Re-conceptualizing the diagnosis of depression in adolescent girls and boys
Re-conceptualizing the Diagnosis of Depression in Adolescent Girls and Boys
_____________________________
Dissertation Proposal
Presented to the Faculty
Of
The Gordon F. Derner
Institute of Advanced Psychological Studies
Adelphi University
_____________________________
In Partial Fulfillment
Of the Requirement for the Degree
Doctor of Philosophy
_____________________________
By
Anna L. Lin, M.A.
September 2010
1
Re-conceptualizing the diagnosis of depression in adolescent girls and boys
The Committee
Committee Chair
Laura DeRose, Ph.D.
Committee Member
Ionas Sapountzis, Ph.D.
Committee Member
Kirkland Vaughans, Ph.D.
Student Member
Simone Levey, M.A.
Student Member
Audrey Reichman, M.A.
2
Re-conceptualizing the diagnosis of depression in adolescent girls and boys
Table of Contents
Abstract
5
Introduction
7
Literature Review
9
Psycho-Social influences: Who wears depression better?
9
Depression in the DSM-IV
11
Depression as a psychodynamic state
13
Empirical studies
15
Questions about measurement Bias
18
Gender neutral depressive symptoms
21
The Present Study
24
Hypothesis
24
Method
27
Participants
27
Measures
29
Child Reported Depression
25
Tanner pubertal timing index
25
Sleep Behaviors
26
Feeling of Loneliness
26
School Bonding
26
Future Outlook
27
References
31
Appendices
42
3
Re-conceptualizing the diagnosis of depression in adolescent girls and boys
Appendix I
42
Appendix II
43
Appendix III
45
4
Re-conceptualizing the diagnosis of depression in adolescent girls and boys
5
Abstract
Previous reports indicate girls and boys are equally likely to be depressed, but depression
likelihood differentiates by gender during adolescence and into adulthood. Various studies
consistently report findings in which the ratio of depressed adolescent girls to boys is 2:1. This
difference in depression first manifests in adolescence (e.g. Cohen, Cohen, Kasen, Velez, & et
al., 1993); Hyde, Mezulis & Abramson, 2008), and persists into adulthood and old age (e.g.
Ernst (1992); Kessler, McGonagle, Swartz, Blazer & Nelson, 1993; Lucht, Schaub, Meyer,
Hapke & et al. 2003). It has been hypothesized that a combination of social, psychological and
biological factors (e.g. Hyde, Mezulis, & Abramson, 2008) contribute to this bifurcation in
depression as a function of gender. We hypothesize that rather than revealing a biological sex
dependent difference in susceptibility, a significant amount of this measured discrepancy is
instead the result of inherent gender biases in the socio-cultural perception of depression.
Other researchers have empirically examined possible gender bias in several commonly
used depression measures (e.g., Cole, Kawachi, Maller & Berkman, 2000; Houghton, Cowley,
Houghton, & Kelleher, 2005), some studies finding evidence for gender-dependent differences in
the ways males and females endorse items on the measures (e.g., Houghton, Cowley, Houghton,
& Kelleher, 2005; Wu, 2010), others concluding no statistically significant biases exist in these
tools (e.g., Carle., Millsap & Cole, 2008).
We address the question of possible gender-bias in the reported 2:1 female:male
depression outcome, which appears in adolescence, from a different angle. We hypothesize that
many of the traits associated with depression, for example passivity, helplessness, and weakness
are ascribed in many cultures to the feminine. Because of this trait attribution, we suggest it may
be easier for women to recognize and identify with their depression, and thus to acknowledge it
Re-conceptualizing the diagnosis of depression in adolescent girls and boys
6
to themselves and others, while the symptoms and subjective experience of depression may be
more difficult for males to accept. We suggest that adolescent boys in many cultures are less
likely to endorse the symptoms and subjective experience of depression and are more likely to
recognize and express their depression by more masculine symptomatology, such as certain
forms of interpersonal aggression, even though their psychodynamic state is depressed.
We hypothesize that the statistic that adolescent girls are twice as likely as adolescent
boys to be depressed reflects a cultural attribution of depression to the feminine, not a difference
in actual depression frequency, and that it causes less cognitive dissonance for adolescent girls to
endorse feeling or being depressed compared to boys. To investigate this hypothesis, we will
examine several measures of child and adolescent depression, social, and interpersonal
functioning collected by the National Institute of Child Health and Human Development
(NICHD) Study of Early Child Care and Youth Development. We will use reported sleep
disturbance frequencies as a gender-neutral correlate of depression (e.g., Alfano, Zakem, Costa,
Taylor & Weems, 2009; Johnson, Chilcoat & Breslau, 2000; Laberge, Petit, Simard, Vitaro, et
al., 2001; Morrison, McGee & Stanton, 1992) and compare sleep disturbance frequencies in 6th
grade and at 15 years old to depression outcomes at those time points. If reported sleep
disturbance frequencies are the same for boys and girls at 15 years old but depression outcome
frequencies are 2:1, the results would be consistent with our hypothesis. We will also analyze
some quantitative relationships between social functioning and depression. We will discuss how
different constructs of depression, such as the DSM-IV model of depression, and
psychodynamic, relational constructions of depression (Granek, 2006; Laughlin, 1967) impact
how depression is recognized in the adolescent population by parents, teachers, healthcare
professions, and adolescents themselves.
Re-conceptualizing the diagnosis of depression in adolescent girls and boys
7
Introduction
Many of the traits associated with a depressed person (helplessness, passivity,
dependency, non-agentic) are considered feminine qualities in many cultures (Bern, 1974; ZahnWaxler, 1993), as are many of the symptoms (crying, sadness, low energy) traditionally
associated with our American cultural conception of depression. Our hypothesis is that because
of these associations it is easier for adolescent girls (and women) in American culture, and many
cultures, to recognize in themselves and to identify with depression, and to endorse their
depression when asked, while adolescent boys (and men) are less likely to recognize, identify
with and endorse depression even if they suffer from it. In addition, we suggest that the
depressive symptoms adolescent boys are more likely to endorse, such as anger and its
interpersonal correlates, are often mis-diagnosed as conduct disorder, or intermittent explosive
disorder for example, because the current DSM-IV construct of depression does not adequately
weight the role of anger in depression. We further hypothesize that these gender identity issues
regarding willingness to endorse depression begin in adolescence, when boys and girls begin to
develop a different relationship to their gender and sexual identity (Aube, 2000; Cox, 2010;
Hartmann, 2009; Priess, 2009; Wilchstrom, 1999) within the cultural context of their society.
The research we propose will build on our previous results using the NICHD data set. In
previous work, we looked at forms of middle childhood interpersonal aggression as predictors of
adolescent depression, finding that peer victimization and exclusion as well as asocial behavior
in 3rd, 4th, 5th, and 6th grade are significantly correlated with depression outcome at age 15 for
boys, and for clinically depressed girls. In addition, we found that depression frequencies were
the same in the 3rd through 6th grades, and boys and girls were susceptible at statistically
Re-conceptualizing the diagnosis of depression in adolescent girls and boys
equivalent frequencies (See Table 1). The gender difference emerged in the age 15 data in our
analysis (Table 1), as has been reported in other studies (Allgood-Merten, 1990; Aube, 2000;
Hyde, 2008; Nolen-Hoeksema, 1994).
Table 1. ANOVA comparison of means by gender: IP aggression & depression
3rd Grade
4th Grade
5th Grade
6th Grade
Age 15
B
G
B
G
B
G
B
G
B
G
Child depression
n/a
n/a
n/a
n/a
1.22,
1.84
1.33,
1.99
1.33,
2.00
1.49,
2.23
1.47,
2.10
2.53
3.01
Asocial
.28,
.35
.25,
.33
.23,
.32
.20,
.29
.29,
.25
.25,
.30
.36,
.40
.31,
.35
n/a
n/a
Excluded
.19,
.33
.19,
.32
.17,
.33
.19,
.35
.19,
.34
.21,
.35
.23,
.40
.25,
.40
n/a
n/a
Aggressive
.32,
.29
.25,
.25
.29,
.29
.22,
.23
.30,
.28
.22,
.25
.31,
.29
.25,
.27
n/a
n/a
Prosocial
1.62,
.36
1.71,
.34
1.61,
.40
1.70,
.39
1.61,
.36
1.71,
.35
1.62,
.37
1.71,
.34
n/a
n/a
Victimized
.27,
.27
.23,
.34
.20,
.33
.18,
.32
.25,
.37
.20,
.32
.27,
.42
.22,
.32
n/a
n/a
Relational
Aggression
.25,
.27
.32,
.33
.25,
.29
.30,
.32
.25,
.27
.31,
.32
.26,
.20
.33,.
.34
n/a
n/a
Cells: Means, SD. Significant differences by gender noted at p < .10; p < .05; p < .01; p < .001.
B = boys; G = girls
8
Re-conceptualizing the diagnosis of depression in adolescent girls and boys
9
Review of Current Literature
Psycho-Social influences: Who wears depression better?
Objects and ideas can take on collective meanings and attributes beyond their original
definition. Most people in American culture if asked to assign a gender to a ship or a car would
specify those objects as female
(http://www.englishforums.com/English/DoesCarHaveGender/bjxxh/post.htm) although there is
nothing in the grammar, linguistic or rational conceptualization of those objects that warrants this
gender association. Objects or behaviors that are at one time in history considered masculine
may later be deemed feminine, and visa versa. Wearing high heeled shoes, at various times in
history, has been a symbol that conveyed status for both men and women
(http://en.wikipedia.org/wiki/High-heeled_footwear), because the wearer was showing he had
the means to be transported. Now, high heeled shoes are associated with women and have been
argued to literally and figuratively keep women bound from making large strides for themselves
(Burns-Ardolino, 2003). We hypothesize that rather than revealing a biological, sex dependent
difference in susceptibility, a significant amount of the measured gender-discrepancy in
adolescent and adult depression frequencies is instead the result of inherent gender-biases in the
socio-cultural perception of depression, i.e. the implicit gender associations people currently
make with respect to depression.
Many of the traits associated with depression, for example passivity, helplessness, and
weakness are ascribed in many cultures to the feminine. Because of this trait attribution, we
suggest it may be easier for women to recognize and identify with their depression, and thus to
acknowledge it to themselves and others, while the symptoms and subjective experience of
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 10
depression may be more difficult for males to accept. We hypothesize that men are less likely to
endorse the symptoms and subjective experience of depression and are more likely to express
their depression in “more masculine” symptomatology (Rettew, 2010; Zahn-Waxler, 1993), such
as interpersonal aggression, even though their psychodynamic state is depressed. We thus
hypothesize that the statistic that females are twice as likely as males to be depressed reflects a
cultural embodiment by women of the experience of being depressed, just as women’s bodies are
more often used as a symbol of heterosexual sex, for example.
If the idea of depression is collectively viewed by Americans as feminine, we suggest this
view influences how symptoms of mental distress are clustered together and given a label, who is
recognized to be exhibiting certain symptoms, and who is willing to endorse having commonly
recognized symptoms of depression, or feeling “depressed”. In the subsection below on the
DSM-IV, we discuss the ways in which behavioral and affective traits are clustered into
categories/diagnoses that may have culturally gender-biased etiology. In several of the following
subsections, we discuss how the construct of depression may currently have a feminine
association in the current American cultural context, even if the mental illness or psychological
state of depression has no sexual preference.
Other researchers have empirically examined possible gender bias in several commonly
used depression measures with inconclusive results (Carle, 2008; Cole, 2000; Ernst, 1992; Lucht,
2003; Twenge, 2002; Wu, 2010). We will discuss this body of literature, and then introduce our
plan to address the question of possible gender-bias in the reported 2:1 female:male depression
outcome from a different angle.
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 11
Depression in the DSM-IV
The construct of mental disorders used in the 4th edition of the Diagnostic and Statistical
Manual (DSM-IV) are clustered lists of most behavioral and affective symptoms. If a person is
determined to exhibit the minimum number of symptoms listed for a given mental disorder, then
he or she is diagnosed with that disorder. The DSM-IV is often referred to as the “medicalmodel” approach to mental illness. A health care professional utilizing the medical-model
methodology will apply deductive reasoning to rule out and hone in on a “correct” categorical
diagnosis(es). The person with this diagnosis is said to have such-and-so disorder. With the 5th
edition of the DSM on the horizon, structural changes are debated raising questions about the
parsing of symptoms (Rettew, 2010). For example, often disorders are found to be co-morbid.
Is this because two correctly defined disorders are often co-morbid, or is it that the symptoms of
the two disorders more accurately are part of the same psychological state?
To be diagnosed with depression using the DSM-IV a person, through self-report or by
the observations of others who know the person well, has experienced five or more of the
following symptoms almost daily during a continuous period of time. The duration of time is a
determining factor in further categorizing the type of depression in the DSM-IV. The list of
DSM-IV depressive symptoms are: (1) depressed mood, (2) markedly diminished pleasure in all
or most activities, (3) significant weight loss when not dieting, or weight gain, (4) insomnia or
hypersomnia, (5) psychomotor agitation or retardation, (6) fatigue or loss of energy nearly every
day, (7) feelings of worthlessness or excessive or inappropriate guilt, (8) diminished ability to
think or concentrate, or indecisiveness, (9) recurrent thoughts of death, recurrent suicidal
ideation without a specific plan, or a suicide attempt or specific plan for committing suicide.
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 12
Part of our hypothesis rests on the idea that there exist inherent gender biases in the
current constructs of depression. Anger, which is a more “masculine” trait (Bern, 1974), is an
important psychodynamic component of depression (McWilliams, 1994), and is treated as a
symptom or emotion distinct from depression in the resent biopsychosocial literature on
depression (Ellis, 2010; Gormley, 2010). It is not directly accounted for in the list of depressive
symptoms in the DSM-IV, nor are behavioral correlates or anger, such as irritability.
Oppositional Defiant Disorder (313.81) in the DSM-IV, on the other hand, captures many
symptoms of anger, e.g. often loses temper, often argues with adults, is often touchy or easily
annoyed, is often angry and resentful, is often spiteful or vindictive. In addition, certain actionoriented (masculine) behavioral symptoms in the list, such as symptoms (5) and (8), are also
symptoms for Attention-Deficit and Disruptive Behavior Disorders (ADHD) (314.9) in the
DSM-IV, a diagnosis more often given to males than females. Part of the question we are
interested in addressing is if boys are more comfortable endorsing the kinds of symptoms listed
in Oppositional Defiant Disorder or ADHD than girls, while girls are more comfortable
endorsing the depressive symptoms listed in the DSM-IV. By endorsing we mean either
willingness to identify the symptoms to themselves, or willingness to “own up” to them by
acknowledging them on a self-report questionnaire.
Equally important, are health care professionals more likely to see symptoms of anger
and inattention in boys and not associate it with feminine, passive depression? Instead, are they
more likely to associate it with the more action-oriented, masculine diagnoses of ADHD and
Oppositional Defiant Disorder, while for girls no such gender-biased cognitive dissonance exists,
and girls with the same symptoms as boys are diagnosed differentially based on gender
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 13
expectations rather than on symptoms or other indicators of the actual underlying psychological
distress?
At its root, from a medical-model perspective, our hypothesis asks does the underlying
psychological state of depression contain behavioral, mood, affect and cognitive correlates of
anger, aggression, helplessness, hopelessness, and fearfulness, i.e. both active and passive traits?
And, are the active symptoms of depression more often embraced and endorsed by males,
recognized in them by others, and differentially diagnosed as a Disruptive Behavior Disorder,
while the passive symptoms of depression are more often embraced and endorsed by women,
and recognized in them?
Depression as a psychodynamic state
There are many different shades and nuances in the psychodynamic literature about how
to conceptualize, recognize, and work clinically with depression. We touch on only a few
aspects of conceptualizing depression psychodynamically. The only objective here is to suggest
how depression might be seen as a gender neutral-psychological solution to inter and intra
personal dilemmas.
Conceptualizing depression as a structural, characterological style is one approach
commonly used by psychodynamic and psychoanalytic clinicians (Josephs, 1992; McWilliams,
1994; Shapiro, 1989). Understood from this perspective, depression is a psychological state of
experiencing oneself as “bad” which results from the defensive, ego-protecting functions such as
turning criticism and anger inward on the self using either the more primitive introjection
(McWilliams, 1994) or less primitive “turning against the self” (Laughlin, 1967). From an
interpersonal perspective this solution is understood as subjectively “preferable” because it
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 14
allows the individual to avoid fully experiencing the pain of loss by instead taking the lost other
fully into the self. The cost of this strategy is that the “bad” parts and experiences associated
with the other are also internalized. Because the internalized object is a lost one, these “bad”
parts are rigid because they are dead/static. This strategy can also give the individual a sense of
control (Josephs, 1992; McWilliams, 1994). We propose this solution is not inherently more
masculine or feminine.
It has been empirically validated that a having a depressed caregiver, especially in a
child’s earliest phases of development, is correlated with depression (Boyle, 1997). Since
primary caregivers have until recently been overwhelmingly women, and psychoanalytically
speaking, boys establish their gender identity by separating from the mother while the girls
indentify with her, it would seem that more girls than boys would be depressed if this were the
case. However, developmentally this gender differentiating period happens in early childhood,
and again, both boys and girls in early and middle childhood are equally likely to endorse
depressive symptoms and meet the criteria for depression (Anderson, 1987; Cohen, 1993). It is
not until adolescence that the gender difference in depression frequency arises (Kessler, 1993;
Twenge, 2002). In addition, some studies have shown that boys are more susceptible than girls
to the more negative affective environment and affective mis-attunement that occurs in depressed
mother-baby dyads (Tronick, 2009), which should trend the data in the opposite direction than
current measurements demonstrate, unless there are mediating factors.
The empirical finding that boys and girls are depressed with equal frequency, we
propose, discounts possible dynamic reasoning for a gender-difference in depression frequencies
that might be based on the different tasks of boys and girls surrounding gender differentiation or
identification with the mother. In addition, the literature that addresses the link between
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 15
depressive caregivers with depression outcomes in offspring reports conflicting, inconsistent
results (Boyle, 1997) (Tronick, 2009) (Reeb, 2010).
The aspect of our hypothesis addressed in this subsection is that although there are ways
to use psychodynamically informed theoretical conjectures to frame depression as a
psychological state that is more likely to be adopted by females than by males, there is no
empirical evidence to support such speculation. In fact, the empirical evidence that depression
rates in boys are girls are equal in early and middle childhood, which, along with infancy, are the
developmental periods in which an individual is most susceptible to developing a depressive
character style, suggests the opposite.
The emergence of gender differences in depression: Empirical studies
All of the theories and models mentioned in this section can be broadly characterized as
proposing explanations for the emergence of the gender difference, i.e. these works are all based
on the assumption that adolescent girls are actually depressed at a frequency twice that of
adolescent boys. While our hypothesis questions the factualness of this ratio, the findings in this
body of work, which accept this ratio as fact, are a substantial and substantive contribution to
current ideas about empirically validated diagnosis and treatment of adolescent depression.
In response to the numerous empirical findings that boys and girls exhibit similar
depression frequencies (Anderson, 1987; Cohen, 1993), and this frequency bifurcates to 2:1
girls:boys during adolescence (Kessler, 1993; Twenge, 2002), and persists into adulthood
(Kessler, 1993), there have been many studies investigating the possible origins of this
difference. In these studies, the gender difference has been attributed to a wide variety of factors
including: that females’ are more likely to engage in ruminative coping (Nolen-Hoeksema,
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 16
1994); females’ have a greater dependence on relationships or affiliative needs (Cyranownski,
2000); pubertal timing and female hormonal changes (Goodyer, 2000; Halbreich, 2001); genetic
factors (Jacobson, 1999); females’ greater cognitive vulnerability (Hankin, 2001); exposure to
negative life events (K. S. Kendler, Karkowski, L., & Prescott, C., 1999; K. S. Kendler, Kessler,
R., Neale, M. Heath, A. & Eaves, L., 1993); body dissatisfaction (Nolen-Hoeksema, 1994);
experience of rape or child sexual abuse (K. S. Kendler, Karkowski, L., & Prescott, C., 1999);
gender intensification and adherence to traditional gender roles (Aube, 2000); and interactions
among these factors (Hankin, 2001; Petersen, 1991).
Recent empirically based theories and models of depression have accounted for the
emergent gender-difference using affective (Cyranownski, 2000; K. S. Kendler, Kessler, R.,
Neale, M. Heath, A. & Eaves, L., 1993), biological (Cyranownski, 2000; Eley, 2004), cognitive
(Hankin, 2001; Nolen-Hoeksema, 1994), or an integration (Hyde, 2008) of these, as identified
causal factors in depression.
As an example of how the evidence for these models is reasonable, but not reasonable
beyond question, let us consider the work reported by Nolen-Heoksema and Girgus (1994), who
developed three models to evaluate if causes (model 1), prevalence of causes (model 2), or more
risk factors (model 3) explain the 2-fold difference adolescent depression between girls and boys.
These authors culled the findings of close to 30 research studies and applied them to their three
models. They concluded that few of the studies they looked at provided direct or comprehensive
evidence for the emergence of gender differences in depression in early adolescence using any of
their proposed models, but that the existing studies provided stronger support for Model 3 than
for either Model 1 or Model 2. Their Model 3 suggests that girls are more likely than boys to
carry risk factors for depression even before early adolescence, and these risk factors lead to
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 17
depression only in the face of challenges that increase in prevalence in early adolescence. A
strength of this study is the large body of research findings they include to test their models.
However, in this often cited work, these researchers make a statement suggesting girls that
exhibit more risk factors for depression than do boys and this statement, by their own conclusion,
weakly supported by their analysis.
Of the empirical variables suggested to explain the emergence of the gender difference in
depression, the one most relevant to our hypothesis is gender intensification and adherence to
gender roles. In a study that examined the relationship between gender role identification,
maternal gender role attitudes, and adolescent girls tendency to ruminate about depressed
feelings, Cox and Hyde (2010) found that greater feminine gender role identity among children
and encouragement of emotional expression by mothers at age 11 significantly mediated the
association between the sex of the child and the development of depressive rumination at age 15,
even after controlling for rumination at age 11. This suggests rumination is a behavior
influenced by gender identity, rather than a biological predisposition.
In a longitudinal study of 410 boys and girls at ages 11, 13, and 15 years old, Priess,
Lindberg and Hyde (2009) assessed whether individuals became more stereotypical in their
gender-role identification as they entered adolescence, and if so, if this pattern predicted
depressive symptoms. Contrary to our hypothesis, they found no evidence of gender
intensification across the three time points for either boys or girls. However, they did find that
higher endorsement of “masculine” traits predicted fewer depressive symptoms in both girls and
boys. Because the researchers found no measureable difference in identification with masculine
traits between boys and girls, only that girls differed from boys by higher levels of identification
with feminine traits, they found no evidence that gender-role identity explained the gender
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 18
difference in depressive symptoms (Wilchstrom, 1999). Although this finding seems to be one
piece of evidence against our hypothesis, these researchers are addressing a slightly different
question, i.e. is there something inherently feminine about depression because more femininely
identified individuals are more often depressed? Our question asks if depression is genderneutral, and if the willingness to recognize depression and endorse it is influenced by gender.
Questions about measurement Bias
A body of empirical research has tested if there are biases in the major tools used to
assess for depression throughout the lifespan. We will mention some results from investigations
of bias in a few of the most commonly used depression measures, including the ones used in the
NICHD study. The results highlighted here are those most relevant to consider with our
hypothesis. The summary conclusion from consideration of the collective results of the studies
presented here is that there is evidence for varying degrees of gender-bias in the prominent
depression measures currently used, both at the level of some individual questions within certain
measures, and in the measures as a whole.
The literature is contradictory and inconclusive regarding the existence of biases in
common depression measures (Carle, 2008; Cole, 2000; Ernst, 1992; Lucht, 2003; Twenge,
2002; Wu, 2010). However, it is difficult to compare study findings directly because most often
one or more critical variables are different. For example, in the two studies on the Children’s
Depression Inventory (CDI) mentioned below, different conclusions are drawn from different
results, but the age range of the populations under study are different. Similarly, studies may
vary by the culture in which they were conducted (Ernst, 1992; Wu, 2010)], age range [(Cohen,
1993; Ernst, 1992), measurement tool (Cole, 2000), etc. Rarely are all variables kept constant
except for one.
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 19
Many studies have examined possible gender bias in the Children’s Depression Inventory
(CDI), a self-report questionnaire and one of the most commonly used measures of depression in
children 7 – 17 years old. One study (Carle, 2008) reported finding no gender bias among a
sample of 779 Australian children in the 3rd and 6th grades on the CDI, using a confirmatory
factor analysis for ordered categorical measures, and so concluded the CDI is a valid tool for
cross-gender comparisons in depression for children in this age range. Another study
(Houghton, 2005) on 2,297 Irish children (median age 16.1 years) found 19.1% of boys
compared to 6.1% of girls failed to answer the question “feel like crying” (item 10), a frequency
between 2 and 3 times higher than any other item, including the suicidal ideation question. The
difference between boys’ and girls’ failure to respond on item 10 was statistically significant.
The significance held for both younger (13 – 15 years) and older (16 -18 years) respondents.
They also found that item 10 “feel like crying” is significantly associated with the other 26 items
on the measure for both boys and girls. Further analysis established that item 10 is not a separate
factor, i.e. it is a significant component of the items that taken together measure depression. The
authors conclude that the “feels like crying” item is a significant question in determining
depression in adolescent aged children, but the wording of the question significantly biases boys
to fail to answer it. This finding is consistent with our hypothesis that some traits associated with
depression are gender biased in a way that makes boys likes willing/likely to endorse them.
A study from a Taiwanese group (Wu, 2010) assessed if the same construct for
depression is being used across gender-groups in the Chinese version of the Beck Depression
Inventory-II (BDI-II) using a differential item functioning (DIF) analysis of adolescent data
collected from 2,922 adolescents (1,578 girls) with age range 13 -18.5 years old. They used the
DIF technique to assess if the BDI-II differentiates one individual from another on the trait level
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 20
of depression, but not other dimensions (e.g. gender groups). DIF occurs when the probability of
endorsing one item relies on both and individual’s trait level, and on his group membership.
This investigation found 8 items on the BDI-II were DIF, meaning they separated within the
sample not only a depressed group from non-depressed group, but also boys from girls. The
gender-patterns found were that girls were more likely to endorse item contents reflecting
negative self-evaluation (self-dislike), emotional vulnerability (suicidal wishes, crying) , and
irritation, while boys were more likely to endorse frustration (failure), moodiness (loss of
pleasure), and somatic habits (sleep habits). Based on their results the authors raise the
question: should males and females be scored and compared on the same depression scale, and
suggest that males and females are using different frames of reference (gender constructs) to
complete the BDI-II.
Although the following results are for a population over age 65, it demonstrates finding
gender and racial biases in a commonly used depression measure for elderly Americans. An
analysis of item-response for the variables of age, gender, and race was conducted for all items
on the Center for Epidemiological Studies Depression (CES-D) scale using data (N = 2340) from
the New Haven component of the Established Populations for Epidemiologic Studies of the
Elderly (EPESE) (Cole, 2000) used a modified Mantel-Hanszel odds ratio analysis showed
blacks endorsing 2.29 times compared to whiles the item “people are unfriendly” and 2.96 times
“people dislike me” when both blacks and whites were matched on overall depressive symptoms.
Because blacks are more likely than whites to endorse those two statements, despite equivalent
overall depression symptoms, the authors state their results indicate these two items will racially
bias depression outcome measures made with the CES-D. This study also found women
responded proportionally 2.14 times higher than men matched for overall depressive symptoms
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 21
on the item “crying spells”, again suggesting this item biases the CES-D results with respect to
gender.
Since child and adolescent reports of depression are often obtained from adult sources
familiar with the child, there is also the question of gender bias in mother, father and teacher
reports of child and adolescent depression. One study utilizing the Achenbach Child Behavior
Checklist (CBCL) and the Youth Self Report of a population of 14 year olds showed mothers
attributed more internalizing symptoms to girls and more externalizing symptoms to boys than
the children themselves (Najman, 2001), supporting our hypothesis that gender-biased societal
expectations influence adults who are assessing and diagnosing children and adolescents.
This sampling of studies is representative of the large body of literature that has
examined possible gender-bias in the most often used depression measures. While the results are
often conflicting and it is difficult to compare studies and build a consensus conclusion since the
study parameters are too variable, there is evidence enough to suggest that gender-bias in the
underlying construct of depression is causing a gender-bias in the measured frequency of male
and female depression.
Sleep disturbance as a gender-neutral measure of depression
There is compelling evidence for a relationship between the regulation of sleep, emotion
and behavior, in particular with respect to depression and anxiety in children (Ivanenko, 2004)
(Johnson, 2000) (Morrison, 1992). Sleep disturbance is a common somatic complaint of those
suffering from depression and is one of the symptoms of depression listed in the DSM-IV. We
will use results reported in the NICHD data on the sleep patterns of children and adolescents in
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 22
conjunction with the NICHD pubertal timing data to develop a gender-neutral measure of
depression.
Based on other research, reports of nocturnal sleep disturbance may be associated with
depression while shifts in bedtime, wake-time and time sleeping are correlated with puberty
(Laberge, 2001). We consider the results reported for changes in sleep patterns during
adolescents without depression (Laberge, 2001), where no gender differences in nocturnal
awakenings was observed for children between 10 – 13 years of age. Weekend versus weekday,
and bedtime and wake-time shifts were found to occur as a function of age, and pubertal onset
was correlated with the difference between girls and boys patterns, i.e. more girls entered
puberty earlier and this explained the discrepancy between boys’ and girls’ sleep habits. Thus,
we will use nocturnal sleep disturbance reports as our gender-neutral sleep measure. We will use
sleep disturbance reports as one variable, and use sleep disturbance results after adjusting them
for pubertal onset as another variable to see how pubertal timing effects sleep disturbance in our
sample, and to control for pubertal timing as a possible independent variable if necessary.
A potential confound of sleep disturbance as a measure of depression is that it may also
be a symptom in other childhood disorders. A review article on sleep disturbance in children and
adolescents reports sleep disturbance are prevalent in youth with internalizing disorders (Alfano,
2009). The results of this study were that depressive symptoms showed greater association with
sleep problems in adolescents (12 – 17 years old), while anxiety symptoms were generally
associated with sleep problems in youth (6 – 11 years old). The association between anxiety and
sleep disturbance was found to be less specific in non-clinical samples of youth. This study
examined the role of gender in comparing developmental differences in sleep patterns,
depression and anxiety and found no significant main effects or interaction terms for gender.
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 23
These finding suggests our choice of sleep disturbance as a measure of depression in adolescence
is a good one, although it suggests sleep may more directly measure anxiety than depression for
our childhood time-point.
The results of the Taiwanese DIF study discussed earlier found no gender bias in any of
the somatic dimension factors of the BDI-II , except in sleep patterns (Wu, 2010), for which they
found a uniform DIF affect, with boys reporting slightly higher levels of sleep disturbance than
girls.
Other gender-neutral variables
Within the NICHD dataset, in addition to sleep disturbance we have identified three other
possible gender-neutral variables that may be associated with depression: Feelings of Loneliness,
Attachment to School (belongingness), and Future Outlook. Withdrawing and isolating behavior
is a symptom of depression, and may cause less cognitive dissonance for boys to endorse than
for girls. The ability or inability to form an attachment to school, an important community in a
child’s life, is a measure of his capacity to form meaningful, sustaining relationships with others.
Hopelessness about the future is another symptom of depression, and currently part of the
construct of depression in the DSM-IV. Each of these measures may or may not be gender
neutral. As part of our analysis we will explore the possible gender relationships of these
variables.
The Present Study
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 24
This study will investigate the possibility that the 2:1 gender-difference in susceptibility to
depression reported in the literature does not measure an actual difference in depression
frequencies in adolescent and boys compared to girls. Instead, we hypothesize that the
bifurcation in depression rates is correlated with gender-identity, and influenced by American
cultural associations of masculine and feminine traits, and the traits culturally ascribed to
depression. Furthermore, we expect that these gender identity issues regarding willingness to
endorse depression begin in adolescence, when boys and girls begin to develop a different
relationship to their gender and sexual identity within the cultural context of their society (Cox,
2010; Priess, 2009).
Hypothesis
Many of the traits associated with a depressed person (helplessness, passivity, lack of
agency, etc) are considered feminine qualities in American culture (Zahn-Waxler, 1993), as are
many of the symptoms (crying, sadness, low energy) traditionally associated with our American
cultural conception of depression. Our general hypothesis is that because of these associations, it
is easier for adolescent girls in many cultures to recognize in themselves and to identify with
depression, and to endorse their depression when asked, while adolescent boys are less likely to
recognize, identify with and endorse depression even if they suffer from it. We will examine if
there is evidence to support this general statement using four specific sub-questions that can be
posed and answered using variables from the NICHD data base.
Question One: Sleep disruptions have been found to correlate highly with
depression in adolescence (Alfano, 2009). The literature suggests pubertal timing affects a shift
in the wake-sleep cycle but not mid-sleep disruptions (Laberge, 2001). Therefore, we propose
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 25
to use a measurement of adolescent sleep disruption as a gender-neutral measure of adolescent
depression. If necessary, we will adjust the sleep disturbance measure for pubertal onset affects
on sleep using the Tanner stage nurse assessment of pubertal development measure.
To test for gender bias in self-reported depression, we will use our previous analysis in
which we calculated separately the depression frequency, at 6th grade and age 15 years, reported
by boys and by girls (see Table 1). We will compare these frequencies to sleep disturbance
frequencies, self-reported by girls and boys, calculating the mean of the sleep disturbance
variable at the same time points. If we find that adolescent boys report a higher frequency of
sleep disturbance compared to depression, while girls report statistically similar frequencies of
sleep disturbance and depression, it will support our hypothesis. If the sleep disturbance
frequency for 15 year-old boys and girls is similar, and this frequency is similar to the depression
frequency for 15 year-old girls, this finding would also be consistent with our hypothesis that
boys are less willing to identify with and/or endorse depressive symptoms.
Question Two: Is there evidence for gender-bias in the way the DSM-IV clusters
symptoms for depression, oppositional-defiant, and conduct disorders?
To address this
question, we will use the data analysis from our previous work on interpersonal aggression, using
variables of (physically) aggressive behavior and relational aggression as behavioral correlates of
anger. We will calculate the frequency of interpersonal aggression exhibited by boys and by
girls in the 6th grade and at age 15. For each time point we will add the calculated boys’
interpersonal aggression frequency to the calculated boys’ depression frequency. If the sum of
these frequencies approaches that of the depression frequency calculated for girls at that time
point, it will be consistent with our suggestion that the symptoms in the DSM-IV are clustered in
ways that enable depression in adolescent boys to be diagnosed as conduct or oppositional
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 26
disorder.
In the language of the DSM-IV, we are looking at the co-morbidity of Disruptive
Behavior Disorders and Depression but in our way of framing the question, we are instead
checking if combining the diagnoses evens out the gender-discrepancy in depression frequency.
Question Three: Is race a moderating factor in the possible under-measurement of
adolescent depression in boys? Because of African-American sub-cultural ideals of masculine
strength, as well as social pressure on black Americans to counter racist assumptions by not
appearing weak in the face of racism (Head, 2004; Lindsey, 2010; Mandara, 2009) it’s possible
that it is harder for black adolescent boys to endorse symptoms and feelings of depression than it
is for white adolescent boys. The explicit and implicit racism against black males in American
society (Mandara, 2009) that stereotypes them as more likely to be violent and criminal, may
cause mental health care workers, teachers and parents alike to be more likely to diagnose
depressed black American adolescent boys with Disruptive Behavior Disorders than white
American adolescent boys, and, because they have internalized the same stereotypes, for black
American adolescent boys to identify with that label. To test if these biases are affecting
depression outcome measures, we will run a regression analysis with depression as the dependent
variable and sleep disturbance and race as independent variables while controlling for socioeconomic status to determine if race is a moderating factor in the measured gender-difference in
adolescent depression frequency.
Question Four: Our final thesis question is exploratory in nature. We selected three
psychosocial variables: Loneliness, School Bonding (belongingness), and Future Outlook as
other variables, in addition to Sleep disturbance, that might be gender-neutral measures of
depression. Similar to our analysis of the Sleep disturbance variable, we will calculate the
frequencies of each variable for boys and for girls at our two time points. We will compare the
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 27
frequency of loneliness, belongingness and future outlook reported by boys to the frequency they
report for depression. We will also compare the frequencies reported by boys to those reported
by girls. If boys report statistically higher frequencies of loneliness than depression, for
example, and the loneliness frequency reported by boys is similar to the depression frequency
reported by girls, this would support the loneliness measure as another gender-neutral variable of
depression.
To further establish if these variables are appropriate variables to include in a genderneutral model of depression, we will run a regression analysis with depression as the dependent
variable and Sleep Disturbance, Loneliness, School Bonding (belongingness), Future Outlook as
the independent variables to determine which of these independent variables are related to the
dependent variable, and to determine the functional form of the relationships. Further step-wise
regression analyses will be run to determine if race moderates the reporting of depression in
adolescent boys, controlling for race.
Method
Participants
The analyses for this study will use data from the National Institute of Child Health and
Human Development (NICHD) Study of Early Child Care and Youth Development. The
children and families who participated in this study were recruited from 10 sites located in or
near: Little Rock, Arkansas; Orange County, California; Lawrence, Kansas; Boston,
Massachusetts; Morganton, North Carolina; Pittsburgh, Pennsylvania; Philadelphia,
Pennsylvania; Charlottesville, Virginia; Seattle, Washington; and Madison, Wisconsin. These
children and their families were followed from the child’s birth through age fifteen.
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 28
Families were recruited during hospital visits following their infant’s birth and screened
for study eligibility. In 1991, during selected 24-hour sampling periods within a 10-month
period, 8,986 women were visited in the hospital and screened for eligibility and willingness to
be contacted again. The mother was required to be able to speak English, her health was
evaluated, and she was required to be at least 18 years old. The birth was required to be a single,
healthy birth, and the infant could not be released for adoption. The family was required to live
within 1 hour of the research site, to have no plans to move from the area in the coming year, and
to live in an area not considered by police to be too dangerous for research assistants to visit in
pairs. Of the women who gave birth during the sampling periods, 5,416 (60%) met the eligibility
criteria and agreed to be contacted after their return home from the hospital. A stratified random
sample of 3,015 mothers was selected for a phone call 2 weeks after the child’s birth to ensure
adequate representation of mothers without a partner, mothers without a high school diploma,
and ethnic minority mothers. At these calls, families were excluded if the infant spent more than
7 days in the hospital or if the family could not be reached after at least 3 contact efforts. The
number of mothers selected for the call that were eligible and agreed to an interview was 1,526.
When the infants were 1 month old, 1,364 families completed a home visit and were
enrolled in the study. The final sample includes 53% boys, 24% ethnic minority children, 11%
mothers who had not completed high school, and 14% single-parent families. Families were
followed, whenever possible, regardless of whether they moved during the course of the study.
Measures
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 29
Child and adolescent reported depression. Child reported depression at age 15 was measured
with the Children’s Depression Inventory (CDI) Short Form (Crick & Grotpeter, 1995) The CDI
has 10-items and is the most widely used questionnaire for assessing depression symptoms in
children and adolescents. Ten sets of three statements were presented and the adolescent selected
the one that best describes the way she/he felt over the last two weeks. The items tap dysphoric
mood, lack of pleasure, and low self-esteem. The goal was to obtain a brief screening measure of
depressive symptoms. The raw items used to create the Child Depression score have moderate
internal reliability (10 items, Cronbach’s alpha = 0.81).
Child and adolescent reported sleep behaviors in 6th grade and at age 15. In the 6th grade and at
age 15, study children were asked to complete the “Circadian Preference Scale and Sleep Habits”
questionnaire designed to assess sleep behaviors. Questions 1 to 15 were developed to ascertain
the adolescent’s bedtimes, amount of sleep, and difficulties going to sleep on the previous night,
weekdays in general, and weekends in general. Several questions were included concerning night
wakings, difficulty getting up on time in the morning on school days, feeling tired on school
days, and adolescent’s wish to get more sleep. Some of the items were adapted from the
Children’s Sleep Habits Questionnaire (CSHQ) by Owens, Spirito, McGuinn (2000).
The
sleep-problems data set contains data collected from 974 study children. The General Sleep
Problem variable score is computed as the sum of responses to items 7-15. Possible and actual
scores range from 9 to 45, with higher scores indicating greater sleep problems. The raw items
used to create this score have moderate internal reliability (9 items, Cronbach’s alpha = 0.78).
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 30
Tanner stage nurse assessment of pubertal development. At 9 ½, 10 ½ and 11 ½ years of age,
all study children and their mothers (or alternate primary caregivers) were asked to participate in
an annual Health and Physical Development Assessment (HPDA). The assessment consists of
three questionnaires completed by the child’s mother and a physical exam of the child completed
by a nurse practitioner or doctor.
The Tanner Stage assessment of pubertal development consists of three questionnaires
completed by the child’s mother and a physical exam of the child completed by a nurse
practitioner or doctor. The main focus of the examination is on physical growth and
development. The procedures included in the physical examination reflect standards for periodic
health examinations for ages 7 to 12 from the U. S. Preventive Services Task Force, as well as
recommendations from Lorah Dorn, a researcher in pubertal development at the University of
Pittsburgh School of Nursing and Karen Winer, a pediatric endocrinologist at NICHD.
Tanner staging for girls was based on instructions from the American Academy of
Pediatrics manual, Assessment of sexual maturity stages in girls (Herman-Giddens & Bourdony,
1995). Tanner staging for boys was based on Tanner's original criteria (adapted from Tanner,
1962). If a child was between stages on any Tanner stage measure, he or she was scored at the
lower stage. For research purposes, they were only scored in the higher stage if all criteria were
met. The data set contains data collected for 885 study children.
Child and adolescent reported loneliness in 5th grade and 15 years old. At age 15 study children
were asked to complete a 25 item questionnaire designed to assess the adolescent’s feelings of
loneliness and social dissatisfaction. This age 15 questionnaire is identical to the one completed
by the study child in Fifth Grade. Twenty-four of the items were taken from the Loneliness and
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 31
Social Dissatisfaction Questionnaire (Asher, Hymel & Renshaw, 1984), and one new filler item
was added at the end of the questionnaire. Sixteen items focus on adolescent’s feelings of
loneliness, feelings of social adequacy, subjective estimations of peer status, and appraisals of
whether important relationship provisions are being met. Two of these items (1 and 22) were
reworded slightly for home schooled adolescents. The remaining nine items are fillers which
focus on hobbies or preferred activities. Responses are scored on a five-point Likert scale
ranging from 1 = “Not at All True” to 5 = “Always True”. The data set contains data collected
from 956 study children. Child Loneliness is computed as the sum of items 1 (reflected), 3, 4
(reflected), 6, 8 (reflected), 9, 10 (reflected), 12, 14, 16 (reflected), 17, 18, 20, 21, 22 (reflected),
and 24. Scores are computed using a method of proportional weighting and range from 16 to 75,
with higher values indicating more loneliness. The possible range of values is 16 to 80. The raw
items used to create this score had high internal reliability (16 items, Cronbach’s alpha = .91).
Child and adolescent feelings of bonding toward school. In 6th grade and at age 15 study
children were asked to complete a questionnaire designed to measure their perceptions of school
climate, teacher behaviors, and study habits. The What My School is Like questionnaire consists
of 19 items. (Note that this questionnaire was not given to home schooled study children). This
questionnaire was adapted from the New Hope Study, which in turn adapted it from the
Adolescent Health Study. The original New Hope items were scored on a 5-point Likert scale
ranging from 1=“Not at all true” to 5=“Always true”, whereas the NICHD measure uses a 4point Likert scale where 1=“Not at all true”, 2=“Not very true”, 3=“Sort of true”, and 4=“Very
true”. The data set contains data collected from 955 study children.
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 32
A “School Attachment” variable (Study Child) is computed as the mean of the responses
to items 2, 8, 10, 13 and 19. This score was imputed by proportional weighting. Possible and
actual scores range from 1.2 to 4 at 6th grade and 1 to 4 at age 15, with higher scores indicating
more attachment to the school. The raw items used to create this score have moderate internal
reliability (5 items, Cronbach’s alpha = 0.74 at 6th grade, Cronbach’s alpha = 0.76 at age 15).
A “Negative Attitude Towards School” variable (Study Child) is computed as the mean of the
responses to items 6, 9, 11, 12, 14 and 15, for cases with complete data. Possible scores range
from 1 to 4. Actual scores range from 1 to 4 for 6th grade and 1 to 3.83 at age 15, with higher
scores indicating a more negative attitude towards school. The raw items used to create this score
have modest internal reliability (6 items, Cronbach’s alpha = 0.69 at both 6th grade and 15 years).
Future outlook as a measure of hopefulness/hopelessness. At age 15, study children were asked
to complete the 8-item Future Outlook Inventory (FOI; Cauffman and Woolard, 1999) designed
to assess time perspective, or the ability to foresee short and long term consequences. Items for
this instrument were drawn from various measures of similar constructs (Scheier & Carver,
1985; Strathman, Gleicher, Boninger, & Edwards, 1994; Zimbardo, 1990). The FOI asks
participants to choose the response that is most true of him or her on a response scale from
1=“Never” to 4=”Always” (e.g., I will keep working at difficult, boring tasks if I know they will
help me get ahead later). The data set contains data collected from 957 study children.
Re-conceptualizing the diagnosis of depression in adolescent girls and boys 33
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