Gender Differences in Adolescent Symptomatology: A Normative Study

Gender Differences in Adolescent Symptomatology: A Normative Study ERIC OSTROV, J.D., PH.D., DANIEL OFFER , M.D.,

AND

KENNETH I. HOWARD, PH.D.

Abstract. A widespread belief that adolescence is marked by disturbance may have contributed to a lack of interest in psychiatri c symptomatology in adolescents . There are few studies of adolescent gender differences. Adolescents ( N = 497) from three Chicago area high schools, represent ing a broad socioeconomic spectrum, were administered the Offer Self-Image Questionnaire. the Delinquency Checklist. and the Symptom Checklist in which they self-report on self-image. experience of symptoms, and delinquent behavior, respectively. Results show that adolescent girls are more prone to report inwardly directed psychiatric symptomatology, such as depression and anxiety. than are adolescent boys; adolescent boys are more prone to report acting out behaviorally. Gender is an important aspect of treating adolescent patients. J. Am. Acad. Child Adolesc. Psychiatry, 1989, 28, 3:394-398. Key Words: adolescent self-image. psychiatric symptomatology, acting-out behavior. epidem iology. Research that includes the study of normal (i.e., non patient) teenagers indicates that , on the whole, most teenagers enjoy life and are happy with themselves. Pride in their physical development, endorsement of parents ' values, comfort with sexuality, and confidence about the future prevail among most teenagers. The data indicate that the vast majority of teenagers have positive feelings toward their parents and are not continually rebelling or in a state of antagonism toward them (Dovran and Adelson, 1966; Offer, 1969; Offer and Offer, 1975; Mitchell, 1980; Offer et al., 1981b, 1984). These empirical studies have been converging toward the conclusion that about 80% of teenagers function normall y; that is, they do not present significant psychiatric symptomatology or experience marked or persistent stress and turmoil. One implication of an 80% prevalence rate of normality among teenagers is that about 20% of teenagers present notable psychiatric symptomatology. Despite the widespread belief that adolescence is marked by disturbance, there have been surprisingly few epidemiological studies of adolescent symptomatology (Offer et al., 1987). Ironically, the view that disturbance among adolescents is to be expected may have contributed to a lack of interest in psychiatric symptomatology in this group . Professionals interested in adolescence may have felt that disturbance in this group was so expectable that studying it was not worth the effort. It may have been believed that epidemiological studies of teenagers would simply discover the wide prevalence of what was believed to be trans ient psychiatric symptomatology. Moreover, the belief in normal adolescent turmoil and psychopathology may have led professionals working with teenagers to minimize the importance

of psychiatric symptomotology. Offer et al. (1981a) found that mental health professionals were particularly prone to regard normal adolescents as typically experiencing marked psychiatric symptomatology. These professionals, confronting a disturbed adolescent , would be likely to assimilate the symptoms they observe to their expectation of normalcy rather than realizing how atypical, and therefore psychopathological, the symptoms are. Many of the existing epidemiological studies of adolescents were conducted in countries other than the United States. A seminal series of studies was conducted by Rutter and colleagues (Graham and Rutter, 1973; Rutter et aI., 1976). These authors found that about 21% of adolescents had psychiatric disorders. Langner et al. (1974) and Kandel and Davies (1982) came to a similar conclusion studying children in the United States. More recent studies presenting comparable results include those by Boyle et al. (1987), and Offord et al. (1987). There are even fewer studies of adolescent gender differences than there are of the epidemiology of adolescent psychiatric symptomatology. Most studies of gender differences among adolescents concern differences between male and female adolescent self-image. These studies suggest that teenage boys and girls do not differ with respect to global selfesteem (Rosenberg , 1965; Wylie, 1979) but do differ with respect to specific dimensions of self-esteem. In several studies girls reported feeling more positive interpersonal relationships than did boys (Wiggins, 1973; Monge, 1973), while boys viewed themselves more positively with respect to achievement (Monge, 1973), academic aspirations (Wiggins, 1973), self-assertion (Gregory, 1977), and body image (Clifford, 1971; Musa and Roach, 1973; Healey and Deblassie, 1974). With regard to psychiatric symptomatology, Locksley and Douvan (1979) found that males reported a significantly higher frequency of aggression and feelings of resentment than did females. In contrast, females reported significantly more tension and psychosomatic symptoms. Kandel and Davies (1982) found that girls were more depressed than boys. Offer et al. (1981b) reported that adolescent boys attested to less depression and neurotic adjustment and better body image than did adolescent girls. Adolescent girls attested to greater adherence to moral standards than did boys. Offord et al. (1987) found a much higher prevalence of emotional disorder for adolescent girls than for adolescent boys. These

Accepted September 21. 1988. From the Department II{ Psychiatry. Michael Reese Hospital and Medical Center (E.O .. D.O.). Department of Psychiatry; University of Chicago (D.O.); and Department I!( Psychology. Northwestern University (K.I.H.). This work I\'as supported in part by a research grant awarded to Dr. Offer from the Chicago Com m unity Trust. 1985-/988. and in part h.1' research grant no. ROI M1I42 90/ awarded to Dr. Howard f rom the National Institute ofMental Health, Rockville, Md. Reprint requests to Daniel Offer, M ,D.. Director. Center for the Study I!{ Adolescence. Michael Reese Hospital and Medical Center. 2959 South Cottage Grove Avenue, Chicago. IL 60616. 0890-8567/89/2803-0394$02.00/0© 1989 by the American Academy of Child and Adolescent Psychiatry. 394

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findings represent only a beginning in research directed toward understanding gender differences in adolescent functioning. The present study was designed to further our knowledge in this area. Method Subjects

This study is part of a large, ongoing research project concerning both the epidemiology of psychiatric illness among adolescents and adolescents' mental health help-seeking behavior. As part of this research, three Chicago-area high schools were studied. The high schools were chosen to reflect contrasting demographic statuses. One high school was located in an affiuent, nearly all-white suburb; another was located in a middle-class, mixed-race suburb; a third was located in a largely lower- and working-class, almost entirely black, inner-city area of Chicago. A list was obtained of all the students in each high school. Students in the samples were contacted first by mail and later by telephone in an attempt to encourage participation. Before the adolescents could participate, they and their parents had to sign a consent form that described the research, and, when they signed it, gave permission for their participation. Students were paid $20 each to complete the various research instruments. Altogether 497 adolescents between 16 and 18 years of age were tested;

249 boys and 248 girls (see Table I). The students tested represent 83% of the students initially contacted for this study. Instruments Used

Research instruments administered to the adolescents included the OtTer Self-Image Questionnaire (OSIQ), the Delinquency Checklist (DeL), and the Symptom Checklist (SCL). The OSIQ is a self-report questionnaire that measures adjustment in 10 areas relevant to an adolescent's life. It inquires about areas of functioning such as relationships with parents, the adolescent's body, and how he or she copes with the internal and external world. The OSIQ's reliability and validT ABLE I. Demographic Characteristics ofthe Research Sample

Studied in Three Midwestern High Schools Suburban Teenagers"

White Black Other Total

Urban Teenagers"

Male

Female

Male

Female

Total

126 6 13 145

135 7 7 149

0 101 3 104

0 99 0 99

261 213 23 497

u Two suburban high schools, N = 294. "One urban high school, N = 203.

IMPULSE CONTROL

EMOTIONAL TONE

BODY IMAGE

SOCIAL RELATIONSHIPS

UOC.

a ED. GOALS

SEXUAL ATTITUDES

FAMILY RELATIONSHIPS

MASTERY

•

FEMALES

•

MALES

EMOTIONAL HEALTH

SUPERIOR ADJUSTMENT

IDEALISM

..~t~y:;i ~:f I

D....c:iil....

~:~~r~~tf

FIG. I. OlTer Self-Image Questionnaire raw scale scores for the 1987 epidemiological study.

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OSTROV ET AL.

ity have been repeatedly demonstrated (Offer et al., 1981 b). The DCL is a self-report inventory of extent of delinquent behaviors engaged in (Short and Nye, 1957). Examples of behaviors inquired about are running away from home, stealing, and problems with the police. The SCL was developed by Derogaitis ( 1977)and covers a wide spectrum of psychiatric symptomatology. It inquires about symptoms such as palpitations, lightheadedness, hopelessness and phobias. All three instruments were modified for use in this study. The OSIQ was shortened by deleting about five items from each of the 10 scales. The DeL was shortened to 19 items and updated to conform with current language usage with respect to various substances and activities. In taking the DeL, adolescents were asked about their behavior during the previous year. A DeL Total Score was used to compare boys and girls. The SCL was shortened to 46 items and modified to be more relevant to adolescents. SCL items concerned adolescent symptoms during the previous 2 weeks and separately during the previous year. Two scores were used for the SCL: Number of Symptoms Endorsed and Severity of the Distress (the average score across all items). In a series of analyses based on the data collected, the DCL Total Score was shown to be reliable (Cronbach's alpha for boys equaled 0.79, and for girls equaled 0.81), as was the SCL Severity Score for I year (alpha for boys equaled 0.92, and for girls equaled 0.92); the SCL Severity Score for two weeks (Cronbach's alpha for boys equaled 0.91, and for girls equaled 0.92); the SCL Number of Symptoms Endorsed for the past year (Cronbach's alpha for boys equaled 0.91, and for girls

equaled 0.90); and the SCL Number of Symptoms Endorsed for the past 2 weeks (Cronbach's alpha for boys equaled 0.91, and for girls equaled 0.90). OSIQ scale alphas ranged from 0.38 to 0.74 for boys and from 0.25 to 0.83 for girls. Low alphas could contribute to a failure to find differences between boys and girls, but the large number of subjects studied should provide enough power to discern any meaningful differences that exist. Statistical Analyses

Adolescent boys' and girls' responses were compared by means of two-tailed t test with respect to their OSIQ, DCL, and SCL scores. Results were considered significant if p was less than 0.003 (using the Bonfirone correction for multiple t test) (Cohen and Cohen, 1983). If scale score differences were significant, they were explored by examining differences at the item level. Results Figure I shows OSIQ score differences between boys and girls. Adolescent girls reported significantly poorer functioning than did adolescent boys with respect to Emotional Tone, Body Image, and Psychopathology. The girls expressed more conservative sexual attitudes than did the boys. On the DCL, adolescent boys reported a greater amount of delinquent behavior over the previous year than did girls. With respect to the SCL, adolescent girls attested to a greater degree of symptomatology both during the previous 2 weeks and during the previous year (Figs. 2 and 3).

NUMBER OF SYMPTOMS ENDORSED

FEHALES

HALES

29

25

SEVERITY OF DISTRESS

FEHALES

HALES

FIG. 2. Two-week Symptom Checklist for the 1987 epidemiological study. The higher the scores, the more symptomatic the adolescent is.

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GENDER DIFFERENCES IN SYMPTOMATOLOGY

NUMBER OF SYMPTOMS ENDORSED

FEHALES

HALES

25

SEVERrrY OF DISTRESS

FEHALES

HALES

II

II.J.

11.2

11.3

11.4

11.5

11.6

11.7

FIG. 3. One-year Symptom Checklist for the 1987 epidemiological stud y. The higher the scores. the more symptomatic the adolescent is.

As has been found in other stud ies, results show greater psychological disturbance reported by adolescent girls-particularly in the areas of Emotional Tone (depression and anxiety) and Body Image-than by adolescent boys. Boys are more likely to describe behavioral disorders and to have poorer vocational and educational goals. Findings with respect to various items composing significantly different scores exemplify these results. With respect to Emotional Tone, about a third of the girls, while only about one-fifth of the boys, attested to frequently feeling sad. In the area of Body Image, about 25% of the girls, but only 15% of the boys, attested to frequently feeling unattractive. Regarding Psychopathology, about 20% of the girls, more than twice the percentage of boys, reported feeling confused most of the time . On the SCl, about 60% of the girls, twice on the percentage of the boys, related feeling easily upset and annoyed during the previous 2 weeks. Three-quarters of the girls, but only half the boys, attested to being easily upset or annoyed during the previous year. Considering the DCl, 2.5 times more boys (30 %) than girls reported having damaged property during the previous year; almost twice as many boys (51 %) reported having been stopped by the police during the previous year. Discussion These results contribute to recent studies on epidemiology of psychiatric illness among adolescents. They are consistent with earlier studies that show the vast majority of teenagers are normal and well-adjusted . Among teenagers who are disturbed, symptom expression, results indicate, is greatly

influenced by gender. These results are consistent with the hypothesis that a teenage boy who is disturbed is likely to express that disturbance through acting-out behavior such as theft, running away, or substance abuse. A teenage girl who is disturbed may express that disturbance through inwardly turned symptomatology, such as depression and anxiety. More inwardly turned emotional disturbance among girls and a greater proclivity toward acting out among boys are consistent with findings obtained by studies of gender differences among adults. Results of these studies indicate that women have more psychological symptoms and distress than do men . Men show a higher incidence of behavior disorders such as alcohol abuse (Schwab et aI., 1974; Briscoe, 1982). Canino et al. (1987) found a much higher lifetime prevalence of phobic disorders and psychosexual dysfunction among women than among men in their stud y. Alcohol abuse was also much more prevalent among males than among females in that study. Weissman and Klerman (1979) found that major depression was about two times as frequent among women as among men, whereas the prevalence of bipolar disorder was almost equal. The greater prevalence of psychological disturbance among women and the greater prevalence of behavior disorders, particularly substance abuse , among men is also consistent with the findings of Robbins et al. (1984), Myers (1984), and Offord et al. (1987). The source of girls' apparent proclivity toward inwardly experienced symptoms and boys' apparent greater proclivity toward acting out is unclear (Weissman and Klerman, 1979). Cultural factors emphasizing the desirability of girls being open to affective and interpersonal experience, and boys being

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prepared for action or oriented to problem solving, may be involved. In addition, fundamental biological differences may be operating. Apart from actual gender differences in the prevalence of various kinds of symptoms, it should be noted that results presented here also are consistent with culturally based differential willingness (or ability) of boys and girls to attest to certain symptoms. Data from parents, available from the larger research project, may help confirm or disconfirm adolescents' attestations. Correlations between parents' and adolescents' responses within gender can be assessed. If such correlations are high, that will bolster the argument that adolescents' attestations are accurate and not simply a function of differential willingness or ability to acknowledge feelings of behavior. These results should help mental health professionals who treat adolescents better understand the problems presented by adolescent patients. Implicitly or explicitly, every mental health professional must assess the symptoms that are presented in terms of how expectable or normal they are, given the patient's developmental stage.Gender is also an important aspect of these considerations. To illustrate, these results might suggest that a teenage boy who is depressed may be more unusual, or even more severelydisturbed, than a teenage boy who is acting out. Conversely,a teenage girl who acts out may be of more concern than a teenage boy who acts out. Future data collection should test the hypothesis generated here regarding gender-based differences in adolescent symptomatology. Planned research can show the prevalence of different DSM II/-R diagnoses among adolescent boys and girls. One focus could be gender-based differences in willingness and ability to obtain help for emotional disturbance. Of particular interest would be-in light of girls' greater extent of inwardly directed symptomatology-whether adolescent girls obtain more (or less) psychiatric help for their problems than do adolescent boys. Gender-based differences in helpseeking behavior with respect to specific psychiatric symptoms also can be explored. References Boyle, M. H., Offord, D. B., Hofmann, H. G. et al. (1987), Ontario child health study. L Methodology. Arch. Gen. Psychiatry, 44:826832. Briscoe, M. (1982), Differences in psychological well-being. In: Psychological Medicine, Monograph Supplement 1. Cambridge, England: Cambridge University Press. Canino, G. J., Bird, H. R., Shrout, P. E. et al. (1987), The prevalence of specific psychiatric disorders in Puerto Rico. Arch. Gen. Psychiatry, 44:727. Clifford, R. E. (1971), Body satisfaction in adolescence. Percept. Mot. Skills, 33: 119-125. Cohen, J. & Cohen, P. (1983), Multiple Regression Analysis for the Behavioral Sciences, 2nd Edition. New York: Lawrence Erlbaum. Derogaitis, L. R. (1977), SCL-90R Manual. Baltimore, MD: Clinical Psychometrics Research Unit, Johns Hopkins School of Medicine. Douvan, E. & Adelson, J. (1966), The Adolescent Experience. New

York: Wiley. Graham, P. & Rutter, M. (1973), Psychiatric disorder in the young adolescent. Proc. R. Soc. Med., 66:58-61. Gregory, R. D. (1977), Self-concept across sex, color, and teacher estimated, annual family income level for students in grades 7 through 12. Dissertation Abstracts International, 38: 1859. Healey, G. W. & Deblassie, R. R. (1974), A comparison of Negro, Anglo-, and Spanish-American adolescents' self-concept. Adolescence, 9: 15-24. Kandel, D. B. & Davies, M. (1982), Epidemiology of depressive mood in adolescents. Arch. Gen. Psychiatry, 39: 1205-1212. Langner, T., Gersten, J. C. & Eisenberg, J. G. (1974), Approaches to measurement and definition in the epidemiology of behavior disorders: ethnic background and child behavior. International Journal ofHealth Sciences, 4:483-50 I. Locksley, A. & Douvan, E. (1979), Problem behavior in adolescents. In: Gender and Disordered Behavior, ed. E. Gombera & V. Frank. New York: Brunner/Mazel, pp. 71-100. Mitchell, J. R. (1980), Normality in adolescence. Adolesc. Psychiatry, 8:201-213. Monge, R. H. (1973), Developmental trends in factors of adolescent self-concept. Developmental Psychology, 8:382-393. Musa, K. E. & Roach, M. E. (1973), Adolescent appearance and se1fconcept. Adolescent, 8:385-394. Myers, J. K., Weissman, M. M., Tischler, G. L. et al. (1984), Sixmonth prevalence of psychiatric disturbance in three communities in 1980 to 1982. Arch. Gen. Psychiatry, 41:959-967. Offer, D. (1969), The Psychological World of the Teenager. New York: Basic Books. - - Offer, J. B. (1975), From Teenager to Young Manhood: A Psychological Study. New York: Basic Books. --Ostrov, E. & Howard, K. L (l981a), The mental health professional's concept of the normal adolescent. Arch. Gen. Psychiatry, 38:149-153. - - - - - - (1981 b), The Adolescent: A Psychological Self-Portrait. New York: Basic Books. - - - - - - eds. (1984), Pal/ems of Adolescent Self-Image. San Francisco: Jossey-Bass. - - - - - - (1987), Epidemiology of mental health and mental illness among adolescents. In: Basic Handbook ofChild Psychiatry, eds. J.D. Call, R.L. Cohen, SJ. Harrison, LN. Berlin & L.A. Stone. New York: Basic Books, pp. 82-88.

Offord, D. R., Boyle, M. H., Szatmari, P. et al. (1987), Ontario child health study. II. Six-month prevalence of disorder and rates of service utilization. Arch. Gen. Psychiatry, 44:832-836. Robbins, L. N., Helzer, J. E., Weissman, M. M. et al. (1984), Lifetime prevalence of specific psychiatric disorders in three cities. Arch. Gen. Psychiatry, 41:949-958. Rosenberg, M. (1965), Society and the Adolescent Self-Image, Princeton, MJ: Princeton University Press. Rutter, M., Graham, P., Chadwick, O. F. D. & Yule, W. (1976), Adolescent turmoil: fact or fiction? J. Child Psychol. Psychiatry, 17:35-56. Schwab, J. J., Fennell, E. B. & Warheit, G. 1. (1974), The epidemiology of psychosomatic disorders. Psychosomatics, 15:88-93. Short, J. F., Jr. & Nye, F. C. (1957), Reported behavior as a criterion of deviant behavior. Social Problems, 5:207-213. Weissman, M. D. & KJerman, G. L. (1979), Sex differences and the epidemiology of depression. In: Gender and Disordered Behavior, eds. E.S. Gomberg & V. Franks. New York: Brunner/Mazel, pp. 381-425. Wiggins, R. B. (1973), Differences in self-perceptions in ninth-grade boys and girls. Adolescence, 8:491-496. Wylie, R. C. (1979), The Self-Concept: A Review of Methodological Considerations and Measuring Instruments: l. Lincoln, NE: University of Nebraska Press.