In a recent article in The New York Times, we met Kyle – a happy, if slightly hyper, first-grader from Louisiana. At six years old, he’s already well into a long psychiatric saga; he’s been diagnosed with bipolar disorder, autism, attention deficit disorder, and oppositional defiant disorder. At 18 months, Kyle’s doctor prescribed him Risperdal, an antipsychotic medication, and by age three he was also taking Prozac, sleeping medications, and multiple drugs for his attention problems.
The article highlights the questionable trend in psychiatry of using heavy-duty psychotropic medications in very young children. But it also brings up the issue: how young is too young to diagnose a child with a mood disorder? How do we sift apart behaviors that are the result of the normal ups and downs of development from conditions needing treatment?
Early-onset depression – “preschool depression” – show up as early as two or three years old according to leading clinicians, and it looks pretty similar to depression in adults. On top of sadness and irritability, the classic symptom is anhedonia – the inability to find joy in normally pleasurable activities. This is not the child who melts down when he can’t take Thomas the Train home from the toy store; it’s the child who never peps up, doesn’t get excited to see a favorite friend or read a much-loved story – it’s an undercurrent of disinterest and listlessness about life.
About one to three percent of preschool kids fit this description (84,000 out of 6 million), and the incidence grows as children get older. But kids are by nature emotionally unstable little creatures, and their minds are in the midst of booming development – so does it mean anything to say that a preschooler is depressed?
To me, the answer depends on whether the preschool blues go away on their own and whether there’s anything productive we can actually do about it. To the first question, the research seems to say that it’s not just a phase. In one of the studies mentioned in another Times article on preschool depression, kids who were “temperamentally low in exuberance and enthusiasm” at age three were more likely to have depressive symptoms at age 10. Other studies have reinforced the link between childhood and adult depression.
When I see adults with depression in therapy, a lot of them say they have the feeling that they’ve “always been this way” – some element of their struggle (like a dark cloud or an emptiness) has been with them as long as they can remember. Of course life and family forces contribute (sometimes they’re the whole answer), but depression has biological roots too, so who’s to say they don’t take hold in early childhood?
The question of what can be done is more complicated. You can’t really ask a three-year-old to lie on the couch and unload his worries, but approaches that focus on the dynamic between parent and kid can be helpful. The Times describes Parent-Child-Interaction-Therapy where, using an earpiece, parents are coached and fed lines by a therapist while playing with their little ones. The coach helps them navigate emotional triggers and pitfalls using encouragement and positive exchanges. The results so far are encouraging.
In a way, kids are primed for help, because their brains are still so malleable. As parents we help them identify and understand their feelings and make them feel safe. I’ve heard parents worry that if they had a hard childhood it might transfer to their kids, but that’s not really how it works. It doesn’t matter so much how we were parented or how it affected us. What matters is whether we’ve made sense of it and can talk about it in what is called a “coherent narrative.” If we’ve got some insight and we know ourselves and our relationships pretty well, we’ve got the skills to form a secure attachment to our kids – that’s the biggest self-esteem booster we can give them.