Preschool Depression and The Language of Play

emma-sadDecades of research advances have made depression less mysterious and less stigmatized in most circles, accepted as a neurobiological disorder rather than a more abstract (and untreatable) entity. But some news about depression remains surprising, at least to people outside the realm of psychiatry. Tuesday’s newspaper had one such example: a new study out of Washington University in St. Louis following a group of clinically depressed and young – very young – children, between the ages of 3 and 6.

Diagnosing a preschool child with major depressive disorder was a new concept to me. But it turns out that it’s relatively old news to psychiatrists, who have been studying the diagnosis and treatment of early childhood depression cases since at least the mid-1980’s. Prior to that, even practitioners  had trouble grappling with the idea of toddlers and kindergartners suffering from a traditionally “adult” disorder like depression, said Sharon Hirsch, section chief for child and adolescent psychiatry in the Department of Psychiatry and Behavioral Neuroscience at the University of Chicago Medical Center.

“People used to have a different concept about kids,” Hirsch said. “They figured, from a developmental point of view, that if you didn’t understand abstract concepts – if you only knew right and wrong, black and white – you didn’t have to worry about the larger concepts in life. Therefore, you weren’t really capable of becoming depressed, because you were only focused on food and basic necessities, which are all provided for you, so what is there to get depressed about?”

But as theories of depression focused less on psychoanalysis and more on neurochemical causes, researchers began asking whether the brains of very young children might be vulnerable to mood disorders such as depression. They found that depression does strike kids, but it takes distinct physical and emotional forms.

“In the brain, circuitry isn’t fully formed until the early 20’s,” Hirsch said. “But we know that enough of the emotional regulation piece is formed early on so that kids may show deficits in neuroregulation that leads to emotional and mood problems including depression.”

In Hirsch’s clinical work, she has seen children as young as 2 diagnosed with bipolar disorder, which can carry some of the symptoms of major depressive disorder. Most of the children she sees from the preschool age group with depression are 4 or 5 years old, and are brought in by their parents after showing signs of delayed development, social problems or behavioral issues that may be rooted in an underlying depression.

“Kids look irritable when they get depressed, they don’t typically look sad and cry,” Hirsch said. “It’s only when you bring them in and sit them down that you understand there’s this deep-seated sadness that drives their irritability and anger.”

Psychiatrists assess children for depression or other disorders by talking to family members and the kids themselves. But with children so young, an indirect interview approach is required.

“The language of childhood is play,” Hirsch said. “I’ll play with a checkerboard or Legos or with dolls, and while playing with the kids we’ll talk about it: ‘what’s that pawn doing?’ ‘He wants to kill everybody on that side.’ ‘Why is he doing that?’ ‘Because he hates them, they’re mean to them.’ That’s why it’s an art, not a science.”

The new study – published in the August issue of Archives of General Psychiatry by Joan Luby and colleagues at Washington University School of Medicine – is the first longitudinal study tracking children age 3-to-6 that have been diagnosed with depression or other psychiatric disorders. One result of interest to pediatric psychiatrists, Hirsch said, is the finding that disruptive disorders such as conduct disorders and ADHD are better predictors of later depression than anxiety, which is known to be an early risk factor for depression in school-age children.

The study also found that children diagnosed between the ages of 3 and 6 with depression were 4 times as likely to show signs of depression at a follow-up 1 or 2 years later. That persistence indicates that the mood disorder can be just as chronic in very young children as it is with older children or adults.

Such a result underscores the importance of early intervention for children exhibiting signs of depression – or other psychiatric disorders, Hirsch said. Treatment can include child centered cognitive-behavioral therapy working with the parents, or even anti-depressant drugs given to older patients, such as fluoxetine or other serotonin reuptake inhibitors. Identifying and treating depression in a parent is also very important in the final outcome of the child with depression.

“[Early treatment] is the whole goal,” she said. “Since the brain is still developing, if you change the trajectory of neuronal attachment you can change the outcome of the disorder. Clearly we know an untreated illness that burns out of control can cause major problems, so if you don’t intervene early on with kids that are depressed, they aren’t going to be able to learn in school. Simply by allowing a better school outcome, you can in essence change their life outcome.”

About Rob Mitchum (525 Articles)
Rob Mitchum is communications manager at the Computation Institute, a joint initiative between The University of Chicago and Argonne National Laboratory.
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