Even preschoolers can be depressed, but their symptoms may not fit the DSM-IV criteria, a situation that may lead to underdiagnosis and inadequate treatment. The preliminary results of a new study funded by the National Institute of Mental Health show that modified DSM criteria may help clinicians improve their ability to identify depression in young children.

"The main purpose of the study is to determine whether preschool children have clinically significant depressive symptoms using modified DSM-IV criteria. Another aim is to validate the modified criteria using the same strategies that validated psychiatric syndromes in adults and advanced the DSM system," said principal investigator Joan Luby, M.D., at the October meeting of the American Academy of Child and Adolescent Psychiatry in New York City.

Luby, an associate professor of child psychiatry, and her colleagues at Washington University School of Medicine in St. Louis, modified the DSM-IV criteria for depression by eliminating the two-week minimum duration for symptoms and one core symptom so that either depressed mood or loss of interest in previously enjoyed activities was required instead of both, said Luby.

"In contrast to the stability we see in adult mood disorders, young children have symptoms that can fluctuate from week to week and range in affect," said Luby.

The preliminary results of the five-year study show that 18 preschoolers were diagnosed with depressive symptoms using the modified criteria, compared with three diagnosed with the DSM-IV criteria.

She and her colleagues also added questions during interviews with each child’s primary caregivers that are relevant to the child’s life experience. For example, mothers in the NIMH-funded study are asked about signs of sadness or destructive behaviors when their child plays, said Luby.

"Current DSM criteria focus on symptoms at work or in relationships that are irrelevant to preschoolers," she noted.

The validity of the modified DSM criteria was tested against four other measures used to detect depression in young children. These are a family history of psychiatric disorders, scores on the Achenbach Child Behavior Checklist (CBCL), a child’s self-reported symptoms of depression and anxiety, and salivary cortisol taken from the child at assessment, said Luby.

Three groups of preschoolers were assessed with the four measures: the 18 preschoolers who met the modified DSM-IV criteria; 11 preschoolers who met the DSM-IV criteria for attention deficit/hyperactivity disorder (ADHD), and 23 preschoolers in the control group who had no DSM-IV psychiatric disorder.

"We chose ADHD for the psychiatric comparison group because it is a known disorder in preschoolers, and we wanted to know whether the symptoms we found were specific to depressive disorders," Luby explained.

"The most significant result was that depressed children had more relatives with major depression, affective disorders, and suicide attempts and/or completions compared with the ADHD group and the control group," said Luby.

"There was also a significant correlation between the children’s self-reported symptoms of depression and the depressed group in particular on the self-reported social inhibition and internalizing symptoms using an age-appropriate puppet interview," according to Luby.

Depressed preschoolers also had significantly higher rates of internalizing symptoms than the group with ADHD and normal controls.