Hidden depths

Depression among
young children is rarely addressed. This is unfortunate, writes Frances
Rickford, as it can serve as an early warning for more acute problems.

Katie was a toddler her mother noticed that she sometimes seemed to have
feelings that went beyond the usual frustrations, fears and concerns of small
children. “She’d seem fine for weeks, then suddenly something would tip her
into a mood of total desolation. It might last only a few hours but during
those hours she was inconsolable. I remember when she was three years old, she
was in my arms, crying bitterly, and announced: “I wish I wasn’t in the world”.

We cherish a fantasy
of childhood as a care-free time, and many adults find it difficult to take
seriously the worries of children who are unburdened by the responsibilities of
adult life, or to believe they could suffer from depression. Perhaps this is
one of the reasons why depression is, according to psychiatrists, hugely
under-diagnosed in both children and teenagers.

The Royal College of
Psychiatrists estimates that about one in every 200 children under 12 is
suffering from a depression so serious that it dominates their life. The rate
among teenagers is much higher – as many as three in every 100 which means that
in a secondary school of 1,000 pupils there are probably about 20 to 30 young
people experiencing clinical depression. And these are low estimates compared
with the US where population studies have shown that at any one time between 10
and 15 per cent of the child and adolescent population has some symptoms of
depression, and one in 20 children between ages nine and 17 have a fully
fledged diagnosis of major depression.

US research suggests
that most children who do get seriously depressed will experience more
depression during their life, and not surprisingly are at greater risk of
suicide than other children. According to a report by the US Surgeon General,
20 to 40 per cent of depressed children relapse within two years and 70 per
cent will do so by the time they are adults. In a long-term follow up study of
73 adolescents diagnosed with major depression, 7 per cent had killed
themselves some time later. Children who experience very long-term, chronic
symptoms (called dysthymia by psychiatrists) are most likely to continue to feel
depressed later in their lives, and between 20 and 40 per cent of teenagers
with depression eventually develop bipolar disorder (manic depression).

Even babies and very
young children can and do experience depression, says Juliet Buckley, manager
of the parents information service at YoungMinds, but the younger the child the
more difficult it can be to recognise. YoungMinds’ own guidance to parents
suggests depressed toddlers might be unresponsive or clinging but unable to
accept comfort. They may refuse to eat and find it hard to settle to sleep.
Slightly older children might also be tearful and clinging, or lose their
appetite, have nightmares, behave destructively or be unresponsive. Sometimes
depression can slow a baby’s general development.

Buckley explains that
for all children, their mental health is partly a function of their family and
school circumstances, but especially for the very young. People working with
young children including nursery staff, health workers and Sure Start workers,
should be especially sensitive to the mental well-being of mothers, says
Buckley. “If the mother is unhappy in the postnatal period and not responding
well, you can be pretty sure there will be problems with the baby. Workers
should be asking parents open-ended questions about their feelings and
listening. If they suspect things are not going well they should also ask about
domestic violence because if you don’t ask, they don’t tell you. We need to
recognise how difficult life can be for parents when a baby comes into the
world, and provide much more core support for parental relationships. Parental
conflict and domestic violence is so widespread and so bad for children.”

Older children who
are depressed may find it hard to concentrate and lose interest in play and
hobbies as well as work. They may refuse to go to school, or say they are bored
or lonely although they seem to have friends. Other children might respond to
depression by becoming irritable and difficult to control. It is also common
for younger children who are depressed to blame themselves for things that go
wrong and to seek out punishment by behaving badly.

Losses can trigger
depression if children are not given an opportunity to express their feelings,
and reactions to loss can also express themselves in ways which further deepen
the problems a child is trying to cope with if they are not well understood by
the adults involved. Buckley tells the story of a boy of 12 whose parents
sought help because he was refusing to go to school. It emerged that the family
moved house just before he started at secondary school so as well as having to
cope with the stressful transition from primary school, he was separated from
his old friends.

Buckley believes
depression is part of a continuum rather than a qualitatively distinct disease
which calls for its own expert treatment programme. “The problem with all
mental health diagnoses is that psychiatric disorders are descriptions of
symptoms. They don’t describe the cause which can be any combination of a large
range of factors.”

But it is important
to distinguish between short-term grief on the one hand and depression on the

“If they have
experienced a loss they are going to be sad but won’t necessarily get
depressed. Experiences like losing a grandparent, or feeling rejected by one of
their parents can cause a lot of pain. It is when grief  turns into an enduring sense of misery that
more help may be needed. The bottom line is if a child isn’t coping – if the
feelings are so disabling  that for
example he or she can’t get to school.”

Sue Kegerreiss is a
child psychotherapist who runs an MSc course in psychodynamic counselling with
children at Birkbeck College, London. She also works as a counsellor in a
secondary school herself, and believes depression explains much of the angry
and disengaged behaviour shown in classrooms as well as much absence from
school. “It is often very hard to spot depression in children because it is
covered by defensive manoeuvres.”

Both Buckley and
Kegerreiss believe that some children are more prone than others to depression
because of family history or temperament, but emphasise that no one is destined
or pre-determined to experience it. Kegerreiss says: “The more we learn about
neuroscience the more it seems that what happens in the early months and years
of life is crucial.”

So how should
professionals respond if they suspect a child’s behaviour might be masking – or
highlighting – depression? Buckley says it’s important to be realistic rather
than believe you can march in and sort the problem out.

“You don’t
necessarily need to be an expert to help. A good school nurse, or teacher or GP
who can build up a relationship of trust based on listening with respect to the
child can make a difference.” Kegerreiss agrees that some people are gifted at
understanding children and can tune in correctly to what is going on with them,
but while teachers are under so much pressure they can rarely make time to give
children careful one-to-one attention. She argues that professionals need
training to be able to listen to children effectively at the right time.

“It’s very important
to be aware of the impact on you of a child in pain or distress. Otherwise it
can be overwhelming and stops you thinking about the youngster and being able
to absorb what they are telling you.” Kegerreiss concludes: “There is not
nearly enough counselling for younger children. That is when the distress sets
in but they do not get the help when they need it.”

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