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. 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
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
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
35.
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
Hinweis der Redaktion
At each time, the key goal was to appraise, via multiinformant and multimethod procedures, levels of symptomatology and adjustment/impairment in key domains of psychiatric, academic, neuropsychological, relational, and occupational functioning.
Range of negative outcomes for girls with ADHD including devastatingly high rates of suicide/self-injurious behavior, academic difficulties, relational difficulties, and neuropsych deficit. So, functional impairments in adolescence and young adulthood common in individuals with ADHD.