Young and desperate: Depression in children and teens

[David Baxter PhD]

Young and desperate
by Carol Midgley, The Times
June 26, 2007

The latest in a series of reports says that one British child in ten suffers depression. In fact, the real figure may be only one in 100. But constant exams, pushy parents and 24-hour communication mean many more are anxious and unhappy

John Marshall still feels jabs of nausea in his stomach at the recollection of those hellish days when he would have to drag his screaming, squirming child to school.

Sometimes Matthew, 12, would claw at his own skin throughout the journey or try to jump out of his father?s car at traffic lights. The headmaster and school chaplain would look on as the boy was hauled through the school gates, weeping and pleading to go home.

John and his wife, Alison, were congratulated for not caving in to their son?s daily refusals to go to school: everyone seemed to agree that it was for the best. The Marshalls had grave doubts. This was the 21st century, yet to them this treatment seemed almost medieval in its cruelty. Matthew had been given a diagnosis of depression.

Surely an adult with the same illness would not be treated in this way?

Probably not. But then, the idea of children becoming clinically depressed is still relatively new. Until the 1980s it was not thought that a child could suffer from the illness in the same way as an adult. Indeed, some doctors still hold with the Freudian view that before puberty children are incapable of experiencing depression in the true sense because they have not yet developed a superego. Some teenagers seeking help for symptoms of depression say that they have met with scepticism and, at times, dimissiveness from their GPs.

Yet at the same time we are being told continually that the incidence of childhood depression is increasing. Between 1991 and 2001 the number of children prescribed antidepressants in the UK rose by 70 per cent, amid an apparent epidemic of self-harm and eating disorders. An estimated 35,000 children and teenagers are currently being treated with Prozac-type drugs.

In recent months experts have cited various possible reasons for an increase in depression: huge pressure from exams; the embedded drink culture; fragmentation of the traditional family unit; a materialistic society that seems to value looks, wealth, thinness and clothes above happiness; and pushy parents who expect too much of their offspring and cram their every waking hour with ?improving? activities.

Last week the Institute of Psychiatry said that the number of teenagers with emotional and behavioural problems doubled between 1974 and 1999. The General Teaching Council has called for exams to be scrapped for under16s because they are putting too much stress on teachers and pupils. A letter signed by 110 teachers, psychologists and other experts, circulated to the press last year by Sue Palmer, the author of Toxic Childhood and a former head teacher, blamed junk food, marketing, overcompetitive schooling and electronic entertainment for poisoning children and accelerating their physical and psychological growth, causing ?an escalating incidence of childhood depression?.

In addition, some experts believe that the increasing tendency for both parents to work ? meaning that many children coming home from a hothouse school environment have no parents, only nannies or childminders, in whom to confide their problems ? exacerbates their anxiety and sense of worthlessness.

But could it be that childhood depression has always been with us, and that its apparent ?rise? is because we now acknowledge it and are better at detecting it?

Three months ago, The Times placed a small appeal in the health pages asking for children or the parents of children who were suffering or had recently suffered from depression to contact the newspaper. The response was far greater than we expected. Over the past few months I have interviewed dozens of those parents and children about their experiences.

This article is an attempt to understand what it is to be a depressed child in modern Britain ? recently declared by Unicef to be the worst of 21 Western states in which to be a minor ? and if depression is on the increase, to examine why this might be so. Many experts in the field have spoken to The Times about a subject that is being debated increasingly. It is estimated that 10 per cent of 5 to 16-year-olds suffer from significant emotional and behavioural problems (ranging from depression to eating disorders), compared with between 5 and 10 per cent for adults.

Serena was 16 when, last year, she found herself standing at the top of a multi-storey car park in Hampshire, willing herself to jump off. She is a bright, engaging and cynically funny young woman from a middle-class home but she had spent the previous two years in what she describes as a profound state of ?disconnectedness? from the world. She had become so low that she had ceased to feel anything except a thudding sense of pointlessness.

Her experience of ?the system? has not been good, she says. The symptoms started when she was 14 and working towards her GCSEs. Like many teenagers at that age she was arguing with her mother. But instead of her feelings of worthlessness dissipating, they started to mount.

?At first I just felt a bit strange, a bit unconnected,? she says. ?Then I started to hate absolutely everything about myself ? my hair, my body, everything. I pushed everyone away; I was angry. I would spend five days in bed just lying there, crying.? She went to see her GP but, she says: ?I got the feeling that he wasn?t taking me seriously. He thought it was normal teenage stuff.?

Her family were not overly sympathetic, adopting a ?snap out of it? attitude. Gradually Serena did ? but a year later the feelings returned with a vengeance.

This time the GP gave her antidepressants. The first batch made her so sick with hot flushes and uncontrollable shaking that she failed one of her GCSEs. The prescription was changed and she had no further violent reactions but felt no better. In fact she felt worse. She doesn?t attribute the beginning of her illness to any one thing, just to a general sense that she wasn?t good enough.

?Eventually I had to quit my A levels because I just couldn?t function in the world like everyone else,? she says. ?Lying there for days on end not being able to get yourself out of it but desperately wanting to ? it?s the worst feeling you can have.

?There are no obvious symptoms ? you don?t have a great big bandage round your head ? so people can?t understand why you don?t just go out, have a drink and cheer up. But it?s just with you all the time, and you can?t understand why other people can cope and you can?t.?

This sentiment is echoed by Anna Booth, 15, from Yorkshire, who began to suffer ?crippling? anxiety and depression after her parents separated acrimoniously. She is now having cognitive behavourial therapy. ?There is a lot of emphasis in youth culture on having a great time, partying, everything being ?wicked?,? she says. ?It sounds like a very liberal, anything-goes culture but it?s not. You are expected to conform and to have that ?great time?, or you?re nowhere.

?There isn?t much interest in people like me who, at our worst, can?t see anything to get out of bed for. And the more you can?t do it, the more you feel like an alien until the only answer is to stay in bed, crying. And you feel that?s where you deserve to be.?

The lack of support from Serena?s family (her mother is still unaware of the full extent of her illness) increased her feelings of failure. One day, when she should have been at school, she walked to the top of the multi-storey car park. ?I think I did want to die,? she says. ?I didn?t see myself as being any use to anybody. But then my mate called me on my mobile and asked why I wasn?t at school. It made me think that someone cared, and that stopped me.?

Serena is now 17 and works in a burger bar. It is all she can cope with at the moment and she enjoys its simplicity. She hopes to return to college to sit her A levels when she feels better, but has told few people about her illness. Nobody, she believes, can understand her feelings of ?horrific blackness?.

So why do some children plunge into depression while others, faced with the same stresses, don?t?

There is strong evidence that some people are born with a genetic predisposition to depression (many of those to whom I talked for this article had parents, grandparents, aunts or uncles who suffered from depression. Some had committed suicide).

But David Cottrell, Professor of Child and Adolescent Psychiatry at the University of Leeds and a trustee of the charity Young Minds, says that there is rarely just one cause of depression; usually it is a combination of factors. Major life events such as a bereavement or a family break-up can act as triggers. So even if a child has that predisposition, if the ?trigger event? never happens it might always lie dormant.

Does he agree that childhood depression is on the increase? ?Children?s lives are probably more stressful now,? he says. ?There are different pressures. But we are also getting better at detecting what has always been there.? He adds that when he first went into psychiatry, it was as if the sexual abuse of children didn?t exist. ?It was in the early 1980s that people started to realise [its extent]. Now we know that it is incredibly common.?

A common theme among some of those I interviewed was that depression struck when they were about to start or had just started a new school, or were embarking on exams. Matthew Marshall, whose grandfather had committed suicide from depression, started to feel anxious in his final year at primary school. Those feelings passed, however, and he completed his first term at secondary school ? a large but respectable comprehensive ? without obvious incident. But towards the end of the Christmas holidays he began to withdraw. On the eve on the new term, he told his mother simply: ?I can?t go.? It was the start of a nightmare.

Matthew was brought up on a farm in Wales, a seemingly idyllic childhood with access to riding and fishing. He was normal, happy and healthy, yet when the illness kicked in he lost interest in everything around him. It was a struggle just to get him dressed in the mornings.

His GP, say the Marshalls, was not very sympathetic to their plight and in their view thought that Matthew was just badly behaved. One day they invited the GP to the house to see for herself the state that he was getting into each morning. She watched, then referred him to his local adolescent psychiatric team, which, after first suspecting agoraphobia, later diagnosed depression. But their advice to his parents was to keep dragging him to school, whatever it took. Sometimes they would take him still wearing his pyjamas.

After several weeks of that appalling routine, the doctors conceded that it couldn?t go on. Matthew stayed at home for nine months, then moved to a smaller, private school where there were only 12 pupils in each class. It was the making of him. His parents believe that the previous school was so huge that it overwhelmed him. Although he had another relapse at the age of 15 and was prescribed antidepressants (he has taken them ever since), he achieved good A-level results and is now 19, reading psychology at university and managing his illness well. His relationship with his father, however, who was given the task of putting him through that ordeal each morning, has never really recovered.

?We will never be the same,? says John Marshall, sadly. ?We don?t talk about it. We have never been close since. I was a nasty bugger, you see. We?ll never be the best of pals.? The parental guilt that he feels is obvious, even though he was only following advice. But as his wife says: ?It felt sometimes as if they were reading from a textbook. Even when it was obvious that this was just making things worse, we were advised to carry on forcing him to school. This child was desperate, anyone could see that. We felt very badly informed by the people who were supposed to be helping us. We felt totally alone, in fact. Seeing him in that desperate abyss was dreadful. There just didn?t seem to be the range of support for children that there is for adults.?

Matthew?s experience was seven years ago, though, and experts say that in the past two years services have improved dramatically. Professor Cottrell, who helped to write the National Institute for Health and Clinical Excellence (NICE) guidelines on children?s mental illness, says that one of the recommendations was early detection and recognition of the illness even though children rarely present with ?pure? depression (it may be masked by disobedience and/ or irritability, for example).

Generally it is advisable to try to keep a depressed child in school as much as possible. ?Forcing yourself to do the thing that you dread usually makes you feel better,? says Professor Cottrell. ?Staying at home and disappearing into your bedroom is terribly bad for you.?

However, he adds that Matthew should have been offered a part-timetable by the school and been given therapy to teach him strategies for coping with the school day. ?I?d like to think horror stories like that wouldn?t happen now,? he says.

In some ways, of course, ?depression? is unquantifiable: it is not a straightforward disease or infection. The Royal College of Psychiatrists says that depression is ?real? when the feeling of lowness or sadness goes on and on, or dominates your whole life.

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[David Baxter PhD]

In her new book on childhood depression, Happy Kids , Alexandra Massey says: “The figures on child mental health demonstrate that more children are unhappy than ever before, but no one organisation or authority . . . can pinpoint the reason why. It’s mystifying and worrying because these children are the next generation of adults who will lead the world into a new age.”

Research from the World Health Organisation found that by 2020 neuropsychiatric disorders will rise proportionately by more than 50 per cent to become one of the five most common causes of morbidity, mortality and disability among children.

But Childline, which in 2005 took 6,000 calls from children complaining of mental health problems as a major issue, says that although thousands of distressed children call each year complaining of depression, numbers have remained steady over the past 20 years with no huge increases. The under12s account for only 5 per cent of calls about depression. Of the 1,200 calls about suicide, 80 per cent were made by girls.

Among the life events that callers say are causing them the most distress are bereavement, divorce, moving house and changing school.

Professor Paul Cooper, a clinical psychologist and director of the Leicester University school of education, has pointed to British children being among the most tested in the world, and underachievers being seen as a threat to the careers of individual teachers. But he argues that there are also new stresses, such as pressure from the media about the way that they look.

“It is a terribly stressful time to be a child,” he says. “We can laugh off . . . having to have the right clothes as trivial but that’s ignoring the reality of it. These children are consumers from the moment they can understand the reality of it. As they become knowing about consumerism they start to judge each other. It is a loss of innocence.”

People point out that children’s lives have improved immeasurably since the days when they were shoved up chimneys or sent out to work at 11. But Professor Cooper says it is important to remember that we have yet to see the full effects of some of the most drastic changes in modern society, such as the fact that in some parts of Britain there are more children born to single parents than to established couples.

“We are moving to an age where the traditional structures in which children grew up are shifting and we have different structures which are to some degree untested,” he says, adding that children can feel anonymous in large schools where “in a sense, nobody knows them” – hence the importance of the Every Child Matters agenda, which requires teachers to ensure that every child is known as an individual.

Dr Madeline Levine, an American psychologist, claims that children from affluent homes (those with an income of more than £63,000 a year) are three times more likely to suffer from anxiety and depression than the average teenager. Since 1950 – during which time living standards have improved immeasurably for children – the number of adolescent suicides has quadrupled.

Rachel, 28, who suffered such severe depression from the age of 12 that she would barricade herself in her bedroom and still manages her illness with medication, is now a teacher and believes sincerely that exam pressure is a major factor in exacerbating depression. For obvious reasons she wishes to remain anonymous. “The new AS system is terrible,” she says. “They say that it gives you more choice but gloss over the fact that it is the equivalent of doing the first year of five A levels.

“As soon as the students get into college they don’t have time to settle in. One of my students has just dropped out, another is very withdrawn. I don’t think there should be this constant pressure of education. Let young people have space to enjoy life.”

On the other hand, Professor David Healy, a consultant psychiatrist at Cardiff University College of Medicine, answers with a direct “no” when asked if he thinks depression is growing among children.

Professor Healy believes that while some children undoubtedly suffer from the condition, others who 20 years ago might have been described as “anxious” or “phobic” are now classed as having depression. This is partly because the Diagnostic and Statistical Manual (DSM IV) on mental disorders – the international bible on medical illness and one of the tools used to diagnose – now encourages doctors to use a coding system to determine the illness, rather than their clinical judgment. Thus a child who displays more than five of the nine symptoms meets the criteria for depression. As Professor Healy says, a person with flu might also tick sufficient symptoms on the checklist “but to give someone with flu antidepressants would be nuts”.

“This is an issue of clinical judgment,” he argues. “We have moved into a world of rating scales and checklists.”

He also believes that parents today are less willing to tolerate variation in how their children behave – they want them to conform to “norms of behaviour” more than previous generations – so they can panic over peculiarities and moods that would once have been seen as part of the normal condition of being a teenager. “The danger is that we get a cultural machine that tries to convert the way we see normal variations in kids – with pills,” says Professor Healy. His personal view is that the number of children with mental problems so severe that they need treatment is nearer one in 100 than one in ten.

“Clearly there are a group of kids in their teens who can get profoundly depressed in a way that we used to think could happen only in later life,” he says. “Younger kids can get awfully unhappy, too, and what you call that is a tricky one.” The temptation, he says, can be to fiddle too readily, as you might with a plant that isn’t growing straight – but in this case the fiddling constitutes giving pills to youngsters whose brains are still taking shape.

But surely many, many children’s lives have been improved by antidepressants? Doesn’t that show that they must have been depressed in the first place?

Not necessarily, says Professor Healy. The pills would be likely to lessen feelings of anxiety, but that doesn’t necessarily mean that the child was ever “depressed” in the clinical sense.

Last year the European Medicines Agency announced that children as young as 8 could be given Prozac. This was a controversial decision, given that in a small number of cases the drug can cause suicidal feelings in children and teenagers when it is first taken or the dosage is changed.

But Professor Cottrell points to the fact that NICE guidelines now recommend that for children with mild depression “talking treatments” – individual or family therapy – should be offered first, and for those with moderate depression it should be talking treatments first and medication second. For those with a severe form of the illness, however, medication can be a lifeline.

“If it was my child who was depressed I would be happy for them to have it [medication],” says Professor Cottrell. “But I would like to think that prescribing has been getting less.”

Barbara Herts, a former head teacher and the chief executive of Young Minds, partly blames society’s materialism and the widening gap between “the haves and have-nots” for the apparent growth in mental health problems. “This is an increasingly consumerist society in which the answer [to problems] is going to the shopping centre and grabbing the nearest gadget,” she says.

“We talk to a lot of young people about the pressures of modern life, the stress over their schoolwork. We also talk to a lot of students about managing their loans – particularly first-years. For the first time they are having to cope not only with looking after themselves but also with their finances.” One theory is that it is such pressures that have fuelled underage drinking – a syndrome of children “self-medicating” against feelings of depression.

But could it not also work the other way? Alcohol and hangovers cause depression, so the easy availability of alcopops might themselves be creating a depression boom.

What seems certain is that even in a so-called liberal age, having mental illness as a child or adult still carries a stigma. Most of the families I interviewed for this article opted to use false names.

Nancy Wilson, from Kent, says that when her daughter Catherine started to show signs of depression at primary school, a teacher friend urged her not to consult a psychiatrist. “It will go on her record and she’ll be stuck with it for life,” she said.

Jessica Murphy and her family, however, are determined not to brush depression under the carpet – so much so that they agreed to be photographed by The Times. As her mother, Glenda, says: “We have always been open and honest about it. I think it’s the best way to be. I have likened it to diabetes: it’s a chemical imbalance in the brain and you need medication to fix it.”

Jessica’s father and grandfather had both suffered from depression. But what almost certainly triggered her first episode was the family’s sudden and dramatic departure from their comfortable home in Zimbabwe in 2001 when she was just 10. They had to leave everything behind – her pet cats, her Barbie dolls, the maid who had been like a second mother to her.

The Murphys settled on the Isle of Man and Jessica, an articulate and mature young woman, seemed fine at first. Initially, she says, coming to the island and starting a new school seemed like an adventure, but a year later the depression kicked in.

The shock of coming from a private Catholic school with small classes and starting at a big comprehensive in a new country was huge. Jessica discovered that her new classmates were all computer-literate while she “didn’t even know what Google was”. She found that she could neither sleep nor eat.

“At night it feels like the whole world is asleep and you are the only one awake, worrying,” she says. “I was really, really sad. You don’t like yourself, you have really really low self-esteem but you can’t lift yourself up and out. You have no control over your thoughts; they completely overrule you.”

Luckily her parents recognised the signs. Her father encouraged her to write her negative thoughts on a piece of paper, then tear it up and burn it. After depression was diagnosed by her doctor she took six weeks off school. The school was exceptionally good in coping with the illness – better, Glenda believes, than an independent school would have been. “There was an open-door policy, a special needs teacher always available, and if she needed to escape from the hurly burly there was a quiet place with an armchair to sit in,” she says.

When she was 15 Jessica suffered a second episode. This could have been partly due to impending exam pressure and partly, she believes, to a letter that she received out of the blue from an old schoolfriend in Zimbabwe – a reminder of the old life she was missing. By now she had been referred to Dr Warren Levine, an adolescent psychiatrist at Alder Hey Hospital in Liverpool, whom the family describe as “wonderful”. A combination of antidepressants and cognitive behavioural therapy aided her recovery. But again the supportiveness of the school was crucial, agreeing to send her bits of work home and not pressuring her to return.

“The worst thing you can do is to force a depressed person to do something,” says Jessica. “If I had felt pressure to go back to school it would have made me want to hide in my bedroom. I couldn’t even eat. You are physically weak. You need the time off.”

She has learnt to recognise the creeping signs of her illness: the inability to sleep, extreme self-criticism, becoming wary of leaving the house, and has learnt methods to tackle them. She has a light box, writes poetry and finds that exercising and “listening to music really loud” help enormously. The bottom line, though, was that when the illness was at its worst she wanted to recover. “I didn’t want to die. I wanted to live,” she says. “I wanted to enjoy life and be happy again, and that pulled me through.”

Alexandra Massey was devastated when her son started showing signs of depression at the age of 5. She hadn’t noticed until one day he said to her “I feel like a brick in that wall” and she realised that own depression was having an impact on him. “I thought I’d been doing a good job by taking care of his needs,” she says. “I even employed someone to help for a few hours a week so I could have some time off, and chose a nice woman who adored him. Now I can see that I just wasn’t in his life. I was paying lip service to parenting him, and he felt my neglect.”

She believes that in most cases “the child who has depression is reflecting some imbalance within the family structure”.

She had suffered depression herself as a child in the 1970s, although it was never diagnosed, partly as a result of her parents’ high expectations of her. Consequently, she says, she became an academic failure. “I felt as if my head was in a fog, as if I couldn’t read or write,” she says. “The pressure was huge and the message children get is that it’s a criticism: you’re not OK as you are.” Her depression made her feel so disconnected, such an “alien” in her family, that she began to suspect that she was adopted and would search for documents around the house to support her theory.

Years later she put her elder child into boarding school as his father wished, but removed him after two years because she was appalled by the zealous competitiveness of other parents.

Pushy parents who obsess over school selection and the achievements of their children should, she suggests, ask themselves which individual they are seeking to fulfil – the child or themselves. “Who are they competing against?” she says. “Is it their peers because they have got their children into the right school?

“Parents who create too pressured an environment at home risk their children ‘switching off’. Children create their own survival mechanisms. They might become heroes and overachieve, or they might rebel completely. They might shut down or go into a dream world; they might get into trouble or steal.”

In a high-achieving, goal-setting family, she says, what’s important is not what you say to your children but what you do. “You might say ‘you are more important than work’ but if you are looking at your watch to catch the train while you say it, it’s not going to mean much.”

She believes that the “onslaught of high-pressure, interactive modes of technology” – texting and messages on sites such as Facebook and Bebo – is also contributing to the stress afflicting young people.

“They keep in touch with each other so much that there doesn’t seem to be any downtime,” she says. “They are getting maybe 20 messages a day and spending hours in front of a screen. Teenagers seem to be very aware of the wider world these days, but not very self-aware.”

But why are some people more prone to depression in the way that others are prone to migraine or weak ankles? Michael Conner, an American clinical psychologist, author and expert in crisis intervention, has said that while some are more vulnerable to it, depression is “almost always” caused by society, not the brain.

“The negative aspects of our society and culture include things like social pressure, intimidation, rejection, abuse, neglect, violence, illness and death,” he says. “These are all potential stressors depending on our state of mind and how we were raised.

“The interaction of our mind with society and our culture can cause pain, fear, sadness and shame. And the stresses in our life can change our physiology, which causes our genes to produce proteins that actually change the function and structure of our brain. This creates physical and psychological symptoms that can last a lifetime.”

The longer we experience stress, the more we change our brain. This is why, with identical twins raised apart, one twin can be depressed and the other not.

Conner says that we have learnt more about depression in the past five years than in the previous 50. “We now know that depression is mostly a perfectly normal response to our experience,” he says. A lousy life, a tragedy or an overwhelming stress can make anyone depressed or anxious: “Depression can be a consequence of long-term anxiety and fear. Many people live in a stressful and toxic world that some can tolerate better than others.”

But, he says, children can be protected from potential stressors by certain “buffers” such as a functional family, friends, recreation, adventure, creativity and sleep.

Many other parts of the developed world are noticing a rise in the number of depressed children. This month new statistics showed French children and teenagers to be the most depressed in Europe, with rates of depression rising by a third in the past decade. Possible factors cited range from the employment market, in which qualifications are prized far higher than practical experience, to rapid transformation in some parts of France from a rural to an industrialised society.

Depression is no respecter of wealth or class. Indeed, chidren of relatively wealthy professional parents are often more at risk. A study in Brittany indicated that local increases in anxiety and suicide closely tracked rising local success in the critical Baccalauréat exams and expanding local access to further education. François Dubet, Professor of Sociology at Bordeaux University, has said: “The middle classes have more to lose. In this country, you keep your social position by getting good diplomas. That guarantees you access to work that is seen as honourable and you are esteemed socially. The working classes have less to lose in terms of social position, so the pressure is commensurately less.”

Whether many children are wrongly being classed as having depression or whether modern, affluent life is more conducive to triggering the illness among less resilient individuals, it seems certain that a lot more children today claim to be profoundly unhappy.

But Massey says it is important to remember that while up to 10 per cent of children may become depressed, 90 per cent do not and cope quite happily with exam pressure and the landscape of modern life.

Even if your child is depressed, coping with the illness can have unexpected positive effects. “What emerges from the changes can be profound for the whole family and really enhance personal growth for the parents as well as the child,” she says. “I have known families that have been transformed as a result of a child’s recovery from depression, because of the impact that their recovery has had on the family as a whole.”

Sufferers such as Jessica, Matthew, Sebastian and Rachel are living proof that depression can be overcome. As Alison Murphy says of her university student son, Matthew, he still has bad days when “he can go to bed right as rain, then wake up the next day and not want to get up”. But he has learnt how to manage it. “He is a really well-rounded young man,” she says.

Childhood depression may well be increasing. But while it can be an exceptionally traumatic time for a family, it is important to remember that having a depressed child really does not have to be the end of the world.

• 10 per cent of 5 to 16-year-olds suffer from behavioural problems
  
• The number of children on antidepressants has risen by 70 per cent
  
• By 2020, cases of depression in children will have risen by more than 50 per cent
  
• Of the 1,200 Childline calls about suicide, 80 per cent were made by girls
  
• Children from affluent homes are more likely to suffer from depression
  
• New statistics show French children to be the most depressed in Europe
  
• Since 1950 the number of adolescent suicides has quadrupled

 

[David Baxter PhD]

‘She fears everything’
JULIETTE is 10 but already she is petrified by the thought of ever having to live without her parents.

She often writes her mother letters saying: “I never want to leave you.” Sometimes she says that she doesn’t deserve to live and talks of ending her life so that she can be “at peace”.

Frances, her mother, knows that her daughter is severely depressed but what she doesn’t know is how best to help her. This sense of complete powerlessness is one of the things that distresses her most.

Juliette sees a counsellor to whom she was referred by her GP, but still spends much of her life crying and often comes home early from school.

Her problems started at the age of 4 when she suffered the early onset of puberty. By 6 her body had fully developed and she gained a lot of weight. Although her three older siblings are slim, she remains overweight despite a strict nutritional regime of salads and fruit and absolutely no crisps, biscuits, chocolate or burgers. Repeated tests have failed to determine the reason for this.

Frances spends hours trying to resassure her youngest child but it seems to make no difference. “The last six months have been terrible”, she says. “Her self-esteem is rock bottom. She is embarrassed about her weight and it’s so unfair because she only ever eats salads.

“She seems to fear everything and at the moment it is going to school and leaving me. She is in a very fragile state of mind and I do fear for her future if we can’t sort it out now.”

‘I don’t think that being gay caused the depression’
SEBASTIAN lives in London. “Depression probably first hit me when I was 14 or 15,” he says. “I became quite uncommunicative with my family. I can’t remember strongly the root of my depression or how I felt particularly, other than lonely. I knew I had my friends and my family, yet I was still alone. I think teenage depression is mostly about the sensation of feeling out of place.”

He found that he had an almost permanent need to sleep, often until 3 or 4pm at weekends, and found it hard to stay awake in class. His mother, Suzanne, says he had no appetite and lost so much weight that she feared he was anorexic. “He hated being touched and recoiled from any contact,” she says. “It was as if he was supersensitive. If you so much as tapped him on the back he would flinch. It was breaking my heart to see him so unhappy.”

At around the age of 14 Sebastian and his friends started drinking. By 16 he had started smoking cannabis and later graduated to Ecstasy, speed, ketamine, cocaine and magic mushrooms. He and his friends would bunk off school.

“The worst situation with my family was when I was 16,” says Sebastian. “We were to go on a skiing holiday which I didn’t want to attend. I was such a bastard I went out of my way to ruin the holiday. I just couldn’t see why they had to bring me.”

Sebastian believes the point at which he started to get better was when he came out as gay. It was a great relief, which surprised him as he had never thought it to be a “great weight”. However, he says he still has not discussed his homosexuality properly with his parents. “I don’t think that being gay caused the depression. It was just one of many factors. By just actively doing something to help myself helped me to overcome the problems.” Suzanne remembers that her son suddenly started to come downstairs and sit with the family again. “It was as if he had been absent and he was saying ‘I’m back’,” she says.

Throughout his illness Sebastian’s parents did not see a GP as the family prefers to use a homoeopath. But they did pay for him to see a cranial osteopath at the Osteopathic Centre for Children in London, something that both Sebastian and his mother agree was of great help to him. Sebastian, 21, is now training to be an osteopath. “I have no doubts that the physical osteopathy helped him, as well as the fact that he found a sympathetic non-judgmental individual in whom to confide without fear of prejudice or recrimination.”

Sebastian also believes that in some ways the drugs were a help to him, despite the downers and the fact that he eventually became so dependent on them that he had to stop using them. “I think drugs were a good thing for me. They helped me to connect back with the world.”

‘I am a freak. I have never met anybody like me’
MEGAN’S first bout of depression came two years ago when she was 11 and about to leave primary school in Scotland. Her mother, Kate, noticed that she had become withdrawn and avoided communicating with anyone. On holiday with her mother, stepfather and younger sister she found no enjoyment in anything they did and complained of a litany of illnesses.

Each morning when she went to school, she would stand at the door, shaking and begging her mother to teach her at home. Megan found it so difficult to express herself that she wrote her mother a letter. In it, she confessed that she was “scared to go out, scared of crowds” because she thought someone might attack her. She also developed an obsessive compulsive disorder about cleanliness and would take a mop and disinfectant to wash her bedroom floor each day and arrange her ornaments in precise positions.

Kate’s attempts to get help for her daughter met with indifference at first. One GP told Megan to “pull herself together and the shaking will stop eventually”. What incensed Kate most was his remark that if she continued to refuse to go to school her mother “might go to prison”. “As someone who had been treated for depression before, I asked this doctor if he would have said that to me,” says Kate. “He looked at me, and I said: ‘No, you wouldn’t, because I am an adult and you would have taken it more seriously’.”

In desperation she turned to social services, who promised to have a team meeting about Megan and get back to her. She heard nothing. Eventually, after months of misery, she found a sympathetic GP who read Megan’s letter and gave her an urgent referral to a local adolescent mental health team, which arranged counselling. She now has counselling with a community paediatrician every two months, which has helped her enormously, as has using a light therapy unit. Kate says the school has been supportive, arranging for a taxi to to take her to school, bring her home at lunch time (she cannot cope with the crowds in the dining hall) and take her home at the end of the school day. At one point she was forced to take three months out of school.

The family is still unsure what has caused Megan’s depression. She had been deeply affected when at the age of 5 her beloved grandmother died. She still has contact with her natural father, but the relationship is an uneasy one since he is a heavy drinker.

Now 13, she still has days when the depression surfaces and she cries at the tiniest of things. She also has rituals – before she leaves home she turns round three times and puts a certain screensaver on her computer.

“Her words are: ‘I am a freak. I have never met anybody like me’,” says her mother. “But she has been incredibly brave. I was begging for help for a long time but there was nothing. I feel the more people who are aware of childhood depression the better."

‘It was sadness rather than madness’
RACHEL was 12 when she went on holiday abroad with her family and caught a virus which caused a severe stomach illness. As a result she had to take several weeks off school. When the time came for her to return, she found that she could no longer cope. Her mother, Christine, said it was like a switch being turned off. “A sparky, energetic little girl had become a frightened, timid little girl.” She began to have panic attacks, pulling out her own hair and hyperventilating. She had a constant fear that she was about to vomit and suffered prolonged black periods. When Christine took her to school she refused to get out of the car and would sit there weeping.

In all she took nearly two school years off – Year 8 to the end of Year 9 – and because of her refusal to attend, the educational welfare officer became involved (she told Rachel that her parents would be fined £2,000 if she didn’t return, which made her anxiety worse). Family counselling was arranged which Christine describes as disastrous.

Eventually she was referred to a child psychiatrist who hinted to Christine that “intelligent children didn’t get depression”. This was in 1991 (Rachel is now a 28-year-old schoolteacher) and Christine felt that there was a resistance to the very word.

“She was referred to the consultant paediatrician at our local hospital and she was very kind and understanding, but she still as good as said that our daughter was having a ’difficult puberty’. Our own GP was extremely kind and supported the whole family, but no one diagnosed depression – children didn’t get depressed, it seemed.” Rachel eventually returned to school and managed to get excellent GCSEs.

But at sixth form college the blackness descended again even more severely. At times her mother, frantic with worry but not knowing how to help, lost her temper. It is something she still feels guilty about. Her daughter told her: “It’s all right for you, you only feel the guilt. I feel the pain.”

“It is like being in a bubble,” says Rachel. “You can see everything around you but you can’t make any contact with anyone. It is complete isolation from the outside world.” This time a new GP accepted that she was depressed and prescribed antidepressants. Although the first type “almost drove her mad – she was banging her head on the bedroom floor” – the second type provided the breakthrough. Rachel has been taking medication ever since. It is a lifeline for her.

As a teacher she believes that the pressure of exams is a major factor in the rising depression rates. “I don’t think there should be this constant pressure of education,” she says. “And the media and TV programmes such as Friends don’t help with such a big focus on beautiful people and great clothes. It’s unrealistic.

“I understand it more now,” she says. “It was sadness rather than madness.”

‘We were just as lost as she was’
ABIGAIL’S parents thought she was having an extreme teenage phase when at 13 she began to withdraw from them, hiding under her duvet for days and putting on weight through comfort-eating chocolate. She seemed to have no self esteem and would suffer panic attacks. Yet when they saw their GP, “he diagnosed depression within five minutes”.

She was put on Prozac, which seemed to help. But as the years went by she also started to use alcohol and cannabis and began to self harm. In her early twenties her depression became so severe that she was considering taking lithium. “We really didn’t know our daughter at all. We were just as lost as her. You never think that this will happen to someone you love from a loving, comfortably-off family. We too felt like failures, especially when, after a family dinner, she tried to commit suicide with an overdose of sleeping pills.”

The family was told it was fifty-fifty whether she would survive. In the family room they read her will. She had asked for her body to be donated to medical science. Thankfully she came round, opening her eyes and saying: “What a f****** stupid thing to do”.

Abigal had suffered from enuresis (bed-wetting) since birth, which caused her a greal deal of anguish. The family believes this is partly the cause. “Common sense tells us that the natural chemicals in her body, which control enuresis and depression, didn’t happen in her metabolism,” says her mother.

The good news is that she is now nearly 30, happily married and with a new baby. “She, her husband and us treat clinical depression like any other long-term disease,” says her mother, “You manage it day-to-day, week-to-week, year-to-year.”

‘At times she has said that she must end it all’
CATHERINE’S parents first became aware of their daughter’s depression when she came downstairs one day at their home in Kent and told them that she had nearly thrown herself from her bedroom window. She was 10. It was the start of a long period of illness in which Catherine missed much of her last year at primary school.

At the local grammar school a few years later the blackness descended again. At the age of 15 her depression was taken seriously by a “fantastic” GP who prescribed antidepressants. However once she turned 16, her mother Nancy realised that one problem with young people and mental illness is that doctors become reluctant to talk to the parents. The children might go to their appointments, she says, but often present false impressions because of their illness.

“Unless you have held a kid all night who has said that life’s not worth living you can’t know what it’s like,” she says.

Catherine says: “One of my most acute memories of struggling with depression and suicidal thoughts was thinking: ‘I’ve only got to 15, there’s too much of my life to go to deal with this for ever’.

“I’d think about Virginia Woolf’s note saying ‘Not again’ . . . every time I got better I thought ‘I’m never going to be like that again’. I wasn’t mature enough to handle it rationally, so when it came back it was devastating.”

Catherine’s great-grandfather committed suicide after suffering from depression. But Catherine has now successfully completed university and is a 24-year-old drama teacher. She has recently completed a private course of cognitive behavioural therapy, which has helped her a great deal. Her mother feels angry, however, that she was not offered such help earlier and that it is only because they could afford to pay that she got it at all.

“A lot of people who are creative have this other side to them,” she says. “Maybe they are more sensitive than other people.”

“We love our daughter dearly and so enjoy her as she is a very caring, funny, kind person,” says Nancy. “That is one of the mysteries of modern life – that so many of the young people with depression whom I know come from very loving, stable homes where they have appropriate care and opportunities and where their strengths are appreciated.

“I was very touched at the doctor’s one day last year when he asked Anna what had actually stopped her taking an overdose and she gestured to me and said, ‘I suppose it’s these guys, I knew how much it would hurt them’.

“At other times she has said that she must end it all because she can’t keep putting us through the misery that she has. I keep telling her that not having her would be far worse than the worst times we have been through together and the joy of having her around, even when she is not 100 per cent, is fantastic, because she is lovely and we love her.”

 

[David Baxter PhD]

Comment:

On the other hand, Professor David Healy, a consultant psychiatrist at Cardiff University College of Medicine, answers with a direct “no” when asked if he thinks depression is growing among children.

Professor Healy believes that while some children undoubtedly suffer from the condition, others who 20 years ago might have been described as “anxious” or “phobic” are now classed as having depression. This is partly because the Diagnostic and Statistical Manual (DSM IV) on mental disorders – the international bible on medical illness and one of the tools used to diagnose – now encourages doctors to use a coding system to determine the illness, rather than their clinical judgment. Thus a child who displays more than five of the nine symptoms meets the criteria for depression. As Professor Healy says, a person with flu might also tick sufficient symptoms on the checklist “but to give someone with flu antidepressants would be nuts”.

“This is an issue of clinical judgment,” he argues. “We have moved into a world of rating scales and checklists.”

This is outright nonsense. Diagnosis, whether one uses DSM or ICD or some other method, is not a simple matter of checklists. It is a skill that requires both training and practice, and an integral part of the process is what is called "differential diagnosis", i.e., ruling out other possible diagnoses that might fit the specific individual symptom pattern.