role of family interactions in adolescent depression: A review of research findings, The
Katz, Steven H
It may seem obvious that parents are a very important influence in an adolescent’s life and that adolescents are sensitive to and affected by their parents’ behaviors. However, research that tests these beliefs in cases of adolescent depression has only recently blossomed. This relative neglect by researchers is understandable. Until the early 1980s, most theorists believed that young people are not capable of being clinically depressed (Rie, 1966; Cantwell and Carlson, 1983). There has also been considerable difficulty in measuring something as fluid as family interactions (Jacobs, 1975). Luckily, there have recently been important theoretical advances. These include the understanding that young people do have depressive episodes and that parental depression is a risk factor for adolescent depression because parenting skills get eroded. There have been diagnostic advances as well. These include clear diagnostic criteria similar to those for adults. Finally, there have been methodological advances. These include the development of reliable observational coding systems, the use of videotaped interactions, and better research on self-report measures. All of these advances have improved our ability to make more definite statements about common interaction patterns in families with a depressed adolescent.
Researchers have found that there are many factors that contribute to adolescent depression. These factors include the child’s temperament, the parents’ child-rearing practices, the parents’ marital distress, family economic status, stressful life events, biochemical and genetic factors, depressive cognitions, and peer and school factors. But, most of these factors exert their influence through family interactions. Although peers may become an equally or more important socializing agent when a child reaches adolescence, family interaction still has an impact and remains an important place to intervene when an adolescent becomes depressed.
Depression in adolescence represents a persistent disruption of normal development and of self-esteem functioning. Although only 5% or fewer of adolescents are clinically depressed, about 20% report significant depressive symptoms (Kashani, Carlson, and Beck, 1987). Adolescent depression can be lengthy and recurrent. It represents a risk factor for continued psychopathology and poorer psychosocial adjustment as an adult. It is often accompanied by other disorders, most notably conduct disorders, anxiety, and substance abuse (Kovacs et al., 1984a, b; Marriage et al., 1986).
This chapter reviews studies that have asked, “Are there family interaction patterns, behaviors, or characteristics that are regularly found in families with a depressed adolescent?” Researchers have gone about answering this question in three ways. First, they have had adolescents complete self-report measures about their family environments or have had depressed adults report about their youth. Second, they have examined families with a depressed mother. Third, they have measured family interactions in depressed youth directly through observations.
The research presented in this review generally uses samples of subjects who self-reported symptoms of depression or met diagnostic criteria for major depression or dysthymia as described in the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition-Revised (American Psychiatric Association, 1987). Although this chapter focuses on depressed adolescents, results from studies with younger children and with depressed adults and from studies that used less stringent diagnostic criteria are included when they add insight into family patterns.
Self-Report Studies of Family Environments
Self-report studies have tested the hypotheses that, compared with families of nondepressed people, families of depressed people are more rejecting, less cohesive, or more overprotecting. Also, the hypothesis has been tested that the depressed person’s view of the family’s functioning is divergent from the view of the rest of his family. Third, selfreport studies have examined a variety of structural variables such as family intactness and marital conflict. Each of these dimensions is examined in turn.
Research findings have consistently found that depressed children, adolescents, and adults, as well as parents of depressed youth, report or recall greater parental rejection and hostility than nondepressed subjects (Puig-Antich et al., 1985a, b; Koestner, Zuroff, and Powers, 1991). A good example of this research is the Koestner, Zuroff, and Powers (1991) study of 12-year-olds whose mothers had earlier completed a research protocol when their children were 5. They found that mother-reported parenting behaviors of restrictiveness and rejection when her child was 5 years old were correlated with the child’s being self-critical at age 12. This relation held while controlling for mother’s report of the child’s temperament before age 5. This finding suggests that rejection of the child may lead to the children’s reinforcing themselves in the same strict and nonaccepting manner that their parents demanded of them. A critique of the studies focused on rejection, however, is that most of them used currently depressed subjects. This design feature is significant, as some researchers find that the perception of parents as rejecting is a function of the subject being currently depressed (Lewinsohn and Rosenbaum, 1987), although other studies found that perceptions of negative parenting were stable at least 3 years beyond the depressive episode (Gotlib et al., 1988).
COHESION, ADAPTABILITY, AND OVERPROTECTION
Several self-report studies have used measures of family cohesion and adaptability. Cohesion is the emotional bonding that family members have toward one another. This variable ranges from enmeshment (an overidentification with the family) to disengagement (characterized by low bonding and high autonomy). Adaptability is the flexibility (from rigidity to chaos) of the family in response to stress (Olson, Bell, and Portner, 1982).
Most studies found that low cohesion was significantly correlated with depression scores. For example, Fendrich, Warner, and Weissman (1990) found that children and adolescents who reported low cohesion in their family had a four-fold increased risk for depression than subjects who did not report it. Research has also suggested that depressed adolescents and adults report their parents to be “guilt inducing” rather than punishing and to be overprotective, emotionally distant, and rigid in their child-rearing attitudes and practices (Brook et al.,1983; Susman et al., 1985; Hetherington and Martin, 1986; Gotlib et al., 1988). Thus, the perception that one’s parents are unavailable, inflexible, or overprotective appears to be correlated with, and possibly results in, the experience of depression.
CONGRUENCE BETWEEN FAMILY MEMBERS’ PERCEPTIONS
Another risk factor that emerges from the literature is that depressed (especially suicidal depressed) individuals hold a view of themselves or some major aspect of their family’s functioning that is markedly at odds with the views of other family members. This pattern has been found in comparing depressed inpatients with other family members (Keitner et al., 1987; Miller et al., 1986), adolescents with low selfesteem with their parents (Offer, Ostrov, and Howard, 1982), depressed college students with their siblings (Oliver et al., 1987; Lopez, Campbell, and Watkins, 1989), and depressed children with their parents (Stark et al., 1990).
These family studies suggest that depressed adolescents, more so than nondepressed individuals, may hold perceptions of their family environments that are not shared by other family members. This discrepancy may be a consequence of, or a contributing factor to, the depression. Either way, if the family’s perceptions are sufficiently different from the adolescent’s, it becomes less likely that the adolescent will be able to make use of the family as a helping resource. For example, when an adolescent, relative to other family members, perceives the family to be less affectively expressive, to observe poorer role boundaries, or to have poorer control over behavior, then negative consequences may ensue for this adolescent. The adolescent may then not find the family to be much of a resource in helping him or her cope with stress, feelings of isolation may increase, and it may feel impossible to communicate in the “family’s language” about troubling problems and feelings.
FAMILY INTACTNESS AND MARITAL CONFLICT
Several studies suggest that parental loss, divorce or single-parenting, and high marital conflict can all result in child depression. Early studies of depression in youth focused on the trauma resulting from losing or being separated from a parent. The results indicated that parental loss during childhood or adolescence increases the risk of depression in adulthood by a factor of two to three times. Losing either parent during the period of birth to 5 years and father loss from 10 to 14 years were especially traumatic (Birtchnell, 1970; Barnes and Prosen, 1985). But, given that only a small portion of depressed youth experienced loss of a parent, other factors must be operative. More recent studies have found that such factors as the quality of pre-loss marriage (Harris and Howard, 1987), high maternal indifference before the loss (Bifulco, Brown, and Harris, 1987), and parental care after the loss (Klerman et al., 1984; Breier et al., 1988) mediate the relationship between parent loss and child depression.
Some studies have found more self-reported depression in the children of divorced or single parents. Only Asarnow, Carlson, and Perdue (1988), however, utilized clinician-diagnosed depressed children and adolescents. They found, interestingly, that more children in their sample with major depression came from two-parent families than children with dysthymic disorder (73% vs. 56%). However, as was true for the parent-loss studies, more recent studies have gone further to show that other variables mediate this relationship. These studies indicate that family process variables account for the association between family intactness and depression rather than divorce or single-parenting per se. These variables include degree of parent involvement, parentadolescent conflict, marital conflict, and communication problems (Emery, 1982; Shaw and Emery, 1987; Feldman, Rubenstein, and Rubin, 1988; Tesser et al., 1989).
With regard to marital conflict, studies have been mixed as to whether there is more marital conflict in families with a depressed adolescent (Emery,1982; Puig-Antich et al.,1985b). As might be expected, studies that measured both marital conflict and parent-adolescent conflict found the latter to be more predictive of child internalizing problems (Forehand et al., 1988).
Studies of depressed mothers and their children are important because as many as 40% to 50% of the children of a depressed parent have a diagnosable psychiatric disturbance. These children have approximately three times the rate of affective disorder and six times the rate of major depressive disorder (Cytryn et al., 1982; Orvashel, Welsh-Allis, and Weijai, 1988; Downey and Coyne, 1990). Although some researchers have not found that normal parents demonstrate better parenting than depressed parents (Goodman and Brumley, 1990), most studies do find group differences.
Although genetic factors are often cited as causes here, psychosocial factors are also clearly implicated. Studies have found that the older the children, the less likely they are to be adversely affected by maternal depression (Burbach and Borduin, 1986; Weissman et al., 1987). For example, Weissman et al. (1987) found that, in a group of depressed children and teens, those that had one or both depressed parents became depressed at a younger age than if neither parent was depressed (12.7 vs. 16.8 years). One way to understand these findings is that a depressed parent’s disturbed psychosocial processes are in part responsible for the transmission of depression. Adolescents with their stronger sense of self would presumably be less vulnerable to these disturbing interactions than young children. Also, Hammen, Burge, and Adrian (1991) demonstrated that, in a sample of depressed children and adolescents, the onset of their symptoms was temporally associated with the occurrence of symptoms in their mothers. In other words, the children’s depressive episodes predictably followed their mothers’ episodes. Hammen et al. conceptualized the mechanism at work as an absence of supportive parenting by the depressed mother-parenting that might buffer stress in the children’s lives. These parenting deficits eventually translate into poorer child functioning.
DEPRESSED MOTHERS AND THEIR INFANTS
To understand more specifically how depression in a parent affects the child, it is useful to look at the field of infant research. The field of infant research is notable for developing reliable coding systems used to rate observed mother-child interactions. Studies of infants in interaction have found that depressed mothers typically exhibit flat affect and provide less stimulation and less responsiveness toward their infants or young children. Their infants then show fewer contented expressions, more fussiness, lower activity levels, and poorer attentiveness toward their mothers than do infants of nondepressed mothers (Field, 1984; Field et al., 1985; Cohn et al., 1986). The infants then exhibit these behaviors in their interactions with nondepressed adults (Field et al., 1988).
Studies with children and adolescents have found that depressed parents display less affection and happy affect, have more problems in communicating, show more dysphoric affect, and demonstrate greater ambivalence toward the family than do nondepressed parents (Weissman et al.,1984; Hops et al., 1987). Depressed parents are more critical, power-assertive, and hostile toward their children than nondepressed parents. Dysphoric mothers also suppressed their children’s aggressive and command-giving behavior (Friedman, 1984; Biglan et al., 1985; Biglan, Hops, and Sherman, 1988; Hops et al., 1987), and depressed fathers interacting with their sons showed less smiling, laughing, and humor than alcoholic or normal fathers interacting with their sons (Jacobs, Krahn, and Leonard, 1991). Families with a depressed parent are also characterized by less cohesion and expressiveness, more conflict, less emphasis on the development of independence, and fewer shared fun activities (Billings and Moos, 1983). It is notable that the impact of disturbed parenting is reduced when one of the parents does not exhibit these behaviors (Hops et al., 1987; Jacobs et al., 1991).
DEPRESSION AFFECTS PERCEPTION
Depression also appears to affect mothers’ perceptions of their children, so that mothers who are depressed see even the normal behavior of their children as depressed (Griest, Wells, and Forehand, 1979; Rogers and Forehand, 1983; Breslau, Davis, and Prabucki, 1988; Dumas, Gibson, and Albin, 1989). However, findings in this area are mixed, as other studies report both that these parents often do not recognize their own children’s depression (Cytryn and McKnew, 1980; Kashani et al., 1985) or that they are more accurate observers of their children’s problems than even normal mothers (Conrad and Hammen, 1989). In fact, there is a growing literature supporting the hypothesis that depressed subjects are more “realistic” and have less “optimistic illusions” than nondepressed subjects (see Alloy et al., 1990, for a review).
Direct-observation studies represent a more valid sampling of actual parental practices than retrospective or self-report accounts. Studies of interaction sequences can provide us clues as to behaviors and sequences of behaviors that lead to or maintain the affective disorder (Hass, Clarkin, and Glick, 1985). Observational studies of interactions in families with a clinically depressed adolescent-which include DSMIll-type diagnoses, psychiatric control groups, and reliable coding schemes-are both few and recent (Cole and Rehm, 1986; Asarnow, Goldstein, and Ben-Meir, 1988; Forehand et al., 1988; Cook et al., 1990; Tompson et al., 1990; Dadds et al., 1992; Sanders et al., 1992; Donenberg, Nelson, and Weisz, 1993).
The observational studies published so far have measured rates of positive reinforcement, levels of expressed hostility, and communication problems in families with a depressed child or adolescent. In an exemplary study, Cole and Rehm (1986) compared normal control families with either a depressed or nondepressed child seeking treatment in an outpatient clinic. The families were observed interacting as the child played a game that involved rolling a ball through a maze. Mothers of depressed children rewarded their depressed children at much lower rates than either of the other groups, and, when these mothers did congratulate or support their children’s performance, it was only after very high levels of achievement. Their children mirrored this in setting higher standards for themselves before stating they had done well.
Three observational studies included a psychiatric control group (Dadds et al., 1992; Sanders et al., 1992; Donenberg et al., 1993). These researchers found that depressed and mixed depressed/conductdisordered children and adolescents showed depressed affect or submissiveness toward their parents and low levels of conflict and anger. The mixed group looked much like the depressed group of children but was not as deferential. Conduct-disordered-only adolescents showed both depressed and angry affect toward their parents. Parents of mixed depressed/conduct-disordered adolescents were less critical and more positive toward their children than parents of conduct-disordered-only adolescents. These results suggest observable interaction patterns specific to families with a depressed adolescent.
In the studies of hostility, researchers sequentially coded interactions in the families of disturbed adolescents who have parents with high or low expressed emotion (EE). As Hooley ( 1990) defines it, “EE reflects the extent to which a patient’s closest relative(s) talks about him or her in a critical or hostile way (in talking with an interviewer)” (p. 58). Thus, EE is a negative attitude toward the patient and is not typically used in observational measures of actual communication within families. Researchers who used this construct found it can predict relapse in depressed patients (Hooley, 1990).
For example, Vaughn and Leff (1976) and Hooley, Orley, and Teasdale (1986) correlated relatives’ levels of expressed emotion toward schizophrenic and depressed adolescent and adult inpatients with relapse over the next nine months. When the researchers interviewed the patients’ relatives, the relatives of schizophrenics and depressives made equal numbers of critical comments. But, for schizophrenics, if a relative made seven or more critical comments to the interviewer, this predicted that the patient would relapse within nine months; for depressed subjects, only two or more critical (or high-EE) comments were predictive of relapse. In fact, the family member’s EE, even more than the severity of depression, was the best predictor of depressed patients’ relapses.
However, when you divide these relatives into high and low EE based on interviews with a researcher, and then observe them interacting with their disturbed adolescent, the findings are not clear. Results have been mixed as to whether high-EE parents are actually more expressive of hostility in interactions. Thus, relatives who express hostility toward the disturbed adolescent do not appear to do so consistently in interactions (Valone et al., 1984; Cook et al., 1989). Unfortunately, no study has coded interactions between depressed-only adolescents and their high- or low-EE parents.
A final focus of observational studies with depressed adolescents has been communication problems. Asarnow, Goldstein, and Ben-Meir (1988) studied depressed and schizophrenic-spectrum disordered (SSD) children and adolescents interacting with their parents. They found that more than half of the depressed youths had at least one parent who demonstrated communication deviance. Communication deviance measures vague, unfocused, and distorted verbal communication patterns. These parent groups differed, however, in that mothers of SSD children were more likely than mothers of depressed children to reciprocate child negativity, whereas mothers of depressed children were more likely than mothers of SSD children to reciprocate child positiveness. In other studies that used self-report measures of family communication, families with a depressed member reported poorer communication than families with an alcoholic, schizophrenic, adjustment-disordered, or bipolar member (Miller et al., 1986).
Another type of communication problem occurs when parents send conflicting messages to their children. These mixed messages include, for example, a positive verbal content but a negative facial expression or tone of voice. Bugental, Kaswan, and Love (1970, 1971, 1972) found that a significantly higher proportion of mothers of disturbed children produced conflicting messages than did the mothers of normal controls (59% vs. 10%). The researchers found that conflicting affective messages predicted aggressiveness but not withdrawal in the children and that children resolve all conflicting messages by accepting the negative component and discounting any positive component.
This review has highlighted and critiqued important ways in which families may contribute to or maintain depression in adolescents. These trends in the research findings give us suggestions for future studies, but, more important, they point out which aspects of the parent-adolescent relationship should be a focus for treatment. Although not all families with a depressed adolescent meet this profile, the following characteristics have found research support. Research suggests that families with a depressed child or adolescent (compared to normal families) tend to show more rejection, more dysphoria, and possibly more overprotectiveness. They are less involved, display less happy affect, are poorer problem-solvers, give less positive-reinforcement, and have poorer rolefunctioning. Also, the depressed adolescent may have a perception of how the family is functioning that is at odds with those of the rest of the family. Family patterns that received less research support but that deserve further study include the family’s use of unfocused or complex communications and being very expressive of hostility.
In addition to identifying these specific family interaction patterns as risk factors for adolescent depression, this review of research on the role of family relations in child and adolescent depression suggests six important conclusions:
1. Chronic or entrenched family interaction patterns, more so than any individual pathogenic events or traumas, are most likely responsible for depression in children and adolescents.
2. Research has not conclusively demonstrated that these patterns predict depression specifically and not psychopathology in general.
3. Research converges in suggesting that it is not depression per se in a parent that is correlated with depression in a child. Rather, it is the impact that parental depression has on other, mediating variables. These include problem solving, affective involvement, and rates of criticism expressed that negatively affect an adolescent’s well-being. These mediating variables are not specific to parental depression.
4. An underemphasized but notable finding is that depressed children or adults have an experience of their families that is at odds with that of other family members (Offer et al., 1982; Keitner et al., 1987). Although this may be a consequence of depressive thinking, the possibility exists that this dynamic contributes to depressive symptomatology.
5. The negative impact of disturbed family processes is reduced in the presence of a nonpathological parent (Valone et al., 1984; Hops et al., 1987; Jacobs et al., 1991). Having a supportive, attentive, low-EE, or nonrejecting parent represents a protective influence in the face of a chronically negative, unsupportive, or rejecting parent.
6. Causality cannot be easily determined. The most elaborate research designs suggest that interpersonal influence is bidirectional (Brunk and Henggeler, 1984; Tompson et al., 1990).
Most treatment models do include a role for the adolescent’s other family members. Many clinicians see the family as crucial in helping adolescents recognize and alter their depressive cognitions, increase their pleasant activities, improve social skills, and increase self-control. Problematic interaction patters are also a focus for intervention. Clinicians and researchers have developed intervention programs that have been shown to be effective both alone and in conjunction with pharmacotherapy (Stark, 1990; Mufson et al., 1993). Future research on the families of depressed adolescents promises to better inform both intervention programs as well as therapy with these families.
An earlier version of this chapter was presented at the meeting of the International Society for Adolescent Psychiatry, Chicago, June 13, 1992.
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