Preschool Depression and Pathological Guilt: A Call for Listening

 Research by Dr Joan Luby at Washington University, whom one might call the mother of preschool depression, exemplifies the illness model of biological psychiatry. While Luby and her group do advocate for interventions that support parent-child relationships as a form of prevention, the danger of this model is its absence of opportunity for listening, for discovering meaning in behavior.

She and her research team have evidence of brain differences in children with behaviors that fall under the  category of Major Depressive Disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM). A recently published study showed that at age 6, children who had received a diagnosis of preschool depression had smaller volumes of a structure called the insula than children who did not have this diagnosis. Furthermore, children who exhibit what they call “pathological guilt” were more likely to have a smaller volume of the insula. Their conclusions are twofold. One is that the insula is implicated as a “biomarker” for major depression. The second is that helping children to “manage” symptoms of “pathological guilt” might offer a path to prevention.

This interpretation sounds alarm bells for me. As there is a pharmacologic treatment for depression, I hope to sound these bells before the DSM defined preschool depression goes the way of ADHD, with children being medicated in the absence of space and time to listen to the story, to understand behavior not as a symptom of a "disorder," but as a form of communication.

4-year-old Isabel’s parents, Martin and Andrea, were distraught that she often described herself as “bad, “even on occasion saying, “I hate myself.” She quickly accepted blame when something went wrong. With time and space to feel safe in my office, they told me the following story. When Martin misbehaved as a child, he was made to sit for hours on the bottom step of the basement stairs, his father berating him for being, “an embarrassment to the family.” He shared vivid memories, accompanied by deep feelings of shame and humiliation, of being grabbed by the ear and dragged away from family gatherings to this spot. Now a father himself, with no other model for discipline, he found himself repeating the same pattern with his own daughter. “What’s wrong with you?” he would shout. Her frequent meltdowns, the reason for the visit with me, precipitated not only yelling and commands to “go to your room” but also such expressions as, “why can’t you be more like your brother?”

Isabel, temperamentally more like her mother than her father, was very sensitive and easily disorganized, a quality she displayed since birth, in contrast to her “easy” baby brother. Both parents acknowledged deep conflict over discipline.  Andrea grew up in a home that, in contrast to Martin’s, had little discipline. “But,” she said, “I was  “good girl” so it wasn’t problem. Now Martin frequently blamed her for Isabel’s behavior, leading to an atmosphere of tension in the home, aggravated by the chronic sleep deprivation accompanying the arrival of a new baby.

I wonder if what Luby and colleagues are calling “ “pathological guilt” is actually shame.  Guilt can be a normal and healthy emotional experience. "I'm guilty" can also mean, “I’m responsible.” Shame, in contrast is pathological, and is associated with both depression and anxiety in childhood and adulthood. But without  opportunity to hear the story, it is impossible to know. Knowing this story, we can understand it as a kind of intergenerational transmission of shame. Perhaps if this pattern were to continue in Isabel’s family, a brain scan in a few years might show that Isabel has a smaller insula than her brother. 

Prevention does not lie in teaching Isabel to “manage her guilt.” This approach represents a devaluing of listening, a devaluing of the healing power of human connection, a direct result of the DSM illness model that places the problem squarely in the child. Supporting parent child relationships makes sense when it is not about "managing behavior," but rather listening and discovering meaning.

Once Martin had an opportunity to identify the source of his behavior in his own history, he could change his behavior with his daughter. He felt heard and understood, and so was better able to listen to his daughter, recognize what pediatrician/psychoanalyst D.W. Winnicott termed her “true self.” both parents could adopt a model of discipline suited to her unique qualities. Andrea and Martin saw how their own conflict, even when they tried to keep it from their children, affected the level of tension in the home. In the normal frenzy of activity that occurs in a household with a new baby, they had no time or space to reflect on these problems. 

The greatest risk of the model of biological psychiatry is failure to protect space and time for listening.  Listening is a kind of bridge between neuroscience and psychology. Without opportunity for listening, by diagnosing preschool age children with major depression we may leave many  standing alone on the shore, with no way over to the other side to growth, healing and resilience.