Dysfunctional attitudes, social support, and adolescent depression

Abstract

Adolescent depressive symptoms represent a significant public health concern, with negative life events and dysfunctional attitudes playing pivotal roles in their development. A cross-sectional study by Yu et al assessed the interplay between dysfunctional attitudes, social support, and depressive symptoms in 795 Chinese adolescents (49.9% male, mean age 15.2 ± 1.8 years, age range 11-18 years) from five middle schools in Shandong Province. Using the Dysfunctional Attitudes Scale, Adolescent Life Events Scale, Beck Depression Inventory, and Social Support Rating Scale, the study identified that dysfunctional attitudes, particularly over-autonomy and over-perfectionism, mediate the relationship between negative life events and depressive symptoms. Social support moderated this relationship, significantly reducing depressive symptoms. These findings underscore the need for preventive and therapeutic strategies targeting dysfunctional attitudes and enhancing social support to address adolescent depressive symptoms. In this article, we extend their findings to highlight the significance of culturally tailored interventions that incorporate familial and community dynamics in mitigating depressive symptoms, particularly in collectivist societies.

Key Words: Adolescent depression; Dysfunctional attitudes; Social support; Negative life events; Over-autonomy; Over-perfectionism

Core Tip: In this study, we discuss the relationship between negative life events, dysfunctional attitudes, and depressive symptoms in Chinese adolescents, highlighting the moderating effect of social support. Over-autonomy and over-perfectionism may mediate the impact of negative life events on depressive symptoms. Strengthening social support can substantially mitigate these effects, offering valuable insights for developing targeted interventions to reduce depressive symptoms among adolescents.

TO THE EDITOR

Adolescent depressive symptoms are an escalating public health concern, significantly impairing mental well-being and contributing to substantial morbidity, including reduced academic performance, strained interpersonal relationships, and elevated risks of substance abuse and suicide[1]. Grounded in Beck’s cognitive vulnerability-stress theory, this study discusses how negative life events (NLEs) interact with dysfunctional attitudes to influence depressive symptoms in adolescents. The theory underscores the interplay between cognitive vulnerabilities (e.g., dysfunctional attitudes), environmental stressors (e.g., NLEs), and mental health outcomes (e.g., depressive symptoms), positing that cognitive vulnerabilities such as over-autonomy and over-perfectionism are activated by stressors, leading to maladaptive emotional responses. This study further extends the model by incorporating the moderating role of social support, a critical factor in mitigating depressive symptoms, particularly among adolescents facing chronic stressors[2,3].

Although the associations between NLEs, dysfunctional attitudes, and depressive symptoms are well-documented, the buffering effect of social support in this context remains underexplored, particularly among Chinese adolescents. Defined as the perceived availability of emotional and instrumental resources, social support is a robust protective factor against depressive symptoms[4,5], promoting adaptive coping, positive self-perception, and emotional well-being[6]. Understanding how social support interacts with NLEs and dysfunctional attitudes is essential for developing effective preventive and therapeutic interventions. A study by Yu et al[7] addresses this gap by examining a moderated mediation model of NLEs, dysfunctional attitudes, and social support in relation to depressive symptoms among 795 Chinese adolescents aged 11-18 years. Conducted across five middle schools in Shandong Province, the study employed validated instruments, including the Dysfunctional Attitudes Scale, Adolescent Life Events Scale, Beck Depression Inventory-II (BDI-II), and Social Support Rating Scale.

The findings demonstrate that NLEs significantly predict depressive symptoms through the mediating role of dysfunctional attitudes, particularly over-autonomy and over-perfectionism. Social support moderates this relationship, effectively buffering the impact of dysfunctional attitudes on depressive symptoms. These results align with the cognitive vulnerability-stress model, which posits that environmental stressors activate underlying cognitive vulnerabilities, amplifying their role in the onset of depressive symptoms[8]. The activation of dysfunctional attitudes shapes maladaptive cognitive and emotional responses, mediating the relationship between stressors and depressive symptoms. This dynamic underscore the dual role of dysfunctional attitudes as both consequences of stress activation and mediators of depressive symptomatology.

The sociocultural context of China, characterized by collectivist values and family-centered social structures, may uniquely influence the dynamics of social support and mental health. Chinese adolescents face significant academic pressures stemming from a competitive education system with long school hours, frequent examinations, and high parental expectations[9]. These stressors contribute to the rising prevalence of depressive symptoms, further limiting adolescents’ capacity to build resilience or seek social support. Addressing these challenges requires culturally tailored interventions targeting dysfunctional attitudes and enhancing social support within school-based and community mental health programs. The findings of this study provide valuable insights for educators, mental health professionals, and policymakers, emphasizing the importance of preventive strategies that consider the unique sociocultural and systemic stressors affecting Chinese adolescents (Table 1).

Table 1 Relationships among negative life events, dysfunctional attitudes, desire for approval, and social support.

Variable	Relationship	Effect type	Implications for practice
NLEs	NLEs, dysfunctional attitudes, and depressive symptoms	Mediated effect	Early identification of high-risk adolescents exposed to NLEs; focus on prevention strategies
Over-autonomy	Over-autonomy and depressive symptoms	Mediated effect	Encourage balanced self-reliance and seeking appropriate help to reduce isolation
Over-perfectionism	Over-perfectionism and depressive symptoms	Mediated effect	Teach adolescents to set realistic goals and practice self-compassion to mitigate perfectionism
Desire for approval	Desire for approval and depressive symptoms	Mediated effect	Help adolescents develop internal self-worth and reduce dependency on external validation
Social support	Social support, dysfunctional attitudes, and depressive symptoms	Moderated effect	Strengthen peer and family support systems to buffer the effects of dysfunctional attitudes

NLEs: Negative life events.

Beck’s cognitive vulnerability-stress theory

Beck’s cognitive vulnerability-stress theory posits that cognitive vulnerabilities (Figure 1)[10], such as dysfunctional attitudes, interact with external stressors, like NLEs, to trigger depressive symptoms. This interaction is central to understanding the dynamics between NLEs and depressive outcomes. In adolescents, NLEs such as academic failures, interpersonal conflicts, or family stressors may activate maladaptive cognitive patterns, particularly over-autonomy and over-perfectionism, which Yu et al[7] identified as key dysfunctional attitudes in their study. These attitudes, in turn, exacerbate emotional distress, shaping adolescents’ emotional and cognitive responses to these stressors and mediating the relationship between NLEs and depression. It is important to emphasize that these dysfunctional attitudes do not merely occur as a reaction to stress but are cognitive vulnerabilities that predispose adolescents to negative outcomes when stressors are present.

Figure 1 Bidirectional partial mediation interpretation of Beck’s cognitive theory. Purple solid lines represent paths in the theoretical model with full mediation, and orange dashed lines represent paths in the model with partial mediation.

A more thorough theoretical integration would involve explicitly outlining how over-perfectionism and over-autonomy interact with environmental stressors to produce depressive symptoms. A study conducted by Rogers et al[11] demonstrated that dysfunctional attitudes, such as the need for approval and perfectionism, act as mediators between stressors and depression in adolescents. These findings underscore the theoretical assertion that dysfunctional attitudes can intensify the emotional impact of stress. Furthermore, research by Kay-Lambkin et al[12] indicated that the specific variables of perfectionism and need for approval showed promise as moderators of treatment efficacy for depression. Further research is warranted to determine whether these factors can assist in tailoring the modality and strategies offered in the psychotherapy. Therefore, over-perfectionism may amplify the emotional impact of NLEs by causing adolescents to interpret challenges as personal failures, while over-autonomy may lead to emotional isolation, preventing adolescents from seeking social support during stressful times.

Dysfunctional attitudes and depressive symptoms

Dysfunctional attitudes, encompassing rigid and maladaptive beliefs about oneself, the world, and the future, are key cognitive factors in the development and persistence of depressive symptoms[13]. These attitudes often manifest as over-perfectionism, excessive need for approval, and over-autonomy, which predispose adolescents to depressive symptoms when exposed to stressors[14]. Over-autonomy, marked by high self-reliance and reluctance to seek support, and over-perfectionism, characterized by harsh self-criticism and unrealistic standards, mediate the relationship between NLEs and depressive symptoms[15,16]. Findings from Yu et al[7] underscore the mediating role of these specific dysfunctional attitudes in the association between NLEs and depressive symptoms in Chinese adolescents. These results align with the cognitive vulnerability-stress model, which posits that cognitive vulnerabilities, such as dysfunctional attitudes, amplify the emotional impact of stressors by reinforcing negative appraisals. Dysfunctional attitudes, particularly over-autonomy and over-perfectionism, were shown to significantly influence the effect of NLEs on depressive symptoms, supporting the view that stressors interact with cognitive vulnerabilities to trigger depressive symptoms[17]. Understanding these cognitive patterns is essential for designing targeted interventions. Cognitive behavioral therapies (CBT) that address maladaptive beliefs, such as over-autonomy and over-perfectionism, hold promise for reducing depressive symptoms in adolescents by mitigating the cognitive processes that exacerbate stress responses.

Role of social support

Social support, defined as the perceived availability of emotional and instrumental resources from others, is a well-established protective factor against depressive symptoms[18]. It mitigates the negative impact of NLEs by enhancing coping mechanisms, fostering positive self-perception, and providing emotional comfort. High levels of social support can moderate the effects of dysfunctional attitudes on depressive symptoms, promoting resilience in adolescents[19]. This moderating role highlights social support’s potential in reducing the adverse effects of over-autonomy and over-perfectionism. Interventions should prioritize enhancing adolescents’ access to support networks, particularly in collectivist cultures, where family and peer relationships are central to buffering stress. Sources of social support, including family, teachers, and peers, create a diverse safety net that helps adolescents navigate challenges, reducing the risk of depressive symptoms.

Addressing academic stressors through targeted social support is particularly relevant in the Chinese context, where the education system is a predominant source of pressure for adolescents. Schools can play a pivotal role by implementing policies that limit excessive homework and reduce the frequency of high-stakes examinations[20]. Teachers should foster a supportive classroom environment, promote open communication, and address students’ individual needs and challenges. Similarly, parents can alleviate academic stress by setting realistic expectations and providing emotional care and encouragement, rather than exclusively emphasizing academic achievement. These targeted strategies can reduce the impact of academic stress on depressive symptoms and promote holistic adolescent development. The role of social support extends beyond buffering stress; it also enhances self-esteem and counters the negative self-perceptions linked to dysfunctional attitudes. Supportive relationships provide adolescents with a sense of belonging and self-worth, alleviating feelings of worthlessness and despair associated with depressive symptoms[21]. Thus, fostering robust social support networks is essential for preventive and therapeutic strategies aimed at addressing depressive symptoms in adolescents.

NLEs and mental health

NLEs are significant stressors that adversely affect adolescent mental health, often triggering or exacerbating depressive symptoms[22]. These events, encompassing academic pressure, interpersonal conflict, and experiences of loss, disrupt emotional equilibrium and increase vulnerability to depressive symptoms. The interaction between NLEs and cognitive vulnerabilities, such as dysfunctional attitudes, amplifies this risk, as adolescents interpret stressors through a negative cognitive lens, heightening emotional distress[23,24]. Findings from Yu et al[7] underscore the direct effect of NLEs on depressive symptoms, mediated by specific dysfunctional attitudes, particularly over-autonomy and over-perfectionism. Addressing the impact of NLEs on adolescent mental health requires comprehensive strategies that combine early identification of at-risk individuals with timely and targeted interventions. Strengthening social support networks and integrating cognitive-behavioral approaches can mitigate the detrimental effects of NLEs by fostering adaptive coping mechanisms and reshaping maladaptive cognitive patterns[25]. Schools, families, and communities are pivotal in providing adolescents with the necessary support and resources to navigate stressors effectively and maintain mental well-being.

Cultural factors in the context of dysfunctional attitudes, social support, and adolescent depression

The complex interplay of cultural values and modern societal stressors plays a crucial role in shaping the psychological outcomes of adolescents, especially in collectivist societies such as China. Additionally, traditional cultural values and modern social pressures are not isolated factors but interact and influence each other in significant ways, affecting adolescents’ dysfunctional attitudes, social support, and depressive symptoms[26]. While the collectivist values of family, community, and academic success are central to Chinese culture, these values often collide with the modern pressures of academic achievement and social comparison, contributing to the development of dysfunctional cognitive patterns among adolescents[27].

In traditional Chinese culture, the family is always regarded as the primary source of emotional support and guidance. Parents play an integral role in shaping their children’s values and expectations. However, the cultural emphasis on filial piety and family honor often leads to heightened expectations regarding academic performance, which could exacerbate dysfunctional attitudes such as over-perfectionism and over-autonomy[28]. Adolescents, under pressure to meet these expectations, may develop maladaptive beliefs about their abilities and self-worth, increasing vulnerability to depressive symptoms. Therefore, Chinese adolescents may internalize the idea that relying on others, particularly parents, for emotional support is a sign of weakness, further exacerbating feelings of isolation and depression. Meanwhile, modern societal pressures, particularly the competitive education system in China, heighten these cultural dynamics. The pressure to succeed academically, coupled with the social comparison and intense examination system, significantly amplifies the emotional strain on adolescents[28]. This intersection of traditional cultural values and modern pressures creates a unique context where adolescents are simultaneously striving to meet familial and societal expectations while coping with the overwhelming stress of the education system. This dual pressure may reinforce the development of maladaptive cognitive patterns, particularly those related to perfectionism and autonomy.

Importantly, social support in Chinese culture, often embedded in familial and communal networks, plays a pivotal role in buffering the negative effects of these dysfunctional attitudes. Strong familial ties, while a source of stress, also provide a safety net of emotional and instrumental resources[29]. Peer relationships, though also influenced by academic competitiveness, offer opportunities for emotional connection and resilience. Thus, social support functions both as a mitigating factor for depressive symptoms and as a mechanism for addressing the dysfunctional attitudes that arise from cultural and societal pressures. To effectively address adolescent depression in China, interventions must acknowledge the complex interaction of these cultural and social factors[30], and tailoring strategies to fit the cultural context by integrating family-centered approaches and promoting a healthier balance between academic achievement and emotional well-being is essential for fostering long-term resilience and mental health in adolescents.

Implications for prevention and intervention

Understanding the trigger effect of environmental stressors on cognitive vulnerabilities underscores the need for early and targeted interventions. Stress management programs can help adolescents mitigate the activation of dysfunctional attitudes, while cognitive-behavioral strategies can address and modify these attitudes before they intensify depressive symptoms. Specifically, targeting dysfunctional attitudes such as over-autonomy and over-perfectionism through CBT may reduce their mediating effects on depressive symptoms. Strengthening social support networks is equally critical, as these networks buffer the adverse effects of NLEs and dysfunctional attitudes on depressive symptoms[31]. School-based mental health initiatives that foster peer support and family engagement can play a pivotal role in prevention. Integrated approaches that combine cognitive interventions with robust social support systems should be prioritized by policymakers and mental health professionals to reduce the incidence and severity of depressive symptoms in adolescents.

In the Chinese context, addressing academic stress is a key component of preventive strategies. Policymakers should prioritize educational reforms aimed at reducing stressors within the competitive education system. Revising curricula to decrease homework loads, limiting the frequency of high-stakes standardized testing, and incorporating mental health education into school programs could alleviate significant stressors for adolescents[31]. Professional development programs for teachers should emphasize the importance of creating emotionally supportive classroom environments and recognizing individual student needs. Parental education programs can guide families to set realistic expectations and offer balanced support that integrates academic aspirations with emotional care. Collectively, these measures can foster a less stressful and more supportive educational environment, ultimately enhancing the mental health and well-being of Chinese adolescents.

Feasibility and effectiveness of interventions

The proposed interventions for adolescents, particularly those targeting school and family environments, aim to reduce the academic pressure and enhance social support networks. These interventions include reducing homework loads, setting realistic academic expectations, and fostering stronger familial engagement in adolescents’ emotional well-being[32]. However, reducing homework loads and setting realistic academic expectations in the Chinese context present both challenges and opportunities. The Chinese education system is known for its competitive nature, with intense emphasis on academic success as a measure of personal worth. As such, reducing homework and adjusting academic expectations might initially face resistance from educators, parents, and policymakers, who are deeply invested in maintaining high academic standards. A study by Yeo et al[33] demonstrated that adolescents who spent more time on homework/studying had less time on sleep, media use, and social activities. Independent of effects on sleep, long hours on homework/studying on weekends may be a risk factor for depression. Therefore, reducing adolescents’ workload outside of class probably could benefit their sleep, schoolwork-life balance, and mental well-being[33]. Translating these findings to the Chinese context, it is plausible that a balanced approach to academic expectations, which focuses on promoting well-being alongside achievement, could yield positive outcomes.

Research on CBT highlights the importance of modifying dysfunctional attitudes to improve emotional well-being. CBT techniques have been shown to reduce over-perfectionism and over-autonomy by encouraging adolescents to challenge unrealistic expectations and adopt healthier coping strategies[34]. Furthermore, social support plays a critical role in buffering the effects of academic stress. A study by Sapkota et al[35] found that patients’ self-ratings of homework engagement CBT significantly predicted rate of change in depression and anxiety symptom severity, and patients who reported higher engagement with assigned homework activities achieved a more depressive symptom reduction on adolescents. In practice, integrating family-focused programs that promote emotional openness and understanding within the home environment can complement school-based efforts. Parents could be trained to set more balanced expectations and provide emotional support, rather than focusing solely on academic achievement[35]. Additionally, school-based mental health programs could offer students a safe space to discuss their emotional struggles, further reinforcing the importance of social support in reducing depressive symptoms.

Limitations

The study by Yu et al[7] offers valuable insights, but several limitations should be acknowledged. First, the sample was exclusively drawn from Shandong Province, which restricts the generalizability of the findings to other regions or cultural contexts. Adolescents from urban or rural areas with varying socioeconomic backgrounds, or those with comorbidities such as diabetes[36], may exhibit distinct patterns of dysfunctional attitudes and social support. Second, the cross-sectional design precludes causal inferences, leaving unclear whether dysfunctional attitudes mediate the relationship between NLEs and depressive symptoms or merely correlate with both. Third, while the study used well-validated scales, cultural differences in interpreting scale items may introduce measurement bias, potentially affecting the validity of the findings. These limitations have important implications for the interpretation of the results. For example, the regional homogeneity of the sample may amplify cultural characteristics such as collectivist values, possibly overestimating the impact of social support. Similarly, the lack of causal clarity may obscure whether dysfunctional attitudes act as mediators or are a consequence of depressive symptoms. Therefore, caution is needed when applying these findings to broader populations. Future research should address these limitations by employing more diverse and longitudinal designs[37]. Multi-center studies involving adolescents from various regions and cultural contexts would enhance the generalizability of the findings. Longitudinal studies could elucidate the temporal and causal relationships between NLEs, dysfunctional attitudes, social support, and depressive symptoms, providing a more comprehensive understanding of these interactions.

Conclusion

Addressing academic stress is critical to mitigating the increasing prevalence of depressive symptoms among Chinese adolescents. Reducing homework and examination pressures, fostering supportive teacher-student relationships, and promoting balanced parental expectations can create nurturing environments that enhance mental well-being[38-40]. These reforms not only help alleviate depression but also contribute to cultivating a resilient and emotionally healthy generation. This study advances understanding of the complex interplay between NLEs, dysfunctional attitudes, and depressive symptoms in Chinese adolescents. Yu et al[7] build on prior research by identifying specific dysfunctional attitudes - over-autonomy and over-perfectionism - that mediate the relationship between NLEs and depressive symptoms. Additionally, their findings highlight the buffering role of social support, offering valuable insights for culturally sensitive interventions in collectivist settings. Our analysis extends these findings by proposing culturally adaptive intervention models that account for variability in social support dynamics across families and communities. Integrating cognitive-behavioral approaches with robust social support systems offers practical guidance for educators, policymakers, and mental health practitioners to design sustainable interventions tailored to adolescent populations.

Beyond over-autonomy and over-perfectionism, the desire for approval represents another critical dysfunctional attitude[41]. This dependency on external validation intensifies emotional responses to rejection or criticism, perpetuating negative self-perceptions. Addressing the desire for approval should be a priority in cognitive-behavioral interventions targeting adolescent mental health. Moreover, emerging stressors such as social media interactions warrant further exploration. Digital environments may exacerbate cognitive vulnerabilities, such as over-autonomy and over-perfectionism, contributing to heightened emotional distress. Incorporating these insights into tailored interventions, including digital cognitive-behavioral therapies, could improve their efficacy in addressing depressive symptoms. While the proposed interventions face challenges in the context of China’s education system, they are feasible with proper implementation and cultural adaptation.

Future research should explore the role of digital stressors and adopt mixed-method approaches, such as qualitative interviews, to capture nuanced cultural and contextual influences. Longitudinal studies examining the interaction of dysfunctional attitudes, social support, and digital stressors will provide deeper insights into evolving mental health challenges and inform more effective intervention strategies, and these interventions should effectively reduce dysfunctional attitudes, enhance social support, and alleviate depressive symptoms among adolescents.