Photography by Timothy Oakberg, courtesy of Washington University School of Medicine
When an old guy’s cranky, we smile affectionately and call him a curmudgeon. He’s earned the worldview. But when a 3-year-old is irritable, sad, discouraged, unenthusiastic, and withdrawn, that’s a different story.
Twenty years ago, it was dismissed as just a story, because nobody thought a 3-year-old had enough cognitive sophistication to feel guilt or sadness so intensely.
Dr. Joan Luby, a child psychiatrist at Washington University School of Medicine, proved otherwise. She did a pioneering study in 1998, and since then, other researchers around the world have echoed her findings. Children as young as 3 can indeed experience depression, and when it starts that early, it’s likely to persist as they grow older.
Children with depression are more sensitive to negative comments or events; they are more easily—and more intensely—irritated, frustrated, or brought down, and they stay upset longer. The reason’s physiological: Their brains literally overreact to the negative—and they respond with far less vigor to something positive. A vat of ice cream weighs less than a single stern word. Clinically, this is called anhedonia—the inability to experience pleasure. And it isn’t some kind of stubborn, arms-folded resistance to cajolery. It’s a dark blanket deep in the brain’s structure, and it dampens pleasurable stimuli before they can take effect.
“The way these kids process information is very different,” Luby says. Talk to two children after a trip to the park. One might babble about a picnic basket and a puppy dog and a shiny swing set. If the other is prone to depression, she’ll remember flies buzzing, Dad yelling at the pup, and a bratty kid stealing her turn on the swing.
It’s no wonder pessimism is a frequent symptom.
“These kids feel like nothing good is ever going to happen to them, and they’re preoccupied with that,” Luby says. “They just don’t see things as ever getting better or becoming fair.” That pessimism is reinforced every day by their brain’s filter, and the data shapes their worldview—which then shapes the next day’s new information.
The problem is not bad parenting, Luby says—although parenting a depressed child is definitely tougher, and if the parent also suffers from depression, it’s even harder to find the joyful, consistent, reassuring tone the child needs. Discipline’s tricky, too: Luby says parents often either abandon all attempts because it’s so hard to discipline a child who’s sad, or they overdo it, forgetting that the child is extra-sensitive to criticism and too quick to blame him- or herself.
But—she repeats it—“it’s not that bad parenting causes depression. Depression is a biological, genetic disorder.” Which sounds as final as a locked door. There’s now a window of hope, though: an approach called Parent Child Interaction Therapy—Emotional Development (PCIT-ED). Luby’s team uses it to help parents teach their children how to understand the emotions they’re feeling, lighten up on themselves, and regulate their moods.
That’s the upside of diagnosing depression in children this young: You can change its trajectory. And a shift of even a few degrees will radically change their adult lives.
Luby has funding from the National Institute of Mental Health to treat, here in St. Louis, 250 children between the ages of 3 and 7 who show signs of depression but aren’t taking antidepressants or receiving other therapy. At press time, her team of trained and certified therapists had completed 18-week treatment sessions with 30 kids, and Luby was looking for 220 more. The study will continue for another four years.
Parents learn alongside their children, practicing how to discipline firmly but without harshness, how to encourage fun and minimize guilt, and how to coach their children about handling emotions so they don’t overwhelm. With bug-in-the-ear technology, a mother can play with her little boy while she’s coached by a therapist watching behind a one-way mirror. In one exercise, a porcelain teacup that is rigged to break is given to the child, who, inevitably, breaks it. The therapist looks upset and leaves the room. “Tell him it really wasn’t his fault,” the other therapist is murmuring in the mother’s ear. “Say, ‘I don’t think you have to feel bad about that. But we might think about how we can fix it.’”
Easing conscience and repairing damage can lessen the pangs of guilt, but how do you infuse joy? Luby has the parents and kids playing bubble-popping games and jumping games—anything exuberant. The idea is for the parent to be having a lot of fun, laughing, engaging the child, giving the child permission to experience and sustain pleasure. “They seem to be preoccupied with darker things,” says Luby. “They just need a little help to let the joy in. Someone else can help stimulate that in you.”
Before entering the program, one 6-year-old boy was either in tears or arguing 10 or 12 times a day, and an irritable mood could last all day. After PCIT-ED, those reactions came less than once a day and lasted maybe 2 minutes. Another child went from sobbing, moping, or pouting three or four days a week for hours to brief flashes of sadness less than once a week.
Those outcomes are possible because the children’s brains are as pliable as Silly Putty. “The idea is, you treat this early in life, when the brain is more neuroplastic,” Luby explains. “The brain is rapidly developing and changing, and it changes in response to environmental stimuli: Its networks change; its structures change. We have a key study that shows that how supportive your primary caregiver is when you’re young actually impacts the size of certain brain structures when you’re older.”
About half of kids with depression also have what Luby calls a “disruptive disorder”—attention deficit hyperactivity disorder or oppositional defiant disorder. Those are separate conditions, but there’s obviously some overlap. The same is true of anxiety: It’s a different issue but with frequent overlap with depression because they’re both disorders of emotional regulation. (Depression is the inability to regulate mood, and anxiety is the inability to regulate fear.)
“In the end,” Luby says, “it all comes down to emotional intelligence.”
And that, especially at a young age, is eminently teachable.
Apply for the study online at eedp.wustl.edu, or email pcited@psychiatry.wustl.edu for more information.
