• By Dartington SRU
  • Posted on Wednesday 01st February, 2012

Small kids, big problems: can we treat depression in preschoolers?

A new treatment offers tentative hope to families of depressed preschoolers, a pilot study has found. When the evidence-based intervention Parent-Child Interaction Therapy (PCIT) was recently adapted to treat preschool depression, the results of a small preliminary trial were promising.Psychiatrists at the Washington University School of Medicine in St. Louis, Missouri, added a new, third module to PCIT, which has already been shown to be very effective in treating disruptive behavior in preschoolers. This new Emotion Development (ED) module appears to produce positive effects on children’s emotion development, reducing depressive symptoms. The ED module, developed by Joan Luby and colleagues, involves teaching and coaching parents to develop their child’s emotional competence and regulation strategies. Parents allow their child to experience a range of emotions and help them to identify, understand, and manage different emotions. Six sessions of ED are delivered after the two core modules of PCIT. The question is: could these three modules work all together to impact preschool depression? Would the results justify the researchers’ decision to make changes to PCIT? The answer is a tentative “yes.” Adding a third module: is three a crowd? Traditional PCIT has proven to be an effective treatment for disruptive behavior disorders in young children. Through two core modules over 12-20 weeks, it focuses on improving the parent-child relationship and interaction patterns to improve behavior. Parents are first coached to increase praise and enthusiasm and decrease commands and criticism during a play situation. Then, parents are trained in the use of more effective commands and behavior management techniques. Coaching takes place via “bug-in-the-ear” communication from the therapist, who observes the parent and child through a one-way mirror.We know that the two-module PCIT works. The risk is that adapting it with a third module – and therefore decreasing the fidelity of implementation – will reduce the impact expected from the program. The adapted PCIT-ED included a reduced number of sessions in the core modules. It also targeted a different population of children – youngsters who have depressive rather than behavior disorders. Adding the third module could have upset the balance of the two core modules or made the intervention more complicated for participants, reducing the effect of PCIT, or it could have been a spare part producing no effect of its own.A pilot RCT by Luby and colleagues was able to provide preliminary answers to these questions. 54 children aged 3-7 years who were diagnosed with major depression were randomized, along with their parents, to receive either PCIT-ED or a psycho-education course that provided parents with information on emotion development, but no coaching. The first good news is that the two core PCIT modules seemed not to be affected by the adaptation. The PCIT-ED intervention was found to produce positive effects on children’s conduct, hostility, and ADHD symptoms – the behaviors targeted by traditional PCIT. The second good news is that the third module appeared to work against depression. Children in the PCIT-ED group showed more improvement in emotion regulation and executive function than children in the psycho-education group, and their parents tended to benefit from lower levels of stress. Why does it work? Why was this implementation positive? First, the researchers explain that the parent-child relationship, emphasized in PCIT, is central to the emotional wellbeing of the child and so is an important foundation for targeting depressive symptoms. Second, the new ED module was designed to fit in with the original PCIT logic model while addressing emotional competencies that are not direct targets of traditional PCIT. Third, the module used the same core teach-and-coach techniques and targeting of the parent as “the arm of the therapist,” altering their behavior/ competence in order to affect the child’s. Finally, fidelity to other parts of the intervention was maintained, apart from a shorter number of core sessions, resulting in an average 97% adherence to the PCIT manual. The adaptation and introduction of the new module was reviewed by PCIT developer Sheila Eyberg.More to learnLuby and colleagues caution against drawing firm conclusions from the trial. The number of children involved (54) was relatively small. Completion rates were low: almost a third of the PCIT group dropped out, and nearly two-thirds of the psycho-education group dropped out. However, the researchers claim that the pilot RCT, although preliminary, validates the PCIT-ED module and warrants a full scale RCT to measure effectiveness.Reference:Luby, J., Lenze, S., & Tillman, R. (2011). A novel early intervention for preschool depression: findings from a pilot randomized controlled trial. Journal of Child Psychology and Psychiatry. doi:10.1111/j.1469-7610.2011.02483.x

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