Chronic Stress and the Risk of High School Dropout

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CHRONIC STRESS AND THE RISK OF HIGH SCHOOL DROPOUT

FEBRUARY 2018 A variety of factors impact a student’s readiness to learn and their educational success, which research finds is a leading determinant in lifelong health. One factor that can impede such readiness is chronic stress, which can manifest in both physiological and psychological ways to undermine a student’s opportunity to learn and succeed in school. This brief provides an overview of chronic stress, with the goal of helping school-based health centers and their partners recognize chronic stress and its root causes as key intervention points to improve health and educational outcomes.

he relationship between quality and years of life are significantly panic students, 6.5 percent for black health and education is reduced.3 For these reasons and many students and 4.6 percent for white fluid and reciprocal. Students more, high school graduation is a pub- students.6 That same year, the dropout Texperiencing health problems lic health priority and a leading health rate was 7.2 percent among students face difficulty learning, whereas young indicator for Healthy People 2020, the from low-income households, com- people without a high school diploma nation’s health objectives for the cur- pared to 4.9 percent among students are less likely to be healthy as adults. rent decade.4 from middle-income households and 3 In fact, high school graduation is the While there has been overall prog- percent for students from high-income 7 social determinant that most strongly ress in improving on-time high school households. Emerging and evolving 1 predicts long-term health. Students graduation rates, students of color and research show racism, food insecurity who do not graduate high school on those living in low-income households and homelessness are just some of the time are less likely to attain higher continue to be pushed or pulled out social stressors driving these disparities. education, practice health-promoting of school at disproportionately higher Students of color living in urban areas behaviors, earn living wages or ac- rates than their peers.5 In 2015, the often face socio-economic inequities 2 cess social capital. As a result, overall dropout rate was 9.2 percent for His- that undermine their ability to learn,

…young people are faced with all kinds of challenges on a daily “basis. They may be homeless. They’re dealing with issues of domestic violence, community violence. Some of them may not have food to eat on regu- lar basis... They’re living in these under resourced environments that come with all of those challenges and then they go into the school building. They don’t leave those issues at the door, they take those issues into the school building and ultimately into the classroom.”10 — Terri D. Wright, PhD, MPH, Founder, Center for School, Health and Education Image by Jermaine Bennett, courtesy Center APHA’s School, for Health & Education

Page 2 CHRONIC STRESS AND THE RISK OF HIGH SCHOOL DROPOUT Self-fulfillment needs

Self-Actualization morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts Esteem self-esteem, confidence, achievement, Psychological respect of others, respect by others needs

Love/Belonging friendship, family, sexual intimacy

Safety Basic security of body, of employment, of resources, of morality, of the family, needs of health, of prosperity

Physiological breathing, food, water, sex, sleep, homeostasis, excretion

Figure 1. Maslow’s Hierarchy of Needs23 cope and make healthy decisions.8 factors alone can hinder educational to fight infections.11 Chronic stress is Many such students are faced with success, contribute to school dropout Social and Environmental chronic poverty-generated and inter- and increase disease risk in adulthood.9 Determinants generational stressors that increase Presenting as a composite, however, POVERTY their chances of dropping out. In fact, only exacerbates their cumulative ef- students often drop out of school for fects. The following pages will describe Poverty can drastically decrease the same reasons that put them at risk the causes and impacts of chronic quality of life and life expectancy, for poor health in adolescence and as stress, the implications for health and and is one of the many complex adults — reasons such as homeless- education professionals, and recom- reasons that students do not ness, teen pregnancy, hunger, school mendations for improving student 3 violence, and chronic or traumatic outcomes. complete high school. Poverty stress. Oftentimes, each of these de- is perpetuated by myriad institu- CHRONIC STRESS: A KEY terminants combines to perpetuate a tional inequities enforced through cycle of poverty and disparities that un- BARRIER TO HIGH SCHOOL GRADUATION derscores why graduation has become policies such as redlining (refus- a key intervention point for public By definition, chronic stress is a response ing loans or insurance to people health research and practice. to persistent social, physical and emo- who live in areas considered a tional pressures over an extended period This issue brief highlights the effects of poor financial risk) and divest- of time.11 Individuals who experience one graduation determinant in particu- chronic stress are likely to have consis- ment in communities of color. lar — chronic stress. If left untreated, tently high levels of cortisol, the body’s chronic stress can contribute to fear, Many families live in poverty due primary stress-inducing hormone.12,13 anxiety, depression, attention and to inconsistent employment or Signs and symptoms of chronic stress concentration problems, an increase in include anxiety attacks, lack of sleep having multiple jobs with insuf- impulsive or risk-taking behavior and and poor focus or concentration.11 High ficient income.17 — particularly among boys — hostility, levels of stress also weaken the immune aggression and violence. Each of these system and decrease the body’s ability

CHRONIC STRESS AND THE RISK OF HIGH SCHOOL DROPOUT Page 3 linked to unyielding feelings of hope- lessness and is often associated with lack supportive and caring relation- Social and Environmental factors such as poverty and traumatic ships. Furthermore, a growing body of Determinants childhood experiences.14 research shows that exposure to ACEs such as food insecurity (see Youth and COMMUNITY DESIGN Over time, the health effects of chronic stress manifest physically and Adverse Childhood Experiences), unex- Historical and current policies psychologically. As the cumulative pected loss of a loved one or exposure and practices have resulted in biological burden, or allostatic load, to violence can negatively impact the neighborhoods that are not imposed on the body by chronic stress physiological development of essential grows, it detrimentally impacts the brain systems that govern attention, designed to promote health or 13,22 cardiovascular, neuroendocrine and memory and the learning process. support people in attaining good central nervous systems.14 A high al- A recent study showed that children health. One example of this is lostatic load is considered a risk factor experiencing three or more ACEs were nearly twice as likely as children with the absence of local healthy food for cardiovascular disease, diabetes, depression and other diseases.15 Such no ACEs to have learning and behav- retailers and an overabundance ioral problems such as a learning dis- health outcomes — often the result of ability or poor impulse regulation.13 of liquor stores and fast foods recurring experiences with “social ineq- restaurants — a community uity and stressful environments” — can In childhood, especially during the early environment known as a food accumulate over a person’s life span years, the brain’s network is highly and contribute to rapid health decline, sensitive to environmental cues. When desert. A 2009 U.S. Department a process described as a “weathering the brain receives stress signals, it of Agriculture study calculated phenomenon.”16 In addition to health responds by increasing blood pressure that 10.8 percent of all house- effects, those exposed to less than and releasing adrenaline and stress hor- holds were low-income, without ideal circumstances from an early age mones such as cortisol, triggering the are ill-equipped to achieve optimal life so called “fight-or-flight” response.13 access to a vehicle and situated outcomes. When the brain receives stress signals in urban areas with no grocery continuously — as it can in conditions By viewing chronic stress through a 18 of chronic stress — the constant physi- store within half a mile. When cumulative life course perspective, we ologic responses begin driving neuro- healthy food options are out of can better understand how graduation logic adaptations.13 The result is that correlates and intersects with the qual- reach, students are more likely to chronic stress can negatively impact ity of our life experiences. go hungry or malnourished and development of the prefrontal cortex are forced to depend on inex- NEUROBIOLOGICAL — the part of the brain that controls UNDERPINNINGS some of our most sophisticated intel- pensive, calorie-dense, high-fat lectual functions as well as emotional Reducing chronic stress among stu- and sugary foods.19 Other poor and cognitive regulation.13,25 dents requires a critical understanding infrastructure examples include of how stress affects neurobiological Emotionally, chronic stress makes it inadequate or unsafe transporta- functions as well as students’ overall difficult for children to control their responses to disappointments or provo- tion options and limited access to well-being and academic achievement. cations. Overstimulation of the body’s A child’s brain goes through a highly safe parks and playgrounds, all stress response can produce behavioral sophisticated trajectory of development of which can serve as barriers to problems in school such as fighting, during which the prefrontal cortex is talking back or even isolation.13,25 On a better health, reduced stress and heavily influenced by both environmen- cognitive level, chronic stress can delay school success.20 tal and interpersonal factors.22 Children or hinder the executive functions that growing up in chronically stressful govern memory, attention span and environments are at risk for having the processing of new information.13,25 many adverse experiences that can When these functions lag, school can impair development, particularly if they

Page 4 CHRONIC STRESS AND THE RISK OF HIGH SCHOOL DROPOUT be an especially frustrating place for read or multiply on time due to dif- safety.28 Chronic stress can also lead struggling students. ficulties concentrating or decreased Social and Environmental brain functionality from processing an Determinants CHRONIC STRESS AND overload of emotions. As these students COMMUNITY VIOLENCE HIGH SCHOOL DROPOUT progress through school and the cur- Students who live in urban areas are riculum becomes more advanced, they High crime rates and commu- often confronted with multiple barri- might begin to lag behind, which can nity violence can also add to a ers to educational success (see Social make the path to graduation seem even student’s chronic stress. Students and Environmental Determinants) and more insurmountable than before. Stu- consistently exposed to such often face increased risk for poor brain dents impacted by chronic stress may development and not completing high also be impulsive, distracted, distrustful environments are more likely to school.26 Collectively, poverty, poor or hyperactive.19 All combined, the cycle emulate such violence in and community design and community of stress is continually perpetuated as outside of school, with such violence indicate that urban students motivation decreases and stress-induced are unlikely to have their fundamental behaviors are misunderstood, punished behavior compounded by a lack needs met (healthy food, stable hous- and stigmatized. The pronounced of social support. Behaviors may ing, etc.). At the same time, Maslow’s impact of chronic stress on the develop- manifest as bullying, gang in- Hierarchy of Needs (Figure 1) suggests ing brain ends up derailing chances for volvement and other risky activi- that physiological and safety needs are educational success. ties.8 This cycle of poor decision- the foundations for arriving at more Chronic stress is also linked to student sophisticated developmental milestones disengagement and absenteeism — in making can interrupt a student’s 27 such as esteem and resilience. When fact, more than half of all absences focus on learning, increase the conditions resulting in unmet needs are 28 have been linked to chronic stress. likelihood of disciplinary actions, persistent, they impede a child’s ability According to a 2015 survey, nearly one and motivation to function daily or at- in four minority students had missed and disproportionately funnel tend and succeed in school. three or more days of school in the them into the school-to-prison For example, students experiencing past month due to factors such as lack pipeline.21 chronic stress may fail to learn how to of transportation, drug use and school

YOUTH AND ADVERSE CHILDHOOD EXPERIENCES

hildhood, and puberty in particular, is already a period marked by a number of cognitive, physical and hormonal changes. Youths’ self-esteem and identity are being constantly shaped and influenced by their Crelationships with family, peers and role models. The presence or lack of relationships can have a signifi- cant impact on a child’s confidence and ability to make healthy decisions. A wide range of stressful experiences can negatively impact growth and development in children. These stressors or traumatic events are sometimes categorized as adverse childhood experiences, or ACEs. ACEs can consist of a variety of conditions and events, from poverty and homelessness to a parental divorce. Unfortunately, ACEs are fairly common, with half of adolescents reporting having experienced at least one ACE in 2014.24,25 Excluding poverty or economic hardship from ACE scores, low-income children and youth are more than twice as likely as more affluent peers to experience three or more ACEs.24 The accumulation of ACEs leads to chronic stress and can directly impact opportunities, support and self-efficacy among school-aged children and derail their path to on-time graduation.

CHRONIC STRESS AND THE RISK OF HIGH SCHOOL DROPOUT Page 5 to compromised health, which also To buffer the impact of chronic stress Photo by fstop123, iStockphoto courtesy increases the risk of dropping out. on students, APHA’s Center for School, Nationally, the cost of high school Health and Education applies an dropout is a steep one, reaching far evidence-based, public health strategy into adulthood. Research finds that for buffering the negative impact of if national high school dropout rates social disadvantages on the entire stu- were cut in half, the country would dent population. The strategy operates save $7.3 billion annually in Medicaid at three levels: clinical interventions spending, $12 billion in costs related with individuals and groups, inside and to heart disease, $11.9 billion associ- outside of clinical settings; primary ated with obesity, $8.9 billion related prevention targeting the school-wide to smoking, and $6.4 billion associated population; and systems changes such with alcoholism.29 as the review, revision or creation of policies and practices in the clinic, A ROLE FOR SCHOOLS school, school district or community. If we can only empower AND THEIR PARTNERS The Center for School, Health and school personnel to With the strategic support and col- Education recommends a number of understand what young laboration of health, public health and strategies to help schools manage and “ people are going through, community partners, schools — and intervene on chronic stress, including: school-based health centers, or SBHCs, Individual and group strategies, they’re not all equally resourced in particular — are uniquely positioned such as group therapy, healing [and] they do not have the cop- circles, time for mindfulness and to mitigate and prevent the effects of ing skills. If we can help them chronic stress on student well-being meditation during the school day, and success. or guided yoga practice. appreciate that and understand As evidenced by the success of SBHCs, School-wide strategies, such as: how they can help them be suc- interventions for marginalized stu- • implementing a de-escalation cessful, we can make a differ- dents are best facilitated when support or cool-down room for students ence in the next generation.”10 services are co-located inside the school to retreat to when they need a building rather than off site. Indeed, safe, calming space to prevent — Terri D. Wright, PhD, MPH, Founder, Center for School, Health and Education SBHCs demonstrate great promise in outbursts and punitive disciplinary their ability to integrate public health- responses; • advocating for in-school suspen- based prevention strategies into school • creating a peer or mediation sion with continued instruction; settings and yield school-wide improve- court to handle disputes and/or • developing a social action or ments in policy, practice and procedure. disciplinary issues; and advocacy program of community Addressing chronic stress among stu- • meeting basic needs of students and school service as part of the dents begins with professional devel- through a food pantry, opening curriculum; and opment to strengthen staff capacity access to on-site laundry facilities • offering professional develop- to: collaborate across sectors (e.g., and showers, or co-locating com- ment workshops to all school primary care, public health, and educa- munity resources on the school staff to improve interactions with tion); understand the root causes of campus. students and respond with tactics mental distress among student popu- Systems strategies, such as: that consider the context of stress lations; support and engage stu- • reviewing school discipline poli- and trauma. dents as change agents in planning cies and providing recommen- and implementation processes; and Through the efforts of a cross-disciplin- dations that acknowledge the implement and evaluate strategies ary team of school-based professionals relationship between child and that promote resilience and optimal addressing the root causes of school adolescent development, stress outcomes school-wide. dropout, students can successfully avoid and trauma, and behavior;

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CHRONIC STRESS AND THE RISK OF HIGH SCHOOL DROPOUT Page 7 ABOUT APHA

APHA champions the health of all people and all communities. We strengthen the public health profession, promote best practices and share the latest public health research and information. We are the only organization that influences federal policy, has a nearly 150-year perspective and brings together members from all fields of public health. Learn more at www.apha.org.

ABOUT CSHE APHA’s Center for School, Health and Education advances school-based health care as a proven strategy for preventing school dropout. We work with health and education partners to develop and implement public health strategies school-wide to improve the well-being and educational success of all students. Learn more at www.schoolbasedhealthcare.org.

ACKNOWLEDGEMENTS This brief was developed by CSHE, with Olufunmilayo Makinde, Darien Mather and Kelly Nelson as contributors, and Kim Krisberg as editor.