Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

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


Published on

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

Published in: Health & Medicine
  • Be the first to comment

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