An invited talk present in Pula a couple of years ago at the International Conference of Education.

1. Mood disorders in preschool
and primary school children
Catina Feresin
Department of Medicine, University of Padua,
Italy
International Conference on
Education for Development
Department of Educational Sciences
University Juraj Dobrila
Pula, april 2013

2. Introduction
In the last few years a number of researchers
has 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.

3. In spite of that, many pupils are not yet
diagnosed and treated. Without any
treatment, this illness can lead to severe
psychiatric problems in the future
adolescents and adults who have been
affected during their childhood.

4. Principal purposes of this talk:
(1)-firstly, to describe types and main
symptoms of mood disorders to help
preschool and primary school teachers to
clearly recognise them;
(2)-secondly, to describe treatments used
today by clinicians to cope with mood
disorders;

5. (3)-thirdly, to suggest a new study
regarding close cooperation between
clinicians and teachers to be held during
the last two years of preschool;
(4)-finally, to suggest another research,
about close cooperation between
clinicians and teachers to be held during
the last two years of primary school.

6. First aim of this talk
(1)
To describe the
principal types and symptoms of mood
disorders among preschool and primary
school children.

7. There are two types of mood disorders
1-depressive disorders
major depressive disorder
dysthymic disorder
2-bi-polar disorders
bi-polar I disorder
bi-polar II disorder

8. 1-Depressive disorders
Major depressive disorder is a severe
condition characterised by one or more
major depressive episodes lasting at least
two weeks.
Dysthimyc disorder is a mild disorder, but is
more persistent, in fact children are
depressed for most of the day on most days
and symptoms may continue for about one
year.

9. 2-Bi-polar disorders
Bi-polar disorder I is considered the classic
form of manic depression, with full manic
episodes followed by major depressive
episodes.
Bi-polar disorder II involves again major
depressive episodes followed by hypo-
manic instead of full manic episodes.

10. Main symptoms of mood disorders
-Sadness / Irritability
-Loss of pleasure (anhedonia)
-Difficulty in concentrating
-Negative self-evaluation Guilt /
Grandiose notion of self
-Recurrent thoughts of death
-Fatigue / Hyperactivity
-Changes in appetite
-Pain complaints without medical cause
-Sleep disorders

11. Sadness / Irritability
Sadness is one of the most significant
emotional-cognitive symptom among
depressed children (usually, bi-polar
children often show more irritability than
sadness). During major depressive episodes,
pupils perceive a deep sadness or cry
without being able to understand the reason
for why they are behaving this way.

12. Teachers can observe this crucial symptom
for a few weeks (at least two weeks
according to the criteria of DSM IV (A.P.A.,
2000); and, if it disappears before two
weeks, it is not connected with depression
(e.g. the pupil may have lost a good friend
or may have changed school).

13. Sadness in depressive disorders
(primary school children)

14. Sadness in depressive disorders
(preschoolers)

15. Irritability in bi-polar disorders
(preschoolers)

16. Loss of pleasure/(anhedonia)
Depressed or bi-polar children during
depressive episodes show a clear emotional-
cognitive symptom: they do not feel
pleasure in anything, lose their normal desire
to play with classmates (i.e. they stop
participating to games activities).

17. Difficulty in concentrating
Difficulty in concentrating is again an
emotional-cognitive symptom. It is a simple
task for a trained teacher to notice if
students cannot concentrate very much.

18. Indeed, depressed or bi-polar children
during both depressive as manic episodes
have their minds busy all day long, while
attention is directed towards themselves,
negatively influencing their ability to
concentrate on common activities at school.

19. Negative self-evaluation-Guilt / Grandiose
notion of self
Negative self-evaluation is a cognitive-
emotional symptom among children
suffering of depression or bi-polar disorder
during depressive episodes.

20. Teachers are generally required to observe
not only if negative self-evaluation affects
school performance, but also if it influences
the perception of pupil's physical aspect and
his/her social ability to integrate with
friends.

21. Guilt is also an emotional-cognitive
symptom: depressed children feel guilty
more often compared to children who do not
suffer from depression. In this case, teachers
are asked to notice whether these pupils
blame themselves also for facts which are
not responsible for (i.e. separation between
their parents).

22. Bi-polar children, during manic or hypo-
manic episodes, often suffer of grandiose
notion of self, showing an increased level of
talking and feeling euphoric: teachers are
able to observe clearly this cognitive and
emotional symptom, especially when it
follows a period of negative self-evaluation.

23. Recurrent thoughts of death and suicidal
ideation
Recurrent thoughts of death and the idea of
committing suicide without a specific plan is
an emotional-cognitive symptom (although
not very common) among primary school
children suffering of depression or bi-polar
disorder during depressive episodes

24. Fatigue/Hyperactivity
Teachers can easily observe if pupils are
tired during classes: fatigue is a very
common physical symptom among children
suffering of depression or bi-polar disorder
during depressive episodes.
Children who suffer of hyperactivity show
an increased energy. This symptom is very
frequent during manic and hypo-manic
episodes in bi-polar children.

25. Changes in appetite
A decrease/increase in appetite may cause
an unbalanced growth of child's body
causing possible serious physical disorders.
A decrease in appetite is considered a
physical symptom and is usually connected
with depressive disorder or bi-polar disorder
(during depressive episodes).

26. Pain complaints without medical cause
Pain complaints are considered symptomatic
when there is no objective illness. This
physical symptom is usually connected with
major depressive disorder and its severity is
given by the intensity of pain and the
frequency of occurrence.

27. Sleep disorders
This physical symptom is divided into
insomnia, if child sleeps less than his/her
necessity and hypersomnia, when child
sleeps longer than his/her necessity (he/she
often has difficulty getting up in the
morning).

28. Among preschool and primary school
children, nightmares during REM sleep are
very common and often disturb the quality
of sleep; on the contrary, night terrors (i.e.
restless leg, sleepwalking) are a common
findings in children affected by bi-polar
disorders and occur during deep sleep.

29. The teacher may notice this symptom when
pupil loses concentration and takes short
naps on his/her desk.

30. Second aim of this talk
(2)
To describe the principal therapies
used by clinicians to treat mood
disorders among preschool and
primary school children.

31. Principal therapies to treat mood
disorders
-Play therapy (preschoolers)
-Verbal therapy (primary school
children) -Antidepressants (primary
school children)
-Parent Child Interaction Therapy
(P.C.I.T.) and Emotion Development
Therapy (E.D.) combined (preschoolers).

32. Play therapy
Play therapy is a common therapy for very
young children. The psychologist makes use
of techniques engaging the child in
recreational activities, observing the child
while he/she is playing with a variety of
toys, expressing in this way his/her
unpleasant feelings which cannot be
communicated verbally.

33. Play therapy

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

35. Antidepressants
There is a common concern regarding
antidepressant pills in preschoolers: indeed,
clinicians are against this treatment for
children that young (see Luby, 2009).

36. Regarding primary school children,
medication, such as antidepressants, may be
used only in severe cases of depression,
(Bailly, 2006). Clinicians prefer to make use
of mood stabilizers instead of
antidepressants in cases of bi-polar disorder
I, because some antidepressants can induce
manic episodes (see Kowatch et al., 2005
for an accurate review).

37. Antidepressants pills

38. Parent Child Interaction Therapy
(P.C.I.T.) and Emotion Development
Therapy (E.D.)
Recently, a parent-child psychotherapy has
been developed for the treatment of
preschool depression: it combines two
different therapies, such as Parent Child
Interaction Therapy and Emotion
Development Therapy.

39. The former (P.C.I.T.) comes from the
common knowledge that the child is not an
independent entity at this early age and the
caregiver is a fundamental part of the child’s
psychological world and plays a key role in
the therapy.

40. The latter (E.D.) is designed to enhance the
child emotional developmental 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.

41. By using this therapy, the clinician hopes
that children will learn to handle depressive
symptoms and parents will reinforce those
lessons. All this is based on the hypothesis
that depressed children will be less reactive
to positive stimuli and more reactive to
negative stimuli than healthy children.

42. The first goal of this therapy is to enhance
the child’s capacity to identify emotions in
self and 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 at
high intensity as well as the capacity to
recover from negative affect.

43. During a single session, the therapist
observes the interaction between the child
and the caregiver through a one-way mirror.
The setting contains also a microphone and
an earbud allowing a more effective
interaction (see Luby, 2009).

44. Third aim of this talk
(3)
First research proposal:
Parent-child therapy should
include a teacher when caregiver
shows affective disorders.

45. It is well known that depression runs in
families: children affected by depressive
disorders often have a parent affected by the
same illness. The two relevant causes of
depression in children are:
1) living with a depressed parent;
2) inheriting depressive traits from
him or her.

46. Very recently, Feresin, Mocinić and
Tatković (2013) suggested to include in a
PCIT-ED session the teacher who is
affectively close to both the child and the
parent/caregiver.
The teacher has to interact with the
caregiver in order to help him/her to
participate effectively in the treatment.

47. At the beginning of the program, the teacher
educates himself attending specific classes,
reading scientific papers and books about
mood disorders in children. Then the teacher
is trained by the psychologist to help the
caregiver to participate more actively in the
treatment (in the meantime, the caregiver
requires an individual psychotherapy).

48. To receive a direct and more objective
confirmation of the validity of the change
brought to PCIT-ED (i.e. the presence of a
teacher) a further research is needed which
directly studies preschoolers' brain by using
a functional Magnetic Resonance Imaging
(fMRI).

49. Functional magnetic resonance imaging
Functional magnetic resonance imaging is
an MRI procedure that measures brain
activity by detecting associated changes in
blood flow. This technique relies on the fact
that cerebral blood flow and neuronal
activation are coupled. When an area of the
brain is in use, blood flow to that region also
increases.

50. fMRI apparatus

51. The procedure is similar to MRI but uses the
change in magnetization between oxygen-
rich and oxygen-poor blood as its basic
measure.
The resulting brain activation can be
presented graphically by color-coding the
strength of activation across the brain or the
specific region studied. The technique can
localize activity to within millimeters.

52. For example, this brain scan represents the
activation of the amygdalae during a
specific emotional task (reddish spots).

53. Nowadays, researchers are starting to study
brain functions in depressed preschoolers by
means of fMRI.
A paper by Gaffrey and colleagues has
indicated that depressed preschoolers
exhibited a significant positive relationship
between depression severity and amygdalae
activity when viewing facial expressions of
negative affect (Gaffrey et al., 2011).

54. According to Feresin, Mocinić and Tatković
(2013) another experiment is needed for
studying the activation of depressed
preschoolers'amigdalae in response to facial
expression of negative affect.
The new experiment must compare two
experimental conditions: a first condition in
which the teacher is present during the
therapy (P.C.I.T.-E.D.) and a second
condition in which the teacher is absent.

55. Then, reproducing Gaffrey's results, the
activation of the amygdalae can be
compared with the degree of depression,
when children are viewing facial
expressions of negative affect.

56. If the idea of combining teacher and
caregiver is correct, a slight positive statistic
correlation or no correlation at all should be
found between the severity of depression
and the activity of amygdala, in the
condition in which the teacher is present.
This hypothetical result should mean that
the child is learning how to deal with
negative emotions to fight depression.

57. Fourth aim of this talk
(4)
Second research proposal:
A three steps precocious
prevention program to be held at
primary schools as a possible way
to fight mood disorders.

58. Primary schools are generally doing a
limited job for precociously identifying
children affected by mood disorders.
Possibly, it is a result of the failure to
recognise prevention as a crucial mental
health service.

59. According to Mocinić and Feresin (2012),
a program on a large scale should be
developed and applied during the last two
years of primary schools, when the children'
knowledge of mother tongue is comparable
to adolescents and when the pupils can
easily follow a written test.

60. All children should be screened for possible
mood disorders, just as they are screened for
visual acuity or other health problems.
Many valid tests can be used to collect data
for identifying children who might suffer of
mood disorders; the most famous of them
are: The Child Behaviour Checklist and
The Children's Depression Inventory
(Achenbach, 1991; Kovacs, 1992).

61. After the screening is completed, a diagnosis
can be started by a trained clinician who is
able to interpret the results of the previous
mentioned tests.
A precise diagnosis of depression is a
complex task, extremely difficult for even
highly skilled clinicians. It requires a careful
examination of physical, mental, emotional,
environmental, and cultural factors related
to the child.

62. At the end of the process, a treatment plan is
traditionally coordinated by a school
psychologist who uses a verbal therapy
helping the depressed child to change
his/her distorted view of himself/herself and
improving his/her social skills.

63. Traditionally, teachers are not expected to
diagnose depression in children: usually, the
major role of educators is to detect the
symptoms of depression, to keep notes and
make appropriate referrals to school
psychologists.

64. However, quite recently, Vulić-Prtorić
suggested a more close collaboration
between educators and clinicians (Vulić-
Prtorić, 2007): school psychologists may ask
teachers to collaborate with them during the
treatment itself: for instance, educators can
participate to therapy, giving the pupil an
emotional support.

65. Teachers may also understand depressed
pupils with patience and encouragement,
making them talking, listening to them
carefully, without underestimate their
feelings, but offering them a real hope of
solving depression.

66. 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 inside the classroom, helping
depressed children to develop positive
relationships with peers and to enhance
optimistic feelings.

67. According to Mocinić et al. (2012), during
the phase of test assignment, mentioned in a
previous slide, teachers can help school
psychologists to allot the tests to the entire
class.

68. It is understood, that many children continue
to attend school during the time they are
being assessed for depression; therefore,
they will benefit from a close collaboration
between their educators and the school
psychologist.

69. Mocinić et al. (2012) claimed that bringing
together educators and clinicians may be a
good practise to fight depression during
childhood.
This is because a multidisciplinary team,
who organises regular meetings, will be able
to sustain the child to solve mood disorders
before he/she shall become an adolescent.

70. Conclusion
The three steps program, the presence of the
teacher when the caregiver is depressed and
the use of fMRI apparatus are probably very
expensive from an economic point of view.
However, the cost of depression for future
adolescents, adults and society is even more
expensive than organising these researches
and applying these programs during the last
two years of preschool and primary schools.

71. Selected references:
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.
AMERICAN PSYCHIATRIC ASSOCIATION (2000). DSM IV-TR:
Diagnostic and statistical manual of mental disorders (4th ed., Text
revision). Washington, DC, USA.
BAILLY D. (2006). Safety of selective serotonin re-uptake inhibitor
antidepressants in children and adolescents. Press Med., 35, 1507-1515.

72. FERESIN C., MOCINIĆ S., TATKOVIĆ N. (2013). Should Parent-Child
Therapy include teachers to treat depressed preschoolers when caregiver
shows affective disorders? Školski vjesnik-Journal for Education and
School Issues, 62 (1), 75-84.
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.
KOVACS M. (1992). Children's Depression Inventory (CDI). New York:
Multi-health Systems, Inc.

73. 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 , 44 (3), 213-235.
LUBY J.L. (2009). Early Childhood Depression. American Journal of
Psychiatry, 166, 974-979.
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.
VULIĆ-PRTORIĆ A. (2007). Depresivnost u djece i adolescenata,
Naklada Slap, Jastrebarsko.

74. Thanks for your
attention !