a roadmap to mental health services for transition age ... · this work would not have been...

A Roadmap to Mental Health Servicesfor Transition Age Young Women:

A Research Review

By Lynne Marsenich, LCSWDeborah Kelch, Editor

A publication of theCalifornia Women’s Mental Health Policy Council

in affiliation withThe California Institute for Mental Health

Funded by a grant from the California Wellness Foundation

A Roadmap to Mental Health Services for Transition Age Young Women: A Research Review i

A Roadmap to Mental Health Servicesfor Transition Age Young Women:

A Research Review

By Lynne Marsenich, LCSW

Deborah Kelch, Editor

A publication of theCalifornia Women’s Mental Health Policy Council

in affiliation withThe California Institute for Mental Health

Funded by a grant from the California Wellness Foundation

ii A Roadmap to Mental Health Services for Transition Age Young Women: A Research Review

A Roadmap to Mental Health Services for Transition Age Young Women: A Research Review was funded by agrant from The California Wellness Foundation (TCWF). Created in 1992 as an independent, privatefoundation, TCWF’s mission is to improve the health of the people of California by making grants forhealth promotion, wellness education and disease prevention programs.

A Roadmap to Mental Health Services for Transition Age Young Women: A Research Review iii

This report is the result of two years of research, thinking, analysis, debating, reading and writingwhich has been supported by many friends and colleagues. I am indebted to Donna Dahl, LCSW, MaryHargrave, Ph.D. and Penny Knapp, M.D. for their clear-sighted advice and for their critical and immenselyknowledgeable critiques of this work.

I wish to acknowledge and thank Renee Becker for constantly reminding me of the monumental effortsparents make in helping their youngsters through the adolescent transition.

I am grateful to the insights provided by Patti Chamberlain and Dana Smith from the Oregon SocialLearning Center. Their work with young women in the Juvenile Justice system provides a model forusing science to understand and formulate solutions to real-world problems.

This work would not have been possible without the support and friendship of Bill Carter and ToddSosna at the California Institute for Mental Health. One could not wish for better colleagues. I have beenblessed by their kindness, honest criticism and readiness to laugh.

Finally, I want to acknowledge the California Women’s Mental Health Policy Council for their leadershipand support of a project focusing on the needs of young women served by the mental health servicesystem.

Lynne Marsenich, LCSWApril 4, 2005

Acknowledgements

California Women’s Mental HealthPolicy Council—Transition AgeYouth Report Oversight Committee

Beverly Abbott, LCSW

William Arroyo, M.D.

Bill Carter, LCSW

Esther Castillo, LCSW

Donna Dahl, LCSW

Cora Fullmore, LCSW

Karen Hart

Penny Knapp, M.D.

iv A Roadmap to Mental Health Services for Transition Age Young Women: A Research Review

The California Women’s Mental Health Policy Council (WMHPC) is pleased to provide A Road Map toMental Health Services for Transition Age Young Women: A Research Review. The WMHPC is dedicated toimproving services for California’s multicultural population of women and girls. Last year the WMHPCpublished: Gender Matters in Mental Health: An Initial Examination of Gender-Based Data. The research forthat report disclosed some important policy considerations. Women under the age of 40 are less likelythan men to receive mental health services, and girls in particular are less likely to be served. Programssuch as AB3632, which provides mental health services for youth in special education, and Children’sSystem of Care: An Interagency Enrollee Based program, serve far fewer girls than boys. This informationled the WMHPC to search for appropriate models for serving girls and to focus on transition age girls, inthe hope that during this vulnerable and formative time of life, appropriate mental health services mightbe provided for more girls.

Sadly, the research found a paucity of models that are both evidence-based and that target the needsof these youth. However, this report does identify outstanding programs, promising models and importantgender-sensitive risks and resiliencies, all of which provide a “road map” for policy makers and managersin mental health services .

With the passage of Proposition 63, the Mental Health Services Act, we have an opportunity for creatinga new agenda for mental health services in California, and also to act on that agenda. Increasing gender-sensitive, culturally competent services for girls must be a part of that agenda. This report is offered as aresource and guide in this opportunity for substantial progress in mental health services.

The WMHPC would like to thank Lynne Marsenich, the author of this report for her dedication anddetermination; our committee of reviewers, and our staff.

Thank you for taking the time to review this material.

Beverly K. Abbott, LCSWPast-ChairCalifornia Women’s Mental Health Policy Council

Foreword

A Roadmap to Mental Health Services for Transition Age Young Women: A Research Review v

Table of Contents

Executive Summary .................................................................................................................1Introduction ............................................................................................................................9

A Developmental Perspective ................................................................................................. 9Methodology and Definitions ................................................................................................10Gender and Mental Health Service Utilization ........................................................................11Trauma and Young Women: Prevalence and Implications ......................................................11Girls in the Juvenile Justice System .........................................................................................15

Characteristics of Female Juvenile Offenders ........................................................................ 15Trauma Among Girls in the Juvenile Justice System .............................................................. 16Risk Factors for Juvenile Offending ....................................................................................... 16Protective Factors in Juvenile Offending ............................................................................... 16Treatment for Youth in the Juvenile Justice System ............................................................... 16

Posttraumatic Stress Disorder ................................................................................................18Risks and Protective Factors................................................................................................. 18Treatment for PTSD ............................................................................................................ 19

Substance Abuse ...................................................................................................................20Substance Abuse and Racial and Ethnic Subgroups .............................................................. 21Protective Factors in Substance Abuse ................................................................................. 22Substance Use, Abuse, Dependence and Psychiatric Comorbidity ......................................... 23Substance Abuse Treatment ................................................................................................ 24

Depression ............................................................................................................................25Lesbians and Depression ..................................................................................................... 26Ethnic Subgroups and Depression........................................................................................ 26Poor, Single Mothers and Depression................................................................................... 27Comorbidity and Depression ............................................................................................... 27Treatment for Depression .................................................................................................... 28

Suicide ..................................................................................................................................30Risks and Protective Factors in Suicide ................................................................................. 31Racial and Ethnic Subgroups and Suicide ............................................................................. 31Gay Teens and Suicide ........................................................................................................ 31Treatment to Prevent Suicide ............................................................................................... 32

Eating Disorders ....................................................................................................................32Racial and Ethnic Groups and Eating Disorders .................................................................... 33Risks and Protective Factors................................................................................................. 33Treatment for Eating Disorders ............................................................................................ 34

Premenstrual Dysphoric Disorder ...........................................................................................34Psychiatric Disorders During Pregnancy .................................................................................34Postpartum Depression .........................................................................................................35Young Mothers and Psychiatric Disorders ..............................................................................35Gender and Attention Deficit Disorder with Hyperactivity ......................................................36

Treatment for AD/HD.......................................................................................................... 37What the Evidence Suggests ..................................................................................................37Recommendations.................................................................................................................38Conclusion ............................................................................................................................39References .............................................................................................................................40

A Roadmap to Mental Health Services for Transition Age Young Women: A Research Review 1

Executive Summary

A Roadmap to Mental Health Services for TransitionAge Young Women: A Research Review was sponsoredby the California Women’s Mental Health PolicyCouncil (WMHPC), in collaboration with theCalifornia Institute for Mental Health (CIMH). TheWMHPC, founded in 1999, is a statewide non-partisan membership organization, with a missionto ensure effective, gender-specific, culturallyappropriate mental health services for women andgirls. CIMH promotes excellence in mental healthservices, emphasizing research and educationalactivities based on scientifically proven mentalhealth treatments and services.

The report focuses specifically on the mentalhealth needs of adolescent girls and young adultwomen, sometimes referred to as “transition age”women, as they move through adolescence toadulthood. The primary purpose of the report is tohighlight the evidence from the social scienceliterature regarding mental health treatments andpractices that are most efficacious for transition agewomen.

The report includes: (a) information aboutspecific mental health problems which dispro-portionately affect young women, (b) evidence fromthe social science literature on mental healthinterventions focused on young women, (c) analysisof evidence-based interventions most likely toenhance young women’s successful transition toadulthood, and (d) implications for mental healthservice delivery.

Gender and Mental HealthService Utilization

There is clear evidence that transition age youngwomen tend to fare more poorly than their malecounterparts, with more sexual assaults, singleparenthood, and homelessness, under employmentand unemployment, and suicide attempts.Moreover, this vulnerable group is often neglectedin social and mental health service systems.Unfortunately, there has been only limited researchconducted on the outcomes of gender-specificprograms and interventions.

A growing body of evidence indicates thattransition age women are not accessing mentalhealth services at the same rates as their malecounterparts, despite demonstrated need. Mentalhealth problems in girls tend to be identified laterthan in boys, or in some instances, are missedaltogether. The knowledge levels of “gateway”service providers—primary health, child welfare,juvenile justice, and education professionals—aboutthe specific mental health service needs of adolescentgirls and young women are primary predictors ofmental health service use.

Understanding developmental stages andmilestones is a prerequisite for effective mentalhealth interventions for adolescent girls and youngwomen. Clinicians who work with young womennot only need to address the presenting problem butalso the normative skills their clients may have failedto develop as a consequence of having an emotionalor behavioral disorder during this criticaldevelopmental phase.

Mental health prevention research has yieldedgreater understanding of the conditions, or riskfactors, which can lead to many of the mental healthproblems young women face. Protective factors arethe personal, social and institutional resources thatfoster development of resiliency in youth andpromote successful adolescent development orbuffer risk factors that might otherwise compromisedevelopment. Programs should focus on the riskfactors most likely to impact girls and build on theprotective factors most likely to promote resiliency.Substantial research exists, and is highlighted in thefull report, on the risk and protective factors foradolescents and to some extent those specifically

Understanding developmentalstages and milestones is a

prerequisite for effective mentalhealth interventions for adolescent

girls and young women.

2 A Roadmap to Mental Health Services for Transition Age Young Women: A Research Review

relevant for adolescent girls and young women.Mental health and social service practitioners needto be more aware of these factors as they choose anddevelop interventions for transition age women.

Trauma and Young Women:Prevalence and Implications

Trauma — exposure to emotionally painful orshocking events with lasting effects — is implicatedas a risk factor for virtually all psychiatric diagnosesaffecting young women, including substance abuse.In addition, the early results from research onjuvenile delinquency suggest that trauma may bethe pathway to delinquency for girls.

Researchers have found extremely high rates ofinterpersonal violence and victimization amongadolescents. Researchers have also found a higherprevalence of all types of victimization amongAfrican American and Native American adolescents.Girls are more likely to have experienced sexualassault than boys, but boys are at significantlygreater risk of experiencing physical assault. Asubstantial number of all adolescents report havingwitnessed violence and rates of physically abusivepunishment are similar for both genders.

Although there is still limited information aboutthe connection between trauma and mental healthproblems in transition age women specifically, theevidence increasingly supports a pattern for youngwomen similar to the known impacts of trauma inadult women. The connection between substanceabuse, mental health problems and trauma for adultwomen receiving substance abuse and/or mentalhealth treatment is well established.

Acute traumatic stress in young women isassociated with Posttraumatic Stress Disorder(PTSD), depression, substance abuse, health riskingsexual behaviors and health-related problems.Adolescent girls are six times more likely than malesto be diagnosed with PTSD following exposure toviolence. Victims of sexual assault also report highlevels of depression, anxiety and substance abuse.Sexual violence may have a detrimentaldevelopmental impact on educational, occupationaland relationship functioning. Interpersonal violenceincreases the risk of PTSD, major depression,substance abuse and dependence and comorbidity.

In addition, childhood victimization seems toincrease the chances of further trauma becauseyoung women do not fully develop the socialcognitions — safe behaviors and ability to perceivedanger — that would protect them from furthervictimization.

Treatment Implications. The research stronglysuggests that clinicians working with young womenwho have been exposed to trauma should evaluatethem for PTSD, major depression and substanceabuse. Research findings also suggest thatidentifying, challenging and modifying inadequatesocial cognitions may help to reduce risky behaviorsand revictimization in young women with a historyof trauma.

Girls in the Juvenile Justice SystemStatistics show that more girls are becoming

involved in the justice system, at younger ages, andfor more violent offenses. Girls from ethnic minoritygroups are disproportionately represented, andfemale delinquents have fewer placement optionsthan their male peers in the juvenile justice system.

Females in the juvenile justice system havespecialized mental health treatment needs. Studiesindicate that female juvenile offenders have greaterexposure to trauma, a greater incidence of mentalhealth problems than male juvenile offenders andhigher incidences of physical, emotional and sexualabuse, physical neglect, and family history of mentalillness than their male counterparts.

Treatment. Effective mental health treatments foryouth in the juvenile justice system need to be highlystructured, emphasize the development of basicskills, and provide individual counseling whichaddresses behaviors, attitudes and perceptions.Cognitive behavioral approaches have been shownto be the most effective treatments for youth in thejuvenile justice system, particularly those withtrauma-related problems. Interventions that involvethe family in treatment and rehabilitation have beenshown to be more successful than usual care indecreasing subsequent arrests, self-reporteddelinquency and time spent in institutions.Interventions should positively impact a youngwoman’s relationships with her family and othersupportive adults, peer culture, school andcommunity.


Dialectical Behavior Therapy (DBT) is amodification of Cognitive Behavioral Therapy (CBT)designed specifically for individuals with self-harmtendencies, including those exhibiting suicidaltendencies and behaviors. Research on theeffectiveness of DBT with female juvenile offendershas shown that DBT is most effective with anintensive training program, motivated staff, andfemale juvenile offenders who exhibit the types ofparasuicidal and aggressive behavior that DBTtargets.

Evidence suggests that it is important to involvefamily members in treatment and rehabilitation ofjuvenile delinquents. Three family interventionswere highlighted as model programs in the 2001Surgeon General’s report Youth Violence —Functional Family Therapy (FFT), MultisystemicTherapy (MST) and Multidimensional TreatmentFoster Care (MTFC). While the outcomes for all threeinterventions demonstrated effectiveness inreducing juvenile offending and increasing parentalcompetencies, only MTFC has been specificallyadapted for intervention with girls. MTFC is acommunity and family-based alternative toresidential and group care for youth with behavioral,emotional and mental health problems.

Posttraumatic Stress DisorderA relatively small portion of those who

experience a traumatic event suffer from PTSD as aresult. However, women are twice as likely as mento have PTSD at some point in their lives. Forwomen, the most common events precipitatingPTSD are rape, sexual molestation, physical attack,being threatened with a weapon, and childhoodphysical abuse.

Treatment. There are currently no treatments forPTSD developed for or tested specifically onadolescent girls or young women. However, giventhe high prevalence of PTSD in women, most of theparticipants in clinical trials have been female.Cognitive Behavioral Therapy is the most efficacioustreatment for PTSD. Exposure therapy, a form ofCBT unique to trauma treatment, uses carefullyrepeated, detailed imagining of the trauma(exposure) in a safe, controlled context, to help thesurvivor face and gain control of the fear and distressthat was overwhelming during the trauma.

Along with exposure, CBT for trauma includes:learning skills for coping with anxiety and negativethoughts, managing anger, preparing for stressreactions (stress inoculation), handling futuretrauma symptoms, addressing urges to use alcoholor drugs when trauma symptoms occur, andcommunicating and relating effectively with people.In addition, there have been recent advances in earlyintervention and in the treatment of disorders thatare comorbid with PTSD.

Substance AbuseWhile there have been promising declines in

adolescent substance abuse in recent years, younggirls have been smoking and drinking as much asboys and are catching up in the use of illicit drugs.However, girls are suffering consequences beyondthose of boys. Girls and young women usesubstances for reasons that differ from boys andyoung men, risk factors are different, and girls andyoung women are more vulnerable to addiction:they get hooked faster and suffer the consequencessooner than boys and young men. Girls who abusesubstances are more likely than boys to be depressedand suicidal and to have eating disorders. Inaddition, substance abuse increases the likelihoodthat girls will engage in risky sex or be the victimsof sexual assault. Although the research is relativelysparse, several studies have identified differencesin substance abuse among girls from different ethnicsubgroups.

As in the broader population of substanceabusers, high percentages (up to 60 percent) ofadolescents have a comorbid diagnosis; mostcommonly conduct disorder and oppositionaldefiant disorder, followed by depression. The dualdiagnosis of PTSD and substance abuse is common.Untreated trauma symptoms in women hamper

Girls who abuse substances are morelikely than boys to be depressed andsuicidal and to have eating disorders.


engagement in substance abuse treatment, lead toearly drop-out and make relapse more likely.

Treatment. Although the number of curricula andintervention programs specifically addressing thesubstance abuse treatment needs of girls and youngwomen is increasing, there are still relatively fewprograms, and very few studies evaluating theireffectiveness. The only empirically supportedsubstance abuse treatment for adolescent girls andyoung women was developed to treat co-occurringPTSD and substance abuse. The program, SeekingSafety, emphasizes clinician selection based onperformance and adherence to the model and hasfour content areas: cognitive, behavioral, inter-personal and case management.

There are two family therapy interventions thathave strong empirical support, have developedcultural adaptations for African American andLatino youth and are currently exploring treatmentsfor adolescent girls. Brief Strategic Family Therapyhas demonstrated effectiveness for adolescentLatinos and their families. Brief Strategic FamilyTherapy is a short-term, problem-focusedtherapeutic intervention, targeting children andadolescents. Multidimensional Family Therapy wasadapted for African American youth and theirfamilies. Multidimensional Family Therapy is acomprehensive and flexible family-based programdesigned to treat substance -abusing and delinquentyouth.

DepressionOne of the most consistent findings in research

on depression is the higher prevalence of depressionand dsythymia (a mood disorder similar todepression) among women and adolescent girls.Gender differences in depression emerge in earlyadolescence, between the ages of 11 and 15. Girlsand women have consistently higher rates ofdepression than boys and men, a phenomenon thatdoes not change until old age when genderdifferences in depression disappear. Research findsevidence of comorbidity with depression fortransition age women, as is generally true for malesand adult women. For adolescent girls, specificcomorbid conditions include anxiety, substanceabuse and eating disorders, such as bulimia.

Depression in adolescence is associated withserious psychosocial dysfunction and can havenegative effects on functioning into youngadulthood. Young adults who were depressed asadolescents are less likely to finish college, tend tomake less money, are more likely to become anunwed parent and are more likely to experience ahost of stressful life events.

Research reveals some differences amongsubgroups of transition age women. Lesbians mayhave an even greater risk for depressive episodesthan other women, are at higher risk for developingalcohol dependency than heterosexual women andare more likely to engage in moderate illicit drugconsumption. Although women in other ethnicgroups experience the same rates of depression asCaucasian women, they are more likely to have theirdepression either go untreated or be inadequatelytreated. Research also consistently documents highrates of depressive symptoms among low-incomemothers with long-term dramatic consequences formothers and their children.

Treatment. These findings suggest that whenadolescent girls are evaluated and treated fordepression they should also be evaluated for thepresence of other comorbid conditions. Given thepotential negative consequences of depression inadolescents, effective early treatment is imperative.

There are efficacious treatments for depressionin adolescent girls and young women. There is alarge body of evidence indicating that CBT is anefficacious treatment for young adult and adolescentdepression. Antidepressant medications are widelyprescribed for adolescents but general practitionersgive the majority of prescriptions. Recent evidencethat treatment of depressed adolescents withantidepressants is associated with a higher risk ofsuicide has caused the U.S. Food and DrugAdministration (FDA) to issue a “black boxwarning” to health care professionals.

It is particularly important that if used,medication be combined with careful monitoring andother treatment approaches. The Treatment forAdolescents with Depression Study Team (TADS),sponsored by the National Institutes of Mental Health(NIMH), has demonstrated the efficacy of CBT incombination with antidepressant medication.


Recent study findings suggest that medicationinterventions may be more effective for low-income,ethnic minority women than psychotherapyinterventions. Research also demonstrates thatevidence-based interventions appear to be moreeffective for poor ethnic minority women if they aregiven support to overcome barriers to care.

Early research findings also suggest that time-limited psychotherapy for depression offers womenrapid relief from their symptoms and may prove tobe an efficacious treatment for women. There is agrowing body of research demonstrating the efficacyof Interpersonal Psychotherapy (IPT) for thetreatment of depression. IPT is a brief, highlystructured, and manualized psychotherapy thataddresses the interpersonal issues in depression. IPTholds that depression occurs within an interpersonalcontext but does not arise exclusively frominterpersonal problems.

SuicideSuicide is currently the third leading cause of

death among 15-to 24-year olds in the United States.Suicide incidence increases markedly in the late teensand continues to rise until the early twenties, reachinga level that is maintained throughout adulthood. Likecompleted suicides, suicide attempts are relativelyrare among children before puberty but increase infrequency throughout adolescence. However, unlikecompleted suicides, attempts peak between 16 and18 years of age after which there is a marked declinein frequency particularly for young women.Although suicide ideation and attempts are morecommon among females, completed suicide is morecommon among males.

The incidence of youth suicide differs amongracial and ethnic subgroups. Youth suicide is morecommon among whites than African Americanyouths in the U.S, with the highest rates in NativeAmericans and the lowest rates among Asian PacificIslanders. A recent study examining suicidalityamong urban African American and Latino youthdemonstrated an association between ethnicity,poverty and suicide. Research also reveals that gayteens are more likely to attempt suicide.

Treatment. Few studies have systematicallyevaluated interventions aimed at reducing suicidal

ideation and behavior in adolescents and youngadults. Only two treatments, neither one of whichwas gender-specific, meet the criteria for probablyefficacious—developmental group psychotherapyand a home-based intervention that includedproblem-solving and communication.

Eating DisordersFemales comprise the majority of individuals

diagnosed with an eating disorder—— anorexianervosa, bulimia nervosa and binge eating. Eatingdisorders often co-occur with depression, substanceabuse and anxiety disorders and can cause serioushealth problems. Adolescent girls are at greater riskthan those of other ages for developing an eatingdisorder. In addition, comorbidity is the rule ratherthan the exception. In general, there are inconsistentfindings concerning ethnicity and eating problems.

Treatment. Research on the causes of eatingdisorders and on effective treatments is in the earlystages. There have been some studies withdemonstrated good outcomes for the treatment ofanorexia and bulimia. Because risk is associated withthe developmental period of adolescence and youngadulthood and because the consequences, if nottreated, can be dire, accurate assessment andtreatment of eating disorders is crucial.

To date there have only been three controlledstudies demonstrating the efficacy of interventionapproaches for eating disorders. An NIMH clinicaltrial found that CBT was superior to IPT in reducingthe symptoms associated with bulimia. A secondcontrolled trial found that both vomiting andbingeing in bulimia were clinically improved bytreatment with fluoxetine or a manual-basedbehavioral program. A combination of the twoapproaches led to the greatest improvement. The

Although suicide ideation andattempts are more common amongfemales, completed suicide is more

common among males.


third study evaluated the efficacy of DBT adaptedto the treatment of binge eating and found thatwomen treated with DBT showed decreased bingeeating and eating problems.

Premenstrual Dysphoric DisorderPremenstrual Dysphoric Disorder (PMDD) is

diagnosed in approximately 5 percent ofmenstruating women and is distinguished from themore common premenstrual syndrome (PMS) bymore severe symptoms and associated functionalimpairments. New research demonstrates thatwomen with PMDD have functional disabilitiessimilar to those found with other mood disorderssuch as depression and dysthymia.

Treatment. Randomized controlled trials focusingon PMDD consistently show that selective serotoninreuptake inhibitor (SSRI) antidpressants arebeneficial in treating symptoms. Research indicatesthat treatment of PMDD is efficacious if medicationadministration is limited to the luteal phase (thedays following ovulation) of the menstrual cycle.The current research on PMDD does not reviewalternatives to medication such as psychotherapy.

Psychiatric DisordersDuring Pregnancy

Researchers are currently studying the specialproblems of treating serious mental illness in womenduring pregnancy, including transition age womenwho become pregnant. Although the effect ofpsychoactive drug treatment on the fetus duringpregnancy has received some attention, informationabout the effectiveness of different pharmo-cotherapies is still limited. A recent prospective studyof newborns whose mothers were treated withSelective Serotonin Reuptake Inhibitors (SSRI’s)showed that their infants demonstrated disruptionin a wide range of neurobehavioral outcomesincluding motor activity, startle and heart rateregulation. The American Academy of Pediatrics,Committee on Drugs (2000) provided research-basedguidelines to assist physicians with appropriate drugselection for women who are either contemplatingpregnancy or are pregnant and who have psychiatricdisorders that require drug treatment.

Postpartum DepressionPostpartum Depression (PPD) typically emerges

over the first two-to-three postpartum months, butmay occur at any point after delivery. Non-pharmacological therapies are useful in thetreatment of PPD. Therapy without medication canbe an important consideration for women who arebreast feeding and unwilling to take medicationbecause of potential harm to their babies. Short-termcognitive-behavioral therapy has been shown to beas effective as treatment with fluoxetine in womenwith postpartum depression. In addition, IPT hasbeen shown to be efficacious for the treatment ofmild-to-moderate PPD. To date, only a few studieshave systematically assessed the pharmacologicaltreatment of PPD. In general, conventionalantidepressant medications (fluoxetine, sertraline,fluvoxamine and venlafaxine) have been shown tobe efficacious in the treatment of PPD.

Young Mothers andPsychiatric Disorders

Under the best of conditions parenting can bestressful for most mothers. However, for a youngwoman with mental health problems, parenting mayoverwhelm her coping capacities and result in pooroutcomes (including abuse and neglect) for herchildren. Intervention to help her manage her mentalhealth symptoms and increase her parentingcompetencies decreases the risk of negativeconsequences for both mother and children.

Research consistently demonstrates thatchildren of mothers with mental health problemsare more likely to live in poverty than children bornto mothers without mental health problems and arethemselves at risk for developing mental healthproblems. In addition, the research on depressiondemonstrates that single, low-income women beara greater burden of depression than women whoare not mothers.

One treatment program, the Nurse-FamilyPartnership Program, has been shown to produceconsistently good outcomes for low-income womenand their children through the child’s fourth yearof life. In comparison to control groups, women whoreceived services from the Nurse-Family PartnershipProgram, had better prenatal health, lower use of


cigarettes, reduced injuries to their children, andlower rates of subsequent pregnancy and less useof income assistance.

Gender and Attention DeficitDisorder With Hyperactivity

Attention Deficit Hyperactivity Disorder (AD/HD) is a prevalent child psychiatric disorder forwhich efficacious pharmacological andpsychological treatments have been established.Nevertheless, several studies indicate that girls andchildren from ethnic minority backgrounds aresignificantly less likely to receive AD/HD treatment,including psychotropic medications, than are boysand Caucasian children. Research has founddifferent behavioral manifestations of AD/HD ingirls and boys and the differences may result ingender-based referral bias unfavorable to girls. Forexample, researchers have found that girls with AD/HD had relatively high rates of verbal aggressiontoward other children, whereas boys with AD/HDengaged in more rule breaking and externalizingbehaviors.

Treatment. There is a paucity of data regardingthe efficacy of medications for the treatment of AD/HD in girls. The limited published literaturesuggests that psychostimulant treatment is equallyeffective in boys and girls with AD/HD. A large-scale randomized clinical trial assessed the efficacyof atomoxetine in school-age girls with AD/HD andfound that atomoxetine was superior to placebo inreducing the core symptoms associated with AD/HD (inattention and impulsivity) and that themedication was well tolerated by the researchparticipants.

What the Evidence SuggestsThe literature reviewed found that there are

relatively few studies focused on the special issuesand treatment needs of transition age women.Where treatments and interventions have beendesigned for adolescent girls and young women,they are in the early stages of implementation andanalysis. The evidence presented suggests thattransition age women experience all of the mentalhealth problems common in adult women, andaffecting young men, to some extent, and may

experience higher rates of some disorders, such asdepression, suicidality and eating disorders. Inaddition, the literature review revealed the following:

• Understanding developmental stages andmilestones is a prerequisite for effective mentalhealth interventions for adolescent girls andyoung women. Clinicians who work with youngwomen not only need to address the presentingproblem but also the normative skills theirclients may have failed to develop as aconsequence of having an emotional orbehavioral disorder during this criticaldevelopmental phase.

• Trauma is implicated as a risk factor for most ofthe psychiatric diagnoses affecting youngwomen. Therefore, treatment of adolescent girlsand young women should include screening forpast and present trauma exposure. Treatment fortrauma-related symptoms should be providedin addition to treatment for a specific mentalhealth diagnosis or problem.

• More girls are becoming involved in the justicesystem, at younger ages, and some for moreviolent offenses. The delinquent behaviors thatpropel these women into the justice system oftencan be traced to trauma and the aftermath oftrauma. Girls from ethnic minority groups aredisproportionately represented, and femaledelinquents have fewer mental health placementoptions than their male peers in the juvenilejustice system.

• Transition age women may not be accessingmental health treatment to the same degree astheir male peers, despite clear evidence that theyexperience many of the same mental healthchallenges.

• Comorbidity is the rule rather than theexception. Assessment for any one of thedisorders reviewed in the report should includeassessment for all others. Particular attentionshould be paid to the relationship betweendepression and substance abuse.

• There are specific risk and protective factors formost of the mental health conditions affectingyoung women. Understanding these factors canimprove prevention, identification, diagnosisand treatment for girls in this important lifestage.


• The high incidence of comorbidity, thecorrelation between mental health problems andtrauma and the complex array of risk andprotective factors affecting the mental healthstatus of young women combine to make acompelling case for integrated service andtreatment programs.

• There are unique issues and challenges foryoung women in ethnic and cultural subgroups,often necessitating specialized research,assessment and treatment approaches.

• Treatments that are effective or efficacious inyoung men or adults may or may not besimilarly effective for young women. Furtherresearch is needed on the most effectivetreatments to meet the unique mental healthneeds of transition age women.

RecommendationsThe following general guidelines are offered for

policy makers and practitioners responsible forproviding services to transition age young women.The findings of the report call for interventions that:

• Are supported by evidence from controlledscientific studies;

• Have the greatest potential to support successfulcompletion of key developmental tasks,including the development of high qualityfriendships, prosocial behavior and academic orvocational success;

• Promote connectedness to community and familyor supportive adults outside of the family; and

• Improve coping skills and self-efficacy foradolescent girls and young women.In addition to these general guidelines, WMHPC

makes the following specific recommendations:

Recommendation 1: Integrate mental health andsubstance abuse treatment services

The rates of comorbidity are stunning and arguefor simultaneous rather than sequential treatment.At the very least, mental health clinicians andsubstance abuse counselors should be cross-trainedto provide or make appropriate referrals tocomprehensive screening for Posttraumatic StressDisorder, major depression, suicide risk andsubstance abuse.

Recommendation 2: Provide gender-specificprogramming for young women in the juvenilejustice system

Adolescent girls entering the juvenile justicesystem bring with them complex health and mentalhealth needs related to trauma histories, includingchildhood abuse and current partner abuse, sexualbehavior and substance abuse. Services for girls inthe juvenile justice system should include treatmentfor depression, traumatic stress, substance abuse,parenting skills and health-risking sexual behaviors.

Recommendation 3: Provide training to allgateway service providers working withadolescent girls and young women

Gateway service providers—child welfare,juvenile justice, primary health and educationproviders—need the information and the tools torecognize risk and protective factors, identify mentalhealth symptoms early and make appropriate referrals.

Recommendation 4: Provide specializedtreatment programs for transition age mothers

Specialized treatment programs need to beavailable for young mothers and should also includethe support services necessary for them toparticipate in their treatment, such as transportation,child care and parenting training.

Recommendation 5: Provide specialized trainingfor clinicians working with adolescent girls andyoung women

Mental health clinicians should receive evidence-based training and education, including under-standing of the distinct risk and protective factors foradolescent girls and young women in racial and ethnicsubgroups. Clinicians need the information and thetools to allow them to offer culturally and genderappropriate services and treatments.

Recommendation 6: Increase funding for mentalhealth treatment research specific to transition agewomen and subgroups of transition age women

Research on the unique treatment and serviceneeds of transition age women is so far inadequateand more research is needed. Further targetedresearch is needed. It is critical that gender andethnicity become routine variables in researchprojects, and a component of all data collected,analyzed and published by funding agencies.


A Roadmap to Mental Health Services for TransitionAge Young Women: A Research Review was sponsoredby the California Women’s Mental Health PolicyCouncil (WMHPC), in collaboration with theCalifornia Institute for Mental Health (CIMH). TheWMHPC, founded in 1999, is a statewide non-partisan membership organization, with a missionto ensure effective, gender-specific, culturallyappropriate mental health services for women andgirls. CIMH promotes excellence in mental healthservices, emphasizing research and educationalactivities based on scientifically proven mentalhealth treatments and services.

This report focuses specifically on the mentalhealth needs of adolescent girls and young adultwomen, sometimes referred to as “transition age”women, as they move through adolescence toadulthood. There is clear evidence suggesting thattransition age young women tend to fare more

poorly than their male counterparts, with moresexual assaults, single parenthood, homelessness,under employment and unemployment, and suicideattempts (Davis & VanderStoep, 1997; Lewinsohn,Rhode, & Seeley, 2001). Moreover, this vulnerablegroup is often neglected in social and mental healthservice systems. Unfortunately, there has been onlylimited research conducted on the outcomes ofgender-specific programs and interventions.

Introduction The primary goal of this report is to providemental health service system decision makers withthe available evidence from the scientific literaturein order to improve outcomes for transition ageyoung women. The report includes: (a) informationabout specific mental health problems whichdisproportionately affect young women, (b)evidence from the social science literature on mentalhealth interventions focused on young women, (c)analysis of evidence-based interventions most likelyto enhance young women’s successful transition toadulthood, and (d) implications for mental healthservice delivery.

A Developmental PerspectiveThis report relies on a developmental

perspective as a cross-cutting theme based on thisvalue assumption: change in young women is bothinevitable and desirable. Fundamentally, under-standing developmental stages and milestones is aprerequisite for effective mental health interventionsfor adolescent girls and young women. Clinicianswho work with young women not only need toaddress the presenting problem but also thenormative skills their clients may have failed todevelop as a consequence of having an emotionalor behavioral disorder during this criticaldevelopmental phase.

One of the primary goals of clinical interventionwith adolescent girls should be helping them attainmastery of the developmental tasks which predictsuccessful adaptation in adulthood. For example, thedevelopmental literature suggests that, inadolescence, developing high-quality friendships,prosocial behavior and academic or vocationalsuccess can increase a young woman’s chance ofenjoying mutually satisfying romantic relationshipsand work success, the primary developmental tasksof young adulthood (Roisman, Masten, Coatsworth,& Tellgen, 2004).

Girls and young women experience distinctstresses and require different skills at various stagesin their development. Young women experienceconcurrent cognitive, social, physical and emotionalchanges. The complex and interacting changes ofthis developmental phase can present uniquestresses and challenges to the healthy physical andpsychological functioning of individual young

Clear evidence suggests thattransition age young women tend

to fare more poorly than their malecounterparts, with more sexual

assaults, single parenthood,homelessness, under employment

and unemployment, andsuicide attempts.


Table 1 Developmental Milestones forAdolescents and Young AdultsDevelopmental Milestones in Adolescence• Sexual development• Higher cognitive abilities, including

abstraction, consequential thinking,hypothetical reasoning and perspectivetaking

• Transformations in youth-familyrelationships; potential increase in familyconflicts

• Peer relationships increasingly importantand intimate

• Making transition from adolescence toadulthood

• Developing sense of identify andautonomous functioning

Developmental Milestones in YoungAdulthood

• Establishment of meaningful andenduring interpersonal relationships

• Identity explorations in areas of love,work and world views

• Peak of certain risk behaviors• Obtaining education and training for

long-term adult occupationAdapted from Holmbeck, Greenley, & Franks2003.

women, but there is some commonality andpredictability. Physiological changes for the teen girlinclude the onset of menses, the ability to procreateand the alterations in her body. Psychologicalchanges include shifting perceptions of body image,development of personal identity, interest in self asa sexual being and an increasing ability to thinkabstractly and to experience increasingly complexemotions. Major developmental milestones duringthis period are outlined in Table 1.

This developmental perspective—that thetreatment needs of transition age women must be metin the context of the complex developmental stagesthey are navigating—is a foundation of this reportand of much of the evidence available on this topic.

Methodology andDefinitions

The primary purpose of this report is to highlightthe evidence from the social science literatureregarding mental health treatments and practicesthat are most efficacious for transition age women.Mental health treatments are classified as effective,efficacious or promising, depending on the level ofscientific evidence in support of a particulartreatment or intervention. A practice is said to beeffective when it achieves outcomes based oncontrolled research (random assignment), withindependent replications in usual care settings. Apractice is deemed efficacious when it achievesoutcomes based on controlled research (randomassignment or quasi–experimental design) and incontrolled settings (e.g. university research, NationalInstitutes of Mental Health). Finally, a practice ispromising when it achieves outcomes based on arigorous evaluation (generally involving acomparison group) or a series of pretests andposttests. In reviewing the literature on outcomesfor gender–specific treatments, there were noexamples of effective or promising interventions,only efficacious ones.

Focus on Mental Health TreatmentThe treatments and practices included in this

report are, in most cases, related to mental healthtreatment for a specific diagnosis or constellation ofsymptoms and functional difficulties. Increasingly,practitioners and researchers recognize that effectivetreatment of youth with mental illness requires morethan discreet mental health treatments but involvescomprehensive, integrated programs that alsoincorporate supportive services, including vocationaltraining, housing, transportation, etc. However, areview of comprehensive service programs is notincluded here. This decision was made for a variety ofreasons. First, the research and development on thesetypes of programs is still in its infancy and therefore,largely conceptual in nature. Second, programs fortransition age youth funded by the federal SubstanceAbuse and Mental Health Services Administration arerelatively new and have not yet produced outcomedata to inform an analysis of effectiveness. Finally, thereis virtually no evidence to support gender-specificconclusions or recommendations.


Identification of Risksand Protective Factors

This report also identifies those factors thatincrease the risk of or protect against mental illnessin transition age young women. Mental healthprevention research has yielded greaterunderstanding of the conditions, or risk factors,which can lead to many of the mental healthproblems young women face, such as substanceabuse, teen pregnancy, suicide, delinquency,violence and early withdrawal from school. Riskfactors exist in four domains: individual, peer group,family, school and community.

Protective factors are the personal, social andinstitutional resources that promote successfuladolescent development or buffer risk factors thatmight otherwise compromise development.Protective factors foster the development ofresiliency in youth. The concept of protective factorshas been instrumental in shifting the focus oftreatment from what is wrong with youth to whatcan be done to facilitate healthy development.

In addition, the report includes availableresearch and related recommendations on the racial,ethnic and gender differences in prevalence, risk andprotective factors and mental health treatments fortransition age women and subgroups of transitionage women.

Gender and Mental HealthService Utilization

A growing body of evidence indicates thattransition age women are not accessing mentalhealth services at the same rates as their malecounterparts, despite demonstrated need (Cuffe,Waller, Addy, McKeown, Jackson, Moloo, &Garrison, 2001; Jordon, 2004; Kataoka, Zhang, &Wells, 2002; Strum, Ringel, & Andreyeva, 2003). Oneof the most likely factors accounting for thisdifference is the gender bias in referral rates fromthe juvenile justice, child welfare and specialeducation systems (Jordon, 2004). Mental healthproblems in girls tend to be identified later than inboys, or in some instances, are missed altogether(McGee and Feehan, 1991). One possible explanation

for this disparity is that the behavioralmanifestations of mental health problems in girlsare different than those in boys and also potentiallyless disruptive in home, school and communitysettings.

Stiffman, et al. (2001) found that “gateway”service providers—primary health, child welfare,juvenile justice, and education providers (Mechanic,Angel, & Davies 1991)—are the first (other thanparents) to identify and refer a youth for mentalhealth services. This research concluded that theprimary predictors of mental health serviceprovision were not mental health need but rathergateway service provider variables. Specifically,provider knowledge of youth mental healthproblems and provider knowledge of mental healthresources were the primary predictors of service use(Stiffman, et al., 2001).

Trauma and YoungWomen: Prevalenceand Implications

This report begins with the prevalence researchon trauma because trauma is implicated as a riskfactor for virtually all psychiatric diagnoses affectingyoung women, including substance abuse. Inaddition, the early results from research on juveniledelinquency suggest that trauma may be thepathway to delinquency for girls.

In psychiatric terms, trauma refers to anexperience that is emotionally painful, distressingor shocking, and which often results in lastingmental and physical effects. Psychiatric trauma oremotional harm is essentially a normal response toan extreme event. It involves the creation of

Trauma is implicated as a risk factorfor virtually all psychiatric diagnosesaffecting young women, including

substance abuse.


emotional memories about the distressing event. Ingeneral, it is believed that the more direct theexposure to the traumatic event, the higher the riskfor emotional harm. However, even “second-hand”exposure to violence or a disaster can be traumatic.

There are a range of traumatic experiences towhich adolescents and young women might beexposed. They include: (a) community violence,including witnessing community violence; (b)domestic violence, including same-sex partnerabuse; (c) man-made or natural disasters; (d) neglect;(e) physical abuse; (f) psychological maltreatment;(g) school violence; (h) sexual abuse; and (i)terrorism.

In addition, adolescent girls might experiencerefugee trauma, childhood traumatic grief andcomplex trauma, which bear some explanation.First, refugee trauma includes exposure to war,political violence or torture. Refugee trauma can bethe result of living in a region affected by bombingsand shootings or experiencing forced displacementbecause of political violence. Second, childhoodtraumatic grief can occur following the death of aloved one. Traumatic grief occurs when traumasymptoms interfere with the child’s ability tonavigate the typical bereavement process. Finally,complex trauma refers to exposure to multiple orprolonged traumatic events which have an impacton development. Exposure to multiple andprolonged traumatic events—and the resulting lossof safety, inability to regulate emotions and theability to detect or respond to cues of danger—oftensets off a chain of events leading to subsequent orrepeated trauma exposure in adolescence andadulthood (www.nctsnet.org).

Trauma researchers use a variety of terms tocommunicate about the trauma experience. Theterms trauma, trauma exposure, exposure andvictimization are used somewhat interchangeably.In general, trauma refers to an event or experience;traumatic stress is the result of that experience(which may or may not include the actual diagnosisof posttraumatic stress disorder). In this review, theterms used generally reflect the terminology usedby the researchers and authors referenced.

Violence against women overall is a seriouspublic health problem and affects relatively highpercentages of all women. The National

Comorbidity Study, using a nationally represen-tative sample, found 9 percent of women reportedbeing raped, 12 percent reported being sexuallymolested, 7 percent reported being physicallyassaulted and 7 percent reported being threatenedwith a weapon at least once in their lifetime (Kessler,Sonnega, Bromet, Hughes, & Nelson, 1995).Respondents in the National Women’s Surveyreported similar rates of violent victimization. Ofthe participants interviewed, 13 percent experiencedrape, 14 percent reported other sexual assault and10 percent had been physically assaulted duringtheir lifetime (Resnick, Kilpatrick, Dansky, Saunders,& Best, 1993).

Two recent large-scale studies reviewed theresults of surveys that included youth—onecommissioned by the United States JusticeDepartment and the other at the Medical Universityof South Carolina—and examined the relationshipbetween youth victimization and mental health anddelinquency outcomes.

The Justice Department survey found that a clearrelationship exists between youth victimization,mental health problems and delinquent behavior(Kilpatrick, Saunders & Smith, 2003). Surveyrespondents reported lifetime prevalence of fourtypes of violence: sexual assault, physical assault,physically abusive punishment and witnessing anact of violence. Researchers found extremely highrates of interpersonal violence and victimizationamong adolescents. Specifically, 1.8 millionadolescents had been sexually assaulted, 3.9 millionhad been severely physically assaulted and another2.1 million reported being punished by physicalabuse. The survey revealed that witnessing someform of violence was the most prevalent traumaexperience, with approximately 8.8 million youthsindicating that they had seen someone shot, stabbed,physically assaulted, sexually assaulted orthreatened with a weapon.

Kilpatrick et al. (2003) also examined variationby race, ethnicity and gender. They found a higherprevalence of all types of victimization amongAfrican American and Native American adolescents.More than half of African American, NativeAmerican and Latino adolescents had witnessedviolence in their lifetime. Native Americanadolescents also had the largest prevalence rate for


sexual assault victimization; Caucasians and Asiansreported the lowest. Native Americans, AfricanAmericans and Latinos reported the highestvictimization prevalence of physical assault;between 20 and 25 percent reported experiencing atleast one physical assault.

Exposure to violence also differed by gender.Girls were more likely to have experienced sexualassault than boys (13 percent compared to 3.4percent of boys). Boys, however, were at significantlygreater risk of experiencing physical assault (21.3percent compared to 13.4 percent of girls). Asubstantial number of all adolescents reportedhaving witnessed violence (43.6 percent of boys and35 percent of girls). Physically abusive punishmentwas similar for both genders (8.5 percent for boysand 10.2 percent for girls).

Consistent with other research on victimizationof youth, the Justice Department survey found thatthe victims typically knew the perpetrators of bothsexual and physical assault. Perpetrators includedfamily members, friends, adult authority figures andromantic partners. In addition, victimization tookplace in familiar settings – home, school andneighborhood.

In addition to epidemiological data about therates of violence and exposure to violence, there isan extensive body of literature describing thenegative sequelae experienced by female victims ofviolence. Data from national samples demonstratethat Posttraumatic Stress Disorder (PTSD) is arelatively common response (Kessler, et al., 1995;Resnick, et al., 1993). Victims of sexual assault alsoreport high levels of depression, anxiety andsubstance abuse (Byrne, Resnick, Kilpatrick, Best,& Saunders, 1999). Since most cases of rape andother sexual assault occur before age 18 (Kilpatrick,Edmunds, & Seymour, 1992), sexual violence mayhave a detrimental developmental impact oneducational, occupational and relationshipfunctioning.

Kilpatrick et al. (2003) also examined the ratesat which adolescents reported mental healthproblems, including substance abuse and delinquentbehavior. Girls were significantly more likely thanboys to have lifetime PTSD (10.1 percent comparedto 6.2 percent of boys) and the prevalence of PTSDincreased with age. Caucasians, Native Americans

and Asians had significantly lower rates of PTSDthan did African American and Latino adolescents.Boys were significantly more likely than girls to havemet diagnostic criteria for lifetime abuse of alcohol,but for marijuana or hard drugs the prevalence rateswere similar for both genders. While the overall ratesof PTSD were lower for witnessing violence thanfor other types of victimization, the PTSD rateamong girls who witnessed violence was nearlydouble that of boys witnessing violence (20.2 percentversus 11.2 percent).

In the other study, a group of trauma researchersfrom the Medical University of South Carolina useddata from the National Survey of Adolescents to testthe hypothesis that exposure to interpersonalviolence increases the risk of PTSD, majordepression, substance abuse and dependence andcomorbidity (Kilpatrick, et al. 2003). The studysupported the hypothesis. Specifically, 15.5 percentof the boys and 19.3 percent of the girls who hadexperienced interpersonal violence had at least oneof the three mental health problems. Roughly twicethe proportion of girls met the diagnostic criteriafor PTSD and major depression. Boys and girls hadroughly the same prevalence for substance abuse,8.2 percent and 6.2 percent, respectively.

Further, the South Carolina study found thatinterpersonal violence consistently increased the riskfor comorbid mental health problems (Kilpatrick,et al., 2003). Nearly three fourths of all adolescentsdiagnosed with PTSD had at least one comorbiddiagnosis, with older girls more likely than otheradolescents to meet the diagnostic criteria for acomorbid condition.

While the evidence from community surveys,such as the National Survey of Adolescents and the

Girls were significantly more likelythan boys to have lifetime PTSD(10.1 percent compared to 6.2

percent of boys) and the prevalenceof PTSD increased with age.


National Comorbidity study, reveal the prevalenceof trauma-induced mental health problems amongyoung women in the general population, emergingresearch in young female clinical populationssuggests an even higher prevalence of trauma-induced mental illness. Although there is still limitedinformation about the connection between traumaand mental health problems in transition age womenspecifically, the evidence increasingly supports apattern for young women similar to the knownimpacts of trauma in adult women. The connectionbetween substance abuse, mental health problemsand trauma for adult women receiving substanceabuse and/or mental health treatment is wellestablished. The prevalence of physical and sexualabuse among women in substance abuse treatmentprograms is estimated to range from 30 percent tomore than 90 percent, depending on the definitionof abuse and the specific target population.(Finkelstein, VandeMark, Fallot, Brown, Cadiz &Heckman, 2004.)

Research on traumatic stress among adolescentsubstance abusers indicates that more females thanmales report traumatic life events and symptomsassociated with traumatic stress. Adolescent femalestypically score higher than males on self-reportmeasures of anxiety, depression and stress reactionsfollowing trauma (Yule, Perrin & Smith, 1998).Despite indications that adolescent boys have higherexposure to violence, female adolescents are morelikely to be diagnosed with PTSD (Stevens, Murphy,& McKnight, 2003) and six times more likely thanmales to be diagnosed with PTSD followingexposure to violence. Acute traumatic stress inyoung women is associated with PTSD, depression,substance abuse, health risking sexual behaviors andhealth-related problems (Steven, et al., 2003).

Stevens, et al. (2003) compared adolescent malesand females enrolled in drug treatment, includingthose with both low and acute levels of traumasymptoms, on the incidence of substance abuse,mental health problems, physical health problemsand HIV risk-taking behavior. The results indicatedthat adolescent females in treatment, including thesubgroup of females with acute traumatic stress,scored higher on all four outcomes than males orthose with low traumatic stress. These findings aresimilar to those found in studies of adult women

being treated for problems associated withsubstance abuse.

One of the most troubling aspects of childhoodvictimization is that it appears to initiate adevelopmental trajectory that increases thelikelihood of exposure to traumatic events inadulthood (Grauerholz, 2000; Messman & Long,1996). The developmental psychopathologyperspective holds that childhood abuse requires achild to make adaptations, which may alter thedevelopmental trajectory (Cicchetti, 1989).

Smith, Davis and Fricker-Elhai (2004) positedthat disruptions in social cognition (the mentalability to effectively perceive, evaluate and react toother people) among abused children andadolescents may be directly relevant forinterpersonal functioning later in life. The studyexplored the relationship between social cognitionsand risk behaviors among adult women withhistories of child sexual abuse, child physical abuse,aggravated assault and adult sexual assault andthose with no history of interpersonal violence. Inaddition, researchers analyzed the extent to whichsocial-cognitive processes differed for traumavictims, and if so, whether these differences wererelated to involvement in risky behaviors.

Smith et al. (2004) found that victims of childsexual abuse and adult sexual assault perceived lessrisk associated with illicit drug use and risky sexualbehavior. Further, victims of child sexual abuse, adultsexual assault, and adult assault reported morebenefits associated with illicit drug use and riskysexual behavior than did the nonvictim group, andthose sexually assaulted as adults reported morebenefits of heavy drinking than the nonvictim group.While the study did not fully examine why victimsperceive these behaviors as having more positiveconsequences than nonvictims, the results highlightthe important role of mental processes in predictinginvolvement in risky behaviors. These findingssuggest that identifying, challenging and modifyingcognitions may help to reduce involvement in riskybehaviors and the risk of revictimization in youngwomen with a history of trauma.

In summary, the evidence consistentlydemonstrates a strong relationship between traumaand mental health problems, substance abuse and


dependence, poor physical health and risky sexualbehaviors for transition age women. The researchsuggests that clinicians working with young womenwho have been exposed to trauma should evaluatethem for PTSD, major depression and substanceabuse. Complaints of health-related symptoms maybe just one indicator that a young woman could beexperiencing PTSD. Finally, the findings highlightedhere make a compelling case for integrating mentalhealth services and substance abuse treatment, giventhe high incidence of co-occurring substance abuseand other psychiatric disorders in young women.

Girls in the JuvenileJustice System

Statistics show that more girls are becominginvolved in the justice system, at younger ages, andsome for more violent offenses. Arrests of adolescentgirls for drug abuse violations have increasedmarkedly in recent years. In some cities, nearly 60to 70 percent of young women ages 15-20 testpositive for drugs at the time of arrest, with 60 to 87percent needing substance abuse treatment (MentalHealth and Adolescent Girls in the Juvenile JusticeSystem, 2004).

Females in the juvenile justice system havespecialized mental health treatment needs. Girlsfrom ethnic minority groups are disproportionatelyrepresented, and female delinquents have fewerplacement options than their male peers in thejuvenile justice system. The delinquent behaviorsthat propel these women into the justice system oftencan be traced to trauma and the aftermath of trauma.A growing body of research is beginning to identifydevelopmental pathways most likely to lead girlsto delinquency. Some scholars are beginning toidentify trauma exposure—physical, sexual and

emotional abuse—as the first step for many youngfemales moving through the juvenile justice system.There are specific characteristics, risk factors andprotective factors for these young women whichhave implications for effective treatment.

Although females represent the minority ofjuvenile offenders, arrests among girls are increasingat an alarming rate (Siegel & Senna, 2000). Femalejuvenile offenders commit less violent crimes thanmale juvenile offenders, but the number of femalesinvolved in violent crime is increasing (Acoca, 1999).Female juveniles are more likely than males to beinvolved in shoplifting, status offenses andprostitution (Chesney-Lind & Sheldon, 1998).However, an increasing number of females areinvolved in armed robbery, gang activity, drugtrafficking, burglary, weapons possession,aggravated assault, and prostitution (Siegel & Senna,2000). Between 1988 and 1997, arrests of maledelinquents increased about 28 percent whereasarrests among female delinquents increased about60 percent (Chesney-Lind & Sheldon, 1998).

Characteristics of FemaleJuvenile Offenders

Female juvenile offenders ages 14-16 are likelyto have some or all of the following characteristics:member of an ethnic minority group, poor academichistory, high-school drop out, physically and orsexually abused and exploited, use and abuse ofsubstances, unmet medical and mental health needs,feelings that life is oppressive, and lack of hope forthe future (Mullis, Cornille, Mullis, & Huber, 2004).

In addition, a number of studies indicate thatfemale juvenile offenders have greater exposure totrauma, a greater incidence of mental healthproblems than male juvenile offenders and higherincidences of physical, emotional and sexual abuse,physical neglect, and family history of mental illnessthan their male counterparts (McCabe, Lansing,Garland, & Hough, 2002). For example, Timmons-Mitchell et al. (1997) reported a prevalence of mentalhealth disorders in 84 percent of female delinquentscompared to 27 percent of males. A more recentstudy carried out by Linda Teplin and her colleaguesat Northwestern University (2002) found that,among teens in juvenile detention, nearly three

Arrests of adolescent girls for drugabuse violations have increased

markedly in recent years.


quarters of the girls had at least one psychiatricdisorder compared to 65 percent of boys. Theinvestigators found that, overall, psychiatricdisorders were more prevalent among older youthand females, and 20 percent of all females in thesample had a major depressive disorder.

Trauma Among Girls in theJuvenile Justice System

Exposure to trauma is higher among adolescentsin the juvenile justice system and appears to increasethe incidence of behaviors likely to lead to juvenilejustice system involvement. For example, exposureto trauma increases the risk of illicit substance abuseand subsequent revictimization among girls.

While data on the prevalence of posttraumaticstress disorder (PTSD) in youth vary significantlydepending on the type of sample, measurementsused and time frames assessed (Abram, et al., 2004),there is evidence that PTSD is more common inyouth in the juvenile justice system than incommunity samples, and more common amongincarcerated girls than boys (Reebye, Moretti, Wiebe,& Lessad, 2000). Chamberlain and Moore (2002) notethat stress-reactivity, developmental lags andimpairment put girls at risk for intrarelational andinterrelational chaos, which can lead to ongoingrelational and social aggression as both victim andperpetrator.

Risk Factors for Juvenile OffendingA number of interconnected risk factors for

adolescent girls being at risk of juvenile offendingand delinquency are identified in the researchliterature (reviewed in Mullis et al., 2004). Riskfactors include:

• Individual characteristics—impaired cognitivefunctioning and poor academic skills; weaklanguage skills; poor peer relationships,including having delinquent peers; early onsetof menarche; early sexual experiences; emotionaland behavioral disorders; low self-esteem;victimization; and African-American or Latinodescent.

• Family characteristics—parental disengagementand inattention in relation to their daughters,

parental abuse, family conflict, intergenerationalpatterns of incarceration and arrests, poverty,single-parent households, and poor educationfor head of household.

• Peer characteristics—association with deviantpeers, involvement in intimate relations withpeers, gang participation, sexual harassment andinterpersonal rivalries, and impulsivity andanger in friendship groups.

• School characteristics—poor school perfor-mance,early occurrence of disruptive behavior inschool, low school bonding and dropping outof school, expulsion from school, highabsenteeism and frequent school changes, andlimited involvement in extracurricular activities.

• Community characteristics—living in an urbanenvironment, early age at first arrest, distressedand disorganized neighborhood environments,lack of social supports in the community anddisruption or lack of available activities.

Protective Factors inJuvenile Offending

Protective factors refer to individual orenvironmental factors that reduce the possibility offemale juvenile offending, while resilience refers tothriving in spite of significant obstacles. Mullins etal. (2004) identified protective factors orcharacteristics of resilient female adolescents asfollows: (a) ability to garner positive attention, (b)stable caregiving, (c) quality relationship with atleast one caregiver, (d) available social networks, (e)confidence and optimism, (f) self-esteem, (g) positiveself-concept, (h) sense of autonomy, (i) stimulatingenvironments, (j) emotional support, (k) safety fromharsh environments and (l) developmental assetssupported by community activities.

Treatment for Youth in theJuvenile Justice System

Effective mental health treatments for youth inthe juvenile justice system need to be highlystructured, emphasize the development of basicskills, and provide individual counseling whichaddresses behaviors, attitudes and perceptions(Altschuler, 1998). Cognitive behavioral approaches


have been shown to be the most effective treatmentsfor youth in the juvenile justice system.

Increases in the number of adolescent girlsentering the juvenile justice system in combinationwith greater understanding of the unique needs ofdelinquent girls have precipitated calls for moregender specific programming (Girls in the JuvenileJustice System, 2004). The known risk and protectivefactors for adolescent girls can form the basis ofgender-specific programming. Programs shouldfocus on the risk factors most likely to impact girlsand build on the protective factors most likely topromote resiliency. Interventions should positivelyimpact a young woman’s relationships with herfamily and other supportive adults, peer culture,school and community.

Females average significantly longer (347 dayson average) incarceration periods than males(Timmons-Mitchell, et al., 1997).The lack ofavailable community-based services for girlsmeans they are twice as likely to be detained (Siegel& Senna, 2000). Timmons-Mitchell, et al., (1997)noted that girls are more likely to receive an out-of-home placement when they become involvedwith the juvenile justice system. These findingslikely reflect the fact that young women involvedwith the juvenile justice system generally havefewer family resources to rely upon than do youngmen. The lack of family support contributes to thelength of detention for young girls. For example,because girls in the juvenile justice system tend tohave less active family involvement, they are lesslikely than boys to be considered for communityplacement options that depend to some extent onfamily involvement in the treatment process.

Despite the growing number of girls in thejuvenile justice system, only a small number ofprograms nationwide focus specifically ondelinquent girls (Acoca, 1999). The results of theprograms and studies that do exist are discussedbelow.

Trauma-focused interventionsThe only therapy with strong research support

demonstrating efficacy for trauma in adolescent girlsand boys is Mannarino and Deblinger ’s (2003)Cognitive Behavioral Therapy for PTSD (Saunders,Berliner, & Hanson, 2003). Cognitive BehaviorTherapy (CBT) combines two very effective kindsof psychotherapy—cognitive therapy and behaviortherapy.

The techniques employed in CBT focus oncognitive, behavioral and affect (mood) difficulties.CBT as used in treating PTSD is designed to reducenegative emotional and behavioral responses andcorrect maladaptive beliefs and attributions relatedto traumatic experiences.

Dialectical Behavior TherapyTrupin, Stewart, Beach and Boesky (2002)

recently evaluated the effectiveness of DialecticalBehavior Therapy for incarcerated female juvenileoffenders. Dialectical Behavior Therapy (DBT) is amodification of CBT designed specifically forindividuals with self-harm tendencies, includingthose exhibiting suicidal tendencies and behaviors.For purposes of the intervention study, DBT wasadapted to treat emotional dysregulation, suicidalideation and aggressive behavior, which often resultin increased incarceration time for female juvenileoffenders. The intervention focused on both staff andgirls in custody. For staff, the goal of the interventionwas to reduce reliance on punishment, restrictionand isolation as the primary response to emotionaldysregulation (defined as suicide attempts,aggression and noncompliance). Adolescent girlswere taught DBT skills, including coaching andactive reinforcement to extinguish old behaviors.Five categories of skills were taught—coremindfulness skills, interpersonal effectiveness skills,emotion regulation skills, distress tolerance skillsand self-management skills (Trupin, et al., 2002).

The findings were mixed. In general, the authors

Interventions should positivelyimpact a young woman’s

relationships with her family andother supportive adults, peer culture,

school and community.


concluded that DBT training is most effective withan intensive training program, motivated staff andfemale juvenile offenders who exhibit the types ofparasuicidal and aggressive behavior that DBTtargets. With these elements, DBT training can besuccessful in reducing behavior problems anddecreasing staff punitive responses to behavior. Inthe study, the training was not as successful ashypothesized because a significant number of girlsdid not exhibit the problems DBT is intended toremediate. The findings from this study underscorethe importance of matching treatment to symptoms,behaviors and/or diagnoses.

Family and parenting interventionsEvidence suggests that it is important to involve

family members in treatment and rehabilitation ofjuvenile delinquents. A recently published meta-analysis of randomized controlled trials of familyand parenting interventions for conduct disorderand delinquency found that family interventions aremore successful than usual care in decreasingsubsequent arrests, self-reported delinquency andtime spent in institutions (Woolfenden, Williams, &Peat, 2002). Three of the family interventionsincluded in the analysis were highlighted as modelprograms in the 2001 Surgeon General’s reportYouth Violence—Functional Family Therapy (FFT),Multisystemic Therapy (MST) andMultidimensional Treatment Foster Care (MTFC).While the outcomes for all three interventionsdemonstrated effectiveness in reducing juvenileoffending and increasing parental competencies,only MTFC has been specifically adapted forintervention with girls and is discussed in moredetail below. Most research on FFT and MST hasfocused on males who continue to make up themajority of juvenile offenders.

Multidimensional Treatment Foster Care(MFTC). MTFC is a community and family-basedalternative to residential and group care for youthwith behavioral, emotional and mental healthproblems (Chamberlain, 2003). Previous research onthe MTFC model demonstrates that it is moreeffective than group care for reducing subsequentjuvenile offending in samples that includedsignificantly more males than females (Chamberlain& Reid, 1998). The model has been adapted and iscurrently being evaluated for effectiveness with

female juvenile offenders.

The MTFC model involves placing girls into afoster home where foster parents are providedtraining, support and access to program staff 24hours a day, seven days a week. Each girl has anindividualized treatment program, includingindividual therapy, skills training and familytherapy, focused on behavior management skills.New behaviors are taught and reinforced throughan individualized, in-home daily point system.Foster parents are trained to identify and providesanctions for social/relational aggression, and girlsare taught to avoid social/relational aggression andto self-regulate their emotions (Leve & Chamberlain,2004). Social and relational aggression has beenimplicated in the development of delinquency ingirls (Underwood, 2003). Outcome data has yet tobe published, but preliminary results suggest theintervention is as effective for female juvenileoffenders as for male juvenile offenders and issuperior to group care (P. Chamberlain, personalcommunication, October 4, 2004).

Posttraumatic StressDisorder

The estimated lifetime prevalence ofPosttraumatic Stress Disorder (PTSD) among adultAmericans is 7.8 percent, with women (10.4 percent)twice as likely as men (5 percent) to have PTSD atsome point in their lives (Kessler, et al., 1995). Thisrepresents only a small portion of those who haveexperienced at least one traumatic event; 60.7percent of men and 51.2 percent of women reporthaving experienced at least one traumatic event(Kessler, et al., 1995). More than 10 percent of menand 6 percent of women report four or more typesof trauma during their lifetimes. For women, themost common events were rape, sexual molestation,physical attack, being threatened with a weapon,and childhood physical abuse.

Risks and Protective FactorsResearch on PTSD has identified risk factors that

include environmental and demographic factors,psychiatric history, cognitive and biological systemsand familial risk (Yehuda, 1999).


Environmental risk factorsA history of prior exposure to trauma or to

chronic stress is a risk factor for depression,particularly if it is experienced at a young age(Halligan & Yehuda, 2000). Social factors may alsoaffect risk. A history of family instability is associatedwith increased prevalence of PTSD (King, King, Foy,& Gudanowski, 1996).

Demographic risk factorsBreslau, et al. (1998) noted that several

demographic factors affect the risk of traumaexposure, including gender, age, socioeconomicstatus, and ethnicity. African American women weremore likely to have experienced trauma than werewomen from other ethnic groups. Gender is anextremely salient risk factor. Breslau et al. (1998)found that the higher risk for PTSD in females isprimarily due to a particular vulnerability toassaultive violence. The authors suggest thatassaultive violence is more threatening and injuriousto females, because most perpetrators are male, andare likely to wield greater physical strength. It maybe that ethnicity is interacting with these otherfactors so that ethnicity alone is not a higher riskfactor for PTSD.

Prior psychiatric disorderBreslau et al. (1998) also found that prior

depression, anxiety or substance abuse disorders allrepresented risk factors for the development ofPTSD, and concluded that having a psychiatrichistory of any kind was a stronger predictor forPTSD than history of one of the specific disorders.

Cognitive risk factorsLower intellectual functioning has been found

to be a risk factor for the development of PTSD(Macklin, et al., 1998). In addition, individuals withPTSD show increased neurological soft signs,indicative of subtle nervous system dysfunction.Furthermore, they also report a large number ofdevelopmental problems, suggesting that there arepreexisting impairments in neurodevelopmentwhich act as risk factors for the development ofPTSD (Gurvits, et al., 2000).

Biological risk factorsResearch on the biological aspects of PTSD

identified several abnormalities that are present intrauma survivors with PTSD. Recent evidencesuggested that at least some of the observed brainabnormalities (e.g. neurotransmitter malfunctions)represent risk factors for the development of PTSD(for a review see Yehuda, 1999).

Familial risk factorsDavidson , Swartz, Storck, Krishnan &

Hammett, (1985) found that trauma survivors withPTSD were more likely to have parents and first-degree relatives with mood, anxiety, and substanceabuse disorders, compared with trauma survivorswho did not develop PTSD. More recently, Yehuda,Schmeidler, Giller, Binder-Byrnes, & Siever, (1998)demonstrated that Holocaust survivors with PTSDare more likely to have children with PTSDcompared to Holocaust survivors without PTSD.

Protective factorsVery little research has been done to identify

protective factors in the development of PTSD.However, both social support and parental warmthand nurturing are associated with lower level ofsymptoms (Solomon, Mikulincer & Avitzur, 1988).

Treatment for PTSDThere are currently no treatments for PTSD

developed for or tested specifically on adolescentgirls or young women. However, because of thegreater prevalence of PTSD among girls and women,most of the participants in clinical trials have beenfemale.

Cognitive Behavioral Therapy is the mostefficacious treatment for PTSD. Exposure therapy, aform of CBT unique to trauma treatment, usescarefully repeated, detailed imagining of the trauma(exposure) in a safe, controlled context, to help thesurvivor face and gain control of the fear and distressthat was overwhelming during the trauma. In somecases, trauma memories or reminders can beconfronted all at once (flooding). For otherindividuals or traumas, it is preferable to work upto the most severe trauma gradually by usingrelaxation techniques and by starting with less


upsetting life stresses or by taking the trauma onepiece at a time (desensitization). Along withexposure, CBT for trauma includes: learning skillsfor coping with anxiety and negative thoughts,managing anger, preparing for stress reactions(stress inoculation), handling future traumasymptoms, addressing urges to use alcohol or drugswhen trauma symptoms occur, and communicatingand relating effectively with people.

Cognitive Behavioral Therapy has also beenfound to be a safe and effective treatment for PTSDwhen it results from specific traumas includingassault, road traffic accidents, combat, terrorism andchildhood physical and sexual abuse. In addition,there have been recent advances in earlyintervention and in the treatment of disorders thatare comorbid with PTSD (for a review see Harvey,Bryant & Tarrier, 2004).

Substance AbuseAddiction has long been considered a male

disease and until recently there has been littleresearch focused on gender differences in the natureand course of addiction. However, the NationalInstitute on Drug Abuse estimated that more than4.4 million women in the United States needtreatment for drug use (National Institute on DrugAbuse, 1994). Research that yields additionalevidence about the unique motivations and

vulnerabilities of girls and young women wouldlead to more effective substance abuse preventionand treatment programs specifically tailored to therisks and consequences for young women.

Despite promising statistics that indicate youthsubstance abuse is declining, more than one-quarterof high school girls currently smoke cigarettes, 45

percent drink alcohol, more than a quarter bingedrink, and 20 percent use marijuana (The FormativeYears, 2003). In recent years, younger girls have beensmoking and drinking as much as boys and arecatching up in the use of illicit drugs. In addition,research reveals that girls are suffering consequencesbeyond those of boys.

A recently published study by the NationalCenter on Addiction and Substance Abuse (CASA)at Columbia University has contributed significantlyto our understanding of the pathways andconsequences for substance abuse and dependenceamong girls and young women. The three-yearstudy titled, The Formative Years: Pathways toSubstance Abuse Among Girls and Young Women Ages8-22, revealed that girls and young women usesubstances for reasons that differ from boys andyoung men, risk factors are different, and that girlsand young women are more vulnerable to addiction:they get hooked faster and suffer the consequencessooner than boys and young men. The ColumbiaUniversity study results are consistent with thegrowing body of evidence identifying genderdifferences in pathways to, and consequences ofsubstance abuse (Amaro, Blake, Schwartz, &Flinchbaugh, 2001). Specifically, researchers found:

• Girls and young women who abuse substancesare more likely than boys or young men to bedepressed and suicidal;

• Girls and young women are likelier than boysand young men to diet and to have eatingdisorders, which also increases the risk forsubstance abuse;

• Girls and young women abusing substances aremore likely to have been physically or sexuallyabused;

• Teenage girls who experience frequent movesare at increased risk for substance abuse;

• Girls who experience early puberty are atincreased risk of using substances earlier, moreoften and in larger amounts than their later-maturing peers;

• Girls and young women appear to experiencemore severe problems from drinking, includingstronger addiction and withdrawal symptoms;

• Substance abuse increases the likelihood thatgirls and young women will engage in risky sexor be the victims of sexual assault.

The National Institute on Drug Abuseestimated that more than 4.4 million

women in the United States needtreatment for drug use.


In addition to the findings above, whichhighlight gender differences, the study identifiedrisk factors common to both girls and boys. Theseinclude: academic failure, poor self control (Griffin,Botvin, Epstein, Doyle, & Diaz, 2000) and poverty(Brooks-Dunn & Duncan, 1997). The study alsofound that youth are at increased risk of substanceabuse if they experience poor and inconsistentfamily management practices, characterized byunclear expectations and poor monitoring ofbehavior; few and inconsistent rewards for positivebehavior and harsh punishment for unwantedbehavior (Hawkins, Catalano, & Miller, 1992).

Substance Abuse and Racial andEthnic Subgroups

Although the research is relatively sparse,several studies have identified differences insubstance abuse in girls and young women amongdifferent ethnic subgroups. In general, AfricanAmerican young women smoke, drink and usedrugs at lower rates than white or Latina youngwomen (CDC, 2002). Even though African Americangirls begin drinking at older ages than girls fromother racial or ethnic groups, they experiencedisproportionately higher consequences of heavydrinking such as unprotected sex, truancy and theuse of illicit drugs (Welte & Barnes, 1987).

Comparable national data are not available onthe prevalence of substance abuse among NativeAmerican and Asian American females. However,the available research suggests that Native Americangirls are more likely to smoke and use marijuanathan girls from other racial and ethnic groups(Wallace & Bachman, 1991). In addition, AsianAmerican girls and young women appear less likelythan white or Latino girls to smoke, drink or use

drugs (Au & Donaldson, 2000). Native Americanwomen appear to have a much higher rate of alcoholuse than do women from other racial and ethnicgroups. Moreover, young Native American women15-24 years of age have death rates from alcohol andother substance abuse that actually exceed those oftheir male counterparts (LaFromboise, Berman &Sohi, 1994).

Acculturation and alcohol consumptionamong Latinos

Acculturation, broadly defined, is the extent towhich ethnic group members participate in thecultural traditions, values, and practices of thedominant society (Snowden & Hines, 1998). Therelationship between acculturation and alcoholconsumption has been examined in nationwide andcommunity samples of Latinos in the United States.The most consistent findings across all of thesestudies is that women who score higher onacculturation scales are more likely to consumealcohol, consume alcohol more frequently, andconsume greater amounts of alcohol than those whoare less acculturated (Caetano & Clark, 2002).

Other analyses indicate that additional factorsmay also contribute to the interaction betweenacculturation and drinking. For example, alcoholconsumption is high among acculturated young,Latina women, but lower among acculturated,middle-aged Latino men (Markides, Krause, &Mendes de Leon, 1988). In addition, the socialcontext of drinking also varies by acculturation level.Those who are highly acculturated are more likelyto visit settings where drinking takes place (i.e.parties and bars), and to drink in these situations,than those who are less acculturated (Caetano, 1987).

Caetano and Medina Mora (1988) examined thealcohol consumption patterns of recent Mexicanimmigrants to better understand the nature of therelationship between drinking and acculturation.While they found a change in drinking patterns formen, the same was not true for women, suggestingthat acculturation-related drinking patterns amongwomen occur primarily in Latina women born inthe United States. In addition, they found that highlyacculturated Mexican American women were morelikely to have experienced various social and legalproblems related to their alcohol use than the

Several studies have identifieddifferences in substance abuse ingirls and young women among

different ethnic subgroups.


respondents who were less acculturated. Thus, theexisting evidence seems to most clearly indicate thatacculturation is positively associated with alcoholconsumption for women.

Protective Factors inSubstance Abuse

This section reviews protective factors thatmitigate the chances a young woman will use orabuse substances: family, religion, coping skills,ethnic identity, and peer and social influences.

FamilyPositive parent-daughter relationships decrease

the likelihood that girls and young women willabuse substances. Girls with strong family bondsare less likely to have substance-abusing peers,making them less likely to use alcohol and drugs(Bahr, Marcos, Maugham, 1995). The relationshipbetween having a strong family bond and havingfewer substance-using peers appears to be moreprotective for girls than for boys (Bahr, et al., 1995).During the teen years, girls tend to communicatemore with their parents than do boys, and this isespecially true for communication with mothers(Catalano,et al.,1992). One reason that girls may bemore communicative is that mothers are more likelythan fathers to initiate open communication andchildren may model their same-sex parent’scommunication style (Noller, 1995). Girls reportbeing influenced by their mother’s opinions whenmaking decisions (Poole & Gelder, 1984), andperceive their relationships as more supportive withtheir mothers than with their fathers (Furman &Buhrmester, 1992). However, as young women reachcollege age, increased conflict with mothers is linkedto problems related to substance abuse (Turner,Larimer & Sarason, 2000).

ReligionResearch consistently demonstrates the

protective role religion plays in preventingadolescent substance abuse (Bahr, Maughan,Marcos, & Li, 1998; Barnes, Farrell, & Banerjee, 1995;Benda & Corywn, 2000; Mason & Windell, 2002),particularly for girls and young women (Adlaf &Smart, 1985; Brown, Parks, Zimmerman, & Phillips,2001; Strawbridge, Shema, Cohen,& Kaplan, 2001).

Religiosity is more protective against substanceabuse for females than for males (Adlaf & Smart,1985; Brown, et al., 2001; DeFronzo & Pawlak, 1994).Girls tend to be more religious than boys and to holdmore favorable attitudes toward religion (Forthun,Bell, Peek, & Sun, 1999). More frequent attendanceat religious services among girls is associated withless drinking and less binge drinking (FormativeYears, 2003) and they are also less likely to reportusing tobacco or marijuana ( National HouseholdSurvey of Drug Abuse, 2001). Among female collegestudents, religiosity is related to less alcoholconsumptions and fewer alcohol-related problems(Templin & Martin, 1999).

The relationship between religion and substanceabuse not only varies by gender, but by race andethnicity (Amey, Albrecht, & Miller, 1996;Maddahian, Newcomb, & Bentler, 1988). The levelof importance African American girls place onreligion or spirituality is significantly greater thanthat of Caucasians or Latina girls (Formative Years,2003). African Americans, in general, not only reportthat religion plays a more significant role in theirlives than do Caucasians, but they also report ahigher frequency of religious service attendance(Barnes et al., 1995; Miller & Hoffman, 1995). ForAfrican American girls who report attending churchon a regular basis, alcohol use is lower than for thosewith less frequent attendance (Brown, et al., 2001).

Coping skillsResearch demonstrates that good coping skills

help protect against substance abuse in adolescentsand young adults (Adger, 1992). Coping skills varyby age. Transition age young women are more likelythan younger girls to cope with serious problemsby hoping they will improve with time, avoidingthinking about them or, at times, using alcohol anddrugs specifically to make themselves feel better(Formative Years, 2003). Young women who reportthat they engage in more adaptive coping methods,such as talking to someone, drink and binge drinkless than girls who use this coping strategy less often(Formative Years, 2003).

Ethnic identityThe evidence from research indicates that strong

ethnic identity protects both female and maleminority youth from substance abuse (Brook, Balka,


Brook, Win, & Gursen, 1998). For example, a recentstudy of seventh graders found that ethnic pridepredicted less substance abuse among AfricanAmerican, Mexican American and mixed-ethnicityyouth (Marsiglia, Kulis, & Hecht, 2001).

Peer and social influencesResearchers hypothesize that girls are more

influenced to use substances by pressure fromfriends, family members (e.g. an older sibling) andpeers than boys (Farrell & White, 1998; Griffin,Botvin, Doyle, Diaz, & Epstein, 2000). Generally, girlsare more vulnerable to peer pressure aroundsmoking and drinking than are boys (Chassin,Presson, Sherman, Montello, & McGrew, 1986),likely because girls tend to spend more time withfriends and be more involved in their lives (Griffin,et al., 2000). However, vulnerability to socialinfluences also varies between and among malesand females at different developmental ages. Peeruse of alcohol is the single best predictor of alcoholuse among boys throughout adolescence. Bycontrast, adolescent girl alcohol use is associatedwith having a conduct disorder and peer alcoholuse is more important in predicting alcohol useamong older adolescent and young adult women(Barber, Bolitho, Bertrand, 1998).

Finally, numerous studies have reported thatdrug use by male partners is a gateway to drug usefor girls and for the progression of drug use amongyoung women (Amaro & Zuckerman, 1990; Anglin,Hser, & McGothlin, 1987; Rosenbaum, 1981). Druguse by the male partner is also highly correlated withwomen becoming victims of violence and abuse(Amaro, Fried, Cabral, & Zuckerman, 1990).

Peer influence also varies among girls fromdifferent racial and ethnic groups (Barnes, et al.,

1994). When compared to African American boys,African American girls have fewer friends whosmoke, whereas Caucasian boys and girls havesimilar numbers of friends who smoke (Robinson& Klesges, 1997). Latina girls have been found moresusceptible to peer influences than Latino boys(Epstein, et al., 1999).

Substance Use, Abuse, Dependenceand Psychiatric Comorbidity

As discussed earlier, high percentages ofsubstance abusers of all ages have mental healthdisorders as comorbid conditions. The adult clinicalliterature suggests that from 50 percent to over 80percent of all types of substance abusers also meetcriteria for at least one psychiatric disorder. The mostcommon comorbidities are anxiety and depression(Armstrong and Costello, 2002). Importantly,retrospective evidence from the EpidemiologicCatchment Area study of adults suggests that themedian age of onset for these disorders is before age20 (Christie, et al, 1988, cited in Armstrong &Costello, 2002). Research has also found a similarlyhigh incidence of comorbidity in adolescents.

To more fully understand substance use, abuse,dependence and psychiatric comorbidity in youth,Armstrong and Costello (2002) reviewed thescientific literature on community studies ofadolescents (distinct from clinical studies which usediagnosed and in treatment samples). They foundthat 60 percent of adolescents had a comorbiddiagnosis; conduct disorder and oppositionaldefiant disorder were most commonly associatedwith substance abuse, followed by depression. Thereview also found that substance abuse andpsychiatric comobidity is at least as common for girlsas it is for boys. Of the twelve studies that reportedon gender effects, six reported no gender differencesand the rest reported a mixed picture (Armstrong& Costello, 2002). The relative paucity of genderdifferences could also be because there were too fewgirls in the sample to detect associations betweengender, substance abuse and comorbidity.

Researchers and treatment providers also agreethat there is a critical need to address trauma, andthe psychological aftermath of trauma, in treatingwomen with substance abuse problems. The dualdiagnosis of PTSD and substance abuse is common.

A recent study of seventh gradersfound that ethnic pride predicted

less substance abuse among AfricanAmerican, Mexican American and

mixed-ethnicity youth


The rate of PTSD for clients in substance abusetreatment is 12 percent to 34 percent; for women itis 30 percent to 59 percent (Kessler, Sonnega, Bromet,Hughes, & Nelson, 1995; Langeland & Hartgers,1998; Najavits, Weiss, & Shaw, 1997). Rates of traumaduring their lifetime are even more common (Kessleret al., 1995). Untreated trauma symptoms in womenhamper engagement in substance abuse treatment,lead to early drop-out and make relapse more likely(Brown, 2000; Najavits, Weiss, & Shaw, 1999;Ouimette, Finney, & Moos, 1999).

Substance Abuse TreatmentAlthough the number of curricula and

intervention programs specifically addressing thesubstance abuse treatment needs of girls and youngwomen is increasing, there are still relatively fewprograms, and very few studies evaluating theireffectiveness. In a recent comprehensive andcomparative review of the substance abusetreatment outcome literature, Williams and Chang(2000) found that the overwhelming majority ofstudies focused on Caucasian males. Furtherresearch on treatment for women and other ethnicgroups is needed. This section highlights thosetreatments for which there is research supportdemonstrating safety and effectiveness.

There are two family therapy interventions thathave strong empirical support. For theseinterventions, practitioners have also exploredcultural adaptations for African American andLatino youth and are currently evaluating theeffectiveness of the treatments for adolescent girls.

Brief Strategic Family Therapy, developed by JoseSzapocznik, has demonstrated effectiveness foradolescent Latinos and their families. Brief StrategicFamily Therapy is a short-term, problem-focusedtherapeutic intervention, targeting children andadolescents. The program improves youth behaviorby eliminating or reducing drug use, and itsassociated behavior problems, and by changing thefamily members’ behaviors linked to substanceabuse risk and protective factors.

Multidimensional Family Therapy was originallydeveloped by Howard Liddell and adapted forAfrican American youth and their families.Multidimensional Family Therapy is a

comprehensive and flexible family-based programdesigned to treat substance abusing and delinquentyouth. Gayle Dakof, a clinical researcher workingwith the Multidimensional Family Therapy groupat the University of Miami, is developing a gender-specific version of Multidimensional FamilyTherapy. She investigated gender, comorbidity andfamily functioning in a sample of clinic referredyouth and found differences in pretreatmentcharacteristics between adolescent boys and girls.Girls used drugs and engaged in externalizingbehavior at the same rate as their male counterparts,but were distinguished by their higher levels ofinternalizing problems and family conflicts anddisruptions (Dakof, 2000).

Treatment specific to young womenThe only empirically supported substance abuse

treatment for adolescent girls and young womenwas developed by Lisa Najavits to treat co-occurringPosttraumatic Stress Disorder (PTSD) and substanceabuse. The program, Seeking Safety, is based on fivecentral ideas: (a) safety as the priority in the firststage of treatment; (b) integrated treatment of PTSDand substance abuse; (c) focus on ideals; (d) fourcontent areas—cognitive, behavioral, interpersonaland case management; and (e) attention to therapistprocesses (Najavits, 2002).

Najavits (2000) recommends that cliniciansdelivering Seeking Safety be selected for their actualperformance with clients rather than for theirprofessional degree, training and experience level(and within the substance abuse community,recovery status). She described clinician selectionand supervision procedures that allow observationof the “clinician in action” rather than throughverbal report (Najavits, 2000). In addition, there is atherapist adherence measure designed to evaluatea clinician’s use of the treatment with fidelity to themodel. A manual on the treatment providesguidelines for clinicians on 25 topics and includeshandouts for clients. Information on training,clinician selection and supervision is available atwww.seekingsafety.org

Seeking Safety has been empirically evaluatedin seven populations thus far: outpatient women(Najavits, Weiss, Shaw, & Muenz, 1998); women inprison (Zlotnick, Najavits, & Rohsenow, 2003); low


income urban women (Hien, Cohen, Litt, Miele, &Capstick, 2004); adolescent girls (Najavits, Gallop,& Weiss, under review); women in a communitymental health center (Holdcraft & Comtois, 2002);men and women veterans (Cook, Walser, Kane,Ruzek, & Woody (in press); and outpatient men(Najavits, Schmitz, Gotthardt, & Weiss, in press). Allof the studies demonstrate that Seeking Safety issuccessful in ensuring treatment completion,establishing a therapeutic alliance and encouraginghelp seeking behaviors. Two of the seven studiesare considered here because they have implicationsfor the treatment of young women.

The study of low-income urban womenemployed a randomized design, comparing SeekingSafety to relapse prevention treatment and treatmentas usual. At the end of treatment, clients in both theSeeking Safety and relapse prevention treatmentgroups had significant reductions in substance abusefrequency and intensity, PTSD symptoms, andpsychiatric symptom severity. Participants in thetreatment as usual comparison did not show anysignificant changes. Statistically significantimprovements in substance abuse and psychiatricseverity were not maintained at the six-monthfollow-up but trends in the direction of lowersubstance abuse and psychiatric severity were found(Hien, Cohen, Litt, Miele, & Capstick, 2004).

In a second randomized clinical trial, adolescentgirls were assigned to Seeking Safety and treatmentas usual. Seeking Safety participants evidencedsignificantly better outcomes than the control groupin a variety of domains at post-treatment, includingsubstance use, trauma-related symptoms, cognitionsrelated to PTSD and substance abuse and psychiatricfunctioning. Some gains were sustained at followup. Seeking Safety appears to be a promisingtreatment for adolescent girls but there may needto be modification in intensity and duration oftreatment (Najavits, Gallop, & Weiss, under review).

DepressionOne of the most consistent findings in research

on depression is the higher prevalence of depressionand dsythymia (a mood disorder similar todepression) among women and adolescent girls. Thelifetime prevalence rate of depression amongwomen in the United States is 17 percent and 10

percent of women experienced depression in theprior year (Kessler et al., 1993). Adult women arenearly twice as likely to be depressed as adult men(Nolen-Hoeksema & Girgus, 1994). Dsythymia isalso twice as prevalent among women as amongmen (Bland, Orn & Newman, 1988). Genderdifferences in depression emerge in earlyadolescence, between the ages of 11 and 15 (Kessler,et al., 1993). From 15 years of age on, girls andwomen have higher rates of depression than boysand men, a phenomenon that does not change untilold age when gender differences in depressiondisappear (Kessler, et al., 1993).

Based upon an extensive review of the literature,Nolen-Hoeksema and Girgus (1994) hypothesizedthat gender differences in depression most likelyemerge in early adolescence when genderdifferences in childhood depression risk factorsinteract with biological and social development inadolescence. Specifically, girls experience more bodydissatisfaction than do boys with the onset ofpuberty, face an increased risk of sexual abuse, andfrequently are confronted with social expectationsto conform to restrictive roles deemed appropriatefor females (Nolen-Hoeksema & Girgus, 1994).

There appears to be continuity between thegender differences in depression found inadolescents and the gender differences found indepression in adults. Many of the challenges thatare prevalent in the lives of teenage girls continueto be challenges for adult women. For example, thereis substantial evidence that social conditions tied tothe status of women in society, and their relativelylow power compared to men, contribute to higherrates of depression in women (Nolen-Hoeksema,2001). Women are more likely than men to sufferphysical and sexual abuse, both strongly linked to

One of the most consistent findingsin research on depression is the

higher prevalence of depression anddsythymia among women and

adolescent girls.


depression (Koss, Bailey, Yuan, Herrera & Lichter,2003). In addition, poverty, inequality anddiscrimination are sources of depression amongwomen in the United States (Bell & Doucette, 2003).

Depression in adolescence is not a benign ortransient condition, but is associated with seriouspsychosocial dysfunction and can have negativeeffects on functioning into young adulthood(Lewinshon, et al., 1994). For example, experiencingan episode of major depression during adolescencegreatly increases the probability of becomingdepressed or abusing substances as a young adult(Lewinshon, Rhodes, Klein, & Seely, 1999). Youngadults who are depressed as adolescents are lesslikely to finish college, tend to make less money, aremore likely to become an unwed parent and aremore likely to experience a host of stressful lifeevents (Lewinshon, et al., 1999).

Lesbians and DepressionIn addition to the elevated risk of depression for

women generally, recent findings suggest thatlesbians may have an even greater risk fordepressive episodes than other women (Cochran,Mays, & Sullivan, 2003). This may be because ofdifferences in life experiences and the pervasive andharmful effects of discrimination (Cochran, 2001).In addition, there is some evidence that lesbians areat higher risk for developing alcohol dependencythan heterosexual women (Cochran, Keenan,Schober, & Mays, 2000) and are more likely to engagein moderate illicit drug consumption (Cochran &Mays, 1999).

Ethnic Subgroups and DepressionAlthough women in other ethnic groups

experience the same rates of depression asCaucasian women, they are more likely to have theirdepression go unrecognized (Borowsky, et al., 2000)and be inadequately treated (Wang, Berglund, &Kessler, 2000). Ethnic minority women are morelikely than their Caucasian counterparts to be treatedin the general medical sector rather than by specialtymental health practitioners, affecting the diagnosisand treatment of their conditions. For example,primary care physicians are most likely to diagnosedepression when there are patient reports of

psychological distress and impaired functioning(Schwenk, Coyne, & Fechner-Bates, 1996). However,the evidence increasingly suggests that ethnicminority women are more likely than Caucasionwomen to manifest their psychological distressthrough somatic symptoms, rather than reportingdistress or impaired functioning, increasing thelikelihood of misdiagnoses in a primary care setting(Mazure, Keita, & Blehar, 2002). Degree ofacculturation is also an important factor indepression rates for Latina and Asian PacificIslander women. Women who are more highlyacculturated are more likely to experiencedepression (Moscicki, Locke, Rae, & Boyd, 1989).

Some studies suggest that many evidence-baseddepression treatments can also be effective withethnic minority women (Brown, Huba, & Melchoir,1995; Miranda & Munoz, 1994). However, there isgrowing evidence that Asians, African Americansand Latinos require lower dosages of psychotropicdrugs because they metabolize those drugs moreslowly (Lin, Poland, & Nakasaki, 1993). In addition,there is a relatively high rate of nonadherence topsychotropic medication regimens by ethnicminority women, possibly due to medication sideeffects.

Depression and African-Americanadolescent girls

Recent research on depression in adolescentsincluded surprising findings for African Americangirls, highlighting the need for more culturallysensitive conceptualizations of depression.Finkelstein, Donenberg and Martinovich (2001)investigated the relationship between maternalcontrol and depression among clinically referredadolescent girls in an urban outpatient setting in theMidwest. They found that higher levels of maternalcontrol were associated with less depression inAfrican American girls, but not for Latinas orCaucasians.

The authors hypothesized that differing culturalvalues may explain the ethnic differences found intheir sample. Since interpersonal connectedness atthe family and community level is valued in AfricanAmerican culture (Boyd-Franklin, 1989), it may bethat firmer control is more normative and lessintrusive for African American girls. The authors


pointed out that a similar difference may exist forLatina adolescents, but the sample size of Latinasin the study was too small to draw any definitiveconclusions.

The 1997 Commonwealth Survey on adolescenthealth (Schoen, 1997) found that the adolescent girlsinterviewed reported high levels of depressivesymptoms (the range was from 17 to 30 percent),but African American girls were the least likely toreport depressive symptoms or low self-confidence.Other research findings offer potential culturalexplanations for these findings. While AfricanAmerican mothers are described as overprotectiveand strict disciplinarians (Green, 1990; Rickel,Williams, & Loigman, 1988), they also place lessgender-stereotyped expectations on their children(Reid, 1985; Staples & Mirande, 1980). In addition, astricter parenting style is viewed by many AfricanAmericans as necessary in order to help theirchildren cope with the harsh realities of racism anddiscrimination (Julian, McKenry, & McKelvey, 1994;Taylor, Gilligan, & Sullivan, 1995).

The findings from the studies on AfricanAmerican adolescent girls and depression suggestthat maternal control is protective againstdepression and perhaps, low self-confidence. Thiscontradicts the conventional wisdom in mentalhealth that maternal control in adolescence isassociated with increased clinical symptoms. Theresearch clearly demonstrates that the impact ofparental control on depression varies for girls fromdifferent ethnic groups.

Poor, Single Mothersand Depression

Young unmarried women and their childrenmake up the bulk of those living in poverty (U.S.Census Bureau, 2001) and mental health researchconsistently documents high rates of depressivesymptoms among low-income mothers (Coiro, 2001;Quint, Boss, & Polit, 1997; Walker, Rodriquez,Johnson, & Cortex, 1995). Low-income single mothersand their children bear a substantial burden fromdepression because of the high rates of depression inthis population, barriers to mental health care (e.g.lack of transportation, child care, and healthinsurance) and the absence of another parent to offsetthe effect of maternal depression on children.

The consequences of maternal depression forchildren are well-documented (Cummings &Davies, 1994; Goodman & Gotlib, 1999; Gotlib & Lee,1990). Maternal depression leads to deficiencies inmotor development, attachment, response to stressand emotion regulation in young children. Similarly,older children with depression have more schoolproblems, are less socially competent and havelower self-esteem. Further, the evidence suggeststhat children of depressed mothers are more likelyto become depressed themselves.

Comorbidity and DepressionResearch finds evidence of comorbidity with

depression for transition age women, as is generallytrue for males and adult women. For adolescent girls,a few specific comorbid conditions include anxiety,substance abuse and eating disorders, such asbulimia. The review of the literature by Armstrongand Costello (2002) cited earlier found 60 percent ofadolescents with substance abuse disorders had acomorbid psychiatric disorder; the most commonbeing conduct disorder followed by depression. Theirresearch found no gender differences.

There is increasing evidence that anxiety anddepression are comorbid, and are geneticallyassociated. These findings suggest that whenadolescent girls are evaluated and treated fordepression they should also be evaluated for anxiety.Evaluation should also include family history ofboth anxiety and depression. Studies of communitysamples have consistently indicated that bulimia isassociated with significant depression and substanceabuse in adolescence (Johnson, Cohen, Kasen, &Brook, 2002; Stice, Presnell & Bearman, 2001).

Given that the comorbidity between bulimia,depression and substance abuse has been clearly

Mental health research consistentlydocuments high rates of depressive

symptoms among low-incomemothers.


established, Stice, Burton and Shaw (2004)conducted a study to identify the underlying causesand relationships. Based on a sample of 496adolescent girls drawn from high schools in a largesouthwestern city, they found that depressionpredicted the onset of bulimia, but not substanceabuse. Bulimic symptoms predicted the onset ofdepression, but not substance abuse; substanceabuse symptoms predicted the onset of depressionbut not bulimia. The authors concluded thatcomorbidity arises because certain disorders are riskfactors for other disorders (Stice, et al., 2004). In sum,if an adolescent girl has one of these three disorders(i.e. bulimia, depression, and substance abuse) sheis also at risk for developing one of the other two.

Treatment for DepressionGiven the potential negative consequences of

depression in adolescents, effective early treatmentis imperative. Early intervention can help prevent arecurrence of depression and prevent progressionto more serious depression in those who are mildlydepressed. Mild depression is a strong risk factorfor more serious depression (Clarke, et al., 1995).Fortunately, there are efficacious treatments fordepression in adolescent girls and young women.The following section describes efficacioustreatments for depression in adolescent girls andyoung women.

Psychotropic medicationAntidepressant medications are widely

prescribed for adolescents and are considered anefficacious treatment for adolescent depression.General practitioners give the majority ofprescriptions. Recent evidence that treatment ofdepressed adolescents with antidepressants isassociated with a higher risk of suicide caused theU.S. Food and Drug Administration (FDA) to issuea “black box warning.” Black box warnings areissued by the FDA to highlight special problems,particularly those that are serious, and to give healthcare professionals information on potential medicalcomplications and prescribing drugs that areassociated with serious side effects. The newguidelines recommend that the clinical indicationsfor treatment be clearly documented, and that allpediatric patients (under age 18) treated withantidepressants be closely observed for clinical

worsening, suicidality and other unusual behaviorchanges. The FDA guidelines urge close observationconsisting of face-to-face physician contact withpatients or their family members and caregivers atleast weekly during the first month children are onthe medicine, biweekly for the second month, againat 12 weeks, and then as clinically indicated. It isparticularly important that if used, medication becombined with other treatment approaches asdescribed below.

Cognitive behavioral therapyThere is a large body of evidence indicating that

Cognitive Behavioral Therapy (CBT) is an efficacioustreatment for young adult and adolescentdepression. Research demonstrating efficacy of theintervention follows a brief description of CBTbelow.

The techniques employed in CBT focus oncognitive, behavioral and affect (mood) difficultiesin adolescents. Cognitive techniques include:constructive thinking; positive self-talk; being yourown coach; coping skills; and self-change skills, suchas self-monitoring, goal setting, and self-reinforcement (Lewinsohn & Clarke, 1999).Techniques to improve family interactions include:conflict resolution, communication skills, andparenting skills (Lewinsohn & Clarke, 1999).Behavioral techniques include: problem-solvingskills; increasing pleasant activities; and social skills,such as assertiveness, making friends, and rolemodeling (Lewinsohn & Clarke, 1999). Relaxationand anger management are the skills taught foraffect management (Lewinsohn & Clarke, 1999).

All CBT programs are limited with respect toduration and number of sessions, and protocolsrange from 5 to 16 sessions (Lewinsohn & Clarke,1999). CBT is delivered in both individual and groupformats. Treatment is structured and most CBTprograms provide an agenda for each session, whichspells out the primary objectives and aims of thetherapy and the content of the session, includingactivities and homework.

Combination Medication andCognitive Behavioral Therapy

The Treatment for Adolescents with DepressionStudy Team (TADS), sponsored by the NationalInstitutes of Mental Health (NIMH), completed a


recent study demonstrating the efficacy of CBT incombination with antidepressant medication. TADSis a multicenter, randomized clinical trial designedto evaluate the effectiveness of treatments foradolescents with Major Depressive Disorder (MDD).

The TADS study compared randomly assignedgroups receiving 12-week treatment with fluoxetinealone, CBT alone, fluoxetine with CBT, and a placebo(JAMA, 2004). The team found that fluoxetine plusCBT offered greater effectiveness in treatment thanthe drug alone. Contrary to what the study teamhypothesized, CBT alone offered no greatereffectiveness than placebo. Compared withfluoxetine and CBT alone, the combination therapyproved superior with a 71 percent response rate, incontrast to the usual 60 percent response rate (TADS,2004). Most previous studies of CBT involved youthwho demonstrated depressive symptoms but mightnot meet the diagnostic criteria for MDD.

TADS also examined the potential danger ofsuicide in adolescents taking antidepressants, butthe findings are complex. They found that suicidalthinking decreased among all treatment groups,with the greatest reduction occurring in the groupreceiving the combination therapy. Althoughfluoxetine alone did not increase suicidal thoughts,it did seem to increase the risk for harm-relatedbehaviors. This effect seemed to be mitigated whenthe drug was combined with CBT (TADS, 2004).

Treatment of depression in low-income womenin ethnic subgroups

Recent study findings suggest that medicationinterventions may be more effective for low-income,ethnic minority women than psychotherapyinterventions. Research also demonstrates that

evidence-based interventions appear to be moreeffective for poor ethnic minority women if they aregiven support to overcome barriers to care.

Jeanne Miranda and colleagues at GeorgetownUniversity Medical Center in Washington, D.C.conducted a randomized clinical trial withpredominately low-income, young women fromethnic minority groups. Participants were randomlyassigned to either an antidepressant medicationintervention (trial of paroxetine switched tobuproprion, if lack of response), an eight week CBTpsychotherapy intervention or referral tocommunity mental health (usual care). Bilingualproviders treated all Spanish-speaking women andall written materials were available in Spanish,including psychotherapy manuals. Of the sixpsychotherapists, one was African American andthree were Spanish-speaking. Two of the nursepractitioners were Spanish-speaking. Outreach wasan essential part of the study. For example, nursepractitioners spoke with participants on average 8.8times prior to a first medication visit andpsychologists spoke with participants an average of10.2 times before they attended a psychotherapyvisit. In addition, participants were giventransportation and child care funds to enable theirparticipation (Miranda, et al., 2003).

The results showed that both the medication andthe CBT psychotherapy interventions reduceddepressive symptoms more than the communitytreatment referral. The medication intervention alsoresulted in improved instrumental role and socialfunctioning, while the psychotherapy interventionresulted in improved social functioning (Mirandaet al., 2003). More women engaged in a sufficientduration of treatment with medication, comparedwith psychotherapy, and the outcomes of care weremore extensive and robust for the medicationintervention. The authors found no ethnicdifferences in response to care, addressing to someextent the potential that existing evidence-basedtreatment might not be effective for AfricanAmerican and Latina women.

Interpersonal psychotherapyThere is a growing body of research

demonstrating the efficacy of InterpersonalPsychotherapy (IPT) for the treatment of depression.IPT is a brief, highly structured, and manualized

Study findings suggest thatmedication interventions may bemore effective for low-income,ethnic minority women thanpsychotherapy interventions.


psychotherapy that addresses the interpersonalissues in depression. IPT holds that depressionoccurs within an interpersonal context but does notarise exclusively from interpersonal problems. Inthis model, depression is conceptualized as havingthree components: symptom formation, socialfunctioning and personality contributions. The aimof IPT is to intervene specifically in socialfunctioning, including interpersonal disputes, roletransitions, grief, and interpersonal deficits. IPTusually runs from 12 to 16 sessions.

Two different groups of researchers haveexamined IPT for the treatment of adolescentdepression with positive results. In a sample ofclinic-referred adolescents with major depression,researchers found that IPT was associated withgreater improvements in depressive symptoms,social functioning and problem-solving skillscompared to the control, a clinical monitoringintervention (Mufson, Weissman, Moreau, &Garfinkel, 1999). Rossello and Bernal (1999)compared CBT, IPT and a waiting list control groupin Puerto Rican adolescents meeting criteria for bothmajor depression and dysthymic disorder. Resultsindicated that both CBT and IPT led to significantreductions in depressive symptoms andimprovements in self-esteem in comparison to thewait list. Youth treated with IPT showed greatergains in social functioning and self-esteem whencompared to the wait-list group and the effect size(magnitude of change) of IPT (.73) exceeded that ofCBT (.43). It is important to note that the Mufsonsample included a large proportion of Latino youth,almost 80 percent of the IPT group. It may be thatIPT produces better outcomes for Latino youth butnot necessarily for youth from other ethnic groups.

Researchers at the University of Pittsburgreported on a pilot study of brief IPT with depressedwomen. The primary aims of the study were toassess the acceptability of the intervention and toassess effect. The study employed an eight-weekquasi-experimental design to compare women whoreceived brief IPT with a matched group of womenwho received pharmacotherapy (sertraline)combined with supportive psychotherapy (Swartz,et al., 2004). Both groups improved significantly overtime with large effect sizes and all but one of thewomen reported that eight sessions were sufficientto meet their needs. Client satisfaction with IPT was

high. Contrary to expectations, the women whoreceived IPT improved more rapidly than those whoreceived sertraline (Swartz, et al., 2004). The resultsfrom this one study suggest that time-limitedpsychotherapy for depression offers women rapidrelief from their symptoms and may prove to be anefficacious treatment.

SuicideSuicide is currently the third leading cause of

death among 15- to 24-year olds in the United States(Lewinsohn, Rhode, Seeley, & Baldwin, 2001).Epidemiological studies suggest that the lifetimerate of suicide attempts among high school studentsranges from 3 percent to 15 percent (Centers forDisease Control, 2000). Although the majority ofthese attempts are of low medical lethality, havingmade a past suicide attempt is the strongestpredictor of both future suicide attempts andcompletions (Hawton, 1992). Youth experiencehigher risk for suicide if antidepressant medicationhas just been started, because they may have a returnof energy before they have lifting of mood, and thenact on suicidal urges. In addition, as noted above,antidepressant medications may present an overallhigher risk of suicide for adolescents.

Suicide incidence increases markedly in the lateteens and continues to rise until the early twenties,reaching a level that is maintained throughoutadulthood (Anderson, 2002). In 2000, the suicidemortality rate for 15- to 19-year-olds was 8.2 per100,000, five times greater than the rate for 10- to14-year-olds (Gould, Greenberg, Drew, Shaffer,2003). Like completed suicides, suicide attempts are

Youth experience higher risk forsuicide if antidepressant medicationhas just been started, because theymay have a return of energy beforethey have lifting of mood, and then

act on suicidal urges.


relatively rare among children before puberty butincrease in frequency throughout adolescence (Velezand Cohen, 1988). However, unlike completedsuicides, attempts peak between 16 and 18 years ofage after which there is a marked decline infrequency (Gould, et al., 2003), particularly foryoung women (Lewinsohn, et al., 2001).

Although suicide ideation and attempts aremore common among females, completed suicideis more common among males (Grunbaum, Kann,& Kinchen, 2002). The Youth Risk Behavior Surveyfound that girls were significantly more likely tohave seriously considered attempting suicide, madea specific plan and actually attempted suicide thanwere boys; however researchers found no significantdifference by gender in the prevalence of medicallyserious attempts (Grunbaum, et al., 2002).

Risks and Protective Factorsin Suicide

Research is available on the factors found topredict and protect against suicidal behaviors inadolescents. Borowsky, Ireland, and Rensnick (2001)reviewed data from the National Longitudinal Studyof Adolescent Health Promotion. Cross-cutting riskfactors identified in the study included previoussuicide attempt, violence victimization, violenceperpetration, alcohol use, marijuana use, and schoolproblems. Additionally, somatic symptoms, friendsuicide attempt or completion, other illicit drug use,and a history of mental health treatment predictedsuicide attempts among African American, Latinoand Caucasian females. Weapon-carrying at schooland same-sex romantic attraction were predictivefor all groups of boys. Perceived parent and familyconnectedness was protective against suicideattempts for African American, Latino andCaucasian males and females. For girls, emotionalwell-being was also protective for all ethnic groupsstudied, while having a high grade point averagewas an additional protective factor for all of the boys.

Researchers combined the estimated proba-bilities of attempting suicide with protective factorsand found that the presence of any three protectivefactors reduced the risk of suicide by 70 percent to85 percent for each gender and ethnic group studied.This included youth with and without identified riskfactors. Promotion of protective factors may,

therefore, offer an effective approach to bothprimary and secondary prevention of adolescentsuicidal behavior.

Racial and Ethnic Subgroupsand Suicide

The incidence of youth suicide differs amongracial and ethnic subgroups. Youth suicide is morecommon among whites than African Americanyouths in the U.S., with the highest rates in NativeAmericans and the lowest rates among Asian PacificIslanders (Anderson, 2002). The historically highersuicide rate among Native Americans is not fullyunderstood, but proposed risk factors include accessto firearms and alcohol or drug use. Studies haveidentified gender differences in the risk factors forNative American youth attempting suicide. For girls,knowing where to get a gun and having been in aspecial education class were associated withattempted suicide. For boys, being involved in agang or having been treated for emotional problemswas associated with attempted suicide (Borowsky,1999). A recent study examining suicidality amongurban African American and Latino youthdemonstrates an association between ethnicity,poverty and suicide. The Reach for Health Studyinvolved African American and Latino high schoolstudents living in economically deprived urbanenvironments in 1999 and 2000. Among youth in thestudy, 15 percent reported thoughts of suicide, 10percent had made at least one attempt, and 4.3percent reported having made multiple attempts(O’Donnell, O’Donnell, Wardlaw, & Stueve, 2004).Students with unmet basic needs were atsubstantially higher risk, as were students whoreported same-gender sexual behavior. Depressionwas also associated with increased risk. Analysis ofsocio-demographic data found that being female orbeing Latino increased the risk of suicideapproximately two-fold (O’Donnell, et al., 2004).

Gay Teens and SuicideResearch reveals that gay teens are more likely

to attempt suicide and many succeed.Epidemiological studies found a significant two- tosix-fold increased risk of nonlethal suicidal behaviorfor homosexual and bisexual youth (Garofalo &Wolf, 1999). Suicide attempts were six times more


likely for gay males than heterosexual males andtwice as likely for lesbians, compared toheterosexual females (Garofalo & Wolff 1999). Gayand lesbian youth account for as much as 30 percentof completed youth suicides annually (Garofalo &Wolff, 1999).

Treatment to Prevent SuicideFew studies have systematically evaluated

interventions aimed at reducing suicidal ideationand behavior in adolescents and young adults.Macgowan (2004) reviewed the evidence fortreatment of adolescent suicidality, classifyingtreatments by the level of empirical support. Of theten empirical studies reviewed, only two met thecriteria for probably efficacious (Macgowan, 2004).While neither of the treatments was gender-specific,in both cases the largest number of participants wasfemale.

In a randomized clinical trial involving youthwho had deliberately harmed themselves in theprior year, group therapy and routine care werecompared with routine care alone (Wood, Trainor,Rothwell, Moore, & Harrington, 2001). Grouptreatment was characterized as “developmentalgroup psychotherapy” and included elements ofproblem-solving, cognitive-behavioral therapy,dialectical behavior therapy and psychodynamicgroup psychotherapy. Group treatment comprisedan initial assessment phase, attendance at six acutegroup sessions oriented around these themes:relationships, school problems, peer relationships,family problems, anger management, depressionand self-harm, and hopelessness and feelings aboutthe future. This phase was followed by weeklygroup treatment in a long term group until the youth

felt ready to leave. Routine care consisted of a varietyof interventions including family sessions, non-specific counseling and psychotropic medication.

At the seven-month interview, results showedthat youth who participated in group therapy wereless likely than those in routine care to have repeateddeliberate self-harm. The group treatment reducedthe risk of a second episode of self-harm by 26percent. Youth in the program were also less likelyto need routine care, had better school attendanceand had a lower rate of behavioral problems thanthose receiving routine care. However, grouptreatment did not reduce depression or suicidalthinking (Wood, et al., 2001)

Harrington and colleagues examined the effectsof a home-based intervention that includedproblem-solving and communication (Harrington,et al., 1998; Kerfoot, Harrington and Dyer, 1995). Thestudy involved 162 adolescents who haddeliberately poisoned themselves and who wererandomly assigned to routine care alone or routinecare plus the home-based intervention. Theintervention consisted of an assessment session andfour home visits by MSW social workers whodirected family communication and problem-solving sessions. Routine services consisted of visitsto the clinic by youth and their families who receiveda diverse range of interventions. Outcomes wereassessed at two and six months.

At posttests, there was no significant differencein hopelessness or suicidal ideation between theintervention and control groups. Youth who hadattempted suicide but did not meet the diagnosticcriteria for major depression had significantly lowersuicidal ideation than the control group (Harrington,et al., 1998)

Eating DisordersFemales comprise the majority of individuals

diagnosed with an eating disorder—anorexianervosa, bulimia nervosa and binge eating. Eatingdisorders often co-occur with depression, substanceabuse and anxiety disorders and can cause serioushealth problems. Research on the causes of eatingdisorders and on effective treatments is in the earlystages. There have been some studies (reviewed laterin this section) that have demonstrated goodoutcomes for the treatment of anorexia and bulimia.

Suicide attempts were six timesmore likely for gay males than

heterosexual males and twice aslikely for lesbians, compared to

heterosexual females.


Eating disorders, such as anorexia nervosa andbulimia nervosa, primarily affect girls, but rarelymanifest before puberty. Adolescent girls are atgreater risk than those of other ages for developingan eating disorder. Prevalence estimates foradolescents and young adults have run as high as0.5 – 1.0 percent for anorexia (Hoek, 1991) and 1-3percent for bulimia (Garfinkel et al., 1995), butgeneral population epidemiological studies tend toshow lower rates. Studies using community samplesindicate that the incidence of eating disorders(anorexia and bulimia) is less than 2.8 percent byage 18 and 1.3 percent for ages 19 through 23(Lewinsohn, Striegel-Moore, Seeley, 2000.).However, for females ages 15-24 diagnosed withanorexia, the mortality rate is more than 12 timesthe annual death rate for females in their age groupfrom all other causes (Sullivan, 1995).

In addition, comorbidity is the rule rather thanthe exception. Eighty-nine percent of young womenmeeting the diagnostic criteria for one or more eatingdisorders demonstrate a comorbid condition,usually depression (Lewinsohn, et al., 2000). Becauserisk is associated with the developmental period ofadolescence and young adulthood and because theconsequences, if not treated, can be dire, accurateassessment and treatment of eating disorders iscrucial.

Racial and Ethnic Subgroupsand Eating Disorders

In general, there are inconsistent findingsconcerning ethnicity and eating problems; somestudies demonstrate that Latinas are diagnosed witheating disorders as frequently as are Caucasianfemales, while others suggest lower rates for Latinas.Studies routinely find African American girls to be

more satisfied with their bodies and to show fewereating problems and disorders than white or Latinagirls (Striegel-Moore, Wilfley, Pike, Dohm, &Fairburn, 2000). Recent study findings suggest thatacculturation plays a significant role in moderatingthe risk for eating disorders for Latinas (McKnight,2003). Specifically, the more likely a girl is to identifyherself as Latina American, the less likely she is todevelop an eating disorder.

Risks and Protective FactorsRisk factors for eating disorders emerge from

family and parenting issues related to physicaldevelopment in childhood and adolescence.

Parents who are themselves overweight, andfocused on their own weight, are more likely to beconcerned about their children’s physicalappearance and instruct their children to diet (Pike,1995). Research has consistently demonstrated thateating disorders tend to “aggregate” in families:having a female family member with an eatingdisorder significantly increases the risk for an eatingdisorder in girls (for review, see Lilienfeld and Kaye,1998).

Several studies have shown that familial factorsor life events that potentially threaten thedevelopment of a secure attachment are risk factorsassociated with eating disorders. Prolonged parent-child separation, unempathetic parenting style, lackof family cohesion and parental mental illness havebeen found to be more common in women with aneating disorder than among healthy women(Cachelin, et al.,1999). Women with eating disordershave higher rates of childhood physical and sexualabuse than women who do not experience an eatingdisorder (Striegel-Moore & Kearney-Cooke, 1994).Abusive parenting and sexual abuse are not specificrisk factors for eating disorders but are correlatedwith many mental health problems, including eatingdisorders. In other words, an eating disorder maybe one of the consequences of having beenphysically and or sexually abused.

Physical development issues can increase thelikelihood of an eating disorder. Early sexualmaturation increases the risk for a wide range ofaffective and behavioral problems, includingdisordered eating (Stattin & Magnusson, 1990). Attie

Eating disorders often co-occur withdepression, substance abuse andanxiety disorders and can cause

serious health problems.


and Brooks-Gunn (1989) argued that the singlebiggest impact of early sexual maturation is bodyimage dissatisfaction. Childhood obesity has alsobeen found to increase the risk for the developmentof bulimia but not anorexia (Fairburn, et al., 1997).

Three broad sets of variables act as protectivefactors contributing to adolescent resilience againstdeveloping eating disorders (as well as other mentaldisorders). Personal characteristics includeintelligence, strong self-concept or sense of identity,feelings of self-efficacy, an easy temperament andgood coping skills. Family variables includeadequate financial and material resources, a positivefamily environment and a positive relationship withone’s parent or primary caregiver or both. Socialcontext factors include social support andopportunities for change and growth (see reviewsby Kimchi & Schaffner, 1990; Wicks-Nelson & Israel,1997).

Treatment for Eating DisordersTo date there have only been three controlled

studies demonstrating the efficacy of interventionapproaches for eating disorders.

An NIMH clinical trial found that CBT wassuperior to Interpersonal Therapy (IPT) in reducingthe symptoms associated with bulimia. In addition,a higher percentage of CBT participants metcommunity norms for eating attitudes andbehaviors. CBT produced clinical gains more quicklythan IPT and was efficacious with a largerpercentage of participants, who also maintainedtreatment gains (Agras, Walsh, Fairburn & Wilson,2000).

A second controlled trial found that bothvomiting and bingeing in bulimia were clinicallyimproved by treatment with fluoxetine or a manual-based behavioral program. A combination of the twoapproaches led to the greatest improvement. Theeffects of the two treatments appear to beindependent and additive (Mitchell, et al., 2001).

The third study evaluated the efficacy ofDialectical Behavior Therapy (DBT) adapted to thetreatment of binge eating. The treatment, based onan affect regulation model of eating disorders, aimedto replace disordered eating behaviors withemotion-regulation skills. Compared with controls,

women treated with DBT showed decreased bingeeating and eating problems, and 89 percent stoppedbinge eating by the end of treatment. Abstinencefrom binging was reduced to 56 percent by the six-month follow-up (Telch, Agras & Linehan, 2001).

PremenstrualDysphoric Disorder

Premenstrual Dysphoric Disorder (PMDD) isdiagnosed in approximately 5 percent of men-struating women. PMDD is distinguished from themore common premenstrual syndrome (PMS) bymore severe symptoms and associated functionalimpairments. New research demonstrates thatwomen with PMDD have functional disabilitiessimilar to those found with other mood disorderssuch as depression and dysthymia (Perlstein, et al.,2000).

Randomized controlled trials of PMDDconsistently show that selective serotonin reuptakeinhibitor (SSRI’s) antidpressants are beneficial intreating symptoms (Dimmock, Wyatt, & O’Brien,2000; Steiner, 2000). Research indicates thattreatment of PMDD is efficacious if medicationadministration is limited to the luteal phase (thedays following ovulation) of the menstrual cycle.This strategy can be of benefit to women since costsand side effects are thereby limited (Mazure, et al.,2002). The current research on PMDD does not offeralternatives to medication such as psychotherapy.

Psychiatric DisordersDuring Pregnancy

Researchers are currently studying the specialproblems of treating serious mental illness in womenduring pregnancy, including transition age womenwho become pregnant. Although the effect ofpsychoactive drug treatment on the fetus duringpregnancy has received some attention, informationabout the effectiveness of different pharmo-cotherapies is still limited. A recent prospectivestudy of newborns whose mothers were treated withSelective Serotonin Reuptake Inhibitors (SSRI’s)show that their infants demonstrate disruption in awide range of neurobehavioral outcomes includingmotor activity, startle and heart rate regulation


(Kallen, 2004). The American Academy of Pediatrics,Committee on Drugs (2000) developed research-based guidelines, including the effects of specificdrugs on the fetus and newborn, to assist physicianswith appropriate drug selection for women who areeither contemplating pregnancy or are pregnant andwho have psychiatric disorders.

Postpartum DepressionPostpartum Depression (PPD) typically emerges

over the first two-to-three postpartum months, butmay occur at any point after delivery. Women whomay be at risk for developing PPD are those with aprevious episode of PPD, a history of depression orbipolar disorder, recent stressful life events,inadequate social supports, marital problems andthose who experienced depression duringpregnancy (Brockington, 2004).

Non-pharmacological therapies are useful in thetreatment of PPD. Therapy without medication canbe an important consideration for women who arebreast feeding and unwilling to take medicationbecause of potential harm to their babies. Arandomized controlled trial demonstrated thatshort-term cognitive-behavioral therapy was aseffective as treatment with fluoxetine in women withpostpartum depression (Appley, Warner, Whitton,& Fairagher ,1997). In addition, InterpersonalPsychotherapy (IPT) has been shown to beefficacious for the treatment of mild-to-moderatePPD. IPT was effective in reducing depressivesymptoms and improving social adjustment(O’Hara, Stuart, Gorman, & Wenzel, 2000). Inaddition, a recent postpartum depression efficacystudy showed both a mother-infant psychotherapygroup and interpersonal psychotherapy to besuperior to a wait-list comparison in reducingmaternal depressive symptoms and increasingmother’s positive affect and verbalization with theirinfants (Clark, Tluczek, & Wenzel, 2003). To date,only a few studies have systematically assessed thepharmacological treatment of PPD. In general,conventional antidepressant medications(fluoxetine, sertraline, fluvoxamine and venlafaxine)have been shown to be efficacious in the treatmentof PPD (Appley et al., 1997; Cohen, et al., 2001; Suri,Burt, Alsthyler, Zuckerbrow-Miller, & Fairbanks,

2001). In all of these studies, standard doses wereeffective and well tolerated by participants.

Young Mothers andPsychiatric Disorders

Under the best of conditions, parenting can bestressful for most mothers. However, for a youngwoman with mental health problems, parenting mayoverwhelm her coping capacities and result in pooroutcomes (including abuse and neglect) for herchildren. Intervention to help her manage her mentalhealth symptoms and increase her parentingcompetencies decreases the risk of negativeconsequences for both mother and children.

Research consistently demonstrates thatchildren of mothers with mental health problemsare more likely to live in poverty than children bornto mothers without mental health problems and arealso at risk for developing mental health problems.In addition, the research on depression demonstratesthat single, low-income women bear a greaterburden of depression than women who are notmothers.

One treatment program, the Nurse-FamilyPartnership Program, demonstrates good outcomesfor young mothers and their children. The keycomponents of the program include: (a) the programfocuses on low-income, first-time mothers; (b)nurses follow program guidelines focusing on themother’s personal health, quality of caregiving forthe child, and the mother ’s own life coursedevelopment; (c) nurses begin making home visitsduring pregnancy and continue through the first twoyears of the child’s life; (d) nurses follow a visitingscheduled keyed to the developmental stages ofpregnancy and early childhood; (e) nurses involvethe mother’s support system and link mothers toother health and mental health services they mayneed; (f) each nurse carries a caseload of no morethan 25 families; and (g) the program is located inand run by an organization known in thecommunity.

The Nurse-Family Partnership Program hasbeen shown to produce consistently good outcomesfor low-income women and their children throughthe child’s fourth year of life. In comparison to


control groups, women who received services fromthe Nurse-Family Partnership program, had betterprenatal health, lower use of cigarettes, reducedinjuries to their children, and lower rates ofsubsequent pregnancy and less use of incomeassistance (Olds, et al., 1997; Olds, et al, 1998).

A 15-year follow-up of women and their nowadolescent children in the Elmira, New YorkProgram found the following effects for the mothers:(a) 79 percent reduction in child abuse and neglect,(b) 44 percent reduction in maternal behavioralproblems related to use of alcohol and drugs, and(c) 69 percent fewer arrests among young mothers.In addition, the project found the following resultsfor the 15-year old children of mothers whoparticipated in the program: (a) 54 percent fewerarrests and 69 percent fewer convictions, (b) 58percent fewer sexual partners, and (c) 28 percentfewer cigarettes smoked and 51 percent fewer daysconsuming alcohol. The program also saved fourdollars for every dollar invested (Olds, et al., 1997;Olds, et al., 1998). More information about thisprogram can be found at http://www.nccfu.org

Gender and AttentionDeficit Disorder WithHyperactivity

Attention Deficit/Hyperactivity Disorder (AD/HD) is a prevalent child psychiatric disorder forwhich efficacious pharmacological andpsychological treatments have been established(Bussing, Zima, Gary, & Garvan, 2003).Nevertheless, several studies indicate that girls andchildren from ethnic minority backgrounds are

significantly less likely to receive AD/HD treatment,including psychotropic medications, than are boysand Caucasian children respectively (Bussing, Zima,& Belin, 1998; Zarian, Suarez, Pincus, Kupersanin,& Zito, 1998; Zito, Safer, desReis, Magder, & Riddle,1997). Research findings from several recent studiesoffer some explanation for these observeddifferences in treatment of AD/HD.

There is a substantial discrepancy in the male-to-female ratio between clinic-referred samples andcommunity samples of children with AD/HD; boysoutnumber girls 10 to 1 in clinical samples, but only3 to 1 in community samples. These findings suggestthat girls may be referred to clinical treatment lessoften and raises questions as to whether there maybe gender differences in the behavioralmanifestations of AD/HD (Biederman, et al., 2002).

Two recent studies examined gender differencesin behavior among children diagnosed with AD/HD. The results of these two studies strongly suggestthat differences in behavioral manifestations of AD/HD could result in gender-based referral biasunfavorable to girls.

Biederman, et al. (2002) systematically comparedboys and girls ages 6 –17 with and without AD/HDon multiple domains of functioning. The resultsindicated that girls with AD/HD were more likelythan boys to have the predominantly inattentivetype of AD/HD, less likely to have a learningdisability and less likely to manifest problems inschool or in their unscheduled or free time. Inaddition, girls with AD/HD were less likely toexhibit comorbid major depression, conductdisorder and oppositional defiant disorder than boyswith AD/HD (Biederman, et al.). The authors didfind that AD/HD in girls was a more serious riskfactor for substance abuse disorders than it was inboys.

Abikoff, et al. (2002) provided additionalcorroboration for differences in behavioralmanifestations of AD/HD between males andfemales. Using baseline observational data from theNIMH MTA study (MTA Cooperative Group, 1999a,1999b), investigators examined gender andcomorbidity differences in the observed classroombehavior of children with AD/HD. The mostsignificant finding between boys with AD/HD andgirls with AD/HD was that girls with AD/HD had

The Nurse-Family PartnershipProgram has been shown to produceconsistently good outcomes for low-

income women and their childrenthrough the child’s fourth

year of life.


relatively high rates of verbal aggression towardother children, whereas boys engaged in more rulebreaking and externalizing behaviors (Abikoff, et al.,2002). The higher rates of verbal aggression withother children among girls with AD/HD were inmarked contrast to their lower rates of physicalaggression and verbal aggression with the teacher.The occurrence of aggression toward the teacherobserved during 16 minutes of structured classroomactivities was extremely low (Abikoff, et al. 2002). Itis possible that instances of verbal aggression occurmore often during less structured school activitieswhen adult supervision is minimal.

Treatment for AD/HDThere is a paucity of data regarding the efficacy

of medications for the treatment of AD/HD in girls.The limited published literature suggests thatpsychostimulant treatment is equally effective inboys and girls with AD/HD (Biederman et al., 2002).A large-scale randomized clinical trial recentlyassessed the efficacy of atomoxetine in school-agegirls with AD/HD. Biederman, et al. (2002) reportedthat atomoxetine was superior to placebo inreducing the core symptoms associated with AD/HD (inattention and impulsivity) and that themedication was well tolerated by the researchparticipants.

What the EvidenceSuggests

This report reviewed the available research onthe mental health conditions affecting adolescentgirls and young women and the literaturesupporting the most promising psychosocial andpsychopharmacological interventions to treat thoseconditions. The review found that there arerelatively few studies focused on the special issuesand treatment needs of these transition age women.Where treatments and interventions have beendesigned for adolescent girls and young women,they are in the early stages of implementation andanalysis. The evidence presented here suggests thattransition age women experience all of the mentalhealth problems common in adult women, andaffecting young men, to some extent, and mayexperience higher rates of some disorders, such as

depression, suicidality and eating disorders. Inaddition, the literature review revealed thefollowing:

• Understanding developmental stages andmilestones is a prerequisite for effective mentalhealth interventions for adolescent girls andyoung women. Clinicians who work with youngwomen not only need to address the presentingproblem but also the normative skills theirclients may have failed to develop as aconsequence of having an emotional orbehavioral disorder during this criticaldevelopmental phase.

• Trauma is implicated as a risk factor for most ofthe psychiatric diagnoses affecting youngwomen. Therefore, treatment of adolescent girlsand young women should include screening forpast and present trauma exposure. Treatment fortrauma-related symptoms should be providedin addition to treatment for a specific mentalhealth diagnosis or problem.

• More girls are becoming involved in the justicesystem, at younger ages, and some for moreviolent offenses. The delinquent behaviors thatpropel these women into the justice system oftencan be traced to trauma and the aftermath oftrauma. Girls from ethnic minority groups aredisproportionately represented, and femaledelinquents have fewer mental health placementoptions than their male peers in the juvenilejustice system.

• Transition age women may not be accessingmental health treatment to the same degree astheir male peers, despite clear evidence that theyexperience many of the same mental healthchallenges.

• Comorbidity is the rule rather than theexception. Assessment for any one of thedisorders reviewed in this report should includeassessment for all others. Particular attentionshould be paid to the relationship betweendepression and substance abuse.

• There are specific risk and protective factors formost of the mental health conditions affectingyoung women. Understanding these factors canimprove prevention, identification, diagnosisand treatment for girls in this important lifestage.


• The high incidence of comorbidity, thecorrelation between mental health problems andtrauma and the complex array of risk andprotective factors affecting the mental healthstatus of young women combine to make acompelling case for integrated service andtreatment programs.

• There are unique issues and challenges foryoung women in ethnic and cultural subgroups,often necessitating specialized research,assessment and treatment approaches.

• Treatments that are effective or efficacious inyoung men or adults may or may not besimilarly effective for young women. Furtherresearch is needed on the most effectivetreatments to meet the unique mental healthneeds of transition age women.

RecommendationsBased on the evidence reviewed for this report,

the following general guidelines are offered forpolicy makers and practitioners responsible forproviding services to transition age young women.The findings of this report call for interventions that:

• Are supported by evidence from controlledscientific studies;

• Have the greatest potential to support successfulcompletion of key developmental tasks,including the development of high qualityfriendships, prosocial behavior and academic orvocational success;

• Promote connectedness to community andfamily or supportive adults outside of the family;and

• Improve coping skills and self-efficacy foradolescent girls and young women.In addition to these general guidelines, the

WMHPC makes the following specific recom-mendations:

Recommendation 1: Integratemental health and substanceabuse treatment services

The evidence clearly demonstrates a strongrelationship between trauma exposure, mentalhealth problems and substance abuse. The rates of

comorbidity are stunning and argue forsimultaneous rather than sequential treatment.Treatment provided in one agency rather thanmultiple agencies is likely to produce betteroutcomes. At the very least, mental health cliniciansand substance abuse counselors should be cross-trained to provide or make appropriate referrals tocomprehensive screening for Posttraumatic StressDisorder, Major Depression, suicide risk andsubstance abuse.

Recommendation 2: Providegender-specific programming foryoung women in the juvenilejustice system

The evidence suggests that adolescent girlsentering the juvenile justice system bring with themcomplex health and mental health needs related totrauma histories, including childhood abuse andcurrent partner abuse, sexual behavior andsubstance abuse. Services for girls in the juvenilejustice system should include treatment fordepression, traumatic stress, substance abuse andhealth-risking sexual behaviors. In addition, manygirls who enter the juvenile justice system arepregnant or are already parents. Providing servicesthat improve their parenting competencies decreasesthe stress associated with parenting and increasesthe likelihood that their children will have the socialand emotional competencies required for success inschool and in adulthood.

Recommendation 3: Providetraining to all gateway serviceproviders working with adolescentgirls and young women

Research shows that a primary predictor ofmental health service provision is the knowledgelevel of gateway service providers—child welfare,juvenile justice, primary health and educationproviders—on mental health problems, symptomsand resources. Gateway professionals need theinformation and the tools to recognize risk andprotective factors, identify mental health symptomsearly and make appropriate referrals. For example,


teacher training should include information on thedistinct behavioral manifestations of AttentionDeficit /Hyperactivity Disorder (AD/HD) in girls,particularly AD/HD Inattentive type. Teachers canbe trained to recognize that verbal aggression maybe a distinctly different indicator of the presence ofAD/HD in girls than the more physically aggressivebehaviors that signal AD/HD in boys.

Recommendation 4: Providespecialized treatment programs fortransition age mothers

Transition age young women who are mothersare likely to be single parents, living in poverty andwithout adequate social support. The barriers tomental health care are greater for low-income singlemothers because of the additional burdens ofparenting without a partner. The children of theseyoung mothers are at risk for abuse and neglect andfor developing serious emotional and behavioralproblems, especially depression. Specializedtreatment programs need to be available for youngmothers and should also include the supportservices necessary for them to participate intreatment, such as transportation, child care andparenting training.

Recommendation 5: Providespecialized training for cliniciansworking with adolescent girls andyoung women

Transition age women have uniquedevelopmental and gender-specific challenges, riskand protective factors and manifestations of mentalhealth problems. The available research revealsimportant diagnostic and treatment implications forgirls in this important developmental stage. Inaddition, existing research reveals differencesamong racial and ethnic subgroups of young womenand highlights the need for specialized treatmentprograms and services. Mental health cliniciansshould receive evidence-based training andeducation leading to culturally competent, gender-appropriate mental health service delivery.

Recommendation 6:Increase funding for mental healthtreatment research specific to tran-sition age women and subgroupsof transition age women

This review repeatedly illustrates the paucity ofevidence-based mental health research specific tofemales and to transition age women. Moreover,there is only limited research on the specializedmental health needs of racial, cultural and ethnicsubgroups among transition age women. Furthertargeted research is needed. It is critical that genderand ethnicity become routine variables in researchprojects and a component of all data collected,analyzed and published by funding agencies.

ConclusionThis review highlights the significant mental

health problems that can affect transition age womenas they move through adolescence to adulthood. Theavailable research provides important insights intothe types of mental health conditions young womenface as well as treatments and programs known tobe effective. Ultimately, however, the research ontheir unique treatment and service needs is so farinadequate and more research is needed. In themeantime, this overview should serve as a guidefor decisionmakers, professionals and mental healthpractitioners working with and developing servicesfor young women.

i For an excellent analysis of the issues facing transition ageyouth with severe emotional and behavioral disorders, seethe work of Hewitt Clark and Maryann Davis (Clark andDavis, 2000)


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