal interest. Manystudents also complain about school work limiting the amount of time they can spendwith friends. One boy says: ‘I haven’t done anything with friends for ages, because it’sjust been eat, sleep, work, and so on. It’s really annoying when it’s like that. Becausethen, then you just feel you’ve only got enough time to survive, not time to live. Andthat’s no fun at all. Then you think, why go to school if it’s going to be this shitty?’(Boy, Class A). The focus on school work may also affect the time one is able to see

Table 4 Categories and sub categories in the semi-structured interviews

Category Time pressure Schoolwork Reconcilingschoolwork andleisure

Manifestations of stress

Sub category • Too much to do atthe same time

• Being late withsomething

• Having to rush toget to school

• Bad planning• Lagging behind

due to illness/absence

• A lot of schoolwork• Homework• Tests• Having several tests at

the same time• A school “spirit” of

hard work and stress• Long schooldays (incl.

travel)• School marks• Specific tasks (e.g. oral

presentations)

• Not being able torelax fromschoolwork

• Difficulty incombiningschoolwork andleisure activities

• Many leisure timeactivities

• Time to survive butno time to live

• Mental symptoms:Depression, feelingmentally bad (oneself orfriend), anxiety, panic

• Somatic symptoms:Stomach ache, headache,loss of appetite

• Tiredness, insomnia, lackof energy, exhaustion


friends. One girl says: ‘But it’s not that, I can be with a friend for a whole weekendwithout thinking: “Oh shit, I must get home and work, so that I can finish.” It’s still, it’salways on your mind. “Oh well, now I have to work again.” On a Saturday, on aSunday.’ (Girl, Class B)

In response to questions about what they associated with the word “stress”, studentsmentioned various manifestations of stress, both mental and bodily, including stomach-ache, sleeping difficulties, feeling depressed or mentally ill, and feeling tired orexhausted. While some students talked about reactions to stress as a response to theword “stress”, all interviewees were subsequently also asked a direct question abouthow stress affected them and their bodies. Many students mentioned sleeping difficul-ties. One girl says: ‘I don’t think it feels so much, it’s more like I can’t concentrate. ButI sleep badly when I’m stressed. I woke up around 5 am every day last week. Or Istopped waking up at 5 am because I began to take pills to sleep better.’ (Girl, Class A)Other respondents mention headache, stomach ache, dizziness, feeling tense, feelingshaky, panic, lack of energy, concentration difficulties, rapid heartbeat. Some manifes-tations concern mood, making students feel annoyed or angry. One boy says: ‘So, I gettired. Usually I get quite angry, that happens often, I’ve had kind of problems withanger before. But that’s mostly with my family. It spills over onto my family when I’vegot a lot to do, and it ends in arguments, so that’s a bit tough.’ (Boy, Class B)

3.3.2 Other Aspects of Stress

In addition to the manifestations of stress grouped under the four major categories,students also mentioned other aspects of stress. In response to the word “stress”, anumber of students mentioned family relations: their own relations with parents,(divorced) parents’ relations with each other, and parental illness. They also mentionedrelations with classmates. Some students associated the word “stress” with parents,either because they saw that their parents were under stress, or because they regardedparents who were pushing them to study hard as stressors. Ideals, i.e. that one should be“perfect”, were mentioned as a stressor. Physical ideals were also mentioned, andaccording to several interviewees, eating disorders were recurrent in (at least) one ofthe classes. Some students distinguished between positive and negative stress, withpositive stress being related to leisure time activities and seeing friends, while negativestress was associated with schoolwork. One boy argued that people nowadays knowmore about stress and are therefore predisposed to feel stress; in other words, thatpeople create stress for themselves even in situations which in fact are not particularlystressful.

As noted above, many respondents said they often experienced stress, but there werealso students who claimed they did not. One boy says: ‘At the beginning of the week,on Mondays for instance, I think that, oh, there’s so much to do this week. But then I doone thing at a time and then it usually works out. So this stress: “Oh, it’s such a drag”, Ihaven’t felt it so much.’ (Boy, Class A)

3.3.3 Girls and Boys

No distinct differences between boys’ and girls’ understanding of the word “stress”were found in the interviews. However, both boys and girls had a perception of girls

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experiencing more stress about schoolwork than boys (although the genderdivide is not clear-cut as there is disparity among both boys and girls). Theview of girls as experiencing more stress than boys was particularly clear inone of the classes (Class B) and much less so in the other class (Class A). InClass A, boys have a higher average sum score of the core subjects Swedish,English and maths than the girls. In contrast, in Class B the pattern is reversed,with the girls performing more highly than the boys.

In Class B, the general opinion is that boys put less effort into school than girls, andare also satisfied with their lower results. ‘They’re happy if they get G [Pass] or VG[Pass with distinction]. VG is like MVG [Pass with special distinction] to them.’ (Girl,Class B) Several interviewees in Class B believe that girls worry more about the futurethan boys and that they therefore strive for high marks in order to get into a certainupper secondary school. Boys, on the other hand, believe it will work out anyway.Indeed boys themselves claim that they have a more relaxed attitude towards school-work than girls, who tend to get worried and experience stress about their performance.This is the view of boys in both school classes:

‘The guys are more relaxed whereas the girls, they work like all evening and allnight before a test.’ (Boy, Class A)

‘I guess we [the boys] have a cooler attitude, we can take it easy and berelaxed when looking at things, while all the girls are really stressed andmake a test into a really big thing, which is so unnecessary since it’s, well,just a test.’ (Boy, Class B)

One boy speculates that reasons for this may include girls’ greater inclination tofulfil parents’ expectations, and that they compare their own performance with that oftheir friends.

Some girls dismiss the boys’ strategy as sloppy whereas other girls are not sodismissive. Some feel that the girls’ high grades are not preferable, because if theyexperience so much stress that they cannot cope the boys will catch up. One girlargues that the boys believe you can succeed in life without getting top marks ineverything, which the girls have not yet realized. She says: ‘They [the boys] havea great attitude towards school, compared with us girls.’ (Girl, Class B) Anothergirl (who claims not to put so much effort into homework because she wants to befree after school) says: ‘The guys realize there is leisure time after school. Me too,kind of.’ (Girl, Class B)

The students’ accounts also reveal that it may be more acceptable for girls than forboys to study hard. In fact, girls are more or less expected to perform well. Accordingto the interviewees, girls can study as much as they want, while boys who work hardare seen as swots.

‘The girls, we can work as much as we want, but if the guys work too much thenthey are, like, swots. And they’re supposed to be smart in general and knoweverything anyway. But the girls can kind of work really hard and still be thesame. It can be a bit annoying for the boys if they feel they can’t work becausethey can’t say like: “I worked five hours last night.”’ (Girl, Class A)


4 Interpretive Integration and Discussion

This study used three methods of data collection targeting the concept of stress, andanalysed gender differences in stress. We conclude that the pattern of girls experiencingmore stress than boys was a consistent finding across the different data collectionmethods. Methodological biases and shortcomings have often been put forward toexplain gender differences in stress. Below the rationale behind such explanations arediscussed in the light of findings from the other methods employed.

The gender difference in perceived stress, as measured in the questionnaire, wasclear in the present study and is an established finding from previous studies. Thisfinding could be spurious if it was due to gender differences in the willingness to reportstress or in the understanding of survey questions on stress. However, such aninterpretation was not supported by the other data collection methods. The genderdifferences in this population were also clearly visible in biomarkers of stress. Morningcortisol levels, an objective measure, were higher among girls than boys. A similarunderstanding of stress was expressed by girls and boys in the semi-structuredinterviews.

The gender difference in the biomarker of stress (salivary cortisol) may to somedegree reflect biological differences between girls and boys, including earlier matura-tion among adolescent girls (see also Folkesson et al. 2013). Nevertheless, it is knownthat cortisol levels (e.g. wake-up levels, diurnal variation and total output) measured inindividuals’ every day settings reflect chronic activation. Morning cortisol levels areassumed to some extent to reflect the individual’s expectations of the coming day andsleep characteristics of the previous night. This means that a higher cortisol concen-tration in the morning can be expected if a student generally perceives daily demands ashigh (e.g. at school) and often finds it difficult to relax and feel really free. According tothe questionnaire data, this was precisely the case for a large share of the girls.Additionally, the semi-structured interviews revealed that the girls experienced morestress and worry, for example about school performance. Thus, the present results givegood reason to believe that the higher morning cortisol levels found among the girls inthis study are not solely explained by biological factors but also by genderedexperiences.

The semi-structured interviews provide adolescents’ own accounts of stress. Stress isoften regarded, more or less explicitly, as an imbalance, such as the imbalance betweenwhat they have to do and the amount of time available, or between obligations andleisure. In this way the respondents’ view of stress corresponded well with commonlyused definitions of stress, according to which imbalance is a key component. In theirconceptualisations of stress they also included specific demands and stressors, mostcommonly linked to school work, such as tests, homework and marks. In addition, theydiscussed the consequences of stress such as emotional and somatic health problemsand sleeping difficulties. In this sense their conceptualization of stress was moreextensive and reflected stress as a process.

No visible gender differences in the perception of stress were revealed by the semi-structured interviews of students in two classes at the inner-city school, and thestressors discussed were similar among girls and boys. This is corroborated by thequestionnaire results for the 8th grade classes at both schools, in which the mostfrequently experienced general pressures were the same for both genders. Nevertheless,

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the interview respondents claimed that girls experienced more stress than boys, and inthe questionnaire girls reported significantly higher frequencies of perceived stress foralmost every item on the stress scale.

Thus, while the results so far indicate that girls experience more stress than boys, themajor general stressors are not exclusive to girls. In the interviews, views about thecommonly acknowledged gender gap in stress revolved around girls’ attitudes to schooldemands and their greater focus on achievement, high aspirations and worries about afuture that depends on good school marks (see also Låftman et al. 2013). Ownachievement was judged against that of others, chiefly friends of the same sex. Boyswere dismissed as a yardstick because of their more relaxed attitude to work. Girls alsoexperienced higher expectations regarding school performance stemming not only fromclassmates but also from other sources such as parents. One frequently used copingstrategy was to work hard. Considering that girls in both schools, according to thequestionnaire, generally reported higher perceived stress related to the above mentionedareas put forward in terms of girls’ “attitudes”, experienced expectations and copingstrategies (e.g. inner and school demands, do many things at the same time, keep highspeed, rush), this may be relevant aspects for the understanding of gender differences instress in the study population as a whole.

This interpretation is supported by previous research. The focus on achievement,marks, hard work, and the future is associated with macro-level changes. It has beenargued that increased stress is linked to a central feature of contemporary Westernsociety, namely individualization (SOU 2006:77) and that the emphasis on individualchoice, freedom and responsibility may be particularly stressful for young people(Wiklund et al. 2010). It has been claimed that, in the neoliberal discourse in whichindividuals are expected to be flexible, competitive, self-disciplined and self-inventing,girls are attributed a special position. They are put forward as subjects of great capacityand are encouraged to achieve both inside and outside school and to self-perfect in theirfree time (Harris 2004). In a study of adolescent girls and young women with stressproblems, the pressure of individual performance along with the pressure to cope alonewas clearly visible. Furthermore, there were close connections between achievements,personal value and identity, and the fear of failure and shame related to weakness andillness (Wiklund et al. 2010). In line with this, Schraml et al. (2011) demonstrate thatgirls are more likely than boys to have a performance-based self-esteem, makingperformance, not least at school, a part of their identity.

In the present study, gender differences in stress are strongly linked to school workand school achievement. However, this link may have been strengthened by the study’soverall focus on school and by its choice of schools which performed above thenational average. The latter factor may imply that the young people participating inthe present study were in a more demanding academic environment than students inother schools. The view of girls as experiencing greater stress than boys was morepronounced in the interviewed class which had a corresponding gender gap in marks,which indicates the importance of the immediate context. However, the finding thatgirls generally report more stress than boys is not exclusive to certain types of schoolsbut has also been found in nationally representative studies (see e.g. Alfvén et al. 2008).It should also be noted that the students interviewed in the present study did mentionother types of stressors, for example relations to parents and peers, and physical ideals.In all, the findings of the present study suggest that girls experience accumulated stress:


they internalize challenges and demands and aim to perform well while at the sametime being exposed to all the contemporary notions of what an adolescent girl shouldstrive for, look like and do. Alongside dealing with pubertal challenges and otherchanges related to this developmental period of life, varying expectations of girls andboys, both at school and elsewhere, may add to the variations in stress found in girlsand boys. While boys seem more likely to adopt attitudes which are associated withlower stress, the ways girls think and behave seems to make them vulnerable toaccumulated stress. If this process continues over time it increases risk of a negativehealth trajectory among women in early adulthood.

Collecting data by means of multiple methods is a major undertaking, but it offers anumber of clear advantages when one is targeting one and the same population.Restricting the data collection to schools reduces the burden considerably, not leastwhen employing multiple methods. Using the school and the school class as one unitfacilitates efficient administration and makes it possible to ask questions and obtaininformation at group level. Questionnaires completed in the classroom commonly havea lower non-response rate, because it is easier to involve all respondents and easy forthem to return their questionnaires. Saliva sampling was also administered at school-class level even though the students were individually responsible for collecting thesamples throughout the day. After close inspection of the information noted in thesampling diaries, we can conclude that they were well capable of doing so. Obtainingparental consent was a time-consuming aspect of this data collection. In general parentswere willing to let their children participate, but posting information about the study ledto non-response and parents often had to be contacted individually by phone.

The integrated findings of this study indicate the existence of a gender gap in stress.Our results suggest that girls’ attitudes, perceived expectations and coping strategiesregarding school performance, with focus on achievement, marks, hard work, andworries about the future, help to explain the higher stress levels among girls. Insofaras features of contemporary Western society have an impact, the influence of individ-ualization seems to be greater on girls, who are rewarded by higher grade pointaverages but who are at greater risk of stress and stress-related health problems. Incontrast, the influence of individualization on boys seems to be counteracted byattitudes and expectations which place less weight on school achievement and hardwork. The consequences of this are less stress but also lower grade point averages.

The results point to the need of an increased awareness among teachers (and othersignificant adults e.g. parents) about the role of perceived expectations in the stressprocess, and that these expectations and their impact on stress may differ according togender. It is indeed valuable and desirable to make an effort in school, and the level ofeffort is relevant for future prospects. However, in cases where high achievementattitudes and behaviors are already internalized, and perhaps part of the individual’sself-esteem, it might be equally important to provide support and tools for enhancingbalance in life. Issues regarding the links between gender and expectations, expecta-tions and internalization, performance and life balance, stress and health, and youngpersons’ worries about the future could be subject to discussion in school. Suchdiscussions could contribute in providing both girls and boys with equal possibilitiesto develop independent ways of handling the more or less explicit expectations thatexist for girls and boys and, in the long run, assist in developing functional and healthpromoting strategies to manage every-day-life.

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Acknowledgement We are grateful to all the students who have made this study possible, and for thecontribution made by parents and school staff. In addition to the research team, thanks to Victoria Blom,Anders Hjern, Roberto Riva, Tove Tullberg and Tina Ulvbane for helping out along the way. Thanks to EdvinSandberg Frid and Johan Rehnberg for valuable research assistance. We thank Ms Ann-Christine Sjöbeck whoperformed the biochemical analysis and Professor Ulf Lundberg who facilitated our use of the laboratory. Theproject has benefitted from discussions with Kate Hunt, Patrick West and Katja Gillander-Gådin. The studywas financed by the Swedish Council for Working Life and Social Research (grant no. 2006-1637 and 2011-0819). Petra Lindfors’ contribution formed part of a senior research fellowship at the Department ofPsychology, Stockholm University.

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the complexity of stress in mid-adolescent girls and boys

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