ADVICE ON MENTAL HEALTH: Warning Signs & What to Look For: Anxiety and Depression in Childhood

ADVICE ON MENTAL HEALTH - from Brain & Behavior Magazine, September 2023 issue

Q&A with Joan Luby, M.D.

Washington University, St. Louis

Samuel and Mae S. Ludwig Professor of Child Psychiatry

Director and Founder, Early Emotional Development Program

BBRF Scientific Council

2020 BBRF Ruane Prize for Outstanding Achievement in Child & Adolescent Psychiatric Research

2004 BBRF Klerman Prize for Exceptional Clinical Research

2008, 2004 BBRF Independent Investigator

1999 BBRF Young Investigator

Symptoms of depression in children as young as age 3 are often missed by parents and teachers. One might see withdrawal, sadness, expressions of guilt. Teachers should look for persistent signs of a child’s inability in school to enjoy joyful activities, a lack of motivation to engage in social relationships, and negative self-perception; these signs should be shared with parents. In adolescence, one may see passive or active suicidality and self-harming behavior, which should occasion referral to a mental health professional.

Dr. Luby, how early can symptoms of anxiety and/or depression start to appear?

That is a really important question that we’ve been interested in. We don’t really know how early symptoms can begin, but available empirical data show that we can identify depression as early as age 3. You may be able to identify some anxiety disorders even before that. But the age of three is when clinicians can start looking for it and we can provide guidance on the signs and symptoms.

What does depression look like at such a young age?

For a very long time, there was a resistance in the field to accept the idea that children could be depressed. It really wasn’t until the 1980s when empirical studies came out showing that children could be depressed, and that depressed children had the same fundamental symptoms as depressed adults. Previously, people said either children were developmentally too immature to experience the core symptoms of depression, or they said they would experience other symptoms, like stomach aches or aggressive behavior.

But then the research started to show that no, this was not the case, that children were a lot more emotionally sophisticated than we had previously understood. One landmark paper provided data showing that in children, depression looks just like it does in adults. In other words, children have anhedonia, which is decreased ability to enjoy activities and play. They have sustained sad mood; the inability to sustain joyful moods; and disturbances in sleep and appetite. We essentially capitalized on that work, which had studied children as young as 6, and then asked the question: what this would look like in even younger children? We discovered we could find depression in children as young as 3. We found symptoms like anhedonia and decline in joyful behavior. Children are inherently so joyful that these markers are very important to pay attention to.

And what do symptoms look like in a slightly older child, a child of elementary school age who may be experiencing depression or anxiety?

That’s where you’re going to see some social withdrawal. Certainly, with anxiety, you will generally see a lot of social withdrawal. You see children showing more sadness, decreased motivation to engage in joyful and social activities. You might see changes in appetite. You might see psycho-motor slowing and fatigue. But the reason why these symptoms are so often missed—and they are often missed—is because caregivers and teachers tend to pay more attention to disruptive behaviors, and depressed kids fade into the background. Perhaps parents may be more sensitive to the symptoms.

What types of things should a teacher look for? And what should a teacher do if they see these signs?

With regard to depression, a teacher would be looking for a change in behavior, unless they’re meeting a child when they’re already depressed. Sometimes you see children who have more of what we call a chronic dysthymic condition—chronic low mood and other depressed symptoms—and in such children you wouldn’t necessarily see a change.

But, in cases of new depression, often you will see more withdrawal, more sadness. Another very important sign is increased guilt. Young children who are depressed experience high rates of guilt. They feel guilty for things that aren’t their fault. When they commit a transgression, it’s much harder to reassure them or for them to shake it. Teachers should also look for the inability to enjoy joyful activities, lack of motivation to engage in social relationships, and also negative self- talk or self-perception.

When a child is depressed, these symptoms should be sustained over a period of a couple of weeks. Obviously, any child can be sad or irritable for one day (irritability is another sign, but it’s a very non- specific sign, which is why I didn’t mention it). But a child with clinical depression has these symptoms in a persistent way. They will brighten at times, so they don’t have to be vegetatively depressed [this refers to symptoms affecting basic bodily processes, for instance, sleep habits, appetite, or the digestive system]. But because children are just inherently happier, depressed children will have sadness for large parts of the day more than usual, or for more days than not in a week, or for a couple of weeks. And when that’s observed, then it would be time for referral to a mental health clinician.

How common is this? Do we have a sense of what percentage of kids experience these symptoms?

Prior to adolescence, there’s about a 2% prevalence rate. Adolescence is when the prevalence of psychiatric disorders goes up sharply (particularly for girls, according to some data) to around 8% to 10%. We do see depression as something that runs in families. So when there’s a family history of depression, we would be more suspicious of it, and those children would be at a somewhat higher risk.

What are the symptoms for adolescents as they go through the teenage years, middle school, high school?

There’s a lot of continuity of the symptoms of depression across the lifespan—increased sadness, increased guilt, anhedonia, changes in sleep and appetite. When you get into adolescence, that’s when you might also see more passive suicidality, and maybe active suicidality. Suicidality can, of course, occur outside of a mood disorder, outside of depression, but as we know, there’s an increasing prevalence of suicidality currently, and that is an important marker that often becomes clear in adolescence. Self- harming behavior might be another sign, although that can be a non- specific sign as well.

But obviously, a very important one to take action on. If a child is having thoughts of hurting themselves, is acting on that, these are issues that need to be addressed right away.

Absolutely. Another thing we’re starting to understand is that suicidality is being observed and occurring much earlier in childhood than we previously understood. We’ve seen suicidality at surprisingly high rates in depressed preschoolers as early as 4 and 5. We’ve done studies looking at whether these children understand the permanence of death and found that those who have suicidal ideation understand the permanence of death even more than other kids who don’t. So expressions of suicidal ideation, either passive or active, can arise early in childhood and should be taken seriously. That doesn’t mean we should panic or take kids to the emergency room, but it does mean we should take it seriously and address it.

Tell us about the importance of early identification of these symptoms, why that makes a difference for the child.

Early identification is so important, and that’s because, generally speaking, when you look at cognitive, social, and emotional skills across development, that’s where we see impairments in depressed children. These affected skills and processes are much more changeable earlier in development, when the brain is much more “plastic,” i.e., it will change more in response to environmental and psychosocial experiences. So that’s one of the reasons we think early identification of psychiatric disorders and particularly mood and anxiety disorders is so important. We believe there’s a window of opportunity earlier in development to more effectively treat.

It’s important to remind our readers that brains are still developing at that younger age, and even among teenagers and adolescents into their early 20s. So the good news is that treatment can have an even greater impact on those developing brains.

Exactly. And many people believe that adolescence is another period of very high neuroplasticity, which is another reason why that’s a real focus of attention.

One of the concerns in adolescents is the issue of substance misuse. I’m curious about the interplay between anxiety and depression and the risk of then experimenting with and misusing drugs and alcohol.

I think that’s a huge risk. Because of the stigma associated with mental disorders, children and families don’t necessarily identify, focus, and seek treatment. Therefore, it leaves these conditions untreated, although still very distressing and impairing. And that’s why, in some cases, adolescents turn to substances as a way of managing symptoms. But of course, it is a very maladaptive way of managing the symptoms that will ultimately exacerbate the symptoms.

If a child was walking with a limp, it’s more straightforward for the teacher to say to the parent, “Your child’s walking with a limp. Have that checked out.” How can teachers approach the sensitive topic of depression or possible substance misuse with a parent?

You’re right. That is very tricky. I think that’s a huge risk. One of the problems that we have with the stigma associated with mental disorders is that children and their families don’t necessarily identify, label, focus, and go for treatment, and therefore, it leaves these conditions untreated. I do think that it’s important for teachers to let parents know when they see concerning signs—across the board.

Now, they may run into parents who are not very receptive, who might be defensive, who might want to write it off. I still think it’s important for teachers to let parents know. Sometimes a parent might not initially or immediately embrace your concerns or take them seriously, but you may be planting a seed. It may take some time for the parent to accept that this is something they need to grapple with. And if the teacher from last year told them, and now, the current teacher tells them, that reinforces it. So I would encourage teachers not to hesitate to notify parents. The work of really educating parents on the existence of mental disorders, their validity, their causes and treatments, is beyond the scope of what a teacher can do. But this is where school systems might come in and educate about mental health.

Sometimes parents know their kids better than anybody. They may have noticed signs on their own, and having an educator say something could be helpful. One idea would be to even say to the parent, “You may want to discuss this with the child’s pediatrician and get some feedback and see what, if anything, needs to be done by getting further professional help.”

Exactly. I agree. I’ve had so many patients come to my clinic where the parent may say, “The teacher thinks there’s something wrong. I don’t see it, or I don’t really agree, but the teacher thinks so.” I think parents do take what teachers say quite seriously, and then they do go seek professional help, and sometimes that leads to a much greater understanding on the part of the parent, ultimately.

Now let’s talk about treatment. What does treatment look like? What happens when somebody goes for an evaluation?

For kids older than 6, there are several forms of psychotherapy, for instance, cognitive behavioral therapy, that are proven to be effective. There are some age-adapted forms of interpersonal psychotherapy (IPT) that have been tested in pre-adolescent kids as well. Of course, there are an array of medications that have been tested for children as young as age 6, which are also proven to be effective. So when you talk about kids 6 and older, there’s a number of treatment options and many of these options are quite effective, even though, of course, we are still searching for more effective treatments.

However, when you look at kids under 6, that’s where you get into the zone where the intervention literature and the interventions are much sparser. First of all, the use of medications for depression in children under age 6 is not recommended because there is no data looking at the safety or efficacy of those medications for these children. There is at least one form of psychotherapy that we have worked on developing and testing at Washington University called Parent-Child Interaction Therapy— Emotion Development (PCIT-ED), which is a manualized form of therapy [i.e., performed according to specific guidelines for administration, maximizing the probability of the therapy being conducted consistently across settings, therapists, and clients]. It was tested in a large- scale, randomized controlled trial. It targets the parent-child relationship, and it targets the child’s emotional competence, and that’s proven to be very effective. The problem is it’s really not widely available right now, even though the manual with instructions on how to do it can easily be downloaded, and there are a number of therapists who know these approaches. But it’s one of those types of therapies that needs to become much more readily available across the country. And that’s where we run into a roadblock.

In PCIT-ED, how long does it take to start seeing results?

For kids under 6, we used an 18-week psychotherapy treatment delivered by a master’s-level clinician, and we saw very positive results after this 18-week period. We saw kids starting to get better even after the first few weeks of treatment, which is part of the reason why I think parents remained so engaged. Now, again, that’s early childhood, where we have the plasticity working for us.

When you get into older kids, sometimes the process might be slower. As for medications, it can take two to three weeks to begin to see effects. So you do have to be patient. It’s a process, not a quick fix.

Another thing to be aware of is that a child who is depressed is vulnerable to another episode, even if they are effectively treated. So it’s something you need to be attentive to over the course of development. And you might need therapy course-corrections, you might need boosters. It’s something to keep your eye on in a lifelong way.

A key point is that with treatment, children get better. That for these fully treatable conditions, therapies may need tweaking at some points, but the children get better. They can function at a high, full level with appropriate treatment.

Absolutely. And the other reason it’s so important to treat it in childhood is because during childhood, children are traversing a steep developmental curve. They have a lot of things to do, developmentally. They face high levels of social challenge, social-emotional development, cognitive challenges, motor development, and if a child has an anxiety disorder or depressive disorder, it doesn’t just impair them in their daily life and increase their distress (which is a problem in and of itself), but it also drags down their development, which can then become a vicious cycle with long-term effects.

You’re speaking to a good number of teachers, and to parents. What do you say to them? What’s your guidance to them?

I would stress that children are very vibrant emotionally, even early in development. They’re much more aware; they have much deeper feelings than we used to think. They have a much broader range of emotions. They’re very capable of complex emotions. They feel intense guilt. These are things that are very important to pay attention to. Just as much as you’re paying attention to their motor skills, to their language skills, children are really burgeoning in this domain and it’s really, really important for us as educators, as caregivers, to foster and facilitate this. And this is the reason why we have to think about emotional functioning, and try to identify disorders as soon as they possibly arise and work to treat them.

Edited By Fatima Bhojani

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