Depression and Anxiety in Preschoolers: A Review of the Past 7 Years

Key points

Research on preschool internalizing disorders

Literature examining internalizing disorders in early childhood has lagged far behind the literature for externalizing disorders, in part because of the nature of symptom presentation. For instance, a shy, withdrawn child is less likely to attract attention and disrupt social activities. Internalizing disorders are theorized to exist on a continuum, with early differences detectable even in infancy.¹⁰ However, work in this area continues to grow. One benefit of this more dimensional approach to

Assessment of preschool depression

DSM-5 makes no distinction between childhood and adult forms of depression, with the disorder being characterized by the same core symptoms and across the lifespan. Symptoms include sadness/irritability, loss of pleasure/anhedonia, concentration difficulty, negative self-evaluations/guilt, recurrent thoughts about death/suicide, fatigue, and changes in appetite. Until recently, diagnoses of clinical depression in preschoolers have historically been met with skepticism and unease. Recent

Prevalence and course of preschool depression

The population prevalence of preschool-onset depression remains understudied, given the recent acceptance by the scientific and clinical community of this phenomenon. Further, there have been few epidemiologic studies using developmentally appropriate diagnostic interviews.7, 34, 37 Egger and Angold⁶ found rates of preschool depression ranging from 0% to 2.1% depending on the sample and assessment measure used. These prevalence rates for preschool depression (∼2%) were later replicated in 2

Factors associated with preschool depression

Factors and mechanisms contributing to preschool-onset depression remain understudied, particularly compared with known risk factors and mechanisms of childhood and adolescent depression. These factors encompass a variety of domains, including constructs both within child, family, and broader environmental systems.⁴⁵

In addition to the anhedonia research described earlier, pathologic guilt46, 47, 48 and irritability49, 50 have also emerged as key markers of preschool depression. Pathologic guilt

Neurobiological correlates of preschool depression

A particularly exciting and innovative area is investigation of neural indicators as predictors of preschool depression as well as the ways in which preschool depression alters neurocircuitry. There have been several studies that investigated neural correlates of currently depressed preschoolers69, 70 and in children/adolescents with a history of preschool depression.51, 71, 72, 73, 74, 75, 76, 77, 78, 79 For example, one study used functional MRI (fMRI) to examine functional brain activity and

Treatment of preschool depression

Evidence-based options for the treatment of preschool depression include both parenting interventions and psychotherapeutic interventions. Again, work from Luby and colleagues26, 81, 82 has been at the forefront of this area.⁸³ There are several psychotherapies designed for other psychiatric disorders in preschool children; however, these do not have empirical validation for the treatment of depression. For example, play therapy is widely used with very young children; this approach is often

Assessment of preschool anxiety disorders

DSM-5 defines anxiety disorders as “disorders that share features of excessive fear and anxiety and related behavioral disorders.”⁸⁷ DSM-5 describes 11 different anxiety disorders, and the 4 most common anxiety disorders experienced in the preschool period are:

• •

  Separation anxiety disorder (excessive fear surrounding separation from caregivers)

• •

  Social phobia (excessive fear of negative social evaluation)

• •

  Generalized anxiety disorder (excessive anxious anticipation of future events)

• •

  Specific phobia

Prevalence of preschool anxiety disorders

Most studies estimate the prevalence of preschool anxiety disorders in the range of 10% to 20%,6, 7, 37, 38, 92, 94, 97, 98, 99 although some studies cite prevalences as low as 1.5%⁸ and others report prevalences of more than 20%.¹⁰⁰ The wide variation likely reflects variation in assessment tools (clinical interview, parental report, direct observation) and geographic location, and demographic differences between study samples. Despite this variation, anxiety disorders are widely acknowledged

Risk factors for preschool anxiety disorders

Heritability estimates for preschool anxiety disorders range widely, from 40% to 65%.¹⁰⁷ These estimates are lower than for other psychiatric disorders such as autism, schizophrenia, ADHD, and bipolar disorder,¹⁰⁸ suggesting a strong influence of both genetics and environment in determining risk for preschool anxiety disorders.

Temperament, defined as early-appearing, traitlike individual differences in emotional, attentional, and motor reactivity to novel stimuli,¹⁰⁹ is one of the most potent

Treatment of preschool anxiety disorders

Evidence-based options for treatment of preschool anxiety disorders include a variety of parenting¹¹⁹ and psychotherapeutic interventions. Several studies support the use of cognitive behavior therapy (CBT)120, 121, 122, 123, 124 with heavy parental involvement during treatment. Including the parent in sessions may increase preschoolers’ comfort and aid in extending therapeutic techniques outside the therapy session. In addition to CBT, evidence also supports the use of modified versions of

Case study

W.H. is a 4.5-year-old white boy who for the last 6 months has displayed frequent sadness and irritability with minor frustrations or having preferences not met (eg, being given the wrong-color cup). He expresses a persistent negative self-view and thinks he is not as good as other children at sports and that no one likes him (when there is no evidence that this is true). He has on several occasions been so upset about this that he has stated that he wished he was dead. When he breaks a rule,

Summary

This article reviews recent literature on preschool-onset depression and anxiety, with a focus on assessment, prevalence, risk factors, and treatment options. A surprising amount of research has been conducted on preschool-onset internalizing disorders over the last 10 years; the field seems to be moving toward general acceptance and recognition for these constellations of symptoms in young children. Despite this growth in research, much work still needs to be done to further elucidate the

Acknowledgments

The authors would like to extend their appreciation to Shana Sanchez, BA, for her assistance with the preparation of this article.