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BMJ 2004;329:1394-1396 (11 December),
doi:10.1136/bmj.329.7479.1394 Education and debateRethinking childhood depressionSami Timimi, consultant child and adolescent psychiatrist11 Lincolnshire Partnership NHS Trust, South Rauceby, Sleaford, Lincolnshire NG34 8QA stimimi{at}talk21.com
Unhappiness among children seems to be rising, but labelling it as depression and prescribing antidepressants is ineffective and possibly harmful. It is time to focus on the underlying reasons
Increasing numbers of children are being treated for depression. At the end of 2003, over 50 000 children were prescribed antidepressants, and over 170 000 prescriptions a year for antidepressants were issued to people under 18 years old in the United Kingdom.1 Recent evidence has suggested that selective serotonin reuptake inhibitors are largely ineffective and may be dangerous in this age group.2 3 Older antidepressants have already been shown to have no beneficial effect in people under 18.4 So how did we get into this mess? Undoubtedly part of the problem is with pharmaceutical industry tactics, designed to enable greater consumption of their products.3 However, the gateway diagnosis to prescribing antidepressants to under 18s is that of childhood depression. In this article I discuss the notion of childhood depression and suggest that the medicalisation of children's unhappiness is hindering our ability to respond effectively to this problem.
Western society's ideas about childhood and child rearing have changed radically in the past 60 years. The West's attitude to child rearing changed from viewing relations between adults and children primarily in terms of discipline and authority to a focus on permissiveness and individual rights.5 In addition, whereas the model used before the second world war prepared children for the workplace within a society of scarcity, the post-war model prepared them to become pleasure seeking consumers (along with their parents) within a prosperous new economy.6 Shifting economic structures also led to profound changes in the organisation of family life. Suburbanisation and the economic demands of successful market economies resulted in greater mobility, less time for family life, and a breakdown of the extended family. Many families (particularly those headed by young women) became isolated from traditional sources of childrearing information. Guides on childrearing took on an unprecedented importance, allowing for a greater change in parenting styles than would have been conceivable in more rooted communities and giving professionals increased ownership of the knowledge base for the task of parenting.7 The new child centred permissive culture was a godsend to consumer capitalism. Childhood could now be commercialised, and an industry of consumer goods for children developed.8 As a result, children have gained access to the world of adult information and entertainment. The boundaries between what is considered adulthood and what is considered childhood have become blurred, and this has led to children coming to be viewed as, in effect, miniature adults.9 One effect of these changing expectations of childhood and parenting is that more childhood behaviours previously considered normal are now seen as problematic, and problematic behaviours are more likely to be medicalised.10
Just as our concepts of childhood have changed, so have our concepts of childhood problems. It was only in the late 1980s that our understanding of childhood depression began a far reaching transformation. Before this, childhood depression was viewed as very rare, different from adult depression, and not amenable to treatment with antidepressants.11 A shift in theory, and consequently practice, then took place as influential academics claimed that childhood depression was more common than previously thought (8-20% of children and adolescents), resembled adult depression, and was amenable to treatment with antidepressants (often resulting in antidepressants becoming a first line treatment3).4 12 Childhood depression has become a popular notion, reflecting the broader cultural changes that have taken place in our view of childhood and its problems. These days we are as likely to use medicalised terminology to describe children's feelings (such as depressed) as we are less pathological descriptions (such as unhappy).
According to the current criteria, psychiatric comorbidity in childhood depression is so high that nearly every child can be diagnosed with at least one other psychiatric condition.4 This raises doubts over the specificity of the construct. Despite awareness of the continuity between normal sadness and clinical depression, the diagnosis assumes that clinical depression exists as a category (rather than on a continuum). It is unclear, however, who decides where the cut-off mark is, and on what basis. Furthermore, the categorical diagnosis bears only a tenuous relation with levels of psychosocial impairment. Many children below the threshold of diagnosis show higher levels of impairment than those above the threshold.13 Similarly, a diagnosis of childhood depression is only weakly associated with suicide (stronger predictors include history of aggression and use of drugs or alcohol).14 The biological markers (such as cortisol hypersecretion) that are sometimes found in adults diagnosed with depression do not work with children and adolescents diagnosed as depressed.4 With regard to genetics, separating environmental from biological factors in the familial clustering has been virtually impossible, particularly as children whose parents have depression are at risk of developing a wide range of psychiatric disorders.14 Childhood depression has been argued to be a precursor of adulthood depression.15 However, follow up studies of children deemed to have had "major depressive disorders" have used dubious standards for diagnosing childhood and adult psychiatric disorders, have discovered high rates of comorbidity (in childhood and adulthood), have been unable to differentiate biological factors from continuing social adversity,15 16 and have not taken into account the possible effects of any treatment received (such as continuing morbidity as a result of toxic side effects of drug treatment and the experience of psychosocial adversity and decreased self worth arising from becoming a psychiatric patient). Leading researchers claim that childhood depression resembles adult depression.4 However, based on symptoms alone, children do not show many of the symptoms said to be common in adult depression (such as loss of weight and appetite, sleep disturbance, and feelings of guilt). Instead more non-specific symptoms such as irritability, running away from home, decline in schoolwork, and headaches are described as indicative of childhood depression.17
The problem with context deprived notions of childhood problems is that they lead to context deprived, often medicalised, solutions of dubious value that may carry considerable risks. The increase in rates of childhood depression in Western society18 may reflect a lowering of the threshold for the diagnosis arising from a change in the meaning we give to childhood unhappiness. However, there may also be a genuine increase in the amount of unhappiness experienced by children as a result of growing up in a cultural context that has seen huge changes in child rearing practices, family structures, lifestyles, and education. Changes in Western economies, working practices in competitive global markets, and capitalism's need for never ending growth mean that more parents feel forced to work for longer hours. State support for children and families has been cut (particularly in the 1980s and 1990s), resulting in widespread child poverty. With the increase in the number of divorces and two working parents, fathers and mothers are around their children for less of the day, contributing to a generation of "home aloners": children who have largely to raise themselves.19
Much evidence suggests that children and adolescents in the West experience greater mental health problems as a result of these sociocultural changes. In the second half of the last century, rates of psychosocial problems (such as crime, suicidal behaviour, anxiety, unhappiness, and substance abuse) increased sharply among children and adolescents in Western societies.18 Understanding the impact of these adverse social changes is likely to be vital in helping us develop appropriate interventions for unhappy children. For example, an increase in family decay (from factors such as divorce rates) is associated with increases in youth violence, substance misuse, and suicide.20 Context deprived models, such as childhood depression, that conceptualise problems in individualistic terms and therefore lead to individualistic interventions (such as pharmacotherapy and cognitive therapy) push more context rich interventions (such as systemic ones) to the margins. We need a multiperspective approach to both assessment and treatment of unhappy children and their families. Such an approach should normalise emotional responses to adverse life experiences, emphasise more positive approaches (such as building on existing strengths and resilience), and engage more systemic biopsychosocial interventions (including biological factors such as diet, exercise, and cognitive abilities).10 Medical researchers need to develop a more creative dialogue with researchers from other disciplines (such as sociology) to integrate within-body perspectives with broader ones. Childhood depression as an individualised, context depleted label that offers little explanatory power and can marginalise more helpful, context rich explanations, may first need to be abandoned before more comprehensive theory and practice with regard to children's unhappiness can emerge.
Contributors and sources: ST studies and writes articles and books on social, cultural, and political aspects of children's mental health. The idea for this article first developed after ST wrote a response, on behalf of the Critical Psychiatry Network, to the National Institute of Clinical Excellence on the subject of treatment for childhood depression. Competing interests: None declared.
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Introduction
Meaning of childhood
