Depression in Early Childhood

Home , Child development, Masked depression

CHAPTER 25

Joan L. Luby Diana Whalen

Only in the last 10 years have the mental health rized that several core emotions are present at and developmental communities generally ac- birth in the human infant. Subsequently, em- cepted that depression may arise in very early pirical studies provided support for this hypoth- childhood. As early as the 1940s, clinical de- esis (e.g., Izard, Huebner, Risser, & Dougherty, pression was observed and described in infants 1980). Despite these early insights, a significant deprived of primary caregiving relationships body of empirical data that began to outline the (Spitz, 1946). However, in subsequent years, trajectory of early emotion development did not prevailing developmental theory suggested that become available until the late 1980s. Over the young children are too immature to experience last two decades, data informing how children the core emotions of depression, thereby ruling recognize and express discrete emotions, devel- out the possibility of clinical depression before op the ability to regulate emotional responses, school age (Rie, 1966). Subsequent advances in understand the causes and consequences of studies of early childhood emotion development emotions, as well as experience more complex provided data refuting this claim, demonstrat- emotions, have become available (for review, ing the previously unrecognized emotional so- see Denham, 1998; Saarni, 1999). While these phistication of infants and toddlers (Denham, data have provided a broad framework illustrat- 1998; Shonkoff & Phillips, 2000). Despite this, ing that emotional competence develops earlier empirical data to validate and describe a clini- in life than previously recognized, many details cal depressive syndrome in infants and toddlers about when and how emotional development under the age of 3 years remains scarce, with unfolds in the infancy and preschool period re- some retrospective data suggesting it may arise main understudied. Further investigation of this in the toddler years (Luby & Belden, 2012). early trajectory may be key to understanding In order to understand whether depression the earliest possible onset of depression and its can arise early in life and how it might mani- developmental characteristics. fest, it is essential to understand the norma- From a public health perspective, the identifi- tive trajectory of early emotional development. cation of depression at the earliest possible point Normative emotional development provides a in development is an important goal because not framework against which alterations in early only is relieving the suffering of young children emotional experiences and expressions can be a necessary and worthy cause, but also earlier assessed. In the late 1800s, based on observa- intervention may provide a window of opportu-

Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. tion of facial expressions, Darwin (1872) theo- nity for greater therapeutic change and benefit.

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The unique efficacy of early intervention dur- ed. This suggests that impairments or altera- ing the preschool period has been demonstrated tions in this domain are likely to be associated for several specific childhood mental disorders with early-onset mood disorders and should such as autistic spectrum disorder and some therefore be explored. disruptive disorders (e.g., Eyberg et al., 2001; Charles Darwin was the first to suggest that Faja & Dawson, 2006; Webster-Stratton, Reid, human infants are born with the ability to ex- & Beauchaine, 2013). This may be related to press a limited repertoire of discrete emotions. greater neuroplasticity and therefore increased Subsequently, developmental psychologist Car- sensitivity to environmental inputs earlier in roll Izard and colleagues (1980) provided em- development (Troller-Renfree & Fox, 2016). pirical data demonstrating that human infants Early intervention may be of particular impor- displayed specific and discrete facial expres- tance in depressive disorders given the known sions that were consistent with incentive events chronic and relapsing course, suboptimal treat- designed to evoke these emotional states. Per- ment responses, and high rates of treatment re- tinent to the development of depression in in- sistance in older depressed children and adoles- fancy is the normative development of sadness cents (Kennard et al., 2006; Weisz, McCarty, & and joy. Izard, Hembree, and Huebner (1987) Valeri, 2006). For these reasons, as well as the showed that facial expressions of sadness can compelling accounts of clinical observation of be clearly and reliably distinguished from other depressive affect very early in life, depression is negative emotions by the age of 2 months in a disorder for which the earliest possible identi- human infants. Furthermore, by age 6 months, fication may hold promise to advance the public sad facial expression arise in response to or con- health; therefore, early identification is impera- current with sadness-provoking incentive events tive and early interventions are necessary. (Izard et al., 1995). Similarly, studies have also We explore in this chapter the empirical and shown that human infants display discrete fa- theoretical literature on depression in infants, cial expressions of joy as early as 6–8 months toddlers, and preschool-age children. We begin of life. The greater differentiation of emotional the discussion with the preschool period, which expression in which more subtle and complex has the largest body of available empirical data. expressions are observed occurs after the first Then, we explore the relevant literature and year of life (Demos, 1986). These findings that available data pertaining to toddlers and in- demonstrate the experiences of sadness and joy fants. In these youngest age groups, there is a appear to arise in human infants during the first much smaller body of available empirical data 6 months of life suggest that depressive affects on clinical symptoms or syndromes. However, also may be possible at this early stage of devel- we do review related literature on early altera- opment. However, as outlined below, apart from tions in emotion expression and neural func- compelling clinical observations, there are no tioning in high-risk groups, and discuss novel empirical data to address the issue of whether early interventions for depression that are cur- depression arises in infancy. rently being tested. Emotional expression of joy and sadness, as well as emotion recognition of these emotions and more complex emotions such as guilt, has Emotion Development in Early-Onset Depression received more empirical attention in older preschool children for obvious reasons. One area of A developmental issue of interest in the study of interest is whether depressed preschoolers may early-onset depression, as well as mood disor- demonstrate an earlier ability to recognize and ders more generally, is the question of whether label negative emotions compared to nonde- early alterations in patterns of emotion devel- pressed preschoolers. There is some support for opment can be identified. This is important the notion that early experiences of depression not only for the purpose of identifying devel- may enhance the ability to recognize and label opmental manifestations of early-onset mood negative emotions, specifically sadness (Han- disorders, but also, and perhaps more clinically kin, Gibb, Abela, & Flory, 2010; Lopez-Duran, relevant, to specify developmental targets for Kuhlman, George, & Kovacs, 2013). Further fo- early intervention. Recognizing that emotional cused investigations of clinically relevant alter- competence develops earlier than previously ations in emotion development are now needed. thought and develops rapidly during infancy An investigation of the development of

Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. and preschool years has been clearly document- more complex emotions, particularly guilt and

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shame, are of special interest given the central clitic depression,” and he speculated that it was importance of these emotions to depressive based on the infant’s reaction to separation from states. Kochanska, Gross, Lin, and Nichols a primary caregiver. Underscoring the life-sus- (2002) have previously shown that children un- taining importance of the emotional elements derstand the experience of guilt as early as 3 of the early caregiving relationship, these in- years of age. In light of this finding, we hypoth- fants deprived of primary caregivers displayed esized that depressed preschoolers, like older failure to thrive, despite adequate nutrition and depressed individuals, would experience higher physical care. Despite this compelling finding levels of guilt than nondepressed preschoolers. of depressed affect and physical growth retar- Two qualitatively different measures were used dation arising from psychosocial deprivation, to assess guilt within our preschool sample. Spitz’s observations, although now recognized One measure, the My Child, is a parent report of as pioneering, had little impact on enhancing the child’s tendency to display guilt and actions the recognition of very early-onset depression to repair guilt (Kochanska, 1992). In addition, in the mainstream mental health community. the MacArthur Emotion Story Stem Battery was used to tap guilt emotions (Bretherton, Op- Infants of Depressed Mothers penheim, Buchsbaum, Emde, & the MacArthur Transition Network Narrative Group, 2001). In Maternal depression (see Murray, Halligan, this latter technique, preschoolers are given a & Cooper, Chapter 10, this volume) is a well- story stem that sets up a conflict that may evoke known risk factor for a range of poor devel- guilt. Their completion of the story is coded opmental outcomes in children (Diego et al., for guilt (and other) themes and content. Luby, 2004; Murray et al., 2011; Murray, Halligan, Belden, Pautsch, Si, and Spitznagel (2009) dem- & Cooper, 2010). Infants of depressed mothers onstrated that depressed children experienced are at high risk for depression based on both ge- higher levels of guilt on both measures than netic and psychosocial factors (Cohn & Tron- did several nondepressed comparison groups, ick, 1989; Field, 1984; Murray & Cooper, 1997; including those with DSM-IV disruptive dis- Murray et al., 1999). In particular, the parent- orders (attention-deficit/hyperactivity disorder ing/caregiving practices of depressed mothers [ADHD], oppositional defiant disorder [ODD], are often characterized as less supportive and and conduct disorder [CD]), anxiety disorders, sensitive (Downey & Coyne, 1990; Goodman and a a bipolar I-like syndrome. Also notable & Gotlib, 1999; Lovejoy, Graczyk, O’Hare, & was that depressed preschoolers had less of a Neuman, 2000), which leads to a range of nega- tendency to take actions to repair feelings of tive emotional developmental outcomes for in- guilt. These findings suggest that the experi- fants (Field et al., 1988; Hernandez-Reif, Field, ence of excessive guilt is a central feature of Diego, Vera, & Pickens, 2006; Murray et al., depression as early as the preschool period and 1999). Infants of depressed mothers have been therefore should be a focus of early clinical observed to be less active, more withdrawn, identification and intervention. and to display less positive affect than infants of nondepressed mothers during face-to-face interactions with their mothers. This body of Depression in Infancy research highlights the early interpersonal and environmental factors that may have a material Despite significant amounts of lay public and impact on emotion development in the infant media attention to the issue of infant depression, and very young child, and may therefore be of there are no empirical scientific data available importance in the developmental psychopathol- at this time to inform the question of whether ogy of mood disorders. a true depressive syndrome can arise before a In addition to inferring differences in in- child is 3 years of age. Nevertheless, the first fants’ emotional responses based on their facial observations of depressed affect arising in in- expression or bodily movements, other physi- fants date back to the mid-1940s, when psycho- ological markers of reactivity, such as brain analyst René Spitz (1946) provided compelling activity, have informed our understanding of reports of withdrawal, apathy, depressed mood, factors that impact development among the off- and failure to thrive among institutionalized spring of depressed mothers during the infan- infants. Spitz described this syndrome as “ana- cy and preschool period. For example, infants Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.

of mothers with depression evidence greater the criteria as presented in DSM-IV (American relative right frontal electroencephalographic Psychiatric Association, 1994). This is in part (EEG) asymmetry, a pattern often associated based on empirical data suggesting that the core with increased negative affect and withdrawal- depressive symptoms show continuity from type behaviors (Jones, Field, & Almeida, 2009). preschool through adulthood. Recently, Lusby, Goodman, Yeung, Bell, and Stowe (2016) found that infants of mothers with high prenatal depressive symptoms had syn- Depression in Preschool Children chronous, negative associations between negative affect and EEG asymmetry at 3 months of The first empirical investigations of clinical age, but asynchronous, positive associations symptoms of depression in preschool-age chil- between these indices at 12 months of age. The dren were conducted by Kashani and colleagues authors interpreted these findings to suggest in the 1980s. These researchers were interested that prenatal depression was associated with in whether preschool-age children could mani- pathways of co-occurring vulnerability early in fest symptoms of depression as described in infancy, as well as additional vulnerability later DSM-III (American Psychiatric Association, in infancy. Prenatal maternal depression has 1980), a previously empirically unexplored also been shown to predict differences in infant issue. This group provided case reports of pre- brain function measured using functional mag- schoolers in clinical settings who met criteria netic resonance imaging (fMRI), specifically for MDD (Kashani & Carlson, 1985). In addi- in the microstructure of the amygdala (Rifkin- tion, they investigated whether preschoolers in Graboi et al., 2013), functional connectivity be- a general population sample could be identified tween the amygdala and frontal brain regions with the disorder. They concluded, based on (Qiu et al., 2015), and alterations within the the finding of a number of preschoolers with amygdala–prefrontal cortex circuits (Posner et concerning symptoms who did not meet full or al., 2016). formal criteria for DSM-III MDD, that developmental modifications to the criteria might be Diagnosing Depression in Infants and Toddlers needed (Kashani, Holcomb, & Orvaschel, 1986; Kashani, Ray, & Carlson, 1984). To date, there have been no large-scale, sys- The findings of Kashani and colleagues, in tematic, empirical investigations of clinical de- addition to the finding of alterations in affect pression in infants and toddlers (under the age in the offspring of depressed mothers known to of 3 years). Despite this, the collective experi- be at high risk for depression, led to larger-scale ence of clinicians and compelling case descrip- investigations of depression in preschoolers at tions, as well as some retrospective accounts the Washington University School of Medicine from depressed adults, strongly suggest that Early Emotion Development Program, as well the syndrome can arise in infants and toddlers. as other national and international sites. The Furthermore, in one prospective investigation first large-scale investigation of preschool de- of depressed preschoolers, Luby and Belden pression advanced earlier methodologies in sev- (2012) suggested that symptoms were evident eral important ways. First, it used an age-appro- as early as 18 months of age. Based on these priate structured diagnostic interview in which observations, diagnostic criteria and symptom developmental translations of symptom states descriptions of depression as it applies to in- were assessed. An example of a developmental fants and toddlers have been outlined in an al- translation was that “anhedonia” was described ternative developmentally sensitive diagnostic as the inability to enjoy activities and play (as system entitled the Diagnostic Classification opposed to lack of libido, for example, as might of Mental Health and Developmental Disorders be evident in an adult). In addition, both healthy in Infancy and Early Childhood (DC:0–5; Zero and psychiatric comparison groups were ascer- to Three, 2005). DSM-5 major depressive disor- tained, so that the specificity of symptoms to der (MDD) criteria may also apply to children depression could be determined. Findings from across the age span, with no specified lower age this study provided evidence for a specific and limit (American Psychiatric Association, 2013). stable depressive symptom constellation arising However, DSM-5, like DSM-IV, also does not in preschool children ages 3–5½ years (Luby specify any developmental modifications to et al., 2002). In addition, based on data about Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.

the psychiatric status of the first- and second- Neurobiological Correlates degree relatives of the preschool subject, the of Preschool Depression finding that depressed preschoolers came from While a specific and stable symptom constel- families with greater histories of related affec- lation, family history of related disorders, and tive disorders compared to families of healthy evidence of social impairment are key markers controls also emerged. Based on these parent- report data, these results suggested that familial of the validity of a psychiatric disorder and of transmission of depression was also evident in preschool depression, biological evidence of- the preschool period, as had been previously fers a more objective level of scientific valid- demonstrated in older child and adult popula- ity. For this reason, biological measures such tions (e.g., Jaffee et al., 2002; Neuman, Geller, as neurophysiological indices and brain struc- Rice, & Todd, 1997). Familial transmission, ture and function are of interest as key mark- whether genetic or psychosocially transmitted, ers of the validity of preschool depression. in addition to a specific and stable symptom Alterations in the physiological response to constellation, are key elements in the validation stress measured through the hypothalamic–pi- of psychiatric disorders as described by Robins tuitary–adrenal (HPA) axis are well established and Guze (1970). in depressed adults (Plotsky, Owens, & Nemer- The question of whether these very young de- off, 1998; Rubin et al., 1987). Consistent with pressed children displayed “masked” symptoms this, Luby and colleagues (2003a) found altera- of the disorder, such as somatic complaints or tions in stress cortisol reactivity in depressed regression in development, also was examined. preschoolers compared to those with other This was of interest, since the idea that young psychiatric disorders and healthy comparison children could not manifest the core symp- groups. Dougherty, Klein, Olino, Dyson, and toms of depression but would instead display Rose (2009) examined relations between morn- “masked” symptoms was a widely accepted ing or evening cortisol and two prominent risk but empirically unexplored clinical adage. No- factors for depression, maternal depression and tably, depressed preschoolers displayed age- child temperament, in 166 four-year-old chil- appropriate manifestations of “typical” DSM dren participating in an ongoing longitudinal symptoms of depression more frequently than study. Prior to the onset of depression, elevated masked symptoms (Luby et al., 2003a, 2003b). waking cortisol was found to be associated with However, masked symptoms also occurred at maternal history of depression and lower posi- higher rates in the depressed group than in the tive emotionality in the children. The authors comparison groups. This finding was remark- suggest that elevated waking cortisol may be ably similar to earlier findings regarding older one vulnerability marker for the onset of later school-age children with depression (Carlson & depression. Cantwell, 1980). The finding that young chil- Other work has focused on neural reactivity dren display the core symptoms of depression, assessed using event-related potentials (ERPs) including vegetative signs, guilt, and anhe- in preschoolers with depression (Belden et al., donia, suggests that clinicians should look for 2016) and as an indicator of risk for depression typical age-adjusted symptoms of depression as onset (Shankman et al., 2011). For example, 53 the most specific and sensitive markers of the depressed preschoolers enrolled in a large, ran- disorder, even in preschool-age children. domized controlled trial completed a guessing Several additional markers of the validity of game while ERP’s were recorded. When com- preschool-onset depression also emerged from pared to 25 healthy preschoolers, depressed pre- this study. Evidence of impairment, which is key schoolers evidenced reduced reward positivity, to determining “caseness” in the DSM system, one ERP component that measures responses was also detected in depressed preschoolers. to positive outcomes. These findings offer the The finding of unique patterns of guilt process- first evidence of positive, reward-related neural ing distinct from healthy preschoolers, those alterations during the preschool period, and the with externalizing disorders, and those with findings continue to support the value of reward anxiety disorders also emerged (Luby, Belden, processing in the pathophysiology of early-on- Sullivan, et al., 2009). Depressed preschoolers set depression. tend to experience high levels of guilt and en- Adding and extending these physiological gage in low guilt reparation behaviors (behav- data, a series of studies have investigated neural correlates of currently depressed preschoolers

(Gaffrey, Barch, Singer, Shenoy, & Luby, 2013; amygdala (Luking et al., 2011). Taken together, Gaffrey et al., 2011) and children/adolescents these findings offer evidence for longitudinal with a history of preschool depression (Barch, alterations in the functioning of several brain Gaffrey, Botteron, Belden, & Luby, 2012; areas as a function of preschool-onset depres- Belden, Barch, et al., 2015; Belden, Pagliaccio, sion, even when children were not in an acute Murphy, Luby, & Barch, 2015; Gaffrey, Luby, episode of depression. Botteron, Repovs, & Barch, 2012; Gaffrey et The PDS study sample has collected up to al., 2010; Luby et al., 2016; Luking et al., 2011; three fMRI scans on each subject, allowing re- Marrus et al., 2015; Pagliaccio et al., 2012; Su- searchers to model trajectories of brain devel- zuki et al., 2013). For example, Gaffrey and col- opment in specific regions of interest. Recently, leagues (2013) have demonstrated alterations Luby and colleagues (2016) examined the im- in amygdala reactivity in response to negative pact of preschool-onset depression on the trajec- faces in 23 acutely depressed preschoolers, con- tory of cortical gray-matter development across sistent with findings in depressed adolescents the three fMRI scans spanning several years. and adults. Children with a history of preschool-onset de- Furthermore, findings from the Preschool pression had differences in their trajectories of Depression Study (PDS) sample indicate that cortical gray-matter development, specifically alterations in the function and structure of key cortical gray-matter volume loss and thinning brain regions known to be altered in depres- over time. These results highlight the impor- sion in adults have also been found in depressed tance of assessing the same children repeatedly preschoolers when they were scanned at school across time in order to more accurately capture age, even when not acutely depressed at the time developmental changes in brain functioning. of scan. For instance, children with a history of These findings taken together demonstrate preschool-onset depression evidenced greater that depressed preschoolers have changes in activation in response to sad faces in the amyg- the structure and function of key brain regions dala, bilateral functional cortex, claustrum hip- involved in emotion processing, as has been es- pocampal and parahippocampal gyrus (Barch tablished in adult depression, suggesting that al- et al., 2012), as well as less activation in regions terations in these biological substrates known to of the prefrontal cortex following a brief, sad be associated with depressive disorders are also mood induction (Pagliaccio et al., 2012). When evident early in development. The finding that compared to healthy children, children with these alterations in neural structure and func- a history of preschool-onset MDD exhibited tion are also evident in early-onset depression significantly smaller left hippocampal volume during the preschool period and in school-age (Suzuki et al., 2013). These individual volumet- children with a history of preschool depres- ric differences were also associated with func- sion suggests some continuity in the underly- tional differences in brain responses to sad or ing pathophysiology of depression across the negatively valenced faces. Greater functional age span. Along these lines, further evidence of connections were found between the subgenual this continuity could provide clues to both the anterior cingulate cortex and dorsomedial pre- developmental psychopathology of depressive frontal brain regions among healthy children, disorders and more effective early intervention whereas greater functional connections were strategies. between the subcortical and posteriormedial parietal regions for children with a history of Melancholic Subtype preschool-onset depression (Gaffrey et al., 2010). Gaffrey and colleagues (2010) suggest A more severe melancholic subtype of depres- that the pattern of functional relations seen in sion characterized by the presence of anhedonia the children with preschool-onset depression also has been identified in preschool children. may be associated with decreased cognitive Preschoolers who met all DSM-IV symptom control and behavioral flexibility, and increased criteria for MDD (when symptoms were trans- visceral—motor/self-focused operations. Even lated for developmental appropriateness as de- after accounting for key covariates, such as scribed earlier) and also had the symptom of age, gender, and IQ, children with a history of anhedonia had significantly higher depression preschool-onset MDD also show alterations in severity scores than a depressed nonanhedonic the default mode network connectivity (Gaffrey group (Luby, Mrakotsky, Heffelfinger, Brown,

Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. et al., 2012) and functional connectivity of the & Spitznagel, 2004). In addition, melancholi-

cally depressed preschoolers had a number of area, every age-adjusted DSM-IV symptom of features similar to melancholically depressed depression, with the exception of irritability, adults, such as lack of brightening in response occurred significantly more frequently in pre- to positive events, as well as higher rates of schoolers meeting criteria for depression com- neurovegetative signs, including sleep distur- pared to those who met DSM-IV criteria for bances and changes in appetite. These findings disruptive behavior disorders and those from a suggest that a subtype of severe depression that healthy control group. Furthermore, symptoms has clear biological correlates known in adults of depression also differentiated depressed pre- may also arise during the preschool period. schoolers from those with anxiety disorders, This melancholic subgroup should be a focus of providing the first discriminant validity to our future longitudinal investigations that address knowledge between depression and another in- outcome and course, as well as other biologi- ternalizing affective disorder (Luby, Belden, cal markers, such as structural and functional Pautsch, et al., 2009). Several epidemiological changes in the brain. Neuroimaging of young studies have also detected depression in pre- children with a history of melancholic depres- school children (Bufferd, Dougherty, Carlson, sion could be illuminating. Rose, & Klein, 2012; Egger & Angold, 2006; Wichstrøm et al., 2012). These findings demon- Suicidal Ideations and Expression strate that a specific depressive syndrome can in Preschool Children be identified in preschool children in community samples and have a prevalence rate similar Surprisingly little work has focused on thoughts to that known in prepubertal children (Egger & of death and suicidal ideation (SI) in preschool- Angold, 2006). onset depression (Connolly, 1999; Pfeffer & Trad, 1988; Rosenthal & Rosenthal, 1984; Clinical Assessment of Preschool Depression Rosenthal, Rosenthal, Doherty, & Santora, 1986; Whalen, Belden, Luby, Barch, & Dixon- The identification of a depressed preschooler in Gordon, 2016; Whalen, Dixon-Gordon, Belden, the clinical setting is not always obvious despite Barch, & Luby, 2015; Zeanah & Gleason, 2015). this empirical information informing the clini- Whalen and colleagues (2015) evaluated suicid- cal picture. Some of the key symptoms are often ality in a sample of 306 children between ages 3 discounted by parents or go unnoticed. Key fea- and 7, enrolled in a longitudinal investigation of tures that clinicians should inquire about care- preschool depression. SI was present in approx- fully in the clinical interview with caregivers imately 11% (N = 34) of young children in this are the presence of a pattern of excessive levels sample, and 75% (N = 25/34) of these youth con- of guilt, low self-esteem or persistent expres- tinued to endorse SI at the school-age follow- sion of negative self-appraisals, as well as the up assessment. Preschool SI was concurrently expression of self-harming behaviors displayed associated with several forms of psychopathol- during emotional distress, such as self-hitting, ogy, including depression, anxiety disorders, head banging or scratching. The clinical inter- ADHD, ODD, and CD. Preschool SI predicted view with the caregiver is key given that many later school-age SI, even when researchers con- symptoms may not be expressed in the clinical trolled for psychiatric disorders, and other rel- setting. However, observation of play is also es- evant covariates at both time points (Whalen sential to establish and verify the presence of et al., 2015). Study findings are consistent with sad or irritable mood and negative themes in and extend extant research on later childhood play, and to ascertain features of self-perception SI, suggesting that this clinical phenomenon and rule out other potential causes for the symp- may be equally valid in younger children. tom presentation.

Epidemiological Evidence Longitudinal Course of Preschool Depression for Preschool Depression One of the key validators that underscores the Findings from several independent samples importance of early identification of depression have replicated and extended the previously during the preschool period is the finding of ho- discussed findings about preschool depression. motypic continuity across development (Luby, Using a screening checklist in a large ascer- Si, Belden, Tandon, & Spitznagel, 2009); that is,

Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. tained sample from the St. Louis metropolitan longitudinal data suggests that children do not

simply grow out of the depression, nor does it strengthening the parent–child relationship evolve into another disorder as young depressed and using the parent as the “arm of the thera- children grow and develop. Rather, these data pist” is central to the treatment. A large-scale suggest that preschool depression appears to be randomized controlled trial of PCIT-ED is cur- an early form of the well-known later childhood rently under way. The launch of this treatment and early adolescent disorder. Longitudinal data study was based on promising findings from a on a study sample ascertained during the pre- small trial of this parent–child therapy showing school period for high symptoms of depression efficacy (Lenze, Pautsch, & Luby, 2011; Luby, and followed into school age and adolescence Lenze, & Tillman, 2012). has demonstrated that preschool depression has In younger and more vulnerable populations, a chronic, remitting, and relapsing course into greater uncertainties about safety and more im- later childhood. Findings from the same dataset mature nervous systems make psychotherapeu- have shown that children with the preschool de- tic interventions preferred treatments over psy- pressive syndrome have a high risk of meeting chopharmacological options. Psychotherapeutic full DSM-5 criteria for depression later in child- approaches, including cognitive-behavioral and hood (Luby, Gaffrey, Tillman, April, & Belden, interpersonal psychotherapies, have demon- 2014). This finding underscores the need for strated efficacy for the treatment of depression early identification and early intervention. As in older children and adolescents. Numerous we mentioned earlier, another key finding that dyadic psychotherapeutic strategies have been suggests the importance of early identification developed, and several have been tested for is that alterations in cortical gray-matter devel- the treatment of a variety of disorders arising opment across school age and early adolescence in the preschool period. Related to the risk for were found in relation to preschool depression early-onset depression, treatment for depressed (Luby et al., 2016). This latter finding suggests mothers designed to ameliorate negative effects that the experience of early-onset depression on infants and toddlers has also been developed may alter the later trajectory of brain develop- and tested (Cicchetti, Rogosch, & Toth, 2000). ment. Consistent with homotypic continuity, These investigators have shown that declines in preschool depression predicts MDD later in cognitive development that are apparent in the childhood and adolescence (Reinfjell, Karstad, infants of depressed mothers can be prevented Berg-Nielsen, Luby, & Wichstrøm, 2015; Whel- when depressed mothers undergo preventive an, Leibenluft, Stringaris, & Barker, 2015). toddler–parent psychotherapeutic (TPP) inter- However, evidence also suggests that preschool ventions. However, to date, no age-appropriate depression can predict anxiety disorders and psychotherapies designed for the treatment of ADHD in later childhood (Bufferd et al., 2012). preschool depression have been tested. Questions often arise about the use of phar- Treatment of Preschool Depression macological agents, in particular antidepressants, for the treatment of preschool depression. As preschool depression has only recently be- It is important to note that no available studies come widely recognized, there have been no inform the safety or efficacy of antidepres- systematic treatment studies conducted to date. sants for preschool depression. Concerns about The literature contains case reports, as well activating side effects of selective serotonin as descriptions of treatments of various types. reuptake inhibitor (SSRI) antidepressants that Luby and colleagues have recently adapted par- may occur at higher rates in younger children, ent–child interaction therapy (PCIT) for the as well as unresolved reports of possible in- treatment of preschool depression by adding an creases in suicidality, make this treatment op- emotion development (ED) component. PCIT tion more complicated and unfeasible for use in is a parent–child psychotherapy originally de- preschool-age children at this time (Zuckerman signed and proven effective for the treatment of et al., 2007). preschool disruptive disorders (Eyberg, 1974). PCIT-ED has an additional component that Future Research: Next Steps specifically addresses emotion regulation and an emotional repertoire designed to address Further replication and extension of the find- the absence of joy and excess of guilt and sad- ings reported here by independent research ness experienced by the depressed preschooler. groups in other geographical sites, as well as

Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. As in the original form of PCIT, the focus on cross-culturally, would be an important next

step in the further validation and clarification stage. Future studies should now focus on this of the clinical features of preschool depression. younger age group, so that the earliest identifi- Furthermore, ongoing longitudinal follow-up of cation and intervention in depressive disorders preschool children with a depressive syndrome can become possible. into early adolescence and early adulthood is also critical to determine whether there is continuity of the early-onset form with later life REFERENCES forms, and such a study is currently under way. If longitudinal continuity in depressive disor- American Psychiatric Association. (1980). Diagnostic ders from the preschool period to later life pe- and statistical manual of mental disorders (3rd ed.). riods could be shown, it would further support Washington, DC: Author. the need for early interventions. Heterotypic American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). continuity also needs to be explored given the Washington, DC: Author. relatively less differentiated nature of psycho- American Psychiatric Association. (2013). Diagnostic pathology in younger individuals. The search and statistical manual of mental disorders (5th ed.). for biological correlates that might give clues Arlington, VA: Author. to the developmental pathophysiology of child- Barch, D. M., Gaffrey, M. S., Botteron, K. N., Belden, hood depression is also critical to understand- A. C., & Luby, J. L. (2012). Functional brain acti- ing, preventing, and treating this disorder. vation to emotionally valenced faces in school-aged children with a history of preschool-onset major depression. Biological Psychiatry, 72(12), 1035–1042. Conclusions Belden, A. C., Barch, D. M., Oakberg, T. J., April, L. M., Harms, M. P., Botteron, K. N., et al. (2015). Numerous studies in independent samples both Anterior insula volume and guilt: Neurobehavioral markers of recurrence after early childhood major nationally and internationally are now avail- depressive disorder. JAMA Psychiatry, 72(1), 40–48. able, providing validation of clinical depres- Belden, A. C., Irvin, K., Hajcak, G., Kappenman, E. sion in children as young as age 3 years. The S., Kelly, D., Karlow, S., et al. (2016). Neural corre- clinical characteristics of the disorder are the lates of reward processing in depressed and healthy same as those described in older children, ado- preschool-age children. Journal of the American lescents, and adults, but clinicians must be alert Academy of Child and Adolescent Psychiatry, 55(12), to developmentally adjusted symptom manifes- 1081–1089. tations (e.g., anhedonia evident as decreased Belden, A. C., Pagliaccio, D., Murphy, E. R., Luby, J. L., ability to enjoy activities and play rather than & Barch, D. M. (2015). Neural activation during cog- decreased libido) and increased guilt. Neu- nitive emotion regulation in previously depressed robiological correlates, including alterations compared to healthy children: Evidence of specific in response to negative stimuli and brain re- alterations. Journal of the American Academy of sponse to reward, are evident during an acute Child and Adolescent Psychiatry, 54(9), 771–781. Bretherton, I., Oppenheim, D., Buchsbaum, H., Emde, episode of depression in preschool children. R., & the MacArthur Transition Network Narrative Furthermore, alterations in the structure and Group. (2001). MacArthur Story Stem Battery Man- function of brain regions and circuits that sub- ual (MSSB). Unpublished manuscript, Denver, CO. serve emotion function have also been demon- Bufferd, S. J., Dougherty, L. R., Carlson, G. A., Rose, strated at school age and early adolescence in S., & Klein, D. N. (2012). Psychiatric disorders in children who were depressed as preschoolers. preschoolers: Continuity from ages 3 to 6. American Early PCIT that focus on enhancing emotion Journal of Psychiatry, 169(11), 1157–1164. development appear promising and are now Carlson, G. A., & Cantwell, D. P. (1980). Unmasking undergoing rigorous testing. Based on this, the masked depression in children and adolescents. identification of clinical depressive disorders in American Journal of Psychiatry, 137(4), 445–449. children as young as age 3 should now become Cicchetti, D., Rogosch, F. A., & Toth, S. L. (2000). The the clinical standard of care. Despite these ad- efficacy of toddler–parent psychotherapy for foster- ing cognitive development in offspring of depressed vances for preschool-age children, currently mothers. Journal of Abnormal Child Psychology, there are no data to inform whether a valid 28(2), 135–148. clinical depressive syndrome can arise earlier Cohn, J. F., & Tronick, E. (1989). Specificity of infants’ than age 3 during the infancy and toddler pe- response to mothers’ affective behavior. Journal of riod, although compelling clinical experience the American Academy of Child and Adolescent Psy- chiatry, 28(2), 242–248.

Connolly, L. (1999). Suicidal behaviour—does it exist Gaffrey, M. S., Luby, J. L., Botteron, K., Repovs, G., & in pre-school aged children? Irish Journal of Psy- Barch, D. M. (2012). Default mode network connec- chological Medicine, 16(2), 72–74. tivity in children with a history of preschool onset Darwin, C. R. (1872). The expression of the emotions in depression. Journal of Child Psychology and Psy- man and animals. London: John Murray. chiatry and Allied Disciplines, 53(9), 964–972. Demos, V. (1986). Crying in early infancy: Affect, cog- Gaffrey, M. S., Luby, J. L., Repovs, G., Belden, A. C., nition, and communication. In T. B. Brazelton & M. Botteron, K. N., Luking, K. R., et al. (2010). Sub- Yogman (Eds.), Affect and early infancy (pp. 39–73). genual cingulate connectivity in children with a his- Norwood, NJ: Ablex. tory of preschool-depression. NeuroReport, 21(18), Denham, S. A. (1998). Emotional development in young 1182–1188. children. New York: Guilford Press. Goodman, S. H., & Gotlib, I. H. (1999). Risk for psy- Diego, M. A., Field, T., Hernandez-Reif, M., Cullen, C., chopathology in the children of depressed moth- Schanberg, S., & Kuhn, C. (2004). Prepartum, post- ers: A developmental model for understanding partum, and chronic depression effects on newborns. mechanisms of transmission. Psychological Review, Psychiatry, 67(1), 63–80. 106(3), 458–490. Dougherty, L. R., Klein, D. N., Olino, T. M., Dyson, M., Hankin, B. L., Gibb, B. E., Abela, J. R., & Flory, K. & Rose, S. (2009). Increased waking salivary corti- (2010). Selective attention to affective stimuli and sol and depression risk in preschoolers: The role of clinical depression among youths: Role of anxiety maternal history of melancholic depression and early and specificity of emotion. Journal of Abnormal child temperament. Journal of Child Psychology and Psychology, 119(3), 491–501. Psychiatry, 50(12), 1495–1503. Hernandez-Reif, M., Field, T., Diego, M., Vera, Y., & Downey, G., & Coyne, J. C. (1990). Children of de- Pickens, J. (2006). Happy faces are habituated more pressed parents: An integrative review. Psychologi- slowly by infants of depressed mothers. Infant Be- cal Bulletin, 108(1), 50–76. havior and Development, 29(1), 131–135. Egger, H., & Angold, A. (2006). Common emotional Izard, C. E., Fantauzzo, C. A., Castle, J. M., Haynes, O. and behavioral disorders in preschool children: Pre- M., Rayias, M. F., & Putnam, P. H. (1995). The on- sentation, nosology, and epidemiology. Journal of togeny and significance of infants’ facial expressions Child Psychology and Psychiatry and Allied Disci- in the first 9 months of life. Developmental Psychol- plines, 47(3–4), 313–337. ogy, 31(6), 997–1013. Eyberg, S. M. (1974). Manual for the coding of parent– Izard, C. E., Hembree, E. A., & Huebner, R. R. (1987). child interactions of children with behavior prob- Infants’ emotion expressions to acute pain: Devel- lems. Unpublished manuscript. opmental change and stability of individual differ- Eyberg, S. M., Funderburk, B. W., Hembree-Kigin, T. ences. Developmental Psychology, 23(1), 105–113. L., McNeil, C. B., Querido, J. G., & Hood, K. K. Izard, C. E., Huebner, R. R., Risser, D., & Dougherty, (2001). Parent–child interaction therapy with behav- L. (1980). The young infant’s ability to produce dis- ior problem children: One and two year maintenance crete emotion expressions. Developmental Psychol- of treatment effects in the family. Child and Family ogy, 16(2), 132–140. Behavior Therapy, 23(4), 1–20. Jaffee, S. R., Moffitt, T. E., Caspi, A., Fombonne, E., Faja, S., & Dawson, G. (2006). Early intervention for Poulton, R., & Martin, J. (2002). Differences in early autism. In J. L. Luby (Ed.), Handbook of preschool childhood risk factors for juvenile-onset and adult- mental health: Development, disorders, and treat- onset depression. Archives of General Psychiatry, ment (pp. 388–416). New York: Guilford Press. 59(3), 215–222. Field, T. (1984). Early interactions between infants and Jones, N. A., Field, T., & Almeida, A. (2009). Right their postpartum depressed mothers. Infant Behavior frontal EEG asymmetry and behavioral inhibition and Development, 7(4), 517–522. in infants of depressed mothers. Infant Behavior and Field, T., Healy, B., Goldstein, S., Perry, S., Bendell, Development, 32(3), 298–304. D., Schanberg, S., et al. (1988). Infants of depressed Kashani, J. H., & Carlson, G. A. (1985). Major depres- mothers show “depressed” behavior even with nonde- sive disorder in a preschooler. Journal of the Ameri- pressed adults. Child Development, 59(6), 1569–1579. can Academy of Child Psychiatry, 24(4), 490–494. Gaffrey, M. S., Barch, D. M., Singer, J., Shenoy, R., & Kashani, J. H., Holcomb, W. R., & Orvaschel, H. (1986). Luby, J. L. (2013). Disrupted amygdala reactivity in Depression and depressive symptoms in preschool depressed 4- to 6-year-old children. Journal of the children from the general population. American American Academy of Child and Adolescent Psychi- Journal of Psychiatry, 143(9), 1138–1143. atry, 52(7), 737–746. Kashani, J. H., Ray, J. S., & Carlson, G. A. (1984). De- Gaffrey, M. S., Luby, J., Belden, A. C., Hirshberg, J., pression and depressive-like states in preschool-age Volsch, J., & Barch, D. (2011). Association between children in a child development unit. American Jour- depression severity and amygdala reactivity dur- nal of Psychiatry, 141(11), 1397–1402. ing sad face viewing in depressed preschoolers: An Kennard, B., Silva, S., Vitiello, B., Curry, J., Krato- fMRI study. Journal of Affective Disorders, 129(1– chvil, C., Simons, A., et al. (2006). Remission and 3), 364–370. residual symptoms after short-term treatment in the Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.

Treatment of Adolescents with Depression Study sler, M. J., Brown, K. M., & Hildebrand, T. (2002). (TADS). Journal of the American Academy of Child Preschool major depressive disorder: Preliminary and Adolescent Psychiatry, 45(12), 1404–1411. validation for developmentally modified DSM-IV Kochanska, G. (1992). My child. Iowa City: University criteria. Journal of the American Academy of Child of Iowa. and Adolescent Psychiatry, 41(8), 928–937. Kochanska, G., Gross, J. N., Lin, M. H., & Nichols, K. Luby, J. L., Lenze, S., & Tillman, R. (2012). A novel E. (2002). Guilt in young children: Development, de- early intervention for preschool depression: Findings terminants, and relations with a broader system of from a pilot randomized controlled trial. Journal of standards. Child Development, 73(2), 461–482. Child Psychology and Psychiatry and Allied Disci- Lenze, S., Pautsch, J., & Luby, J. (2011). Parent–child plines, 53(3), 313–322. interaction therapy emotion development: A novel Luby, J. L., Mrakotsky, C., Heffelfinger, A., Brown, K., treatment for depression in preschool children. De- & Spitznagel, E. (2004). Characteristics of depressed pression and Anxiety, 28(2), 153–159. preschoolers with and without anhedonia: Evidence Lopez-Duran, N. L., Kuhlman, K. R., George, C., & for a melancholic depressive subtype in young Kovacs, M. (2013). Facial emotion expression rec- children. American Journal of Psychiatry, 161(11), ognition by children at familial risk for depression: 1998–2004. High-risk boys are oversensitive to sadness. Journal Luby, J. L., Si, X., Belden, A. C., Tandon, M., & Spitzna- of Child Psychology and Psychiatry, 54(5), 565–574. gel, E. (2009). Preschool depression: Homotypic Lovejoy, M. C., Graczyk, P. A., O’Hare, E., & Neuman, continuity and course over 24 months. Archives of G. (2000). Maternal depression and parenting behav- General Psychiatry, 66(8), 897–905. ior: A meta-analytic review. Clinical Psychology Re- Luking, K. R., Repovs, G., Belden, A. C., Gaffrey, view, 20(5), 561–592. M. S., Botteron, K. N., Luby, J. L., et al. (2011). Luby, J. L., & Belden, A. (2012). Depressive-symptom Functional connectivity of the amygdala in early- onset during toddlerhood in a sample of depressed childhood-onset depression. Journal of the Ameri- preschoolers: Implications for future investigations can Academy of Child and Adolescent Psychiatry, of major depressive disorder in toddlers. Infant Men- 50(10), 1027–1041. tal Health Journal, 33(2), 139–147. Lusby, C. M., Goodman, S. H., Yeung, E. W., Bell, M. Luby, J. L., Belden, A. C., Jackson, J. J., Lessov-Schlag- A., & Stowe, Z. N. (2016). Infant EEG and tempera- gar, C. N., Harms, M. P., Tillman, R., et al. (2016). ment negative affectivity: Coherence of vulnerabili- Early childhood depression and alterations in the ties to mothers’ perinatal depression. Development trajectory of gray matter maturation in middle child- and Psychopathology, 28(4, Pt. 1), 895–911. hood and early adolescence. JAMA Psychiatry, 73(1), Marrus, N., Belden, A., Nishino, T., Handler, T., Rat- 31–38. nanather, J. T., Miller, M., et al. (2015). Ventromedial Luby, J. L., Belden, A., Pautsch, J., Si, X., & Spitzna- prefrontal cortex thinning in preschool-onset de- gel, E. (2009). The clinical significance of preschool pression. Journal of Affective Disorders, 180, 79–86. depression: Impairment in functioning and clinical Murray, L., Arteche, A., Fearon, P., Halligan, S., markers of the disorder. Journal of Affective Disor- Goodyer, I., & Cooper, P. (2011). Maternal postnatal ders, 112(1–3), 111–119. depression and the development of depression in off- Luby, J. L., Belden, A., Sullivan, J., Hayen, R., McCad- spring up to 16 years of age. Journal of the American ney, A., & Spitznagel, E. (2009). Shame and guilt Academy of Child and Adolescent Psychiatry, 50(5), in preschool depression: Evidence for elevations in 460–470. self-conscious emotions in depression as early as Murray, L., & Cooper, P. J. (1997). Effects of postnatal age 3. Journal of Child Psychology and Psychiatry, depression on infant development. Archives of Dis- 50(9), 1156–1166. ease in Childhood, 77(2), 99–101. Luby, J. L., Gaffrey, M. S., Tillman, R., April, L. M., & Murray, L., Halligan, S., & Cooper, P. (2010). Effects Belden, A. C. (2014). Trajectories of preschool disor- of postnatal depression on mother–infant interac- ders to full DSM depression at school age and early tions and child development. In J. D. Bremner & T. adolescence: Continuity of preschool depression. D. Wachs (Eds.), The Wiley-Blackwell handbook of American Journal of Psychiatry, 171(7), 768–776. infant development (Vol. 2, 2nd ed., pp. 192–220). Luby, J. L., Heffelfinger, A., Mrakotsky, C., Brown, New York: Wiley-Blackwell. K. M., Hessler, M. J., & Spitznagel, E. L. (2003a). Murray, L., Sinclair, D., Cooper, P., Ducournau, P., Alterations in stress cortisol reactivity in depressed Turner, P., & Stein, A. (1999). The socioemotional preschoolers relative to psychiatric and no-disorder development of 5-year-old children of postnatally comparison groups. Archives of General Psychiatry, depressed mothers. Journal of Child Psychology and 60(12), 1248–1255. Psychiatry, 40(8), 1259–1271. Luby, J. L., Heffelfinger, A. K., Mrakotsky, C., Brown, Neuman, R. J., Geller, B., Rice, J. P., & Todd, R. D. K. M., Hessler, M. J., Wallis, J. M., et al. (2003b). The (1997). Increased prevalence and earlier onset of clinical picture of depression in preschool children. mood disorders among relatives of prepubertal ver- Journal of the American Academy of Child and Ado- sus adult probands. Journal of the American Acad- lescent Psychiatry, 42(3), 340–348. emy of Child and Adolescent Psychiatry, 36(4),

Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Luby, J. L., Heffelfinger, A. K., Mrakotsky, C., Hes- 466–473.

Pagliaccio, D., Luby, J., Gaffrey, M., Belden, A., Bot- Shonkoff, J. P., & Phillips, D. A. (2000). From neurons teron, K., Gotlib, I. H., et al. (2012). Anomalous to neighborhoods: The science of early childhood functional brain activation following negative mood development. Washington, DC: National Academies induction in children with pre-school onset major Press. depression. Developmental Cognitive Neuroscience, Spitz, R. (1946). Anaclitic depression: An inquiry into 2(2), 256–267. the genesis of psychiatric conditions in early child- Pfeffer, C. R., & Trad, P. V. (1988). Sadness and suicidal hood. Psychoanalytic Study of the Child, 2, 313–342. tendencies in preschool children. Journal of Devel- Suzuki, H., Botteron, K. N., Luby, J. L., Belden, A. opmental and Behavioral Pediatrics, 9(2), 86–88. C., Gaffrey, M. S., Babb, C. M., et al. (2013). Struc- Plotsky, P. M., Owens, M. J., & Nemeroff, C. B. (1998). tural–functional correlations between hippocampal Psychoneuroendocrinology of depression: Hypotha- volume and cortico-limbic emotional responses in lamic–pituitary–adrenal axis. Psychiatric Clinics of depressed children. Cognitive, Affective, and Behav- North America, 21(2), 293–307. ioral Neuroscience, 13(1), 135–151. Posner, J., Cha, J., Roy, A., Peterson, B., Bansal, R., Troller-Renfree, S., & Fox, N. A. (2016). Sensitive pe- Gustafsson, H., et al. (2016). Alterations in amyg- riods of development: Implications for risk and re- dala–prefrontal circuits in infants exposed to prena- silience. In J. L. Luby (Ed.), Handbook of preschool tal maternal depression. Translational Psychiatry, mental health (2nd ed., pp. 3–26). New York: Guil- 6(11), e935. ford Press. Qiu, A., Anh, T. T., Li, Y., Chen, H., Rifkin-Graboi, A., Webster-Stratton, C., Reid, M. J., & Beauchaine, T. P. Broekman, B. F. P., et al. (2015). Prenatal maternal (2013). One-year follow-up of combined parent and depression alters amygdala functional connectivity child intervention for young children with ADHD. in 6-month-old infants. Translational Psychiatry, Journal of Clinical Child and Adolescent Psychol- 5(2), e508. ogy, 42(2), 251–261. Reinfjell, T., Karstad, S. B., Berg-Nielsen, T. S., Luby, Weisz, J., McCarty, C., & Valeri, S. (2006). Effects of J. L., & Wichstrøm, L. (2016). Predictors of change psychotherapy for depression in children and ado- in depressive symptoms from preschool to first lescents: A meta-analysis. Psychological Bulletin, grade. Development and Psychopathology, 28(4), 132(1), 132–149. 1517–1530. Whalen, D. J., Belden, A. C., Luby, J. L., Barch, D., & Rie, H. E. (1966). Depression in childhood: A survey of Dixon-Gordon, K. (2016). Dr. Whalen et al. reply. some pertinent contributions. Journal of the Ameri- Journal of the American Academy of Child and Ado- can Academy of Child Psychiatry, 5(4), 653–685. lescent Psychiatry, 55(3), 243–245. Rifkin-Graboi, A., Bai, J., Chen, H., Hameed, W. B. R., Whalen, D. J., Dixon-Gordon, K., Belden, A. C., Barch, Sim, L. W., Tint, M. T., et al. (2013). Prenatal ma- D., & Luby, J. L. (2015). Correlates and consequenc- ternal depression associates with microstructure of es of suicidal cognitions and behaviors in children right amygdala in neonates at birth. Biological Psy- ages 3 to 7 years. Journal of the American Academy chiatry, 74(11), 837–844. of Child and Adolescent Psychiatry, 54(11), 926–937. Robins, E., & Guze, S. B. (1970). Establishment of diag- Whelan, Y. M., Leibenluft, E., Stringaris, A., & Barker, nostic validity in psychiatric illness: Its application E. D. (2015). Pathways from maternal depressive to schizophrenia. American Journal of Psychiatry, symptoms to adolescent depressive symptoms: The 126(7), 983–987. unique contribution of irritability symptoms. Jour- Rosenthal, P. A., & Rosenthal, S. (1984). Suicidal be- nal of Child Psychology and Psychiatry, 56(10), havior by preschool children. American Journal of 1092–1100. Psychiatry, 141(4), 520–525. Wichstrøm, L., Berg-Nielsen, T. S., Angold, A., Egger, Rosenthal, P. A., Rosenthal, S., Doherty, M. B., & San- H. L., Solheim, E., & Sveen, T. H. (2012). Prevalence tora, D. (1986). Suicidal thoughts and behaviors in of psychiatric disorders in preschoolers. Journal of depressed hospitalized preschoolers. American Child Psychology and Psychiatry and Allied Disci- Journal of Psychotherapy, 40(2), 201–212. plines, 53(6), 695–705. Rubin, R. T., Poland, R. E., Lesser, I. M., Martin, D. J., Zeanah, C. H., & Gleason, M. M. (2015). Suicidality in Blodgett, A. L., & Winston, R. A. (1987). Neuroen- very young children. Journal of the American Acad- docrine aspects of primary endogenous depression. emy of Child and Adolescent Psychiatry, 54(11), III. Cortisol secretion in relation to diagnosis and 884–885. symptom patterns. Psychological Medicine, 17(3), Zero to Three. (2005). Diagnostic classification of 609–619. mental health and developmental disorders of in- Saarni, C. (1999). The development of emotional com- fancy and early childhood: DC:0–3R. Washington, petence. New York: Guilford Press. DC: Author. Shankman, S. A., Klein, D. N., Torpey, D. C., Olino, T. Zuckerman, M. L., Vaughan, B. L., Whitney, J., Dodds, M., Dyson, M. W., Kim, J., et al. (2011). Do positive A., Yakhkind, A., MacMillan, C., et al. (2007). Tol- and negative temperament traits interact in predict- erability of selective serotonin reuptake inhibitors in ing risk for depression?: A resting EEG study of 329 thirty-nine children under age seven: A retrospective preschoolers. Development and Psychopathology, chart review. Journal of Child and Adolescent Psy-

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