childhood depression case study example

• About Steven: A children’s mental health case study about depression
• Courses and events

The About Steven case study is an interactive, web-based tool that helps professionals and would-be-professionals explore children’s mental health. 

The case study focuses on a young white family and their son Steven, from his infancy through adolescence.

This case study is currently offered to instructors and their staff and students in graduate and undergraduate level courses. It is designed to supplement existing course curricula.

By completing the About Steven case study, participants will:

Use research in making practice decisions regarding infant and early childhood mental health.

Examine the needs of children from an interdisciplinary perspective.

Think holistically about working with other providers to serve children.

Recognize the importance of prevention and early intervention in children’s mental health.

Apply ecological and developmental perspectives to children’s mental health.

Predict probable outcomes for children based on services they receive.

Currently, the About Steven case study is only available as part of an academic course. The About Steven case study is ideal for use within graduate course settings but can also be used in undergraduate course settings. It is designed to be used as a supplement to existing course curricula. This case study has been incorporated into courses and trainings related to:

Child welfare.

Nursing, psychology, public health, social work, psychiatry, medicine, and other disciplines.

This case study consists of 11 chapters. Each chapter includes case story content, questions, critical learning components, and links to research.

The way this case study is set up, people can either:

Read through and complete the activities fairly quickly.

Dive in more deeply to the research and resources.

The exact length of time for completion is a function of how much an individual user wishes to engage with the content they have access to.  Participants average 15-25 minutes per chapter. They generally take an average of 2-3 hours to complete the whole case study.

Evaluation data has been collected from instructors, trainers, and users for the past ten years.

Feedback from instructors and trainers

“We love this case because it provides information at each major stage and it allows the students to see the developmental progression, and explore the supports and risk factors”

“I really like the format. Nice way to look at the whole situation.”

“I am currently developing an education module for school nurses to increase their awareness of teenage depression and teach them how to use the PHQ-9 as a screening tool.”

“Everyone was really engaged in the discussion. It was fun to hear the discussion again this year with a really different group of fellows!”

Feedback from participants

“The real-life information presented in this seminar series was incredibly helpful when thinking about the mental health of young people. I appreciated that we focused on one aspect of public health, so we could really dig deep into it. Our discussions were engaging and thought-provoking.”

“Solid case study as a way to discuss depression in pediatric and adolescent populations. Appreciated the interdisciplinary approach.”

“[This module] has been one of the few opportunities where we have been able to have interdisciplinary conversations, where each of us brings to the table their own trainings”.

“Interdisciplinary research is critical to seeing the various players in the lives of young people; great to think about how each profession has a separate role.”

“Very applicable!  These are situations that I encounter in my clinical work regularly.  I found the discussion insightful for how to approach my practice in a new way.”

“[The course discussions] pushed me to think of framework of mental health in a new way.”

Cost and registration

Now available free.

Fees are now removed from this curriculum. To support the need for online learning, instructors, trainers and their students may use this curriculum free of charge.

The About Steven case study is only available as part of an academic course. 

To get started, the primary instructor for the course needs to register by clicking the "Register now" button below. Once you register for the course, you will have access to the case study for the length of the course(s) you list. Instructors should then direct their co-instructors, teaching assistants, and students to this page and invite them to register as well (they will need instructor name and course name to complete registration). Get tips  about integrating this case study with your course. You may use this form to  contact us  if you have any issues accessing the course. 

Questions or comments about this case study? Interested in using this case in a setting besides an academic course? Contact us .

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Center for Leadership Education in Maternal & Child Public Health

School of public health, children’s mental health case study about depression.

Those using the case studies will:

• Utilize research in making practice decisions
• Examine the needs of children from an interdisciplinary perspective
• Recognize the importance of prevention/early intervention in children’s mental health
• Apply ecological and developmental perspectives to children’s mental health
• Predict probable outcomes for children based on services they receive

Explore the case of Steven, a 15-year-old male with depression,  here .*

* Best using Safari , Mozilla Firefox , or Chrome .

Major Depressive Disorder in Children: A Case Study

• By: The DIG for Kids
• Time to read: 3 min.

As an affiliate, we earn from qualifying purchases including Amazon. We get commissions for purchases made through links in this post.

Depression can affect any of us, at any age or stage in our lives and can be triggered by a number of factors or events. Children are no exception to this and can suffer from depression in the same way as adults do. Feelings of hopelessness, anxiety, sadness and worthlessness can make children feel isolated, and it is important that they receive the help and support that they need.

Table of Contents

Behavioural Changes

Jane and Rob took their nine-year-old son Alex to see a psychiatrist when they became concerned about his behaviour during their divorce.

Alex had become irritable and developed behavioural difficulties, and his parents were very concerned about him, and how his behaviour would impact on his social and school life, as well as his life at home.

Although Jane and Rob were in the middle of a divorce, they had reached an amicable situation, and were both concerned about their son. Alex’s parents described him as a bright, pleasant and easygoing child who loved school, but when his parents separated, Alex began defying teachers and got involved in confrontations with other children.

Sleeping and Eating Difficulties

His work began to suffer, and he started having trouble sleeping, often waking up sometimes as much as four times in the night. He also became really fussy about what he ate, stopped playing football with his club, and lost interest in all his after school activities. For a previously outgoing, sociable and sports mad young boy, this behaviour was out of character and very worrying for Jane and Rob.

Medication Helped

After two months of therapy and help, Alex’s therapist recommended that he should be evaluated to see if a course of medication would help. The therapist came to this decision because Alex began to say things like “I wish I’d never been born,” “I’m stupid,” and “I hate myself.”

He also complained of stomach aches and headaches, which caused him to miss school. Alex’s GP found no cause for the physical complaints, but it transpired that two close relatives had suffered from depressive disorders.

When the therapist spoke to Alex, he was reluctant to answer too many questions, avoided eye contact, and appeared lethargic. He said his mood was about three out of 10, with 10 being the best he’d ever felt.

He said he had a death wish, but no true suicidal plan. He didn’t admit to a current desire for self-harming, but he had cut his wrists about two months before. The psychiatrist recommended continued individual and family therapy, and Alex was prescribed medication to help him sleep and enhance his mood.

Improvements and a Happier Child

At his six-week visit, Alex said his mood had improved to about five out of 10. He was sleeping better, and his parents noticed an improvement in their son’s mood and attitude, and he was also happy to go to school. The dose of his medication was increased and after 12 weeks, Alex rated his mood at eight out of 10. His school work was back on track, he was sleeping well and beginning to see his friends again. Alex was also planning to take part in a school residential.

Alex will see his psychiatrist every three to four months for the next 12 months.

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Patient Case Presentation

Figure 1.  Blue and silver stethoscope (Pixabay, N.D.)

Ms. S.W. is a 48-year-old white female who presented to an outpatient community mental health agency for evaluation of depressive symptoms. Over the past eight weeks she has experienced sad mood every day, which she describes as a feeling of hopelessness and emptiness. She also noticed other changes about herself, including decreased appetite, insomnia, fatigue, and poor ability to concentrate. The things that used to bring Ms. S.W. joy, such as gardening and listening to podcasts, are no longer bringing her the same happiness they used to. She became especially concerned as within the past two weeks she also started experiencing feelings of worthlessness, the perception that she is a burden to others, and fleeting thoughts of death/suicide.

Ms. S.W. acknowledges that she has numerous stressors in her life. She reports that her daughter’s grades have been steadily declining over the past two semesters and she is unsure if her daughter will be attending college anymore. Her relationship with her son is somewhat strained as she and his father are not on good terms and her son feels Ms. S.W. is at fault for this. She feels her career has been unfulfilling and though she’d like to go back to school, this isn’t possible given the family’s tight finances/the patient raising a family on a single income.

Ms. S.W. has experienced symptoms of depression previously, but she does not think the symptoms have ever been as severe as they are currently. She has taken antidepressants in the past and was generally adherent to them, but she believes that therapy was more helpful than the medications. She denies ever having history of manic or hypomanic episodes. She has been unable to connect to a mental health agency in several years due to lack of time and feeling that she could manage the symptoms on her own. She now feels that this is her last option and is looking for ongoing outpatient mental health treatment.

Past Medical History

• Hypertension, diagnosed at age 41

Past Surgical History

• Wisdom teeth extraction, age 22

Pertinent Family History

• Mother with history of Major Depressive Disorder, treated with antidepressants
• Maternal grandmother with history of Major Depressive Disorder, Generalized Anxiety Disorder
• Brother with history of suicide attempt and subsequent inpatient psychiatric hospitalization,
• Brother with history of Alcohol Use Disorder
• Father died from lung cancer (2012)

Pertinent Social History

• Works full-time as an enrollment specialist for Columbus City Schools since 2006
• Has two children, a daughter age 17 and a son age 14
• Divorced in 2015, currently single
• History of some emotional abuse and neglect from mother during childhood, otherwise denies history of trauma, including physical and sexual abuse
• Smoking 1/2 PPD of cigarettes
• Occasional alcohol use (approximately 1-2 glasses of wine 1-2 times weekly; patient had not had any alcohol consumption for the past year until two weeks ago)

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Constructing childhood depression: a qualitative study with international experts in child psychiatry

• Original Contribution
• Open access
• Published: 30 August 2023

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• Alexis Rayapoullé 1 , 2 ,
• Marine de Chassey 1 ,
• Laelia Benoit 1 , 3 ,
• Christine Hassler 1 &
• Bruno Falissard 1  

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After decades of controversy, the concept of childhood depression now seems to be part of standard medical knowledge. Yet the form and content of this nosological entity, like many psychiatric diseases, is continuously shaped by the scientific, clinical, and political communities involved in child psychiatry. In this qualitative study, we explored how the concept of childhood depression is constructed in early twenty-first century child psychiatry. We conducted a series of 18 interviews with practising child psychiatrists, international experts in the field, and interpreted them with thematic analysis informed by discourse analysis. We identified five overarching discourse themes across interviews, relating to the definition of depression, the diagnostic process, the causes of this condition, the therapeutic strategy, and the scientific role of child psychiatry. Most participants agreed that childhood depression was a mental disorder where irritability prevailed, heavily influenced by psychosocial factors, and for which psychotherapy was the ideal treatment. However, subtle points of dissent also surfaced: whether depression is primarily a mood state or psychological suffering, whether categories or dimensions are more suitable to make the diagnosis, and whether there is a genetic predisposition were some of the most controversial topics. Theoretical considerations regarding childhood depression may have significant scientific, moral, and socio-political implications beyond child psychiatry and should be addressed appropriately.

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Introduction

In 2021, the World Health Organization (WHO) considered depression to be a common illness all over the world, affecting 3.8% of the global population (280 million people in 2019) [ 1 ]. As such, the WHO qualified depression as the “ leading cause of disability worldwide .” Like all nosological entities, particularly psychiatric ones, the concept of depression has been described, defined, and used in many ways in the history of medicine. A popular belief is that words have true meanings attached to fixed objects and phenomena of reality. Yet, reality does not speak for itself; we humans attempt to arrange our perceptions of this reality with abstract words [ 2 ]. Scientific concepts are no exception: they have not designated and will not always designate the same phenomena, nor have they occupied or will they always occupy the same place within our body of knowledge. Our perspective in the following falls precisely within this constructivist approach: all scientific consensus is temporary, and the form and content of concepts are continuously shaped by the people using them [ 3 ].

The pathologisation of out-of-proportion fear and sadness goes back to Hippocrates with the concept of melancholia, although its properties (delusions, risk of mania and dementia when left untreated) could make it as much a precursor of modern depression as of schizophrenia and bipolar disorder [ 4 ]. In the early twentieth century, ‘depression’ overtook ‘melancholia’ and was conceived, in the psychoanalytic tradition, as a defence mechanism against anxiety neuroses [ 5 ]. In the 3rd edition of the Diagnostic and Statistical Manual (DSM-3) of the American Psychiatric Association (APA), all references to psychoanalysis were abandoned in favour of a claimed atheoretical classification of mental disorders. The concept of major depressive episode (MDE) entered the taxonomy as part of major affective disorders, markedly distinct from anxiety disorders [ 6 ]. A syndromic approach based on clinical symptoms was preferred to etiological speculations, in which dysphoric mood and/or loss of interest or pleasure in all or almost all usual activities and pastimes were—and still are—the chief characteristics. This clinical shift in the definition of depression was decisive to the current pre-eminence of this disorder among psychiatric illnesses. The recent epidemiological outburst of depressive conditions could be explained by an ever-increasing depressogenic environment to which human beings are maladapted [ 7 ], but some argue it is better explained by these changes in the criteria than changes in actual rates of depression [ 8 ].

Depression in children became conceivable in the second half of the twentieth century: another significant conceptual shift. René Spitz and Katherine Wolf coined the term “ anaclitic depression ” in 1946 to describe infants separated from their primary caregiver, whose behaviour was similar to adults diagnosed with depression [ 9 ]. Weinberg et al. seem to have been the first, in 1973, to describe depression in children aged 6–12 years, dominated by irritability and hyperactivity [ 10 ]. Before the 1970s, in Western psychiatry, most psychiatrists seemed to consider severe depression as impossible in children based on theoretical assumptions [ 11 ]. The epistemological shift introduced by the DSM-3 later created some space for children-specific criteria of MDE. In the latest version of the classification (DSM-5-TR), major depressive disorder (MDD) is still very similar to the clinical picture formerly labelled MDE, with the specification that in children and adolescents, depressed mood can be irritable mood [ 12 ]. Due to concerns about the potential overdiagnosis of bipolar disorders in children, another depressive disorder was created in the DSM-5 and restricted to children 6–18 years: disruptive mood dysregulation disorder (DMDD), in which temper outbursts, irritability, and anger are also the dominant characteristics [ 12 , 13 ]. All in all, persistent and pervasive sadness of mood, loss of interest in activities previously enjoyable, boredom, tearfulness, difficulty concentrating, feeling worthless, feeling fatigued, changes in weight and appetite, school-related difficulties (academic decline, school refusal), temper tantrums, and irritability make, at the present day, the typical childhood depressive syndrome in the biomedical scientific literature [ 14 ]. Based on these criteria, the prevalence of prepubertal depression is estimated at 1–2%, an onset before 9 years old appears highly improbable (although the incidence seems to increase and the age of onset to decrease with time), and an episode lasts on average 7–9 months with a remission up to 90% at 1.5–2 years, but a recurrence of the disorder up to 40% at 2 years and 70% at 5 years [ 15 ].

In short, both concepts of depression and childhood depression seem to have been relatively unstable and changing over the past decades. It is an excellent opportunity for us to study the ‘science in action’ as sociologist Bruno Latour once wrote [ 16 ]. Manuals and scientific articles are worthy study materials to explore the history of ideas and research programmes, but interviews with prominent researchers and clinicians is a better way to identify the present doubts, motivations, and certainties that will make the future of psychiatry, before the ‘black box’ closes and knowledge is stabilised. How do contemporaneous experts of child psychiatry use, define, and understand the concept of childhood depression? And what are the implications of such instability? Reflecting on the pertinence of psychiatric nosological categories was at the core of the atheoretical ambition promoted by the DSM-3 authors, who viewed their classification as temporary hypotheses to be revised. In this study, we propose to carry on this endeavour with the use of qualitative methods of investigation. Our goal is to assess the rationale underlying the use of childhood depression as a mental disorder category, to help guide its refinements and future developments.

Materials and methods

Our study consists of an analysis of interviews with experts in the field of child mental health. The research team was made of five members of a research unit with expertise in the analysis of social and cultural determinants of mental health, three of whom are psychiatrists. The core analysis and writing were performed by physicians trained in public health, social sciences, and philosophy. Thus, the background of the team led to an international design with a constructivist perspective. The impact of culture, epistemology, and professional practices was a specific focus for this research, hence the use of thematic analysis informed by discourse analysis. Debriefing was held on a regular basis with an outside group of researchers in social sciences (Grounded Lab) to ensure good reflexivity on our part, in addition to the methodological rigour we applied ourselves.

Using contacts provided by the International Association for Child and Adolescent Psychiatry and Allied Professions (IACAPAP) [ 17 ], two researchers (BF, MDC) selected 18 child psychiatrists in an attempt to have the broadest spectrum of location, age, gender, and epistemology (which aspects of the biopsychosocial framework of their discipline seemed the most meaningful to them: biology, social sciences, psychology) based on their clinical, scientific, and academic activities (including research topics and preferential activities in professional societies such as the IACAPAP). With this method, we tried and collected as many different perspectives as possible from socially and scientifically recognised experts. All contacted experts agreed to participate.

The interviews were conducted in 2020 by MDC alone by videoconference (except for one, face to face) and lasted 30–65 min, following a semi-structured guide. Sensitising questions addressed the following topics: the existence and definition of childhood depression, its differences with adult and adolescent depression, the pertinence of the DSM criteria to define the disorder, the clinical signs leading to a diagnosis of childhood depression, the usefulness of scales for practice and/or research, the meaning of somatic complaints, their potential encounter with suicidal children, their preferred treatments, the perceived risk factors and comorbidities, the truth and impact of genetic predisposition, and the relationship between child depression and subsequent psychopathology (see Supplementary materials). All the interviews were recorded with the participants’ consent and transcribed by MDC. In the end, the sample included 6 women and 13 men; their ages ranged from 45 to 78, with a mean of 58.2 years (SD = 10.4). Seven were conducted in French, MDC’s mother tongue, and 11 were conducted in English (among which 6 were with non-native speakers). Quotes that were originally in French were translated into English and are marked by an asterisk (*). The participants practised in Europe ( n  = 7) (two in France, one in Iceland, UK, Croatia, Spain, and Germany), North America ( n  = 4) (two in the USA, one in Canada and Mexico), Africa ( n  = 3) (Tunisia, Morocco, Egypt), Asia ( n  = 2) (Singapore, Japan), South America ( n  = 1) (Chile), and Oceania ( n  = 1) (Australia). It should be specified that not all of them were born in or were citizens of the country they practised in, nor were they necessarily trained there. All of them produced academic work and had clinical activities.

Two researchers (AR, CH) analysed the transcripts in 2022–2023, using a qualitative analysis software (NVivo) to conduct a thematic analysis informed by discourse analysis [ 18 ]. A primary coding of each interview was performed (following the chronological order) and revealed that data sufficiency had been reached after interview #15. After confirming that interviews #16 to #18 appeared to overlap with earlier ones, the research team decided not to resume recruitment and carry on with the transversal analysis. AR and CH then independently formulated themes and labels following an inductive process, a constructivist epistemology and an interpretative framework. AR and CH then confronted their findings and agreed upon a tree map of nodes for analysis. Both researchers coded three interview transcripts separately to triangulate the themes induced from the data and ensure that the attribution of quotes to nodes was sufficiently similar. This process led to a minor revision of the tree map. AR coded the rest of the interviews and performed the transversal analysis, i.e. the main ideas brought up by participants, if they were unanimous or divided, if they could be linked to some sociodemographic elements, and if they were related to and/or redundant with other themes and subthemes. The entire research team discussed the overall themes, and all co-authors contributed to the final manuscript.

We will present the results in five themes and their subthemes (see Fig.  1 ): (1) what makes ‘childhood depression’ depression (mood, affect, emotion/psychological suffering); (2) how to make a diagnosis in child psychiatry (category, dimension, and development/the time factor); (3) why childhood depression happens (environment/biology); (4) how to deal with childhood depression (medication/psychotherapy/social care); and (5) child psychiatry: a rising speciality (institutionalisation/scientific paradigm).

Final tree map of nodes: 5 themes (left) and 11 subthemes (right)

What makes ‘childhood depression’ depression

Our interviewees almost unanimously considered childhood depression as a mental disorder affecting the mood. But whether the mood itself was the core of the definition or a consequence of a particular psychological state seemed to vary among participants.

Mood, affect, and emotion

Many participants considered the emotions felt by children as the central item to the definition of a depressive episode. They agreed that “ low mood ” (P5, P6, P7, P10, P14), “ depressed mood ” (P7, P11, P13, P18), or “ sadness ” (P1, P2, P3, P4, P5, P6, P7, P8, P9, P12, P15, P16) were central definitional items in adult depression, but also agreed to claim that it was largely optional in the case of children, with irritability and anger being the primary affects. One participant even said that sadness and low mood were beyond optional: they are arguments against childhood depression.

When I witness an obvious case of sadness with some psychomotor retardation and suicidal ideation, I am suspicious. It’s a child who borrows from the adult depressive repertoire. I am against diagnosing a child that easily. (P15*)

For this participant, a child who displays obvious sadness instead of irritability might be mimicking adults surrounding them, meaning that they are might appear depressed but are not authentically depressed.

What usually distinguishes mood from emotion is its duration and stability, contrary to the transience and instantaneity of the latter [ 19 ]. In adults, ‘depressed mood’ or ‘low mood’ is considered a state of profound and permanent sadness with loss of interest and pleasure [ 20 ]. But interviewees also insisted on the lability of mood in children in general, including those diagnosed with depression.

They might be very very depressed and the next minute we might get them involved in doing something and then they turn back to being depressed. They are very ‘here and now’ creatures. (P6)

These views negate the fundamental link between sadness/anhedonia and depression as defined in adults. Some participants were therefore led to hold childhood depression as a specific paediatric disease, qualitatively distinct from adult depression. For instance, Participant 9 developed three arguments in favour of childhood depression being a specific and separate disease: a balanced sex ratio up until adolescence, the inexistence of psychotic forms of depression before puberty, and a poor response to pharmaceutical treatments. With these viewpoints, the link between childhood depression and depression becomes blurry at best, if not meaningless, thus questioning if childhood depression should be called ‘depression’ at all. One participant did draw a similar conclusion:

Yes, a child will be abused. Yes, a child will not do well. Yes, they will be agitated instead of sad. All that is true. But is it depression? (P1*)

This participant argued that individuals organise their mental life in accordance with concepts they have acquired in the past. In adults, it would be structured around the notion of ‘loss’ and result in depressive disorders (major depression, dysthymia, etc.). In children, the psychological reaction (here because of past trauma, see theme #3 ‘why childhood depression happens’) would be different because the structure of their mind is not the same, resulting in a different mood state and behaviour (irritability). With this perspective, depression would not be a clinical picture, but a precise psychopathological reaction. Participant 1 claimed he was therefore “ embarrassed ” to call these psychological phenomena in children ‘depression’ if they were “ phenomenologically different .”

Psychological suffering

Participant 1 was the only psychiatrist showing scepticism about the similar nature of psychological mechanisms between depressed adults and children. Most participants considered that depression existed in children and adults, leaving the clinical variations only to how depression is expressed.

Although participants agreed on the clinical picture, several distinguished a definition of depression based on mood and emotions from a psychological definition based on the subjective interpretation and meaning one person attributes to their experiences. As such, Participant 15 taught his students to separate the “ clinical discussion ” (a syndromic approach based on the mood) and the “ psychopathological discussion ” to address the possible meaning and function of depression in the child’s life.

Let’s think of this more broadly than just as a disease condition, let’s think of this as a feature of the way life seems to this person right now. (P12)

These participants mainly defined depression as an intellectual experience of suffering. Participant 12 avoided labelling children with the diagnosis of ‘depression’ and would instead use what he termed an “ empathic diagnosis ”: a statement co-constructed with the child about what they feel and think of themselves and the world, such as “ you feel like there’s nothing you can do to change your life ,” “ you feel like your life is not good ,” “ you feel that nobody understands what’s going on .” Other participants phrased similar statements capturing low self-esteem and feelings of injustice (P8, P9, P16). Participants considered that the emotional and behavioural expression of depression varied following the child’s age due to young children’s presumed limited verbalisation capacities.

It’s a mood disorder and there are some differences because it depends on the age of the child: they cannot express in words what they are living or what they are feeling so maybe, it is more of a behaviour thing than in other ages. (P13)

Aware of this variability in the presentation of depression in children, the participants insisted on the importance of a developmental perspective on psychiatric disorders.

How to make a diagnosis in child psychiatry

Diagnosis is both a category and a process [ 21 ]. This section focuses on diagnosis as a process, i.e. how participants applied the label of childhood depression.

Category, dimension, and development

Most of our participants heavily criticised the diagnostic criteria of major depressive disorder as established in the DSM-5. For some participants, the problem was its categorical approach; they felt a dimensional one would be more suitable, i.e. that there is no qualitative difference between normal and disordered, only a difference in intensity of symptoms (see Discussion). In a way, they reconnected with the psychoanalytic view of mental disorders, in which depression and neuroses in general were continuous dimensions. They did not, however, necessarily re-engage with the content of these theories.

Childhood depression would be, in my opinion, more dimensional, let’s say, than a clear-cut nosographic picture as we see in adults. (P15*)

Most participants, however, considered the categorical approach to mental disorders adequate for child psychiatry. The DSM-5 appeared to be a disappointing clinical tool because of the content of the categories, not because of the approach itself. The mention of irritable mood potentially replacing depressive mood is, in this perspective, a step forward in the conception of a child-specific clinical picture. In that respect, they wished for refined categories matching children’s developmental stages.

You have to admit that the criteria are beginning to show some developmental differentiation. But for now, the risk is that one might use the adult criteria without knowing these fundamental developmental notions. (P16*)

Finally, one participant made an explicit difference between the lay sense of the word ‘depression’, perhaps blurrier and more continuous with normal states, and the clear-cut syndromic approach in the medical sense.

[Depression is] the term that now everyone knows because they didn’t succeed at an exam or they didn’t succeed at the sports game; they are ‘depressed,’ but it’s not like the clinical depression. (P5)

Making sense of diagnostic criteria: the time factor

Participants massively advocated for what we could call a longitudinal diagnostic process over a transversal one. They considered that the chief alert was not so much a state, like a bored or an irritable child, but a rupture in time: a previously energetic and vivacious child who would lose interest in life. “ Change ” was the keyword to describe this diagnostic process (P7, P8, P9, P15, P16, P18).

You have to look for a change compared to the previous state because some children have always had… Parents tell me, ‘He has always had this look. He has never been a very social or funny kid.’ (P8*)

Incorporating a time factor in the diagnostic process gives parents a particular role that clinicians alone cannot fill. Many participants considered the parents as keen observers of their child, almost like whistleblowers (P2, P3, P4, P5, P6, P8, P12, P15, P19).

First of all, I think you have to trust parents when they come in and they say, ‘There’s something wrong with my child.’ That’s the starting point. Because parents are, for the most part, very good observers of their children. (P3)

Why childhood depression happens

This section will expose all the elements in our participants’ discourses regarding the various factors leading to childhood depression. No participant claimed that there was one unique and identifiable cause of this condition. All participants mentioned many underlying, triggering, and aggravating factors, never sufficient nor necessary by themselves, and integrated those within a biopsychosocial-like model of depression. Yet, they did not all give the same weight to the bio-, psycho-, and social components in their understanding of this phenomenon. In particular, genetics seemed to be a point of controversy.

Environment: culture, society, and life events

Many words used by our interviewees positioned the causes of childhood depression as external to the child: “ environmental ,” “ psychosocial ,” “ socio-cultural aspects ,” “ family structures ,” “ social stability ,” “ trauma ,” “ loss ,” “ reaction to the world ,” “ situational ”, and “ life story .”* One participant even used the term “ psychopathology of the environment ” to emphasise how much the social environment matters to a child’s mental health.

We sorted these environmental factors into three categories. The first refers to structural social factors: poverty, social adversity, socio-cultural challenges, and academic pressure (P2, P3, P13). In particular, participants from North African countries (Tunisia and Morocco) stressed that school systems in their countries caused significant psychological harm to young children. One participant even referred to “ school terrorism ” to describe the violence schools exerted on children.

An important risk factor: school pressure is a sort of school terrorism exerted on children.*

Psychiatrists from North African countries stressed that undue academic pressure and interpersonal challenges such as bullying could induce suicidal ideations in children as young as 7 years old, and that suicide attempts in children aged 6–12 years had increased in the last five years. One participant mentioned that the recent political history in North African countries has led to considering suicide as empowering, because it can be seen as heroic and socially desirable, counteracting feelings of worthlessness often associated with such mental states.

Death is seen as a solution. It is glamourised in this very particular economic context. In Tunisia, we have been since 2011 in an era we qualify as ‘post-revolutionary.’ Many adults have committed suicide, thankfully fewer now. But every time there is a problem, or someone sees an obstacle along the way, they threaten to set themselves on fire in the street.*

The second type of external factors we have identified is significant life traumas (P1, P4, P5, P6, P8, P13, P14, P16, P17). These included physical, emotional, and sexual abuse, neglect, domestic violence, and bullying. According to participants, such painful events could throw off balance a child’s mental stability. But our interviewees also framed other life events as potentially traumatising: bereavement, parental divorce, problematic family interactions (e.g. parental depression), and academic struggle were considered triggers for child depression.

Of course life events, we all know, would have an important role to play. More and more we are seeing adverse childhood experiences, childhood trauma, traumatic events for attachment relationships, current relational issues, break-up in relationships whether it’s family relationships or whether it’s, you know, boyfriend-girlfriend relationships: any break or loss of any kind would all be considered as factors. (P17).

The third environmental factor we identified was the social response to other disorders. Participants framed the environment’s reaction to comorbidities—namely, stigma affecting the child’s self-esteem—as a risk factor for depression. Participants described chronic somatic diseases as negatively impacting family bonds.

With these children, there is a chronic problem coming from the—we say ‘physical’, although I don’t like separating [from mental]—disease, and it is always pretty tough for families. It’s a public hospital, they are poor people with a long-term [comorbid] medical problem, and these people have a lot of difficulties going through this. So depression is almost a logical consequence. (P2*)

Anxiety, attention-deficit hyperactivity disorder (ADHD), learning disabilities, developmental language disorders, and obsessive–compulsive disorders were described as distressful in a maladapted school system once children became aware of their academic difficulties. Children with autism, whose interactional challenges are not considered in school settings, were said to experience isolation. As these children had several issues entangled with one another, participants struggled to address them separately.

What we do have is a combination of things, so we have plenty of children that have ADHD and depressive features or some conduct disorders that have some depressive features, but it’s very rare that we get just a depressed case. (P4)

Some participants mentioned the conceptual difficulties of distinguishing ‘pure’ or ‘isolated’ depression (without any external cause) from a depression triggered by a psychosocial experience, thus highlighting how debates on causes and definitions of disorders are fundamentally linked (P2, P5). But others did not seem to consider depression as less ‘real’ when it was solely induced by psychosocial events (P7, P11).

Children from age 10 to 12 come and say, ‘I’m depressed,’ but don’t have emotional support in their families; it’s not like a real depression. (P5) It is definitely a comorbid disorder, and the other disorder is the major disorder. So obviously, major depression is a common comorbid disorder. (P11)

These quotes show how participants can have differing views on what it takes to have a true depression. Participant 5 considered that lack of family support (a legitimate psychosocial cause for many other participants) was not enough to cause a “ real depression ,” whilst for Participant 11, the negative psychosocial impact of other disorder was compatible with depression as a rightful comorbid disorder, not just as a figure of speech.

All participants mentioned anxiety as closely linked to depression. Our interviewees expressed various opinions: anxiety and depression as distinct and exclusive disorders, as separate but frequently co-occurring in a common anxiodepressive syndrome, and anxiety as a cause of depression through emotional exhaustion. Several of them interpreted somatic complaints as anxiety consequences rather than depressive equivalents (P9, P11, P13, P15).

The somatic complaints, I wouldn’t immediately associate them with childhood depression. […] I see them more in relationship to anxiety disorders. Obviously, anxiety disorders can also be associated with, so it could be comorbid depression. But the somatic complaints would most likely tend to be associated more with the anxiety disorder than the depression itself. (P11)

In adults, the differential diagnosis between depression and anxiety is a well-known challenge [ 22 ]. But more specific to children, and due to irritability being the main agreed-upon symptom of childhood depression, participants also mentioned the challenge of differential diagnosis between depression and ADHD. Are they exclusive? Does ADHD cause depression? And if so, how do we diagnose the latter?

Many children have these acting-out reactions because of the irritability, and we have to make assessment whether it’s a behavioural disorder or a depression. But children with depression usually feel guilty when they act out aggressively. So that’s how we distinguish depression from ADHD. (P5)

Conjunctions of adverse life events and social hardship remained at the forefront of participants’ understanding of children’s mental health. This led several participants to consider childhood depression as a fundamentally reactive disorder, meaning that environmental factors have more impact on childhood depression than on adult depression.

Biology: brain and genes

Participants also made use of a biomedical vocabulary when describing childhood depression: “ neurobiological ,” “ genetic predisposition ” or “ load ,” “ genetically based mood disorder ,” “ family history ,” “ biological determination ,” “ neurohormonal ,” and “ familial genetic structure .”* Almost all interviewees acknowledged biological causes of depression, while still downplaying their relevance (P1, P2, P4, P5, P6, P8, P10, P11, P12, P13, P14, P17, P18). Most of them considered that the biomedical model of depression was epistemologically weak.

Genetics is a small component; the bigger one is the psychological factors. (P10)

A minority still held dominant biological explanations. One participant, prompted by his work on hormonal causes of childhood depression, believed there might be different subtypes of depressive disorders with different aetiologies (P11). Another participant considered biology as the leading cause of depression and environment as contingent (P3).

There are environmental factors that play a role in mood disorders. I suspect they may not account for a huge portion of the aetiology, but they certainly can count for a huge portion of the aggravating factor. (P3)

While no participant rejected the idea of an environmental influence on the onset of depressive disorders, some entirely denied genetic factors any explanatory power for childhood depression (P7, P9, P15, P18).

I don’t believe it [genetic predisposition to childhood depression] one bit. I find it totally absurd. Data absolutely do not go this way. We are just saying that psychiatric conditions have something to do with brain development, which we already know. So, I am very cautious. (P9*)

In sum, all the participants agreed that childhood depression is more rooted in environmental issues and adverse childhood experiences than adult depression, whether they framed depression more as a biomedical or a psychosocial condition. Disagreements revolved around the status of biology and genes as significant causal factors of childhood depression. Whereas this argument does not seem to have much consequences in terms of treatment strategy (see theme #4: how to deal with childhood depression), it has a lot of consequences on how parents are perceived by clinicians. They can be made powerless or responsible according to how we attribute the cause of the disorder.

It’s not parents who cause it. And I think we need to stay away from, when we do diagnoses and we talk about treatments, we need to be very careful to not blame anybody, because I think that’s just not very helpful in the process of treatment and recovery. (P3) [I say to the parents] “ they’re hurt, look, it’s normal! They hear you yell at each other, they sometimes hear shouting and are afraid for themselves ”. […] Just saying “ stop messing around ” [to the parents,] they understand 3 out of 4 times. (P1*)

How to deal with childhood depression

Discourses on the treatment of childhood depression were the most homogenous among all participants.

All participants considered medication as a symptomatic treatment, never sufficient on its own, and unable to address the cause of depression. Two participants (P3, P17) mentioned using medication as a first-line treatment alongside psychotherapy. But most participants (P4, P6, P7, P10, P11, P14, P15, P16) referred to medication as a second-line option after failure of psychotherapy. Fluoxetine was by far the preferred medication, but sertraline was also brought up on a regular basis. Escitalopram, aripiprazole, and tricyclics were occasionally mentioned to handle specific situations.

After three or four weeks [of psychotherapy], we would start with an antidepressant. For children, basically, almost always fluoxetine. (P11)

Participants who did not systematically prescribe medication provided insight into what would make them consider pharmaceutical treatment. Most stated that severe depression with suicidal ideation or behaviour would lead them to immediately prescribe medication (P2, P3, P4, P6, P8, P9, P13, P14, P18). Three participants used the anxiolytic effects of SSRIs to treat impairing co-occurring anxiety symptoms (P1, P14, P15). One participant initiated an antidepressant medication when the clinical assessment concluded that the child was at risk for a severe episode: if the depression had started long ago, if there was a family history of depressive disorders, and if the symptoms were numerous (P12).

For all the depression disorders, the important is psychotherapy, and this psychotherapy must involve the family and also the school in most of the times. But for severe, it’s also important to include antidepressants. (P13)

The FDA authorisation for fluoxetine to treat childhood depression is based on evidence for children above 8 years. When asked about it, four participants excluded prescribing any medication for children under 8 years old, either to avoid using a psychoactive substance on a yet developing brain without enough evidence, or simply because they found it unnecessary (P2, P4, P6, P8).

MDC*: Recommendations speak of fluoxetine above 8 years old. Below 8, do you sometimes prescribe? P8*: Never. I think there is not enough evidence or clinical trials. It is still a developing brain.

An interesting feature of the participants’ discourse about treatment was how family preferences were essential in deciding whether to prescribe medicine (P5, P9, P14, P19). Participants stressed the importance of a good therapeutic alliance and considered parents’ views on pharmaceutical treatment as rooted in cultural aspects. One participant described parents as afraid of the effect of psychotropic medication on their child’s brain development (P14). Elsewhere, depriving a child of a drug was like prolonging their suffering and wasting the time needed to grow up healthy (P18).

Some parents get very alarmed because the child feels very tired and drowsy because whenever they are given psychotropic medicine, at least in [my country], they think it’s working on the brain and the brain is very important for studying. (P14) There are many cultural things in this. What a family [of my nationality] would like is categorically refused by a family in [my country of practice]. Actually, and in contrast, families [here] want the pharmaceutical treatment because they consider that depriving the child of treatment is to make them suffer for no reason, and to waste their precious development time. Whereas in [my country of origin], it is the opposite. [There], we consider that we have to avoid medication at any cost, that it is toxic for the development of the nervous system, and delay and avoid as much as possible. So, in my practice, I do like [people here] because I am [here]. (P18*)

Lastly, some participants thought that fluoxetine was probably inefficient. This, however, did not prevent them from prescribing medication in specific contexts. They seemed to consider drug therapy as useless but not deleterious.

Patients with childhood depression often do not respond to drug therapy. (P7)

Psychotherapy

Contrary to medication, which was considered a symptomatic treatment by all participants and often limited to the most urgent and severe cases, psychotherapy was unanimously designated as the gold-standard treatment of childhood depression.

The technique of choice, however, varied greatly among interviewees and was often very eclectic within interviews. Cognitive behavioural therapy (CBT) was the most cited psychotherapeutic approach (P3, P4, P5, P6, P7, P8, P10, P11, P12, P13, P14, P15, P16, P17) and the preferred one for these psychiatrists, except for two participants. The second most cited approach was family therapy (P5, P8, P11, P13, P14, P18). Psychodynamic therapy was promoted by three participants (P6, P8, P14), and could be their first-line choice in specific situations (for children under 6 years old or with a history of trauma and abuse). Group therapy was also mentioned as producing good results (P5, P19), although sometimes prompted by the material impossibility of performing individual therapy. Other types of therapies were art therapy (P8, P11), psychoeducation (P7, P11), applied behaviour analysis (P7), recreational therapy (P10), animal-assisted therapy (P10), and talking therapy (P11, P12).

Two participants (P1, P9) stepped out of this discussion about the best psychotherapeutic approaches because they were not convinced that the technique mattered; or if it did, much less than the quality of the human relationship between a therapist and their patient.

When a child sees a shrink, it’s not because the professional is labelled ‘psychoanalyst’ or ‘behaviourist’ that it’s in any way meaningful to them. The child comes to see an adult who cares about them, who asks them questions, and who wants to help them. In the end, even an ignorant can help a depressed child. (P9*)

Participants’ discourses revealed what they considered to be the ideal care for depressed children. But most interviewees mentioned the gap between theory and practice, as the economic system in which they work constrains the quality of care: a lack of trained psychotherapists, too few practitioners to maintain an optimal follow-up frequency, not enough consultation time (P1, P2, P3, P5, P6, P7, P13, P15, P16, P18). Such economic constraints led them to rely on sub-optimal psychotherapy techniques, interspaced follow-ups, and in the end, to increase the use of medication.

Unfortunately, most cases do not have immediate access to the type of psychological therapies we want. So the question is: should we initiate medication even if the guidelines clearly say that medication should be used in combination with psychological treatments? (P16*)

In sum, all participants claimed psychotherapy was the first-line and ideal treatment. CBT appeared widely favoured, but many interviewees had an eclectic approach, motivated either by theoretical pluralism or by practical constraints. Family therapy, for one, seemed relatively popular.

Social care

Some participants called for an action that, in our analysis, goes beyond psychological care and could be referred to as social care (P2, P5, P7, P9, P11, P15). Their primary motivation was considering the child’s environment a significant lever to alleviate their suffering.

When the family was thought to be dysfunctional at worst and overwhelmed at best, some interviewees suggested groups of discussion, information, and guidance with parents. One participant even saw hospitalisation as a form of exfiltration from an inadequate domestic environment (P11).

We remove the kids from home for one, which is a major intervention. Then we provide the kids with a daily structure which they commonly did not have prior to coming into the unit. (P11)

If school was perceived as the main problematic environment for the child, like cases of bullying or tremendous academic pressure, participants advocated working with teachers and suggesting school arrangements (P7, P9, P15). One participant involved social welfare services (P5) for a more comprehensive approach. For most of these participants, these forms of social care were complementary, perhaps secondary, to the aforementioned pharmaceutical and psychological treatments. One participant however, made it clear that improving the environment was the primary treatment for childhood depression.

When choosing treatment, I mainly adjust environment for childhood depression. (P7)

In sum, although most participants recognised the importance of environmental factors as triggers or aggravators of childhood depression, only a few claimed to act directly upon this environment. Perhaps they believed it was beyond their mission as physicians, or out of their control, or that these environmental factors were past events and not ongoing situations.

Child psychiatry: a rising speciality

This last result section highlights how the participants viewed their professional role and scientific knowledge in a larger health-care ecosystem, beyond childhood depression.

A speciality in its early institutionalisation within the medical world

Participants from different geographic areas shared how their medical education had been based on adult psychiatry, and how child and adolescent psychiatry had only recently become an independent speciality (P2, P8, P13, P18).

We have just started, two years ago, a training programme for residents. Child psychiatry becomes, for residents, a medical speciality in its own right, ‘independent’ if I may say so, which means we no longer depend on adult psychiatry to train residents. (P18*)

Child psychiatry’s scientific paradigm: development

The notion of development was already explored to analyse its impact on how our participants theorise and classify mental disorders. It surfaced again here as a way to unify child psychiatry with adult psychiatry while maintaining its specificity. Participant 16, for instance, explicitly promoted the developmental paradigm as a key research programme for academic child psychiatry.

I think we have to push more as an academic child psychiatry unit to really show the differences relating to development. (P16*)

With these developmental goggles, depression is thought to be a continuous disease—despite various expressions—between children, adolescent, and adults. Yet, scrutiny of some participants’ discourse showed that this continuity was often considered due to a persistence of the psychosocial causes (a deleterious environment) rather than an inner vulnerability to depressive disorders (P5, P6).

There is a continuation, particularly if the psychosocial situation is continuous, such as parental discord, abusive family, or domestic violence. If the psychopathology of the environment continues, I think you don’t have much chance not to continue with your psychopathology. (P6)

Some participants even doubted that there was such continuity between child depression and adult depression (P1, P10, P15).

MDC*: Do you think that depression in a child can lead to a psychological vulnerability at adult age? P15*: Not particularly. I even think it can be maturing. I here go back to my initial psychodynamic training: I think it’s healthy to have losses and do restructuring and arrangements. So I believe it is maturing in many cases and not necessarily harmful.

The concept of development holds together what happens in children and adults, but it seems to limit the pertinence of a unique nosological concept to capture both phenomena.

The first question of our interview grid was always: “ Does childhood depression exist? ” The answer was invariably “ yes ” among our interviewees, often accompanied by an adverb picked in the lexical field of certainty and assertiveness (definitely, of course, obviously, sure). We chose not to put this in the results because we argue that it is no outcome but rather the starting point of our study.

We were cautious not to systematically attribute an ontological meaning to sentences like ‘childhood depression exists.’ In some interviews, it did unambiguously reflect a position rooted in scientific realism. Others were not so easy to map on the realism/antirealism debate. Whether depression exists as an entity of the material world is a continuing and open question for philosophers, to which neither our interviewees nor us can pretend to answer, and certainly not with this study design. Whether there is a phenomenon that our interviewees, the medical institution, and most lay people come to understand as childhood depression is, on the contrary, rather obvious. In that sense, we claim that our interviewees saying ‘yes’ to that first question is not an outcome, nor a metaphysical statement, but the very reason why conducting this study is relevant.

‘Illness’ is the preferred term to describe the subjective and concrete reality of the experience of suffering. ‘Disease’ relates to the abstract medical category, and its status regarding reality is subject to more debate. But doubts about the ontological reality of disease should not obliterate its more tangible social reality. Disease exists inasmuch as the concept produces an effect on society, i.e. what people are willing to do in the name of it (creating institutions, seeking help and care, demanding retribution, defining one’s identity, etc.) [ 23 ]. So, ‘definitely,’ ‘of course,’ ‘obviously,’ and ‘for sure’ childhood depression exists in this minimal interpretation. It is precisely because it exists in that social sense, and because one distinctive feature of social reality is that the discourses about this reality shapes it, that child psychiatrists’ understanding of this concept is of interest [ 23 ].

Defining childhood depression

The emergence and critique of the concept of childhood depression were both born in the 1970s. Leon Cytryn and Donald H. McKnew decided to use the term ‘depression’ in 1972 to describe hospitalised children whose mental states appeared, in their opinion, similar to adults with depressive neurosis [ 24 ]. They proposed a classification with three subtypes: masked depressive reaction of childhood, acute depressive reaction of childhood, and chronic depressive reaction of childhood.

The link between childhood depression and adult depression was back then rooted in psychoanalytic theory. Although this paradigm is nowadays widely criticised among psychiatrists, three notable features of Cytryn and McKnew’s descriptions seem to live on: the fact that childhood depression is a reaction, that all acute depressive reactions in children are caused by the trauma of loss (death, remarriage, new sibling, moving out, etc.), and that anger is found in all three subtypes. Critiques came shortly after, as Monroe M. Lefkowitz and Nancy Burton wrote in 1978 that “ almost any behavior that is disturbing enough to prod parents into referring a child for professional help may earn for a child a label of depressed ” and that “ if the notions of masked depression and depressive equivalents are considered in the diagnosis, childhood depression reaches a state of omnipresence ” [ 25 ] (p. 717).

Of note, when asked about childhood depression, many participants spoke indistinctively of children and adolescents, in opposition to adults. Others spontaneously made a distinction between children and adolescents, but the tipping point was always unclear. When age was brought up, the transition from childhood to adolescence was estimated around 11–13 years old.

The limitation between children and adolescents is blurry because professionals considered them in one continuous dimension: development, at the core of child psychiatry thinking. Child psychiatry is a speciality still searching for its proper place within medicine’s professional and scientific structure. Its tenants are in a delicate equilibrium, having to differentiate it from other medical and nonmedical disciplines and insert it into a common and comprehensive knowledge of mental illness. We contend that the developmental paradigm has a ‘same but different’ explanatory power. It enables the comprehension of a mental disorder as being the same disease across age groups, with a different phenotype following the developmental stage. As such, this paradigm makes rigid age categories irrelevant. Nonetheless, we have seen that it is compatible with both categorical and dimensional approaches to diagnosis. Much like culture in the recent history of psychiatry, it is useful to theorise the unicity of disorders (disease) along with the multiplicity of their expressions (illness). “ Cultural concepts of distress ” appeared in the DSM-5 [ 12 ]. Arthur Kleinman wrote in his work on anthropology and psychiatry that “ Depression experienced entirely as low back pain and depression experienced entirely as guilt-ridden existential despair are such substantially different forms of illness behavior with different symptoms, patterns of help-seeking, course and treatment responses that though the disease in each instance may be the same, the illness rather than the disease is the determinant factor ” [ 26 ] (p. 450). This analysis, which stems from the variability of depression presentations between Western and Asian adults, could also be meaningful for the variability between children and adults. Participants have said that children have more behavioural and somatic manifestations than adults. The standard clinical picture of this condition may be the unusual one: the cognitive aspects and complex psychology of self-blame and immiserating introspection might be distinctively Western [ 27 ], but also adult.

The focus on emotional states versus psychological suffering in the definition of depressive mood amongst our interviewees can be thought through the disease/illness distinction. In a way, emphasising emotions is considering disease as the determining factor, and emphasising subjectively meaningful suffering is considering illness as most relevant. This dispute is not only verbal and conceptual because it has implications for the analysis of scientific data and therapeutic choices. Psychologist Irving Kirsch claims that “ Meanings are not inert ,” that “ they can and do affect people ,” and that “ the way we feel does not depend on the events that happen to us, but rather on the meaning these events have for us ” [ 28 ] (p. 136). Theories of meaning can shed light on the significant part the placebo effect is known to play in the treatment of depression. Such statements echo our interviews, for example, with the concept of empathic diagnosis brought on by one participant. Indeed, participants who adhere to the importance of meaningful suffering, independently of the presence of specific affects and emotions, seemed more sceptical of the pharmaceutical efficacy claimed by SSRI adovcates and tended to think that psychotherapy was the only thing that worked (and sometimes, regardless of the psychotherapeutic technique employed).

Why is it so hard to stabilise the concepts of depression and childhood depression? When Participant 5 raised the issue of depression meaning different things for lay people and for professionals (see Results theme #2), she made an interesting point. Depression might be one of those ‘boundary objects’ [ 29 ], i.e. concrete or conceptual objects, robust enough to maintain unity but plastic enough to be manipulated in different social worlds. These boundary concepts have the particularity of being weakly structured in the common use but strongly structured in the individual use, much like we have observed in our interviews. In her history of the development of immunology, historian of science Ilana Löwy has shown that boundary concepts have important heuristic roles, and are not necessarily meant to become better defined with time [ 30 ]. Loose concepts have cognitive benefits, facilitating the interaction of different scientific cultures to produce new knowledge. They also have social virtues, allowing the development of intergroup alliances and the promotion of particular social interests. They are, therefore, not necessarily a problem and have been shown to be fruitful in scientific processes [ 31 ]. Besides, vagueness in words does not imply vagueness in knowledge. Epistemologist Michael Polanyi convincingly argued that we can know more than we can tell, which he called ‘tacit knowing’ [ 32 ]. The need for precise criteria to define diagnoses could even put unnecessary intermediaries between clinician and patient, undermining the identification of pathological situations [ 33 ]. Perhaps identifying depression or childhood depression is more of a practical knowledge than a theoretical one. Yet, these criteria and these theories exist, are put into words, and have numerous implications.

Definitional criteria and causal attributions: ethical and epistemological implications

The controversy between using categories and dimensions to define and assess psychiatric disorders is ancient and has been widely discussed by illustrious figures of twentieth century science like Hempel and Eysenck [ 34 , 35 ]. On the one hand, the categorical approach aims at establishing precise categories, with unambiguously defined features, underpinned by a binary logic: the individual is either subsumed or not subsumed in the category. In medicine, this approach is well exemplified by the creation of syndromes. On the other hand, the dimensional approach considers that healthy and pathological are quantitative differences of the same kind of substrate, only varying in intensity. It leads in psychiatry to the creation of spectrums [ 36 ].

This discussion, brought on by some participants, has some practical and ethical implications that are not reducible to the operational goal of classifications. Categories, like the DSM-5’s definition of major depressive disorder, have the disadvantage of producing numerous atypical cases and comorbidities, which is indeed what professionals report in childhood depression. They furthermore create an arbitrary delineation between normal psychology and psychopathology, and can lead to excessive reification of diagnoses, i.e. the belief that these categories are a pure mirror of nature [ 36 ]. On the contrary, dimensional approaches facilitate diagnosis from nonspecific symptoms, avoid premature conclusions from fully syndromic approaches, and allow for a better translation of therapeutic efficacy in clinical trials [ 36 ]. Therefore, it is not surprising that several participants have advocated using dimensions over categories in childhood depression. However, dimensions have some downsides which should not be overlooked. They weaken the communication between professionals (reliability), which was at the core of the DSM-3 project. Perhaps more worrying, they also break down the barriers between normal and pathological, by conceiving them both on a single continuous axis, which could lead to a massive utilisation of psychotropic medicines [ 36 ]. In the end, a categorical approach suggests that the problem is something that the patient has, whereas a dimensional one suggests that the problem is something that the patient is [ 37 ]. This issue is far from being ethically neutral, and the debate between categories and dimensions should not be simplified to purely technical and theoretical questions. Besides, medicine’s pragmatic goal—diagnosis for treatment, not for knowledge—generally leads to set cutoffs between normal and pathological along continuous dimensions, reverting to a categorical reasoning [ 37 ]. There are indeed very different kinds of categories: all do not need to fit nature’s underlying reality adequately, but all have a precious practical utility in action-oriented endeavours like providing health care [ 38 ].

The definition of depression in relation to its cause is also subject to many debates with many implications. Sociological studies describe a drift in psychiatry’s causation model from personal and interpersonal individual history to biological mechanisms [ 39 ]. While this analysis may be accurate in the production of knowledge, we cannot say the same about our interviews with clinicians. As we have seen, the participants kept claiming to look for causes of childhood depression in their life history. Among our interviewees, including the minority who rejected genetics as being epistemologically relevant to childhood depression (which we should not overgeneralise to child psychiatry as a whole), the dominant paradigm was a biopsychosocial model [ 40 ], not a biological one. The biopsychosocial model is exemplified for mental disorders in the ‘stress-diathesis’ model: genetic influences combined with unshared environmental influences make the baseline biological susceptibility to psychiatric illness, and later life events are triggers for the occurrence of mood episodes. As psychiatrist Nassir Ghaemi puts it, “ later life events do not cause the illness in a general sense; they only determine how frequently and when the illness reveals itself in mood or psychotic episodes. The episodes are part of the illness, not the entire illness. […] Both life events and underlying biological susceptibility are legitimate targets of interventions, with psychotherapies and medications, respectively ” [ 41 ] (p. 201). But he does not oppose biopsychosocial to psychosocial and/or biomedical; he claims that the biopsychosocial model is a “ vague eclecticism ” that is as dogmatic as the psychosocial and the biomedical alone, leading to give everyone everything, irrespective of what works best. It is falsely pluralist in that it mixes various scientific methods and theories of mental health without working on which is the better, problem by problem [ 41 ].

Which model would then work best for childhood depression? Firstly, there are ethical considerations to take into account. We had anticipated that different theories on childhood depression would lead to different therapeutic strategies. Yet, these strategies were surprisingly homogenous despite the epistemological dispute on whether environment or biology was the leading cause. Therefore, we tried to look for other motivations to adhere to one or another epistemological model. A biomedically dominant model of disease has great destigmatising virtues, as exemplified by Participant 3’s caution to not blame parents (see Results theme #3). Biological explanations of disease allow to take off stigma attached to psychosocial explanations, which may partially explain why they are largely advocated by patients, loved ones, and associations [ 39 ]. Psychologist Ilana Singh showed in a study on ADHD that parents tended to say their child did not have a behavioural problem, but their brain did; thus considering they knew the true and authentic child while ADHD was alien and inauthentic [ 42 ]. On the other hand, psychosocial explanations do seem to spark a much welcome change in the child’s social environment. Parents, in particular, were in this perspective strongly prompted to change their attitude. The label of ‘depressed’ itself could be problematic for these psychiatrists if understood in a biomedical way. For example, Participant 12’s ‘empathic diagnosis’ fits this approach.

Choosing between a biomedical and a psychosocial model for childhood depression also has deep epistemological implications. All the participants agreed to say that psychosocial causes were more influential in childhood depression compared to adults. In a way, it means that childhood depression is a sensible human emotional response to adverse life events. ‘Sensible’ here is used in the literal sense ‘that we can make sense of’ and does not mean ‘okay’ or ‘unproblematic’, because there is no denying the terrible social, developmental and psychological consequences for these children. ‘Sensible’ means that there is a socially understandable reason for such an emotional response. Sociologists Allan V. Horwitz and Jerome C. Wakefield have suggested that distinguishing normal sadness from pathological sadness could only be done by assessing the causes, not the state of sadness itself [ 4 ]. They contend that this has been crucial throughout the history of psychiatry, for Hippocrates, Freud and even Kraepelin, to whom it is customary to attribute the birth of a biomedical model of psychiatry. Indeed, even after the nosographic twist of the DSM-3, the diagnosis of MDD was subject to the ‘bereavement exclusion’: i.e. that depression could not be diagnosed with the same criteria after the loss of a loved one. It seemed reasonable; it also seems likely that other life events could explain episodes of intense sadness. Yet, in 2013, the bereavement exclusion was removed from the DSM-5, precisely because no differences could be found between psychological states of sadness in bereavement and MDD [ 43 ]. This move enshrined the end of psychiatry’s ‘causeless tradition’ in the diagnosis of depression.

The extreme distress that anxiety and sadness can cause is not to be taken lightly and undoubtedly call for care, but if we consider it part of ‘normal’ human functioning, it does, however, raise the question of the medicalisation of such suffering. All our participants advocated for a multidisciplinary care of depressed children to try and activate all levers: psychotherapy, medication and social life. If medication is in most cases useless and avoidable, if physicians do not perform psychotherapy and social care (because they are not trained for it, because it is out of their prerogatives, or simply because they do not have enough time), and if the pathological status of childhood depression is doubtful, is there still a rightful role for medicine to play?

Medicalisation

There is no moral overtone in our use of the word ‘Medicalisation.’ It is a mere description, not value laden like ‘overmedicalisation’. Over the last couple of centuries, there has been a general tendency to increase medicalisation of social behaviours, albeit paralleled with demedicalisation of certain behaviours (homosexuality, masturbation) [ 44 ]. The concept of childhood depression in its current use can be thought through this larger medicalisation process. Yet if medicalising nonpathological states should be questioned, it cannot be an argument per se. Birth pain is considered normal, and this does not automatically lead to saying the involvement of physicians should be stopped because pregnancy is not a disease.

The case of ADHD is an interesting example of the medicalisation process. Initially, only hyperactive children were targeted. Attention was then added to the syndrome and eventually broadened to adults in the 1990s, leading to a medicalisation of underperformance [ 44 ]. Perhaps depression, first losing the imperative of causelessness, then being adapted from adults to children and added other symptomatic behaviours like irritability, is undergoing a similar process.

“ Persons are in the psychiatric realm when their body, psychology and/or particular expressions of emotional and mental distress are constructed as ‘mental illness’ or ‘disorder’ ” [ 45 ] (p. 1182). For Horwitz and Wakefield, “ All professions strive to broaden the realm of phenomena subject to their control, and whenever the label of disease is attached to a condition, the medical profession has the primary claim to jurisdiction over it ” [ 4 ] (p. 213). For them, the medicalisation process is promoted by the profession of medicine, as doctors are the main beneficiary of a definition that allows labelling and treating previously nonmedical problems as disorders. Conrad and Slodden make a different analysis: clinicians are not (anymore) the major drivers of this medicalisation process. As we have seen, all our participants were likely to adopt an eclectic biopsychosocial model, and to downplay their part in the care of psychologically suffering children in favour of a wide network of medical and nonmedical care. In a qualitative study with 60 participants (depressive adults and their doctors), Kokanovic, Bendelow, and Philip made similar observations [ 21 ]. They found that physicians easily took liberties from the DSM categories to diagnose depression and that they experienced a tension between the biomedical discourse of depression in which they were trained and which accords them clinical authority, and the recognition that the social context of patients’ lives contributed to their experience of emotional distress. As a result, many prescribed antidepressants reluctantly. On the patients’ side, although they agreed that the source of their suffering was outside of medicine’s scope (life events), their first instinct was still to consult a doctor, short of any other accessible kind of help and care. Since the 1980s (at least in Western countries), promoters of medicalisation have instead been medical care consumers, insurances, and the pharmaceutical industry, with doctors increasingly becoming gatekeepers rather than advocates [ 44 ].

What are the consequences of such medicalisation? This is a subject for another study altogether. We can however make some remarks based on our material and the literature. The participants said that some of their patients were in extremely severe condition, with high risk of dramatic social consequences or even death, prompting them to give medication even when they were not convinced it was useful. There is probably a selection bias towards most severe cases in our sample of recognised international experts, often working in tertiary and quaternary health-care facilities. No doubt that the amount of urgency and risk associated with these cases called for radical interventions—radicality within the power of the medical institution. Given how problematic they are, such cases probably do not allow to explore the frontier between normal and pathological. Therefore, using this minority as a starting point to define the whole concept of childhood depression is likely to play a role in pathologising what would otherwise be normal sadness and irritability in less severe cases. For the majority, the use of medication (which is more personality enhancers than antidepressants according to many researchers [ 4 , 28 , 41 ]) is far from being insignificant. The side effects are not negligible and the benefit/risk equilibrium could be revised. On the individual level, it does raise the question of the (yet unknown) physiological role of sadness and anger, and potential harm of blocking their manifestations. On the collective level, it erroneously misconstrues social problems as personal problems. Indeed, with the way we frame the concept right now (both in children and adults), it is not surprising that epidemiological studies find enormous rates of prevalence (since it will pick up states of lesser emotional distress that will not necessarily lead people to consult a physician) and qualify depression as a major public health concern [ 1 , 4 ]. It does catch up with Lefkowitz and Burton’s 1978 concern that depression could reach the state of omnipresence.

Strengths and limitations

Overall, our study meets a fair amount of quality criteria for qualitative research [ 46 ]. Credibility is ensured by the prolonged engagement of two researchers full-time for six months each, peer debriefing within the larger research unit and with an external group of researchers, and a large portion of our data is provided in the Supplementary materials. The detailed account of where the participant population came from and why they were recruited ensures good transferability. Dependability and confirmability were assessed by triangulation to ensure a satisfying fit to the data, the avoidance of the inquirer’s terminology and a priori concepts, and surveillance of potential methodological shifts. Trustworthiness might have been further improved by the use of a full audit or a reflexive journal.

There are some limitations in our study. Intrinsic to the methodology of interviews is the potential gap that could exist between discourses and actual practices. This is why we have focused so much on the concepts and the way professionals arrange them, than on the phenomena themselves. Ethnographic observations should be envisaged in future research, to measure the importance of this gap. Likewise, to frame the discussion more on actual phenomena and less on concepts, interviews which children and their families should be considered.

Some limitations are also strengths in our opinion. First, having conducted the analysis by researchers working on transcripts produced by other researchers increases the risk of distortion in the interpretation of participants’ discourses. However, involving several researchers is a more robust process, as science is by definition an intersubjective and collective activity.

Second, interviews were conducted in two different languages (French and English). Analysing discourses is thus harder because it gives a lot of importance to the words themselves. Furthermore, many participants were not native French or English speakers, and sometimes their fluency was an obstacle. The importance to give to the choice of certain words and certain syntaxes was sometimes difficult because it was unclear whether they were chosen on purpose, or short of better language skills. Nonetheless, having participants coming from all six continents was extremely precious and a rare feature of qualitative studies. The language barrier is probably an acceptable limitation in contrast to the strength of an international design.

Finally, we have not seen as many culturally linked views of childhood depression as we had anticipated. It may mean that the concept is not as culture relative as we think. But as recognised figures and reference professionals worldwide, it is also likely that their affiliation to this common international community homogenise their views on the question. Yet, as major contributors to the intellectual livelihood of the field, their reflections are also more likely to impact the medical community as a whole and the construction of knowledge.

Using a constructivist approach and a qualitative study design, we have been able to explore how early twenty-first century international experts in child psychiatry shape the concept of childhood depression. Most participants agreed that childhood depression was a mental disorder in which irritability was prevailing, heavily influenced by psychosocial factors, and for which psychotherapy was the ideal treatment. Many points of subtle dissent have also surfaced: whether depression is primarily a mood or a psychological mechanism, whether categories or dimensions are more suitable to make the diagnosis, and whether there is a genetic predisposition were some of the most controversial topics.

Child psychiatry is increasingly gaining acceptance and independence in medical institutions across the world. Like its adult counterpart, its body of knowledge and theories is a constant work in progress, subject to displacements and refining. Definitional criteria and causal attributions are not mere verbal disputes, they have concrete epistemological (what is normal, what is pathological?), ethical (who or what gets blamed for causing the disease?), social (what is medicine’s role?), and political implications (what is of major public health concern?). These theoretical discussions should not be overlooked and must be continued in further research.

Data availability

The original data for our study cannot be shared openly to protect study participant privacy. We however provide in a supplementary file a large portion of (anonymised) quotes drawn from the raw material, which were are the foundation of our analytical work.

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Acknowledgements

We heartily thank Pr Ghizlane Benjelloun, Pr Vlatka Boričević Maršanić, Pr David Cohen, Pr Samuele Cortese, Pr Valsamma Eapen, Pr Joaquin Fuentes, Pr Daniel Fung, Pr Naoufel Gaddour, Pr Gordon Harper, Pr Johannes Hebebrand, Pr Bertrand Lauth, Pr Bennett Leventhal, Pr Vania Martínez, Pr Suaad Moussa, Pr Ally Ndjukendy, Pr Oscar Sánchez, Pr Inagaki Takahiko, and Pr Chris Wilkes for their support in conducting this study. This research has received methodological assistance by Drs Alexandre Michel and Ludovic Cacheux as members of the qualitative research team of the Grounded Lab (groundedlab.org), to whom we are immensely grateful.

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AR conducted the analysis along with CH, and wrote the main manuscript text. MdC designed the study and collected the material. LB provided methodological support. BF provided overall supervision. All authors reviewed the manuscript.

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Rayapoullé, A., de Chassey, M., Benoit, L. et al. Constructing childhood depression: a qualitative study with international experts in child psychiatry. Eur Child Adolesc Psychiatry (2023). https://doi.org/10.1007/s00787-023-02270-0

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Early Childhood Depression

Joan l luby.

Department of Psychiatry, Washington University School of Medicine.

Although empirical evidence has recently validated clinical depression in children as young as age 3, few data are available to guide treatment of early childhood depression. Considering this gap in the literature, a novel dyadic psychotherapeutic model, Parent Child Interaction Therapy–Emotion Development, based on a well-known and effective manualized treatment for disruptive preschoolers, is currently being tested for use in depression. To balance safety and efficacy, dyadic developmental approaches are currently recommended as the first line of treatment for preschool depression. In the absence of data on the safety and efficacy of antidepressants in preschool depression, these agents are not recommended as a first- or second-line treatment at this time. This article provides an illustrative case example of preschool depression, outlines key considerations in differential diagnosis, and describes this novel form of treatment. It also clarifies parameters for the rare situations in which antidepressants may be tried when psychotherapeutic options fail and depression is severe and impairing.

Key Clinical Characteristics

The case vignette below illustrates several clinical features typical of early childhood depression. Intense irritability is perhaps the most common symptom prompting parents to bring a young child for mental health evaluation other than disruptive behavior. While irritability is nonspecific and may be a symptom of a variety of early childhood disorders, when it presents along with social withdrawal and anhedonia and/or excessive guilt, early depression should be considered. The absence of significant developmental delay and the report that the symptoms are not impairing in a preschool setting that the child attends for short blocks of time are also common features. Data have shown that, similar to depression in older children, preschool depression is more often characterized by age-adjusted manifestations of the typical symptoms of depression than by “masked” symptoms, such as somatic complaints or aggression ( 1 , 2 ). Notably, while irritability was added to the DSM-IV criteria for major depressive disorder for children based on the assumption that it may serve as a developmental proxy for sadness, there is little empirical data to support this thesis. In a sample of 75 depressed preschoolers, only five (7%) failed to meet criteria for major depression when the symptom of irritability was set aside, suggesting that irritability is not a key proxy for sadness in preschool children (J.L. Luby et al., unpublished 2008 data).

A key issue in the assessment of internalizing disorders, particularly depression, in young children is that caregivers may fail to spontaneously report symptoms (changes in play, social interest, sleep, and so on) or may unwittingly accommodate these behaviors and thereby fail to regard them as symptoms (e.g., anxious rituals, rigidities, and social withdrawal), making it incumbent on the clinician to make detailed inquiries into all aspects of a young child’s functioning.

Validation for Early Childhood Depression

The study of depression arising during the preschool period (prior to age 6) is relatively new. However, over the past decade, empirical data have become available that refute traditional developmental theory suggesting that preschool children would be developmentally too immature to experience depressive affects (see reference 3 for a review). Basic developmental studies, serving as a framework and catalyst for these clinical investigations, have also shown that preschool children are far more emotionally sophisticated than previously recognized ( 4 – 8 ). While some of these emotion developmental findings are new, others have been available for some time but never previously applied to clinical models of childhood affective disorders. These findings on early emotion development, obtained using narrative and observational methods, provide a key framework for studies of early childhood depression, as they establish that very young children are able to experience complex affects seen in depression, such as guilt and shame. Indeed, guilt and shame have been observed to occur more frequently in depressed than in healthy preschoolers ( 9 ).

Adding to early studies by Kashani and colleagues first identifying preschool depression ( 10 , 11 ), larger studies have investigated the validity of the early-onset disorder. Markers of the validity of preschool depression include findings of a specific and stable symptom constellation, biological correlates evidenced by alterations in the hypothalamic-pituitary-adrenal axis (elevated stress hormone reactivity) similar to those seen in adult depression, and increased rates of affective disorders in family members of depressed preschoolers ( 2 , 12 , 13 ). These findings encompass several of the proposed markers of a valid psychiatric syndrome as proposed by Robins and Guze ( 14 ), used in the application of the medical model to psychiatric disorders. In addition, preschool depression has been detected in four independent study samples ( 2 , 15 – 17 ). Whether early childhood depression shows longitudinal continuity with later childhood depression remains a key empirical question. Along this line, recent longitudinal data ( 18 ) demonstrate that preschool-onset depression shows homotypic continuity over a 2-year period and has a chronic and recurrent course continuous with and similar to that seen in school-age depression.

A 4-year-old child presents with high irritability, periods of social withdrawal, negativity, and periods of decreased appetite

“Jane,” age 4 years and 8 months, is a Caucasian female who was brought to the infant/preschool mental health clinic by her parents because of concerns about extreme irritability, periods of social withdrawal, negativity, and periods of decreased appetite during which she lacks interest in even her favorite foods. These behaviors were first noted by Jane’s parents at age 3 and have been increasing in intensity and frequency until becoming the source of family problems. Jane attends preschool 3 half days a week, and no problems have been reported in that setting. There is a family history of affective disorders. Both parents are employed, there are no reported significant psychosocial stressors, and two older siblings are developmentally on track without behavioral or emotional problems.

On further interview, Jane’s parents described her as reacting to minor frustrations with intense sadness and/or anger often lasting hours. Along with these symptoms, a lack of interest in activities and play was also noted. Play observations with the child interacting in turn with each parent revealed a young child who displayed elaborate and age-appropriate representational play as well as intact motor and language skills. However, also notable was a preoccupation with negative play themes and pessimistic thoughts. Despite being engaged, Jane was unusually quiet and withdrawn during play, and this mood state was sustained throughout both play observations. Despite an interest in play, she lacked the expected age-appropriate exuberance during play.

Differential Diagnosis

Identification of preschool depression in the clinical setting remains challenging. Common symptoms such as irritability and even sadness, when present without other depressive symptoms, are relatively nonspecific markers and cannot be used to differentiate preschool depression from other disorders. One relatively large empirical study ( 15 ) that investigated the likelihood of specific depressive symptoms being associated with major depression compared to a variety of other preschool disorders suggested that anhedonia, excessive guilt, extreme fatigue, and diminished cognitive abilities are the most useful markers of preschool depression as distinguished from other early-onset psychiatric disorders. These findings are useful to guide the differential diagnosis of early childhood depression. However, further work is needed to educate parents and primary care physicians about early signs and symptoms of depression in young children, as referrals for this concern remain relatively infrequent compared to those for other early childhood problems, even when accounting for the lower prevalence rate ( 19 ). Adding to the confusion is that high rates of comorbidity with other, more commonly occurring behavioral disorders, such as attention deficit hyperactivity disorder and oppositional defiant disorder, are also observed in preschool depression (ranging from 40%–60%), similar to rates reported in older depressed children ( 2 , 20 ). These disorders characterized by disruptive symptoms are often more readily apparent, increasing the risk that such symptoms will overshadow co-occurring depression.

Treatment: Background and Progress

Very little empirical literature is available to guide treatment once the diagnosis of depression is established. Given the relatively recent scientific validation and related acceptance of preschool depression, no systematic treatment studies have yet become available. This is a particularly challenging scientific issue, as to date, effective treatments for depression during the school-age period have remained elusive. Psychotherapies known to be effective in adult and adolescent depression, in particular cognitive-behavioral therapy (CBT) and interpersonal psychotherapy, have been adapted for use in school-age children. While several empirical investigations of CBT for children have shown positive treatment effects, data demonstrating the efficacy of interpersonal psychotherapy are currently available only for adolescents. The results of several smaller CBT trials in school-age children have been promising ( 21 – 23 ). However, a comprehensive meta-analysis of studies of psychotherapies for childhood depression suggests a much smaller effect size than previously reported, concluding that longer-term efficacy of CBT for school-age children has not been established ( 24 ). A large multisite treatment study of adolescent depression that investigated CBT and medication, independently and in combination, demonstrated promising short-term outcomes but high relapse rates ( 25 ). In addition, novel and highly feasible treatments for depression in school-age children, using group formats and/or behavioral activation strategies, are also undergoing testing and appear promising ( 26 , 27 ). Given these remaining challenges in the treatment of school-age depression, no clear model for extending effective treatments to early childhood populations is yet available. Another potential area for extrapolation would be the application of prevention strategies designed for and known to be effective in older children to younger populations. Alternatively, novel approaches adapted from psychotherapies with established efficacy in treating other early childhood disorders applied to the treatment of depression may be worthwhile, and one such approach that is currently being tested is described below.

Although one study has demonstrated the efficacy of fluoxetine for the treatment of school-age depression ( 28 ), further complicating the treatment of early childhood depression is the idea that depression in younger children is characterized by unique alterations in neurotransmitter systems. These developmental differences have been proposed as an explanation for the known lack of efficacy of tricyclic antidepressants as well as several negative studies of the newer-generation antidepressants (see reference 29 for a review). Short of a few case reports ( 30 , 31 ), no data are available on the safety or efficacy of antidepressant medication in any form of preschool psychopathology. Based on this and the finding that younger children may be at greater risk for activation from selective serotonin reuptake inhibitors (SSRIs) ( 32 ), the use of antidepressants is not a first- or even second-line treatment for early childhood depression at this time.

Considering these findings, and balancing the need for safety and efficacy, parent-child dyadic psychotherapeutic interventions are currently recommended as the first line of treatment for early childhood depression. Dyadic approaches (defined by focus on child and caregiver together) are central to psychotherapies appropriate for young children, given the fundamental reliance of the child on the caregiver for socioemotional and adaptive functioning. Early psychotherapeutic and behavioral approaches have shown promise in the treatment of disruptive disorders in early childhood ( 33 – 36 ). Following these promising findings, a novel parent-child psychotherapy has been developed for the treatment of preschool depression and is currently undergoing testing. Parent Child Interaction Therapy–Emotion Development (PCIT-ED) utilizes and expands a well-validated manualized treatment (PCIT) developed by Eyberg that has proven efficacy for preschool disruptive disorders ( 37 ). For the treatment of mood disorders, a newly developed key module has been added that focuses on enhancing emotion development. This emotion-development module is designed to target and enhance the preschooler’s emotional developmental capacities through the use of emotion education. Perhaps most important, it also targets the child’s capacity for emotion regulation by enhancing the caregiver’s capacity to serve as an effective external emotion regulator for the child. The module is based on a model of early mood disorders that links alterations in emotion development to risk for and onset of depression ( 38 ). Several independent lines of empirical evidence provide support for such an emotion developmental model ( 39 , 40 ), with at least one study emphasizing the role of parental depression history and parent-child interaction in these risk trajectories ( 41 ). Therefore, the intervention targets the enhancement of emotional skills as well as a more adaptive pattern of emotional response to evocative events experienced in daily life.

PCIT-ED is a manualized 14-session psychotherapeutic treatment. As originally outlined by Eyberg in PCIT, the primary caregiver is key to the implementation of this treatment and serves as the “arm of the therapist.” A microphone and earbud are used during interactions with the child in session to allow the therapist, who observes through a one-way mirror, to provide in vivo coaching of the caregiver to intervene more effectively on the child’s behalf. Homework is designed to enhance skill achievement between weekly sessions. In the case of the depressed young child, enhancing positive emotion in response to incentive events and reducing negative emotion in response to frustrating or sad events are targets of treatment by coaching the parent to respond to the child during contrived (and spontaneous) in vivo experiences in session. Enhancing the child’s capacity to identify emotions in self and others is a primary goal. These therapeutic targets are based on an emotion dynamic model of depression in which the child’s capacity for emotional responses at peak intensity, but with the capacity for optimal regulation (i.e., return to euthymic baseline), is deemed key to healthy emotion development and amelioration of early mood symptoms.

A central feature of this treatment for early depression is the emphasis on the ability to experience positive affect at high intensity as well as the capacity to regulate and recover from negative affect. This is based on the hypothesis that depressed children will be less reactive to positive stimuli and more reactive to negative stimuli than healthy children. Related biases in the areas of cognitive distortion and emotional memory are well established in depressed adults and have also been detected in older depressed children ( 42 , 43 ). The emphasis on achieving a broad emotional repertoire, an important basic developmental goal, is also central. In essence, the key emotion-development element of treatment is fundamentally developmental and has relational elements, as it identifies the caregiver’s strengths and weaknesses in serving in this capacity for the child based on their own temperament, interpersonal and caregiving relationship history, emotional maturity and, in some cases, overt psychopathology. Caregivers with affective disorders (not uncommon in this population) are referred for their own treatment. However, when affective symptoms impede their ability to participate effectively in treatment, this is also directly addressed through in vivo coaching and in individual parent sessions.

PCIT-ED is currently undergoing randomized controlled testing. In a phase I open trial, significant and robust-appearing amelioration of symptoms of depression and anxiety were observed in treated preschoolers. Testing of an adaptation of PCIT for the treatment of anxiety disorders by an independent research group is also under way, and preliminary results have shown positive treatment responses ( 44 ).

Early intervention targeting developmental skills during the preschool period is an area of increasing interest and promise for the treatment of early childhood mental disorders in general. Several early-intervention programs have been empirically tested and proven to successfully ameliorate preschool disruptive symptoms ( 34 , 36 ). A prevention program designed to enhance emotion competence in high-risk preschoolers has also shown efficacy ( 45 ). New therapeutic modalities that adapt cognitive-behavioral approaches as well as PCIT to target early childhood anxiety show promise ( 44 , 46 ). Intensive behavioral approaches that target social and speech development in autism have shown remarkable outcomes in subgroups of young patients ( 47 ).

Although it remains unclear why early interventions are effective and whether they are more effective than later intervention, several lines of developmental evidence suggest this may be the case ( 48 – 51 ). While there is a need for careful empirical studies of the relative efficacy and mechanisms of early intervention, the possibility of critical periods of development, based on relatively greater neuro-plasticity during early childhood, is intriguing. Such processes have been demonstrated in medical disorders (e.g., strabismus) and have driven early-treatment strategies so that these windows of opportunity for more effective treatment can be captured ( 52 , 53 ). Treatment models utilizing critical periods of neurodevelopment have unclear applicability to early-onset mood disorders; however, empirical testing is well warranted given the potential positive public health impact.

Summary and Recommendations

A growing body of empirical data supports the existence of clinically significant depression during early childhood, as young as age 3. The available data can guide us in distinguishing depression from other early-onset disorders during the preschool period. A parent-child psychotherapy designed to treat early childhood depression that focuses on enhancing emotion development is currently undergoing testing, with early open trials appearing promising. Based on these results and a larger body of early intervention literature, such approaches are now recommended as a first line of treatment. Watchful waiting is no longer an acceptable approach to these early-onset symptoms. The treatment of parental psychopathology is necessary but not sufficient to adequately address the young child’s symptoms. The use of antidepressant medications should be attempted only in circumstances in which very severe psychopathology is present with failures of appropriate psychotherapies.

Treatment in Clinical Practice

The relative dearth of scientific evidence to guide the treatment of early childhood depression leaves the clinician with the challenge of attempting to ameliorate the symptoms and suffering of the young child and family while also doing no harm. In this light, the focus on emotion development, as described in the experimental treatment reviewed above or in other, related forms, is the treatment of choice at this time. If the primary caregiver also suffers from an axis I affective (or other) disorder, referral for treatment of the caregiver is warranted and known to ameliorate the child’s risk ( 54 ). However, it is important to recognize that treatment of the caregiver’s mood disorder alone, while necessary, is also known to be insufficient to effectively address the young child’s symptoms ( 55 , 56 ). Therefore, a developmental/psychotherapeutic treatment that targets the young child directly is also necessary. When emotion development programs are unavailable, behavioral activation strategies as described above may also be worth pursuing given their high feasibility and ease of implementation. Notably, the evidence base suggests that watchful waiting, the common and traditional but misguided approach to early childhood psychopathology, is ill advised.

The use of antidepressant medications is not recommended as a first- or second-line treatment at this time. Based on unknown efficacy and risks, SSRIs should be considered only in cases of very severe symptoms and in the context of failures of adequate trials of developmentally appropriate psychotherapies. In such cases, it is critical to explain to the parents or caregivers that the treatment is experimental and that efficacy as well as effects on growth and development remain unknown. When such rare circumstances arise, very small doses and slow titration schedules should be used under close observation. High vigilance on the part of parents and clinician for the possibility of activating side effects should be emphasized. This therapeutic intervention should be applied only in highly reliable families who can fully comply with this treatment plan.

Acknowledgments

The author receives royalties from Guilford Press for a book on childhood mental disorders.

Supported by NIMH grants R34MH080163-01 and R01 MH64769-01 and -02.

Perspectives

A Case Study of the Early Childhood Mental Health Therapeutic Consultation Protocol within a Specialty Multidisciplinary Pediatric Clinic for Adopted and Foster Care Children

Experiences of maltreatment, caregiver transitions, and other forms of chronic stress in early childhood have been related to an increased likelihood of health and mental health disorders. Despite having a number of well-developed and validated therapeutic options for fostered and adopted children, families are often overwhelmed by their child’s multiple health needs and have a difficult time accessing care. This case report describes a 2-year old female child in foster care who took part in a multidisciplinary program for fostered and adopted children ages 0 to 5 years old. This family’s experience highlights that patients can receive streamlined evaluations, short-term therapeutic interventions, and long-term service recommendations by providing families with a single point of contact in an integrated care setting. This approach decreases the time burden placed on parents, increases the effectiveness in understanding and addressing a child’s needs, and improves family and provider collaboration. Further, models of integrated care reduce the likelihood of misdiagnosis. Many symptoms of early childhood adversity and attachment disorders can present like other common mental (i.e., Autism Spectrum Disorder) and physical disorders (i.e., motor delays). Misdiagnosis can lead to recommendations that are ineffective or ultimately harmful to children with experiences of trauma. Given the range of general and mental health effects of multiple housing transitions, maltreatment, and/or neglect, this case underscores how a team approach is invaluable for promoting at-risk young children’s wellbeing and development.

Keywords: Foster Care; Adoption; Mental Health; Early Childhood; Integrated Care

Introduction

Over 443,000 children were involved in the foster care system in the United States during 2017 (Child Trends Databank, 2019). Children under the age of five are the largest group within foster care (~41%, N = 183,959; Child Trends Databank, 2019). Almost all children involved in these systems have experienced multiple transitions, maltreatment, and/or neglect. Many have also experienced malnourishment, pre-and post-natal substance exposure, premature birth, and exposure to infectious diseases. Environmental stress, bodily harm, and illness in early childhood can carry consequences for physical and mental health functioning across the lifespan (Cicchetti & Handley, 2019; Malionsky-Rummel & Hansen, 1993; Smith & Thornberry, 1995; Vachon, Krueger, Rogosch, & Cicchetti, 2015; Anda et al., 2006). Given the medical complexity of foster children, multi-disciplinary care models, including medical providers, mental health specialists, public health nurses, social workers, and occupational therapists (OT), are essential.

The purpose of this paper is to highlight the experience of a 2-year old female in foster care with a program that integrates early childhood mental health therapeutic consultation with a unique multidisciplinary medicine program for fostered and adopted children. We will, 1) illuminate the need for new ways for fostered and adoptive children under five to engage with health, mental health and other services, and 2) highlight an early mental health therapeutic consultation protocol within a pediatric setting. Ultimately we aim to motivate the development of this and similar programs across the United States to better serve young children facing threats to their life long trajectories of mental and physical illness due to early experiences of adversity.

Early Childhood Mental Health Evaluation in an Interdisciplinary Pediatric Team

Multiple housing transitions, maltreatment and/or neglect can be related to a range of medical, developmental, and emotional symptoms, with treatments located outside of the sphere of early childhood psychological intervention. Early childhood experiences of abuse and neglect have been linked to cardiovascular concerns, sensory processing disorders, failure to thrive, and chronic infections associate with immune system dysfunction (Anda et al., 2006; Felitti et al., 1998). Malnutrition, often associated with experiences of neglect, can have a detrimental impact on a child’s development trajectory if left unaddressed – including an increased risk for cardiovascular and metabolic disease in adulthood (Campbell et al., 2014), lower IQ scores in early adolescents (Liu et al., 2003), and micronutrient deficiencies that cause irreversible alterations to brain development (Monk et al., 2013).

While physicians in the United States are typically underprepared to address mental health ramifications of early childhood trauma, mental health providers similarly lack the training to fully conceptualize a child’s necessary medical interventions for their physical health needs. Due to this increased medical complexity for children who have faced early adverse experiences, it is invaluable to have a team approach that addresses concerns and efficiently rules out multiple etiologies for symptoms.

Further, many mental health symptoms related to trauma or attachment disorders can present like other common early childhood disorders. This may be difficult for providers without specialized training in early childhood trauma and attachment disorders to accurately determine the appropriate diagnosis. Misdiagnosis can lead to recommendations that are ineffective or ultimately harmful to children with experiences of trauma. For example, Autism Spectrum Disorder (ASD), trauma-related disorders, and attachment disorders have a similar profile of symptoms in early childhood. This includes delayed speech, delayed social cueing, difficulties with attention, and self-harm behaviors. However, for children with experiences of neglect, clinicians would recommend trauma-informed treatments focused on building attachment relationships and stability. For children with ASD, more behavioral oriented approaches would be recommended to target the growth of specific social skills. An ASD diagnosis for children with a trauma-related or attachment disorder could further disturb the child’s developmental trajectory by delaying appropriate services that focus on bolstering the child’s relational needs.

Access to Care and Therapeutic Consultation

Early childhood interventions that address parent-child attachment for children who have experienced early trauma have shown efficacy in reducing children’s negative behavioral and emotional outcomes (Reyes et al., 2017; Dozier et al., 2017; Cohen et al., 2000). However, a large number of children facing adversity do not ever receive the benefits of early interventions (Hartinger-Saunders et al., 2019). Specialty pediatric care settings that work with early mental health providers and their state’s department of human services have the unique opportunity to dramatically increase the likelihood that children who are at risk are identified and receive evidence-based interventions. However, to our knowledge, there are no standardized protocols, on how to incorporate early mental health and relationship-based evaluations into pediatric specialty care. This paper aims to highlight the benefits of a cross-systems integrated care model for addressing mental health concerns among young children in foster and adoptive care.

In the United States, foster care and adoption legislation is determined by the State. In Minnesota, children in foster care have a case review hearing 90 days after a child’s removal from parental care. After the court reviews the parent’s progress on their case plan, there may be a 6-month extension on the child’s foster care placement. Once a child has been in foster care for 12 months, the court will file a petition to decide on a permanency plan. Children in foster care can be adopted when their birth parents sign a voluntary consent, after which they have a ten-day period to change their mind. Children may also be made available for adoption through a court procedure to end parent rights. Birth parents have 20 days to appeal the court’s order.

The Adoption Medicine Clinic (AMC) at the University of Minnesota has been evaluating internationally adopted children since 1986 and in the past decade has focused on providing more services for children who have been domestically adopted or are in foster care. Funded by a grant from the Minnesota Department of Human Services the clinic has incorporated specialists into pediatrician visits, including psychology, OT, pediatric/public health nurses, and genetic counseling to address the far-reaching effects of early childhood adversity on physical and psychological functioning.

In 2019, approximately 48% (N = 188) of the population seen by AMC were children 5 years old or younger and were noted to have high rates of behavioral and emotional difficulties. Throughout 2019 and the beginning of 2020, the program spent large amounts of time doing community outreach to create partnerships and referral pathways. The program encouraged social workers across the state to refer young children and their foster families to the AMC for integrated care. All data and the case review were collected via chart review and approved by the University of Minnesota Institutional Review Board. At the onset of visits to the AMC, foster parents were provided with consents by check-in staff to choose to include their clinical information in research.

Early Childhood Mental Health Therapeutic Consultation Program Description

The over-arching goal of integrating the Early Childhood Mental Health Evaluation Protocol into AMC was to identify young children who are at high risk for long term mental health difficulties and displacement from their current foster or adoptive home. The mental health portion of the evaluation protocol consists of three components by which children are screened for (1) prenatal and postnatal experiences of trauma, (2) current behavioral, social, cognitive, and emotional concerns, as well as (3) current service access. In addition to the evaluation, the service includes referrals and a tailored psychoeducational intervention.

The first component of the evaluation consists of collecting information on pre and post-natal experiences of adversity. Prenatal risk factors can include the biological parent’s level of stress, access to prenatal care, prenatal substance use, and genetic liability for psychopathology. Postnatal risk factors for this population often include neglect, abuse, chronic mobility, food insecurity, and multiple separations or transitions from primary caregivers. We identify the duration and age of these experiences in order to integrate a developmental framework that considers how the developmental timing and duration of these experiences could affect functioning. The clinician utilizes a standardized traumatic event screening form to identify risk for post-traumatic stress disorder as well as the Disturbances of Attachment Interview (Smyke & Zeenah, 1999) which inquiries about symptoms of Reactive Attachment Disorder and Disinhibited Social Approach Disorder (DC:0-5; Klaehn, 2018).

The second component of the evaluation is collecting information on the child’s mental and behavioral health difficulties. Information is gathered via medical chart review, foster parent interview, and behavioral observations in the clinical setting. Providers review the child’s previous psychological evaluations and diagnoses. Clinicians complete a foster parent interview assessing the child’s developmental trajectory and the formation of their current attachment relationship using the Disturbances of Attachment Interview (Smyke & Zeanahm, 1999).

Mental health providers then observe child behavior in the context of a medical and occupational therapy exam. The observation protocol is designed to help mental health providers identify children’s difficulties in cueing distress elicited by the exam, using foster or adoptive parents for emotion regulation and support, as well as indiscriminate friendliness with unfamiliar medical staff. Mental health providers observe the parent-child relationship (Crowell, 2003; Cooper, Hoffman, Powell, & Marvin, 2011). The observation protocol captures a snapshot of how foster and/or adoptive parents attend to children’s distress and how, they provide structure, guidance and direction to their children. Children lacking a caregiver with these skills are the most likely to experience high levels of maladjustment related to early experiences of risk. Consistent and responsive caregiving has been shown to act as a buffer between young children and their environment, preventing the negative consequences of stress on mental and physical health (Johnson et al., 2018; Measelle & Albow, 2018; Liberman et al., 2004).

At the end of the exam, mental health providers review the foster parent and/or adoptive parents’ concerns and goals for the child’s mental health, and evaluate if there are any risks for these foster/adoptive parents requesting the child be removed from their current placements. Child placement instability has been related to a host of emotional, behavioral and developmental difficulties in children (Fisher et al., 2016). Unfortunately, many states have a high rate of foster care placement instability (U.S. Department of Health and Human Services, 2014). Foster parents who are at risk for requesting that children be moved to a different placement often have young children with high medical, behavioral, and emotional needs. Research suggests that children with more trauma symptoms are at an increased risk for foster care displacement (Clark et al., 2020). During the interview, foster/adoptive parents at risk often highlighted feeling exhausted by the child’s needs, feeling as if they do not have the skill set to help the child, and feeling like they don’t have the resources to identify those skills. Through our work, we have found it to be really important and impactful to have a candid discussion with foster parents about any of these concerns. Many foster parents were very grateful to have a space to talk through these concerns without judgement.

The third component of the evaluation consists of reviewing the child and their foster/adoptive family’s current service utilization and needs. This involves reviewing if full developmental assessments using the DC:0–5™ Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood have been completed as well as what mental health services the families may be using. In evaluating current mental health services, we review families’ satisfaction with those services as well as provide recommendations for evidence-based interventions and providers with whom those interventions can be accessed. Families then receive a brief educational therapeutic consultation, based on our conceptualization of the child’s current functioning and history. Foster/adoptive parents are provided with information on how to best emotionally and behaviorally support children’s development in the context of their early adverse experiences. Most foster/adoptive parents receive educational information based on the Circle of Security (Zanetti et al., 2011) as well as in the moment feedback during the end of the session based on the Attachment Biobehavioral Catch-Up protocol (Dozier et al., 2017). We also discuss ways young children signal distress and ways foster/adoptive can help buffer those responses.

Young children who are identified as high-risk for placement disruption or long-term mental health difficulties are referred for a full mental health evaluation (using the DC:0–5™) and trauma-informed as well as relationship-centered evidence-based treatment. Children that need immediate intervention and care because their current level of dysfunction is a risk for their wellbeing receive rapid access to a one to three session brief intervention while they wait for longer-term therapeutic options to become available.

Rationale for a Case Study

We chose to highlight Anna’s* participation in our program as a case study for multiple reasons. First, there is limited knowledge on the feasibility of integrated care consultation models for young children in foster care. We will highlight how a common point of contact can increase high-risk children’s access to appropriate and timely early intervention services. Relatedly, we hope to use this case to highlight the medical complexity of these young foster care children and hope to support program and policy development. Third, many of these children are at risk for experiencing multiple foster-care placements. Multiple placements have been related to increased maladaptive functioning (Lloyd & Barth, 2011). We hope to use this case to highlight how providing consultations services, short term emergency care, and facilitating the prioritization and referrals to community services, integrated care settings like these may decrease the likelihood of multiple placements.

Case Background

Anna is a 2-year 8-month-old Black female who presented to the AMC. Anna was accompanied by her foster mother Rachel*, who was interested in gaining a better understanding of Anna’s behaviors and wanted to learn additional techniques to help support her development. Rachel described Anna as bold, talkative, active, and loving. Rachel had an initial interest in adopting Anna, but had concerns about her ability to provide long term care due to Anna’s many medical and emotional needs.

Based on a medical record review and foster/adoptive parent interview, Anna was prenatally exposed to marijuana, cocaine, and alcohol. Anna’s biological mother experienced homelessness and engaged in sex work while pregnant. Anna’s biological mother has a history of substance use, an anxiety disorder, and depression. Anna was born at 36 weeks gestation via cesarean section due to maternal preeclampsia. At birth Anna weighed 3 lbs. and spent one week in the neo-natal intensive care unit due to her low birth weight. At birth, she had Δ9-tetrahydrocannabinol (THC) in her system and was potentially exposed to a Sexually Transmitted Disease. As a young infant, Anna was reported to have spent time with various caregivers for extended periods of time while under her biological mother’s care and experienced residential mobility. At 10 months, Anna had a documented emergency room visit after reportedly being dropped by her biological mother. At 11 months, she was removed from her biological mother’s care due to concerns for neglect and placed with her current foster family. At placement, Anna was malnourished – weighing only 11 lbs. – and was diagnosed with failure to thrive. Since being placed with her foster parent, Rachel reported multiple ear infections but otherwise noted that Anna had appeared to be medically healthy. At the time of the AMC visit Anna was living with her two foster parents, her biological sister (1-year-old), and three foster siblings (9, 5, and 2 years old). Anna did not have any contact with her biological mother or father since being in foster care.

At the initial foster care placement, Anna displayed flat affect and was socially uninhibited. At the time of evaluation, Anna displayed extreme difficulties with separating from her foster parents, often refused food, and had no independent self-soothing behaviors. Anna and Rachel had previously engaged with play therapy, but Rachel reported that it seemed to make Anna’s symptoms worse. Rachel noted high levels of intense meltdowns after play therapy sessions as well as regression in her toileting abilities. Due to these symptoms, they ceased services. Over the few months leading up to the appointment, Anna displayed high-intensity distress and anger at home and appeared inconsolable. In order to manage Anna’s emotional and behavior needs, Rachel took 6 months off of work and sent Anna’s 1-year old biological sister and foster siblings to daycare. This was a challenging experience financially and emotionally for Rachel and the other children. Additionally, there were concerns with sensory processing, speech development, and muscle reflex issues. Anna covered her ears during loud noises, displayed freezing behaviors in new or unfamiliar situations, and had a hard time with zippers and putting clothes on.

Implementing the Early Childhood Mental Health Therapeutic Consultation Protocol

Anna and her foster mother spent an hour with our multi-disciplinary team of occupational therapist, nurses, medical doctors and psychologists. All team members were present for the duration of the visit. Results of the medical exam noted generalized muscular weakness, vitamin D insufficiency, iron deficiency, and tonsillar hypertrophy. Anna was prescribed a series of vitamin supplements. The experience of traumatic stress and micro-nutritional deficit prenatally and in early childhood may cause an altered vitamin D metabolism in children (Terock et al., 2020). Further, iron deficiency – also related to micro-nutritional deficits – can worsen for children directly in proportion to the amount of rapid post-placement growth (Fugelstad et al., 2008). Both nutritional issues have been related to numerous long-lasting developmental and cognitive deficits (Doom et al. 2014; Terock et al., 2020).

Due to prenatal exposure to substances, the medical team assessed Anna for the facial features of prenatal alcohol exposure. Her facial feature measurements were not consistent with those seen in children with Fetal Alcohol Spectrum Disorder. The occupational therapy team noted a speech delay and slight sensory processing difficulties on their developmental screening. They recommended a full assessment with a speech language therapist.

In Visit Observations

The mental health team observed Anna’s interactions with her primary caregiver, Rachel, and her emotional reactivity/regulation during novel situations. During the visit, Anna started by cuddling into her foster mother and was not interested in exploring the toys in the room. Throughout the hour Anna became increasingly more interested in the toys and displayed more positive emotions. Anna looked to her foster mother for support when she was unsure of toys or new people. Her mother provided comfort as well as acknowledged and validated her emotional expressions (both positive and negative). Anna appeared to experience her foster mother as an emergent secure attachment figure. However, Anna appears to have a difficult time relying on Rachel to provide support when she became distressed. At those moments Anna would appear to freeze in the middle of the room. Anna appeared to become particularly distressed and cover her ears if she believed something would make a loud noise. Observations of Anna suggested that she was developmentally delayed in her fine motor movements, and speech. Anna also demonstrated potential delays in social-emotional development.

Mental Health Treatment and Therapeutic Outcomes

At the end of the initial visit, the mental health provider engaged in a short educational intervention, using augmented protocols from the circle of security program (Zanetti et al., 2011). We described the impact of children’s trauma on development and highlighted the ways Anna’s trauma was playing out in her relationship with Rachel. Trained Circle of Security providers ( https://www.circleofsecurityinternational.com/trainings/about-trainings/ ) introduced the circle and being with Anna on the circle. The provider and Rachel practiced identifying when Anna was on the top or bottom of the circle over the course of the medical exam. The mental health team referred Anna to receive a full DC-0-5 screening from our team and engaged with two brief emergency intervention sessions to build Rachel’s skills on identifying when Anna was experiencing distress and how to help soothe that distress. The team also assisted Rachel in setting up respite caregiving services. Anna was referred to and subsequently engaged in early childhood day-treatment therapy services. Rachel also engaged with a circle of security group through our partner community clinics. Outside of the mental health and medical interventions described above, Anna received OT services for her speech and sensory concerns. At a follow-up appointment approximately one year later with AMC, Anna was still placed with the same foster family. They reported that many of the interventions helped reduce Anna’s symptoms and that they are hoping to move forward with adoption.

Piloting the Early Childhood Mental Health Evaluation Protocol

In the pilot of the evaluation protocol that Anna took part in at the AMC, there were 105 children like Anna seen by the clinic team in the span of ten months. Children ranged from 0.7 to 71 months of age and were 41.38 months on average. They were 43.3% female and 72% (n = 75) of the children were in foster care. There were thirty-one domestically adopted children and twenty children adopted internationally. Of those adopted internationally, fourteen had experiences of institutional care. On average children experienced 2.35 transitions, but this ranged from one transition to seven. Children were 10.61 months old on average at their first primary caregiver transition, and children were 24.49 months at their most recent transition. All children had experienced some form of neglect or abuse, with the most common experience being parental drug use (n = 49 parental drug use; n = 64 prenatal drug exposure; n = 43 prenatal alcohol exposure). Of the children seen at the clinic, 21 experienced physical abuse, 19 witnessed domestic violence, and 36 experienced neglect.

Approximately 68% (n =71) of primary caregivers noted behavioral, social, or emotional concerns for their children at the onset of the visit. Concerns included failure to thrive, broad developmental delays, sleep difficulties, feeding difficulties, high amounts of emotional distress and difficulty soothing. Clinical observations noted that 24% (n = 25) of children exhibited maladaptive stress behaviors. However, the vast majority of children sought and received comfort from their caregivers effectively (n = 82; 79%). There were five children who exhibited significant levels of indiscriminate friendliness by clinician observation.

Only 32% (n = 23) of these children were accessing psychological services at the time of their visit, and 29% (n = 30) of all children had seen a neuropsychologist. Three of those receiving neuropsychological evaluations were based in DC:0-5 protocols (2016). DC:0-5 evaluations review the development and functioning of young children in the context of their relationship with caretakers and other environmental inputs such as traumatic events. Of the children who had caregiver reported emotional and behavioral concerns or exhibited difficulties in the clinic, six were referred for an immediate consultation or brief therapeutic interventions with the early childhood mental health team.

At the time of this manuscript, four of those referrals have been fulfilled. Of the two whose referral has not been fulfilled, one lived out of state and the other is unknown. Further, twenty-six individuals were referred for a full mental health assessment with our team and eleven of those have been fulfilled. Many families traveled to the clinic from multiple hours away and either preferred to see a provider closer to them and/or we also recommended they could receive services from a member of the community closer to their homes. We recommended that forty-eight children (46.7%) receive a trauma-informed diagnostic assessment and pursue evidence-based therapeutic treatment.

Conclusions and Clinical Recommendations

We found that social, emotional, and behavioral concerns are highly prevalent and a central concern for foster care and adopted children (Measelle & Ablow, 2018; Shonkoff et al., 2012). These concerns often present in addition to the many medical symptoms’ that foster children are experiencing. Working with an interdisciplinary collaborative team can offer the opportunity for an efficient consideration of other etiologies for behavior and intervention programs to address sensory, physical, genetic, or neurodevelopmental issues. In Anna’s case, she was able to benefit from all aspects of these interventions including medical interventions for micronutrient deficiencies, as well as OT services. Collaborative consultation programs lower the amount of time families spend going to appointments as well as the time demands on providers. This is particularly a positive for families who live in rural communities, who have to travel far distances to receive care. It is essential to not only provide recommendations but also explicitly state how families should prioritize these recommendations. Anna needed help to first address her emerging attachment relationship with Rachel in addition to her immediate medical concerns. Following these services, additional pediatric rehabilitation and sensory-based interventions were effectively introduced.

Collaborative environments should create access points to care while also decreasing the strain of accessing care on families who are balancing the many needs of their children. Potential community mental health referrals should be located in a convenient location for families and operate under a developmental and trauma-informed lens and offer evidence-based treatment. Creating referral lines and professional relationships with community clinics that provide this care was an element central to this program’s success.

However, we also found that for cases like Anna’s it is essential to have opportunities for immediate longer therapeutic sessions with a mental health provider. Many families seeking our care are families currently in crisis where children are facing potential long-term harm to their developmental trajectory. This includes highly distressing child symptoms such as self-harm behaviors or those that are highly challenging for caregivers to manage and who are at risk for placement disruption due to these symptoms.

Integrated care settings that specialize in foster and adoptive care experiences in early childhood could greatly reduce the probability that children will sustain long term consequences of early childhood stress. This case study demonstrated the feasibility and need for these services. Future work should evaluate if access to multiple service providers in one meeting decreased the number of appointments for those children and if it increased knowledge, and access to appropriate therapeutic care for families. Further, studies should evaluate if access to therapeutic care reduces the child’s likelihood of foster care displacement.

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Palmer, Alyssa R., Institute of Child Development, University of Minnesota

Dahl, Claire, Department of Pediatrics, University of Minnesota

Eckerle, Judith K., Department of Pediatrics, University of Minnesota

Spencer, MaryJo, Department of Pediatrics, University of Minnesota

Gustafson, Kimara, Department of Pediatrics, University of Minnesota

Kroupina, Maria, Department of Pediatrics, University of Minnesota

Author Note:

Corresponding author is Maria Kroupina, PhD, LP. Department of Pediatrics, University of Minnesota, 717 Delaware St SE, Minneapolis, MN 55414; e-mail: [email protected]

This work was supported by the Minnesota Department of Human Services [1501MNAIPP-75-1516-1536]; The National Institute of Health [T32 MH015755] and the University of Minnesota Interdisciplinary Fellowship to the first author.

We thank the children and families who participated in our services and the work of Amina Qureshi for data processing.

Ethics Statement: The case study and descriptive pilot data provided were approved by the BLINDED Institutional Review Board. All participants provided consent for their data to be included in scientific research and their related products.

*All names presented in this publication have been changed for privacy.

Data Availability: The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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• Published: 17 April 2024

How much do adverse childhood experiences contribute to adolescent anxiety and depression symptoms? Evidence from the longitudinal study of Australian children

• Berhe W. Sahle 1 ,
• Nicola J. Reavley 1   na1 ,
• Amy J. Morgan 1   na1 ,
• Marie Bee Hui Yap 1 , 2   na1 ,
• Andrea Reupert 3   na1 &
• Anthony F. Jorm 1   na1  

BMC Psychiatry volume  24 , Article number:  289 ( 2024 ) Cite this article

287 Accesses

Metrics details

This study aims to: (i) examine the association between adverse childhood experiences (ACEs) and elevated anxiety and depressive symptoms in adolescents; and (ii) estimate the burden of anxiety and depressive symptoms attributable to ACEs.

Data were analyzed from 3089 children followed between Waves 1 (age 4–5 years) and 7 (16–17 years) of the Longitudinal Study of Australian Children. Logistic regression was used to estimate the associations between ACEs and child-reported elevated anxiety and depressive symptoms at age 16–17. Anxiety and depressive symptoms were measured using the Children’s Anxiety Scale and Short Mood and Feelings Questionnaire, respectively. The punaf command available in STATA 14 was used to calculate the population attributable fraction (PAF).

Before the age of 18 years, 68.8% of the children had experienced two or more ACEs. In the analysis adjusted for confounding factors, including co-occurring ACEs, both history and current exposure to bullying victimisation and parental psychological distress were associated with a statistically significant increased likelihood of elevated anxiety and depressive symptoms at age 16–17. Overall, 47% of anxiety symptoms (95% CI for PAF: 35–56) and 21% of depressive symptoms (95% CI: 12–29) were attributable to a history of bullying victimisation. Similarly, 17% (95% CI: 11–25%) of anxiety and 15% (95% CI: 4–25%) of depressive symptoms at age 16–17 years were attributable to parental psychological distress experienced between the ages of 4–15 years.

The findings demonstrate that intervention to reduce ACEs, especially parental psychological distress and bullying victimisation, may reduce the substantial burden of mental disorders in the population.

Peer Review reports

Introduction

Mental disorders remain a major cause of morbidity, mortality, and economic burden worldwide [ 1 , 2 ]. The lifetime prevalence of having one or more mental disorders by the age of 75 years is estimated to be up to 47% [ 3 ]. Despite an increase in the availability of treatment in many countries, there is little evidence that the burden of mental illness is decreasing [ 4 , 5 , 6 ]. Moreover, the global economic burden of mental disorders is predicted to rise to $16 trillion by 2030, primarily due to early onset of mental illness and lost productivity across the life course [ 4 ].

There is growing evidence that the lack of emphasis on prevention and early intervention underlies the lack of improvements in the population burden of mental disorders [ 5 , 6 ]. While increasing access to mental health services is central to improving population mental health, even if all those requiring treatment obtained it, approximately 60% of the burden of mental disorders would not be averted [ 7 ]. This underscores the importance of prevention of mental disorders with accumulating evidence pointing to the benefits of preventive interventions that aim to reduce risk factors and enhance protective factors [ 1 , 5 ]. Making progress in this area requires us to target the biggest contributors to mental disorders in order to have a major impact on the population prevalence and burden of disease [ 8 ]. These include adverse childhood experiences (ACEs) [ 8 ].

ACEs are defined as exposures to traumatic experiences during childhood (0–17 years). They include childhood maltreatment, maladaptive parenting practices (e.g., harsh discipline, aversiveness, over-involvement or parent-child conflict), household dysfunction (e.g., substance or alcohol misuse, family violence, and parental separation/divorce), violence and socio-economic adversity [ 9 , 10 ]. Globally, ACEs are prevalent, with three in five adults having experienced at least one ACE and a quarter of adults having experienced at least three [ 11 , 12 , 13 ]. ACEs are associated with an increased prevalence of physical and mental health problems across the life course, including mental health disorders, suicidal behaviours, unhealthy lifestyle behaviours and chronic non-communicable diseases [ 14 , 15 ]. For example, children exposed to four or more ACEs have four times higher odds of having anxiety or depressive disorders, compared with children who were not exposed to any ACEs [ 14 ]. Furthermore, there is evidence that ACEs and their negative effects can be transmitted from one generation to the next, leading to their intergenerational transmission [ 16 ]. In this study we defined ACEs as stressful and potentially traumatic events occurring in childhood or adolescence that can negatively impact health and well-being. ACEs include financial hardship, family drug or alcohol abuse, marital separation, verbal or physical interpersonal conflict, unsafe neighbourhood, parental psychological distress, death of family member, and bullying victimisation [ 14 , 17 ].

ACEs are common globally, however, the prevalence of specific types of ACEs and their contribution to the risk of mental disorders varies across and within populations [ 15 , 18 ]. Therefore, intervention efforts need to prioritise those ACEs with the largest potential population benefits in terms of preventing poor mental health outcomes. Calculating the population attributable fraction (PAF) of each ACE can inform action in this area. The PAF combines the prevalence of a risk factor and the strength of association with an outcome, allowing us to measure the proportion of an outcome that would have been prevented in a population over a given period of time by reducing the population’s exposure to a risk factor to a theoretically minimal risk.

Previous studies on the association between ACEs and common mental disorders have a number of limitations, as they are largely focused on individual types of ACEs, such as child maltreatment or bullying [ 18 , 19 , 20 , 21 ] This approach has been employed despite the frequent co-occurrence of multiple forms of ACEs in certain families, which can have an additive or multiplicative impact on a range of health outcomes. Second, most of the studies examining the links between ACEs and mental disorders involve adults and are based on cross-sectional designs or retrospective assessment of exposure to ACEs in childhood [ 14 , 15 ]. In addition to the inherent limitations of retrospective assessment, onset of mental disorders in adulthood is likely to be confounded by exposure to a wide range of life events after childhood. Prospective longitudinal studies that include exposure to multiple ACEs across childhood are required to better understand the PAF of ACEs on mental disorders.

Using data from the Longitudinal Study of Australian Children (LSAC), this study examines the association between a range of ACEs and elevated depression and anxiety symptoms, in order to estimate the PAF of anxiety and depressive symptoms associated with ACEs. The LSAC is a large, community-based cohort of Australian children that investigates the effect of children’s social, economic and cultural environments on their wellbeing over the life course [ 22 ]. The LSAC provides an excellent opportunity to identify which ACEs are associated with the largest burden from mental disorders in the Australian population.

Data source

This study analysed seven waves of data from the LSAC. Details of the study design, sampling, recruitment, and data collection for LSAC have been described previously [ 22 ]. LSAC commenced in 2004 (Wave 1) with a nationally representative sample of 10,090 children drawn from two cohorts of Australian children. Cohort B (“Birth”) includes 5107 children aged 3–19 months and Cohort K (“Kindergarten”) includes 4983 children aged 4 to 7 years at Wave 1. Data have been collected biennially. Overall, LSAC collects data from multiple informants, including children, parents, teachers and childcare workers. Variables collected include family demographics, finances, health status, health behaviour and risk factors, relationships, parenting, long-term chronic conditions, and children’s social and emotional outcomes, via face-to-face interview, self-administered questionnaire, child self-report interview, computer-assisted telephone interview, and observations made by interviewers.

We analysed ACEs reported between Waves 1 and 7 of the K-cohort of the LSAC survey, and anxiety and depressive symptoms reported by the child at Wave 7. Our analyses focus on children’s self-reported anxiety and depressive symptoms in the most recent wave because children are deemed to become more reliable reporters of their own mental health as they get older [ 23 ].

Anxiety symptoms were assessed based on the 8-item Children’s Anxiety Scale (CAS-8) derived from the Spence Children’s Anxiety Scale short form. Children are asked to rate on a 4-point scale (1 = Never, 4 = Always), the frequency with which they experience symptoms of anxiety such as: ‘I worry about things’; ‘I feel afraid’; and ‘I feel nervous’. The CAS-8 has demonstrated good reliability as an indicator of anxiety symptoms. Total scores of ≥ 13 for males and ≥ 16 for females are considered indicative of elevated or clinical levels of anxiety [ 24 ].

Depressive symptoms were assessed using the Short Mood and Feelings Questionnaire (SMFQ). The SMFQ is a 13-item self-report measure of depressive symptoms for children aged 8–16 years. Assessed over the last two weeks, items include, ‘I felt miserable or unhappy’, ‘I didn’t enjoy anything at all’, and ‘I felt I was no good at all’. Response options are true (= 2), sometimes true (= 1), and not true (= 0). Total SMFQ scores range from 0 to 26, and a score of 11 or higher has been shown to have a high sensitivity and specificity in identifying those who meet criteria for a diagnosis of major depressive disorder [ 25 ]. In this study, scores of 11 or higher were considered indicative of elevated depressive symptoms.

In each Wave of the LSAC, parents were asked six questions relating to their experience of stressful financial events that occurred in the year preceding the survey. A count of the number of stressful financial events (0–6) was used to indicate the extent of financial hardship, with higher values indicating higher levels of financial stress. Financial stress was dichotomized as having parent 1 and/or parent 2 have at least 1 financial stress vs. neither parent has financial stress.

Parental psychological distress was assessed for each parent at all Waves using the 6-item Kessler Psychological Distress Scale (K-6). Parents reported on a five-point rating scale the extent to which they experience symptoms of psychological distress, such as feeling nervous, hopeless, restless, extremely sad, and worthless over the previous four weeks. Responses were summed and a cut-off point of 13 and above was used for the assessment of probable clinical-level psychosocial distress [ 26 ]. Parental psychological distress was dichotomized as: parent 1 and/or parent 2 have psychological distress, or neither parent has psychological distress.

Hostile parenting, which refers to parenting behaviour that expresses hostility, aggression, irritability, and anger towards a child, was assessed through reports by both parents in Waves 3 and 4 [ 27 ]. Hostile parenting behaviours were reported on a frequency rating scale (never/almost never; rarely; sometimes; often; always/almost always) to a battery of 4-questions relating to how parents had been feeling or behaving with the child during the preceding four weeks. Item scores were averaged to give overall scores for hostile parenting with higher values indicating higher levels of hostile parenting. Hostile parenting was dichotomized as: parent 1 and/or parent 2 have hostile parenting score in the top 10% vs. neither parent has hostile parenting score in the top 10% [ 28 ].

Bullying victimisation between Waves 1 and 4 was reported by the child’s mother and is based on a single question asking whether the child has been picked on or bullied by other children. At Waves 5, 6, and 7, children were asked (on a 4-point rating scale) the following question to assess whether they have experienced bullying: Please indicate if any of the following statements happened during the past 30 days at school: (i) Kids hit or kicked me on purpose; (ii) Kids grabbed or shoved me on purpose; (iii) Kids threatened to hurt me or take my things; (iv) Kids said mean things to me or called me names; (v) Kids tried to keep others from being my friend; (vi) Kids did not let me join in what they were doing; (vii) Kids sent me a mean text message/email; or posted mean things about me on the Internet. Those children who responded ‘never’ to all seven questions were categorised as “not victims of bullying” or otherwise as “bullying victims”.

Verbal inter-parental conflict was assessed in all Waves by asking mothers to rate on a 5-point scale about how often they and their partners engage in disagreements (e.g. ‘‘How often is the conversation awkward or stressful?”). Verbal inter-personal conflict was present if mothers responded “often” or “always” to at least one of the four items [ 29 ].

Physical inter-parental conflict was measured at all Waves, by asking mothers to rate on a 5-point scale “How often do you have arguments with your partner that end up with people pushing, hitting, kicking or shoving?’’. A response of “sometimes’’, ‘‘often’’ or ‘‘always’’ represented presence of physical inter-parental conflict [ 29 ].

Parent alcohol or substance use problem was assessed by asking the mother if either of the parents had an alcohol or drug problem (Yes/No) in the last year.

Unsafe neighbourhood was defined as “disagreement” or “strong disagreement” with the statement “This is a safe neighbourhood”.

Data analysis

We estimated the prevalence of the ACEs across the seven Waves, and the prevalence of elevated anxiety and depressive symptoms at Wave 7. We then used logistic regression models to estimate the Odds Ratios (ORs) ± 95% Confidence Interval (CI) of having elevated anxiety or depressive symptoms among those who experienced ACEs compared to those who did not. We ran two separate regression models to compare the: (i) cross-sectional associations between ACEs and elevated anxiety and depressive symptoms at age 16–17 (Wave 7), and (ii) history of exposure to ACEs between ages 4–15 (Waves 1–6) and elevated anxiety and depressive symptoms at age 16–17. In our analyses, where we explored the associations between the prior history of ACEs and depressive and anxiety symptoms at Wave 7, we excluded individuals with elevated anxiety and depressive symptoms in the preceding wave (Wave 6). A cumulative ACE score was calculated based on report of the first exposure to individual ACEs across any of the six follow up waves (1 = yes, 0 = no), and then grouped into categories: 0, 1, 2, and 3 or more. PAFs for anxiety and depressive symptoms due to ACEs significantly associated ( P  < 0.05) with elevated anxiety and depressive symptoms were estimated based on the respective prevalence rates of ACEs and the ORs. The punaf command available in STATA 14 was used to calculate the population attributable fraction (PAF) from the final multivariable logistic regression model. Ethics approval was not required for this because it uses de-identified publicly available data from the LSAC survey.

Characteristics of study participants

A total of 3089 children (51% males) responded to Wave 7 of the LSAC survey and were included in this study. Aged 16–17 years, most children (95.9%) were born in Australia and only 9.8% spoke a language other than English at home. Table  1 presents a summary of sociodemographic and other background characteristics of the study population.

Prevalence of ACEs and elevated anxiety and depressive symptoms

Before the age of 18 years, 68.8% of the children had experienced two or more ACEs. Bullying victimisation (54.1%) and exposure to verbal or physical interparental conflict (23.4%) were the most commonly reported ACEs. About a quarter of the parents (23.4%) had experienced two or more (2.1%) financial stresses (e.g., could not pay mortgage or rent on time) and 13.8% had psychological distress. Children had a mean of 2.4 ACEs (SD = 1.3) across the seven Waves. The number of ACEs was comparable in both males and females, but was higher in children of parents who were unemployed or who lived in disadvantaged areas. Table  2 and Supplementary File Table S1 ) show the prevalence of ACEs between Waves 1 and 7 of the LSAC.

30% of children reported elevated depressive symptoms and 16.1% reported elevated anxiety symptoms at age 16–17 years. The prevalence of both elevated depressive symptoms (36.4% vs. 26.6%) and elevated anxiety (17.6% vs. 14.5%) symptoms was higher in females than males.

Cross-sectional association between ACEs and anxiety and depressive symptoms

Table  3 shows the cross-sectional association between ACEs and elevated anxiety and depressive symptoms at Wave 7 and the corresponding PAF. After adjusting for potential confounding factors, elevated anxiety and depressive symptoms were significantly higher in children who reported being bullied by other children, and children whose parents experienced psychological distress. Children who reported being bullied by other children (OR = 2.91, 95% CI: 2.23–3.80) and whose parents had psychological distress (OR = 1.90, 95% CI: 1.20–2.99) had greater odds of having elevated anxiety symptoms. Similarly, bullying victimisation (OR = 1.76, 95% CI: 1.28–2.41) and parental psychological distress (OR = 1.86, 95% CI: 1.23–2.79) were independently associated with increased odds of elevated depressive symptoms. Furthermore, a larger total number of ACEs experienced by children was associated with greater odds of elevated depressive or anxiety symptoms. The odds of elevated anxiety symptoms were 2.27, 3.69 and 4.88 times higher in children who reported one, two and three or more ACEs, respectively, compared to those who reported no ACEs. Similarly, children who reported one, two, and three or more ACEs had 1.52, 2.02 and 2.76 times greater odds of elevated depressive symptoms. The association between several other ACEs, including household alcohol or drug abuse, unsafe neighbourhood, and household financial stress, and elevated anxiety and depressive symptoms did not persist after adjusting for potential confounding factors.

Overall, 47% of anxiety symptoms (95% CI for PAF: 40–57) and 21% (95% CI for PAF: 33–45) of depressive symptoms were attributable to bullying-victimisation. A small but significant proportion of anxiety (PAF: 6%, 95% CI: 3–9) and depressive (PAF: 5%, 95% CI: 2–8) symptoms were attributable to parental psychological distress.

Association between history of ACEs and elevated anxiety and depressive symptoms

We analysed the association between exposure to ACEs between Wave 1 (4–5 years) and Wave 6 (14–15 years) and elevated anxiety and depressive symptoms at Wave 7 (16–17 years) (Table  4 ). Bullying victimisation (OR = 1.49, 95% CI: 1.06–2.09) and parental psychological distress (OR = 1.84, 95% CI: 1.24–2.75) were associated with a statistically significant increased odds of elevated anxiety symptoms. Similarly, the odds of elevated depressive symptoms were significantly higher for bullying victimisation (OR = 1.78, 95% CI: 1.24–2.56) and parental psychological distress (OR = 1.41, 95% CI: 1.05–1.91). Children who reported two, three and four or more ACEs had 1.34, 2.75 and 2.53 times greater odds of elevated anxiety, compared to those who reported no ACEs. Similarly, children who reported two, three, and four or more ACEs had 1.43, 1.81 and 1.84 times greater odds of elevated depressive symptoms compared to those who reported no ACEs. However, the increased odds of elevated anxiety and depressive symptoms in children exposed to only one ACE did not reach statistical significance. There was no significant interaction between sex of child and ACEs for elevated depressive or anxiety symptoms. The PAFs of anxiety symptoms associated with ACEs ranged from 6% for financial stress to 15% for parental psychological distress. The PAFs of depressive symptoms associated with bullying victimisation and parental psychological distress were 17% and 15% respectively (Table  4 ).

Our findings of the associations between ACEs and elevated depressive symptoms did not substantially change when the cut-off for elevated depressive symptoms was defined as the top 10% of the SMFQ score, and anxiety symptoms as CAS-8 of ≥ 18 for males and ≥ 21 for females (Supplementary File Table S2 ).

Using a large population-based cohort of Australian children, this study explored the prevalence of a comprehensive list of ACEs and their contribution to the risk of anxiety and depressive symptoms in the population. While ACEs were highly prevalent across all demographic characteristics, bullying victimisation and parental psychological distress were the major contributors to elevated anxiety or depressive symptoms independent of demographic characteristics and coexisting ACEs. The findings strengthen evidence that a substantial burden of anxiety and depressive symptoms in adolescence may be preventable through evidence-based interventions targeting bullying victimisation and parental psychological distress.

A key finding of this study is that even though most of the ACEs were associated with anxiety and depressive symptoms in the individual analyses, after adjusting for potential confounding factors including other ACEs, only bullying victimisation and parental psychological distress remained significant. Previous studies have focused on the association between individual ACEs and mental illness, often without accounting for the effect of co-occurring ACEs, even though most children experience multiple ACEs [ 15 , 30 ]. In those studies focusing on a single type of ACE, it is not possible to assess whether observed associations represent the downstream effect of other ACEs or are linked to other co-occurring ACEs [ 31 ]. Differences in the prevalence of ACEs across populations [ 32 ], and variations in access to health and social services that could moderate the impact of ACEs on mental disorders [ 33 ], may also partly explain why some ACEs were not significantly associated with anxiety and depressive symptoms in those studies.

It has been consistently reported that ACEs are common across all population groups, although the prevalence rates vary across populations and according to the definition of ACEs [ 32 ]. Our findings that two out of three Australian children had experienced two or more ACEs before the age of 18 years is comparable with data from previous studies in other countries [ 32 , 34 , 35 ]. A recent meta-analysis of 96 studies reporting the prevalence of ACEs in school-aged youth (≤ 18 years) found that two thirds of youth experience ACEs no matter where they reside across the world [ 32 ]. There was no sex difference in the prevalence of ACEs in this study. Despite the importance of disaggregating the prevalence rates of ACEs by population characteristics, the gender-specific prevalence rate of ACEs is not commonly reported in the literature [ 32 ].

Our findings of the extent to which bullying victimisation contributes to elevated anxiety and depressive symptoms are in line with the literature [ 30 ]. For example, a birth cohort study from United Kingdom found that 29.2% (95% CI:10.9–43.7) of depression diagnosis at age 18 years was attributable to bullying victimisation at the age of 13 years [ 30 ]. Findings from the World Mental Health Surveys showed that parental mental illness was strongly associated with a range of mental health problems in offspring, with a PAF of 13% for anxiety disorders and 10% for mood disorders [ 36 ]. Although previous studies have found that both bullying victimisation and parental psychological distress contribute to the risk of anxiety disorders and depression in adolescents, the PAFs may vary across studies mainly due to difference in the prevalence rates of bullying victimisation and parental mental illness. A recent global study of more than 317,000 adolescents (12–17 years) from 83 countries found that the prevalence of bullying victimisation varies across countries, ranging between 8% and 45% [ 37 ]. Similarly, the burden of psychological distress varies substantially across population groups [ 38 ].

In light of the significant burden of anxiety disorders and depression in adolescence, our findings have important implications for policy and health promotion interventions. Given that bullying victimisation and parental psychological distress are the major contributors to elevated anxiety and depressive symptoms in adolescence, intervention programs that show evidence of reducing rates of these ACEs are likely to have substantial population benefits over time. A meta-analysis of 14 randomized clinical trials of anti-bullying school programs found a significant reduction in bullying and improvement in attitudes against bullying [ 39 ]. Another meta-analysis of 53 different anti-bullying programs demonstrated that school-based anti-bullying programs result in a 20% decrease in bullying victimisation [ 40 ]. However, it has also been demonstrated that these programs have greater impact in younger children and their effectiveness decreases with age [ 39 , 41 ]. The substantial burden of elevated anxiety and depressive symptoms attributable to parental psychological distress, and existing evidence of clustering of ACEs in families [ 13 , 42 ], suggest that children whose parents have elevated psychological distress constitute an essential target group for preventive interventions. There is evidence to show that preventive interventions such as mental health treatment for parents, parenting support and family-focused interventions result in small but significant improvements in child mental health outcomes and a reduction in the risk of intergenerational impacts of parental mental illness [ 43 ].

This study has some limitations that should be considered when interpreting the findings. One of the major limitations is that data on child maltreatment, a key ACE that is strongly associated with poor mental health outcomes [ 15 ], was not collected in the LSAC. Some of the variables included in the analyses, including depressive symptoms, bullying victimisation and hostile parenting, lack validated measures and thresholds for objectively defining risk, and were therefore defined based on commonly used definitions from previous studies. However, sensitivity analyses conducted with a higher threshold level for indicating elevated depressive symptoms largely support these findings. Given the underrepresentation in the LSAC sample of children from families with a lower socioeconomic status, Aboriginal and Torres Strait Islander families, and children born overseas, the current findings may underestimate the association between ACEs and mental disorders in these subgroups of the Australian population. Although ACEs were collected prospectively in each wave, anxiety and depressive symptoms were not assessed in earlier waves, thereby limiting longitudinal analyses.

In this large population-based cohort study of Australian adolescents, two-thirds of children were reported as having experienced two or more ACEs before age 18 years. Between 13 and 47% of the burden of depressive or anxiety symptoms at age 16–17 years could be attributed to bullying victimisation, and between 6 and 15% to parental psychological distress. The findings suggest that interventions targeting these ACEs, as the major contributors to elevated anxiety and depressive symptoms in adolescence, may reduce the substantial burden of mental disorders in the population.

Data availability

The authors do not have permission to share data. LSAC data can be requested through an application to the Australian Data Archive Dataverse at the Australian Government Department of Social Services ( https://dataverse.ada.edu.au/ ).

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Acknowledgements

This study is based on data set from the Longitudinal Study of Australian Children. The study is conducted in partnership with the Department of Social Services (DSS), the Australian Institute of Family Studies (AIFS) and the Australian Bureau of Statistics (ABS). The findings and views reported in this paper are those of the authors and should not be attributed to the DSS, the AIFS or the ABS.

This study is funded by NHMRC and Beyond Blue co-funded Centre of Research Excellence in Childhood Adversity and Mental Health (#1153419). The funders had no role in study design or preparation of this report.

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Nicola J. Reavley, Amy J. Morgan, Marie Bee Hui Yap, Andrea Reupert and Anthony F. Jorm contributed equally to this work.

Authors and Affiliations

Centre for Mental Health, Melbourne School of Population and Global Health, University of Melbourne, 207 Bouverie Street, Carlton, Melbourne, VIC, 3010, Australia

Berhe W. Sahle, Nicola J. Reavley, Amy J. Morgan, Marie Bee Hui Yap & Anthony F. Jorm

School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia

Marie Bee Hui Yap

Faculty of Education, Monash University, Melbourne, VIC, Australia

Andrea Reupert

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BWS, NJR, AJM, MBHY, AR, AJF contributed to the design of the study. BWS did the analyses and wrote the draft report. NJR, AJM, MBHY, AR, AJF contributed to critically revising the consecutive drafts. All authors reviewed the study findings and approved the final version before submission.

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Correspondence to Berhe W. Sahle .

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Supplementary Materials 1: Supplementary file Table S1:

Distribution of adverse childhood experiences in Wave 7 of the K-cohort of Longitudinal Study of Australian Children; Supplementary file Table S2: Association between adverse childhood experiences prior to Wave 7 and anxiety and depressive symptoms at Wave 7 in the K-cohort

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Sahle, B.W., Reavley, N.J., Morgan, A.J. et al. How much do adverse childhood experiences contribute to adolescent anxiety and depression symptoms? Evidence from the longitudinal study of Australian children. BMC Psychiatry 24 , 289 (2024). https://doi.org/10.1186/s12888-024-05752-w

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Received : 16 February 2023

Accepted : 09 April 2024

Published : 17 April 2024

DOI : https://doi.org/10.1186/s12888-024-05752-w

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