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Trajectories of Preschool Disorders to Full DSM Depression at School Age and Early Adolescence: Continuity of Preschool Depression
Joan L. Luby, M.D.; Michael S. Gaffrey, Ph.D.; Rebecca Tillman, M.S.; Laura M. April, B.A.; Andy C. Belden, Ph.D.
Am J Psychiatry 2014;171:768-776. doi:10.1176/appi.ajp.2014.13091198
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Dr. Luby has received funding from NIMH, the CHADS Coalition, and the Sidney Baer Foundation. The other authors report no financial relationships with commercial interests.

Supported by NIH grants 2R01 MH064769-06A1 and PA-07-070 NIMH R01 to Dr. Luby. Dr. Belden was supported by NIMH grant K01 MH090515-01, and Dr. Gaffrey by NIMH grant K23 MH098176.

From the Department of Psychiatry, Washington University School of Medicine, St. Louis.

Address correspondence to Dr. Luby (lubyj@wustl.edu).

Copyright © 2014 by the American Psychiatric Association

Received September 09, 2013; Revised December 23, 2013; January 27, 2014; February 04, 2014; Accepted February 10, 2014.

Abstract

Objective  Preschool-onset depression, a developmentally adapted form of depression arising between ages 3 and 6, has demonstrated numerous validated features, including characteristic alterations in stress reactivity and brain function. This syndrome is characterized by subthreshold DSM criteria for major depressive disorder, raising questions about its clinical significance. To clarify the utility and public health significance of the preschool-onset depression construct, the authors investigated diagnostic outcomes of preschool children at school age and in adolescence.

Method  In a longitudinal prospective study of preschool children, the authors assessed the likelihood of meeting full criteria for major depressive disorder at age 6 or later as a function of preschool depression, other preschool axis I disorders, maternal history of depression, nonsupportive parenting, and traumatic life events.

Results  Preschool-onset depression emerged as a robust predictor of major depressive disorder in later childhood even after accounting for the effect of maternal history of depression and other risk factors. Preschool-onset conduct disorder also predicted major depression in later childhood, but this association was partially mediated by nonsupportive parenting, reducing by 21% the effect of preschool conduct disorder in predicting major depression.

Conclusions  Study findings provide evidence that this preschool depressive syndrome is a robust risk factor for developing full criteria for major depression in later childhood, over and above other established risk factors. The results suggest that attention to preschool depression and conduct disorder in addition to maternal history of depression and exposure to trauma may be important in identifying young children at highest risk for later major depression and applying early interventions.

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FIGURE 1. Association of Preschool-Onset Depression, Conduct Disorder, and Nonsupportive Parenting With School-Age Depression in a Logistic Regression Modela

a Covariates included baseline age, family income-to-needs ratio, traumatic life events frequency, maternal history of depression, and the interaction between preschool-onset depression and preschool-onset conduct disorder.

*p<0.05. ***p<0.001.

FIGURE 2. Nonsupportive Parenting as a Partial Mediator of the Relationship Between Preschool-Onset Conduct Disorder and School-Age Depressiona

a Covariates included baseline age, family income-to-needs ratio, traumatic life events frequency, maternal history of depression, and the interaction between preschool-onset depression and preschool-onset conduct disorder. The solid arrows indicate total effect; the dotted arrow indicates direct effect. In the mediation analysis, t-tests were conducted for continuous outcomes and Z-tests for dichotomous outcomes.

*p<0.05. **p<0.01. ***p<0.001.

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TABLE 1.Comorbid Diagnoses in Children With Preschool-Onset Depression and in Those With School-Age Depression
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TABLE 2.Demographic and Clinical Characteristics of Children in a Longitudinal Prospective Study of Depression (N=246)
Table Footer Note

a Total family income at baseline divided by the federal poverty level based on family size.

Table Footer Note

b Parental education was recorded for the parent who completed the assessment, which was the biological mother in 93% of cases.

Table Footer Note

c Children may be counted in more than one diagnostic group because of comorbidity.

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TABLE 3.Odds Ratios for School-Age and Early Adolescent Disorders From Preschool Disorders (N=246)
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TABLE 4.Hierarchical Logistic Regression Model of School-Age Depression in All Participants (N=246)
Table Footer Note

a Total family income at baseline divided by the federal poverty level based on family size.

Table Footer Note

b For children with school-age depression, the time frame is prior to onset of the disorder, and for those without, the time frame is through the final assessment.

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TABLE 5.Nonsupportive Parenting by Preschool-Onset Depression and Conduct Disorder Diagnoses in a General Linear Model With Pairwise Group Contrasts
Table Footer Note

a Bonferroni-corrected significant p=0.008.

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