|Year : 2016 | Volume
| Issue : 2 | Page : 105-110
Stress in preschool children and its correlation with salivary chromogranin A
Sunil Kumar Jena1, Biswabhusan Mohanty2
1 Department of Physiology, Veer Surendra Sai Institute of Medical Sciences and Research, Burla, India
2 Department of Anatomy, Institute of Medical Sciences (IMS) and SUM Hospital, Bhubaneswar, Odisha, India
|Date of Web Publication||30-Jun-2016|
Sunil Kumar Jena
Department of Physiology, Veer Surendra Sai Institute of Medical Sciences and Research (VIMSAR), Burla - 768 017, Odisha
Source of Support: None, Conflict of Interest: None
Background: When preprimary school students enter school, there is definitely a chance of developing psychological stress, which for a prolonged period is harmful to their lives. Different researchers have proved that salivary chromogranin A is a potent biomarker of psychological stress. There are very less studies regarding preschool stress. Thus, we proposed this study to find out the severity of stress in preschool children and its correlation with salivary chromogranin A. Materials and Methods: Fifty-six preprimary school students in the age group of 2.5-5 years were involved in this study. The severity of stress was evaluated by a self-structured questionnaire, preprimary stress questionnaire (PPSQ) and these questionnaires were distributed to different study groups, i.e., no stress, mild stress, moderate stress, and severe stress. Salivary chromogranin A was estimated by enzyme-linked immunosorbent assay (ELISA) test. Result: Out of 56 participants, 7 did not face stress, 14 faced mild stress, 14 faced moderate stress, and 21 faced severe stress. The mean rank stress score rose with severity of stress and was found to be significant. The mean salivary chromogranin A level was analyzed between the different groups and found to be significant at P < 0.001. Correlation coefficient between stress and salivary chromogranin A was 0.875 and significant at P < 0.01. Conclusion: We found that preprimary school students faced stress in different severities and their salivary chromogranin A was raised. Salivary chromogranin A was considered as a biomarker of psychological stress in this study because it is noninvasive and easy to collect from the samples of all the small children with convenience.
Keywords: Preschool children, salivary chromogranin A, stress
|How to cite this article:|
Jena SK, Mohanty B. Stress in preschool children and its correlation with salivary chromogranin A. Muller J Med Sci Res 2016;7:105-10
|How to cite this URL:|
Jena SK, Mohanty B. Stress in preschool children and its correlation with salivary chromogranin A. Muller J Med Sci Res [serial online] 2016 [cited 2017 Mar 23];7:105-10. Available from: http://www.mjmsr.net/text.asp?2016/7/2/105/185007
| Introduction|| |
Preprimary curriculum is the first experience of modern era children in the formal education system. It is an anxious and stressful experience for both children and parents. Parents send their children to the preprimary school with positive thinking that their child would learn better people's skill but instead, they develop new behavioral problems. At present, students belong to different socioeconomic backgrounds. Some students are academically engaged and participate energetically in class and extracurricular activities while others are less engaged and achieve poorly.  Proper developmental skills are very much essential for the future life of a child. Many students become more disengaged from school as they progress from preprimary to higher classes. It is estimated that 40-60% of urban, suburban, and rural high school students become chronically disengaged from school without taking into account those who already drop out.  All these statements presented here provide evidence that preprimary school students definitely experience stress though the severity of stress varies among students.
The school is a natural place where stress can manifest itself in children. It is quite common for children to feel some form of stress, anxiety, and uneasiness at school. Increase in the amount of homework, competition for good grades, fear of failure, peer pressure, and bullying are some of the more common reasons for stress in school.  Anxiety over situations such as answering and asking questions in class, attending social events, showing assertiveness, and being in front of peers can often lead to avoidance of many different social situations including school.  Long-term avoidance of these situations can create behavior patterns that may interfere with the developmental growth of students.  The avoidance of these situations can also lead to other problems such as poor school performance, depression, and possible substance abuse in students in higher classes. 
Stress and anxiety can be viewed as the cause and effect of poor school performance. Students can be overwhelmed, which causes anxiety and then their poor performance can, in turn, produce more anxiety.  Stress and anxiety can interfere with focusing of attention, learning, and taking tests.  According to Woolfolk, highly anxious students feel the need to divide their attention between learning the new information being presented while worrying about the evaluation of the information being taught.  Many highly anxious students have poor study skills, and if the information being presented is not done so in a well-organized manner the anxiety levels in these students may increase.  During the period of examination, many students find it hard to demonstrate the knowledge due to a lack of the skills.  Children who are the targets of peers' aggressive behaviors are at higher risk for adjustment problems including depression, anxiety, stress, low motivation in school, loneliness, and dropping out.  Chromogranin A is an acidic glycoprotein secreted from the adrenal medulla and sympathetic nerve endings. , It has been also reported that chromogranin A is secreted by submandibular salivary glands into the saliva.  It has been reported that salivary chromogranin A shows diurnal variation of the highest level at the time of awakening in the morning and is stable throughout daytime.  Increased level of salivary chromogranin A has been observed in situations of anxiety such as traffic noise.  Decreased level of salivary chromogranin A has been observed in stress-relieving events such as inhalation of aroma.  Salivary chromogranin A is considered to be a more sensitive biomarker of psychological stress in comparison to salivary cortisol  because chromogranin A released in the saliva is involved in innate immune response against bacteria, fungi, and yeast by its cationic nature.  Studies regarding stress in preschool students are very rare. Thus, with the above background we proposed a hypothesis to find out the severity of stress in preschool children and its relationship with salivary chromogranin A. Salivary chromogranin A was considered as a biomarker of psychological stress in this study because it is a noninvasive procedure and easy to collect from the sample of these small children.
| Materials and Methods|| |
The study was conducted in the Department of Physiology, Veer Surendra Sai Institute of Medical Sciences and Research (VIMSAR), Burla, Odisha, India. It was conducted from January 2015 to December 2015 after getting ethical approval from the Institutional Ethical Committee, VIMSAR. The aim and objective of this study was to assess the severity of stress among preschool children by the questionnaire method and find out its correlation with salivary chromogranin A. Students of single parents, students who were mentally and psychologically ill, belonged to disturbed families, and had a family history of psychiatric disorder were excluded from the study. A total of 56 students of the preprimary age group, which included those studying in the Nursery, Lower Kindergarten (LKG), and Upper Kindergarten (UKG) classes were included for this study. A self-structured questionnaire, preprimary stress questionnaire (PPSQ) was used for assessment of the degree of stress. This was a teacher report questionnaire in which class teachers of the respective classes (Nursery, LKG, and UKG) were involved and they filled the questionnaire for each student separately. PPSQ was a reliable and valid questionnaire in English that included 20 questions and each question was rated from 0 to 3 according to the severity of stress.
The total stress score is to be derived by summing the score of the 20 items. However, prior to summation of the items, some of the items (9, 10, 11, 12, 13, 14, 15, 17, and 18) will need to be reverse scored, as these questions are indications of positive ways of handling stress. For example, if one indicated "0" on item number 9, it is to be counted as 3 points (e.g., 0 = 3, 1 = 2, 2 = 1, 3 = 0). Once the scores for items 9, 10, 11, 12, 13, 14, 15, 17, and 18 are reversed, the scores for all the 20 items are to be added to determine the total stress score. The score is to be recorded on the front page. The total score ranges from 0 to 60: Total score 0 = No stress, 1-20 = Mild stress, 21-40 = Moderate stress, and 41-60 = Severe stress. Accordingly, we found out the severity of stress of each student and divided the students into different groups. A written consent was taken from the parents of each student and they were explained about the purpose ant output of the study. Collection of the saliva was done between 6 AM and 7 AM using a rinsing solution of saliva collection system (Greiner Bio-One, Kremsmuenster, Austria) according to the manufacturer's instruction. Students were instructed not to eat, drink, brush, or put anything in mouth after dinner on the night day before the sample was collected to avoid contamination of the saliva sample. First, the mouth was rinsed to remove food debris present in the mouth and then there was a 10-min wait before the saliva sample was collected. Then, the sample was sent to the laboratory for chromogranin A assay by enzyme-linked immunosorbent assay (ELISA).
| Result|| |
[Table 1] shows the distribution of subjects according to class and severity of stress. The number of students who participated in this study were 17, 19, and 20 in Nursery, LKG, and UKG, respectively. The distribution of students according to severity in different classes was depicted in [Table 1] in detail. Out of 17 nursery students, 12 had severe stress, 3 had moderate stress, 2 had mild stress, and 0 had no stress. Out of 19 students in LKG, 6 had severe stress, 7 had moderate stress, 4 had mild stress, and 2 had no stress. Out of 20 students, 3 had severe stress, 4 had moderate stress, 8 had mild stress, and 5 had no stress. Overall, according to the results 7 students had no stress, 14 had mild stress, 14 had moderate stress, and 21 had severe stress. Thus, out of 56 participants 7 did not suffering from stress, which included 2 in LKG and 5 in UKG and all students of Nursery experienced stress.
[Table 2] depicts the comparison of mean rank stress score of students of different classes. Data were analyzed by Kruskal-Wallis Test. The mean rank stress score increased with severity of stress in students of Nursery, LKG, and UKG. Variation in the severity of stress was significant at P < 0.01 in nursery and UKG students but in LKG it was significant at P < 0.001. On comparison, the overall mean rank stress score of subjects with mild stress was 7.5, moderate stress was 21.5, and severe stress was 39. This variation in stress score was significant at P < 0.001.
[Table 3] and [Figure 1] depict that mean salivary chromogranin A concentration increased with the severity of stress. In this study, we found that the salivary chromogranin A level was increased in stress subjects compared to nonstress subjects as well as between subjects of different stress groups. Mean salivary chromogranin A of nonstress subjects was 22.85 pmol/mL, mild stress subjects was 24.14 pmol/mL, moderate stress subjects 33.42 pmol/mL and severe stress subjects was 44.38 pmol/mL. Data were analyzed by one-way analysis of variance (ANOVA) test and this variation was found to be significant at P <0.001.
|Figure 1: Depicts salivary chromogranin A level in different groups of subjects. Data analysis by one-way ANOVA and significant at P < 0.001.|
Click here to view
[Table 4] and [Figure 2] depict the correlation between stress score with salivary chromogranin A. Data analysis was done by Spearman's correlation test. We found a positive correlation between stress score and salivary chromogranin A with correlation coefficient (ñ) of 0.875 and it was significant at P < 0.01.
|Figure 2: Depicts correlation between stress score and salivary chromogranin A. Data analysis by Spearman's correlation and significant at P < 0.01|
Click here to view
| Discussion|| |
Everyone experiences stress and our body has the inherent property to cope with stress. If our body copes with stress properly, it is good for health or else it may lead to different harmful diseases for human beings. Preprimary school students are exposed to a new environment, new peers, workload of stress, strangers, etc. that are the ultimate stressors for them. These small children are unable to cope properly with the stressful situations. If stress and its severity are detected early, the hazardous effect of stress on the lives of children can be avoided. Studies regarding preschool children are scarce; we proposed this study to evaluate stress in a noninvasive technique by estimation of salivary chromogranin A.
From this study, we found that preschool students faced the challenges of different varieties of stressors in the school environment. The severity of stress varied among the students of Nursery, LKG, and UKG. Out of 56 participants, 7 did not face stress and these are LKG and UKG students. Twenty-one students faced severe stress, out of which 12 were nursery students. Seventeen students participated from Nursery class and 12 faced severe stress. The mean stress rank scores were compared among students of different stress groups and it was found that with the severity of stress the mean rank stress score increased in all classes. This suggested that nursery students were exposed to a sudden change of environment from the home to the school, exposed to new people, friends, teachers, and study pattern that were causes of stress. The number of students who faced severe stress decreased in LKG and UKG in this study, which suggested that with the passage of time the students become familiar with the situations. The results of salivary chromogranin A of subjects of different stress groups were compared and it was found that the mean salivary chromogranin A level was increased in stress subjects than in nonstress subjects as well as within the stress groups. Salivary chromogranin A level was also correlated with the stress score and it was found that there was a positive correlation between stress score and salivary chromogranin A.
Salivary glands are innervated by both sympathetic and parasympathetic nerves and different researchers have identified salivary chromogranin A as a biomarker of sympathetic activity. Salivary chromogranin A has been demonstrated as a biomarker of psychological stress such as examinations in nursing students by some researchers.  In one study with salivary chromogranin A as a measure of stress response to noise, researchers found that salivary chromogranin A level increased with significant exposure to noise while it decreased immediately after the noise stopped.  Another study was conducted to find out the level of salivary chromogranin A as a biomarker of stress in patients having halitosis and it was found that there was an increased level of salivary chromogranin A to stress response.  There was another study in which researchers found out salivary stress marker chromogranin A in psychological stress in simulated microgravity: 21 days in 68 head-down tilt.  Another study was conducted to find out the change in salivary chromogranin A in persons exposed to naturalistic traffic noise stress. In that study, there was a significant rise in salivary chromogranin A.  Salivary chromogranin A has been proposed as a marker of the sympathetic nervous system activity involving the sympathetic adrenomedullary system.  It has been proposed that salivary chromogranin A might be promising as a sensitive index for psychosomatic stress in adults. ,,, Salivary chromogranin A changes more rapidly and is more sensitive to psychological stressors than salivary cortisol. This is because the cortisol level remains high for some time even though the person is free from stress and this has been well-proved because salivary chromogranin A levels respond rapidly. After relief from stress, this level drops immediately and a stress-free level is attained. 
| Conclusion|| |
As there are very less studies on the stress of preschool children, we proposed this study and conclude that preprimary school students react to the school environment as a stressor. Severity of stress varies from student to student to a particular stressor. The severity of stress decreases as the students are promoted to higher classes, for example, the number of students in severe stress is less in UKG in comparison to nursery students. We found that there was a positive correlation between the severity of stress and salivary chromogranin A. Salivary chromogranin A was taken as biomarker of stress because it was convenient to get samples from these small children and it was a noninvasive procedure.
We, the authors, are happy to acknowledge the participants involved in this study without whom it would not be completed. We thank the teachers involved in this work for their active participation in selecting the subjects.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Blum RM, Libbey HP. School connectedness - Strengthening health and education outcomes for teenagers. J Sch Health 2004;74:231-2.
Klem AM, Connell JP. Relationships matter: Linking teacher support to student engagement and achievement. J Sch Health 2004;74:262-73.
Allen JS, Klein RJ. Ready, Set, Relax. Watertown, WI: Inner Coaching; 1996.
Fisher PH, Masia-Warner C, Klein RG. Skills for social and academic success: A school-based intervention for social anxiety disorder in adoloscents. Clin Child Fam Psychol Rev 2004;7:241-9.
Woolfolk A. Educational Psychology. Boston, MA: Pearson Education; 2007.
Naveh-Benjamin M, McKeachie WJ, Lin Y. Two types of test-anxious students: Support for an information processing model. J Educ Psychol 1987;79:131-6.
Kochenderfer-Ladd B, Skinner K. Children′s coping strategies: Moderators of the effects of peer victimization. Dev Psychol 2002;38:267-78.
Weiler R, Steiner HJ, Fischer-Colbrie R, Schmid KW, Winkler H. Undegraded chromogranin A is present in serum and enters the endocytotic lysosomal pathway in kidney. Histochemistry 1991;96:395-9.
Landsberg L. Chromogranin A. N Engl J Med 1984;311:794-5.
Saruta J, Tsukinoki K, Sasaguri K, Ishii H, Yasuda M, Osamura YR, et al
. Expression and localization of chromogranin A gene and protein in human submandibular gland. Cells Tissues Organs 2005;180:237-44.
Den R, Toda M, Nagasawa S, Kitamura K, Morimoto K. Circadian rhythm of human salivary chromogranin A. Biomed Res 2007;28:57-60.
Wagner J, Cik M, Marth E, Santner BI, Gallasch E, Lackner A, et al
. Feasibility of testing three salivary stress biomarkers in relation to naturalistic traffic noise exposure. Int J Hyg Environ Health 2010;213:153-5.
Toda M, Morimoto K. Effect of lavender aroma on salivary endocrinological stress markers. Arch Oral Biol 2008;53:964-8.
Lee T, Shimizu T, Iijima M, Obinata K, Yamashiro Y, Nagasawa S. Evaluation of psychosomatic stress in children by measuring salivary chromogranin A. Acta Paediatr 2006;95:935-9.
Briolat J, Wu SD, Mahata SK, Gonthier B, Bagnard D, Chasserot-Golaz S, et al
. New antimicrobial activity for the catecholamine release-inhibitory peptide from chromogranin A. Cell Mol Life Sci 2005;62:377-85.
Takatsuji K, Sugimoto Y, Ishizaki S, Ozaki Y, Matsuyama E, Yamaguchi Y. The effects of examination stress on salivary cortisol, immunoglobulin A, and chromogranin A in nursing students. Biomed Res 2008;29:221-4.
Miyakawa M, Matsui T, Kishikawa H, Murayama R, Uchiyama I, Itoh T, et al
. Salivary chromogranin A as a measure of stress response to noise. Noise Health 2006;8:108-13.
Fukui M, Hinode D, Yokoyama M, Yoshioka M, Kataoka K, Ito H. Levels of salivary stress markers in patients with anxiety about halitosis. Arch Oral Biol 2010;55:842-7.
Rai B, Kaur J. Salivary stress markers and psychological stress in simulated microgravity: 21 days in 6°
head-down tilt. J Oral Sci 2011;53:103-7.
Nakane H, Asami O, Yamada Y, Harada T, Matsui N, Kanno T, et al
. Salivary Chromogranin A as an index of psychomatic stress response. Biomed Res 1998;19:401-6.
Nakane H, Asami O, Yamada Y, Harada T, Matsui N, Kanno T, et al
. Effect of negative air ions on computer operation, anxiety and salivary chromogranin A-like immunoreactivity. Int J Psychophysiol 2002;46:85-9.
Kanamura Y, Kikukawa A, Shimamura K. Salivary chromogranin-A as a marker of psychological stress during a cognitive test battery in humans. Stress 2006;9:127-31.
Ng V, Koh D, Mok BY, Chia SE, Lim LP. Salivary biomarkers associated with academic assessment stress among dental undergraduates. J Dent Educ 2003;67:1091-4.
Obara S, Iwama H. Assesment of psychological tension after premedication by measurement of salivary chromogranin A. J Clin Anesth 2005;17:554-7.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]