SUMMARY: This article reviews the correlates and rates of depressive symptoms in preadolescent and adolescent boys and girls. Examples of differing socialization paths available to the genders are supplied. Diagnostic criteria for depression for each gender are reviewed. Implications for the living with and the treating of depression in a family are considered from the perspective of systems theory. Some parental advice is given. Long term conclusions about the ultimate hope to reconcile the gender differences of adulthood starting with the pre-adolescent serve as a conclusion. A consistent finding in the literature has been that women are more often diagnosed depressed than men from adolescence through adulthood. In contrast, prepubescent boys have rates of depressive symptoms equal to or higher than those of their female agemates. A change occurs for girls around 13 years of age where higher rates of depressive symptoms appear. By age 18, the difference in rates is well established in favor of girls. One estimate points to a rate of depression of 2% to 3% for boys and 10% to 13% for girls in early to middle adolescence (Kutcher & Marton, 1989). What happens? The explanation for this dramatic reversal in rates has been debated. One view is that since women are expected to be and then are later diagnosed to be more depressed than men girls are seen to be well on their way. Arguments around bias in the “new” DSM-IV captured this theme. The diagnostic criteria favor labeling girls depressed. A more recent set of explanations center around the failure to recognize criteria for male depression that are different from those of female depression. The imposition of a “Boy Code” where the central explanation of the kind of behaviors observed results from the oblique kind of socialization that governs the way boys are raised rather than the more direct socialization that girls receive. To oversimplify, boys are taught what not to do or to be rather than what to become. What boys suffer from is more covert and not as diagnosable. To the extent that the myriad of avenues that lead to socialization differ the depressive symptomatology can also vary in an individual case. There are also group gender differences in classification at least if not in actuality. About 3.5 million children under 19 are called clinically depressed. In 1996, around 5% of the age group 5 to 19 or about 580,000 received prescriptions for Prozac. Nolen-Hocksema (1991) found more boys (aged 8 through 12) reported depression than girls. The higher depression centered on behavior disturbances and irritability or misbehavior and a lack of pleasure in relation to friends and relationships (the classic adhedonia). These symptoms may not always be called depression but are socially allowable in most sub-cultures for boys and the diagnosis may be missed. In contrast, no difference in the number of boys and girls who were depressed or in the severity of the ailment were found in a Penn State survey in 1982 (Smucker, 1982). Differences in these populations may be no different than the outcome of different diagnostic criteria. The Contrast Between The Genders When Does It Start? A surprising exception to a common societal expectation is the realization that boys are not always ready to separate from their mothers on the first day of school. Some need a more gradual time than the “clean break” that is often suggested by teachers. The adage, ” push him out of the nest or he will never fly,” becomes “he may not leap when ready.” The advice to set firm limits may actually intensify the problem and a more flexible time frame may be needed. Separation is acknowledged as difficult for girls. Boys are not to appear vulnerable and have to be independent or their peers may make fun of them then ostracize them and call attention to their “sissy behavior”. Both parents and teachers fear boys may become overdependent. Boys may separate from their parents before they are emotionally ready as in: sleeping alone in a crib, the first day of school, or sleep away camp. If boys rebel against this push to separate, they cry, feel fearful and often they are made to feel ashamed. Shame can undermine their self-esteem and may lead to loneliness, sadness and disconnection as the boy may be told to “tough it out”. David and Brannon (1976) offer 4 prototypes of the “Boy Code” to be followed as a model of behavior. I. The Sturdy Oak. Men never show weakness. Act like it doesn’t hurt. Only women cry. Keep acting. Never share pain or grieve openly. II. Give `Em Hell. Bravado works; men show attraction to violence, as is evidenced by high energy dares. Parents sometime back off if you come on tough enough. “Primates will be primates.” Be competitive. III. The Big Wheel. Status, dominance, and power are the goal. Avoid shame, be cool, and push self to the extreme to avoid failure and unhappiness. Keep a stiff upper lip. IV. No Sissy Stuff. Dependence, warmth, and empathy are seen as feminine. No sissy feelings is the ideal; feelings often are to be buried. Self-reliance is king. The latency age boy knows that being masculine is defined as avoiding the feminine. Being a boy is the negative of being a girl. Warmth, empathy, tenderness and sensitivity are feminine and to be eschewed. Tears and hugs are gender alien. A deliberate attack on feminine traits such as compassion protects against any vulnerability. A boy’s disidentifying from mother and replacing it with a “healthier” male self-image from his father often involves separation from a caring person to be thrust into a world hostile to his dependency needs. “Walk like a man”, he is told by his brothers and peers whether he is equipped to do so or not. Self-hatred, inadequacy, and loneliness may often follow as a natural emotional expressiveness is squelched in the toughening up process. As he covers his need for dependency a boy hides his feeling of love and caring. When he says “So What?”, don’t believe him. In New Guinea, manhood is called the “Big Impossible”. For too many in our culture this involves a shut down of the tender side of life. A code of silence follows, which helps boys become silent witnesses to cruelty against others. To remain strong is to be silent and masculine and quiet. How Girls Get Depressed Shame silences girls and prevents them from expressing their true feelings and inhibits or suppresses self-expression at an earlier age than for boys. “Big girls don’t cry!” Girls are shame sensitive; boys are shame phobic. Fear, dependence and sadness lead to shame. This may be the relevance of Gilligan’s (1982) findings. Younger girls 7, 8 or 9 had a sense of outspokenness and were honest about who they were and the things that hurt them. They appeared confident, assertive and felt positive toward selves. By 14, 15 or 16, girls seemed to have lost their resistance and would say, “I don’t know, I don’t know.” They start not knowing what they had known. Their self-confidence and self-image is poorer. This may be necessary for a girl to develop her second moral voice – the care voice as opposed to the first – the justice voice. Her voice although softer is not inferior to the male voice, it is just different, more concerned with human relationships than just principles. It is quieter for a longer while according to Gilligan. Girls are said to be oppressed by the tyranny of the kind and nice. Boys may be said to be socialized by being disconnected. While her sample or questionnaire format can be criticized as not being as broad based as a researcher would like, the point remains a cultural environment was found where some interesting gender differences were well established. A multicultural replication of her research is needed to see how generalizable her findings are. In a given local setting boys who reported doing poorly in math and science may call the subject irrelevant; while girls may see their poor performance as a personal failure. Diasthesis – Stress Model An explanation where girls are seen to possess predisposing risk factors which when confronted with increasing social and physical challenges of adolescence render them susceptible to a variety of depressive symptoms: low levels of mastery, low levels of aggression and dominance in groups and high levels of ruminative rather than active coping was said to place girls at a risk for depression. Girls are more interested in the causes of their sadness; they are more likely to cry and admit they are unhappy, helpless and hopeless and to seek support. Girls are twice as likely to talk to friends as boys are. Nolen-Hocksema and Girgus (1994) refer to this as a diathesis – stress model that provides the best explanation of the available data from the symptomatology observed. Early loss, grief, family functioning and a host of other psychosocial events are linked to depression and demonstrate the varied and complex variety of depressive symptoms that are available. Descriptive procedures are used in diagnosis and the symptoms are collected. Coping style identification is rare at intake when a “problem” precipitates a “mental health crisis.” Individual differences in coping style with stressful events may often predict the likelihood of depression and its duration. A ruminative or self-focused response style typically deals with problems by directing attention internally toward negative feelings and thoughts about the troubling situation. This style has been associated with the development and persistence of depression in girls and women. Distraction redirects the attention of other individuals to more pleasant activities. Avoidance or denial is often more associated with boys and men. At the onset of adolescence do girls ruminate more than boys? Getting mad, punching a wall, going out to play ball or to just “hang out,” putting it aside and moving on are all male behaviors – boys distract themselves. In adults, the daily stressful events of life are more important than major life events in developing psychological symptoms. Rumination prolongs a depressed mood by increasing the focus of negative events and by interfering with attention and concentration. Girls were more likely to use rumination than boys; boys and girls ruminated less when it came to peer problems as opposed to academic and family problems in this research (Compas, Davis, Forsythe and Wagner, 1987). Is rumination present there beforehand? Or is it in itself a response and consequently a risk factor? Is it a predisposing event that follows one depressive event and precedes the next? No longitudinal research was found that could isolate this question or others connected with other coping styles that could be connected to gender. While this line of research should be pursued, it ignores the more basic reality that depression of a parent or a boy or a girl occurs in a family. How Boys Get Depressed Because a boy wears a mask, he may not be the Lone Ranger. At any age boys need to be told they are good, they make good friends, and they are loved and supported. If it is difficult to admit sadness or vulnerability and the cultural ideal is for men to minimize their genuine pain, more boys than they or we realize are depressed. In Elementary School, boys receive lower grades than girls. Eighth grade boys are held back 50% more often. Boys in high school comprise 66% of Special Education classes. 71% of school suspensions involve boys. There are fewer boys in college and 59% of all Master of Arts candidates are now women (Pollack, 1996). Michael Gurian (1999) argues that boys are the worse off and are in fact the more depressed gender. Adolescent boys are significantly more likely than adolescent girls 1) to die before age 18 from violence, disease or accident 2) to die at the hands of a caretaker (2 out of 3 incidents involve a male) 3) to be a victim of violent crime (15 times) One third of boys carry a gun or other weapon to school. Gunshot wounds are the second leading cause of accidental death among 10 to 14 year olds. Compared to the diagnosis for a girl the boys diagnosis of – emotional disturbance is four times as likely – autism is twice as likely – schizophrenia is 6 times as likely (65% to 75% of juvenile mental patients are male) – conduct disorders, thought disorders and brain disorders are almost always male diagnoses. The majority of adolescent alcoholics and drug addicts are male. The rate of overt depression in girls is two to four times the male rate. Covert depression evidenced by drug/alcohol use, criminality, isolation rather than intimacy from family are much more male phenomena and may serve to even up the score for males, at least in terms of the rate of depression. Male depression is less expressive bordering on the stoic. A depressed female is overt; she may talk about suicide, or claim she is fatigued and may seem aimless and unmotivated. Success at suicide is rising for males and not for females. Males are four times more likely to commit suicide. The fear this statistic generates points to the reluctance of the male to ask for help except through violence to self or to someone else. A set of criteria to fine-tune the diagnosis of male depression was supplied by William Pollack (1998). About 17 separate indices were listed and these can only be inadequately summarized here. Reference to the text Real Boys may be necessary for complete coverage. A few signs requiring further exploration are listed here. _ Withdrawal from family, friends or favorite activities _ Tense, worried, impulsive behaviors appear. Angry outbursts point to increased aggressiveness in general _ demands for autonomy and refusal to fit into family rules or curfews _ excessive sleeping, tiredness, eating patterns shift, concentration or other physical symptoms may develop _ changes in school performance, athletic interests, work ensue _ avoiding help form others _ inappropriate turning to sex, drugs, alcohol or risk taking behavior _ discussion of death or suicide Some phrases that may serve as warning flags are: What’s the big deal? Why are you (his parents) getting excited? Everything’s all right. Nothing’s wrong. Leave me alone What are you trying to say? I’m no good at (science, relationships, telling people what’s going on) I can do it myself. I don’t want any help Why do I have to go and talk to somebody about this for? It’s probable that more boys are depressed than our rates indicate. The conclusion is not to decide that one gender is better off than another in depression rates. The proper recognition of depression for what it is will lead to the acknowledgement of symptoms in either gender early on and lead to appropriate treatments. The Depressed Family Systemic adjustments in dealing with a depressed member must profoundly adjust the experience of socialization a child receives. A differential rate of depression must be linkable to different systemic constellations. While depression is said to run in families, the best understanding of this may not always be so linear. A depressed child may be associated with a depressed parent. Either one may have “caused” the change in the system. Apart from the biological transmission of the predisposition to depression from parent to child a range of social factors, i.e., marital satisfaction, discipline, stress, and peer group influence may contribute to a child’s or adolescent’s depression. Family environmental factors associated with the onset and course of juvenile depression include high parental criticism, family discord, and poor communication between parent and child. Of course, depression in children may also be related to mental illness and dysfunctional family relationships which may have even more severe effects. Children are more likely to end up sad, critical and angry in certain homes (Harrington, 1996). The focus of treatment in such a clear case would be to reduce those factors that predict depression rather than to attempt to reduce depression itself.
Families with a depressed parent show decreased positivity and congeniality compared to families with a non-depressed parent. Even communication between the child and the non-depressed parent is less positive. A person’s depression has an impact on relationships in which the person may not even be involved. Parenting and other family connections are seriously affected for other family members. Families with a depressed mother displayed less positivity than families with a depressed father. Perhaps because women are expected to express more affect than men, a depressed mother may often have a more significant effect in a family than a depressed father. In a traditional family maternal influences are expressed in organizing the child’s daily life; meals, homework, social calendar items, etc. and the sheer number of mother-child interactions may be greater than father-child interactions. Sheeber et al. (1997) found that parents of depressed adolescents are more sympathetic in responding to their adolescent’s depressive behaviors than parents of non-depressed adolescents. Mothers displayed facilitative and problem solving behaviors when the adolescent displayed depressive behavior. Mothers may “reinforce” these behaviors by supplying more attention to them. Depressive behaviors stimulate mothers to respond and often cause fathers to remain inactive. Perhaps when mothers respond fathers are inhibited and remain withdrawn. Other fathers may just become poised to act later on. More research on the parental interaction, as a response to a depressed adolescent is needed. Families with a daughter exhibited more negativity than families with a son and mother-child interactions appeared to be more negative and less congenial than father- child interactions. The presence of a depressed mother is more predictive of a daughter’s depression than a son’s depression. A father’s depression does not predict depression in an offspring. If males are more oriented to problem solving, females may be more oriented to rumination and intensifying negative affect. Fathers in traditional families at least have the opportunity for specific and focused communications for conflict resolutions (Sheeber, 1998). To be helped, a depressed male needs to be invited to step up to the plate to increased relational responsibility, a move he may not make if his partner allows him to avoid it. My view of systems theory suggests that depression is transmitted through decreased parental support and reinforcement. A depressed parent models poor coping behaviors, helpless problem solving styles and negative attributions. There would be very different paternal versus maternal models of these. This too should be researched A depressed mother, for example, may exhibit dysfunctional parenting styles and may be hostile and show criticism or may just be unresponsive to family events. Children often find it difficult to communicate their own distress in a fear of exacerbating her depression or to increase her hostility and grow up with an attitude where they don’t expect much support. Weissman (1988) demonstrated the effects of psychotherapy on parenting took 6 months to develop despite improvements in parents’ depressive symptoms. This lag persists in spite of the relatively fast decrease in depressive symptoms (in particular when therapy is combined with some medication). It is possible for a depression to lift faster than the family system can change. When this happens some motivational input with a longitudinal follow-up is necessary to convince the parties of the need to keep changing the system. Parenting – What’s It All About? Girls are pushed inward; boys are pushed outward. Boys need to be socialized to develop self-esteem rather than shame or grandiosity. Masculinization teaches boys often to replace self-worth with performance-based esteem. Sometimes the very feelings that could help boys connect have to be disowned because they may make a boy feel vulnerable. Boys are always entitled to express anger. Boys once focused on achievement, may not be as sensitive to the needs of others and may be seen as damaged in their ability to relate to others. Hundreds of acts of reconnection will be needed to restore the relationship. Anger is the one acceptable emotion allowed to the early adolescent boy. Girls can speak of their sadness and hope for a return to harmony. Retaliation is too often allowed as a parental response to a boy’s anger. Anger becomes the easiest feeling for a boy to express and he may serve as a lightening rod for harsh power oriented discipline after an incident of apparent disregard for property or people. Boys often show a high intensity lack of self-control. The non-pushy inquiring adult who tries to get behind the anger can explore the gamut of feelings operating in the person and not let the expectation of finding anger short-circuit all emotional expression. Behind the anger or roughhousing or disruptive feelings might be a deeper more significant feeling governing the present situation. Girgus, et al. (1989) found that the boy’s depression scores were significantly correlated with both popularity and rejection while girl’s depression scores were correlated only with rejection. Rohde, et al. (1997) found boys were more likely to think about suicide if they were suffering stressful life events and if they lacked social supports. Teenagers who feel connected to their families are less likely to experience emotional distress or attempt suicide or use harmful substances. “Shared activities” with teens where together several times during the day parents and teens expressed warmth, love and caring work provide a nurturing place for self-esteem to develop. Teens who ate dinner with their parents five nights a week end up better adjusted than any alternative. Implications For Parenting Courage is resistance to fear or the mastery of fear – not absence of fear. Mark Twain When it comes to viewing depression, it is a mental illness but also feminine. Men externalize pain and conflicts, women internalize pain. This often weakens and hampers her capacity for direct communication. A boy disavowal of the feminine in himself falls into spheres, the rejection of expressivity and the rejection of vulnerability. Early signs of masking of feelings may show up as bad grades, rowdy behavior, being too quiet in school or at home or with peers, using alcohol or drugs or violence as a victim or a perpetrator. To “get behind the symptom,” parents need to avoid shocking, intimidation or preaching. Psychologists are allowed to preach to parents however. Parents should invite a report from the boy yet at the same time not accept it verbatim as fact. Parents should be advised to trust their instincts. Boys often operate on their own emotional schedule. Lots of silence gets punctuated with some self-disclosure. Type-A parents would like the silence at the end and the talking “up-front.” After a while parents conclude the majority of time is silence or dead air and the revelation may come at the most inopportune time. Adolescents (especially boys) need encouragement to offer a report on their feelings. Yet adults need to validate the feelings that are expressed to them. Answers sometimes are too brief and the raconteur needs to appear to be strong and competent. Once honored, he will talk once he feels he doesn’t have to be so guarded. Two key principles governing parenting a boy: I. Help your child have an internal life and help develop a shaded emotional vocabulary so he may better understand self and articulate his feeling to others. Adults often need to model what they themselves are feeling. II. Accept a boy’s needs to have something to do. Boys often work in an action space and playing catch or throwing the football – a requisite psychomotor jog – is a pre-requisite to open exchange. Male friendship relies on being together; doing things together not always talking together. In a sense it is harder to sustain since it is not just conversation driven. The obstinate, distracted, underachieving boy whose parents are at their wits’ end looks like a protester, a striker – someone who refuses to grow up into the state of alienation we call mankind. He is someone who won’t move. Delinquents can be demonized. In simple terms they refuse to play. Rather than succeed they wonder about connection. By staying connected they avoid loss. Their connection is tied to their self-esteem; their achievement needs to be linked as well. To Preach To Parents In short, be there for him; let him have space; but remind him you will be there when he comes back. [The focus here will be on boys.] To recover from depression it helps to give up feelings of stoicism with emotional reserve. A person who feels alone and unloved convinced that there’s something to dread around the corner wallows in guilt and shame. Success at something doesn’t guarantee victory over depression. The focus of treating depression is relational. Often the relationship with others seems to be the problem but it is the relationship with self that is the primary fault. A cruel relationship with self demonstrates the total absence of feeling for self and is reminiscent of a parental relationship that was abusive. The Advice I. Get a barometric reading of his relational life – _ Who his friends are. _ Who his favorite teachers are. _ How are his relationships with his siblings going. Relationships are the glue that connect the boy to who is significant to him. II. Early intervention is necessary III. Consult with an appropriate therapist IV. Severe depression requires medication V. Review the context: home, school. Being bullied at school; overwhelmed by the subjects; peers who tease, parental conflicts. What does he like? What are his problem areas? VI. Parents and teachers need to teach emotional literacy where a boy can bend under emotional strain without the bough breaking. _ Life is not always fair _ You can’t hurt those you’re angry with _ Actions have consequences; some of these can be foreseen _ Controlling anger is possible VII. Aggression is more defensive or protective and reactive for the vulnerable, and the cornered VIII. Boys often see neutral situations as threatening and respond with aggression IX. What makes someone angry is not always clear. Some people feel emotional pain before others Is a Reconcilation of the Genders Possible? Some women may wonder why a man cannot be more like a woman, is it testosterone or is testosterone over-rated – that is, it’s just learned. It is worse than that if it is learned. Women do the teaching. In grammar schools in the U.S., women are more often the teachers. Girls should benefit by having female role models as a direct example. Boys somehow learn something different. Do they get miseducated? Boys have to infer indirectly what is “good” about being a “good boy”. Big boys don’t cry yet nurturing and gentleness is good as an example. A manly man in touch with his feelings may cry at a movie or at a loss of a football game. Men share and care and are sensitive and nurturing. Men do not sit down and share directly; they remain oblique. A competent man hears oblique references and translates these and infers that another guy likes him and cares about him. This indirectedness exasperates wives; yet, men have often been trained (by women) to make oblique inferences about important interpersonal matters. Certain women who do not understand this consider men emotionally immature. The communication is clear and accurate unless the man is depressed. A depressed man may consistently misinterpret oblique references that he in fact is doing well at his job or position by translating the effort – they are trying to make me feel better. Men are masterful at connecting and are capable of deep friendships and deep abiding love. A man would risk his life for a friend, a squad car partner, a member of the fire brigade, or for a long time boating buddy. It is not as common certainly in legal, but also in other professional circles. Men don’t talk or share the way women do. Some war veterans don’t want to talk about certain experiences. Sharing implies a common experience; it is only partly verbal; it may refer to what is held in two hearts. To propose a feminine model for how boys or men should emote is counter-productive. If men break out of the gender straitjacket, they still may not become female. It’s not that they are or are not biologically wired it’s that they are open to different emotional expressions of masculinity. Some female teachers hope that eventually boys will talk about their feelings and the reinvented male will be less aggressive and development for both genders will be more androgynous. This idealizing view can be developed further. If boys could just be taught to calm down, be less aggressive, be more socially aware, and feel less entitled when in mixed company girls’ self-esteem would not be destroyed. Bravado or posturing may cover male fragility, but at a cost. By appearing more self-confident, weakness isn’t apparent. Attention seeking is often just posturing that can lead to a loss of focus. Boys seem more aggressive. Study habits, grades, participation in activities show girls doing better than boys. Girls talk less often in class and let others talk for them and grow more passive even depressed. Their obsession with body image can become really obsessive. There are some problems with this hope. For one, men and women use language differently to struggle with how they understand their current emotional life and their best guess at what the emotional state of another actually is. This is one of the better arguments for having a therapist of the opposite gender. Men easily express somehow in their own way the very emotions that by some feminine perceptions they are supposed to lack, unless they are depressed. The language used hints at the emotions expressed. Only a man skilled at the art of minimization where his depression has sawed off the peaks and troughs of his emotional life into the appropriate bandwidth could ever say “It was frustrating when my car hit the abutment and it was interesting when my leg got broken.” The tough love we associate with conditional, fatherly love is still love even if it is high drama. In oblique masculine terms, it is like the love Jesus had for Peter (when Peter was drowning, when he was called the Rock, when he was told get behind me Satan, and after Peter’s denial). The emotional expression is not direct. Instead men banter. Banter seems sarcastic; it’s always ironic it’s dry rather than slapstick; sometimes it’s facetious or whimsical; it is always satirical and wry. The noble art of bantering moves fast; builds on previous building blocks and is habit forming. This fun is the dialect of men. Some women see it as regressive, shallow, and ludicrous, and may miss the sharing and bonding which is meaningful. Banter is often the primary mode of exchange in the company of men. It pushes the envelope and the limits and is vibrant. “You got a haircut – what happened did you lose a bet?” Communication pattern is only one example. Men and women differ in many ways including the ways they get depressed. There are too few all-encompassing statements that apply to every member of every gender. The hope to universalize springs eternal particularly to psychologists who believe in stage theories. Citing authorities or findings and proposing principles are the closest we come to settled truths. What is somewhat troubling is that we see through a glass darkly and are only able to universalize one aspect at a time and only for so long. In restoring equality oftentimes the deficit gets exaggerated and the perceived competitor has to be weakened. In the 80’s, the lack of confidence of young girls was pointed out to be the adolescent problem. In the 90’s, the oblique socialization of boys, putting them at risk for a variety of problems, is the problem. Since most educators, pastors and therapists deal only with one adolescent at a time, their approach to every adolescent problem remains unique and atheoretical – this is our greatest hope.