450. Q&A: How to know if my child may have depression?

Dr. Sarah Bren (00:02):

Ever wonder what psychologists moms talk about when we get together, whether we’re consulting one another about a challenging case or one of our own kids, or just leaning on each other when parenting feels hard, because trust me, even when we do this for a living, it’s still hard. Joining me each week in these special Thursday shows are two of my closest friends, both moms, both psychologists, they’re the people I call when I need a sounding board. These are our unfiltered answers to your parenting questions. We’re letting you in on the conversations the three of us usually have behind closed doors. This is Securely Attached: Beyond the Sessions.

(00:44):

Hello. Welcome back to the Securely Attached Podcast. This is the Beyond the Sessions segment of our podcast where we answer listener questions. And Rebecca Hershberg, thank you so much for being here.

Dr. Rebecca Hershberg (00:56):

My pleasure.

Dr. Sarah Bren (00:57):

It’s lovely to see your face.

Dr. Rebecca Hershberg (00:59):

And yours.

Dr. Sarah Bren (01:01):

And for all of our listeners who are used to our BTS Q&A episodes being audio only, you can now see Rebecca’s beautiful face on YouTube because we’re doing video now. But so first of all, I’m very glad that you’re here because I got a really, I think what I feel like is a really important listener question that I’m glad you are here to weigh in on. So are you ready for our question of the week?

Dr. Rebecca Hershberg (01:33):

Sure.

Dr. Sarah Bren (01:34):

Okay. So this mom wrote in, “Hi, Sarah. I have a sensitive four-year-old boy who recently in the last couple of months has been telling me he’s feeling sad. He would tell me he is feeling sad forever, multiple times a day, sometimes constantly when I’m with him. And sometimes it’s the first thing he says to me when he wakes up in the morning. I usually try not to make a big fuss, acknowledge it, remind him that it’s okay to feel sad and give him a hug, then move on. When I ask him what is making him feel sad, he will usually say, I just am, or I’m not sure why, and tells me that he wants to be happy instead. Since this, we’ve been reading lots of books about emotions and learning about jealousy. He has an 18 month old sister, disappointment, anxiety, et cetera, which I think he could be lumping with sadness.

(02:27):

He also often tells me he is sad when he is also tired, so I think that is related too. I guess I’m just trying to seek some reassurance and your thoughts on how to support him better. I grew up with emotionally inattentive parents and have been plagued by anxiety and depression throughout my life and I do not want the same for him. Thanks for all your help. Kind regards.” I know.

Dr. Rebecca Hershberg (02:47):

What a beautiful question.

Dr. Sarah Bren (02:49):

I know. It really was. And just so you know, Rebecca, just for context, because I have a feeling we’ll talk about this in this episode, but because this email feels, it felt like it really warranted a very specific, not wait for a podcast episode to be aired, but specific response.

Dr. Rebecca Hershberg (03:06):

Yes, good. I’m very glad that you’re about to say what I think you’re going to say.

Dr. Sarah Bren (03:09):

Yeah. I responded in email and gave her some resources and some specific kind of encouragement to like, “Hey, let’s get some second eyes on this,” which is kind of what I was curious on your thoughts on for family. I mean, I still wanted this to be an episode because one, we don’t really have an episode that speaks about this. So I think it’s an important resource to build out for families. But two, I want there to be a resource for families who didn’t email someone and get a suggestion to go see a mental health professional if your kid is expressing this. I also want to be like, I don’t want to freak anyone out either and be like, “This is a crisis and we have to get scared.” It’s like this balancing act of when do we get help?

Dr. Rebecca Hershberg (03:52):

No, I don’t think it’s a crisis.

Dr. Sarah Bren (03:54):

No, it doesn’t sound like it.

Dr. Rebecca Hershberg (03:55):

I think hopefully for most families and getting help isn’t a huge lift because getting help can mean just talk to someone at the preschool or at school. As you were reading it, I was like, “This kid needs to be seen.” I think that four year olds can have, and even younger actually than four, can have depression. I’m not diagnosing him based on the email, but there’s enough in there that leads me to feel like this kid would have benefit from being evaluated for that. It’s rare that kids that young meet criteria for official depression, but the combination of what stood out to me in this email was how long the symptoms have been going on or how long he’s been saying, I shouldn’t say symptoms, but she said a few months. For a four year old, that’s a long time.

(04:59):

And the other thing that jumped out was the genetic loading. And I think I so applaud this mom for, as we’ve been saying at home, controlling the controllables. She’s saying, “I’m going to parent differently than I was parented. I’m going to seek help and reassurance when I need it. I’m going to read about emotions,” all those things. One of the things we can’t control is genetic loading and there is some genetic loading when it comes to mental illness and having a four year old say that often and for that long that he’s feeling really sad and he can’t say why, and it seems like maybe it’s combined with being tired or disappointed, but not only that. To me, again, what’s the con in getting some professional help? What’s the downside? I’m not sure there is one.

Dr. Sarah Bren (05:56):

Yeah. I think that makes me feel good because when I got the email, I was like, “Okay, I want to do an episode about this, but I don’t think that’s the first step for me in responding to that.” I would say, “I think it doesn’t hurt to get some eyes on this.” And the other part of me that always has this ear when I’m recording podcast episodes, knowing parents are going to listen. And I know that sometimes parents will listen to an episode and get scared or anxious or afraid like, “Oh gosh, depression. Could this be depression?” And one, I just want to name, while it’s rare, it’s also treatable and it might not be depression, but it’s never a bad idea to rule it out. And if it is depression, that’s also okay. We can deal with that. I guess it’s trying to help.

(06:46):

I’m going to try to hold this with open hands and a light touch of we don’t know what it is and it’s a rule out. And even if it ends up being a rule in, that’s also okay. It’s very treatable.

Dr. Rebecca Hershberg (07:04):

But it’s funny because I think often, and funny may not be the right word, but I think often on this podcast we’re talking about we’re just allaying parents’ fears like, “Oh my gosh, all kids hit. Even all kids sometimes bite. And here’s how to increase distress tolerance and here’s how to…” This mom that wrote in is clearly a listener because she said, “I’m trying not to make a big fuss about it,” or whatever word she used, which is absolutely right. Regardless, that I think is spot on, but it’s a new tone in some ways to this beyond the sessions because I think what we’re saying is like, “No, this is one to actually pay attention to.” And what I can see parents asking is sort of like, “Well, but how do I know? How do I know when?” You’re saying, Dr. Hershberg, that it’s duration.

(07:55):

So what’s the duration? What if my kid’s been saying it for two weeks? What about a month? And unfortunately, as with all of these things, there’s no formula, but we look at the usual stuff, the duration, the intensity. And with something like this, if this mom was in my office, I would go right to other indicators. So how is this child’s appetite? How is this child’s sleep? How is this child interfacing with peers to get a big picture? And so if you’re a parent listening and starting to worry, those are considerations.

Dr. Sarah Bren (08:38):

Yeah. And even things like, I’m thinking about things that might not obviously feel like they’re related to mood and feelings, but medical stuff. Sometimes you want to look at thyroid things for kids who are really low mood chronically. And again, these are just rule outs, but I don’t know.

Dr. Rebecca Hershberg (08:56):

Yeah, your pediatrician is always a good first stop. I mean, hopefully you have a pediatrician whom you trust. That’s something I speak with families about a lot. And if you do, it’s always kind of a good first with the understanding that most pediatricians are not experts in mental health, but they do get some training in some of the preliminary stuff and sort of that gateway into, do we need further evaluation or not?

Dr. Sarah Bren (09:23):

And they do know your kid too. And they know your kid. They know their baseline. That’s another thing is, to your point, Rebecca, we were talking about how do I know is looking at, is there a big shift from baseline? Is this a change in the way that they move through the world or is this temperamentally that’s always sort of been their pace and their speed and their mode of managing feelings? Sometimes when we’re looking at things like depression, it usually comes as something feels different. Something feels like I can’t quite put my finger on it, but they don’t quite feel like themselves will be a lot of things that people will describe when they’re talking to me in my office about when we’re looking at depression, changes in relationships, changes in interests, changes in what they want to do, losing interest in things they used to like to do, which sounds like also things she’s describing a little bit.

(10:34):

So I think that that’s also, for me, an indicator, a reason to kind of look into this and take it really, again, take it seriously, not because it’s a crisis, but because elevating it to a slightly more intentional level of care could really, really be supportive and helpful.

Dr. Rebecca Hershberg (10:54):

And this kid is asking. This kid is asking for help. I mean, this kid isn’t just walking around saying they’re sad and then that’s the end of the conversation. This kid is saying, “I want to be happy.” Now granted, he’s four. And so that’s a very simplistic way to phrase that. I’m sad and I want to be happy, but that’s a version of, “Can you help me, mom? I don’t feel the way I want to feel. I don’t feel good. Something’s wrong. Can you help me?”

Dr. Sarah Bren (11:19):

Yeah. And maybe we could talk a little bit about what that might look like. Obviously different therapists have very different approaches to working with kids this young, but maybe we could talk a little bit about the types of options out there for parents who are like, “I think I would like to get some mental health kind of… I want an evaluation to have them take a look.” But also if they do feel like therapy would be the next step, what might those types of interventions look like for a four year old showing signs of sadness, pervasive sadness?

Dr. Rebecca Hershberg (11:52):

Yeah. I mean, I think generally with kids this young… So first of all, I just want to say that if you are looking for a mental health provider to see a child this young, you need to sort of really look and make sure they do because there’s a lot of providers, even child therapists who will say that they see kids only 10 and over or five and over.

Dr. Sarah Bren (12:17):

Even like six and over.

Dr. Rebecca Hershberg (12:18):

Yeah.

Dr. Sarah Bren (12:18):

Exactly. Four is really young for therapy, but it certainly can be done.

Dr. Rebecca Hershberg (12:23):

It certainly can be done, but you’re looking for people that typically on their websites or whatever specify that, that they have an expertise in working with really young kids, with toddlers, with preschoolers. Certainly one component of that is, of course, especially when it comes to giving the history and whatnot, is family work. It’s a lot of work when your kid is that young with a parent or caregiver or guardian. And then with the child themselves, it’s frequently very play-based. Whatever angle you’re coming at it from, you’re not going to sit and talk to a four-year-old, but it’s a lot of use of stories, of books, often stuffed animals or puppets. And the idea is through play or through activities, getting an understanding of what’s going on for that child and are there thinking patterns or are there stressors we don’t know about? And then through play and activities, helping to provide some coping advice, not in a didactic way, but in a kind of experiential way. That sounds probably very difficult to understand as someone who’s not a psychologist.

Dr. Sarah Bren (13:40):

To me it makes sense.What I’m hearing is we’re not going to teach a four-year-old. We might explicitly say, when you feel sad, we could build this little box of…

Dr. Rebecca Hershberg (13:51):

Happy though.

Dr. Sarah Bren (13:52):

Happy thoughts or places that you can go to feel better, but that’s very on the nose. I think for a four-year-old, it’s often going to look like working out some of these strategies through play secondary, indirectly like, “Oh, this doggie’s feeling a little bit sad today. What could we do to help this doggie feel better?” And we could build a whole world for the doggy that what does this doggie need? And it’s because kids work better inside of this sort of zone of play and this once removed world of imagination. And for them, there’s very little separation between my internal world that’s about me and my internal world that’s about play. It’s fused. It’s appropriately fused. It’s the fantasy blends into reality in an appropriate way, in a developmentally on track way, which gives us a lot of room as therapists working with really little kids to be able to use symbolic and experiential practicing coping or learning about feelings or even just processing experiences that might be leading to feelings and kind of rewriting them a bit.

(15:12):

If there’s like you were saying, thinking cognitive patterns or what I would say in lay terms is if I have a certain way I often interpret stuff, if I tend to sort of have a negative appraisal or a negative bias towards interpreting the things that happen, there could be a way that therapy helps rewrite some of those biases or helps build perspective. But again, you don’t always have to touch it right on the nose with little kids. A lot can be done.

Dr. Rebecca Hershberg (15:42):

Yeah. And I think if listeners are feeling like, Sarah, you and I are having a hard time explaining this, it’s because it is quite nuanced. I don’t want anybody to hear this and be like, “Oh, sweet. I’m going to go do therapy with my kid.” It really is, by all means, play with your kid and notice the themes, but I think the reason that we’re having a hard time putting it in terms that are easy to access is because it is quite a sophisticated practice and it’s a real art. There’s also something just to take it to a different place where just having a child, especially one with a younger sibling in this email, just have 45 minutes a week to play with an adult that is just there to play with them and is so curious about what they’re saying and so interested in having them lead the play.

(16:38):

And that can be really curative in and of itself. So there’s a lot of levels on which it operates. And there’s also a lot of times, and I don’t know if this merits saying on this episode and perhaps linking to others, but there’s a lot of times where parents are interested in getting therapy for their four year old and that’s not indicated where actually it’s more about the parent work and the family work. And I would say oftentimes behavioral issues fall into that category. So I think the reason we’re emphasizing play therapy here, which we haven’t, at least as far as I remember in a lot of other episodes, is because we’re talking about what’s called an internalizing issue. When a child is walking around with a lot of internal sadness, potentially anxiety, worry, trauma certainly is an area where play therapy can be very helpful.

(17:34):

If your child is four and kind of being aggressive or impulsive, those sorts of issues tend not to be as easily addressed by something like play therapy. And there are a lot of therapists out there who will say that they can, and that’s where being an educated consumer of these things becomes important.

Dr. Sarah Bren (17:54):

I don’t know if that’s a tangent, but – Because you call an externalizing kind of presentation, which again, it’s not that that can’t be supported in therapy. It’s just very hard for that to get generalized to outside of the therapy room. So it tends to be more of like how do we work with the whole family system to kind of when the lava gets sprayed out into the world with an externalizing behavior, we have to actually work with the whole environment. The whole system is usually, there becomes like all these feedback loops when that happens.

Dr. Rebecca Hershberg (18:28):

Right. There’s different therapies that have been shown to be more and less effective with different ways that very young kids can present. And you want to go to someone who is well versed in understanding those distinctions so that you’re getting the best help that you can for your family.

Dr. Sarah Bren (18:50):

And I’ll say one other thing just about what it could look like because you were talking about play therapy, play individual therapy, and you were talking also about parenting support, which I don’t think parenting support would be unhelpful, but I also think, like you’re saying, having the child be part of this and allow their internal world to be very much the focus of the work requires their presence. But sometimes I find that it’s easier to do that with a parent in the room. And so sometimes I could see a use case of doing individual play-based therapies with the child, but I also feel like sometimes a parent-child work can be very useful, not because we’re necessarily addressing the parent-child dynamic, although that might be part of it too, but also just because when you’re dealing with things like sadness and this internal pain, having that secure base, having that person present in the room with really young kids can help.

(20:01):

It’s almost like the parent’s presence that gives the child almost like, it’s like a warm handoff. It’s like, “I’m here. I’m showing you this adult, this therapist is a safe person. And so you can use me as a barometer in the room. When we go into painful places, I’m here. The therapist is here.” It just kind of leverages the whole attachment system in the work, which is hard for a four-year-old to be able to do that work with a therapist that they don’t know that well.

Dr. Rebecca Hershberg (20:39):

Absolutely.

Dr. Sarah Bren (20:39):

And so that’s why I think, which is different than a parent-child therapy that’s focused on repairing dynamics within the relationship. Again, maybe that’s also part of this. Who knows? The beautiful thing about having the parent in the room is we can do all kinds of wonderful things at the same time. But I do think that there’s worlds in which I’d see a kid by themselves at this age, but there’s also mostly I would do parent-child ideally if it made… Again, it’s like every situation’s so different. Every therapy is going to be individualized to that unique kid and system.

Dr. Rebecca Hershberg (21:14):

And that’s why I don’t want to get lost in the weeds here because most of our listeners, frankly, probably don’t have four-year-olds that are going to need that level of intervention just if we’re playing a numbers game. But I do think you can link to, and I’m sure you have in past episodes, just general things to look for in a qualified therapist. How do you know someone has good training? How do you know someone is trustworthy so that whatever, if you do need that, you are able to trust that the person you have gone to see will offer the correct options for you, your child and your family. And two different experts may offer two different options, right? There may not be one size fits all there even for the same situation and family and child, which is why going to people that have a certain level of training and sort of training, I’ll leave it there, is important.

Dr. Sarah Bren (22:16):

Yeah. Well, I hope that this is helpful. I hope this was helpful for the mom who wrote this email in. And I really appreciate you doing that because I think it’s really hard to reach out when you feel like you’re doing everything and it’s a very vulnerable time when you have a kid who’s suffering. And I really hope that for anyone who’s listening who maybe is like, this resonates and now I feel like I have maybe permission to take certain steps and use these resources. I hope that this is helpful.

Dr. Rebecca Hershberg (22:53):

Yeah.

Dr. Sarah Bren (22:56):

Thank you so much for listening. As you can hear, parenting is not one size fits all. It’s nuanced and it’s complicated. So I really hope that this series where we’re answering your questions really helps you to cut through some of the noise and find out what works best for you and your unique child. If you have a burning parenting question, something you’re struggling to navigate or a topic you really want us to shed light on or share research about, we want to know, go to drsarahbren.com/question to send in anything that you want, Rebecca, Emily, and me to answer in Securely Attached: Beyond the Sessions. That’s drsarahbren.com/question. And check back for a brand new securely attached next Tuesday. And until then, don’t be a stranger.