View Full Version : Preschool Depression

10-17-04, 03:57 AM
Major depression at age 5? Researchers say it can happen


The Kansas City Star

“For me, I consider medication with very young children a last resort.”
— child psychiatrist and epidemiologist Helen Egger

Thirty years ago mental health experts thought it was impossible. Five years ago there was no proof.

Preschoolers with major depression?

Children 3, 4 or 5 years old so sad they think of killing themselves?

It can't be, psychiatrists theorized. The brains, egos and self-concepts of children that young, they thought, were not developed enough for major psychiatric disorders to take hold.

Well, tell that to physician Sharon Cain, director of child psychiatry at the University of Kansas Medical Center, where, she said, “we have had young kids who have thought about hurting themselves, who wish they were dead.”

“We've had young kids, around 5 or 6, say, ‘I want to run out in front of a school bus or in front of a truck.' ”

Tell it to psychiatrist Joan Luby of the Washington University School of Medicine in St. Louis whose decade-long research on scores of children from ages 3 to 5 1/2 is redefining when depressive illness begins.

“I think there is social resistance to the belief that preschool kids can have mental disorders,” Luby said in a recent telephone interview.

Luby's paper on “Preschool Major Depressive Disorder,” which was published in a 2002 issue of the Journal of the American Academy of Child and Adolescent Psychiatry, is among the first major studies to identify depression in kids younger than 6.

“Depression, in particular, is a hard one to swallow,” Luby said. “We don't want to believe it's true because the idea of it is inherently disturbing.”

Yet at a handful of childhood research centers across the country — in Boston, Chicago, New Orleans, Washington, St. Louis and Durham, N.C. — mental health experts are now looking at the minds of preschoolers with fresh eyes.

More than finding depression, they are finding preschoolers with other psychiatric disorders, including post-traumatic stress disorder, behavioral disorders in which children severely injure other children, bipolar disorder (also known as manic-depression) and anxiety disorders such as OCD, or obsessive-compulsive disorder.

“We want to think of childhood and particularly infancy as a blissful, carefree time. We have the Gerber Baby as our image,” said pediatric psychiatrist Charles Zeanah, director of the Institute for Infant and Early Childhood Mental Health at Tulane University in New Orleans.

“It is very discomforting thinking of children as having psychiatric problems early on. We don't want to think about it. So we don't.”

To be sure, the topic of kids and psychiatric illness has always been controversial.

Earlier this month advisers to the federal Food and Drug Administration, concerned that some of the nation's best-known anti-depressants may increase children's thoughts of suicide, recommended that the drugs (in a class known as SSRIs, or selective serotonin re-uptake inhibitors) carry the nation's strongest warning, a black box on the packaging warning of the possible suicide link. Only one anti-depressant, Prozac, has been approved by the FDA for use in children.

Experts agree that the earlier kids are identified as having depression or other psychiatric illnesses, the more the debate over kids and drugs is likely to intensify.

In February 2000 University of Maryland pharmacy professor Julie Magno Zito stirred a national debate after she estimated, in a study published in The New England Journal of Medicine, that 150,000 preschoolers (10 percent of them 2-year-olds) were on psychotropic drugs in 1995, up from 100,000 only four years before.

Since then the numbers have been on the rise. Close to 11 million prescriptions for anti-depressants are written each year for children under age 17, according to testimony before the FDA advisory committee. Researchers say that although they know some preschoolers already are being treated with anti-depressants and other drugs, it should never be the first-line treatment.

“For me, I consider medication with very young children a last resort,” said child psychiatrist and epidemiologist Helen Egger. At Duke University she's conducting studies on the rate of depression among preschoolers.

At least one large study on the effects of Ritalin on preschool children is being conducted at Columbia University in New York City. Egger said that other than that one study, whose results have yet to be published, “we have no empirical evidence — none — on the use of psychotropic medications on preschoolers.”

“You certainly would never put a kid on meds and say, ‘I'll see you in three weeks.' ”

The question of how to best treat preschoolers with depression is just one among many.

Currently the therapy involves intense counseling, not just for the child, but also for the family. Sometimes medication is also used, but reluctantly.

“The hope is that we can catch them early so we don't need medications,” said psychologist Lisa Hale, director of KU's new anxiety research and treatment program.

At this point, said Luby of St. Louis, researchers have far more questions about depression in preschoolers than they do answers.

Researchers suspect that depression in preschoolers is likely biological and environmental. Some kids, they suspect, may be born with a genetic predisposition to depression, just as some children are born with autism, or Asperger's syndrome or attention deficit/hyperactivity disorder.

But they really don't know.

Nor do they know what triggers the depression — in other words, the role of environment.

Whereas some depressed kids clearly come from parents who are depressed or have other psychiatric disorders, said Zeanah of Tulane, other depressed children have been abused or neglected, sometimes from infancy.

But not all abused kids end up with depression. Nor do all the children of parents suffering depression end up depressed. Some preschoolers, Zeanah said, seem to be depressed for no apparent genetic or environmental reason.

What is certain?

“We know how to recognize them,” Luby said. “I think we do.”

That's because, in many cases, the symptoms of depression in preschoolers is fairly obvious, Luby said.

Years ago researchers thought that depression in even older children was a “masked” disease. Instead of showing symptoms of deep melancholy, depressed kids might, for example, becoming extremely aggressive or complain of stomach aches or headaches.

Occasionally, that is still true. Even now parents rarely take their children in for a psychiatric evaluation because they think they are depressed. Typically, parents call for an evaluation because their child has displayed some extreme aggression, hitting, biting or scratching in preschool or at home that seems uncontrollable or unexplainable.

But more often depressed preschoolers truly look and act depressed, researchers said.

The word they use is “adhedonia,” meaning utter joylessness in life. Their faces are sad. Their movements are sad. They play but extract no fun from their activities.

Diagnosing depression in preschoolers can be an intense process. It involves interviews with the child, parent and day-care providers. A long questionnaire is used. Therapists should always observe the child at play.

“In play, depressed preschoolers will sometimes have more death scenes, even suicide scenes,” said Egger of Duke.

To be sure, violence in play is not unusual among kids. But among depressed kids, the violence is often intense and repeated.

A particularly controversial area of child depression involves childhood “accidents.” Some question whether some of the children who seem to fall from roofs accidentally or walk into traffic or hurt themselves in other various ways are doing so unconsciously because they are laden with painful depression. Unable to express themselves, and unable to make the pain stop, they try to hurt themselves instead.

As more and more psychiatric disorders are uncovered in preschoolers, Luby said, the lesson for parents simply is to be aware.

“There is resistance and reluctance to think of children as having very serious psychiatric problems,” Zeanah said. “One fear is that we will pathologize childhood and scare parents to death.

“The point is not to scare parents, but only to have them recognize that, in fact, young children can have problems. If they do, there are places they can go and people they can see.”

To reach Eric Adler, call

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