Among children whose depression was severe enough that they were referred for treatment, three quarters had a subsequent episode of severe depression, according to data collected by Maria Kovacs, a psychologist at Western Psychiatric Institute and Clinic in Pittsburgh.27 .Kovacs studied children diagnosed with depression when they were as young as eight years old, assessing them every few years until some were as old as twenty-four.
The children with major depression had episodes lasting about eleven months on average, though in one in six of them it persisted for as long as eighteen months. Mild depression, which began as early as age five in some children, was less incapacitating but lasted far longer—an average of about four years. And, Kovacs found, children who have a minor depression are more likely to have it intensify into major depression—a so-called double depression. Those who develop double depression are much more prone to suffer recurring episodes as the years go on. As children who had an episode of depression grew into adolescence and early adulthood, they suffered from depression or manic-depressive disorder, on average, one year in three.
The cost to children goes beyond the suffering caused by depression itself. Kovacs told me, "Kids learn social skills in their peer relations—for example, what to do if you want something and aren't getting it, seeing how other children handle the situation and then trying it yourself. But depressed kids are likely to be among the neglected children in a school, the ones other kids don't play with much."28
The sullenness or sadness such children feel leads them to avoid initiating social contacts, or to look away when another child is trying to engage them—a social signal the other child only takes as a rebuff; the end result is that depressed children end up rejected or neglected on the playground. This lacuna in their interpersonal experience means they miss out on what they would normally learn in the rough-and-tumble of play, and so can leave them social and emotional laggards, with much catching up to do after the depression lifts.29 Indeed, when depressed children have been compared to those without depression, they have been found to be more socially inept, to have fewer friends, to be less preferred than others as playmates, to be less liked, and to have more troubled relationships with other children.
Another cost to these children is doing poorly in school; depression interferes with their memory and concentration, making it harder to pay attention in class and retain what is taught. A child who feels no joy in anything will find it hard to marshal the energy to master challenging lessons, let alone experience flow in learning. Understandably, the longer children in Kovacs's study were depressed, the more their grades dropped and the poorer they did on achievement tests, so that they were more likely to be held back in school. In fact, there was a direct correlation between the length of time a child had been depressed and his grade-point average, with a steady plummet over the course of the episode. All of this academic rough going, of course, compounds the depression. As Kovacs observes, "Imagine you're already feeling depressed, and you start flunking out of school, and you sit home by yourself instead of playing with other kids."
DEPRESSIONOGENIC WAYS OF THOUGHT
Just as with adults, pessimistic ways of interpreting life's defeats seem to feed the sense of helplessness and hopelessness at the heart of children's depression. That people who are already depressed think in these ways has long been known. What has only recently emerged, though, is that children who are most prone to melancholy tend toward this pessimistic outlook before they become depressed. This insight suggests a window of opportunity for inoculating them against depression before it strikes.
One line of evidence comes from studies of children's beliefs about their own ability to control what happens in their lives—for example, being able to change things for the better. This is assessed by children's ratings of themselves in such terms as "When I have problems at home I'm better than most kids at helping to solve the problems" and "When I work hard I get good grades." Children who say none of these positive descriptions fits them have little sense that they can do anything to change things; this sense of helplessness is highest in those children who are most depressed.30
A telling study looked at fifth and sixth graders in the few days after they received report cards. As we all remember, report cards are one of the greatest sources of elation and despair in childhood. But researchers find a marked consequence in how children assess their role when they get a worse grade than they expected. Those who see a bad grade as due to some personal flaw ("I'm stupid") feel more depressed than those who explain it away in terms of something they could change ("If I work harder on my math homework I'll get a better grade").31
Researchers identified a group of third, fourth, and fifth graders whom classmates had rejected, and tracked which ones continued to be social outcasts in their new classes the following year. How the children explained the rejection to themselves seemed crucial to whether they became depressed. Those who saw their rejection as due to some flaw in themselves grew more depressed. But the optimists, who felt that they could do something to change things for the better, were not especially depressed despite the continuing rejection.32 And in a study of children making the notoriously stressful transition to seventh grade, those who had the pessimistic attitude responded to high levels of hassles at school and to any additional stress at home by becoming depressed.33
The most direct evidence that a pessimistic outlook makes children highly susceptible to depression comes from a five-year study of children beginning when they were in third grade.34 Among the younger children, the strongest predictor that they would become depressed was a pessimistic outlook coupled with a major blow such as parents divorcing or a death in the family, which left the child upset, unsettled, and, presumably, with parents less able to offer a nurturing buffer. As the children grew through the elementary-school years, there was a telling shift in their thinking about the good and bad events of their lives, with the children increasingly ascribing them to their own traits: "I'm getting good grades because I'm smart"; "I don't have many friends because I'm no fun." This shift seems to set in gradually over the third to fifth grades. As this happens those children who develop a pessimistic outlook—attributing the setbacks in their lives to some dire flaw in themselves—begin to fall prey to depressed moods in reaction to setbacks. What's more, the experience of depression itself seems to reinforce these pessimistic ways of thinking, so that even after the depression lifts, the child is left with what amounts to an emotional scar, a set of convictions fed by the depression and solidified in the mind: that he can't do well in school, is unlikable, and can do nothing to escape his own brooding moods. These fixed ideas can make the child all the more vulnerable to another depression down the road.
SHORT-CIRCUITING DEPRESSION
The good news: there is every sign that teaching children more productive ways of looking at their difficulties lowers their risk of depression.* In a study of one Oregon high school, about one in four students had what psychologists call a "low-level depression," not severe enough to say it was beyond ordinary unhappiness as yet.35 Some may have been in the early weeks or months of what was to become a depression.