March 11, 2003 -- Determining childhood depression may be a matter of child's play -- or more specifically, watching it.
"The most specific symptom of depressive disorders in kids under age 6 is something called anhedonia -- essentially, appearing to have no fun while at play," says psychiatrist Joan L. Luby, MD, of Washington University School of Medicine in St. Louis. "Enjoying activities in play is essential to a child's life, so if you notice that your child consistently doesn't want to play, or doesn't seem to enjoy playtime, it could signal that your child may need to be clinically assessed for depression."
"That's not to say if a child is playing war and gets shot, that is cause for concern because all children explore some negative play themes," Luby tells WebMD. "But depressed preschoolers tend to be preoccupied with play themes in which sad or bad things consistently happen. When playing house, there will be a persistent pattern in which there will be lots of fighting in the household, or people are mean to each other, or a tornado comes and destroys the house."
These findings are part of a new study, published in the Journal of the American Academy of Child and Adolescent Psychiatry, adding to evidence that even preschoolers can have clinical depression. In fact, they often display the same tell-tale symptoms as their older counterparts, such as sadness, irritability and lethargy -- a finding that Luby says defies long-standing thinking.
"Popular opinion has always suggested that if young children were indeed depressed -- and many disputed that they were -- they did not express these symptoms directly, but rather in what used to be called "masked" symptoms such as complaining about a stomachache," she tells WebMD. However, her study on 174 children between ages 3 and 5 1/2 shows that depressed preschoolers display typical symptoms of depression and sadness or irritability more frequently than masked symptoms.
The key indicators: anhedonia and death-centric play themes, sadness and grouchiness, low or recent changes in energy levels, low self-esteem, and frequent crying. Each of these symptoms was far more common in children diagnosed with depression than two other groups -- those who had other psychiatric disorders such as attention deficient hyperactivity disorder and those with no diagnosable psychiatric conditions.
Some say that Luby's study provides the latest pieces to solving the puzzle of diagnosing and treating depression in patients under age 6, on whom antidepressant medications haven't been tested and are rarely administered.
"This is a very helpful finding because we need to learn more about how to diagnose and treat depression in younger children," says psychiatrist David Fassler, MD, of the University of Vermont College of Medicine and author of Help Me, I'm Sad, a book about childhood depression. "The real message for parents is that depression in children this young is very real. When we identify and diagnose depression in school-aged children and go backwards, we often find there were signs and symptoms at a much earlier age, even in preschool."
With early diagnosis, childhood depression can be more effectively treated -- which for preschool-aged kids often involves individual and family counseling as well as "play therapy," in which the child is encouraged to draw or act out feelings of despair.
What causes childhood depression to occur? It may be a family tradition, says Luby. "Most studies indicate that depression runs in families, but it's not clear whether it's primarily caused by genetics or environment."
But others believe that childhood depression is extremely rare in a typical nurturing and functioning family and can usually be traced to a specific cause.
"The type of depression that seems to come out of nowhere usually doesn't kick in until about age 8 or 9," says Glen R. Elliott, MD, PhD, director of the Children's Center at Langley Porter Psychiatric Institute at the University of California, San Francisco. "In children this young, there is usually a significant disruption in the child's environment -- a divorce, the death of a parent, moving to a new location, or something like that. If not, we typically look to see if the child has been neglected or abused."
When preschoolers suffer a family death, divorce, or other situational trauma, they should be expected to display depressive symptoms. But these symptoms usually resolve after several weeks.
"You may need some help helping your child adjust -- and play can be very useful," Elliott tells WebMD. "Letting kids draw what happened and then thinking about other possible endings may be helpful. For instance, after the earthquakes here in which some children lost their families, that therapy was used and proved to be very beneficial. But if you see a sudden change in a preschooler's behavior or overall involvement in play or other activities that cannot be explained, it may be something to worry about."