Last year, a Primary 5 pupil fell 17 floors from his bedroom window on the day he was supposed to take his exam papers home.
He had never fared poorly in his examinations from Primary 1 to 4, and scored an average of 70 marks.
His mother would cane him on his palm "lightly" for every mark he fell short of her stipulated standard of 70 per cent.
But he failed his Higher Chinese and mathematics in his latest mid-year exam. Out of 100 marks, he scored 50 for English, 53.8 for Chinese and 57.5 for science.
This case shows what too much stress can lead to.
BE THERE FOR THEM
We need to be there for teenagers when they are hurt emotionally, when they are sad and when they are celebrating.
ASSOCIATE PROFESSOR JOHN WONG, head of the National University Hospital's psychological medicine department.
Primary schoolchildren may complain of headaches, and chest and abdominal pain.
They may be more clingy, emotional, demanding or con- frontational. And they may also be more regressive in their play and behaviour.
Meanwhile, teenagers may be more withdrawn from social and family interactions.
They may also be more tearful, sad, irritable or rebellious.
Some could have problems sleeping, or sleep too much, and seem tired in the daytime.
•Source: Dr Vicknesan Marimuttu of the KK Women's and Children's Hospital's psychological medicine department.
•Institute of Mental Health's Mental Health Helpline (24 hours) Call 6389-2222
•Samaritans of Singapore (24 hours) Call 1800-221-4444
•Singapore Association for Mental Health Call 1800-283-7019
•Care Corner Counselling Centre (Mandarin) Call 1800-353-5800
Stress can trigger anxiety, depression and self-harming behaviour, and cause sleep problems, social withdrawal, angry outbursts and obsessive-compulsive behaviours.
Experts have observed a rise in the number of stressed-out children and youth in Singapore. While the demands of school are often blamed, the stress often stems from multiple sources.
Some have trouble making friends or being accepted by their peers, and face family problems or have high personal expectations.
The NurtureSG committee, a taskforce formed to promote the physical and mental health of children, suggested steps that included training students to look out for peers in distress and setting up a workgroup to study suicidal and self-harming behaviours in children and youth.
The Health Promotion Board said last month it would enhance the training for pre-school educators so that they can help build emotional resilience in young children.
"There has been an increase in the number of teens who present at KK Women's and Children's Hospital (KKH) with stress and emotional problems," said Dr Vicknesan Marimuttu, a consultant at the child and adolescent mental wellness service of the hospital's psychological medicine department. "Most of them are between 13 and 16 years old."
Increased awareness of mental health services as well as efforts to move away from the stigmatisation of seeking help could have led to the rise, said Dr Marimuttu.
Young people may also not be getting adequate support from their parents, who are busy with work.
SCHOOL STRESS IS A BIG THING
Associate Professor John Wong, head of the National University Hospital's psychological medicine department, said a Primary 6 pupil told him last August that he was stressed because he had to score at least 245 for the PSLE.
His mum wanted him to aim for that score as it was the cut-off point for a good neighbourhood school and she had promised him a laptop.
"The child is not psychologically mature to know he wants 245, but he wants a computer," said Prof Wong.
"His mum wanted to motivate him. But she didn't tell him she'd still be happy with a 240 score."
Academic and social pressures tend to pile up in school. In Singapore, many children attend tuition, enrichment classes or sports activities on top of a long school day.
They do homework when they reach home, leaving little "me" time, and often do not have enough time to sleep.
School is a big stressor because they spend most of their time there, doctors said.
During the Education Ministry's budget debate last week, Mr Lim Biow Chuan (Mountbatten) asked if some schools were setting the bar too high for non-national examinations. And Dr Intan Azura Mokhtar (Ang Mo Kio GRC) called for an end to streaming students into normal and express classes.
Stress is not necessarily a problem but a challenge, said Prof Wong. "Minimal stress may not motivate a child aged seven to 18, but some stress can facilitate his learning. It's when it exceeds his capacity that it becomes a problem."
BUT DON'T JUST BLAME SCHOOL
While academic stress can be a problem in the pressure-cooker education system here, social issues are a big stressor for teens.
Dr Chua Siew Eng, a specialist in psychiatry and consultant at Raffles Counselling Centre, cited the case of a 16-year-old boy who had been seeing a cardiologist for his heart palpitations that surfaced whenever he had a panic attack.
The boy had complained of feeling anxious for an entire year. His anxiety worsened during situations such as speaking up in class and ordering food at the canteen.
He slept poorly and criticised himself for not performing well. This led to fatigue and poor concentration, said Dr Chua. The boy was diagnosed with social anxiety disorder.
Another often-overlooked factor is that each child has his own expectations, said Prof Wong.
A child will want to achieve something that his parents want or he may form his own expectations based on the incentives or how his siblings have performed.
"As a result, stress occurs. It's not the fault of the school or the curriculum," added Prof Wong.
CHILD'S TEMPERAMENT IS KEY
"It's okay for parents to motivate their child but don't use a blunt approach," said Prof Wong.
A child's temperament is something he is born with and it may result in him reacting differently to situations. "Those who are happy- go-lucky tend to be more resilient," he said.
"For those who are more sensitive and fragile, their parents and teachers must understand their temperament and make sure they do not get rushed."
Rather than have unrealistic expectations of their child, parents should find out his interests and capabilities, he said.
Parents may also not think through their demands and expectations to make sure these are attainable. As a result, he added, they do not know why their child is depressed or overwhelmed.
"As parents, we may miss opportunities to validate them and recognise their efforts," said Prof Wong.
"I learnt from a youth social worker that we need to be there for teenagers when they are hurt emotionally, when they are sad and when they are celebrating."