Tài liệu TEXTBOOK OF MEN’S MENTAL HEALTH doc

TEXTBOOK OF MEN’S
MENTAL HEALTH
This page intentionally left blank
Washington, DC
London, England
TEXTBOOK OF MEN’S
MENTAL HEALTH
Edited by
JON E. GRANT, M.D., M.P.H., J.D.
MARC N. POTENZA, M.D., PH.D.
Note: The authors have worked to ensure that all information in this book is
accurate at the time of publication and consistent with general psychiatric and
medical standards, and that information concerning drug dosages, schedules,
and routes of administration is accurate at the time of publication and consis-
tent with standards set by the U.S. Food and Drug Administration and the gen-
eral medical community. As medical research and practice continue to advance,
however, therapeutic standards may change. Moreover, specific situations may
require a specific therapeutic response not included in this book. For these rea-
sons and because human and mechanical errors sometimes occur, we recom-
mend that readers follow the advice of physicians directly involved in their care
or the care of a member of their family.
Books published by American Psychiatric Publishing, Inc., represent the views
and opinions of the individual authors and do not necessarily represent the pol-
icies and opinions of APPI or the American Psychiatric Association.
All patient names in this book are fictional. To protect confidentiality, these
cases are composites of several people’s stories, and case details have been
changed to protect patients.
Copyright © 2007 American Psychiatric Publishing, Inc.
ALL RIGHTS RESERVED
Manufactured in the United States of America on acid-free paper

1009080706 54321
First Edition
Typeset in Palatino and Futura Condensed.
American Psychiatric Publishing, Inc.
1000 Wilson Boulevard
Arlington, VA 22209–3901
www.appi.org
Library of Congress Cataloging-in-Publication Data
Textbook of men’s mental health / edited by Jon E. Grant, Marc N. Potenza.—
1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 1-58562-215-X (hardcover : alk. paper)
1. Men—Mental health. 2. Men—Psychology. I. Grant, Jon E.
II. Potenza, Marc N., 1965– . III. Title: Men's mental health.
[DNLM: 1. Men—psychology. 2. Mental Health. 3. Mental Disorders.
4. Sex Factors. WA 305 T3558 2006]
RC451.4.M45T49 2006
616.89'0081—dc22
2006014699
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
CONTENTS
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
I
Boys and Men at Different Life Stages
1 Childhood: Normal Development and Psychopathology . . . . . . . . . . . . . . . .3
Eric L. Scott, Ph.D.
Ann M. Lagges, Ph.D.

2
Adolescence: Neurodevelopment and Behavioral Impulsivity . . . . . . . . . . .23
Craig A. Erickson, M.D.
R. Andrew Chambers, M.D.
3
Older Men. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47
Rani Desai, Ph.D.
II
Psychiatric Disorders in Men: Assessment and Treatment
4 Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69
Carlos Blanco, M.D., Ph.D.
Oriana Vesga López, M.D.
5 Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Yael Levin, B.A.
Gerard Sanacora, M.D., Ph.D.
6
Substance Use Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
N. Will Shead, M.Sc.
David C. Hodgins, Ph.D.
7
Antisocial Personality Disorder, Conduct Disorder, and Psychopathy. . . . . . 143
Donald W. Black, M.D.
8
Sexual Health and Problems: Erectile Dysfunction,
Premature Ejaculation, and Male Orgasmic Disorder. . . . . . . . . . . . . . . . . 171
David L. Rowland, Ph.D.
9
Impulse Control Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Jon E. Grant, M.D., M.P.H., J.D.
Marc N. Potenza, M.D., Ph.D.

10
Posttraumatic Stress Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Dolores Vojvoda, M.D.
Steven Southwick, M.D.
III
Sociocultural Issues for Men
11 Fathering and the Mental Health of Men . . . . . . . . . . . . . . . . . . . . . . . . . 259
Thomas J. McMahon, Ph.D.
Aaron Z. Spector, M.S.N., A.P.N.
12
Men, Marriage, and Divorce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
Scott Haltzman, M.D.
Ned Holstein, M.D., M.S.
Sherry B. Moss, M.A.
13
Body Image and Muscularity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Roberto Olivardia, Ph.D.
14
Aggression, Violence, and Domestic Abuse . . . . . . . . . . . . . . . . . . . . . . . . 325
Caroline J. Easton, Ph.D.
Tara M. Neavins, Ph.D.
Dolores L. Mandel, L.C.S.W.
15
Culture, Ethnicity, Race, and Men’s Mental Health. . . . . . . . . . . . . . . . . . . 343
Declan T. Barry, Ph.D.
16 Mental Health of Gay Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .363
Michael King, M.D., Ph.D., F.R.C.P., F.R.C.G.P.,
F.R.C.Psych.
17
Overcoming Stigma and Barriers to Mental Health Treatment . . . . . . . . . .389

Deborah A. Perlick, Ph.D.
Lauren N. Manning, B.A.
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .419
This page intentionally left blank
ix
CONTRIBUTORS
DECLAN T. BARRY, PH.D.
Associate Research Scientist, Yale University School of Medicine, New
Haven, Connecticut
DONALD W. BLACK, M.D.
Professor of Psychiatry, Department of Psychiatry, The University of Iowa
Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa
CARLOS BLANCO, M.D., PH.D.
Assistant Clinical Professor of Psychiatry, New York State Psychiatric In-
stitute at Columbia University Medical Center, New York, New York
R. ANDREW CHAMBERS, M.D.
Director, Laboratory for Translational Neuroscience of Dual Diagnosis
Disorders, Institute of Psychiatric Research, Department of Psychiatry,
Indiana University School of Medicine, Indianapolis, Indiana
RANI DESAI, PH.D.
Associate Professor of Psychiatry and Epidemiology and Public Health,
Yale University School of Medicine, West Haven, Connecticut
CAROLINE J. EASTON, PH.D.
Assistant Professor of Psychiatry, Director of Forensic Drug Diversion,
and Director of Substance Abuse and Domestic Violence Services, Divi-
sion of Substance Abuse, Department of Psychiatry, Yale University
School of Medicine, New Haven, Connecticut
CRAIG A. ERICKSON, M.D.
Chief Resident in Psychiatry and Fellow in Child Psychiatry, Depart-
ment of Psychiatry, Indiana University School of Medicine, Indianapo-

lis, Indiana
JON E. GRANT, M.D., M.P.H., J.D.
Associate Professor of Psychiatry, University of Minnesota Medical
Center, Minneapolis, Minnesota
x TEXTBOOK OF MEN’S MENTAL HEALTH
SCOTT HALTZMAN, M.D.
Clinical Assistant Professor of Psychiatry and Human Behavior, Brown
Medical School, Providence, Rhode Island
DAVID C. HODGINS, PH.D.
Professor of Psychology, Department of Psychology, University of Cal-
gary, Alberta, Canada
NED HOLSTEIN, M.D., M.S.
Clinical Assistant Professor, Department of Community and Environ-
mental Medicine, Mount Sinai School of Medicine, New York, New
York
MICHAEL KING, M.D., PH.D., F.R.C.P., F.R.C.G.P., F.R.C.PSYCH.
Professor of Primary Care Psychiatry, Department of Mental Health Sci-
ences, Royal Free and University College Medical School, London, En-
gland
ANN M. LAGGES, PH.D.
Assistant Professor of Clinical Psychology in Clinical Psychiatry, Co-
chief, Mood Disorders Clinic, Riley Child and Adolescent Psychiatry
Clinic, Riley Hospital for Children, Indiana University School of Medi-
cine, Indianapolis, Indiana
YAEL LEVIN, B.A.
Research Assistant, Yale Depression Research Program and Depart-
ment of Psychiatry, Yale University School of Medicine, New Haven,
Connecticut
ORIANA VESGA LÓPEZ, M.D.
Assistant Clinical Professor of Psychiatry, New York State Psychiatric

Institute at Columbia University Medical Center, New York, New York
DOLORES L. MANDEL, L.C.S.W.
Program Coordinator of Drug Diversion, Forensic Drug Diversion, and
Director of Substance Abuse and Domestic Violence Services, Division
of Substance Abuse, Department of Psychiatry, Yale University School
of Medicine, New Haven, Connecticut
Contributors
xi
LAUREN N. MANNING, B.A.
Research Assistant, Northeast Program Evaluation Center, West Haven
Veterans Affairs Medical Center and Department of Psychiatry, Yale
University School of Medicine, New Haven, Connecticut
THOMAS J. MCMAHON, PH.D.
Associate Professor, Yale University School of Medicine, Department of
Psychiatry and Child Study Center, West Haven Mental Health Clinic,
West Haven, Connecticut
SHERRY B. MOSS, M.A.
Lecturer in Psychiatry, Harvard Medical School, Boston, Massachusetts
TARA M. NEAVINS, PH.D.
National Institute on Drug Abuse Postdoctoral Fellow, Forensic Drug Di-
version, and Substance Abuse and Domestic Violence Services, Division
of Substance Abuse, Department of Psychiatry, Yale University School of
Medicine, New Haven, Connecticut
ROBERTO OLIVARDIA, PH.D.
Clinical Instructor of Psychology, Department of Psychiatry, Harvard
Medical School, Belmont, Massachusetts
DEBORAH A. PERLICK, PH.D.
Associate Professor of Psychiatry, Mount Sinai School of Medicine, New
York, New York
MARC N. POTENZA, M.D., PH.D.

Associate Professor of Psychiatry, Yale University School of Medicine,
New Haven, Connecticut
DAVID L. ROWLAND, PH.D.
Professor, Department of Psychology, Valparaiso University, Valparaiso,
Indiana
GERARD SANACORA, M.D., PH.D.
Director, Yale Depression Research Program and Associate Professor of
Psychiatry, Yale University School of Medicine, New Haven, Connecticut
xii TEXTBOOK OF MEN’S MENTAL HEALTH
ERIC L. SCOTT, PH.D.
Assistant Professor of Clinical Psychology in Clinical Psychiatry, Co-
chief, OCD/Tic/Anxiety Disorders Clinic, Riley Child and Adolescent
Psychiatry Clinic, Riley Hospital for Children, Indiana University School
of Medicine, Indianapolis, Indiana
N. WILL SHEAD, M.SC.
Doctoral Student, Department of Psychology, University of Calgary, Al-
berta, Canada
STEVEN SOUTHWICK, M.D.
Professor of Psychiatry, Department of Psychiatry, Yale University School
of Medicine, New Haven, Connecticut
AARON Z. SPECTOR, M.S.N., A.P.N.
Graduate Student, Yale University School of Nursing, Psychiatric and
Mental Health Nursing Specialty Program, New Haven, Connecticut
DOLORES VOJVODA, M.D.
Assistant Professor of Psychiatry, Department of Psychiatry, Yale Uni-
versity School of Medicine, New Haven, Connecticut
xiii
INTRODUCTION
Since the late 1990s, the volume of research on gender issues in mental
health has grown significantly. One important point that the gender lit-

erature has demonstrated, in addition to clarifying how women’s health
differs from that of men’s, is how little we actually know about men’s
mental health concerns. Although the great body of research in mental
health has historically been based on men, until recently the research has
largely failed to address how male gender integrally influences the clin-
ical presentation and treatment of various disorders. Thus this volume
reflects an exciting moment in the history of men’s mental health. Re-
search on women’s health has highlighted the important premise that
diagnosis, etiology, prevention, and treatment efforts should carefully
consider how men and women differ as well as how they are similar.
This volume builds on this premise by presenting the latest research on
what mental health care professionals should know about men’s psychi-
atric issues.
Although many clinicians encounter men with mental health issues,
many have never considered the unique issues faced by men at various
stages in life or how men present differently with certain disorders. In ad-
dition, clinicians may be relatively unaware of how treatment responses
in men differ from those in women. Thus, a primary aim of this book is to
document salient aspects of men’s mental health throughout the life
span, the clinical presentation and treatment of various psychiatric disor-
ders frequently observed in men, and sociocultural topics of particular
relevance to men.
The first part of this text highlights three important stages in men’s
lives. Scott and Lagges (Chapter 1, “Childhood: Normal Development
and Psychopathology”) and Erickson and Chambers (Chapter 2, “Adoles-
cence: Neurodevelopment and Behavioral Impulsivity”) provide compre-
hensive descriptions of normal childhood and adolescent development,
respectively, and highlight the major developmental issues encountered
by boys and how boys differ from girls in their developmental trajectories.
At the other end of the age spectrum, Desai (Chapter 3, “Older Men”) de-

scribes the biopsychosocial changes that occur as men age.
xiv TEXTBOOK OF MEN’S MENTAL HEALTH
A primary aim of this book is to provide clinicians with information
on how men differ from and are similar to women with respect to clin-
ical presentation and treatment of psychiatric disorders. As such, the
second part of this text addresses areas of clinical care in which men
present unique clinical issues. Disorders that are more prevalent in men
are examined by Shead and Hodgins in Chapter 6, “Substance Use Dis-
orders,” and by Black in Chapter 7, “Antisocial Personality Disorder,
Conduct Disorder, and Psychopathy.” These chapters provide a com-
prehensive understanding of these various disorders as well as treat-
ment approaches. Although the treatment of men’s sexual functioning
has made tremendous advances since 2000, few mental health clinicians
address this important topic. To enhance the overall care of male pa-
tients, Rowland has provided an invaluable chapter on male sexual
functioning (Chapter 8, “Sexual Health and Problems: Erectile Dysfunc-
tion, Premature Ejaculation, and Male Orgasmic Disorder”).
Certain psychiatric disorders are seen less frequently in men. There-
fore, when men present with these disorders, clinicians often assume
that the presentation and treatment will be similar to what is seen and
used in women. Disorders less commonly seen in men but with impor-
tant clinical and treatment differences are explored by Blanco and López
in Chapter 4, “Anxiety Disorders,” by Levin and Sanacora in Chapter 5,
“Depression,” and by Vojvoda and Southwick in Chapter 10, “Posttrau-
matic Stress Disorder.” Finally, in Chapter 9, “Impulse Control Disor-
ders,” we address certain disorders that are seen more frequently in men
(pathological gambling, compulsive sexual behavior) and other disor-
ders that are less commonly encountered (trichotillomania, kleptoma-
nia, compulsive buying).
The last section of the book, Part III, focuses on several sociocultural

issues of particular salience to men. McMahon and Spector discuss the in-
fluence of fathers on the family and the impact of fathering on children’s
mental health in Chapter 11, “Fathering and the Mental Health of Men.”
Haltzman and colleagues examine how men think about and behave in
intimate relationships in Chapter 12, “Men, Marriage, and Divorce.”
Body image, a problem long associated with women, has become a seri-
ous and underrecognized health issue for many men. Olivardia discusses
the clinical presentation of and treatment options for male eating disor-
ders, muscle dysmorphia, and steroid abuse in Chapter 13, “Body Image
and Muscularity.” Easton and colleagues address the complex issues un-
derlying male aggression and violence and how various interventions of-
fer hope for this public health problem in Chapter 14, “Aggression,
Violence, and Domestic Abuse.” Mental health issues appear to be intrin-
sically linked to issues of culture and ethnicity in men. In Chapter 15,
Introduction
xv
“Culture, Ethnicity, Race, and Men’s Mental Health,” Barry provides in-
sight into how these factors may influence men’s willingness to seek
treatment and the effectiveness of the services offered. Because of the
high rates of psychiatric disorders among gay men and gay men’s reluc-
tance to access mental health care, King has provided a thorough look at
issues particular to gay men and how clinicians may better understand
and address these concerns in Chapter 16, “Mental Health of Gay Men.”
Finally, an important clinical issue involves the reluctance of many men
to access mental health treatment. In Chapter 17, “Overcoming Stigma
and Barriers to Mental Health Treatment,” Perlick and Manning examine
the issues men face as they consider seeking help for their mental health
problems and what clinicians may do to address these concerns.
In summary, men’s mental health represents an important yet largely
neglected area of clinical care. As the chapters of this volume eloquently

attest, extraordinary progress has been made regarding how men with
various psychiatric disorders present differently from women and how
treatment interventions may need to be modified based on gender issues.
This volume presents a multidisciplinary perspective on men’s mental
health issues by addressing developmental issues, incorporating psycho-
social issues unique to men, and presenting treatment options for a wide
array of psychiatric disorders. We hope that clinicians who wish to better
understand how they can make wise decisions regarding the care and
well-being of men with mental health issues will find this text valuable.
Jon E. Grant, M.D., M.P.H., J.D.
Marc N. Potenza, M.D., Ph.D.
This page intentionally left blank
PART I
BOYS AND MEN AT
DIFFERENT LIFE STAGES
This page intentionally left blank
3
1
CHILDHOOD
Normal Development and Psychopathology
ERIC L. SCOTT, PH.D.
ANN M. LAGGES, PH.D.
Boys and girls differ during childhood in patterns of normal develop-
ment and in the psychiatric disorders most frequently encountered. In
this chapter, we focus on major developmental issues encountered by
boys and girls and highlight how boys and girls differ in their develop-
mental trajectories. For example, boys tend to acquire language more
slowly and experience childhood psychiatric disorders like attention-
deficit/hyperactivity disorder (ADHD) and autistic disorder more fre-
quently than do girls. Additionally, we highlight areas in which male

gender may be a protective factor that enhances the way children can
cope with challenges along their developmental paths.
Case Vignette
Mrs. Smith brought her 12-year-old son, Tony, in for an evaluation at the
local mental health clinic, believing he had significant mental health
problems manifesting as behavioral outbursts, irritability, and a poor at-
tention span. She saw some increased irritability at home, and his teach-
4 TEXTBOOK OF MEN’S MENTAL HEALTH
ers complained that he was performing poorly in school, had been
uncooperative and refused to do his work, had been fighting more with
his peers, and appeared to be having staring spells. His appetite had
waned lately, and he had always been a poor sleeper.
Upon his interview with the mental health professional, Tony was
irritable and resentful of his mother for making the appointment, choos-
ing to look at the floor of the office rather than make good eye contact.
His minimal answers to questions usually ended with “I don’t know.”
He vehemently denied feeling depressed but endorsed sleep and appe-
tite problems, poor concentration, and irritability. He was somewhat
hopeful about the future but expressed many comments such as “what
difference does it make?” and “who cares?” He had dropped many con-
tacts with his friends and was staying in his room more often than usual.
His mother chalked up his behavior as a combination of the cold winter
weather and changes in his interests in friends, particularly the drinking
that she knew some of his friends were doing. The most bothersome
portion for her was the decline in his school performance. She feared the
educational implications that would accrue if this downward slide con-
tinued into high school.
Considerations in the diagnostic process for Tony would include any
history of early attachment problems between Tony and his mother as
well as recent stressors such as divorce or fights at school that could indi-

cate a significant adjustment problem. Although the school personnel
may consider Tony a prime candidate for ADHD, many of his problems
are highly consistent with a major depressive disorder or a learning dis-
ability. In a thorough workup for each of these disorders, it may be help-
ful to observe Tony for several sessions alone, without his parents, and
also to speak with the school personnel directly to rule out any learning
difficulties. Finding out more about his family’s history of depression or
other affective problems may also offer a clue about both his genetic and
his environmental loading for depression.
TYPICAL EMOTIONAL DEVELOPMENT AND MOOD DISORDERS
Infants are capable of expressing a range of emotions soon after birth.
Being able to display feelings such as contentment, distress, and fear al-
lows the infant to communicate on a basic level and therefore have basic
needs met long before language develops. Smiling encourages adults to
continue interaction, and cries of distress motivate caregivers to try to
ascertain and remedy the source of the distress. Interestingly, a sponta-
neous neonatal smile, a startle response, distress, and disgust are all
present at birth. A social smile appears at 4–6 weeks. Anger, surprise,
and sadness can be expressed by 3–4 months. Fear and shame or shy-
Childhood
5
ness are observable at approximately ages 5–8 months, and contempt
and guilt appear in the second year of life (Santrock 1990).
Early studies of gender differences suggested that girls and boys
show few, if any, differences in emotional development before age 1 year
(Maccoby and Jacklin 1974). However, findings emerged in the decades
that followed and suggested that some gender differences in emotional
functioning are apparent as early as birth. For example, during the neo-
natal period, male infants tend to smile less, be more irritable and diffi-
cult to soothe, and show greater emotional lability than female infants

(Feldman et al. 1980).
Many of these gender differences appear to persist into the first year
of life. Weinberg et al. (1999) explored these differences, using Tronick’s
face-to-face still-face paradigm. This interaction involves 2 minutes of
the mother and infant playing, then 2 minutes of the mother looking at
the infant, but not smiling, talking, or touching the infant, and finally,
2 minutes of the mother and infant playing (Tronick et al. 1978). The
second segment of this procedure, the still-face portion, is theoretically
the most difficult for the infants because they must regulate their own
emotional state without any cues from their mother. Male infants dis-
played more difficulty than female infants in regulating their emotional
states when faced with these abrupt shifts in interaction with their
mothers (Weinberg et al. 1999). As a group, the boys displayed more
negative emotion than did the girls during all three portions of the pro-
cedure, not just the still-face portion. One possible explanation for this
finding is that male infants may rely more on emotional cues from and
interaction with others to help regulate emotional states; girls may be
more able to self-regulate at an earlier age. It is important to note, how-
ever, that individual differences were present; some girls in the study
displayed high levels of negative emotion and some boys displayed rel-
atively low levels of negative emotion during the exercise (Weinberg et
al. 1999).
Studies have also shown that during the early childhood years, boys
tend to show greater emotional effects from parental conflict and stress
in caregivers (Kerig 1999; Laumakis et al. 1998). One possible explana-
tion for this finding, given the previously discussed research involving
younger children, is that during these early years boys may still be look-
ing to their primary caregivers for assistance in emotional regulation.
Highly stressed parents are unlikely to be able to provide calming cues
for their young boys.

For many years, it was believed that boys were more vulnerable to pa-
rental conflict and environmental stressors throughout development.
More recent research has suggested, however, that as girls and boys grow
6 TEXTBOOK OF MEN’S MENTAL HEALTH
older, girls tend to be more vulnerable than boys to parental conflict; spe-
cifically, parental conflict during the adolescent years has been found to
be more associated with depressive symptoms in girls than in boys
(Davies and Lindsay 2004). One partial explanation for this difference
may involve the social expectations for boys to become more indepen-
dent and self-sufficient as they grow older, whereas girls are expected to
become more connected with others on an emotional level as they enter
adolescence.
These findings may in part explain why, during the prepubertal
years, boys display a slightly higher rate of depressive disorders than
do girls; after puberty, rates of depressive disorders in adolescents mir-
ror the gender split of adults, with depressive disorders occurring about
twice as frequently in girls than in boys (Hankin et al. 1998). A review
of the literature exploring possible reasons for this gender by age inter-
action in rates of depression suggests that a number of factors are in-
volved, including social (Davies and Lindsay 2004) and biological
(Cyranowski et al. 2000) factors. Regarding biological factors, hormonal
differences that appear in adolescence (Angold et al. 1998) as well as ge-
netic factors (Merikangas et al. 1985) have been implicated in this gen-
der by age interaction. Differences in gender-based socialization, such
as the previously described expectation for girls to be more emotionally
connected to others, are also likely to play a role (Wichstrom 1999).
Kessler et al. (2001) suggested that cross-cultural studies are likely to be
helpful in further separating biological and social influences on adoles-
cent depression.
In considering a diagnosis of a depressive disorder in a boy, either

major depression or dysthymic disorder, it is important to remember
that in children, mood may be irritable rather than depressed or sad.
Depressed boys often express their irritability by throwing tantrums or
showing an increase in aggressive or destructive behavior. It is also im-
portant to remember that concentration problems can be a symptom of
a depressive disorder rather than always indicating ADHD. Grades of-
ten drop due to these concentration problems, feelings of worthless-
ness, and the lack of motivation to do well in school associated with a
broader experience of anhedonia; getting good grades is no longer plea-
surable. When a boy presents with general “behavior problems,” drop-
ping grades, and concerns from parents and teachers regarding poor
attention, the child should be screened for depressive disorders as well
as the more commonly diagnosed ADHD.
Studies consistently indicate that the majority of both boys and girls
diagnosed with depression also carry at least one comorbid diagnosis.
Patterns of comorbidity differ with gender; girls are more likely to present
Childhood
7
with comorbid anxiety disorders, whereas boys are more likely to present
with comorbid substance use disorders. Both girls and boys frequently
present with comorbid conduct disorder (Kessler et al. 2001; Ruchkin and
Schwab-Stone 2003).
Although gender by age differences in rates of depression have been
well documented, no comparable differences have been found in rates of
new-onset manic symptoms (Kessler 2000). In addition, no gender differ-
ences have been found regarding the frequency of cycling between manic
and depressive episodes; suicidality; rates of specific manic symptoms
such as elated mood, grandiosity, or racing thoughts; psychotic symp-
toms; or rates of comorbid oppositional defiant disorder (ODD; Geller et
al. 2000). Boys diagnosed with bipolar disorder are, however, more likely

than girls to carry a comorbid diagnosis of ADHD (Geller et al. 2000).
Suicide is the most serious possible outcome of depression or any
other psychiatric disorder. Although it has been well documented that
adolescent girls attempt suicide more often than adolescent boys, ado-
lescent boys complete suicide at a higher rate (Salkind 2002). The most
frequently cited explanation for the greater completion rate of suicide at-
tempts by adolescent boys is that they tend to choose more violent, lethal
methods such as firearms or hanging, whereas adolescent girls are more
likely to use methods such as drug overdose that are more frequently
less lethal (Salkind 2002). These findings suggest that the intersection be-
tween depression and impaired impulse control (see Chapter 9, “Im-
pulse Control Disorders”) may be particularly lethal for boys and men.
SOCIAL DEVELOPMENT
The first social task infants face involves forming an attachment to the
caregiver. Attachment refers to the bond between a caregiver and the
child that leads the child to feel safe, secure, and trusting that his or her
needs will be met by the caregiver. Insecurely attached infants may be
indifferent toward the caregiver or may simultaneously cling to and
push away from the caregiver and appear inconsolable.
Although it is commonly believed that females are “more social”
than males, research suggests that this supposition may not be the case
for infants. Male infants were found to be more likely than female infants
to look at, smile at, fuss for, reach to be picked up by, and vocalize to their
mothers during a structured interaction (Weinberg et al. 1999). These au-
thors suggest that this higher level of both positive and negative social
behavior may serve to assist the infant boys in obtaining more assistance
from their mothers in regulating their emotional states, such as when
8 TEXTBOOK OF MEN’S MENTAL HEALTH
their mother smiles in response to their smile to confirm a happy mood
or their mother soothing them in response to their distress. These types

of interaction help assure the infant that his mother will help keep him
comfortable emotionally and can further facilitate attachment.
Social demands and types of social interaction change as children
grow older. The child’s social world expands beyond the family, and
peer relationships become increasingly important beginning in the pre-
school years. By middle childhood, friendships and group activities
tend to play major roles in a child’s life. Although individual differences
are always present, boys as a group tend to form friendships based on
common activities rather than the emotional intimacy more often cited
by girls. Boys are also more likely than girls to select competitive over
cooperative forms of play. Both boys and girls display aggression in
their social relationships, but boys tend to display more overt forms of
aggression, such as physical or verbal aggression, whereas girls tend to
rely on more covert forms of aggression, such as social isolation (Sal-
kind 2002).
LANGUAGE DEVELOPMENT AND DISORDERS
Infants typically begin to babble at about ages 3–6 months and usually
speak their first words between 10 and 13 months. By ages 18–24
months, children are typically using two-word phrases. Between 27 and
34 months, children normally begin using three-word phrases and are
able to use some basic grammatical principles such as plurals and past
tense. At this age, they are also able to ask the ever-popular toddler
“who, what, where, and why?” questions (Santrock 1990).
There has been some suggestion that expressive language delays are
more common in boys (19.2%) than in girls (7.9%) up to approximately
age 18 months (Horwitz et al. 2003). Because this difference seems to be-
come nonsignificant in the age groups above 18 months, and because
behavior problems first become significantly associated with language
delay around age 30 months (Horwitz et al. 2003), it is unclear whether
there are any clinically meaningful implications of this difference in the

very young age group. It may simply be that boys are more likely than
girls to show some initial delay in expressive language but that this de-
lay may not be indicative of later pathology. Therefore, parents who
note that their baby boy is not speaking quite as early as his sister did
may not have cause for alarm.