Adolescent Depression: Family-Centered Treatment Approaches

Introduction

The adolescent years are a time of great confusion for many teens. Their bodies are growing and going through many changes, many of them hormonal, which can cause a wide variety of emotional reactions. This all comes at a time when teens are shedding their childhood and trying to define themselves as they move toward adulthood. It is normal for teens to go through periods of doubt, emotional turmoil, and even depression. Often this depression is short-lived and can be considered a normal part of growing up.

Because of these changes, and because teens often go through emotional swings, real teenage depression has frequently been misdiagnosed or simply attributed to a "stage" the teen is going through. Until recently, it was not even considered possible that teens could suffer from true clinical depression. It was thought that depression had a Freudian cause and that teens were incapable of genuine clinical depression. Depression was considered a normal part of adolescence.

Recently, there has been a great deal of media attention focused on teens who commit violent acts against themselves and others. One prominent example is the shootings at Columbine High School. These events caused officials and psychologists to search for answers. Previously, teens who committed such acts were automatically assumed to come from lower socioeconomic backgrounds or certain ethnic groups. However, the perpetrators at Columbine did not fit that stereotypical profile.

These and similar events have focused attention — both in the media and in the academic world — on how children from high-income, highly educated families can become so distraught that they commit horrific acts. According to prevailing social assumptions, these children have everything. How could they have serious problems compared to those less fortunate?

Many studies, most of them recent, have focused on teenage depression to identify contributing factors and propose treatment methods. Much of this research was based on studies of adult depression, making the erroneous assumption that teen depression stems from the same causes and responds to the same therapies. As this research will demonstrate, adolescent depression is very different from adult depression — it is more complex and more difficult to diagnose and treat.

The effects of relationships, especially those within the adolescent's family, play one of the most important roles in diagnosing and treating adolescent depression. In adult depression, the emphasis is on the individual. Until recently, this same approach was applied to depressed teens. This research focuses on demonstrating, through examination of past literature, that a more family-centered and holistic approach will be more successful in diagnosing and treating teen depression.

There has been a wealth of credible information published in academic journals in recent years. A library search at any given point is limited and cannot encompass the majority of information on this subject. University libraries are often limited to a selection of journals in their reference sections — typically the most recent versions of popular academic journals such as the Journal of American Psychology or the Journal of Clinical Psychology. However, many thousands of additional journals are now available online.

Most of these journals can be found via the Internet. Many abstracts are available, but there are also thousands of full-text articles with their journal references included. Many articles are published in hard-copy journals and are available online as facsimiles of the originals. These are the types of articles used in conducting this research. No abstract-only articles were referenced; only articles for which the full text was available were used.

All articles used for this review were published in actual academic journals, or in some cases by government agencies, but were located in their entirety online. In the Works Cited section, both the academic journal in which each article appeared and the online location where it can be viewed are provided.

There are thousands of articles relating to teenage depression and the many factors found to have causal attributions. A comprehensive literature review could contain hundreds of references and run to hundreds of pages. For the sake of keeping this research to a reasonable length, studies were selected that referenced and summarized the results of many other studies. This was the most efficient way to encompass the largest amount of information in the most concise manner. In some cases, references are cited for which the full article was not directly located — particularly older works — but which are summarized within the works examined. These are indicated as being contained within another reference, and the full citation is included in the Works Cited section.

Factors That May Lead to Adolescent Depression

Early studies on adolescent depression were based on work regarding adult depression. Many factors were blamed for teen depression, including divorce, a history of child abuse, and a neglectful mother. In many cases a correlation was found and celebrated in the field of clinical psychology. However, these studies continued to fail to produce real results in actual practice and could not explain instances of depression and maladaptive behavior in which these factors were absent. The idea of finding a single causal link was gradually abandoned, and researchers began to focus on cases that did not fit the stereotypical mold of coming from poor, uneducated, dysfunctional families. Early studies also failed to explain why some children from those backgrounds did not develop depression or maladaptive behaviors at all, leaving too many questions unanswered.

It was this recognition that led to the more widely accepted holistic approach, now considered the current standard of practice for the diagnosis and treatment of teen depression. Depression used to be considered of little consequence, with the assumption that children would eventually outgrow it. We now know that depression can lead to involvement in self-destructive behaviors such as substance abuse, crime, sexual risk-taking, and even suicide or violence. Left untreated, adolescent depression can have devastating consequences for the individual, the family, and the community at large.

Adolescence is a stressful time as youth deal with pressures from family, school, friends, and employers. Some youth navigate this period unscathed, while others experience extreme stress without the coping mechanisms or communication skills to manage it effectively. This stress can lead to depression with serious consequences (Walker, 1986).

A study conducted in Minnesota (Garfinkel et al., 1986, in Walker, 1986) identified several biological, personality, and familial characteristics that may increase a youth's likelihood of developing adolescent depression. Crucially, the study stressed that an individual's ability to deal with stress was more important than any single identified factor, and that one or a combination of factors needed to be present to produce depression in some individuals. Approximately 39% of all students surveyed in the University of Minnesota study were found to be suffering from mild to severe depression (Walker, 1986).

Stress can be accompanied by feelings of tension, frustration, worry, sadness, or withdrawal, lasting from a few hours to a few days. Depression entails these same feelings in more intense form, and may also include feelings of hopelessness or worthlessness. The Minnesota study found a significant connection between suicide attempts, stress, and depression.

The Minnesota study identified several events considered stressful by youth, and found that many depressed youth had experienced two or more of these events in the previous six months. These included: a breakup with a girlfriend or boyfriend, arguments with parents, trouble with a sibling, a change in the parents' financial status, serious illness or injury of a family member, trouble with classmates, and trouble with parents (Walker, 1986). These events all involved conflict or loss — at home or at school.

Many youth have coping mechanisms that help them deal with stress, such as listening to music, daydreaming, problem-solving, talking with friends, or spending time with people they care about (Walker, 1986). Everyone has a stress threshold, and it is impossible to predict exactly where each individual's threshold lies. The more coping mechanisms a person has, the greater the amount of stress they can withstand. However, some teens lack effective coping mechanisms, and stress tends to accumulate. In the Minnesota study, many youth who had attempted suicide had more than five significant stressors in their lives (Walker, 1986).

Some families have a biological predisposition toward poor stress management, and youth from these families must be closely monitored for signs of maladaptation (Walker, 1986). Warning signs may include a sudden change in behavior — such as a previously high-achieving student beginning to fail — or manifestations such as impulsive behaviors, obsessions, unrealistic fears, aggressive behavior, antisocial behavior, withdrawal, isolation from family or friends, expressions of negative self-image, extreme pressure to achieve, and eating or sleeping disorders.

Often stressors accumulate and create a vicious cycle. A youth who feels they do not meet their parents' expectations may stop doing homework, begin to fail, and come to see themselves as a failure. These feelings can cause teens to turn to substance abuse, running away from home, self-destructive behavior, or even a suicide attempt. It is unlikely that a single stressor will cause a teen to become depressed; it is the accumulation of stress factors that spells serious trouble.

Windle and Windle (2001) found a bidirectional relationship between adolescent depression and cigarette smoking. They found that smoking increased the likelihood that a teen would develop depressive symptoms, and that depressed teens were likely to take up smoking. Their study summarized and supported the findings of many earlier researchers who obtained similar results. The study was statistically conclusive but may be criticized for its biased sample — all subjects were from white, middle-class families — making it unclear whether the findings are applicable to a wider population.

Hammen and Brennan (2001) studied the relationship between youth depression and the occurrence of depression in their mothers. They found a significant likelihood that a child would display depressive behaviors if the mother had at any time shown depressive tendencies. This raises a compelling question: is the child's behavior learned by observing the mother as a role model, or do these children carry biological differences that make them more susceptible to depression?

Depressed persons often display maladaptive behaviors and struggle in interpersonal relationships. Many studies have focused on depressed mothers and their interpersonal relationships (Cummings & Davies, 1994; Downey & Coyne, 1990; Kaslow, Deering, & Racusin, 1994, as reviewed in Hammen and Brennan, 2001). These studies suggest that many factors contribute to maladaptive behaviors in children, including genetic influences and the family relationships modeled within the home.

Marcotte (1999) found that not only are there differences in the prevalence of depression between males and females, but that there are also differences in the ways each gender expresses depression. The Marcotte study, however, contained many confounding variables that were not identified or controlled for. The subjects were not matched demographically, and important factors such as family history were not considered. For these reasons, Marcotte's conclusion that females have a significantly higher chance of being depressed than males cannot be accepted as definitive.

Students with higher levels of problem-solving skills exhibit lower levels of depression than those with weaker problem-solving abilities (Nezu & Ronan, 1988, in Marcotte, 1999). There is also a connection between a person's sense of self-efficacy and their problem-solving abilities, which in turn may affect both self-image and depression. As Marcotte (1999) notes, many of these studies involved adults, and it is not certain whether the findings apply equally to adolescents. However, Marcotte does review several studies showing that this concept holds true in adolescents, and connects stronger problem-solving abilities with higher self-esteem and confidence — characteristics that tend to produce individuals who are better able to cope with stress and therefore less susceptible to depression.

The Marcotte study was conducted on French-speaking adolescents, and the results may carry a cultural bias that was never discussed or accounted for. Socioeconomic status of the subjects was not reported, and factors such as divorce or other familial circumstances were not considered.

Reinherz (2000) identified several factors that place individuals at risk for depression or substance abuse by early adulthood. She found that when a sibling engages in substance abuse, the individual is likely to do so as well. Female participants who experienced anxiety, depression, or feelings of peer rejection were at greater risk. If one or both parents were depressed, risk increased for both genders. The study also identified socioeconomic factors, including larger family size, lower socioeconomic status, and parental drug abuse, as contributors to increased risk of substance use.

The Reinherz study drew its sample primarily from low-income, low-education, and largely ethnic populations. This limits its generalizability and risks reinforcing stereotypes that associate teen depression only with certain demographic groups. Making assumptions based on studies like these could cause severe cases of teen depression to be missed in youth who do not fit the expected profile, or could lead to erroneous conclusions about children who do. Studies such as these must be applied with great caution in clinical practice.

Nunley (1997) discusses the history and characteristics of adolescent depression, drawing on clinical studies by many researchers. She found that adolescent depression is most prevalent during mid-adolescence, between the ages of 13 and 17. A major concern is that many serious cases are dismissed as the result of normal hormonal changes. Left untreated, this results in a significant number of suicide attempts and acts of violence.

Taken together, the relationships between depression and factors such as smoking, low self-esteem, and poor problem-solving skills cannot be ignored. However, diagnosing depression and predicting who is at risk is as complex as the lives of teenagers themselves. Individual differences in the ability to cope with stress appear to be one of the most important variables in determining a teen's risk. Stereotypes are of no use in this process, and a multi-factored approach to assessing risk is essential.

The Family and Teen Depression

During the teen years, relationships are among the most important factors in a young person's life. Teens seek to define themselves through how they relate to others — to adults and peers alike. The quality of these relationships helps determine their level of self-esteem and shapes their sense of identity. Research on these relationships reveals how profoundly they influence the incidence of teen depression.

Brown (1999) investigated the effects of childhood neglect, physical abuse, and sexual abuse on adolescent and adult depression and the tendency toward suicidal behavior. The study found that children who had been victims of these occurrences were three times more likely to become depressed and suicidal in their teen and adult years. This suggests that measures to reduce child abuse and neglect would also have a positive effect on rates of teen depression and suicide. This study is more reliable than many earlier studies that made similar claims, as it used a diverse sample and controlled for factors such as socioeconomic status and parental education level.

The U.S. Department of Health and Human Services commissioned a report to assess the long-term effects of adolescent risky behavior on families (Pergamit et al., 2001). The report examined three family variables — family structure, socioeconomic status, and parental alcoholism — and used criminal activity and marijuana use as measures of risky behavior. It found that sibling or parental engagement in these activities were primary predictors of individual engagement, and that a feeling of connectedness with family and school tended to reduce the likelihood of a child engaging in such activities.

The study also found that engaging in one risky behavior made it more likely that a teen would engage in others. Consequences of destructive adolescent behavior can include a criminal record, risk of pregnancy, and exposure to HIV or other sexually transmitted diseases. Boys were found more likely to resort to alcohol abuse and criminal activity than girls. The earlier the onset of risky behavior, the more likely it was to continue into adulthood.

Parental models and family relationships serve as reliable predictors of antisocial and criminal behavior. There is some debate over the effects of divorce on these tendencies. Children from divorced families showed a greater chance of developing maladaptive behavior than those from intact families, though it remains unclear whether this stems from the divorce itself or from dysfunctional family dynamics that preceded the separation. Reduced family resources and decreased parental time with children in single-parent households may also be contributing factors.

Although this report did not specifically address teen depression, it is highly relevant to its study: depression has been found in other research to correlate directly with the activities examined in the report — substance abuse, criminal behavior, and sexual risk-taking. These maladaptive behaviors are key indicators of depressed teens, and the family circumstances documented in the report serve as important context for understanding adolescent depression risk.

McFarland and Marsh (2002) studied relationships between three maternal factors and teen depression: maternal attachment, maternal autonomy, and maternal relatedness. They found that teens who showed greater emotional dependence and insecure attachment to their mothers also showed greater signs of depression. Maternal relatedness — the mother's perceived interest in and positive responses to the adolescent's thoughts and feelings — emerged as a significant protective factor.

The relationship between a teen and their family is central to understanding teen depression. This relationship shapes how the teen defines all other relationships. For this reason, family dynamics must be examined in any comprehensive assessment of teen depression. Unlike adult depression, teen depression cannot be effectively addressed without involving the entire family in the diagnosis and treatment process.

The effects of teen depression extend beyond the individual. Consequences such as substance abuse, suicide attempts, criminal behavior, or academic failure affect the cohesion of the entire family. Family members may experience guilt, blame, or shame. There may also be significant financial impact, as families bear medical or legal costs associated with their teen's behavior. Teen depression is not a single-person event — it can be contagious within a family system. As one family member struggles, others may feel helpless or inadequate, potentially developing their own depressive symptoms. This can affect parents, siblings, and even close friends.

Conclusion

The goal of this research was to support through a literature review the hypothesis that adolescent depression should be diagnosed and treated using a more holistic approach than has been used previously. The evidence presented suggests that past studies made an erroneous assumption that the diagnosis and treatment of adolescent depression would mirror that of adult depression. As the literature demonstrates, teenagers are very unlike adults. The focus of adolescence is on developing relationships with others, whereas the focus of adult life tends to be on the development of the individual self.

Teen depression often involves a breakdown in the relationships surrounding the teen, and until those relationships can be addressed, depression cannot be properly treated. A direct causal relationship between any one factor and teen depression is nearly impossible to ascertain. Many early researchers attempted to identify such a relationship, but as demonstrated, many of their conclusions were flawed. There are many circumstances that may contribute to teen depression, and an individual's ability to cope is the single most important factor in determining who is at risk.

Regardless of risk factors, depressed teens give signs that something is wrong. These signs are as varied as the individuals themselves. Some will present blaring signals resembling overt calls for help, such as running away or attempting suicide. Others will give subtler signals that are often dismissed, but could eventually lead to more serious behaviors if left unaddressed. The only truly common factor among teens suffering from depression is some change in behavior or mood. If a teen exhibits a change from their norm, those symptoms cannot be ignored and professional examination should be sought.

Many treatments currently used for adult depression can be effective with teens as well; however, none are seldom effective when used in isolation. In order to treat teen depression effectively, the root cause must be identified. If the problems are relationship-oriented, then relationships must be the focus of therapy. If the problem centers on family dynamics, family and individual therapy techniques must be employed together. If the source of distress is not resolvable through therapy alone — for instance, dealing with a school bully — then the teen must be equipped with coping strategies for managing the situation.

Instilling a sense of self-confidence and providing a solid support system are the most important elements in treating and preventing teen depression. Teens must feel that they have somewhere to turn when things become difficult. This support can come from parents, schools, other adults, or friends. In any case, relationships must be positive and affirming — they must help the teen build trust in themselves and in those around them.

The research clearly shows that the current shift toward treating the depressed teen within a holistic environment is the best approach for combating this illness and its many negative effects on the individual, family, and community. A single-cause explanation and single-modality treatment are of no use in either diagnosing or treating teen depression. All of the relationships in a teen's life must be considered and healed. The healing of a depressed teen encompasses the healing of the entire family.

As the holistic approach is a relatively new development in the field of adolescent psychology, there is still much to be learned. Many individual therapies have proven effective on a limited basis. More research is needed on the use of combinations of therapies and techniques. Greater academic emphasis should be placed on categorizing teen depression and identifying the most effective treatments for each type. For instance, depressed teens may share characteristics based on the initial cause of their depression, or they may benefit from culturally informed treatment strategies. These possibilities need further examination in order to develop more effective approaches for teens and their families. There is still much work to be done.

Teen depression is a serious condition that not only affects the individual, but also has lasting and sometimes devastating effects on the teen's family and community. The diagnosis and treatment of teen depression requires cooperation and communication among many individuals. Even minor depression, if left untreated, can escalate into serious consequences. Cooperation and communication are the two most important principles in addressing adolescent depression, and they must be sustained at all times. When the problems associated with teen depression are effectively addressed, the entire community benefits — through reduced youth crime, more productive learning environments, lower health costs, and stronger families. Combating teen depression is everyone's responsibility.