The Noonday Demon (34 page)

A distinct form of depression, called anaclitic depression, occurs in the second half of the first year for children who have been separated too much from their mother. In various combinations and degrees of severity, it mixes apprehension, sadness, weepiness, rejection of environment, withdrawal, retardation, stupor, lack of appetite, insomnia, and unhappy expressions. Anaclitic depression may develop into “failure to thrive” starting at four or five; children with this complaint don’t have much affect and don’t bond. By five or six, they may show extreme crankiness and irritability and poor sleeping and poor eating. They do not make friends and have inexplicably low self-esteem. Persistent bed-wetting points to anxiety. Some become withdrawn; others become steadily more cranky and destructive. Because children do not tend to consider their own future as adults do, and because they do not organize their memories lucidly, they are seldom preoccupied with the meaninglessness of life. Without the development of abstract feeling, children do not feel the
hopelessness and despair characteristic of adult depression. But they can suffer persistent negativity.

Recent studies have been at such statistical odds as to be ludicrous: one of these definitively proved that depression affects about 1 percent of children; another demonstrated that about 60 percent of children experience major affective disorders. Attempts to assess children through self-reports are much more complicated than they are for adult populations. In the first place, questions must be put in such a way that they do not dictate apparently “desirable” answers; therapists must be brave enough to ask about suicide without proposing it as a feasible alternative. One therapist provided the formulation “Okay, if you hate all these things so much in your life, do you ever think about ways you could just make it so you’d never be around anymore?” Some kids will say, “What a stupid question!” and some will say “yes” and provide full details, and some will become quiet and thoughtful. The therapist needs to watch the child’s body language. And the therapist has to persuade the child that he is prepared to listen to anything. Children with really serious depression talk about suicide under such circumstances. One depressed woman I met, who was striving to keep up a good front for her children, described the despair she felt when her son said, at age five, “You know, life’s crummy and a lot of times I don’t want to live.” By age twelve, he had made a serious suicide attempt. “They’ll talk about wanting to join someone, maybe a relative, who has died,” says Paramjit T. Joshi, who heads the children’s mental health division at Johns Hopkins Hospital. “They say they want to sleep forever; some five-year-olds will actually say, ‘I want to die; I wish I was never born.’ Then the behaviors set in. We see many kids who have jumped out of second-story windows. Some of them take five Tylenol and think it’s enough to die. Others try to cut their wrists and arms, or to smother themselves, or to hang themselves. A lot of little children hang themselves with their belts in their closets. Some of them are already abused or neglected, but some of them are doing these things for no apparent reason. Thank goodness, they’re seldom competent enough to succeed in suicide!” In fact, they can be surprisingly competent; suicides in the ten-to-fourteen age group increased by 120 percent between the early eighties and the midnineties, and the children who succeed are mostly using aggressive means: guns and hangings account for almost 85 percent of the deaths. The rate has been rising, as children, like their parents, experience escalating stress.

Children can be and increasingly are treated with liquid Prozac or liquid nortriptyline, carefully dripped into a glass of juice. Such medication appears to help. There are not, however, any adequate studies of how
these medications work in children nor of whether they are safe or effective; “We have made children into therapeutic orphans,” says Steven Hyman, director of the NIMH. Only a few of the antidepressants have been tested to show that they are safe for use with children, and almost none have been tested for efficacy in children. Anecdotal experience varies widely. One study showed, for example, that SSRIs work better with young children and with adults than they do with teenagers; another showed that MAOIs are the most effective for young children. One should not take the results of either study to be definitive, but they point to the distinct possibility that treating children may be different from treating adolescents, and that both may be different from treating adults.

Depressed children also require therapy. “You just have to show them that you are right there with them,” says Deborah Christie, a charismatic child psychologist who is a consultant at University College London and Middlesex Hospital. “And you have to get them to be there with you too. I use a metaphor of mountain climbing a lot. We’re thinking about climbing a mountain and we’re sitting at base camp and just thinking about what kind of luggage we might need, and how many of us should go up together, and whether we should rope together. And we may decide to make the journey or we may decide we’re not ready to make it yet, but maybe we can walk around the mountain so we can see which will be the easiest or best way up. And you have to acknowledge that they’ll be doing some climbing, that you can’t pick them up and carry them up there, but that you can stick by them every inch of the way. That’s where you have to start: you have to stir up motivation in them. Kids who are really depressed don’t know what to say or where to begin, but they know that they want change. I’ve never seen a depressed child who didn’t want treatment if he could believe that there was a chance it would change things. One little girl was too depressed to speak to me, but she could write things down, so she’d write these words, randomly, on Post-its, and then she’d paste them on me, so that by the end of a session I was just a sea of the words she wanted to get through to me. And I took on her language and I started writing words on Post-its too, and putting them all over her, and that’s how we broke through her wall of silence.” There are many other techniques that have proven useful for helping children to recognize and improve their mood states.

“In children,” says Sylvia Simpson, a psychiatrist at Johns Hopkins, “depression prevents personality development. All this energy goes into fighting depression; social development is retarded, which does not make life any less depressing later on. You find yourself in a world which expects you to be able to develop relationships, and you just don’t
know how to do it.” Children with seasonal depression, for example, frequently spend years doing badly at school and having trouble; their complaint is not picked up because it appears to coincide with the school year. It’s hard to know when and how aggressively to treat these disorders. “I work on the basis of family history,” says Joshi. “It can be very confusing whether it’s attention deficit hyperactivity disorder (ADHD) or real depression, or whether a child with ADHD has developed depression also; whether it’s an abuse-related adjustment disorder or depressive illness.” Many children with ADHD show extreme disruptive behaviors, and sometimes the natural response to these is to discipline the child; but the child is not necessarily able to control his actions if they are tied to deep cognitive and neurobiological problems. Of course the conduct disorders tend to make these children unpopular even with their own parents, and that exacerbates the depression—it’s yet another of depression’s novel downward spirals.

“I have to warn the parents of these children when they come in,” Christie says, “ ‘Well, we’ll be getting rid of this angry stuff, but you may then have a very sad child for a while.’ Children never come by themselves. They are brought to therapy. You have to find out from them why they think they’re there with you, and what they think is wrong. It’s a very different situation from one in which people seek out psychological care on their own.” One of the important elements in therapeutic work with young children is the creation of an alternative world of fantasy, a magical version of the safe space of psychodynamic therapies. Asking children to name their wishes will often reveal the exact nature of their deficits in self-esteem. It is important, as an opening gambit, to get silent children to transit into speech. Many of them cannot explain their feelings except to say that they feel okay or they feel not okay. They must be given a new vocabulary; and they must be taught, on the cognitive model, the difference between thoughts and feelings, so that they can learn to use thoughts to control feelings. One therapist described asking a ten-year-old girl to keep a diary of thoughts and feelings for two weeks and then bring it in. “You could say your thought is ‘Mommy’s angry at Daddy.’ And your feeling could be ‘I’m frightened.’ ” But the distinction was beyond this child’s cognitive grasp because her depression had so disabled her cognitive functioning. When she brought the diary, she had written each day: “Thoughts: ‘I’m sad’; Feelings: ‘I’m sad.’ ” In her hierarchy, the world of thought and the world of feeling were simply inseparable. Later on, she was able to make a pie chart of her anxieties: this much of her anxiety was about school, this much about home, this much about people hating her, this much about being ugly, etc. Children who have worked with computers are often receptive to metaphors that
work on the principle of technology; one therapist I met said he told such children that their minds have programs to process fear and sadness and that treatment would take the bugs out of those programs. Good child therapists inform and distract their patients at once; as Christie has observed, “There is nothing as unrelaxing to children as being told to relax.”

Depression is also an acute problem for children who suffer physical illness or disability. “Kids come in with cancer and they are constantly being poked and prodded and having needles stuck in them, and they become accusatory and accuse their parents of punishing them with these treatments, and then the parents become anxious; and then everyone becomes depressed all together,” Christie says. Illness breeds secrecy, and secrecy breeds depression. “I sat down with a mother and her very depressed son, and I said, ‘So, tell me why you’re here,’ and the mother said, right in front of this little boy, in a loud stage whisper, ‘He’s got leukemia but he doesn’t know it.’ It was extraordinary. Then I asked to have some time alone with the little boy and I asked him why he had come to see me. He said it was because he had leukemia, but not to tell his mother because he didn’t want her to know that he knew. So the depression was tied into huge issues around communication, and those were exacerbated and brought into play by the leukemia and the treatments that disease required.”

It has now been established that depressed children usually go on to become depressed adults. Four percent of adolescents who have experienced childhood depression commit suicide. A huge number make suicide attempts, and they have high rates of almost every severe social-adjustment problem. Depression occurs among a good number of children before puberty, but it peaks in adolescence, with at least 5 percent of teenagers suffering clinical depression. By that stage, it is almost always combined with substance abuse or anxiety disorders. Parents underestimate the depth of the depression of their teenagers. Of course adolescent depression is confusing because normal adolescence is so much like depression anyway; it is a period of extreme emotions and disproportionate suffering. Over 50 percent of high school students have “thought about killing themselves.” “At least twenty-five percent of teenagers in detention have depression,” says Kay Jamison, a leading authority on manic-depressive illness. “It could be treated and they might become less obstructive. By the time they’re adults, the depression level is high but the negative behavior has been ingrained into personality, and treating the depression isn’t enough.” Social interaction also plays a role; the onset of secondary sexual characteristics often leads to emotional confusion. Current research is directed at delaying the onset of depressive
symptoms—the earlier your depression starts, the more likely it is to be resistant to treatment. One study says that those who experience depressive episodes in childhood or adolescence have seven times the rate of adult depression of the general population; another says that 70 percent of them will suffer recurrence. The need for early interventions and preventative therapies is absolutely clear. Parents should be on the lookout for early disengagement, disrupted appetites for food and sleep, and self-critical behavior; children who show these signs of depression should be taken in for professional assessment.

Teenagers in particular (and male teenagers most of all) fail to explain themselves clearly, and the industry of treatment pays too little attention to them. “I have teenagers who come in and sit in the corner and say, ‘There’s nothing wrong with me,’ ” one therapist explained. “I never contradict them. I say, ‘Well, that’s fantastic! How terrific that you’re not depressed like so many kids your age and like so many of the kids who come in to see me. Tell me what it’s like to feel totally okay. Tell me what it’s like right this minute to be in this room feeling totally okay.’ I try to give them opportunities to think and feel together with someone else.”

It is unclear to what extent sexual abuse causes depression through direct organic processes, and to what extent the depression is reflective of the kind of fractured home environment in which sexual abuse tends to occur. Sexually abused children tend to have life patterns of self-destructive behavior, and they encounter high levels of adversity. They usually grow up in constant fear: their world is unsteady, and that unbalances their personalities. One therapist describes a young woman who had been sexually abused and couldn’t believe that anyone could care for her and be reliable—“all she needed was for me to be consistent in my interactions with her” to break down the automatic mistrust with which she related to the world. Children deprived of early love and of encouragement toward cognitive development are often permanently disabled. One couple who adopted a child from a Russian orphanage said, “This was a kid who at five didn’t seem to have any cause-and-effect thinking, who didn’t know that plants were alive but furniture wasn’t.” They have been trying to compensate for that deficit ever since and now acknowledge that no full recovery will be possible.