Early Childhood Depression
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Demographics:
Date of referral: 31 January 2009.
 8 sessions are completed.
 Age/gender: 5 years 3 months, boy.
 Lives with his mother-father-6 month-old
brother.
 Parents work in private sector.
 Child goes to a private nursery.
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Social-Developmental Background:
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Planned birth with caesarean.
No psychological, medical treatment history.
No psychological problems in the family.
Mother stayed with him for 3 months, then
the nanny comes, mother goes to work.
Walks in 1 year, talks in 1.5 years, toilet
control in 2.5 years.
Starts nursery when 2.5 year-old.
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Stress factor for depression:
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Unavailability of mother during her
second pregnancy due to her nausea and
tension problems.
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Symptoms of depression started 1 year
ago.
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Family environment:
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Mother:
- Before the pregnancy: mother was very
responsive to child’s social, cognitive, and
emotional development, they had very strong
emotional bond.
- After the pregnancy: unresponsive and
unavailable to child’s needs and demands, distance
between the mother and child.
• Father:
- Physical play partner, not sensitive to his
emotional needs in the absence of mother, no
emotional bond between them.
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
With 6 month-old brother:
- Neglects him, behaves as if the baby isn’t
there, isn’t living with them.
- When he sees his mother, dealing with the
baby, he starts asking for something from his
mother continuously and becomes angry,
unhappy whatever parents do.
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Changes in child’s temperament:
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Before the pregnancy: very lively, happy,
joyful with his family and friends.
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In first 3-6 months: stubborn, restless, easily
hurt, had anger crisis, tried to draw attention by
behaving moody.
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In the last 1 year: due to his failure of drawing
his mother’s attention, repressed his anger
inside, became silent, dull and withdrawn.
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DSM Criteria for Depression:
1) Depressed or irritable mood
2) Loss of interest or pleasure
3) Change in weight or appetite
4) Sleep problems
5) Motor agitation or retardation
6) Fatigue or loss of energy
7) Feelings of worthlessness or guilt
8) Difficulty thinking, concentrating or making decisions
9) Thoughts of death or suicidal thoughts/behavior
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5 or more symptoms must be present, and one of these symptoms must be
either depressed mood or loss of pleasure.
Symptoms must be present for at least 2 weeks.
Symptoms must cause clinically significant distress or impairment in important
areas of the child or adolescent’s functioning.
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Symptoms of Depression:
Sleeping problems: cries, wants somebody with
him, wakes up for 7-8 times each night. (no
sleep problems before pregnancy)
 Can’t wake up in the morning, feels tired,
fatigue, sleepy. (he started the day very excited
and energetic, before)
 Loss of apetite. (very excited to eat hamburgers,
and chips, before)
 No preference for what to wear, when asked
what he wants to wear, very quiet and lost in
thoughts.
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Symptoms, cont’d:
Doesn’t want to go to nursery. (For 2 years, he is
in the same nursery, he used to be very excited to
go to school)
 At nursery: Follows the activities that are
required in a dull mood, but doesn’t initiate any
activity, conversation in the free time, sits alone
in a corner. (Used to be a lively, social child,
before)
 Cries very easily, for example, when he is
instructed to tidy his room.
 No excitement for eating cookies and milk. (He
used to be very excited to eat them)
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Symptoms, cont’d:
At home: unhappy, depressed, doesn’t take off his
coat when he comes home.
 Disconnected from mother, parents can’t find any
activity to make him happy, or excited. (Before:
very enthusiastic to play with parents after work.)
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5 symptoms are present for 1 year.
Symptoms cause impairment at every context of his life.
So, this is categorized as “Childhood Depression”
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Assessment:
No diagnostic test.
 Self report of the parents.
 Observation of child during therapy.
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Conclusion of the clinician:
1)
Ufuk is Preoperational Stage of cognitive
development (Piaget, 1932). So he,
 Did not mentally develop concrete logic,
 Cannot take point of view of other people,
so
he lives “egocentric”.
 He thinks “I did something bad, and my mother
became ill, now my mother is okey, we live
together now, but she no longer wants to look
after me, she doesn’t love me”.
Misinterprets mother’s unavailability as his
fault.
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2) Psychoanalytic perspective: Ufuk cannot
express his negative feelings, anger to his
brother, and parents, and directs them to
himself and represses
withdrawal and
depression.
3) Father lacks the skills for emotional support in
the unavailability of mother: doesn’t
understand and share his feelings.
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The Therapy Approaches:
Follows an eclectic approach:
1) Psychoanalytic approach
to make him
realize and express his anger towards his parents
and his brother.
2) Cognitive-Behavioral approach
to make
him realize that unavailability doesn’t mean
decrease in love and to make him learn to wait.
3) Family systems approach
to understand
emotional relationship patterns in the family and
to show family members, how to understand and
encourage him to express his emotions.
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1) Psychoanalytic approach:
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To enable Ufuk to realize and show his anger,
disappointment to his parents and his brother,
To prevent represssion and to facilitate his expression.
To integrate ‘anger’ into his personality.
Reflective functioning, mentalizing (Fonagy, 1999):
to develop the ability to understand the existence of
emotions and mental processes taking place in both the
self and in others, to teach social causality.
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Example :
 Uses a pillow and colorful balls:
 When
gets angry to mother: “Bad mother, I’m very
angry to you, I will throw this red ball to the pillow”
 “Baby is shocked, let’s throw yellow ball to the pillow”
 There is a bear toy, he is permitted to show his anger,
when he is angry to his brother.
Aim:
 To realize, name and act out his emotions without
hurting anybody.
 When he didn’t act his emotions out, he became
depressed.
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2) Cognitive-Behavioral approach:
 To correct his errors in thinking that, mother is
unavailable, because she no longer loves him.
Example 1: Clinician requests mother to read a magazine,
during 10 minutes. When Ufuk asks her to play lego,
mother refuses and says, she isn’t available but will be
available after 10 minutes.
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Clinician verbalizes Ufuk’s emotions: “ I’m very angry
now, mother is very bad, I want to play but she doesn’t
respond!”
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Then Clinician says: “Maybe she is occupied now, she
played with me 10 minutes ago, so this means she
loves us, yes you want your mother, but everybody
may not be available all the time, this doesn’t mean she
doesn’t loves us. Maybe after 10 minutes, so she will
play with us”.
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After 10 minutes, mother joins the play.
By mirroring child’s emotional situation, and providing
verbal information about the reasons behind mother’s
unavailability, clinician:
Approves his emotions.
Corrects his cognitive errors that he is being denied by
his parents.
Teaches him that he may not reach his parents any time
he wants.
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1)
2)
3)
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Behavioral cont’d:
Example 2: Therapist, sets her clock for 20 minutes
and says, “Now, I will only be playing with you for
the whole 20 minutes”.
 Clock rings, clinician says, their play ends, and now
she has other things to do.
 Parents repeat the same arranged plays everyday, at
home.
Aim: to teach child that, he is special for his parents,
they spend time with him but they may not be
available every time he asks for them.
 Clinician contacts with the nursery teacher, gives her
supervision and sends sample group games about
availability.
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3) Family Systems Approach (Bowen, 1974):
Ufuk’s behavior should be interpreted according to his
interactions with family members. His problems, will be
solved when his emotional interaction with his parents are
treated.
 Ufuk’s mother couldn’t respond to his socio-emotional
needs for 1 year due to her health problems.
 Father doesn’t have emotional bond with Ufuk, he is play
friend.
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Responsive Parenting (Darling, & Steinberg, 1993):
when parents respond, to child’s needs sensitively, child
is equiped with mechanisms for coping with stress and
self-regulation due to his emotional bond with his
parents.
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To make parents become responsive to Ufuk’s emotional
needs
Watch, wait and wonder technique is used
during play therapy.
Watch, wait and wonder technique (Cohen et al., 1999)
aims to increase emotional sensitivity and responsivity of
parents and equip children with skills of emotional
regulation in return. During play:
Therapist, parents and child sit on the ground,
Parent doesn’t initiate activity, but follows the child’s lead,
Child is given opportunity to explore everything during
the play,
Therapist, watches, waits, wonders, and reflects on childparent relationship,
Therapist asks the parent, what he/she observes through
his play.
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Example: In 3rd session, the whole family sat on the
ground, demonstrated what activities are done at home,
by using bear family toy.
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Firstly clinician models how to accompany him:
Clinician: “Ufuk ayıcığı aldı, yürüyor…”
Ufuk: “Evet şimdi gidiyor…”
Clinician: “Evet gidiyor, ne olacak bakalım…”
 Then, mother takes turn
 Ufuk throws baby bear away from mother bear’s laps,
and puts his own bear, and says: “Now, Ufuk bear wants
to sit”
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Aim:
 To make parents responsive to child’s emotional
needs,
 To train parents how to accompany him, in nonintrusive manner.
 To enable child’s self-expression through play.
 To make child realize that, his parents are
curious and accepting towards him.
 To make father, develop emotional bond with
child and help him in the absence of the mother.
 This 20 minute one-to-one play is repeated
everyday at home.
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Elaboration
From cognitive perspective:
Internal Attributional/explanatory style (Seligman
& Peterson, 1986) : blame himself, for negative
events and view causes of events as being stable over
time and applicable across situations: “I did
something bad, that made mother ill and non
responsive”
 Cognitive distortions: (Beck, 1967; 1976) Certain
errors in thinking that make him to catastrophize,
overgeneralize, personalize negative events:
“Mummy doesn’t care about me, she isn’t available,
she doesn’t love me”
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model: Child’s
psychological vulnerability for depression, may
have interacted with mother’s unavailability
(stress) during pregnancy which resulted in
depression.
 Vulnerability-stress
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From psychoanalytic perspective:
 Containing (Bion, 1957): child sends signs of
frustration, and fear to parents but parents don’t
receive, contain and transform the baby's
depressed emotional state. When this external
support in managing anxieties is unavailable or
insensitive or distorted, child feels neglected.
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Changes in child across sessions:
 Better
apetite
 Sleep problems decreased
 More energetic and social at home and
school
 Lively and happy
 Shows his anger to his brother by attempts
to hurt him
 Doesn’t become depressed when his
mother is unavailable.
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Prognosis:
3
sessions of treatment left.
 Clinician will look into emotion repartoire of
child during play, and check whether there is any
emotion that is repressed and will work on how
to express them.
 Parents spend 20 minutes playing with the child,
after work in watch, wait, wonder style,everyday.
 Not chronic, a temporary problem, due to lack of
parental responsivity during mother’s pregnancy.
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 Positive
prognosis, symptoms started to disappear
in 8 sessions.
 Protective factors:
1) Nursery supervision and support to child (games
on availability).
2) Parents are very supportive to participate, do
homeworks, aware of the problem.
3) Child used to have positive, lively affectivity
before the depression.
4) No history of psychological problems in familyno genetic predisposition
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THANK YOU
FOR LISTENING!
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