When Mike Shooter was in medical school, he suffered the first of what he calls “thunderous depressions.” More followed. Shooter’s efforts to come to grips with these experiences has made him acutely aware of what young people with mental-health problems endure and forged his career as a preeminent child psychiatrist in England. He was the first such specialist to be elected president of the Royal College of Psychiatrists, a position he held from 2002 to 2005. Recently he published “Growing Pains,” which is based on 40 years of working with young people. The book explains why it’s imperative to differentiate between depression and the ordinary but often intense difficulties some children face. He recently spoke with The Washington Post on these issues. This transcript was edited for clarity and length.
Q: Do you think young people are more vulnerable to mental illness now?
A: Research suggests that the United Kingdom is the least happy place for a child to be brought up in the Western world; America cannot be far behind. Some of this could be attributed to the grinding effect of poverty. But not all: The frenetic competition, in school, in the scramble for jobs, in peer-group relationships, means many children fall off the bottom of the ladder of competition and feel as if they’ve failed. Or are so unsure of their own worth that they sit up all night searching for “likes” on social media in lieu of proper friendships.
But it’s not all bad news. There is currently much research into resilience: what enables some children to cope while others do not. I know from experience that there is one thing that can make all the difference: a relationship with an adult close enough to them, that supports them, listens to their distress and treats them as worthwhile. That person could be a relative, a family friend, a teacher or, dare I say it, a child psychiatrist.
Q: What’s the difference between depression and sadness?
A: Depression is a formal psychiatric diagnosis with recognizable symptoms, well-researched treatments and a predictable outcome. Sadness is a normal reaction to sad circumstances, or a free-floating mood typical of adolescents.
The danger is that the sort of distress I describe, if it ever reaches the clinic, will either be squashed into a psychiatric category that it does not warrant or will be dismissed as a problem for which the psychiatrist has no answer. The children in “Growing Pains” have been unable to get help because they haven’t met the formal criteria, reinforcing their sense of failure. These children need help, whatever we call them — sad or depressed.
Q: Is there a danger in labeling a disorder?
A: Labeling can be very dangerous. At best, it can fossilize a child’s image and the way they are seen and handled by those around them. At worst, it can wreck their lives.
I was once contacted about two young girls, both 14, both labeled. The first was given a diagnosis of depression by her general practitioner and put on a course of antidepressants. When I saw her, she told me she felt unloved in her family, her only friend had been killed in a road accident and her grandmother, her sole confidant, had died. Despairing of finding an outlet for her grief, she had resolved to join them by committing suicide — swallowing the tablets she had been prescribed. What she needed was the opportunity to talk about her unhappiness.
The second girl was labeled as a personality disorder — anxious about everything, always blaming herself, sleeping poorly, unable to make friends. That’s just the way she is, the adults said, nothing to be done about it. In reality, she had almost certainly slipped into a clinical depression that might have responded to treatment, but it went unrecognized. Following an argument with girls at school, she went missing and was found dead two days later. I was asked to do grief works with those left behind: vital for them, but too late to save the daughter.
Q: How best, then, to support a vulnerable child?
A: Most helpful is a relationship that can hold the child in trust while we work together on trying to change things.
The trust must be earned. Some children feel safer talking in the privacy of a clinic. Some are so young and so frightened that they are beyond words and need special techniques to uncover the cause of their distress. Many will need to be seen on their own patch — at home, school, wherever they feel most comfortable. It may require negotiation with adults to secure the necessary space, and unless the child needs immediate rescue from harm, it will take time.
Once trust is established, we must work together to build the child’s self-confidence so they can explore new ways of thinking about themselves and the world. In other words, it must be an empowering relationship that searches out the strengths that all children have and builds upon them. We cannot guarantee them a trouble-free future, but we can help them discover ways of coping better. When that is done, we need to say goodbye to the therapeutic relationship in a way that does not repeat and compound the anxieties with which the child presented.
This takes time, it involves risk, it means getting so close to distress that it may stir up our own unfinished emotional business, and it treats our children and young people as partners in the work rather than passive recipients of formal diagnosis and medication. And at the center of it all, it is not a textbook or a set of guidelines, but the child’s individual experience. Their story.
Q: Do we overmedicate?
A: I try not to blame people: the children and young people who have so often been blamed for their own distress and have felt so guilty that they have blamed themselves; parents and carers who are unable to understand what children are going through and are often just as needy of help; fellow professionals, who are desperate to help but are clinically trained and emotionally more comfortable with traditional ways of doing things.
So, yes, we are in danger of overdiagnosing distressed children and reaching too quickly for a prescription more appropriate for adult illness. But I understand why. Showing how a young person might fulfill — or not — a set of criteria and dishing out a course of pills is very obviously “doing” something, and the pressure to do something is huge.
Q: What do you think about the new American Association of Pediatrics guidelines that say children over age 12 should be screened annually for depression during routine pediatrician checkups?
A: Clinical depression has been underrecognized in the past.
As a sufferer myself, I know how it crippled much of my adult life before I got help. Without that help, I might still be drifting through life from one short-term job to another, metaphorically kicking my father in the crotch. So I can understand the wish of the association to make sure that such a lack of recognition never happens on their watch.
I do worry, though. I’m sure that clinicians will err on the side of safety, so regular checkups will run the risk of dragging adolescent unhappiness into the diagnostic net.
These checkups seem designed to capture established depression that would otherwise escape recognition. Our resources should be used to prevent such disorders being established in the first place. There is ample evidence that late adolescent and adult mental illnesses have their roots in childhood and that there are many opportunities in those children’s lives to intervene. It requires a switch of attitude — by professionals and carers — to prevent unhappiness crystallizing into formal disorders.
Money spent on early intervention will save many times as much in the later development of mental illness and social upheaval.
Q: How has your own experience with depression influenced your work?
A: I have a recurrent depressive disorder. The help I have received made sense of the terrifying feelings inside me, uncovered their origins in my childhood and enabled me to behave differently with my own family. Talking about it in the media has encouraged more professionals to come forward with their own stories, and the public to seek help.
Though my illness has made me more sympathetic to the young people in my care, it does not give me the right to trespass on the uniqueness of their experience. Everyone’s depression feels different; we must help young people to explain what it feels like to them. The worst thing you can say is “ I know exactly how you feel!”