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Adolescents, Depression, and Self-Harm: Girls and Boys, Risk, and Resilience

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Keynote presentation by Stephen Hinshaw, PhD, at the UCSF Depression Center's "Adolescent Depression: What We All Should Know" event on November 16, 2015.

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Adolescents, Depression, and Self-Harm: Girls and Boys, Risk, and Resilience

  1. 1. Adolescents, Depression, and Self-Harm: Girls and Boys, Risk, and Resilience Stephen Hinshaw UC Berkeley & UC San Francisco 11/16/15
  2. 2. Goals  Initial motivation for examining teen depression— and teen mental health problems more generally  Rising rates and earlier onset  Girls: triple bind; Boys: other cultural messages  Biology and experience  Stigma and solutions
  3. 3. Initial Motivation  NIH-funded research program: findings on girls with ADHD  Summer camps; 5-, 10- and 16-year follow-up  Wider literature on girls and teen years, in general, well beyond ADHD  Confluence of risk and protective factors during early-mid adolescence…and in the midst of today’s cultural changes
  4. 4. BGALS 228 girls: 140 with ADHD, 88 comparisons  Ethnically and socioeconomically diverse  Group-matched comparison sample  Three waves to date, 4th just completed (94% retention)  Largest female sample of childhood ADHD  Follow-ups: Multi-domain assessments  Psychiatric, academic, neuropsychological, family/social, occupational functioning Childhood (Ages 6-12) Childhood (Ages 6-12) Adolescence (Ages 11-17) Retention: 92% Adolescence (Ages 11-17) Retention: 92% Early Adulthood (Ages 17-24) Retention: 95% Early Adulthood (Ages 17-24) Retention: 95%
  5. 5. Self-harm  Suicidal behavior: intent is to die Suicidal ideation (common) Suicide attempt (rarer)  Non-suicidal self-injurious behavior (NSSI) No express intent to die, but to express (or ease) psychological pain Linked to poor emotion regulation Wide range—cuticles to cutting/burning  NOTE: Many suicide attempters have history of NSSI NSSI may be lethal
  6. 6. BGALS Follow-up: Self-harm 10-year follow-up (M age = 20) Hinshaw et al. (2012), Journal of Consulting and Clinical Psychology
  7. 7. MEDIATION: WAVE 1 ADHD STATUS TO WAVE 3 NSSI Data represent indirect effect and standard errors using 10,000 bootstrap samples to obtain bias-corrected and accelerated 95% confidence intervals. Swanson, Owens, & Hinshaw (2014), Journal of Child Psychology and Psychiatry l
  8. 8. l MEDIATION: WAVE 1 ADHD STATUS TO WAVE 3 SUICIDE ATTEMPTS Data represent indirect effect and standard errors using 10,000 bootstrap samples to obtain bias-corrected and accelerated 95% confidence intervals Swanson, Owens, & Hinshaw (2014), Journal of Child Psychology and Psychiatry
  9. 9. Meza, Owens, & Hinshaw (2015) Figure 3. The relationship between W1 Commissions and W3 NSSI was partially mediated by W2 Peer Victimization over and above: WISC Full-Scale IQ, mother’s education, household income, and age at W3. Data represent indirect effect and standard errors using 10,000 bootstrap samples to obtain bias- corrected and accelerated 95% confidence intervals. W1 Commissions W3 NSSI Severity W2 Peer Victimization IE: .0022 SE: .0012 CI95: .0004 - .0054
  10. 10. Figure 2. The relationship between W1 Commissions and W3 Suicide Attempts (y/n) was partially mediated by W2 social preference scores over and above: WISC Full-Scale IQ, mother’s education, household income, and age at W3. Data represent indirect effect and standard errors using 10,000 bootstrap samples to obtain bias-corrected and accelerated 95% confidence intervals. W1 Commissions W3 Suicide Attempts W2 Social Preference IE: .0775 SE: .0537 CI95: .0049 - .2257
  11. 11. Trauma and peer relationships?  Physical abuse, sexual abuse, and/or neglect higher in ADHD than comparison girls  Within ADHD group, maltreated subgroup more likely to show depression and especially suicide attempts (nearly 35%)  But not externalizing behavior)  Guendelman et al. (2015a, Development and Psychopathology)  Girls with ADHD likely to be victims of intimate partner violence by early adulthood  Guendelman et al. (2015b, Journal of Abnormal Child Psychology)  NOTE: HIGH RATES IN OUR COMPARISON PARTICIPANTS
  12. 12. Adolescence  When ‘discovered’?  1904, officially; but most cultures have recognition  When does it begin?  Puberty  Ever earlier and why  When does it end?  !!  What does it signal?  Most ‘thriving’ time of life, physically and cognitively  BUT huge increase in risk: accidents, substances, mental health
  13. 13. Adolescence 2 Psychologically:  Surge in risk taking and cognitive ‘independence’  Yet frontal lobe maturation lags far behind Mid-late 20’s! Physiologically:  Hormone release (hypothalamus to pituitary to glands)  But same hormones circulate back to brain, acting as ‘transmitters’: stress vulnerability Resculpting of adolescent brain
  14. 14. Adolescence 3: Mechanisms?  Do teens not understand risk?  No, they ‘get it’ cognitively  Increased risk-taking and delay aversion  Salience of reward, NOW  Importance of peers  Teens do risky things even if they think peers are observing, far more than if no one there  Evolution: prepare for independence; exploration
  15. 15. Adolescence 4 Real ‘goal’—formation of identity But how to do this? Trying things out Failing at some Seeing what truly interests you WON’T HAPPEN WELL under conditions of impossible perfection
  16. 16. Girls: Best of Times, Worst of Times Unprecedented success and opportunities for girls and women today  Academic, athletic, professional, lifestyle choices At another level, greatly increasing risks that teenage girls face re: serious disorders  Increasing realization of rates of sexual assault , too…
  17. 17. The Best of Times...  Girls outperform boys in verbal skills, empathy, close social relationships during early to middle childhood  Thus, girls have lower rates of psychopathology before 11  ADHD, autism, aggression, Tourette, some LD’s  Even for depression, boys have slightly higher rates before adolescence  Girls skyrocketing re: test scores/college admissions; unprecedented success re: professional education  ‘New’ opportunities athletically  Scholarships, professional leagues (though non-equal pay)
  18. 18. Maybe it’s boys who are at greater risk  In fact, a host of recent books and recent press on the contention that boys are disenfranchised  Boys: losing the advantage they’ve had ?  So, isn’t the crisis for slow, dull, non-socially skilled boys?
  19. 19. 1. Major Depression  World Health Organization:  1st or 2nd most impairing disease on earth  Boys have a slightly higher risk before puberty  Girls’ rates skyrocket between 11 and 18 years of age  By that age, rates are 2-2.5 time those of boys, which holds until late life  Not a true epidemic, but AGE OF ONSET lowering  From 30’s to 20’s, and now to teen years
  20. 20. What is major depression?  Not just sad mood…  But lack of motivation, poor sleep and appetite, irritability, loss of ability to experience pleasure, negative beliefs about self, and suicidal ideation  Risk factors:  Genes (moderately heritable)  Negative parenting  Cortisol over-reactivity  Rumination  Many more  The leading contributor to suicide we know of  Bipolar disorder more virulent predictor but depression more widespread
  21. 21. 2. Suicide  Absolute rates still low, but third leading cause of death for boys 11-24 years of age LEADING CAUSE FOR FEMALES < 25 YEARS (WHO, 2014)  1950-1988, rates of adolescent suicide tripled  Then, gradual decline from 1989-2004  In last decade, rates went up 76% in girls 10-14 and 32% in girls 15-18 (not so for boys)
  22. 22. 3. NSSI Also known as self-mutilation, parasuicidal behavior, non- suicidal self-injury (NSSI), cutting, etc. Little literature until last 25 years Continuum: picking skin to severe cutting, burning, etc. Skyrocketing in teens, with girls at highest risk
  23. 23. 4. Binge Eating Rates of anorexia nervosa and bulimia nervosa remain relatively low (ca. 1% each), but precursor behaviors (dieting, preoccupation with weight) are endemic OVER HALF OF GIRLS IN 3RD GRADE ARE WORRIED ABOUT WEIGHT A third are dieting
  24. 24. Developmental Psychopathology
  25. 25. Overall prevalence: 25%-30% of girls 11 through 19  Depression  15-20%  Suicide  Completion rate low, but attempts rising  Self-Harm  At least 15%  Binge Eating  3-4% by young adulthood  Aggression/Delinquency  Self-report: 25% of girls report serious violent act  Even when overlap subtracted out, rate is 1 in 4 to 1 in 3 by end of adolescence--higher if ‘moderate’ considered
  26. 26. Hypothesis: The Triple Bind  #1: Girls still have to be nurturing, kind, caregiving  #2: Girls must now compete, academically and athletically, and show assertiveness and ambition  #3: Girls must conform to narrow, unrealistic standards, effortlessly, with alternatives co-opted into ultrafeminized/hypersexualized role models  Internalization  Learned helplessness  Pseudo-individuation/”false self”
  27. 27. More…  Relentlessness of pressure  Alternative role models  But so many co-opted; rock singers, athletes  How to develop identity and true self if you’re relentlessly pleasing others the whole time?  Cyberculture  Never-ending instant replay, fueling rumination
  28. 28. Analogy/Metaphor  Teen girls in room full of tobacco smoke  Harmful for all, but ones with vulnerability have worst outcomes  Triple Bind is toxic culturally  The most vulnerable girls will be the ones at highest risk as the TB “hits”—e.g.,  High-risk genes But see most recent research on genetic vulnerability to a wide range of mental disorders  Modeling from mood-disordered parents  Maltreatment
  29. 29. Switch of protective and risk factors From early childhood, girls… Have higher empathy/more prosocial; small groups Have higher levels of verbal skills Are more compliant with adult commands All of these are protective vs. externalizing problems But by early adolescence, these can be risk factors… In presence of vulnerabilities (e.g., depressed mom, abuse) Excessive emotional empathy becomes guilt Compliance: overconcern with welfare of others instead of self Verbal skills predict rumination, spiraling toward depression Parentification/adultification
  30. 30. Mechanisms Is the core problem “overscheduling”? Actually, data show the opposite Mahoney: the amount of extracurricular activities is correlated with nearly every good outcome, esp. for low SES youth A better candidate: “pressure” Homework, pad extracurric’s for resume, no quality time with parents, lack of privacy related to 24/7 media
  31. 31. Sleep Associated factor: lack of sleep  Carskadon, Walker: Delayed onset in puberty Add in early school hours and social media and academic pressure Consequence of sleep deprivation: Inability to consolidate memory Inability to suppress negative affect, mediated by inability of PFC to inhibit “emotional brain” fMRI investigations, paralleling sleep deprivation studies
  32. 32. Self-focus, sexualization  Fredrickson et al. (JPSP, 1998) swimsuit study  Randomly assign men and women to swimsuit vs. sweater  Men: pride…and better performance on complex math test  Women: shame…and worse performance on the test  Preoccupation with body, and sexualized images (“observer role”) reduces cognitive resources  Failures taken more “to heart”  And, because girls are more socialized to please:  Empathy, here, may lead to belief that failure has let everyone down
  33. 33. Boys!  Hearing same messages as do girls  Still not the ‘power’ of all 3 prongs of TB  IF a boy is smart and good-looking and empathic…WHAT A GUY!  But if a girl is not empathic and nurturing, WHAT’S WRONG WITH HER?
  34. 34. Stigma Hinshaw (2007), The Mark of Shame (Oxford U. Press)  Ancient Greece: Literal ‘mark of shame’  Brands placed on slaves or traitors/today: Psychological “branding”  What groups are stigmatized?  Racial minorities, sexual minorities, women, left-handers, physical disabilities, adoptees, obese, delinquent youth, many more… Can things change? See attitudes re: gay marriage Thus, hope for optimism—malleability of social views Most stigma today: mental illness, homelessness, substance abuse  Distinguish  Stereotypes (cognitive)  Prejudice (affective)  Discrimination (behavioral)  Stigma: All this plus global nature of castigation/self-fulfilling prophecies
  35. 35. Self-stigma (internalized stigma)  Nearly all members of stigmatized groups are aware of the culture’s stereotypes/beliefs/practices  Thus, likelihood (though not certainty) that such individuals will internalize these beliefs  Antidotes: identity, group solidarity  Double whammy: disorders themselves likely to fuel demoralization, but self-stigma multiplies the risk  Important research findings:  Even controlling for initial levels of symptoms, self-stigma predicts (a) lack of treatment seeking and (b) early termination from treatment
  36. 36. Courtesy Stigma  Goffman:  If society has stigmatized a given class of people, it’s common courtesy to stigmatize those associated with such individuals, particularly family members  Parents of youth with mental disorders: Directly blamed for offspring’s problems for decades  Even genetic transmission leaves blame on parents  Objective burden and subjective burden  Subjective burden usually experienced as worse  Mental health professionals/scientists ‘in the shadow’
  37. 37. MI Stigma is Decreasing, Right?? Actually, higher rates of violence beliefs in 2005 than 1955  US public 2.5 times more likely to believe that MI linked to violence  Involuntary commitment laws: ‘danger’ to self/others; public homelessness  No fundamental change in US stigma levels from 1995 -2005  Greater knowledge does not necessarily translate to greater empathy  Does ascription of MI to biogenetic causes reduce stigma?  Kvaale et al. (2013): yes regarding blame, but increases in pessimism and social distance related to such attribution  Martinez, Piff, Mendoza-Denton, & Hinshaw (2011): dehumanization
  38. 38. Triple Bind: Solutions?  #1: TALK ABOUT IT  My own family history: professionally prescribed silence  Now, this isn’t always simple with teen girls, and let’s remember that adolescence is time of identity consolidation  YET, silence is contagious  # 2: GET PROFESSIONAL HELP IF INDICATED  Low rates of help-seeking  Kessler: 10-year delay  Lack of utilization of evidence-based treatments  Back to stigma…
  39. 39.  #3: CRITICAL THINKING/SELF-DISCOVERY  E.g., what’s an ad vs. what’s a news story Do ALL girls/women actually look like this?  New avenues and pursuits, rather than right answer, first time every time
  40. 40. Maybe most important…  #4: IDENTIFICATION WITH WIDER COMMUNITY AND PURPOSE  Not always easy to do; but efforts in families, schools, communities, and societies to foster involvement may be truly worthwhile  This is NOT the same as resume padding with multiple clubs…
  41. 41. Mealtimes, active interest, avoiding objectification  Luthar: protective factors in suburban control samples—  Mealtimes together  The family values the teen or more than products or achievements  Avoiding criticism during every interaction
  42. 42. Larger actions?  Pass/fail courses in schools  Same-sex schools: not as protective as hoped  Modeling (do what I do, not what I say)  Parents: coming to terms with own sense of power and powerlessness, with own sense of communication vs. being shut off
  43. 43. Thanks…and questions  NIMH grants  Research participants  Collaborators and students  UCSF Depression Center  You, the audience

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