Depression in Pre-Schoolers?

When researchers at the Washington University School of Medicine published the first longitudinal study of Major Depressive Disorder (MDD) in preschool children, it came as a surprise to many that young children even get depressed. Most people were unaware that MDD had already been found to be as common among preschoolers as among school-age children (approx. 2%).

The significance of the longitudinal study conducted by Dr. Luby and her colleagues is their evidence that depression in preschoolers is similar to that of school-age children. It's already known that an episode of severe depression in childhood often leads to more episodes as children get older. The researchers examined whether the same was true for preschoolers, that is, whether children depressed at the beginning of the study would be depressed two years later.

They also examined the risk factors that predicted depression both at baseline and at follow-up. Among school-age children, the strongest predictor of depression is a family history of depression. Both genetics and a depressed mother independently contribute to childhood depression. Stressful or traumatic events also predict depression, especially, in combination with a family history.

At the beginning of this study, depressed children were more likely to have mothers with a history of depression compared to children with other psychiatric disorders or no disorder. They also had experienced more traumatic events than the other groups. The types of events included "death of a parent, experience of physical or sexual abuse, and removal from one's home."

At follow-up, the strongest predictor of chronic depression was earlier depression. Children who were diagnosed with MDD at baseline were 4 times as likely to have MDD 2 years later. The second most powerful predictor was a family history of depression. Traumatic events contributed to a lesser degree.

Unfortunately, the popular press has reacted with the usual concerns about stigma and psychiatric medication. As Jennifer Gibson states in How Young is Too Young to Diagnose Depression? | Brain Blogger :

Experts are wary of labeling preschool-aged children with depression, since the diagnostic tools for this age group are not well established. However, early identification of depression may save a child from a lifetime of social and emotional consequences. Many adolescents and adults present to health care providers for mental health treatment, indicating that their symptoms started at an early age, and most adults with depression did, in fact, meet diagnostic criteria for depression in childhood. However, if children are labeled as “depressed” so early in life, are they set up for a lifetime of medications and treatments and stigmatization?

This ignores the opportunity for prevention by treating children who have experienced stressful or traumatic events. Most child clinicians are aware that the death of close relatives, prolonged separations from caretakers, separation and divorce of parents, and chronic abuse or neglect can lead to depression in children. I believe the results of this study provide further support for the early treatment of childhood trauma.

The treatment of choice for preschoolers should be psychotherapy. Given that research has found psychotherapy and medication equally effective at treating depression in adolescents and adults, there is no reason to assume it would be different for young children. For safety reasons, I believe anti-depressant medication should be considered only for children with severe or chronic depression that has not responded to psychotherapy.

Luby, J., Si, X., Belden, A., Tandon, M., & Spitznagel, E. (2009). Preschool Depression: Homotypic Continuity and Course Over 24 Months Archives of General Psychiatry, 66 (8), 897-905 DOI: 10.1001/archgenpsychiatry.2009.97

For those without access to the full article, see Dr. Nestor-Duran's review Depression in preschool children: not a temporary phase. - Child Psychology Research Blog.
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This post was featured in Grand Rounds, Vol. 6, No. 13

Many Depressed Teens Go Untreated

According to a recent report from the 2007 SAMHSA National Survey on Drug Use and Health, during the past year, 8% of teenagers ages 12-17 experienced at least one episode of major depression defined as:

...a period of 2 weeks or longer in which there is either depressed mood or loss of interest or pleasure and at least four other symptoms that reflect a change in functioning, such as problems with sleep, eating, energy, concentration, and self-image.

Even though 70% of the depressed teens reported severe impairment in daily functioning (chores at home, school or work, close relationships with family, or social life), only 39% received any mental health treatment!

Why did less than half of the depressed teens get help? The study points to at least one cause--lack of health insurance. Only 17% of uninsured, depressed teenagers obtained treatment. However, this does not explain why nearly 60% of teens covered by health insurance weren't treated.

The primary reason depressed teens don't get help is that neither they nor their parents recognize the source of their problems. It's easy to ascribe moodiness, irritability, lack of energy, and poor concentration to the stress and sleep deprivation experienced by today's over-scheduled teens.

In addition, the stigma of mental illness affects teenager's willingness to ask for help. Many suffer in silence and hide their pain from parents and friends. In an excerpt from Day for Night: Recognizing Teenage Depression, teens who have dealt with major depression describe the symptoms they had:

It's important for both teens and parents to become better informed about the symptoms and treatments for depression. The following publications from the National Institute on Mental Health are a good place to start. Because they are not currently available from NIMH, I've linked to pdf's on my website's Resources page:

Let's Talk About Depression

What to Do When A Friend is Depressed

Howie Mandel on Stigma and Children's Mental Health

According to Mental Health America, 1 in 5 children and adolescents have a diagnosible mental health condition, yet only 1/3 of them get help. One reason is the stigma associated with having a mental illness.

Howie Mandel, host of "Deal or No Deal," often talks about his own mental illnesses of obsessive-compulsive disorder (OCD) and attention-deficit hyperactivity disorder (ADHD). As ambassador for National Children's Mental Health Awareness Day (May 7, 2009), he speaks on the stigma of seeking help:

Because children and adolescents often don't tell anyone about troubling thoughts and feelings, it is up to adults to notice symptoms of possible mental illness. The U.S. Dept. of Health & Human Services' on-line publication Child and Adolescent Mental Health lists the following warnings signs:

A child or adolescent is troubled by feeling:

• Sad and hopeless for no reason, and these feelings do not go away.
• Very angry most of the time and crying a lot or overreacting to things.
• Worthless or guilty often.
• Anxious or worried often.
• Unable to get over a loss or death of someone important.
• Extremely fearful or having unexplained fears.
• Constantly concerned about physical problems or physical appearance.
• Frightened that his or her mind either is controlled or is out of control.

A child or adolescent experiences big changes, such as:

• Showing declining performance in school.
• Losing interest in things once enjoyed.
• Experiencing unexplained changes in sleeping or eating patterns.
• Avoiding friends or family and wanting to be alone all the time.
• Daydreaming too much and not completing tasks.
• Feeling life is too hard to handle.
• Hearing voices that cannot be explained.
• Experiencing suicidal thoughts.

A child or adolescent experiences:

• Poor concentration and is unable to think straight or make up his or her mind.
• An inability to sit still or focus attention.
• Worry about being harmed, hurting others, or doing something "bad".
• A need to wash, clean things, or perform certain routines hundreds of times a day, in order to avoid an unsubstantiated danger.
• Racing thoughts that are almost too fast to follow.
• Persistent nightmares.

A child or adolescent behaves in ways that cause problems, such as:

• Using alcohol or other drugs.
• Eating large amounts of food and then purging, or abusing laxatives, to avoid weight gain.
• Dieting and/or exercising obsessively.
• Violating the rights of others or constantly breaking the law without regard for other people.
• Setting fires.
• Doing things that can be life threatening.
• Killing animals.
  

The presence of one or more of the above symptoms indicates a need for further evaluation. Pediatricians and family physicians can refer families to psychiatrists or psychologists in their area who specialize in treating children and adolescents. For other resources, see Mental Health America's factsheet How Do I Find Treatment?