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

1. Adolescents, Depression, and Self-Harm:
Girls and Boys, Risk, and Resilience
Stephen Hinshaw
UC Berkeley & UC San Francisco
11/16/15

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. 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. 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. 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. BGALS Follow-up: Self-harm
10-year follow-up (M age = 20)
Hinshaw et al. (2012), Journal of Consulting and Clinical Psychology

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Developmental
Psychopathology

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. 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. 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. 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. 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. 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. 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. 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. 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. 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

36. 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

37. 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’

38. 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

39. 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…

40.  #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

41. 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…

42. 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

43. 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

44. Thanks…and questions
 NIMH grants
 Research participants
 Collaborators and students
 UCSF Depression Center
 You, the audience