Early intervention changes trajectory for depressed preschoolers

Depression affects 1–2% of children younger than 13 in the U.S. and can arise as early as age 3, but a specialized therapeutic intervention can help preschool-aged children find relief from this condition—with benefits lasting at least four years, according to a new study led by researchers at Washington University School of Medicine in St. Louis.

The researchers, led by Joan Luby, MD, the Samuel and Mae S. Ludwig Professor of Psychiatry at WashU Medicine, and Mei Elansary, MD, an attending developmental behavioral pediatrician at Boston Medical Center, measured the long-term effects of a dyadic (parent-child), 18-week intervention developed by Luby.

They found the treatment to be effective in achieving long-term remission in a majority of children. Luby and Elansary also found that the children in remission had lower rates of mental health service and psychiatric medication use compared to kids who didn’t achieve remission from depression after treatment.

The results were published in the Journal of the American Academy of Child and Adolescent Psychiatry.

“The beauty of this therapy is that it’s a short-term, parent-child interaction therapy that’s delivered by a master’s level clinician, so it’s very accessible, very low risk, and it’s literally changing the trajectory of mental health over four years,” said Luby, who also directs the Department of Psychiatry’s Early Emotional Development Program at WashU Medicine.

“From a public health perspective, it’s a really good early investment, and, in terms of return on investment, it’s huge.”

Emotional intervention

Parent-Child Interaction Therapy-Emotion Development (PCIT-ED), which Luby developed and applied in this study, is the first and only psychotherapeutic intervention designed to treat depression in preschoolers that has been rigorously tested in a large-scale trial.

PCIT-ED was modified from PCIT, which is a standard intervention for treating children experiencing behavioral difficulties. In PCIT-ED, therapists coach caregivers in real-time interactions with their children, helping them reinforce positive behaviors, develop effective parenting skills and build a supportive and nurturing environment.

The focus is on improving the child’s emotional awareness and expression, fostering a secure parent-child relationship and mitigating early symptoms of depression.

Prior work by Luby’s team has shown that children receiving PCIT-ED had remission rates of 73% after the 18-week intervention compared to 23% of children who were on a waiting list for treatment. Several months after treatment, the vast majority of children remained in remission.

This latest study is the first follow-up examining the long-term effects of PCIT-ED for children and their families. It included 105 children who received a full course of PCIT-ED in the earlier trial and were reassessed four years after the end of treatment, at which point they were 8 to 12 years old.

To measure depression, the researchers conducted diagnostic interviews with the children and their primary caregivers. The interviewers assessed symptoms of major depressive disorder, such as guilt, sadness, aggression and sleep problems. They also looked at other family characteristics, such as parenting strategies and whether caregivers had depression.

They found that 57% of 3- to 7-year-olds with major depressive disorder were in remission four years later, without any follow-up or booster sessions.

“One of the reasons why this therapy has such enduring efficacy is because it trains the parent to interact differently with the child in the emotional domain,” Luby said.

“After the treatment ends, the parent continues to interact with the child with greater sensitivity, and that becomes a draw to the child. The truth is there’s nothing a child wants more than a validating, nurturing caregiver. It’s like the foundation of a house. That’s what it’s all built on.”

The findings underscore the value of early diagnosis and intervention for young children with depression, said Elansary, who is also an assistant professor of pediatrics at Boston University Chobanian & Avedisian School of Medicine.

“Our results offer promising evidence that PCIT-ED can reduce the risk of future mental health challenges into preadolescence,” she noted. “Perhaps most strikingly, children who achieved remission required significantly less use of psychotropic medications and intensive mental health services, suggesting a more favorable long-term trajectory.”

Furthermore, parents of preadolescent children in remission reported less parenting stress in Luby and Elansary’s follow-up study, highlighting the holistic benefits to the family.

With the long-term benefits of PCIT-ED established, Luby said she anticipates that providers nationwide will take advantage of downloadable training materials she has developed and start offering the protocol at their facilities. She also plans to develop additional modules to help people who would benefit from further support, such as extra emotional development for caregivers.