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Evidence-Based Mental Health Online First, published on January 21, 2015 as 10.1136/eb-2014-101974 Causes and risk factors
Preschool-onset depression predicts major depressive disorder and other psychiatric disorders in later childhood and early adolescence Sylia Wilson Department of Psychology, University of Minnesota, Minneapolis, Minnesota, USA; [email protected]
COMMENTARY ON: Luby JL, Gaffrey MS, Tillman R, et al. Trajectories of preschool disorders to full DSM depression at school age and early adolescence: continuity of preschool depression. Am J Psychiatry 2014;171:768–76. WHAT IS ALREADY KNOWN ON THIS TOPIC Preschool-onset depression is defined by age-adjusted subthreshold criteria for major depressive disorder (MDD) in children aged 3–6 years.1 Preschool-onset depression has shown preliminary evidence of validity as a psychiatric disorder,2 but the long-term outcomes of preschool-onset depression are still unclear. Identifying the earliest manifestations of depression will help target intervention efforts.3 METHODS OF THE STUDY This is a prospective, observational study. Children (n=246) aged 3–6 years were recruited from primary care and day care sites in St. Louis. Children with depressive symptoms were oversampled using the Preschool Feelings Checklist, a brief screening measure—children whose caregivers endorsed two or more depression symptoms were recruited for this study; children with symptoms of other psychiatric disorders and children without symptoms were also included so that depressed children could be compared with children with other disorders and healthy controls. Children and primary caregivers were assessed for 6 years. Child MDD and other psychiatric disorders were assessed using caregiver reports (for children younger than 8 years) and combined caregiver and child reports (for children older than 8 years) on diagnostic interviews (the Preschool Age Psychiatric Assessment and the Child and Adolescent Psychiatric Assessment) at baseline and follow-up assessments. Other potential risk factors were also assessed, including children’s experiences of stressful and traumatic life events, family income-to-needs ratio, child pubertal status, maternal history of depression and non-supportive parenting. Logistic regression analyses were conducted to examine the likelihood of a diagnosis of school-aged MDD using preschool-onset MDD and other disorders, as well as other potential risk factors. Mediation analyses were conducted to determine whether non-supportive parenting mediated effects of preschool-onset disorders on school-aged MDD. WHAT DOES THIS PAPER ADD ▸ This study is the first to describe the psychiatric outcomes of preschool-onset depression in later childhood and early adolescence. ▸ Preschool-onset, subthreshold depression predicted MDD as well as other psychiatric disorders in later childhood and early adolescence. Children with preschool-onset depression were more likely to be diagnosed with school-aged MDD (OR 2.70, 95% CI 1.43 to 5.08), with an anxiety disorder (OR 3.48, 95% CI 1.86 to 6.51), or with attention deficit hyperactivity disorder (ADHD; OR 3.69, 95% CI 1.84 to 7.40). Although other risk factors (a lower family incometo-needs ratio, maternal history of depression, traumatic life events) also predicted school-aged MDD, these risk factors were not significant when preschool-onset depression was included in the model. ▸ Preschool-onset conduct disorder also predicted MDD in later childhood and early adolescence. Children with preschool-onset conduct disorder were more likely to be diagnosed with school-aged MDD (OR 3.38, 95% CI 1.50 to 7.62). This link was partially mediated by non-supportive parenting, so that the association was reduced by 21% when non-supportive parenting was included in the model. EvidCopyright Based Mental Health Monthauthor 2015 Vol 0(or No 0their Article
LIMITATIONS ▸ Children were primarily recruited from paediatric settings. Preschoolonset depression may be more commonly seen in clinical settings among treatment-seeking populations, while subthreshold MDD in non-clinical community-based settings, like those considered in the present study.2 Full threshold depression may show stronger or different patterns of associations with psychiatric disorders in later childhood and early adolescence. ▸ Other potential risk factors that were not considered in this study may account for the link between preschool-onset depression and later depression. Temperamental positive and negative emotionality, assessed in preschool, predict depressive symptoms in later childhood, even after accounting for preschool depressive symptoms.4 ▸ This study design does not speak to whether preschool-onset depression reflects an MDD prodrome—subthreshold symptoms of the disorder that precede development of full MDD—or is a distinct form of MDD. WHAT NEXT IN RESEARCH Longitudinal studies to examine if preschool-onset subthreshold MDD, preschool-onset full MDD, and later-onset full MDD have similar risk factors and outcomes. This will better characterise preschool-onset depression and determine its validity as a psychiatric disorder.
DO THESE RESULTS CHANGE YOUR PRACTICES AND WHY? The results of this study have direct implications for my clinical practice, as in the future I’ll assess full as well as subthreshold MDD using these age-adjusted criteria. Unlike more commonly diagnosed childhood disorders (eg, ADHD), depression is not characterised by overt disruptive symptoms. It is also likely that providers fail to recognise the seriousness of depressive symptoms in preschool-aged children. However, the results of this study indicate that clinically meaningful depressive symptoms are not only identifiable in children as early as 3 years, but that preschool-onset depression has serious implications for mental health. Paediatricians and other childcare providers should carefully assess depression using age-adjusted subthreshold MDD criteria. Competing interests None.
doi:10.1136/eb-2014-101974
Received 17 November 2014; Revised 02 January 2015; Accepted 05 January 2015
REFERENCES 1. 2.
3. 4.
Luby JL, Heffelfinger AK, Mrakotsky C, et al. The clinical picture of depression in preschool children. J Am Acad Child Adolesc Psychiatry 2003;42:340–8. Egger HL, Angold A. Common emotional and behavioral disorders in preschool children: presentation, nosology, and epidemiology. J Child Psychol Psychiatry 2006;47:313–37. Costello EJ, Pine DS, Hammen C, et al. Development and natural history of mood disorders. Biol Psychiatry 2002;52:529–42. Dougherty LR, Klein DN, Durbin CE, et al. Temperamental positive and negative emotionality and children’s depressive symptoms: a longitudinal prospective study from age three to age ten. J Soc Clin Psychol 2010;29:462–88.
employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from http://ebmh.bmj.com/ on March 31, 2015 - Published by group.bmj.com
Preschool-onset depression predicts major depressive disorder and other psychiatric disorders in later childhood and early adolescence Sylia Wilson Evid Based Mental Health published online January 21, 2015
Updated information and services can be found at: http://ebmh.bmj.com/content/early/2015/01/21/eb-2014-101974
These include:
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Articles on similar topics can be found in the following collections Depressive disorder (533) Attention-deficit hyperactivity disorder (109) Neurology (1016) Conduct disorder (52) Epidemiology (1486) General practice / family medicine (198) Screening (epidemiology) (156)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Evidence-Based Mental Health Online First, published on January 21, 2015 as 10.1136/eb-2014-101974 Causes and risk factors
Preschool-onset depression predicts major depressive disorder and other psychiatric disorders in later childhood and early adolescence Sylia Wilson Department of Psychology, University of Minnesota, Minneapolis, Minnesota, USA; [email protected]
COMMENTARY ON: Luby JL, Gaffrey MS, Tillman R, et al. Trajectories of preschool disorders to full DSM depression at school age and early adolescence: continuity of preschool depression. Am J Psychiatry 2014;171:768–76. WHAT IS ALREADY KNOWN ON THIS TOPIC Preschool-onset depression is defined by age-adjusted subthreshold criteria for major depressive disorder (MDD) in children aged 3–6 years.1 Preschool-onset depression has shown preliminary evidence of validity as a psychiatric disorder,2 but the long-term outcomes of preschool-onset depression are still unclear. Identifying the earliest manifestations of depression will help target intervention efforts.3 METHODS OF THE STUDY This is a prospective, observational study. Children (n=246) aged 3–6 years were recruited from primary care and day care sites in St. Louis. Children with depressive symptoms were oversampled using the Preschool Feelings Checklist, a brief screening measure—children whose caregivers endorsed two or more depression symptoms were recruited for this study; children with symptoms of other psychiatric disorders and children without symptoms were also included so that depressed children could be compared with children with other disorders and healthy controls. Children and primary caregivers were assessed for 6 years. Child MDD and other psychiatric disorders were assessed using caregiver reports (for children younger than 8 years) and combined caregiver and child reports (for children older than 8 years) on diagnostic interviews (the Preschool Age Psychiatric Assessment and the Child and Adolescent Psychiatric Assessment) at baseline and follow-up assessments. Other potential risk factors were also assessed, including children’s experiences of stressful and traumatic life events, family income-to-needs ratio, child pubertal status, maternal history of depression and non-supportive parenting. Logistic regression analyses were conducted to examine the likelihood of a diagnosis of school-aged MDD using preschool-onset MDD and other disorders, as well as other potential risk factors. Mediation analyses were conducted to determine whether non-supportive parenting mediated effects of preschool-onset disorders on school-aged MDD. WHAT DOES THIS PAPER ADD ▸ This study is the first to describe the psychiatric outcomes of preschool-onset depression in later childhood and early adolescence. ▸ Preschool-onset, subthreshold depression predicted MDD as well as other psychiatric disorders in later childhood and early adolescence. Children with preschool-onset depression were more likely to be diagnosed with school-aged MDD (OR 2.70, 95% CI 1.43 to 5.08), with an anxiety disorder (OR 3.48, 95% CI 1.86 to 6.51), or with attention deficit hyperactivity disorder (ADHD; OR 3.69, 95% CI 1.84 to 7.40). Although other risk factors (a lower family incometo-needs ratio, maternal history of depression, traumatic life events) also predicted school-aged MDD, these risk factors were not significant when preschool-onset depression was included in the model. ▸ Preschool-onset conduct disorder also predicted MDD in later childhood and early adolescence. Children with preschool-onset conduct disorder were more likely to be diagnosed with school-aged MDD (OR 3.38, 95% CI 1.50 to 7.62). This link was partially mediated by non-supportive parenting, so that the association was reduced by 21% when non-supportive parenting was included in the model. EvidCopyright Based Mental Health Monthauthor 2015 Vol 0(or No 0their Article
LIMITATIONS ▸ Children were primarily recruited from paediatric settings. Preschoolonset depression may be more commonly seen in clinical settings among treatment-seeking populations, while subthreshold MDD in non-clinical community-based settings, like those considered in the present study.2 Full threshold depression may show stronger or different patterns of associations with psychiatric disorders in later childhood and early adolescence. ▸ Other potential risk factors that were not considered in this study may account for the link between preschool-onset depression and later depression. Temperamental positive and negative emotionality, assessed in preschool, predict depressive symptoms in later childhood, even after accounting for preschool depressive symptoms.4 ▸ This study design does not speak to whether preschool-onset depression reflects an MDD prodrome—subthreshold symptoms of the disorder that precede development of full MDD—or is a distinct form of MDD. WHAT NEXT IN RESEARCH Longitudinal studies to examine if preschool-onset subthreshold MDD, preschool-onset full MDD, and later-onset full MDD have similar risk factors and outcomes. This will better characterise preschool-onset depression and determine its validity as a psychiatric disorder.
DO THESE RESULTS CHANGE YOUR PRACTICES AND WHY? The results of this study have direct implications for my clinical practice, as in the future I’ll assess full as well as subthreshold MDD using these age-adjusted criteria. Unlike more commonly diagnosed childhood disorders (eg, ADHD), depression is not characterised by overt disruptive symptoms. It is also likely that providers fail to recognise the seriousness of depressive symptoms in preschool-aged children. However, the results of this study indicate that clinically meaningful depressive symptoms are not only identifiable in children as early as 3 years, but that preschool-onset depression has serious implications for mental health. Paediatricians and other childcare providers should carefully assess depression using age-adjusted subthreshold MDD criteria. Competing interests None.
doi:10.1136/eb-2014-101974
Received 17 November 2014; Revised 02 January 2015; Accepted 05 January 2015
REFERENCES 1. 2.
3. 4.
Luby JL, Heffelfinger AK, Mrakotsky C, et al. The clinical picture of depression in preschool children. J Am Acad Child Adolesc Psychiatry 2003;42:340–8. Egger HL, Angold A. Common emotional and behavioral disorders in preschool children: presentation, nosology, and epidemiology. J Child Psychol Psychiatry 2006;47:313–37. Costello EJ, Pine DS, Hammen C, et al. Development and natural history of mood disorders. Biol Psychiatry 2002;52:529–42. Dougherty LR, Klein DN, Durbin CE, et al. Temperamental positive and negative emotionality and children’s depressive symptoms: a longitudinal prospective study from age three to age ten. J Soc Clin Psychol 2010;29:462–88.
employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from http://ebmh.bmj.com/ on March 31, 2015 - Published by group.bmj.com
Preschool-onset depression predicts major depressive disorder and other psychiatric disorders in later childhood and early adolescence Sylia Wilson Evid Based Mental Health published online January 21, 2015
Updated information and services can be found at: http://ebmh.bmj.com/content/early/2015/01/21/eb-2014-101974
These include:
References Email alerting service
Topic Collections
This article cites 4 articles, 0 of which you can access for free at: http://ebmh.bmj.com/content/early/2015/01/21/eb-2014-101974#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Depressive disorder (533) Attention-deficit hyperactivity disorder (109) Neurology (1016) Conduct disorder (52) Epidemiology (1486) General practice / family medicine (198) Screening (epidemiology) (156)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
