The role of body dissatisfaction as a risk factor for depression in adolescent girls

Journal of Psychosomatic Research 53 (2002) 975 – 983

The role of body dissatisfaction as a risk factor for depression in adolescent girls Are the differences Black and White? Debra L. Frankoa,*, Ruth H. Striegel-Mooreb a

Department of Counseling and Applied Educational Psychology, Northeastern University, 203 Lake Hall, Boston, MA 02115-5000, USA b Department of Psychology, Wesleyan University, Middletown, CT 06459-0408, USA

Abstract Body dissatisfaction, disordered eating and depression differentially affect adolescent girls (compared to boys); however, these variables have not been examined in relation to ethnicity. A review of the literature finds that Black adolescent girls are more satisfied with their bodies than White adolescent girls and engage much less frequently in dieting or disordered eating than do White girls in the US. A central question raised by this review is whether body dissatisfaction and pubertal timing are as relevant to our under-

standing of the etiology of depression in Black girls as they appear to be in White girls. Based on the available data, it does not seem that a risk factor model supporting the role of early pubertal timing, weight increases and body dissatisfaction in the development of depression applies to Black adolescent girls. This review underscores the need for future research with a variety of ethnic minority groups to better understand the etiology of adolescent depression. D 2002 Elsevier Science Inc. All rights reserved.

Keywords: Body image; Body dissatisfaction; Depression; Disordered eating; Eating disorders; Ethnicity; Black; Adolescence

Introduction Improving the scientific knowledge base regarding the mental health of ethnic minority populations, adolescents in particular, and ensuring the provision of culturally competent services have been identified as public health priorities [1]. Detailed reviews of the empirical literature focusing on specific mental disorders are needed to determine the prevalence of and risk factors for specific disorders as a basis for establishing the clinical services and preventive intervention needs for adolescents from culturally diverse groups. Such reviews also may identify gaps in knowledge and point to further research needs. Moreover, much of what we know about adolescent mental disorders is based on largely White samples. Research agendas and treatment approaches are often developed from this vantagepoint, which may be inappropriate or unwarranted for minority populations. Thus, a better understanding of ethnic differences in the disorders

* Corresponding author. Tel.: +1-617-373-5454; fax: +1-617-373-8892. E-mail address: [email protected] (D.L. Franko).

common to adolescents will broaden the scope of research and assist in the development of appropriately tailored treatment and prevention strategies. Depression ranks among the most common mental health problems of adolescent girls [2,3] and a growing literature suggests that depression is persistent, recurring and contributes to numerous secondary adverse health and mental health outcomes [4]. The persistence and negative consequences of depression may be explained by the fact that depression ‘‘erodes personal and psychological resources’’ [4] (p. 203) and interferes with the accomplishment of important normative developmental tasks [5]. Improving our understanding of depression is critical if we are to develop interventions aimed at reducing the prevalence and incidence of this disorder. Two major conceptual questions will be addressed in this review. One, do Black and White girls differ in depression and body dissatisfaction? Two, does an etiological model of adolescent depression apply equally well to Black as to White girls? In this review, we will examine the available evidence for each of these questions to determine whether any empirically based conclusions can be derived. A systematic literature search of two major databases (Medline

0022-3999/02/$ – see front matter D 2002 Elsevier Science Inc. All rights reserved. PII: S 0 0 2 2 - 3 9 9 9 ( 0 2 ) 0 0 4 9 0 - 7

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and American Psychological Association PsychLit) was conducted, using the following key words in various combinations: Black, African American, White, Caucasian, depression, eating, body image, eating disorders and adolescence (e.g., Black and depression; depression and eating).

Depression in Black and White adolescents Depression is one of the most prevalent mental disorders in the US. Longitudinal studies of White samples have shown that adolescence is a high-risk period for the onset of depression. For example, the Oregon Adolescent Depression Project reported point prevalence rates of major depression in female adolescents of 3.37% (Time 1) and 3.58% (1 year later) [2]. Lifetime prevalence rates for this group were 24.8% and 31.6%, respectively. Reinherz et al. [6] found that 13.7% of female adolescents met lifetime criteria for major depression by age 18, confirming that adolescence is a period of particular risk for depression. A recent review of the literature on adolescent mental health concluded that although the prevalence of depression is similar in White, Latino and Asian adolescent girls; Black girls report fewer symptoms of depression [7]. However, to our knowledge, a detailed review focusing specifically on depression in Black adolescent girls has not yet been published. One purpose of the current paper is to exhaustively review the studies of depression in Black and White adolescent girls, to determine whether or not differences in prevalence rates actually exist between these two groups. The data base search identified eighteen studies of depression in Black and White youth [8 – 25]. Table 1

summarizes the main design features of these studies. Close inspection revealed that only five studies specifically examined the differences between Black and White girls. The remainder combined males and females in the two ethnic groups and simply examined Black/White differences. This is particularly puzzling given overwhelming data documenting clear gender differences in adolescent depression across ethnic and cultural groups [26 –28]. The prevailing assumption of lower rates of depression among Black girls notwithstanding, none of these five studies found statistically significant differences between Black and White girls on measures of symptom severity or prevalence of depression. In addition, four of these five studies have significant methodological problems. The studies by Lubin and McCollum [8] and that of Lester and DeSimone [9] included only 52 and 40 adolescents, respectively, raising concerns about the generalizability of the results and the adequacy of the statistical power to detect group differences. The study by McDonald and Gynther [10] was conducted in South Carolina where high schools at that time were segregated; thus, it is not clear whether these findings would hold today. Pumariega et al. [11] examined rates of depression in adolescents under the care of the Department of Social Services who were living in residential group homes. Thus, the only large representative study comparing Black and White adolescent girls found no differences in the rates of depression between these two groups [12]. The null hypothesis, that Black girls do not differ from White girls in the prevalence of depression, could not be rejected in these five studies. Several explanations can be entertained regarding this finding. One is that Black girls are

Table 1 Differences between Black and White participants on depression scales Reference

Grade or age (sample size)

Measure

Means/prevalence rates

Results

McDonald and Gynther [10] Kandel and Davies [13] Schoenbach [14] Helsel and Matson [15] Doerfler et al. [16] Reynolds and Graves [17] Emslie et al. [18] Garrison et al. [19] Worchel et al. [20] Lubin and McCollum [8] Lester and DeSimone [9] Treadwell et al. [21] Wrobel and Lachar [22] Pumariega et al. [11] Roberts et al. [23]

16 – 19-year-olds (n = 132 WF, 196 BF) high school students (n = 5873 W, 683 B) 7th – 9th graders (n = 155 WF, 92 BF) 4 – 18-year-olds (n = 108 W, B, Hispanic F) 4th – 12th graders (n = 599 W, 608 B) 3rd – 6th graders (n = 52 W, 73 B) high school students (n = 365 WF, 912 BF) 7th – 9th graders (n = 254 WF, 40 BF) 5th, 6th and 9th graders (n = 451 W, 165 B) 15-year-olds (n = 21 WF, 19 BF) high school females (n = 19 W, 33 B) 9 – 13-year-olds (n = 144 W, 34 B) 12 – 17-year-olds (n = 119 W, 99 B) 12 – 17-year-olds (n = 87 WF, 53 BF) 6th – 8th graders (n = 741 W, 1091 B)

MMPI Scale 2 ‘‘self-reported scale’’ CES-D CDI CDI, CES-D RCDS BDI CES-D CDI DACL BDI CDI MMPI Scale 2 CES-D DSM scale

mean scores mean scores frequency of symptoms mean scores mean scores mean scores prevalence rates mean scores mean scores mean scores mean scores mean scores mean scores prevalence rates prevalence rates

Siegel et al. [24] Cole et al. [25] Schraedley [12]

12 – 17-year-olds (n = 85 WF, 46 BF) 6th – 8th graders (n = 664 W, 326 B) 5th – 12th graders (n = 4374 W, 1041 B)

CDI CDI CDI

mean scores mean scores mean scores

Black > White NS Black > White NS White > Black; NS NS Black > White Black > White NS NS NS NS NS NS Black > Whitea, Black = Whitea NS NS NS

Key: MMPI Scale 2 = Minnesota Multiphasic Personality Inventory Depression scale, CES-D = Center for Epidemiological Studies — Depression Scale, CDI = Children’s Depression Inventory, DSM Scale = Diagnostic and Statistical Manual of Mental Disorders Depression Scale, RCDS = Reynolds Child Depression Scale, DACL = Depression Adjective Checklist, BDI = Beck Depression Inventory. a Black youth scored higher than White youth on depression without impairment and the groups were equivalent with impairment.

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as likely as White girls to experience depression. It is important to remember, however, that one cannot ‘‘prove’’ the null hypothesis, i.e., failure to find group differences does not prove that such differences do not exist. A second explanation is that methodological limitations, as noted above, made it difficult to adequately test the hypothesis. Furthermore, since all of the published accounts have relied on self-report questionnaires to measure symptoms of depression, the question of whether Black and White girls differ in the prevalence of syndromes has not been answered. Research suggests that questionnaires are quite reliable in detecting symptoms, yet for a clinical diagnosis of a syndrome, interview methods are considered superior to questionnaire methods. In summary, the five studies that examined the ethnicity by gender interaction found no differences in the rates of depression between Black and White adolescent girls, suggesting that the statement by Slater et al. [7] that African American girls show fewer depressive symptoms than European American girls is not consistent with the available data. Thus, although we are left without a definitive answer as to whether there are ethnic differences in the prevalence rates of depression in adolescent girls, the preponderance of the data suggests that there are not.

Gender-specific explanations of adolescent depression Depression is a gender-specific disorder, with twice as many women (12%) as men (7%) diagnosed with depression each year [29]. This two-to-one ratio remains constant across socioeconomic status and ethnic groups [30] and begins in early to midadolescence. In a large ethnically diverse sample, Ge et al. [31] reported that gender differences first appeared in 8th grade and continued through 12th grade. Wade et al. [32] found in a large study of Canadian, British and US adolescents that the gender gap consistently emerged by age 14 across all three samples. Recently, experts have introduced theoretical models and preliminary evidence suggesting that the development of gender differences in depression during adolescence can be attributed to the gender differences in body image dissatisfaction. Nolen-Hoeksema and Girgus [26] posit that girls carry risk factors prior to adolescence, that, when combined with certain social and biological challenges, lead to depression. Two biological challenges are proposed as major explanatory variables for the gender differences in adolescent depression: early pubertal development and body dissatisfaction. Puberty is associated with weight gain for both boys and girls, but the increase in fat is significantly greater in girls. Because of this additional weight and body fat, puberty is associated with a rise in body dissatisfaction for girls. Nolen-Hoeksema and Girgus [26] stress that this combination of pubertal weight changes with resultant body dissatisfaction, in conjunction with social challenges, may explain the greater prevalence of depression in adolescent

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Fig. 1. Hypothesized model of risk factors for adolescent depression. (Note: figure adapted from Nolen-Hoeksema and Girgus [26].)

girls compared to boys. Moreover, because girls who mature early report the greatest degree of body dissatisfaction [33], the timing of puberty may be a potentiating factor for depression. Specifically, it has been hypothesized that a girl who enters puberty before her peers experiences more body dissatisfaction and may be at particularly high risk for depression (see Fig. 1). Although there are a number of studies that have examined various aspects of this model, most have been conducted with White girls (see below). One central question for this review is whether this etiological model of adolescent depression also applies to Black girls. We will now review the existing data on the components of this model (body dissatisfaction, pubertal timing and depression) in both Black and White girls, in order to examine whether the model informs our understanding of the pathways to depression for Black girls as well as for White girls.

Body dissatisfaction and disordered eating in Black and White adolescent girls In a 1996 review, Crago et al. [34] concluded that ‘‘eating disturbances appear to be less frequent among Black women and girls than in their Caucasian counterparts, perhaps because of their greater weight tolerance, less body dissatisfaction and less reliance on restrictive dieting and selfinduced vomiting for weight control’’ (p. 245). Because there are a considerable number of studies in this area [35,36], we chose to limit our review to studies that used validated instruments with representative samples of Black and White adolescent girls. Across several studies (see Table 2) using a variety of measures, remarkably similar results have been reported: White adolescent girls, compared to Black adolescent girls, report more body dissatisfaction, dieting and disordered eating [37 – 47]. White girls have been found to report a thinner body size ideal [37] and be more likely to describe themselves as ‘‘overweight’’ [43,44] or ‘‘too fat’’ [39,42,45] than Black girls. White girls also are more likely than Black girls to report that they are trying to lose weight [38,46] or dieting [40,41,44,46]. These ethnic group differences are remark-

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Table 2 Differences between Black and White participants on eating disorder symptoms and body dissatisfaction Reference

Grade or age (sample size)

Measure

Results

Rosen and Gross [46]

high school students (n = 1059 W, 220 B)

Survey

Casper and Offer [38] Serdula et al. [45] Story et al. [43] Felts et al. [39] French et al. [40] Neumark-Sztainer [41]

12th graders (n = 262 W, 213 B) adolescent girls (1498 W, 370 B) 7th – 12th graders (n = 15,088 WF, 1403 BF) high school students (n = 3278 WF, 1195 BF) adolescent females (n = 14,760 WF, 1428 BF) 7th, 9th and 11th graders (n = 3347 W, 462 B)

Questionnaire Wt. perceptions Survey YRBS Health Behav. Survey Adol. Health Survey

Rhea [42] Siegel et al. [83] Strauss [44]

high school athletes (n = 185 W, 291 B) 13 – 18-year-olds (105 WF, 46 BF) 12 – 16-year-olds (n = 1097 W, 743 B)

EDI Questionnaire NHNES

Adams et al. [37] Striegel-Moore et al. [47]

4th and 7th graders (n = 848 W, 749 B) 11 – 16-year-olds (n = 1166 WF, 1213 BF)

Questionnaire EDI

Blacks > Whites on weight gain, Whites > Blacks on dieting and trying to lose weight Whites > Blacks on weight and diet concerns Whites > Blacks see self as fat Whites > Blacks on body dissatisfaction Whites > Blacks reported being ‘‘too fat’’ Whites > Blacks on history of frequent dieting Whites > Blacks on dieting, Blacks > Whites on weight gain Whites > Blacks on 6/8 EDI subscales Blacks > Whites on body satisfaction Whites saw selves as overweight > Blacks, Whites > Blacks on dieting Black > whites on ideal body size Whites > Blacks on Body Dissatisfaction and Drive for Thinness subscales

Key: YRBS = Youth Risk Behaviors Survey, EDI = Eating Disorders Inventory, NHNES = National Health and Nutrition Examination Survey.

able because Black girls were on average significantly heavier than White girls. For example, Striegel-Moore et al. [47] found ethnic differences in body image in the National Heart, Lung and Blood Institute Growth and Health Study (NGHS), a multisite longitudinal study of over 2000 Black and White girls. From age 11 to age 16, White girls scored higher than Black girls on the Body Dissatisfaction and Drive for Thinness subscales of the Eating Disorders Inventory [48] even though on average White girls were thinner. In both groups, higher drive for thinness (i.e., greater preoccupation with dieting) was found for heavier girls, but at comparable BMI levels, White girls reported greater drive for thinness than Black girls. Thus, evidence from these studies strongly suggests that Black and White girls differ with respect to body dissatisfaction, dieting and disordered eating behaviors. Noting these differences, an examination of possible explanations for this disparity will inform our research and prevention efforts. Thus, we will now briefly review family and peer influences, self-esteem differences and the role of the culture and of media in promoting sociocultural attitudes toward thinness.

Why are there differences in body dissatisfaction in Black and White girls? Data from several studies suggest that Black women tend to underestimate their body weight and not view themselves accurately when they actually are overweight [36]. Even when they perceive themselves to be overweight, many Black women still consider themselves attractive [49]. In addition, overweight Black women are less likely than overweight White women to enter weight loss programs [50]. It is possible that when these Black women are mothers, they communicate their weight-related attitudes

to their daughters. Few studies have examined this maternal link directly; however, Brown et al. [51] found that Black mothers, compared to White mothers, were more tolerant of build and eating habits of heavy daughters. Maternal and family influences may translate into positive body image attitudes that Black adolescent girls take into and share with their peer networks. Parker et al. [52] concluded that rather than using thinness as a standard for beauty, African American girls emphasized making what they had work for them. Black girls reported receiving more positive than negative feedback about their looks from their friends and family. Further, Black girls described themselves as being very supportive of each other, as compared to White girls who expressed competitiveness and envy regarding body-related issues. Greater comfort with and even idealization of fuller figures occurs among Black girls, as compared to White girls, despite being on average heavier and more prone to overweight than Whites [53]. In the NGHS, Black teenagers were more likely to endorse statements indicating that being fat is healthy or makes one feel more like a girl [54]. Black girls appear to take pride in their bodies in a manner that sets them apart from White teenagers, suggesting they hold a different and heavier body ideal. The role of self-esteem may also be important in understanding differences in body satisfaction. African American girls have been found to have higher self-esteem and feel a greater sense of personal and familial importance than White girls [55]. In the first 5 years of follow-up of the NGHS cohort, Black girls demonstrated higher and more stable self-esteem compared to White girls [56]. Simmons et al. [57] have suggested that higher self-esteem in Black girls and adolescents may be related to the greater flexibility in sex roles found in female-headed households for Black girls. Greater self-esteem may serve as a protective factor in the face of developmental challenges in adolescence.

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What are the cultural differences that may provide a protective function for Black girls? Standards for attractiveness are less equated with thinness in Blacks than the majority culture [49,58]. A strong African American cultural identity has been found to play a protective role against disordered eating attitudes and behavioral risk factors [59]. Two studies have found less eating disorder symptomatology in Black women at predominantly Black versus predominantly White universities [60,61]. The influence of the media may be different for Black and White girls; however, few studies have examined this question. Botta found that White adolescent girls who watched a lot of television displayed more eating disordered behaviors (as measured by the Eating Disorders Inventory) than Black girls [62]. She suggested that ‘‘African American subjects respond differently to and are differentially affected by thin images compared to White subjects’’ (p. 144). Milkie [63] conducted in-depth interviews with 60 9th and 10th grade White and Black girls to clarify the effects of media images. Black girls did not identify with ‘‘White’’ media images and did not believe that their family and friends compared them to these images. White girls, although they did not see the images as realistic, believed that family members, peers and especially boys, would evaluate them in comparison to these images. Hebl and Heatherton [64] showed first-year Black and White college females photographs of thin, average and large women. The White students rated large women lower on attractiveness, intelligence and occupational/relationship success compared to thin or average women. On the other hand, Black women rated all body sizes (thin, medium and large) similarly; in fact, the differences between the subject groups were most pronounced for pictures of large Black women, who were rated most positively by Black participants and most negatively by White participants. Taken together, these studies suggest that the influence of the media may differentially affect Black and White adolescent girls, and may play some role in explaining the disparate degrees of body satisfaction in these groups. In sum, very few studies have examined why differences exist between Black and White girls with regard to body image and disordered eating behaviors. At this time, although there are no definitive explanations, maternal, peer and media-related factors appear to play a protective role for Black adolescent girls with regard to body satisfaction. Additional research that examines the confluence of risk factors is needed to broaden our understanding of differences in body dissatisfaction and eating disorders in Black and White girls.

Pubertal timing and body dissatisfaction The relationship between the onset of puberty and body dissatisfaction plays a pivotal role in the etiological model of depression. Early onset puberty has been associated with

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significantly elevated body weight in both White girls and Black girls [65], and a recent study of over 19,000 Finnish girls found that early puberty predicted the onset of bulimic behaviors [66]. A Scottish study of nearly 1900 11- and 13-year-old girls found significant relationships between early maturation and lower ratings of body image [33]. Results from the NGHS showed that for both White and Black girls, timing of sexual maturation and body dissatisfaction were highly correlated. Girls with early onset menarche reported the highest body dissatisfaction and girls with late onset menarche reported the lowest body dissatisfaction. Analyses further showed that these differences were mediated by differences in BMI among the three maturation groups: when controlling for BMI, early, on-time and late-maturing girls no longer differed on body dissatisfaction [65]. Thus, it appears that pubertal timing affects body dissatisfaction similarly for both ethnic groups, and it is the increase in body weight that accounts for this relationship.

Body dissatisfaction and depression As noted earlier, body dissatisfaction has been linked to the development of depression in adolescent girls, and is hypothesized to be one of the factors responsible for the emergence of gender differences in adolescence. In a series of studies of over 600 White adolescent girls, Rierdan et al. [67] and Rierdan and Koff [68,69] found that weight dissatisfaction and concerns were associated with more depressive symptoms. Stice et al. [70] developed a model describing the relationship between body dissatisfaction and depression in adolescent girls. Specifically, the ‘‘dual pathway model’’ proposes that elevated body mass index, body dissatisfaction and dieting lead to both depression and the development of eating disorder symptoms. This model was tested in a longitudinal study of 1124 adolescent girls in which initial body dissatisfaction, dietary restraint and bulimic symptoms predicted the onset of depression [71]. Recently, Stice and Bearman [72] replicated these findings in a sample of girls attending a private high school. These studies provide initial evidence for a relationship between body dissatisfaction and depression in adolescent girls. Siegel [73] extended an earlier study by following her multiethnic sample of adolescents 13 months after the initial study (n = 675, 77% follow-up rate). In order to examine the temporal relationship between body image and depressive syptomatology, she defined body image change between Time 1 and Time 2 as either ‘‘more favorable,’’ ‘‘unchanged’’ or ‘‘less favorable,’’ and examined the effect of this change on depressive symptoms. Consistent with previous studies, Black girls had the most positive body image of any group (White, Hispanic or Asian). Contrary to hypotheses, African American girls whose body image remained unchanged or had become more negative had higher scores on the Children’s Depression Inventory [74] than White, Hispanic or Asian adoles-

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cent girls (who did not differ from each other). African American girls whose body image became more positive over time had the least number of depressive symptoms, relative to the other ethnic groups. Siegel suggested that the higher rates of depression may have occurred because a negative body image is not normative for African American adolescent girls, and thus not liking one’s body may have resulted in feelings of ‘‘not fitting in’’ with one’s peer group, leading to depressive symptoms. Although these findings are compelling, several caveats should be noted. First, the sample of African American girls was quite small. Although the author did not provide the exact number of African American girls, she reported that there were a total of 100 African American participants and that 46.5% of the entire sample was female. Two, the measure of body image consisted of four items assessing satisfaction with four variables: weight, physical development/maturation, figure and overall appearance. Although the internal consistency coefficients were adequate (.73 – .80), the validity of such a measure in assessing the complex construct of body image, particularly in diverse groups, is unclear. Finally, although the rationale for combining the ‘‘unchanged body image’’ group with the ‘‘negatively changed body image’’ groups was based on the small sample size, it is possible that the findings would be different if these two groups were analyzed separately. That being said, this is the first study we know of to find that a change to a more negative body image in Black girls was related to greater depression. Clearly, further research is needed to better understand the mechanisms by which decreases in body satisfaction appear to be so distressing for Black adolescent girls. We found one additional study that tested a mediational model of body dissatisfaction and weight concern in relation to depression in Black and White women. Although the participants were adults rather than adolescents, we felt that this was an important study to include in this review. BayCheng et al. [75] tested a model proposing that weight concerns mediate the relationship between ‘‘embodied femininity’’ and depressive symptoms. Embodied femininity was defined as the degree to which a woman accepted mainstream values of thinness and the degree of importance a woman placed on appearance goals, such as ‘‘being womanly’’ or ‘‘looking young.’’ Among the 608 White women studied (ages 18 –45, mean age 34.4 years), weight concern was found to be a potent mediator between embodied femininity and depressive symptomatology. In other words, for White women, thinness was found to be essential to the ideal feminine body, and weight concern was clearly and significantly linked to depression. In contrast, this model was not supported for the 113 Black women (ages 18 –45, mean age 32 years) who were tested. In this group, weight concern did not predict depression, suggesting that for Black women an emphasis on thinness did not play a role in the development of depressive symptomatology. Although additional research is needed to examine this

question with Black adolescent girls, the low levels of body dissatisfaction and weight concern found in this group suggest that similar results might be obtained.

Pubertal timing and depression The other biological risk factor described by NolenHoeksema and Girgus [26] was puberty. The data on the role of pubertal timing in the development of depression has been collected primarily from White girls, so our understanding of this relationship for Black girls is less clear. As girls approach puberty, their risk for depression increases [76]. Petersen et al. [28] reported that those entering puberty earlier than their peers had higher depression scores, and others have found that pubertal status was a better predictor of adolescent depression than was age [77,78]. Based on data from the Oregon Adolescent Depression Project, Graber et al. [79] demonstrated that early-maturing girls, compared to ‘‘on-time’’ girls, showed more depression (30% vs. 22%), substance use (15% vs. 7%) and eating disorders (3.5% vs. 0.8%). Using a community sample of nearly 500 girls, Stice et al. [80] found that early menarche was associated with elevated rates of depression based on a structured clinical interview. In a study of 236 middle to lower middle class rural White girls, Ge et al. [31] indicated that girls who experienced menarche at a younger age reported more depressive symptoms than those who matured later. Although the available data support the connection between early maturation and depression, this may not be true for all groups. In the only investigation of pubertal timing and depression in a multiethnic sample (n = 3216), Hayward et al. [81] found a significant association between the onset of puberty and depressive symptoms, but only in White girls. Specifically, the White girls who reached puberty early had higher depression scores than those who had not yet reached puberty, whereas a higher rate of depression was not found in Black girls with early pubertal onset. Hayward and his colleagues suggested that the timing of pubertal increases in body fat might may have different consequences for Black and White girls, and, as a result, confer risk for depression only in White girls but not Black girls.

Pubertal timing, body dissatisfaction and depression To return to our original question, ‘‘does an etiological model of adolescent depression that posits body dissatisfaction and early puberty as risk factors apply equally well to Black and White girls?,’’ we found two studies that examined the combination of these variables in multiethnic samples. Ge et al. [82] investigated pubertal transitions, perceptions of being overweight, and depression in data gathered from the National Longitudinal Study of Adolescent Health (n = 1863 girls, Grades 7– 12). Using a struc-

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tural model, they hypothesized that pubertal growth would affect perception of overweight, which in turn would predict depressed mood. They found that for all girls, regardless of ethnicity (White, Black and Hispanic), those who were more physically mature perceived themselves as more overweight, relative to their less mature counterparts. Further, the effect of perceiving oneself as overweight on depressed mood was significantly greater for White girls than for African American girls. The authors stated that the perception of being overweight among African American girls ‘‘is not related to any adjustment difficulties. . . and therefore the psychological consequences of physical change at puberty may be less negative for African American adolescents than for others’’ (p. 374). Siegel et al. [83] also examined body image and pubertal timing in relation to depression across ethnic groups in a (n = 877) cross-sectional study of 12 – 17-year-old adolescents. Pubertal development was rated from 1 (no development) to 4 (development was complete) for height growth spurt, body hair, skin changes and onset of menstruation. In addition, they also asked a single question to assess perceived development relative to one’s peers (‘‘Compared to most girls your age, would you say that your body has developed much earlier, somewhat earlier, about the same, somewhat later or much later?’’). Consistent with Hayward et al. [81], they found that White girls who matured earlier reported more symptoms of depressed mood than those who developed on time. However, there was no indication that Black girls who perceived that they had matured earlier than their peers were dissatisfied with their bodies or were depressed [83]. Both these studies suggest that the relationship between pubertal timing, body dissatisfaction and depression is different for Black and White adolescent girls and that the pathways to depression may vary by ethnicity.

Conclusion Returning to the first of the two conceptual questions initially posed, the preponderance of data finds few differences in the prevalence rates of depression for Black and White adolescent girls. In contrast, the studies on body dissatisfaction and disordered eating provide ample evidence that Black girls are significantly more satisfied with their weight and shape and engage in less disordered eating than White girls. Black girls may be protected from body dissatisfaction by powerful familial and peer influences as well as the role of the culture in acceptance of larger body size. We also asked whether body dissatisfaction and early pubertal development are as relevant for an understanding of depression in Black girls as they seem to be for White girls. The answer to this question appears to be a qualified ‘‘probably not.’’ Although Siegel’s study [73] found that decreases in body satisfaction over time resulted in greater depression for Black girls, both her earlier study and Ge et al.’s recent and larger study [82] suggest that when pubertal

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timing is added into the model, the relationship between pubertal timing, body dissatisfaction and depression differs for Black and White girls. For White girls, early maturation appears to lead to greater body dissatisfaction resulting in increased risk for depression. However, for Black girls, there does not seem to be a mediational relationship between early puberty and depression. Although weight gains in puberty result in greater body dissatisfaction relative to on-time peers [34], this dissatisfaction does not predict depression [81,83]. Thus, this review raises a cautionary note regarding current etiological models of depression, which may need to be reconceptualized and re-evaluated in consideration of ethnic and cultural factors. We hope our review provides some broader implications with regard to adolescent mental health. First, we have learned that statements concerning ethnic differences should be corroborated and evaluated by a careful examination of the empirical literature. It is too easy for data from a very few studies to be inadvertently translated into a conclusion that may not be warranted. Second, there are multiple problems with assuming that different ethnic groups react similarly to the developmental challenges of adolescence. Because mental health research conducted in the US is based on primarily White samples, it is not appropriate to generalize findings to any other group. Although a recent mandate from the National Institutes of Health to include ethnic minority participants in all research studies may eventually reverse this trend, we must be alert to the ethnicity of study participants before extrapolating results to other groups. Clearly, more research is needed with adolescents from a wide variety of ethnic groups, including Hispanic, Asian and Native American girls in the US, and with adolescents of multiple ethnicities around the globe. Future research should examine the myriad of risk factors faced by adolescents from diverse ethnic groups, including familial, peer, cultural and socioeconomic variables. In doing so, our ability to develop preventive interventions appropriately tailored to all groups will be strengthened.

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