Preschool Depression

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Investigations of preschool psychopathology: unique developmental considerations

The study of psychopathology in the preschool period is complicated by several factors. A key consideration is that the preschool period is a time characterized by multiple developmental challenges for young children. For example, during this time many children have their first experience in a formal school program and with a group of same-age peers. Although a growing sense of autonomy develops during the preschool years, children remain inextricably reliant on caregivers. The rapid cognitive

Early findings

Following Spitz's [21] compelling descriptions of depressed affect in institutionalized infants, there was little investigation of mood disorders in young children for several decades. Kashani and colleagues [7], [8], [9], [10], [11], [12], [22], [23], [24] provided the first series of studies that showed evidence of depression in preschool children in clinical and community samples. Several preschoolers who met standard DSM-III criteria for major depressive disorder (MDD) were identified. The

Diagnostic systems

Since Kashani and colleagues first published evidence that depression could occur in preschool-aged children, increasing attention has been given to the need for well-defined and developmentally appropriate diagnostic criteria for young children in general. Because the DSM system was designed primarily for adult populations, DSM criteria generally lack sensitivity to developmental variation in symptom manifestations, especially as they pertain to young children. With the exception of the

Evidence supporting the validity of preschool depression

In their first controlled study of preschool-aged children drawn from clinical and community settings, Luby and colleagues [13] investigated the basic validity of developmentally translated DSM-IV depressive symptoms (Box 1) using a version of the Diagnostic Interview Schedule for Children, Version IV young child (DISC-IVYC) [28], which was modified to allow for assessment of developmentally sensitive symptom manifestations. Because preschoolers have limited, if any, experience in formal

Prevalence

Because the availability of evidence clarifying the nosology of preschool depression is a recent development, methods used to investigate the presence of depressive disorders in population based studies of preschool children have varied and are potentially inaccurate. Correspondingly, there is variation in the reported rate of prevalence of the disorder among community samples. In a two-stage study in which 3860 community children were screened and 510 received an extensive evaluation, Lavigne

Comorbidity

High rates of comorbidity are well known in older depressed children [54] and have been found in depressed preschoolers [14]. Notably, patterns of comorbidity in these young children differ from patterns found in older children and adolescents, in whom anxiety disorders are most frequently comorbid with major depression [54]. Among a group of preschoolers identified as depressed, 42% had comorbid attention deficit hyperactivity disorder, 62% had comorbid oppositional defiant disorder, and 41%

Differential diagnosis

Just as in older children and adults, the accurate clinical diagnosis of MDD requires consideration of other disorders that have similar presenting features. In particular, posttraumatic stress disorder and adjustment disorder with depressive features should be considered in the differential diagnosis for a child who presents with depressive symptoms, such as loss of interest, psychomotor retardation, and difficulty concentrating. The key differentiating feature between these disorders and

Accessing appropriate informants

One of the difficulties of identifying and assessing internalizing disorders is the covert nature of many relevant symptoms. Unlike disruptive behavior disorders, in which diagnostic criteria include robust observable behaviors, a diagnosis of depression requires determination of internal states that are more difficult for parents to assess accurately. Further complicating the issue is the potential for inaccuracy and bias known to be inherent in parent report. For example, parents who

Treatment

To date, no studies have been conducted regarding the safety or efficacy of medication treatment of preschool mood disorders. Use of antidepressants in this age group is necessarily “off label” and empirically unsupported. Similarly, no empirically supported psychotherapy treatment of preschool MDD currently is available. Luby and colleagues (unpublished data) developed a treatment protocol focusing on targeting the parent/child dyad with the goal of teaching parents to serve as more effective

Summary

Significant strides have been made in the past 5 years in the characterization and validation of the nosology of preschool depression, perhaps related, in part, to greater developmental sensitivity of the measures used to assess depressive symptoms. Evidence is available to support the validity of this disorder, including a stable and specific symptom constellation, associated impairment, biologic markers, and greater family history of similar disorders. Because the area of study is relatively

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    Funding for the study of preschool depression was provided by National Institute of Mental Health grant K08-MH3250-5148 and R01-MH64769-01.

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