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MOODDISORDERSINPRESCHOOLANDPRIMARYSCHOOLCHILDREN

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223 MOOD DISORDERS IN PRESCHOOL AND PRIMARY SCHOOL CHILDREN

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MOOD DISORDERS IN PRESCHOOL AND PRIMARY SCHOOL CHILDREN

Catina Feresin

Department of Medicine, University of Padua (Italy)

Abstract

In the last few years a number of researchers have pointed out that the seriousness of mood disorders among preschool and primary school children is still underestimated when compared to the seriousness of the same illness during adolescence and adulthood (Luby, 2009). In spite of that, many pupils are still not diagnosed and treated. Without any treatment, this illness can lead to severe psychiatric problems in future adolescents and adults who suffered from it during their childhood (Carretti et al., 2009; Muratori, 2008; Muratori & Apicella, 2008).

The objective of this work is threefold: firstly, to describe the principal symptoms of mood disorders in order to help preschool and primary school teachers to clearly recognise them; secondly, to describe the treatments which psychologists and psychiatrists are using nowadays to treat young children affected by this illness. Finally, as educators, we would like to suggest two programmes which include a close cooperation between clinicians and teachers themselves. The former is a three-step prevention programme to be held during the last two years of primary school, whilst the latter is a programme to be held during the last two years of preschool. It is understood that educators are not asked to become clinicians, but they might closely collaborate with clinicians by supporting children which are coping with mood disorders.

Keywords: mood disorders in preschool and primary school children, collaboration programmes between teachers and clinicians.

224 Catina Feresin

Introduction

In the last thirty years the experimental interest in depressive disorders among children has gradually increased among researchers. Although a historical observational study by Spitz had already documented the presence of depression during childhood (Spitz, 1946), it was only in 1980 that the authors of DSM III (A.P.A., 1980) pointed out the importance of a systematic study of mood disorders during childhood. In fact, during the 1980’s and 1990’s the results of numerous studies, based on the use of accurate tests, confirmed the likelihood of identifying clinical mood disorders during this early period of human life (Birmaher et al. 1996 a, 1996 b; Keller et al., 1984; Kovacs et al., 1984a, 1984b, 1994).

More recently, a number of researchers have observed that the seriousness of mood disorders among preschool and primary school children is still underestimated when compared to the seriousness of the same illness during adolescence and adulthood. This means that many children are still not diagnosed and treated, and without any treatment, this illness can lead to severe psychiatric problems for the future adolescent who felt depression during childhood (Carollo et al., 2004). Mood disorders are particularly dangerous if they strike children at an early age: according to Shuchter (Shuchter et al., 1997), when adults suffer from depression, they do not lose the ability to recognise that the odd mental phenomena they experience are a logical product of a pathological condition, so they try to cope with their illness by starting psychotherapy and, eventually, taking antidepressants. Children, on the contrary, may get lost in their depression: they do not have sufficient life experience and appropriate cognitive skills to make a proper distinction between illness and health; what they are experiencing is reality, so they are often emotionally paralysed.

In 1984, Kashani and collaborators identified 4% of preschoolers in a child development unit who met the DSM III criteria for depression (Kashani et al., 1984; A.P.A., 1980). In a 1997 study by the same author, 2.7% of 300 preschool children met the DSM-IV criteria for dysthymia (Kashani et al., 1997; A.P.A., 2000). Nevertheless, although Kashani identified depression in preschool children already in 1984, the study of depression which occurs during the preschool period is relatively new.

Luckily, as Luby had pointed out, “...over the past decade, empirical data have become available that refute traditional developmental theory suggesting that preschool children would be developmentally too immature to experience depressive affects (Stalets & Luby, 2006). Basic developmental studies, serving as a framework and catalyst for these clinical investigations, have also shown that preschool children are far more emotionally sophisticated than previously recognized. While some of these emotion developmental findings are new, others have been available for some time but never previously applied to clinical

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models of childhood affective disorders. These findings on early emotion development, obtained using narrative and observational methods, provide a key framework for studies of early childhood depression, as they establish that very young children are able to experience complex affects seen in depression, such as guilt and shame. Indeed, guilt and shame have been observed to occur more frequently in depressed than in healthy preschoolers.” (Luby, 2009).

Children may exhibit depression in different ways: bad school performance (both at preschool and at primary school), an increased irritability, constant sadness, low self-esteem, a difficult social integration with friends. The main consequence of this way of feeling is a different way of behaving in comparison with their classmates: in fact, such children do not explore the world around them as much or play with their friends as much, they do not develop significant interpersonal skills with adults, which can be a disadvantage as it influences the correct development of personality. Moreover, in the context of a class (often very large), these pupils are generally quiet: they usually do not disturb the work of the teacher or attract his/her attention (except for bipolar children during manic or hypomanic episodes). It is therefore imperative for the teacher to be able to recognise the principal symptoms of this illness. In order to accomplish this task with more competence and to provide the most effective help, teachers must further train themselves by attending specific courses and reading scientific papers and books about mood disorders (Lo Piccolo, 2005; Stark, 1995; V.A., 2001).

Main types of mood disorders among preschool and primary school children

According to Caretti et al. (2009), to Ismond (1996) and to the DSM IV-TR criteria (A.P.A., 2000); there are basically two types of mood disorders: 1) depressive disorder and 2) bipolar disorder (Actually, there are more than two types of mood disorders which clinicians use to make different diagnoses among children, but the ones we have just mentioned remain the principal two).

1) Depressive disorder can be divided into a) major depressive disorder and b) dysthymic disorder; the first is a severe condition characterised by one or more major depressive episodes lasting at least two weeks; the second is a mild disorder, but is more persistent: children are depressed for most of the day on most days and symptoms may continue for about one year (several years among adults). Children affected by major depressive disorder sometimes show another mental disorder, such as conduct disorder, anxiety, phobias, and attention deficit hyperactivity disorder. This phenomenon is called comorbidity (Rietveld et al., 2002).

2) Bipolar disorder can be further classified into bipolar I and bipolar II disorders. Bipolar I disorder is considered as the classic form of manic depression, with full manic episodes followed by major depressive episodes; bipolar II disorder also involves major depressive episodes

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which are, however, followed by hypomanic instead of full manic episodes (Kovacs et al, 1994; Kovacs et al., 2005).

We are aware of the fact that recognising mood disorders among children is a complex task; however, we firmly believe that, after an appropriate training, preschool and primary school teachers should be able to recognise the presence and duration of depressive and bipolar disorders, observing the emotional/cognitive and physical symptoms of this illness, as explained in the following paragraph.

Main symptoms of mood disorders among preschool and primary school children

In a recent review by Mocinić and Feresin (2012), the symptoms of depressive disorders are precisely defined for primary school children. However, as Luby pointed out in 2009, symptoms of depression in pre-school children are quite similar to those already found in school children and, sometimes, in adults (Luby, 2009; Luby et al., 2003; States & Luby, 2006). The following is the list of symptoms mentioned by Mocinić and Feresin:

Sadness / Irritability

Sadness is one of the most significant emotional/cognitive symptoms among depressed children (usually, bipolar children show more irritability than sadness). During a major depressive episode, pupils experience a deep sadness or start crying without being able to understand why they are behaving this way. Teachers can observe this crucial symptom for a few weeks (at least two weeks according to the DSM IV-TR criteria, 2000); if it disappears in less than two weeks, it is not connected with depression (e.g. the pupil may have lost a good friend or may have changed school).

Loss of pleasure (anhedonia)

Generally, children lose interest in things they once loved very much; this is normal behavior. On the contrary, during depressive episodes, depressed or bipolar children show a clear emotional/cognitive symptom: they do not feel pleasure in anything and they lose their normal desire to play with classmates (i.e. they stop participating in games and activities). Teachers must also observe a potential decline in these children’s grades, because these pupils do not complete their homework and sometimes they even miss school.

Difficulty in concentrating

Difficulty in concentrating is another emotional/cognitive symptom. It is a simple task for a trained teacher to notice if students cannot concentrate well; in fact, during both depressive and manic episodes, depressed or bipolar children keep their minds busy all day long, focusing their attention on themselves, which has a negative influence on their ability to concentrate on regular school activities.

227 MOOD DISORDERS IN PRESCHOOL AND PRIMARY SCHOOL CHILDREN

Negative self-evaluation / Guilt / Grandiose self-image

Negative self-evaluation is a cognitive/emotional symptom which occurs among children suffering from depression or bipolar disorder during depressive episodes. Teachers are generally required to observe whether negative self-evaluation affects school performance, but also if it influences the pupil's physical aspect and his/her social ability to integrate with friends. Guilt is also an emotional/cognitive symptom: depressed children feel guilty more frequently than children who do not suffer from depression. In this case, teachers are required to notice whether these pupils blame themselves for facts they are not responsible for (i.e. separation of their parents). During manic or hypomanic episodes, bipolar children often suffer from grandiose self-image, accompanied with an increased level of talking and feeling euphoric. Teachers are able to clearly observe this cognitive and emotional symptom, especially when it follows a period of negative self-evaluation.

Recurrent thoughts of death, suicidal ideation and suicide attempts

Recurrent thoughts of death and the idea of committing suicide without a specific plan is an emotional/cognitive symptom among primary school children suffering from depression or bipolar disorder which occurs during depressive episodes, whilst actual suicide attempts or ideations of a specific plan for committing suicide are more frequently encountered among adolescents than among primary school children (Cheung et al., 2007).

Fatigue/Hyperactivity

Teachers can easily observe if pupils are tired during classes. Fatigue is a rare condition among healthy children, but it is a very common physical symptom among children suffering from depression or bipolar disorder which occurs during depressive episodes. It can occur in a mild form without changing the child's habits, or it can influence daily activities by obstructing the normal rhythm of life. On the contrary, hyperactivity with an increased level of energy is a frequent symptom during manic and hypomanic episodes in bipolar children.

Changes in appetite

A decrease in appetite may cause an unbalanced growth of a child's body: he/she increases in height but remains equal in weight, with possible serious physical disorders. Abnormal decrease in appetite is considered to be a physical symptom and is usually associated with depressive disorder or bipolar disorder (during depressive episodes). The opposite case, an increase in appetite, should not be confused with the normal growth process: it is considered abnormal if it is accompanied by obesity, when the child eats at all times and when the thought of eating interferes with his/her daily activities. Abnormal increase in appetite is another physical symptom which is generally associated with bipolar disorder during manic or hypomanic episodes.

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Pain complaints without medical cause

Sometimes children complain to the teacher about headaches, stomach aches or other kinds of pain. Pain complaints are considered symptomatic when there is no objective reason for feeling them. This physical symptom is usually associated with major depressive disorder and its severity is defined by the intensity of pain and the frequency with which it occurs.

Sleep disorders

This physical symptom can be divided into insomnia, when the child sleeps less than he/she needs, and hypersomnia, when the child sleeps longer than he/she needs (and often has difficulty getting up in the morning). Furthermore, insomnia can be divided into initial insomnia and intermediate insomnia during the night. The teacher may notice this symptom if the pupil loses concentration and takes short naps at his/her desk. Among preschool and primary school children, nightmares during REM sleep are very common and often disturb the quality of sleep; on the other hand, night terrors (e.g. restless leg syndrome, sleepwalking) are commonly encountered in children affected by bipolar disorder and they occur during deep sleep (Mocinić and Feresin, 2012).

Main therapies to treat mood disorders among preschool and primary school children

According to Luby, despite the fact that many studies have shown the existence of depression in preschool children, there is little scientific literature available to guide treatment once depression has been diagnosed (Luby, 2009).

Play therapy

Play therapy is a common form of therapy for very young children which uses techniques for engaging children in recreational activities to help them cope with their problems and fears. During this kind of therapy, a psychologist observes the child while he/she is playing with a variety of toys, thus expressing his/her unpleasant feelings which cannot be communicated verbally. According to many researchers, more experiments are required in order to prove the effectiveness of this kind of therapy as a means of coping with depression in preschoolers (see Luby, 2009).

Verbal therapy

Verbal therapy is very helpful for primary school children, but not for very young children who haven't developed sufficient verbal skills to correctly express their feelings, lacking the linguistic sophistication to describe any kind of emotional experience.

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Antidepressants

Regarding antidepressants, there is a general concern among mental health providers about this form of medical treatment, since they tend to avoid using medication for treating children at such a young age. Researchers have different opinions about antidepressant for primary school children and adolescents (Bailly, 2006; Wagner, 2005): some are pro such medicines, while others are against them. On the other hand, regarding preschoolers there is a common concern among researchers about the use of this type of medical treatment (including also the recently developed antidepressants). According to Luby, “the use of antidepressants is not the first- nor even the second-line treatment for early childhood depression at this time”(Luby, 2009). A study by Nulman and collaborators (Nulman et al., 2012) provides relevant information by distinguishing the effects of maternal depression from the effects of exposure to antidepressants (e.g. venlafaxina). Indeed, this study included a group of women with histories of depression who had discontinued antidepressants prior to conception (mothers' depression was defined according to the DSM-IV criteria). The preliminary conclusion of this study is that exposure to untreated maternal depression in utero and during early childhood is associated with worse cognitive and behavioral outcomes in children.

Parent-Child Interaction Therapy (P.C.I.T.) and Emotion Development Therapy (E.D.)

Recently, parent-child psychotherapy has been developed for the treatment of preschool depression. It combines two separate therapies, i.e. Parent-Child Interaction Therapy (P.C.I.T.) and Emotion Development Therapy (E.D.). The former (P.C.I.T.), originally developed in the 1970s to treat disruptive disorders in preschool children, is based on the common knowledge that the child is not an independent entity at this early age and that the caregiver is a fundamental part of the child’s psychological world, which is why the caregiver figure is always involved in this kind of therapy. The latter (E.D.) is designed to enhance the child’s emotional development capacities through the use of emotional education. Parent-Child Interaction Therapy/Emotion Development (P.C.I.T./E.D.) combines the use of emotional education by enhancing the caregiver’s capacity to serve as an effective external emotion regulator for the child. The primary goal of this therapy is to enhance the child’s capacity to identify emotions in oneself and in other people; the second goal is to teach the child to develop healthy emotions; the third goal is to enhance the child's capacity of experiencing positive affect as well as the capacity to recover from negative affect. Those who advocate this type of therapy hope that children will learn how to handle depressive symptoms and parents will reinforce those lessons. All this is based on the hypothesis that depressed children are less reactive to positive stimuli and more reactive to negative stimuli than healthy children. As Luby explained in one of her articles, “P.C.I.T./E.D. is a treatment

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which usually includes fourteen psychotherapeutic weekly sessions. During a single session, the therapist observes the child and the caregiver interaction through a one-way mirror. The setting also contains a microphone and an earbud which allow the therapist to interact more easily with the caregiver and to intervene more effectively on the child’s behalf. In the case of a depressed young child, enhancing positive emotion in response to incentive events and reducing negative emotion in response to frustrating or sad events are targets of treatment by coaching the parent to respond to the child during contrived (and spontaneous) in vivo experiences during the therapeutic session” (Luby, 2009).

Conclusion: The importance of a close collaboration between teachers and school psychologists for helping children to cope with mood disorders.

First proposal: a three-step early prevention programme to be held at primary schools as a possible way to fight an illness as frequent as depression:

Primary schools are generally investing limited efforts in the early identification of children affected by mood disorders. Cash and Cowan (2006) supposed that the main cause for this lack of early identification is connected with school psychologists' profession itself. The two authors literally wrote: “Unfortunately, many people, including some members of the profession, still do not perceive school psychologists as providers of mental health services. Perhaps this is, in part, due to the fact that it is common to narrow mental health service provision down to psychotherapy. Possibly it is a result of the failure to recognise prevention, assessment, and crisis intervention as mental health services.”

As Mocinić and Feresin recently suggested (Mocinić & Feresin, 2012), we need a three-step early prevention programme to be held at primary schools as a possible way of fighting an illness as common as depression:

1) Firstly, a large-scale programme should be developed and applied during the last two years of primary school, when the knowledge of mother tongue is comparable to that of adolescents and when pupils can easily follow a written test. All children should be screened for possible mood disorders, just as they are screened for visual acuity or other health problems. Many valid and reliable tests can be used to collect data for identifying children who might suffer from mood disorders: “The Child Behavior Checklist (CBCL)” and “The Children's Depression Inventory (CDI)” (Achenbach, 1991; Gregory, 2004; Rivera et al., 2005). The Australian clinicians designed the other two questionnaires for assessing mental health of children in primary schools. As suggested by Dix et al. (2008), “...the first measure is Goodman’s Strength and Difficulties Questionnaire (SDQ), which needs to be completed by each participating child’s parent/caregiver and teacher. The second measure, the Flinders SCS, contains items about school, family and child factors, along with the outcome measures of student mental health.”

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2) Secondly, after the screening is completed, the diagnosis process can start, carried out by a trained clinician who can interpret the results of the previously mentioned tests. As Guetzloe (2003) pointed out, “...a precise diagnosis of depression is a complex task, extremely difficult even for highly skilled physicians and other clinicians. It requires a careful examination of physical, mental, emotional, environmental, and cultural factors related to the child.”

3) Thirdly, a treatment plan is traditionally coordinated by a school psychologist at the end of the process, and the most frequently used therapies are cognitive behavioral therapy and interpersonal therapy which help the depressed child to change his/her distorted view of himself/herself by improving his/her social skills (Sherril & Kovacs, 2002). Only in severe cases of depression, medication, such as antidepressants, may be used (Bailly, 2006; Emislie et al., 1997; Wagner, 2005). In cases of bipolar I disorder, clinicians prefer to use mood stabilizers instead of antidepressants because some antidepressants can induce manic episodes (for an accurate review see Kowatch et al., 2005).

Traditionally, teachers are not expected to diagnose depression in children. Usually, the major role of educators is to detect symptoms of depression, keep notes and make appropriate referrals to school psychologists. However, quite recently, Vulić-Prtorić suggested that there is a need for a closer collaboration between educators and clinicians (Vulić-Prtorić, 2007). For example, during the test assignment phase, teachers can help school psychologists to distribute these tests to the entire class. Also, school psychologists may ask teachers to collaborate with them during the treatment itself; for instance, educators (and, of course, parents) can participate in therapy by providing the pupil with a warm human touch and emotional support. Educators should also understand depressed pupils and provide them with patience and encouragement, making them talk, listening to them carefully without underestimating their feelings, and offering them a real hope of solving depression. Clinicians and teachers can provide a supportive environment not only during the therapy but also during classes: teachers can invite school psychologists to join collective activities in the classroom, thus helping depressed children to develop positive relationships with peers and to enhance optimistic feelings.

It is understood that many children continue to attend school while being assessed for depression; therefore, they will benefit from a close collaboration between their educators and the school psychologist. Mocinić and Feresin (2012) claim that bringing educators and clinicians together might be a good approach to fighting depression during childhood, because a multidisciplinary team, which organises regular meetings, will be able to provide support to the child in solving mood disorders before he/she becomes an adolescent.

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The three-step programme suggested by the two authors is likely to be very expensive from an economic point of view, but the cost of depression among future adolescents and adults in the society is even more expensive than the provision of this programme during the last two years of primary school.

Second proposal: Parent-child therapy should include teachers when the caregiver shows affective disorders – a new clinical approach to treat depressed preschoolers

It is well known that depression runs in families – children affected by depressive disorders often have a parent affected by the same illness. This is probably due to the fact that the two predominant causes of depression in children are the following: 1) living with a depressed parent, 2) inheriting depressive traits from him or her.

Very recently, Feresin, Mocinić and Tatković (2013) proposed that the teacher – a person who is affectively very close both to the child and to the parent/caregiver – be included in the treatment process. The three authors emphasized that “he/she spends a lot of time with school or preschool children and their parents; therefore, he/she is in a unique position to provide a strong emotional support both to caregivers and to children themselves”. Furthermore, the authors say that “...preschoolers are younger than school children, and for them the caregiver is more fundamental in terms of affective development than for primary school children. They therefore suggest that the teacher should interact with the parent/caregiver to help the caregiver to participate effectively in the treatment. Instead of the usual triadic relationship (child–caregiver–psychologist), they proposed a different relationship (child–caregiver–psychologist–teacher), in which the four people follow a short-term programme which generally may last up to 14 weeks (similar to Luby's programme). During the first stage of the programme, teachers are trained by attending specific courses and classes and reading scientific papers and books about mood disorders in children. After that, teachers can be trained by psychologists to help the caregiver to actively participate in the treatment, while the caregiver is undergoing a personal psychotherapy (e.g. cognitive therapy). During the treatment itself, the teacher effectively helps the caregiver to encourage his/her child to achieve a normal emotion regulation, to work on fighting the feeling of guilt, and to learn how to handle depressive symptoms.”

As Feresin et al. (2013) pointed out, “To develop the project and to have a direct confirmation of the validity of this kind of psychotherapy which includes the presence of a teacher, further research is necessary which directly examines depressed preschoolers' brain function by using f.M.R.I., and uses an experiment to compare the first situation in which the teacher is present with the second situation in which the teacher is absent.”

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Nowadays researchers are starting to study brain functions in depressed preschoolers by means of f.M.R.I.; for example, a paper by Gaffrey and colleagues has indicated that “depressed preschoolers exhibited a significant positive relationship between depression severity and right amygdala activity while viewing facial expressions of negative affect… The results suggest that, similar to older children and adults suffering from depression, the relation between amygdala responsivity and degree of depression severity exists from as early as age 3” (Gaffrey et al., 2011). A more recent work by Suzuki and collaborators (Suzuki et al., 2012) indicated that “smaller bilateral hippocampal volumes were associated with greater cortico-limbic activation to sad or negative faces versus neutral faces.” It is a well-established fact that amygdala, hippo-campus and prefrontal cortex are strongly connected to perception of emotions in mammals. Further studies are necessary to explore the relationship between the degree of depression, emotions and activations of cortical and limbic areas. However, these findings are interesting because they show how developed the emotions are and how sophisticated their perception is in children who are less than three years old, even if they do not have the linguistic capacity to verbally express themselves.

According to Feresin et al. (2013), “a further research is necessary which directly analyses depressed preschoolers' brain function by f.M.R.I., comparing the activation of amygdala, hippo-campus and prefrontal cortex and the degree of depression when children are viewing facial expressions of negative affect”, as Gaffrey and Suzuki recently did (Gaffrey et al., 2011; Suzuki et al., 2012). If the idea of involving teachers along with the caregiver is correct, a slight positive correlation or no correlation at all should be found between the severity of depression and the activity of cortical and limbic areas, in the case when the teacher is present. This hypothetical result should mean that the child is learning how to deal with negative emotions to fight depression.

Of course, modification of P.C.I.T./E.D. therapy and the f.M.R.I. study are only proposals and they might be the topic of future papers.”

234 Catina Feresin

References

1.) Achenbach T.M. (1991). Child Behavior Checklist/4-18. Manual for the Teacher's Report Form Profile, Department of Psychiatry, University of Vermont, Burlington, USA.

2.) American Psychiatric Association (1980). DSM III: Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC, USA.

3.) American Psychiatric Association (2000). DSM IV-TR: Diagnostic and statistical manual of mental disorders (4th ed., Text revision). Washington, DC, USA.

4.) Bailly D. (2006). Safety of selective serotonin re-uptake inhibitor antidepressants in children and adolescents. Press Med., 35, 1507-1515.

5.) Birmaher B., Ryan N.D., Williamson D.E., Brent D.A., Kaufman J., Dahl R.E. Perel J., Nelson B. (1996 a). Childhood and adolescent depression: A review of the past 10 years. Part I. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1427-1439.

6.) Birmaher B., Ryan N.D., Williamson D. E., Brent D.A., Kaufman J. (1996 b). Childhood and adolescent depression: A review of the past 10 years. Part II. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1575-1583.

7.) Caretti V., Dazzi N, Rossi R. (a cura di), (2009). DSM-IV Guida alla diagnosi dei disturbi dell'infanzia e dell'adolescenza, Masson, Milano. Original English version: Rapoport J.L., Ismond, D.R. (1996). DSM-IV-Training guide for diagnosis of childhood disorders, Elsevier.

8.) Carollo V., Provenzano V., Lo Piccolo A., Sidoti E., Benigno M.T., Tringali, G. (2004). Childhood depression: A descriptive study on a group of children/students in Palermo. Acta Medica Mediterranea, 20, 135-138.

9.) Cash R.E., Cowan K.C. (2006). School psychologists are mental health providers. In Mood Disorders: What Parents and Teachers Should Know. Communiqué, Newspaper of the National Association of School Psychologists, 35, 2, 24.

10.) Cheung A.H., Zuckerbrot R.A, Jenson P.S., Ghalib K. (2007). Treatment and ongoing management guidelines for adolescent depression in primary care. Pediatrics, 120, 1313-1326.

11.) Dix K.L, Askell-William H., Lawson, M.J. (2008). Different measures, different informants, same outcomes? Investigating multiple perspectives of primary school students’ mental health. Paper presented at the annual Australian Association for Research in Education conference, Brisbane, Australia.

12.) Emslie G., Rush J., Weinberg W., Kowatch R., Hughes C, Carmody T. (1997). A double-blind, randomized, placebo-controlled trial of fluoxetine in children and adolescents with depression. Arch Gen Psychiatry, 54, 1031-1037.

13.) Feresin C., Mocinić S., Tatković N. (2013). Should Parent-Child Therapy include teachers to treat depressed preschoolers when caregiver shows affective disorders? Educational and School Issues,62 (1), 75-84.

14.) Gaffrey M.S., Luby J.L., Belden A.C., Hirshberg J.S., Barch D.M. (2011). Association between depression severity and amygdala reactivity during sad face viewing in depressed preschoolers: an fMRI study. Journal of Affective Disorders, 129 (1-3), 364-70.

235 MOOD DISORDERS IN PRESCHOOL AND PRIMARY SCHOOL CHILDREN

15.) Gregory R.J. (2004). Psychological Testing: History, Principles, and Applications, 4th Edition. Boston, MA, Pearson Education Group, Inc.

16.) Guetzloe, E. C. (1991). Depression and suicide: Special education students at risk. Reston, VA: Council for Exceptional Children.

17.) Guetzloe E.C. (2003). Depression and Disability in Children and Adolescents. Reston, VA: The Council for Exceptional Children.

18.) Kashani J.H., Ray J.S., Carlson G.A. (1984). Depression and depressive-like states in preschool-age children in a child development unit. American Journal of Psychiatry, 141, 1397-1402.

19.) Kashani J.H., Allan W.D., Beck N.C. Jr, Bledsoe Y., Reid J.C. (1997). Dysthymic disorder in clinically referred preschool children. Journal Am Acad Child Adolesc Psychiatry, 36(10), 1426-33.

20.) Keller M.B., Klerman C.L., Lavori P.W. (1984). Long-term outcome of episodes of major depression: Clinical and public health significance. Journal of American Medical Association, 252, 788-792.

21.) Kovacs M. (1992). Children's Depression Inventory (CDI). New York: Multi-health Systems, Inc.

22.) Kovacs M., Feinberg T.L., Crouse-Novak M.A. (1984 a). Depressive disorders in childhood: I. A longitudinal prospective study of characteristics and recovery. Archives of General Psychiatry, 41, 229-237.

23.) Kovacs M., Feinberg T.L., Crouse-Novak M.A. (1984 b). Depressive disorders in childhood: II. A longitudinal study of the risk for a subsequent major depression. Archives of General Psychiatry, 41, 643-649.

24.) Kovacs M., Akiskal H.S., Gatsonis C. (1994). Childhood onset dysthymic disorder: Clinical features and prospective naturalistic outcome. Archives of General Psychiatry, 51, 365-374.

25.) Kowatch R. A., Fristad M., Birmaher B., Dineen Wagner K., Findling R. L., Hellander M., and The Workgroup Members. (2005). Treatment Guidelines for Children and Adolescents With Bipolar Disorder. Journal Am. Acad. Child Adolesc. Psychiatry , 4 4 (3), 213-235.

26.) Lo Piccolo A. (2005). Stress e depressione dell'infanzia: percorsi di educazione e di prevenzione. Carbone Editore, Palermo.

27.) Luby J.L. (2009). Early Childhood Depression. American Journal of Psychiatry, 166, 974-979.

28.) Luby J.L., Heffelfinger A.K., Mrakotsky C., Brown K.M., Hessler M.J., Wallis J.M., Spitznagel E.L. (2003). The clinical picture of depression in preschool children. J Am Acad Child Adolesc Psychiatry, 42, 340-348.

29.) Mocinić S., Feresin C. (2012). The importance of collaboration between teachers and school psychologist for helping children to cope with mood disorders. Occasional papers in education and lifelong learning (OPELL): An international Journal, 6 (1-2), 98-108.

30.) Muratori F. (2008). Introduzione. Infanzia e adolescenza, 7(1), 1-2.

31.) Muratori F., Apicella F. (2008). Lo spettro dell'umore nell'infanzia e nell'adolescenza. In Cassano G.B. e Tundo A. (a cura di), Lo spettro dell'umore. Psicopatologia e Clinica, Elsevier, Milano.

236 Catina Feresin

32.) Nulman I., Koren G., Rovet J. (2012). Neurodevelopment of Children Following Prenatal Exposure to Venlafaxine, Selective Serotonin Reuptake Inhibitors, or untreated maternal depression. American Journal of Psychiatry, 169, 1165–1174.

33.) Rietveld S., Prins, P. J, Beest, I. (2002). Negative thoughts in children with symptoms of anxiety and depression, Journal of Psychopathology and Behavioral Assessment, 24, 2.

34.) Rivera C.L., Bernal G., Rossello J. (2005). The Children's Depression Inventory (CDI) and the Beck Depression Inventory (BDI): Their Validity as Screening Measures for Major Depression in a Group of Puerto Rican Adolescents. International Journal of Clinical and Health Psychology , 5(3), 485-498.

35.) Sherril J.T., Kovacs M. (2002). Nonsomatic treatment of depression. Child Adolesc. Psychiatr. Clin. N. Am., 11 (3), 579-593.

36.) Shuchter S.R., Downs N., Zisook S. (1997). La depressione: conoscenze biologiche e psicoterapia, Italian translation. Raffaello Cortina Editore, Milano.

37.) Spitz R.A. (1946). Anaclitic depression: An inquiry into the genesis of psychiatric conditions in early childhood, II. Psychoanal Study Child, 2, 313-342.

38.) Stalets M.M., Luby J.L. (2006). Preschool depression. Child Adolesc Psychiatr Clin N Am, 15, 899—917, VIII-IX.

39.) Stark K. (1995). La depressione infantile. Intervento psicologico nella scuola. Edizioni Erickson, Trento.

40.) Suzuki H., Botteron K.N., Luby J.L., Belden A.C., Gaffrey M.S., Babb C.M., Nishino T., Miller M.I., Ratnanather J.T., Barch D.M. (2012). Structural-functional correlations between hippocampal volume and cortical and limbic emotional responses in depressed children. Cogn. Affect Behav Neurosci, Oct 5. [Epub ahead of print].

41.) V.A. (2001). Teaching students with mental health disorders: Resources for teachers. Volume 2, Depression, British Columbia, Ministry of Education, Special Programs Branch, Canada.

42.) Vulić-Prtorić A. (2007). Depresivnost u djece i adolescenata, Naklada Slap, Jastrebarsko.

43.) Wagner K.D. (2005). Pharmacotherapy for major depression in children and adolescents. Prog Neuropsychopharmacol Biol Psychiatry, 29, 819-826.