Almost everyone feels sad sometimes, but most often sad moods are transitory, reactive to negative experiences -- separation, loss, failure, family conflict -- and do not necessarily point to depression. However, when sad feelings persist over time and color the way a person functions, he or she may be experiencing a clinical depression. The term 'depression' is often used to refer to a depressive mood, which may be transient; it also refers to a diagnosis of an illness known as a clinical depression. Depression in children and adolescents can interfere with normal developmental tasks - forming friendships, mastering social and academic skills, achieving independence.
The gender shift
Before adolescence, equal numbers of boys and girls are depressed. About 10 to 15 percent of all children report moderate to severe signs of depression. By age 13, a dramatic shift occurs, and more than twice as many girls as boys are depressed, a proportion that persists into adulthood.1 This two-to-one ratio exists regardless of racial or ethnic background and has been reported in other countries. What changes occur in early adolescence to cause this disparity? Although a number of explanations have been proposed, it is not likely that the gender difference is due to only one cause. Multiple processes are at work, and research is currently being conducted into the interactive effects of biological, genetic, psychosocial, and family factors.
In many cases there appears to be a genetic component to depression. Studies have found a higher percentage of depression and other mental disorders in the families of people diagnosed with depression than is found in the general population. In regard to the gender difference, some research suggests that during puberty, a combination of genetic factors and negative life events, is more likely to result in depression for girls than boys.2
Since hormone levels increase dramatically during adolescence, it seems obvious to question whether depression is caused by hormonal fluctuations. Although researchers report that hormones have an effect on the brain chemistry that controls emotions and moods, a specific biological mechanism explaining the role of hormones in depression has not been identified. Furthermore, the effects of hormone levels on depression have been found to be minimal compared to the influence of social factors.3
Recent research focusing on the impact of stress on biological functioning shows some differences between males and females. For example, studies that have examined the long-term effects of early stress on the hypothalamic-pituitary-adrenal (HPA) glands suggest that their functioning in females is more reactive to stress, possibly contributing to an increased vulnerability to depression.
Puberty has different meanings for boys and girls, although both experience simultaneous changes in biological functioning and social demands Individual girls develop at different rates, and pubertal age is more accurate than chronological age in predicting depression. Girls who mature physically earlier than their peers are more likely to feel self-conscious and to experience depressed moods.4 For some girls, menstrual cycles are associated with behavioral and physical changes, and menstruation can be accompanied by feelings of tension, the perception of loss of control over their bodies, and irritability. Girls view body changes, such as increased fat layers, as negative. Boys, on the other hand, view body changes, such as increased muscular development, as positive.
Some studies suggest that the lower social status of females and the traditional upbringing of girls foster certain traits that may increase the vulnerability of adolescent girls to depression. Sex roles take on new importance as adolescents' bodies become more sex-differentiated.5,6 In early adolescence girls compare themselves with the standard female stereotypes; many become dissatisfied with their bodies, which in turn leads to increases in depressed mood, lowering of self-esteem and disappointment with their physical appearance. Emphasis on weight diverts girls from developing their own interests, talents and internal character to obsessing over their appearance. During adolescence, the self-esteem of many formerly self-confident and assertive girls gradually becomes eroded. Self-esteem in girls peaks at the age of nine, then, for some, begins to plummet. In addition to low self-esteem, some adolescent girls develop certain characteristics -- pessimistic thinking, a sense of having little control over life events, and proneness to excessive worrying - which place them at risk for depression. These attributes may exaggerate the effect of stressful life events or interfere with taking action to cope with them.
It has also been hypothesized that higher depression rates among girls occur when they start to interact with boys more frequently. Intelligence, assertiveness, and competence are seen as liabilities rather than assets by some adolescent girls. Fearing that competition with boys may interfere with their relationships, some girls are likely to minimize their capabilities. These attitudes are subtly encouraged by society and reinforced by the media. Movies, sitcoms and teen magazines feature articles about techniques of getting and holding your man as the key to a successful life.
In addition to genetic issues, family factors such as the quality of the parents' marriage, parenting style, role modeling and the emotional status of the parents are related to depression in girls. Research shows that daughters whose parents have an egalitarian relationship, and daughters whose parents are supportive, attentive, receptive to emotions, rather than punishing and restricting, show lower levels of depression.7Research results also indicate that girls are more likely than boys to react to negative events in the family.8 Adolescent girls, closely bound to their families, are more likely to be exposed to family stresses over a longer period of time.
Girls learn about being female from modeling themselves on their mothers. In addition to the genetic factor, children of depressed mothers are vulnerable to emotional problems. In a 10-year follow-up study of the children of depressed mothers, the daughters, not the sons, were found to have low self-esteem.9 Female development throughout the lifespan, according to self-in-relation theorists, is based on the importance of attachment and relationships. Some experts think that females' tendency to place greater value than males do on interpersonal connection and relationships with other people renders them more vulnerable to losses and depression.
Negative life events: Sexual abuse
Adolescent boys and girls react in different ways to stressful life events, which are considered by most researchers to play a critical role in the development of depression.10The increase in depressed mood of adolescent girls, not boys, correlates with stressful life events. Childhood sexual abuse is an important early stressor, and the rates of sexual abuse in girls increase substantially in early adolescence with the greatest increase occurring between ages 10 and 14. Far more girls than boys are sexually abused, with the ratio of female to male victims estimated to be as high as 12:1.
Sexual abuse impacts on both physiological and psychological functioning. Recent research suggests that sexual abuse may result in heightened physiological responses in females, such as the dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis similar to that seen in depressed patients.11 Sexual abuse undoubtedly has a major psychological impact on its victims although individual differences exist and not all individuals are traumatized in the same way or for the same length of time. The effects depend on the type of abuse, whether the abuser was a family member or a stranger, whether the abuse was short or long term, and the age of the child at the time of abuse. Children's reactions to sexual abuse may be immediate and/or delayed. In general, sexual abuse causes young children to become very anxious, and adolescents often act out. Long term reactions occur in two-fifths of sexually abused girls. For many victims of sexual abuse, long term psychological symptoms include symptoms of depression, substance abuse and sexual problems.
Cognitive factors and coping styles
According to cognitive theories of depression, how individuals view and interpret stressful events affects whether or not they become depressed. If people feel they can't anticipate or predict what will happen to them, they are likely to feel helpless and unable to make changes. A child or adolescent who feels helpless sees problems as insurmountable; she becomes overwhelmed and gives up, feeling she is ineffective and unable to influence the events in her life. Then when something bad actually does happen, it provides her with further proof that her efforts are useless. In contrast, when a child who does not feel helpless meets with difficulty, she doesn't give up but tries harder and thinks of other ways to tackle the problem.
The helpless pattern results in depression only for some. One important factor is the explanation the person uses - how she explains the causes of bad events - her explanatory style. The person who explains events in a negative way - who believes that bad events are her fault, that things will always be hard, that the causes of bad things are always present, -- is more likely to become depressed than the person who does not believe bad events are her fault and will always happen to her.
Girls and boys typically have different styles of explaining their experiences to themselves. At a young age, boys tend to have a more negative explanatory style than girls; then in the upper elementary grades, more girls than boys show a helpless cognitive style.
Coping strategies make a difference in whether or not a person becomes depressed when stressed. During early adolescence, as boys and girls develop different explanatory styles, they also develop different styles of coping in stressful situations. Research has shown that rumination (thinking and talking about a problem, rather than seeking out a distracting activity or solution) is one of the risk factors associated with higher rates of depression among adolescent girls. Boys, in contrast, use more problem solving and distraction techniques. A number of studies show that individuals who ruminate when distressed show longer and more severe periods of depression symptoms and are more likely to develop a depressive disorder. 12
Depression can be treated effectively. Both medication and psychotherapy have been found to be helpful. Medications such as monoamine oxidase inhibitors, tricyclic anti-depressants and SSRI's (Selective Serotonin Reuptake Inhibitors) have been utilized successfully, particularly with adolescents with a family history of depression. Therapies such as Interpersonal Therapy and Cognitive Behavior Therapy, either alone or in combination with medication, have been shown to be helpful with girls in changing the way they think about themselves, constructing rational explanations of life events and developing adaptive coping strategies. Physical activity has also shown to be beneficial. The appropriate treatment for each individual depends on the nature and severity of the depression. In mild or moderate depression, one or both of these treatments may be useful. In severe or incapacitating depression, medication is usually recommended as the first step. In combined treatment, medication can relieve the physical symptoms quickly, while psychotherapy provides the opportunity to learn more effective ways of handing problems.
Depression in girls and women results from a complex interaction among biological, genetic, cognitive and psychosocial factors.
Research shows that depressed adolescent girls may have:
- a family history of depression
- parents whose style is restrictive rather than supportive and open to emotional expression
- low self-esteem; difficulty in assertiveness; over concern with appearance and notions of popularity
- experienced early puberty, with physical development more advanced than their peers
- encountered negative life events
- been a victim of physical and/or sexual abuse
- distorted interpretation of life events
- difficulty in developing adaptive coping strategies
The importance of intervention is highlighted by research that shows substantial continuity in depression from adolescence to adulthood. The risk for both a new onset of depression and recurrence is high during late adolescence and the risk continues throughout early adult years.13 Further research is needed to identify causes and factors associated with the rates of depression in adolescent girls and women and to develop targeted treatments.
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