Diagnosing Early-Onset Depression in Young Children
From Brain & Behavior Magazine, July 2017
Joan Luby, M.D. is the Samuel and Mae S. Ludwig Professor of Child Psychiatry and Director of the Early Emotional Development Program at the Washington University in St. Louis. She is also the Co-Principal Investigator of the university’s National Institute of Mental Health Post-doctoral training program in developmental affective neuroscience. Dr. Luby received a Young Investigator Grant in 1999 and Independent Investigator Grants in 2004 and 2008.
What’s the earliest age at which symptoms of early-onset childhood depression seem to appear?
The available data suggests that age three is the lowest threshold at which childhood depression appears, but that doesn’t mean it can’t be identified earlier or that there aren’t risk signs earlier.
Is there something about being three years old that somehow makes it possible to diagnose or measure depression reliably?
We know how to distinguish extreme behavior from the norm in that age group. Children at age three start to have enough social, interactive and emotional behavior by that time that it is possible to more easily make a diagnosis.
How was early-onset childhood depression formerly viewed in the literature? People were very skeptical, right? To what extent was its existence acknowledged?
There was a longstanding belief that pre-pubescent children were too developmentally and cognitively immature to experience the core aspects of depression. In the mid-1980s research studies disputed those claims. By the late ‘80s, it was widely accepted that children ages six and older could experience clinical depression. Subsequently, treatment studies looked at various forms of psychotherapy and psychopharmacology for that age group. Recent studies, including ours at Washington University, have extended that story down to age three.
Why do you think it took so long to acknowledge the existence of childhood depression?
One reason is that people don’t want to consider that possibility, just like you don’t want to think about children having cancer. But while cancer makes itself clear in the body, depression can be ignored or overlooked. The other problem is that we were looking for adult-style manifestations of depression, and not thinking about how symptoms appear in the context of a child’s life. For example, anhedonia (the inability to experience pleasure in normally pleasurable activities) in adults is often identified by decreased sexual drive and motivation. In young children anhedonia would equate to decreased enjoyment in play. Nobody had designed an interview that captured age-adjusted manifestations until the mid-1990s.
Do children have any of the same symptoms seen in depressed adults?
It was speculated that pre-pubescent children would have masked symptoms of depression such as stomach aches or acting out, rather than the classic symptoms. Studies that validated depression in pre-pubescent children refuted that claim, showing that these children more frequently have the core symptoms like adolescents and adults do, such as sad or irritable mood, and disturbances in sleep and appetite.
What are the telltale signs for a concerned parent?
Look to see if the child has a preponderance of sadness and irritability, that is, one who spends more than two hours a day in a sad or irritable state, even if they have periods of brightening. Children who have experienced loss or trauma may have a more transient sad or irritable mood, which resolves relatively quickly. Depressed children stay in negative mood states for sustained periods of time; they are easily tipped into these states, and don’t extract pleasure from normal activities or play as they once did.
Another important sign is excessive guilt and taking responsibility for things that aren’t their fault. Also look at self-concept: Does the child have a negative, pessimistic view of himself?
Where does a concerned parent begin if they suspect symptoms?
I would recommend probably starting with a pediatrician, with the hope that they are well informed. If you are seriously concerned about your child, it can’t hurt to go see a psychologist or psychiatrist with an expertise in early childhood.
And they can point you to the next level of care or provide therapy themselves?
Exactly. It’s important not to take the attitude of “Don’t worry, they’ll grow out of it.” Our longitudinal neuroimaging study— one in which we followed kids from preschool into adolescence —showed that repeated experiences of depression in early childhood alter the way the brain develops and functions over time. So it’s not something either parents or we as a society should continue to ignore.
Where does early childhood depression come from? Is there a play between genetic predisposition and environmental factors?
It was once thought that only abused or neglected children were vulnerable to depression. That’s a major misconception. Children who grow up in nurturing, supportive and well-resourced families can have depression. It’s a disorder with genetic roots, although the genetic element of it has not been clarified. And there is an interaction between genetic vulnerability and stressful life events: you can have a genetic vulnerability and experience a stressful event, and that could spur a child’s plunge into depression.
How do you make a diagnosis in a very young child?
We start by with looking at symptom manifestations and taking a detailed history from caregivers. Teacher reports are also useful. Additionally, we consider family history because this is a disorder that runs in families. We also look at general development because we have to rule out developmental problems. We primarily focus on parenting because it can either exacerbate or alleviate depressive proclivities in a child: we observe the child in two different interactive play sessions with a primary caregiver and a secondary caregiver. One of the play sessions has a mildly stressful event that is designed to put pressure on the child and the caregiver.
Usually with those three pieces of information—a mental status exam, an observation at two occasions, and a detailed parent report, we’re able to come up with a diagnosis.
How do you treat a young child with depression?
That’s where our current state of knowledge needs more help. We are in our last year of a large, randomized controlled trial we designed to test a form of psychotherapy for preschool depression. The treatment involves working closely with the primary caregiver and the child together, and it views depression as a disorder of emotional development. That’s the only form of treatment specific to preschoolers that has any testing to date. The other potential treatment modality is psychopharmacology [drug treatments], but that’s not been looked at in children under six.
Tell us about the form of psychotherapy that you favor, and how you came up with it.
We call it Parent Child Interaction Therapy Emotion Development (PCIT-ED), and we based it on an empirically tested form of psychotherapy called Parent Child Interaction therapy (PCIT). PCIT was developed in the 1970s by the psychologist Sheila Eyberg and is designed to target the parent-child relationship: to teach the parent how to interact with the child like a play therapist, and how to set loving, yet firm limits.
There were several things that made PCIT compelling. It has a great deal of empirical backing, has been very well tested, and as we scientists say, it has an effect size of over 1.0, which is huge for psychotherapy. This means that it has a powerful impact on reducing symptoms.
Why do you think PCIT is so successful?
One reason is that it targets children when they’re young. Another is that it uses a completely different psychotherapeutic approach. The parent and child are seen together. The parent is wearing a “bug” in their ear and they’re coached by a therapist standing behind a one-way mirror, helping the parent interact with the child in a new way. So for example, we would be coaching the parent on how to play with the child in a way that follows the child’s interests, gives positive feedback, and isn’t critical. Parents come to us with all different levels of skills in this domain, but pretty much everybody could use a little help.
The nature of the bond between the primary caregiver and the child, especially at this phase of life—and arguably from infancy—seems absolutely critical.
Absolutely. We know from case studies, and studies on institutionalized children, that in the absence of a caregiver and the nurturing and psychological stimulation they provide, children do not develop normally. This is true even if there is appropriate food and shelter.
So that’s why you are particularly optimistic about this therapy?
Exactly. We’re optimistic because a) we’re focusing on a fundamental, foundational issue; b) we’re focusing on early childhood, when the brain is more plastic; and c) we’re targeting a caregiver who is then part of the child’s life for the next 20 years. It’s like cleaning the air you’re breathing and then you keep breathing it.
The availability of any type of psychiatric care in this country is difficult. You have written that the availability of these interventions is a pretty big problem?
Yes. Accessing psychotherapy is especially hard. The standard PCIT is somewhat more available. You could get PCIT probably in most major cities, although it wouldn’t be that easy. But at no place other than St. Louis (Washington University) could you get PCIT-ED at this time.
So this really is a frontier, and you’re a pioneer in this field?
Exactly. Our therapy takes fundamentally a developmental approach to the treatment of early-onset depression. It looks at emerging depression in a young child in terms of the child not experiencing normative or optimal emotion development. In other words, the child is not learning to regulate his or her emotions in an optimal way, is not experiencing sustained positive affect, and does not have a successful way of resolving transgressions. If we target really early in childhood when the brain is rapidly developing—if we can alter the foundation—it may result in a better lifelong trajectory.
So you’re optimistic that early interventions are particularly effective?
We see very large effect sizes in a number of treatments implemented in early childhood. This is clearly true for treatment of speech disorders, motor disorders and autism. We speculate it’s because you’re treating a brain-behavior dimension when the brain is rapidly developing. Another thing to note is that brain development is not just genetically driven, but also very responsive to environmental inputs, which have a much bigger impact earlier in development.
Tell us about the biological correlates of these behaviors.
Depressed people tend to be focused more on negative affect, are more reactive to negative affect, and are ruminative. Some of those things have also been found in depressed preschoolers using functional magnetic resonance imaging (fMRI) and other methods like electroencephalography (EEG), which records electrical waves in the brain. So all of this information really helps us target our treatment, for example by helping children regulate negative emotions, and helping their parents serve as coaches in those domains. In our current study, we are measuring brain activity at the beginning, middle and end of treatment to see, in addition to behavioral changes, if there is a change in neural activity in the expected direction.