Diagnosing Depression In Young Kids Is Harder, Incredibly Important

Until he began doodling bloody pictures of bleeding necks, April Lisbon wasn’t worried about the mental health of her 4-year-old student. As a psychologist working with young children in District of Columbia public schools, Lisbon had seen her share of disaffected youth. Besides, this particular boy was known to be difficult. He came from a broken home. His father was in jail. His mother was absent. He would crawl under tables at school and fall asleep. When teachers woke him, he lashed out. But all that was, from a clinical perspective, normal — regrettable, absolutely, but not uncommon. The drawings, however, were a red flag. Looking at the bloodied figures, Lisbon knew this wasn’t just another angry preschooler. Barely out of diapers, the boy was already wrestling with clinical depression.

“Is it hard to believe? Absolutely,” Lisbon says. “But it’s possible for even a 3-year-old to experience depression. We should not overlook the signs just because of the ages. If we do, we miss out on critical years to intervene.”

Experts agree that preschoolers are entirely capable of suffering from clinical depression — and that this depression is not always the result of abuse or neglect. Depression in small children works in much the same way as it does in teenagers and adults, studies suggest. It is partly environmental, to be sure, but largely genetic and neurological. So parents of preschoolers who have faced little adversity may still find themselves caring for listless, unmotivated, or self-harming children.

Still — perhaps because it sounds implausible or doesn’t align with cultural ideas about childhood — preschool depression remains largely unstudied and undetected. Troubled children use crayons to cry for help, but most don’t receive any.

“Most tend to assume young children cannot be depressed. This is a false assumption,” says Joan Luby of Washington University School of Medicine in St Louis. Luby is one of the only researchers currently involved in large-scale investigations of preschool depression, and she has published several papers on the subject. “We’ve been studying depression in young children, and what it looks like. We know that it’s a familial disorder, that there’s some genetic underpinning, and that it’s a combination of environment and genes that bring it out.”

Luby suspects that 1% to 2% of preschoolers suffer clinical depression, a rate similar to that of school-aged children. By comparison, depression affects up to 10% of adolescents. Studies have found that preschoolers at risk of depression express less joy and excitement during activities such as blowing bubbles, racing cars, and receiving gifts. As a rule, depressed preschoolers are irritable, unable to enjoy activities and play, and prone to experiencing excessive guilt when they break the rules. They are preoccupied with negative feelings and thoughts, and engage in negative play themes, such as drawing graphic pictures of death and violence. They eat infrequently and mope around in a somber daze.

In extreme cases, depressed preschoolers may attempt to self-harm. “In our last study, we were very surprised to find a high proportion of preschoolers who have expressed suicidal ideation, and some who have self-harmed,” Luby says. “We’re trying to get a handle on it and figure out why kids are doing this. It is an increasingly big concern in this younger population.”

This is all horrifying, but also fairly standard for the depressive population. The unique problem with early childhood depression is that the most salient adult symptoms of the disorder are generally diagnosed by those who suffer from it. Self-awareness tends to be a prerequisite for intervention. But preschoolers don’t understand that they are unusually listless or that their feelings are irrational. They lack context and emotional intelligence. They also don’t have exactly the same sort of emotional experiences, which means that their symptoms can be easy for even professionals to overlook.

“Young children are less likely than adults to have feelings of worthlessness and low self-esteem, and experience hopelessness about the future,” says Sara Bufferd, program director of child and adolescent development at California State University. “As children grow the capacity to think more abstractly about themselves, the world, and the future, they may be more prone to these depressive symptoms.”

Even then, it is necessary to translate run-of-the-mill depression symptoms into age-appropriate analogues. “With adults, we think about decreased libido. With children, decreased ability to enjoy activities and a general lack of joyfulness is a more salient symptom,” Luby says. “In this age group, joyful mood states are normative. Lack of joy can be a clinical symptom.”

It is trickier to figure out where preschool depression comes from in the first place. Of course, adverse environmental conditions can contribute to the problem. “The young kids I saw for therapy, who were diagnosed with depression by their psychiatrist, were all in the foster care system,” says Heidi McBain, a Texas-based marriage and family therapist.

Bufferd agrees. “My colleagues and I have identified predictors that contribute to the diagnosis of a depressive disorder by age 6, such as stressful life events, parental history of mood, anxiety, and substance use difficulties, child history of anxiety, and poor peer functioning.”

Recent evidence suggests preschool depression, like adult depression, is largely a genetic condition. Although depression does not have a clear pattern of inheritance (and no one gene has been isolated that causes or even increases risk of depression), studies have shown that parents with depression are three times more likely than the general population to have kids with depression. It is unclear how much of this is nature — the heritability of depression — and how much is nurture. But growing up around depressed people can certainly be depressing.

“When an individual has a depressed parent, they have both genetic risk for the condition as well as environmental risk given that a depressed parent may model depressive symptoms,” Bufferd says. “It is difficult to disentangle genetic from environmental causes, particularly for young children whose experiences weigh so heavily on their caregivers.”

And then there’s the neuroscience. In both adults and children, traumatic experiences have been shown to impact the white and grey matter of the brain, and recent work in depressed preschoolers has turned to brain scans to demonstrate that such children are indeed clinically depressed and not merely sad or listless. Like adults, for instance, depressed children’s brains have telltale reduced connectivity between the amygdala, which is involved in emotion processing, and the brain networks responsible for both passive and active cognitive control.

“Neuroscience has done a lot to help validate preschool depression,” Luby says. “We can describe preschool depression, and say that this is what it looks like but, when you can show an alteration in brain structure and function people, take it a lot more seriously.”

Generally speaking, experts do not recommend antidepressants for preschoolers suffering from depression. “I wouldn’t recommend it unless all other options have been exhausted,” Luby says. “We don’t really know whether they’re safe for children, and how they may affect development.”

Instead, Luby and colleagues have developed a technique known as Parent-Child Interaction Therapy, which involves a therapist coaching the parent while the parent interacts with the child. Recent trials that tested this therapy have been very promising, and suggest that treatment can in fact normalize brain function in depressed preschoolers — an unprecedented victory in the field of depression.

“The hypothesis is that, the younger you are with a brain-based disorder, the more traction you can get with treatment, because the brain is rapidly developing,” Luby says.

Still, the prognosis is not great. Studies suggest at least half of adults with depression reported their symptoms beginning before age 15. And Luby and colleagues have been following a population of depressed preschoolers for 15 years, and they have found that few grow out of their depression. “Just like in the adult form of depression, they have remissions and relapses,” she says. “There is every reason to believe preschool depression is a chronic, lasting disorder.”

What can parents do with all this information? The concern among experts is that the most likely reaction would be an overreaction. Parents should not suspect that their children are depressed, unless symptoms persist for more than a week. Keep an eye out for signs that your preschooler is no longer enjoying the things they used to enjoy, or spending a good portion of the day in a bad mood. “If your child is at the point where they used to enjoy being hugged and talked to and played with, and you’re noticing a shift, you may want to talk to a school counselor or a pediatrician,” Lisbon says.

Indeed, parents raising the concern of preschool depression out in the open could seriously benefit children who would otherwise be forgotten, or dismissed as merely “sad.” Our understanding of medical conditions works in a feedback loop. If more parents expressed concern, more studies would be conducted, and parents would know more about when to be concerned. In the DC school system, Lisbon and colleagues were forced to rely on relatively limited data sets and clinical descriptions, and do much of their work by feel. “I just wish there was more concrete research being done on a regular basis,” Lisbon says.

“The voice has to come from parents really sharing this as a concern.”