Final Version

Running Head: FAMILIAL FACTORS AND DEPRESSION

Familial Factors Associated with Symptoms of Depression in Preschool Children

by

MALKA ISMACH

A dissertation submitted to the Graduate Faculty in Educational Psychology in partial fulfimment of the degree of Doctor of Philosophy, The City University of New York

Familial Factors 2009

© 2009 MALKA ISMACH

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Familial Factors All Rights Reserved This manuscript has been read and accepted for the Graduate Faculty in Educational Psychology in satisfaction of the dissertation requirement for the degree of Doctor of Philosophy. Dr. Marian C. Fish ___________________________________

__________________ Date

__________________________ Chair of Examining Committee Professor Dr. Mary Kopala _______________________________________

__________________ Date

__________________________ Executive Office

Dr. Ida Jeltova Dr. Mary Kopala Dr. Georgiana S. Tryon Dr. Jay Verkuilen Supervisory Committee The City University of New York

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Abstract

FAMILIAL FACTORS ASSOCIATED WITH SYMPTOMS OF DEPRESSION IN PRESCHOOL CHILDREN By Malka Ismach Advisor: Professor Marian C. Fish

The purpose of this study was to investigate whether or not preschoolers can be identified as at risk for depression, if there was agreement between parents and teachers regarding the symptoms that children display and to identify the familial factors that impact the development of depression in preschool children. Recent evidence suggests that preschoolers have symptoms indicating possible feelings of depression. In order to help these preschoolers, it is important to ascertain the factors associated with the development of depressive symptoms. The research consistently shows that parenting styles, discipline practices, and family functioning impact depression in school age children and adolescents. This study examined the relationship between these factors and depressive symptomatology in preschoolers. Low levels of flexibility and high levels of

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rigidity in the home were found to have a significant relationship with preschoolers who show signs of depression. Additionally, when all the familial factors were plotted on an ROC curve, they demonstrated the ability to make good predictions about preschoolers who may be at risk for depression. Educational implications of the study as well as limitations are discussed.

Dedicated to my mom, Pess Epstein, may she rest in peace

whose presence and pride on this day

would have made my joy complete.

And to my husband Shmuel,

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with whom I share all of my joy,

without his love and support,

this day could not have been.

Acknowledgements A sincere thank you is in order to my advisor, Dr. Marian C. Fish, for without her endless support, encouragement and availability, I would not be where I am today. Dr. Fish’s accessibility, speedy responses and positive outlook made the dissertation process a very pleasant one, and for that I am grateful. Thank you also to my other committee members, Dr. Jay Verkuilen and Dr. Ida Jeltova whose assistance, skill and knowledge base as well as their availability, allowed me to experience this process feeling supported and well guided. Thank you.

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Table of Contents Chapter

Page

I. Introduction

1

Research Questions II. Literature Review \ Depressive Disorders

7 9 109

Depressive Symptoms in Preschool Children

14

Familial Factors and Depression

22

Risk Factors

41

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Agreement between Parents and Teachers

423

Summary

434

Rationale

44

Hypotheses

456

III. Methods

47

Participants

47

Measures

47

Procedure

55

Design

56

IV. Results

587

Demographics

598

Risk Factors

631

Hypothesis #1

632

Hypothesis #2

643

Hypothesis #3

675

Hypothesis #4

697

Hypothesis #5

7068

ROC Curve

710

V. Discussion

752

Depressive Symptoms in Preschoolers

753

Agreement between Parents and Teachers

764

Familial Factors Associated With Depression in Preschoolers

774

Erikson’s Stages of Psychosocial Development

83

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Risk Factors

8379

Limitations and Future Research

840

Educational Implications

862

Conclusion

873

Appendices

884

A. Informed Consent

884

B. Preschool Feelings Checklist

9086

C. FACES IV

9187

D. Parenting Scale

940

E. Parenting Styles and Dimensions Questionnaire

984

F. Table 15 - Table 14 – Definitions of At-Risk 10096 References

10196

List of Tables Table 1

Crosstabulation of Gender and Age of Participants

598

Table 2

Gender of Preschool Children in Sample

6059

Table 3

Age of Preschool Children in Sample

6059

Table 4

Ethnic Makeup of Sample

6059

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Table 5

Number of children in family

610

Table 6

Income of Parents Completing Parenting Scale

621

Table 7

The Observation of Depressive Symptoms in Preschool Children

643

Table 8

PFC – Means and Standard Deviations

64

Table 9

Crosstabulation of Parent and Teacher Reports of At Risk Children According to the Clinical Definition

Table 10

Crosstabulation of Parent and Teacher Reports of At Risk Children According to the Less Stringent Definition

Table 11

654

665

Logistic Regression Analysis for relationship between Parenting Styles and Depressive Symptoms using the Teacher Report and the Less Stringent Definition of At Risk

Table 12

687

Logistic Regression Analysis for the relationship between the centered Authoritarian Parenting Style and Depressive Symptoms using the Teacher Report and the Less Stringent Definition of At Risk

Table 13

687

Logistic Regression Analysis for the relationship between Family Functioning and Depressive Symptoms using the Teacher Report and the Less Stringent Definition of At Risk

7169

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Logistic Regression Analysis for the relationship between the Centered Variable of Flexible Family Functioning and Depressive Symptoms using the Teacher Report and

Table 15

the Less Stringent Definition of At Risk

7169

Definitions of At-Risk

10096

List of Figures Figure 1

ROC Curve using the seven predictor (authoritarian parenting, permissive parenting, laxness, over reactivity, hostility, cohesive family functioning, and flexible family functioning) logistic regression model with the teacher report

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and the less stringent definition of at risk (TARLS) as the outcome variable Figure 2

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ROC Curve using the seven predictor (authoritarian parenting, permissive parenting, laxness, over reactivity, hostility, cohesive family functioning, and flexible family functioning) logistic regression model with the teacher report and the clinical definition of at risk (TARC) as the outcome variable

743

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Chapter 1 Introduction In recent decades, research (e.g., Kovacs, 1996; Stark, 1990; Stark et al., 1990) has emerged regarding the existence of depression in school age children and adolescents; yet research regarding preschool children who show signs of depression is lagging behind despite studies (e.g., Luby, Heffelfinger, Mrakotsky, Hessler, & Brown, 2002; Luby et al., 2003) demonstrating that signs of depression can be detected during the preschool years. In order to effectively help these preschoolers, a thorough understanding of the factors impacting the development of depression at such a young age is necessary. There is empirical evidence (e.g., Normura, 2002; Rodriguez, 2003; Sander & McCarty, 2005) demonstrating that familial factors appear to affect the development of depression in school-age children and adolescents, but no studies have examined whether these factors affect the development of depression in preschool children as well. According to the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM-IV) (1994) there are three diagnostic categories of depression, all of which can occur at any age. These include Major Depressive Disorder (MDD), Dysthymic Disorder (DD), and Depressive Disorder Not Otherwise Specified (DDNOS). While many of the symptoms are shared between MDD and DD, these categories are characterized by differences in severity, chronicity, and persistence. DDNOS is diagnosed when an individual is suffering from depression, but the severity, frequency, or number of symptoms is not sufficient enough to warrant a diagnosis of DD or MDD.

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The DSM-IV (1994) specifies some of the ways depression may manifest itself in children. Symptoms of MDD that are seen more frequently in young children include somatic complaints, irritability, and social withdrawal. Dysthymic Disorder often has an early onset. It is not unusual for a child to develop DD early on in life and later on develop MDD. In children, DD frequently results in poor school performance and impaired social skills. Children with Dysthymic Disorder are often irritable and cranky as well as depressed. Low self-esteem and pessimism are also observed in children with DD. Over the past two decades, the existence of depression in children has become widely recognized and taken very seriously by practitioners as well as researchers. According to Stark (1990) when both cases of MDD and DD are considered, between five and seven percent of the general school population from fourth, fifth, sixth, and seventh grades may be experiencing a depressive disorder at any given time. This figure progressively increases through middle school and high school. Due to the increasing prevalence of depression in children, it seems urgent to identify and treat symptoms of the disorder while the children are in preschool, prior to reaching the abovementioned age range so as to improve the prognosis and prevent more severe problems from developing later on in life (Luby, Heffelfinger, Mrakotsky, Hessler, & Brown, 2002; Luby et al., 2003; Zito et al, 2000). Research exists demonstrating that depression does exist in the preschool population (Kashani, Holcomb, & Orvaschel, 1986; Kashani, Ray, & Carlson, 1984;; Zito, et al., 2000). It is important to collect data from multiple sources, such as parents and teachers, regarding children who might be at risk for the disorder due to the

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discrepancies in observations by different individuals (Junttila, Voeten, Kaukianinen, & Vauras, 2006; Kashani, Holcomb, & Orvaschel, 1986). We also know that depression in preschoolers is characterized predominantly by typical symptoms such as sadness, irritability, and vegetative states. Depressed preschool children also exhibit more destructive and suicidal play themes than the comparison groups (Luby et al., 2003). Additionally, depressed preschool children exhibit less symbolic play than non-depressed peers as well as less coherence of play, as they tend to switch play behaviors more often than non-depressed children (Mol, De Wit, & De Bruyn, 2000). An effective screening tool has been developed to identify preschool children with depressive symptoms (Luby et al., 2004). Psychotropic medications are being prescribed, perhaps irresponsibly (Zito et al., 2000), as an intervention for the disorder, indicating that families are seeking assistance for their children who are experiencing some symptoms of depression. There are various family-related factors that have been demonstrated to be important with regard to the development of children in general. Some of these factors have been empirically demonstrated to be related to the development of depression in children and may also play a role in depression in preschoolers. These factors include parenting styles, parenting discipline practices, and family functioning. The concept of parenting styles was developed by Baumrind (1971) and includes three prototypes including authoritative, authoritarian, and permissive parenting. Authoritative parents are described as controlling and demanding as well as warm, encouraging, rational, and receptive to the child’s communication. Authoritarian parental behavior refers to parents who are detached and controlling and somewhat less warm than other parents. Permissive parents refer to parents who are not controlling or

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demanding and relatively warm. The research has consistently indicated that parents utilizing the authoritative parenting style tend to raise children who are more socially competent and independent (Robinson, Mandleco, Frost Olsen, & Hart, 1995). While there are no direct studies of Baumrind’s three parenting typologies and how they are associated specifically with depression in children, there are many studies looking at characteristics of parenting styles that overlap with the authoritative typology described by Baumrind. The results of these studies indicate that family environments that are not emotionally supportive, are punitive, and are not democratic in decisionmaking are more likely to raise depressed children. Conversely, parents who are authoritative, firm, and value the opinions of their children are more likely to bring up children who are content and well-adjusted (Arieti & Bemporad, 1980; Gallimore & Kurdek, 1992; Sander & McCarty, 2005; Stark, Humphrey, Crooke & Lewis, 1990). The only study looking at parental factors and depression in the preschool population was conducted by Belden and Luby (2006) who investigated the relationship between preschool depression severity and parent emotional support. They found that preschoolers who demonstrated higher depression severity scores experienced parenting strategies that were less emotionally supportive. Emotional support was viewed as a mother’s expression of positive regard, encouragement on novel tasks, a sense of when her child is in need of encouragement, and respecting the child’s need for autonomy. While the authors did not refer to this as authoritative parenting, the descriptions are very much similar to Baumrind’s authoritative prototype. Thus, parents with less authoritative parenting styles yielded children with elevated depression severity scores.

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Parenting discipline practices refer to parents’ methods of training their children to act according to a certain set of rules or guidelines. Discipline practices are the strategies that parents use to manage their children’s behavior or misbehavior. There is an empirically-established relationship between parenting discipline mistakes and the behavior disorders of children. Less is known about the relationship of discipline practices to childhood anxiety, fear, and depression (O’Leary, 1995). O’Leary describes three potential mistakes that parents of young children can make. The first mistake, referred to as laxness, is the tendency to give in to one’s children and not enforce rules. The second mistake, overreactivity, involves frequent displays of anger, irritability, and meanness. The third mistake, called hostility, involves a parent’s use of physical punishment, cursing, and name-calling. While there is only one study looking at parental discipline practices and depression in children using the three discipline mistakes described by O’Leary (1995), there are many studies looking at parenting discipline practices, utilizing different definitions and variables. An attempt was made to connect the variables that exist in the literature to O’Leary’s three discipline mistakes, thereby utilizing the existing studies as evidence supporting the connection between parenting discipline mistakes and the development of depression in children. These studies seem to indicate that there is an association between the discipline mistake of overreactivity and the development of depression in children (Asarnow, Goldstein, Tompson, & Guthrie, 1993; Leve, Kim, & Pears, 2005; Rodriguez, 2003). Normal family functioning refers to basic patterns of interactions that sustain the preservation of the family unit and its ability to facilitate the performance of certain tasks

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that foster the growth and well-being of its members (Walsh, 2003). One useful way of looking at family functioning is using the Circumplex Model, which has its roots grounded in systems theory. The model includes three dimensions of family functioning including family cohesion, flexibility, and communication. Family cohesion refers to the emotional bonds that couples and families have towards one another. Extreme levels of either separateness or togetherness are considered dysfunctional. Family flexibility refers to the amount of change that occurs in terms of its leadership, role relationships, and relationship rules. The focus of flexibility is on the quality and expression of leadership and organization, role relationship, and relationship rules and negotiations. As with cohesion, a system that functions at the extremes of flexibility is more problematic than a system that is more balanced between the two. The third dimension, communication, is referred to as a facilitating dimension, as this dimension aids families in adapting their cohesion and flexibility to meet the demands of changing circumstances. Communication is measured by assessing a family’s listening skills, speaking skills, continuity tracking, self-disclosure, respect, and regard (Olson, Gorall, & Tiesel, 2007). There are no studies, to date, that look at the relationship between family functioning and the development of depression in preschoolers. Yet, the studies done with older children seem to indicate that families of depressed individuals do function more poorly than families without depressed individuals. When viewed from the Circumplex model, low cohesion and adaptability have been observed in families of depressed patients (Kashani et al., 1995; Kashani, Suarez, & Jones, 1999; Shiner, 1998). It is important to mention that there are two risk factors which appear to be related to the development of depression in both school age as well as preschool children. These

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include a family history of mood disorders and stressful life events (Luby, Belden, & Spitznagel, 2006). Based on the literature reviewed, it appears that certain family factors identified as related to childhood depression may also be associated with depression in preschool children. The literature review leads to the following research questions: 1.

Are depressive symptoms observable in the preschool population?

2. Will there be a lack of agreement between teacher and parent responses to a behavior checklist regarding the child’s symptoms? 3. Is there a relationship between parenting styles and depressive symptomatology in young children? 4. Are dysfunctional discipline practices related to depressive symptomatology in young children? 5. Is family functioning related to depression in preschool children? Data were gathered from preschools in Queens, Manhattan, and Long Island. The data were analyzed using descriptive statistics, Cohens’s Kappa statistics, logistic regression, and a receiver operating characteristic curve (ROC curve). Findings of the study indicate that depressive symptoms were observable in the preschool population. There was a lack of agreement between teacher and parent responses to a behavior checklist regarding the child’s symptoms. The regression analyses yielded significant findings only when the teacher report of symptoms was used. Findings indicate that there was a relationship between the authoritarian parenting style and depressive symptoms. Dysfunctional discipline practices were not significantly related to depressive symptomatology. Rigid family functioning was related to signs of depression in

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preschool children. Finally, when all the familial factors were plotted on an ROC curve, they demonstrated the ability to make good predictions about preschoolers who may be at risk for depression. The authoritarian parenting style and rigid family functioning are consistent in many ways. Controlling parents who demand obedience and do not allow for negotiation create a home environment that is rigid and inflexible. Such a parenting style fosters a home environment that does not adapt to new situations and circumstances in a flexible and functional way. Therefore, it is intuitive that those two variables were both significant predictors for preschoolers who are at risk for developing depression. The ROC curve indicated that familial factors can work together to predict preschoolers who are at risk for depression. Based on this model, the true positive rate is counter-balanced by the low false positive rate, which is desirable for good predictions. There are several limitations to the study including objectivity of responses on the scales, size of the sample, and homogeneity of the samples. Nevertheless, findings of the current study have important implications for preschools. Prevention and intervention programs can be developed for children, teachers, and families so that symptoms of depression are prevented or decreased before they become severe enough to significantly impact daily functioning.

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Chapter Two Literature Review Over the course of the past several decades, professionals have become increasingly aware of the existence of depressive disorders in children. While children as young as 6 years old have been diagnosed with Major Depressive Disorders, empirical evidence and public awareness that the disorder exists at younger ages is lagging. Recently, there has been some research indicating that symptoms of depression do exist in preschool children. In order to effectively help them, a thorough understanding of the factors impacting the development of depression at such a young age is necessary. Research has demonstrated that there are familial factors that appear to affect the development of depression in school-age children and adolescents. These factors might be applicable to the development of depression in preschoolers as well. In the following pages the research on children with depression as well as preschool children with depressive symptoms will be discussed. That will be followed by a review of the research on familial factors and depression in school age children and adolescents, including parenting styles, discipline practices, and family functioning. Risk factors for the development of depression in preschool children will be discussed as well as agreement between teachers and parents regarding symptoms of depression. Finally, a study is proposed which will investigate the association between these familial factors and the development of depressive symptoms in preschool children.

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Depressive Disorders According to the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM-IV) (1994) there are three diagnostic categories of depression, all of which can occur at any age. These are Major Depressive Disorder (MDD), Dysthymic Disorder (DD), and Depressed Disorder Not Otherwise Specified (DDNOS). While many of the symptoms are shared between MDD and DD, these categories are characterized by differences in severity, chronicity, and persistence. DDNOS is diagnosed when an individual is suffering from depression, but the severity, frequency, or number of systems is not sufficient to warrant a diagnosis of DD or MDD. Each of these disorders are defined and a description of what the disorders might look like in young children is provided below. Major Depressive Disorder There are several subcategories of Major Depressive Disorders as per the diagnostic categories of the DSM-IV (1994). The differentiation between categories is based on the number of major depressive episodes that an individual experiences. The critical characteristic of a major depressive episode is either depressed mood or the loss of interest or pleasure in most activities for a period of at least two weeks. Additionally, the individual must experience at least four of the following symptoms for a two week period: 1.

Considerable weight loss or gain or considerable increase or decrease in appetite almost everyday.

2.

Insomnia or hypersomnia almost daily

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Psychomotor agitation or retardation almost everyday that is visible to others

4.

Exhaustion or loss of energy almost daily

5.

Feelings of worthlessness or extreme unjustifiable guilt nearly every day

6.

Reduced capacity to think/concentrate or inability to make decisions every day

7.

Repeated thoughts of death or suicidal ideation or a suicide attempt or plan

There are two subtypes of Major Depressive Disorder. Major Depressive Disorder, Single Episode involves the presence of a single Major Depressive Episode and Major Depressive Disorder, Recurrent involves the presence of two or more major depressive episodes with at least two months between episodes. While the onset of MDD can occur at any age, the average age of onset is in the early 20s. Dysthymic Disorder Dysthymic Disorder involves a chronically depressed mood that happens most of the day, for more days than not, and for at least two years. During the time period in which the individual is depressed, two of the following symptoms must be present and cannot be absent for more than two months at a time: 1. poor appetite or overeating 2. insomnia or hypersomnia 3. low energy or fatigue 4. low self-esteem

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5. poor concentration or difficulty making decisions 6. feelings of hopelessness Major Depressive Disorder may have been present previously, but there must have been full remission prior to the development of Dysthymic Disorder. Additionally, after the initial two years of the disorder it is possible for there to be superimposed episodes of Major Depressive Disorder in which case both diagnoses may be given. In order to be diagnosed with Dysthymic Disorder, the symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of life functioning Depressive Disorder Not Otherwise Specified Individuals diagnosed with this disorder experience symptoms of depression but do not meet the criteria for any of the other disorders. Depression in Children The DSM-IV (1994) specifies some of the different ways depression may manifest itself in children. In children with Major Depressive Disorder, the mood may look irritable rather than sad. Additionally, instead of considerable weight loss or weight gain, children with MDD may experience a failure to make expected weight gain. There may be psychomotor agitation, such as restlessness or excessive fidgeting or psychomotor retardation such as lack of energy or lethargy almost every day. Symptoms of MDD that are seen more frequently in young children include somatic complaints such as frequent complaints of headaches or stomachaches, irritability, or the tendency to often be “on edge” around others, and social withdrawal, such as a once social child who stops hanging out with his or her friends outside of school. Psychomotor retardation,

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hypersomnia, and delusions are less common in young children. Additionally, young children often experience major depressive episodes in combination with other mental disorders such as disruptive behavior disorders, attention deficit disorders, and anxiety disorders. In children with Dysthymic Disorder, the mood may also seem irritable rather than sad, and the minimum duration is one year rather than two. Dysthymic Disorder often has an early onset. It is not unusual for a child to develop DD early on in life and later on develop MDD. In children, DD frequently results in poor school performance and impaired social skills. Examples of how impaired social skills may be exhibited in children are through behaviors such as inappropriate touching, an inability to initiate a successful social interaction with a peer, or social withdrawal. Children with dysthymic disorder are often irritable and cranky as well as depressed. Low self-esteem and pessimism are also observed in children with dysthymic disorder. Over the past two decades, the existence of depression in children has become widely recognized and of serious concern to practitioners and researchers. Since the addition of the diagnostic criteria for Major Depressive Disorder in children in the Diagnostic and Statistical Manual of Mental Disorders – Third Edition – Revised (APA, 1987) , it has been confirmed that childhood depression is an illness that is both chronic and relapsing and does not develop spontaneously (Kovacs, 1996). According to Stark (1990) when both cases of major depression and dysthymic disorder are considered, between five and seven percent of the general school population from fourth, fifth, sixth, and seventh grades may be experiencing a depressive disorder at any given time. This figure progressively increases through middle school and high school.

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Due to the increasing prevalence of depression in children, it seems urgent to identify and treat symptoms of the disorder while the children are in preschool, prior to reaching the abovementioned age range so as to improve the prognosis and prevent more severe problems from developing later (Luby, Heffelfinger, Mrakotsky, Hessler, & Brown, 2002; ). Depressive Symptoms in Preschool Children In the past several decades, attention has been directed at whether depressive symptoms occur in preschool children. Research indicates that symptoms of depression do exist in preschoolers more so than was previously perceived. Kashani and Ray (1983) conducted a preliminary study in which they utilized parent reports to determine if depressive symptoms existed in preschool-age children. They mailed parents a questionnaire about symptoms of major depression and found that no depression was reported among these preschoolers. While there were many shortcomings to this study, relying on only one source of information was a major flaw in the research design. Additionally, including only questions regarding symptoms of Major Depressive Disorder was considered a limitation. At the conclusion of the study, the authors recommended a more comprehensive approach to identifying depressive symptoms within this age group. Subsequently, Kashani, Ray, and Carlson (1984) designed a study with the goal of collecting data regarding the existence of depression in preschool children. The sample consisted of 100 children ages 1 to 6 years old who were referred to a child development unit for developmental, behavioral, or emotional problems. Following the referral, a twoday evaluation took place by a child psychiatrist and a clinical child psychologist. All

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aspects of the children’s functioning were explored including emerging academics, motor skills, speech and language, psychological functioning, and family functioning. Parents were also interviewed regarding the functioning of the referred child. Additionally, children and parents were observed interacting with each other and these interactions were recorded. Out of the 100 referred children, 7 children reported frequent feelings of sadness and all seven were confirmed by their parents as being unhappy most of the time. Another 10% of parents reported that their children were unhappy most of the time, but these children did not report feeling sad. Comprehensive evaluations indicated that only four out of the 100 referred children met DSM-III criteria for one of the depressive disorders. Three out of the four children would have been diagnosed with Dysthymic Disorder and one with Major Depressive Disorder. Thus, while depression does exist in preschool children, it is possible that young children experience more minor symptoms characteristic of Dysthymic Disorder and these symptoms become more severe with time. While these authors found that preschoolers do experience symptoms of depression, it is less common than in older children and adolescents and it is also often less severe. Kashani, Holcomb, and Orvaschel (1986) then set out to investigate whether or not depressive symptoms exist in the general preschool population. They examined a group of children ranging in age from two and a half to six years old, who had depressive symptoms but did not meet DSM-III criteria for affective disorders. Additionally, they wanted to compare the responses of parents and teachers with regard to the depressive symptoms of preschool children. Finally, they wanted to investigate whether life events had a correlation with depressive symptoms in preschool children.

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Participants in Kashani et al.’s (1986) study included 109 preschool children enrolled in two community nursery schools. Data were collected from a variety of sources; preschool children participated in a psychological assessment, and parents as well as teachers completed several different checklists and questionnaires.

Children

whose psychological testing or questionnaires demonstrated symptoms of Major Depressive Disorder or Dysthymic Disorder were interviewed and observed in the preschool setting. Based on the interview and observations, attempts were made to identify those children who presented with depressive symptoms. There were several key findings of the Kashani et al. (1986) study. Earlier results acknowledging the existence of depressive symptoms in preschool children in a clinic were reportedly true for the general population as well. It was also found that although preschool children did exhibit concerning depressive symptoms, the symptoms were usually not sufficient to reach a diagnosis of clinical depression (only one child met criteria for major depression). Comparisons of parent and teacher responses indicated no correlation and at times, even a negative correlation leading to the conclusion that there is a discrepancy between parents’ and teachers’ ratings of depressive symptoms in preschoolers. An individual case study was investigated as part of the larger study and demonstrated that the parent underreported her child’s symptoms while the teacher responded more accurately. Thus, teachers serve as important sources of information, but multiple sources of data should always be gathered.

Results also indicated that parents

of preschool children with depressive symptoms report more stressful life events than parents of preschool children without depressive symptoms.

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Luby et al. (2002) hypothesized that developmentally modified criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM) are necessary in order to identify and treat preschool children with depressive symptoms. One hundred and thirty six preschool children ages 3-0 to 5-6 were assessed via a variety of scales and observations to determine if they met criteria for a developmentally modified DSM diagnosis of Major Depressive Disorder. The modified diagnosis was referred to as “preschool diagnostic criteria for MDD”, or “P-DC-MDD.” Data demonstrated that when age appropriate symptom manifestations were assessed, preschool children who met the modified criteria for MDD exhibited elevated levels of “typical” depressive symptoms. Seventy-six percent of these children would not have met standard DSM guidelines. The authors concluded that as per their hypothesis, modified criteria are required. It is noteworthy to mention that the children with depressive symptoms were found to be significantly more socially impaired than normal children and, therefore, should not merely be considered an at-risk group, but rather a clinically significant population who require early identification and intervention. The diagnostic criteria for Preschool Major Depressive Disorder, proposed by Luby et al. (2002) included five or more of the following symptoms that have been present but not necessarily persistent over a 2-week period and represent a change from previous functioning. At least one of the symptoms is either depressed mood or loss of interest or pleasure in activities or play. If both the above criteria are present, a total of only four symptoms are needed. The symptoms include: 1.

Observed or reported depressed mood for a portion of the day for several days. The mood may be irritable instead of depressed.

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Noticeably diminished interest or pleasure in all, or almost all activities or play for a portion of the day for several days (as indicated by either subjective account or observation made by others).

3.

Considerable weight loss when not dieting or weight gain or decrease or increase in appetite almost every day.

4.

Insomnia or hypersomnia almost daily.

5.

Psychomotor agitation or retardation almost every day (observable by others, not merely subjective feelings of restlessness or being slowed down).

6.

Fatigue or loss of energy nearly every day.

7.

Feelings of worthlessness or extreme amounts of or inappropriate guilt (which may be delusional) that may be evident in play themes.

8.

Reduced ability to think or concentrate, or indecisiveness, for several days (either by subjective account or as observed by others).

9.

Repeated thoughts of death (not just fear of dying), repeated suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. Suicidal or self-destructive themes are persistently evident in play.

Using these new diagnostic criteria for preschoolers, Luby et al. (2003) investigated the clinical characteristics of depression in preschoolers. They found that depression in this population is characterized predominantly by “typical symptoms” such as sadness, irritability, and vegetative states. Depressed preschool children also exhibited

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more destructive and suicidal play themes than the comparison groups. “Masked symptoms,” such as somatic complaints were not as common as typical symptoms. Mol, De Wit, Cees, and De Bruyn (2000) conducted an exploratory study investigating the differences in the play behavior of depressed and nondepressed 3 to 6 year olds. More specifically, they looked at whether depressed and non depressed children differed in the amount of play in which they engaged. They also investigated if there was a difference in the level of coherence in their play and if affect regulation problems influenced the play of young children. Finally, they explored whether inducing positive or negative moods during play situations affected the play behavior of depressed and nondepressed children. The behavior of seven depressed and seven non depressed 3 to 6 year olds was compared in three different play situations: solitary free play, interactive free play, and play narratives. Each play situation was subdivided into a positive, negative, or neutral mood. In each of the three play situations, nine behavior categories were coded. In order to observe the amount of coherence in the behaviors of depressed and nondepressed children, the number of behavior changes was computed for each child. A behavior change was recorded each time the child’s behavior changed from any category of play or nonplay behavior to another. The findings of the Mol et al. (2000) study indicated that depressed 3 to 6 year old children demonstrated less play behavior than their nondepressed peers during symbolic play. In this situation, they also exhibited more nonplay behavior such as more orientation towards the environment and towards the experimenter. The groups did not differ with regard to manipulative play. Additionally, depressed children demonstrated

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less coherence of play as they switched behaviors more often than nondepressed children. Mood induction did not influence the play of depressed or nondepressed children. These findings indicate that while there are differences in the play behavior of depressed and nondepressed preschool children, the depressed children did not exhibit the typical low level of activity or retardation that is often observed in adults with depression. Instead, the play behavior of depressed preschool children appears to be different, but still active, or “differently active.” These findings are similar to the findings of Kashani et al. (1997) who found that young depressed children demonstrate psychomotor agitation more often than they demonstrate decreased activity. The results of Mol et al. (2000) and Kashani et al. (1997) shed additional light on the screening and identification of preschoolers with depression. Teachers and parents can observe play styles and preferences in order to gather evidence for diagnosis and treatment. Additionally, counter to what one might automatically assume, depressed preschoolers often do not appear withdrawn and lethargic, but rather they are irritable and agitated. Teachers and clinicians may automatically assume the child has attention or regulation difficulties characteristic of attention deficit hyperactivity disorder, without even considering the possibility that the child is experiencing depression. Frequency of use of antidepressants with preschool children is another indicator of concern about depression in preschool children. The prevalence of psychotropic medication as a treatment for children younger than five years old has not received much attention in the literature until recently. Zito et al. (2000) used three large computerized data sources to estimate the prevalence of psychotropic medications in 2 through 4 year olds. They found that antidepressants were the second leading treatment among this age

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group. Additionally, the rate of the use of psychotropic medications prescribed for preschoolers increased significantly from 1991 to 1995. The increase was greatest for three medications, antidepressants being one of them. These findings are somewhat surprising in light of the limited knowledge base not only about the existence of depression in preschool children but also about the use of psychotropic medications in such young children. The findings of Zito et al. indicate that despite the limited knowledge base in this area, families are recognizing depressive symptoms in preschool children, to such an extent that antidepressants are being prescribed often. While the practice of prescribing psychotropic medications with such limited amounts of research is troubling, it alerts researchers that depression in preschool children is certainly occurring. While we do not know a lot about preschoolers and depression, there have been some important findings in this area. While the research regarding preschool children is not at all extensive, it does demonstrate that the disorder exists in the population (Kashani, Ray, & Carlson, 1984; Kashani, Holcomb, & Orvaschel, 1986; Zito et al., 2000). The sources of information that are necessary in order to collect information regarding the children at risk for the disorder are known (Kashani, Holcomb, & Orvaschel, 1986) as well as what the symptoms look like (Luby et al., 2003; Mol et al. 2000). Psychotropic medications are being prescribed, perhaps irresponsibly as an intervention for the disorder, indicating that families are seeking assistance for their children who are experiencing some symptoms of depression. Additional data are needed regarding factors that affect depression in such young children in order to develop empirically supported interventions.

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It seems clear that depressive disorders exist in the preschool population. It is imperative that valid and effective prevention and intervention programs are developed to address these symptoms. Due to the fact that symptoms can be apparent as early as preschool, intervening then may be an ideal way of preventing the problem from becoming more severe. In order to do this, we must investigate why increasing numbers of preschool children are showing signs of chronic unhappiness. Familial Factors and Depression There are various family-related factors that have been demonstrated to be crucial with regard to the development of children in general. Some of these factors have been empirically demonstrated to be related to the development of depression in children. These factors are parenting styles, parenting discipline practices, and family functioning and are discussed below. Parenting Styles One family factor that has been established as crucial in many areas of child development is the parenting styles of mothers and fathers. Baumrind (1971) conceptualized three main prototypes of parenting styles that have lead to a plethora of research regarding these styles and their effects on child-rearing outcomes. The three typologies of parenting styles are authoritative, authoritarian, and permissive. The research on these three typologies has been fairly consistent in its findings regarding the effect that such parenting styles have on middle-class children. Children raised by parents utilizing the authoritative parenting style tend to be more socially competent and independent (Robinson, Mandleco, Frost Olsen, & Hart, 1995).

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Authoritative parents are described as controlling and demanding as well as warm, encouraging, rational, and receptive to the child’s communication. They value both autonomy and conformity and demand that their children take part in family functioning and household tasks. They respect their own rights as adults as well as the rights of their children as individuals with unique interests. Children of authoritative parents have been found to be self-reliant, self-controlled, explorative, and content. Preschool children from authoritative homes were consistently found to be significantly more competent than their peers. Girls were observed to be purposive, dominant, and achievement-oriented, while boys were friendly and cooperative (Baumrind, 1989). Authoritarian parental behavior refers to parents who are detached and controlling and somewhat less warm than other parents. They attempt to shape, evaluate, and control their children’s attitudes and behaviors according to a set standard of behavior, usually a code of conduct that is theologically based or developed by a higher authority. There is no negotiation between parents and children as parents are viewed as the absolute authority. Obedience is considered a virtue and punishments are usually punitive and forceful and are used when there is a conflict between the beliefs or actions of their child and their standard of acceptable conduct. Children of authoritarian parents were found, relative to others, to be unhappy, withdrawn, and distrustful. More specifically, boys were found to be hostile and resistive, and girls were found to be lacking in independence and dominance (Baumrind, 1989). The third prototype, called permissive parenting, refers to parents who are noncontrolling, nondemanding, and relatively warm. They give children autonomy. They are accepting of their children’s impulses, demands, and desires and are

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nonpunitive. They make few maturity demands. Permissive parents allow their children to regulate their own activities. Parents are present as resources for their children to use as they wish but are not there to alter their children’s current or future behavior. They do not demand that the attitudes or behaviors of their children meet externally defined standards. Children of such parents have been found to be the least self-reliant, explorative, and self-controlled as well as quite immature. Compared with children of authoritative parents, girls have been found to be less socially assertive and both girls and boys were less achievement oriented (Baumrind, 1989). While there are no direct studies of Baumrind’s three parenting typologies and how they are associated specifically with depression in children, there are many studies that examined characteristics of parenting styles that overlap with the authoritative typology described by Baumrind. Sander and McCarty (2005) reviewed some of the literature regarding familial risk factors related to depression in youth. They came to several conclusions regarding these risk factors. First, parental depression is clearly linked to childhood depression. Second, relationships between parent and child, interactions between the child’s temperament and the child’s ability to cope with the family environment, and the impact of stress on the family system are all contributing factors to depression in youth. Additionally, lack of parental warmth and availability have consistently been found to be a risk for youth depression. “Affectionless control” was a term used by Nomura, Wickramaratne, Warner, and Weissman (as cited in Sander and McCarty, 2005) to describe a style of discipline that was characterized by a high level of control and little warmth and was found to be highly predictive of depression in youth of nondepressed

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parents. While the authors did not utilize Baumrind’s typologies, affectionless control appears to be similar to elements of the authoritarian parenting style. Gallimore and Kurdek (1992) looked at parenting style and how it relates to depression in adolescents. More specifically, they hypothesized that the severity of the adolescents’ depressive symptoms would be negatively related to the extent to which fathers, mothers or both parents used authoritative discipline techniques. Thirty-five eighth-grade and ninth-grade students who lived with both parents served as participants of the study. Students filled out the Child Depression Inventory (Kovacs & Beck, 1977) and the Authoritative Parenting: Adolescent Version, which is a modification of a measure designed by Buri, Louiselle, Misukanis, and Mueller (1988) for college students. Parents completed the Beck Depression Inventory (Beck, Rush, Shaw, & Emery, 1979) and the Authoritative Parenting: Parent Version. The results of the study indicate a significant and negative correlation between the amount of authoritative discipline of the father (as reported by the adolescent) and depression in the adolescent, that is, the more authoritative discipline techniques used by the father, the less symptoms of depression existed in the adolescent and vice versa.

Moreover, it was found that a father’s

authoritative parenting mediated the effects of parental depression on child development: when fathers utilized an authoritative parenting style, adolescents with depressed parents were less depressed. Thus, not only is authoritative parenting beneficial in the development of emotionally healthy children, but it can reduce the powerful effects that parental depression often has on a child’s emotional development. One hypothesis provided by the authors to explain the significant correlation observed with regard to fathers’

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parenting styles but not mothers’ is that during adolescence, conflicts between child and parents typically increase, and mothers and fathers tend to react differently to the increase. Mothers tend to back off and, therefore, adolescents usually confront them, while fathers become more assertive and adolescents defer to them. Therefore, fathers may be vital socialization agents during early adolescence. Stark, Humphrey, Crook, and Lewis (1990) examined the perceived environments of families with a depressed, depressed and anxious, anxious, or normal child from fourth to seventh grade. Results of the study demonstrated that the child pathology could be predicted based on knowledge of their perceived family environments. Children from the pathological group as compared with the normal control children perceived their family environments to be less supportive, less engaged in outside recreational, social, or religious activities, and more enmeshed. Children felt less involved in decisions made about them and their family. One of the most consistent findings of the study was that families of depressed children were perceived to be significantly less democratic than all the other families. In other words, depressed children consistently reported having less of an impact in the family decision-making. Democratic families and a tendency to value the opinions of the children is another important factor in authoritative parenting. Arieti and Bemporad (1980) found that parents of depressed youngsters often display a critical, punitive, and belittling or shaming parenting style that leads the child to feel bad, worthless, unlovable, and depressed. Such parenting resembles Baumrind’s descriptions of the authoritarian parenting style. While the abovementioned studies of children did not all utilize Baumrind’s three parenting styles, they all yield similar results. Family environments that are not

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emotionally supportive, are punitive, and are not democratic in decision-making are more likely to bring up children who are depressed. Parents who are authoritative, firm, and value the opinions of their children are more likely to bring up children who are content and well-adjusted. Some research has studied parenting styles and preschoolers. Baumrind’s observational studies of parenting styles and preschoolers’ behavior (Baumrind, 1968) indicate that different parenting styles correlate with different behaviors in preschool children. Mothers who were either very harsh (authoritarian prototype) or permissive (permissive prototype) in their discipline tended to have children who were poorly behaved or aggressive. In one of her studies, Baumrind (1967) set out to identify the parent attitudes and behaviors that are associated with competent behavior in nursery school for both boys and girls. The goal of the study was to empirically examine a mainstream preschool population to determine the relationship between parent behaviors, parent attitudes, and child behaviors. Ninety-five families and their preschool children (ages 3 and 4) participated in the study. The behavior of the children was observed and rated by psychologists over a 3-month period of time. The domains of behavior that were rated included neurotic symptoms, mood and energy characteristics, and interpersonal behaviors such as self-control, perseverance, self-reliance, self-assertiveness, friendliness, and cooperativeness. They also attempted to assess dominance and independence in the children. An analysis of the items observed yielded an eight-cluster structure for the boys and a different eight-cluster structure for the girls. The eight clusters for boys included unlikable-likeable, hostile-friendly, impetuous-self-controlled, rebellious-dependable,

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autonomous-compliant, imaginative-stereotyped, adaptive-regressive, and confidentfearful. The eight clusters for the girls included hostile-friendly, unsocialized-well socialized, obstructive-helpful, rebellious-dependable, domineering-tractable, autonomous-compliant, at ease-ill at ease, confident-fearful, and adaptive-regressive. A second set of clusters were also developed that were the same for both boys and girls including clusters such as independent-dependent, assertive-withdrawn, irresponsibleresponsible, and nonconforming-conforming. Data regarding parenting styles were obtained by assessing parental behavior in the home. The observations took place from before dinner until after the child’s bedtime. Parent-child interactions were recorded during the observation and coded after the visit was over. The coded information was later used as the basis for defining theoretically relevant variables. The parents were also interviewed regarding their attitudes as parents and their child rearing practices. Results of the study indicated several key findings. First, parental warmth was not found to be an important predictor of child behavior. Second, punitive attitudes of the parents were not found to be associated with fearful or compliant behavior. Third, paternal consistent discipline (authoritative parenting) was associated with independence and assertiveness in boys and with affiliativeness in girls. Maternal maturity demands were also correlated with independence and assertiveness for boys. For girls, maternal socialization demands were correlated with independence and assertiveness. Additionally, parental willingness to offer justification for directives and to listen to the child (authoritative parenting) was associated with competent behavior on the part of the child. Restrictiveness and refusal to grant enough independence (authoritarian parenting)

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were correlated with dependent and passive behavior in boys. In sum, parents of mature children were less authoritarian, but just as firm and more loving. In 1971, Baumrind set out to replicate parent-child relationships found in two previous studies and to differentiate further among patterns of parental authority as well as to measure their effects on the behavior of preschool children. One hundred and fortysix preschool children and their families participated in the study. Child behavior in school was observed over a period of 3 to 5 months. A cluster structure similar to the previous one was developed. Home visits were made which lasted from before dinner to after bedtime. Additionally, parents were interviewed regarding attitudes and childrearing practices. There were several key findings to this study. First, authoritative parental behavior was strongly associated with independent, purposive behavior for girls. The same was true for boys only when the parents were nonconforming. Additionally, authoritative parental control was associated with social responsibility in boys and with high achievement in girls when compared to authoritarian and permissive control in boys. Baumrind summarized her findings by saying that authoritative parents are more likely to foster the development of competence in children through responsible and independent behavior. The only study that examined parental factors and depression in the preschool population was conducted by Belden and Luby (2006) who investigated the relationship between preschool depression severity and parental emotional support in 150 three, four, and five year olds. Child and parent behaviors during challenging structured dyadic tasks were observed and coded. Children belonged to one of three diagnostic groups –

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depression, disruptive, and healthy preschoolers. Preschoolers who demonstrated higher depression severity scores experienced parenting strategies that were less emotionally supportive. The authors viewed emotional support as a mother’s expression of positive regard, encouragement on novel tasks, a sense of when her child was in need of encouragement, and respecting the child’s need for autonomy. While the authors did not refer to this as authoritative parenting, the descriptions are similar to Baumrind’s authoritative prototype. Parenting Discipline Practices Parenting discipline practices refers to parents’ methods of training their children to act according to a certain set of rules or guidelines. Discipline practices are the strategies that parents use to manage their children’s misbehavior. Parents have significant impact on their children’s behavior and misbehavior. The younger a child is, the greater the influence that parents have on them. There is an empirically established relationship between parenting discipline mistakes and the behavior disorders of children. Less is known about the relationship of discipline practices to childhood anxiety, fear and depression (O’ Leary, 1995). One example of a discipline practice is parents’ use of reprimands for their child’s misbehavior. Pfiffner and O’Leary (1989) looked at the effects of immediate, short, firm (ISF) reprimands and delayed, long, gentle (DLG) reprimands delivered in high and low nurturant environments. The authors predicted that ISF reprimands would result in less misbehavior than DLG reprimands and that the presence of nurturing interactions would result in fewer misbehaviors. Results indicated that immediate, short, firm reprimands were clearly more effective than delayed, long, gentle reprimands in controlling the

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misbehavior of children. Children transgressed less often, and when they did, they stopped misbehaving sooner after an ISF reprimand was issued. Arnold, O’Leary, Wolff, and Acker (1993) investigated specific dimensions of parental discipline that might be setting the stage for children’s disruptive behavior. Studies of noncompliant preschoolers indicated that when parents were taught to replace maladaptive discipline practices with clear, firm, consistent, and appropriate consequences, their children became more compliant (Webster-Stratton, Kolpacoff, & Hollinsworth, 1988). O’Leary (1995) described three potential discipline mistakes that parents of young children can make. The three mistakes are referred to as laxness, overreactivity and hostility. Laxness refers to a tendency to give in to one’s children, not enforce rules, and positively reinforce negative behaviors. Overeactivity involves frequent displays of anger, irritability, and meanness. Hostility is the tendency of a parent to engage in physical punishment, cursing, and name-calling. While there is only one study that looked at parental discipline practices and depression in children using the three discipline mistakes described by O’Leary (1995) there are many studies that examined parenting discipline practices utilizing a variety of definitions and variables. An attempt was made to connect the variables that exist in the literature to O’Leary’s three discipline mistakes, thereby utilizing the existing studies as evidence supporting the connection between parenting discipline mistakes and the development of depression in children. Leve, Kim, and Pears (2005) looked at childhood temperament and family environments and how they predicted internalizing and externalizing problems in

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children. Harsh parental discipline was one of the factors investigated as part of the family environment. They found that harsh discipline techniques predicted internalizing problems for boys at age 17. Harsh discipline techniques are a component of O’Leary’s overreactivity. Rodriguez (2003) investigated whether children receiving physical discipline have difficulties with internalizing problems. Forty-two children between the ages of eight and twelve and their parents were recruited for the study. Two measures were administered to parents. The first was the Child Abuse Potential Inventory (Millner, 1986) and the second was an unpublished measure called Discipline Scenarios, where parents read several scenarios involving physical discipline and were asked to rate on a 7point Likert scale how frequently they use similar physical punishment on their own children. Child Measures included The Children’s Attributional Style Questionnaire (Kaslow, Tannenbaum, & Seligman, 1978), The Children’s Depression Inventory (Kovacs, 1983, 1985) and The Children’s Manifest Anxiety Scale – Revised (Reynolds & Richmond, 1985). The research was done in the homes of the families. Parents completed instruments on a computer while children were taken to a quiet room in the home to complete the measures. Results of the study indicated that parents who held more physically abusive attitudes as well as parents who were practicing harsher discipline techniques had children with elevated depression scores. Rodriguez (2006) examined parents’ potential to physically abuse children which had been found to correlate with dysfunctional discipline practices and the use of corporal punishment. Part of her study looked at the relationship between the frequency of physical discipline/dysfunctional parenting practices and symptoms of depression in

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children. Participants of the study included seventy-five parent-child dyads with children between the ages of 8 and 12. The Parenting Scale, developed by Arnold et al. (1993), was used to identify dysfunctional parenting practices, and the Children’s Depression Inventory (Kovacs, 1983, 1985) was used to assess childhood depressive symptoms. There was a significant positive correlation at the .001 level between children’s scores on the Children’s Depression Inventory and scores on the Parenting Scale, that is, there was a positive correlation between the number of depressive symptoms reported by children and the level of dysfunctional discipline practices exhibited in the home. Garber, Robinson, and Valentiner (1997) looked at the relationship between depression and three components of parenting in young adolescents, (a) emotional connectedness or caring, warmth, acceptance and affection, as opposed to hostility and rejection (overreactivity), (b) psychological autonomy, or individuation versus overcontrol and intrusiveness (overreactivity), and (c) behavior regulation, or supervision, monitoring, limit-setting, and firm control in comparison to lax and inconsistent control (laxness). The authors also explored the relationship between management strategies and depressive symptoms. They hypothesized that low levels of parental acceptance and high levels of psychological control would predict depressive symptoms. Two hundred and forty sixth-grade children and their mothers participated in the study. Interviews were conducted with the mothers regarding their mental health history and current psychiatric disorders. Several months later, each mother was interviewed by a different interviewer regarding her child and her parenting practices. Assessments were

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conducted with the children as well regarding depressive symptoms and parenting practices exhibited by their parents. Results of the study indicated a significant negative relationship between psychological acceptance and depression as well as a significant positive relationship between psychological control and depression. Therefore, parents who are warm and accepting raise children who are less likely to develop depression. Additionally, parents who are over controlling and intrusive are more likely to raise children with depression. Parents who are hostile and rejecting as well as those who are overcontrolling and intrusive are similar to the overreactive discipline mistake described by O’Leary (1995). Laxness did not yield significant results with respect to its relationship with depressive symptoms. Asarnow, Goldstein, Tompson, and Guthrie (1993) looked at depressed children who had been hospitalized and what their 1-year post hospitalization outcome was. More specifically, they looked at the association between the 1-year outcome and homes with high levels of expressed emotion, which resembles the discipline mistake of overreactivity. Expressed emotion refers to criticism, hostility, and emotional over involvement, and was hypothesized to be a predictor of outcomes for depressed children. The authors hypothesized that during the first year after discharge, higher rates of continuing mood disorder and/or relapse will be observed among children returning to homes with higher levels of expressed emotion when compared to children returning to homes with less expressed emotion. Participants of the study included 26 child psychiatric inpatients between the ages of 7 and 14 with diagnoses of Major Depression or Dysthymic Disorder and their parents.

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DSM-III diagnoses were made at intake based on several different sources. A five minute speech sample of expressed emotion was obtained in an individual session with the parent during the first month of the child’s hospitalization. Parents were told to speak for five minutes about their child and how they got along. High expressed emotion is defined based on high score on either criticism or emotional over involvement. Children’s outcomes at one year after discharge were classified as either recovered or persistent mood disorder. Results of the study indicate a highly significant association between mother’s expressed emotion and child outcome. While none of the children in the high expressed emotion homes recovered, 53% of the children who went back to homes with low expressed emotion did recover. Thus, a brief measure of expressed emotion was highly predictive of 1-year post discharge outcome for the present sample of child psychiatric inpatients with diagnoses of Major Depression or Dysthymic Disorder. Mothers with high levels of expressed emotion share strong similarities to the over reactive parenting practice described by O’Leary. Many of the characteristics of parenting practices that were investigated share similarities with over reactivity and hostility. One study which did specifically address the three abovementioned discipline mistakes as it utilized the Parenting Scale developed by Arnold et al. (1993) found that elevated levels of dysfunctional discipline practices were associated with depression in children. Additionally, the literature is lacking research regarding the relationship between the parenting discipline practices and the development of depression in preschool children. While there are many studies examining parental discipline and externalizing disorders in preschool children, the

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connection between discipline and internalizing disorders in preschoolers has not been investigated thus far in the literature. Family Functioning Normal family functioning refers to basic patterns of interactions which sustain the preservation of the family unit and its ability to facilitate the performance of certain tasks that foster the growth and well-being of its members (Walsh, 2003). Nurturing and protecting children and taking care of elders and other vulnerable members are examples of such tasks. Every family develops its own set of norms which are communicated through rules that are explicitly stated as well as those that are unspoken. Each family’s set of rules is communicated through repeated and ongoing interactions and sets expectations about roles of members, actions, and consequences of actions. There are many models of family functioning including the Beavers Systems Model, The McMaster Model, and the Circumplex Model (Walsh, 2003). A useful way of looking at family functioning is using the Circumplex Model, which has its roots grounded in systems theory. The model includes three dimensions of family functioning including family cohesion, flexibility, and communication. Family cohesion refers to the emotional bonds that couples and families have towards one another. The focus is on the balance that family systems find between being separate and being together. Extreme levels of either separateness or togetherness are considered dysfunctional. Family flexibility refers to the amount of change that occurs in terms of its leadership, role relationships, and relationship rules. The focus of flexibility is the quality and expression of leadership and organization, role relationship, and relationship rules and negotiations. As with cohesion, a system that functions at the extremes of

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flexibility (i.e., being too rigid or overly flexible) is more problematic than a system that is more balanced between the two. The third dimension, communication, is referred to as a facilitating dimension, as this dimension aids families in adapting their cohesion and flexibility to meet the demands of changing circumstances. Communication is measured by assessing a family’s listening skills, speaking skills, continuity tracking, selfdisclosure, respect, and regard (Olson, Gorall & Tiesel, 2007). There are several hypotheses that have been derived regarding the circumplex model and family functioning. The first hypothesis is that balanced families will function more adequately overall than unbalanced families. Balanced families can function at extreme levels, at times, but they do not typically function at these extremes for extended periods of time. It is possible for there to be cultural exceptions to his hypothesis, where a family’s expectations or cultural norms are that families should function at extreme patterns. Families can function well in this way as long as all family members are comfortable with that pattern of functioning. The second hypothesis is that positive communication skills will facilitate and assist balanced families to change their levels of cohesion and flexibility when necessary. The third hypothesis is that families will alter their levels of cohesion and flexibility to adapt to changes and stressors that take place throughout the life cycle (Olson & Gorall, 2003). Kashani et al. (1995) set out to examine the relationship between childhood depression and family functioning of psychiatrically hospitalized depressed and non depressed children on the dimensions of cohesion and adaptability. They also analyzed the circumplex model for use with childhood depression. The authors hypothesized that families of children with depression will generally fall within the extreme ranges of the

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circumplex model as opposed to within the balanced ranges. More specifically, they hypothesized that children with depression would report less cohesive and less adaptive family functioning than children without depression. Additionally, the authors hypothesized that children with and without depression would differ when compared on group placement (i.e., balanced, midrange, and extreme) on the circumplex model of family functioning. To test their hypotheses, 22 boys (ages 10-12) were chosen from an inpatient unit, 11 of whom were depressed and 11 of whom were not depressed. The 11 depressed boys were matched with the 11 non-depressed boys and no significant differences were found with regard to demographic characteristics such as SES, race and family structure. A modification of the Family Adaptability and Cohesion Evaluation Scale-III (FACESIII-K) was used to assess family functioning. FACES-III was modified for use with young children and was administered to each of the 22 children. Results of the study indicate that depressed children report a less cohesive family environment than children without depression. The two groups did not differ significantly with regard to the adaptability dimension. The hypothesis regarding family cohesion was confirmed and families of depressed children appear to be less cohesive and more disengaged than families of children without depression. Thus, low family cohesion, according to the results of this study appears to be the crucial factor between adverse family functioning and childhood depression. In another study, Kashani et al. (1999) compared anxious and depressed children and adolescents with respect to their perceptions of their family environments. Specifically, they looked at the differences in perceived family adaptability and cohesion

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of an inpatient sample of depressed and anxious children. They also investigated whether these two clinical samples differ in their level of perceived family support. Twenty-one depressed (mean age of 14) and 18 anxious children (mean age of 11) participated in the study and were administered several questionnaires including Family Strengths (assesses the positive attributes of a child’s family), Family Adaptability and Cohesion Scales-II (FACES II), the Social Support Questionnaire – revised (SSQS-R), and the Children’s Interview for Psychiatric Syndromes (ChIPS). Findings of the study indicated that youngsters diagnosed with a depressive disorder differed from those diagnosed with an anxiety disorder in several key aspects. Depressed youngsters reported less trust, respect, and loyalty between members of their families, viewed their families as less adaptable in stressful situations, and indicated being less satisfied with the amount of support they received from their family members.

Thus, Kashani et al. supports the findings that

family characteristics are different between children diagnosed with depression and those diagnosed with anxiety as measured by the child’s perception. This study lends further support to the connection between poor family functioning and depression in children. In this case, low adaptability was observed in families of depressed children. Shiner (1998) investigated the family functioning of adolescents with a history of depression, taking into account maternal history of depression. Family characteristics of adolescents with lifetime major depression and a control group of adolescents with no history of significant depressive symptoms were assessed. Family functioning of three types of families was assessed including (a) families that have an adolescent and a mother with lifetime major depression, (b) families with an adolescent with major depression and a never-depressed mother, and (c) families with never depressed adolescents. These three

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groups of families were compared in terms of overall family cohesion and flexibility, relationships between adolescents and mother and adolescents and father, and the rate of divorce in the families. Both adolescents and their parents provided reports of family functioning. The author hypothesized that of the three groups of families compared, the families with adolescents and mothers with lifetime depression would be reported to be functioning the most poorly. Seventy-nine males and females with a diagnosis of major depression and 82 never-depressed control subjects were included in the sample. Parents of depressed and control adolescents were also included in the study.

The Family Adaptability and

Cohesion Scale 3rd edition (FACES-III) was used to assess family members’ perceptions of the family’s overall functioning, specifically cohesion and adaptability. The Parental Environment Questionnaire was also used to assess relationships between each of the parents and the adolescents. The SCID was utilized to assess each family member in terms of past and present symptoms of depression. Results of the study indicate that a higher proportion of depressed adolescents had mothers with lifetime depression than did the never-depressed controls.

Families with depressed adolescents and depressed

mothers reported significantly poorer family functioning than did the other groups. Additionally, depressed adolescents, regardless of their mothers’ depression history came disproportionately from divorced families relative to control adolescents. Only the subset of depressed adolescents with depressed mothers described disturbed family relationships relative to the control adolescents. Thus, when looking at the family functioning of individuals with depression, it is important to take into account a history of depression in the family.

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There have been no studies to date that examined the relationship between family functioning and the development of depression in preschoolers. Yet, the studies with children have indicated that families of depressed individuals do function more poorly than families without depressed individuals. When viewed from the Circumplex Model, low cohesion and adaptability have been observed in families of depressed patients. When considering family functioning, it is important to take family history of depression into account as that could be an important factor in the poor functioning of the family. Risk Factors for Preschool Depression Key risk factors in the development of major depressive disorder in older individuals are a family history of mood disorders and stressful life events (Jaffee et al., 2002). Moreover, Jaffee et al. (2002) established that juvenile onset depression was associated with a higher frequency of psychosocial risk factors than the adult onset disorder. The only study to date to examine the mediating relationships between risk factors and very early onset depression in preschool children was done by Luby, Belden, and Spitznagel (2006). Luby et al. (2006) considered the current research indicating that depression can occur in preschoolers as young as 3 years old and thought it necessary to consider potential mediators for depression in this population. Specifically, the authors used regression analyses to investigate the roles of family history of psychiatric disorders or behaviors such as mood disorders, suicidality and stressful life events as risk factors of early onset depressive symptoms in preschool children ages 3.0 to 5.6. The authors hypothesized that a family history of mood disorders and a history of stressful life events that were reported at baseline would serve as risk factors for depression and would be associated with higher depression severity sum scores 6 months later.

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Results of the study confirmed both hypotheses. A family history of mood disorders was significantly associated with higher depression severity sum scores 6 months later. Approximately 5% of the variance in the depression severity of preschool children was accounted for by its linear relationship with family history of mood disorders in first and second degree relatives. Additionally, stressful life events ranging from mild (birth of a sibling) to more severe (death of a parent) events during the past year prior to baseline was a significant predictor of the depression severity of preschool children 6 months later. Stressful life events accounted for 10% of the total variance in preschoolers’ depression severity score 6 months later. Thus, a family history of mood disorders and stressful life events are crucial in a child’s development and are risk factors for the development of depression even in the preschool period of development. Agreement between Parents and Teachers In 1987, Achenbach, McConaughty and Howell conducted a meta-analyses looking at the reports of various informants including parents and teachers. The correlation between ratings of parents and teachers (.27) represented a small degree of association according to Cohen’s criteria. Kashani, Holcomb, and Orvaschel (1986) looked at depressive symptoms in the general preschool population and as part of their study had both parents and teachers complete checklists regarding each participating child. Results of comparisons between parent and teacher responses indicated no correlation, and at times, even a negative correlation, leading to the conclusion that there is a discrepancy between parents’ and teachers’ ratings of depressive symptoms in preschool children. When an individual case study of one of the participants was investigated, it was found that the parent underreported the child’s symptoms while the

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teacher responded more accurately. This finding indicates that while multiple sources of respondents should always be gathered, teachers serve as important resources when gathering data regarding symptoms. Correlations between reports of parents and teachers have also been found to be low for ratings of adolescent personality (Laidra et al, 2006), social competence of children (Juntiltila, Voeten, Kaukiainen, & Vauras, 2006), and attention deficit hyperactivity disorder (Hartman, Rhee, Willcutt, & Pennington, 2007). Hartman et al. (2007) also found that parents may be more biased than teachers in their ADHD ratings. Thus, disagreement or low levels of agreement seem to occur between parents’ and teachers’ reports of children across various aspects of the child’s functioning. It is possible that the ratings of teachers are more accurate and less biased descriptions of the child’s behaviors. Summary The literature appears to support the fact that while the symptoms might be milder, depression does exist in preschool children. Research also supports the fact that there is often little agreement between teachers’ and parents’ reports of symptoms (Achenbach, McConaughty & Howell, 1987; Juntiltila et al., 2006; Laidra et al., 2006). Additionally, there are several familial factors associated with the development of depression in children that might be applicable to preschool children. Baumrind’s (1971) three typologies of parenting styles are important predictors in child outcomes. The authoritarian parenting style is associated with the development of depression in children. Additionally, dysfunctional discipline practices, as described by O’Leary (1995) can include three discipline mistakes including laxness, verbosity, and over reactivity. High

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frequencies of these mistakes, especially over reactivity, are associated with the development of depression in children. Family functioning is an important factor of family life. Low cohesion and adaptability, in families, as described by Olson and Gorall (2003) are associated with depression in children. Finally, there are several important risk factors that have been demonstrated as crucial in the development of depression in children and preschool children. These risk factors include a family history of mood disorders and stressful life events. Rationale

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Based on the literature reviewed, it appears that certain family factors identified as related to childhood depression may also be associated with depression in preschool children. These factors include parenting styles, parenting practices, and family functioning. While this has been established with parents of older children with depression, this has not been studied with preschoolers. However, we do know that depression occurs in preschool children, and there are screening measures and observation methods which have been demonstrated to be good diagnostic tools for this population. Modified criteria for depression in preschool children have been proposed to aid in the identification and diagnostic process (Luby et al., 2002). It is not yet known what factors are associated with the development of depression in preschool children. Since familial factors such as parenting styles and practices as well as family functioning have been demonstrated to be associated with the disorder in older children, it is hypothesized that the same would be true for preschoolers. Obtaining this knowledge would aid in developing effective prevention and intervention programs when children are still quite young, and when prevention and intervention are most effective. The literature review leads to the following research questions. First, are depressive symptoms observable in the preschool population? Second, will there be a lack of agreement between teacher and parent responses to a behavior checklist regarding the child’s symptoms? Third, is there a relationship between parenting styles and depressive symptomatology in young children? Fourth, are dysfunctional discipline practices related to depressive symtomatology in young children? Fifth, is family functioning related to depression in preschool children? Hypotheses

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This investigated the relationship among parenting styles, parenting discipline practices, family functioning and depressive symptomatology in young children. There were several hypotheses of the study: H1 Depressive symptoms are observable in preschool children. H2 There will be a lack of agreement between teacher and parent responses to a behavior checklist regarding the child’s symptoms. H3 There is a relationship between parenting styles and depressive symptomatology in preschool children. Authoritarian or permissive parenting styles will be related to depressive symptomatology in preschool children. H4 Dysfunctional discipline practices will be related to depressive symptomatology in preschool children. H5 Family functioning will be related to depression in preschool children. Families who are less cohesive will have children who show more signs of depression. Less cohesiveness is associated with depression in preschoolers. Less adaptability is associated with depression in preschoolers.

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Chapter Three Method Participants Sixty parents of typically developing children in preschools were recruited from six private preschools in Queens, Manhattan and Long Island, New York, comprised of mostly Caucasian children from middle and upper class families. Twenty preschools were contacted to ask permission to recruit participants from their parent bodies and six (30%) agreed. Three schools were located in Great Neck, Long Island; two schools were

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located in Queens, NY, and one school was located in Manhattan. The Manhattan preschool only consisted of 20 children while all the other preschools had between 90 and 120 children. Parents with preschool children between the ages of 3 and 5 were invited to participate. Consent forms were sent home to parents with their children. Parents who agreed to participate sent back signed consent forms and indicated whether they preferred the questionnaires in paper and pencil format or via e-mail. Fifty-five out of the sixty participating parents completed the questionnaires and checklists online while five preferred using the paper and pencil format. Parents who agreed to participate completed questionnaires in one of the two formats. Teachers of the children whose parents agreed to participate also completed surveys. None of the teachers completed the checklists online. They all preferred the paper and pencil format. Measures Several instruments were utilized for this study including the Parenting Styles and Dimensions Questionnaire, the Parenting Scale, the Family Adaptability and Cohesion Evaluation Scale and the Preschool Feelings Checklist. The instruments are described below. Parenting Styles and Dimensions Questionnaire. The Parenting Styles and Dimensions Questionaire (PSDQ) can be found in Appendix E. The PSDQ was completed by one of the parents or a legal guardian of the child. Robinson, Mandleco, Frost Olsen, and Hart (1995) developed a 32-item parenting scale using Baumrind’s three major typologies which assesses whether the parenting style is authoritative, authoritarian, or permissive. This scale was originally developed as a 62-item parenting instrument which yields three global dimensions consistent with Baumrind’s three major

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typologies of parenting styles: authoritative, authoritarian, and permissive. These 62 items correlated significantly with the total factor score. There are 27 authoritative items with a reliability of .91, 20 authoritarian items with a reliability of .86, and 15 permissive items with a reliability of .75. Once the reliability of the factors was established, the authors set out to determine the dimensions and internal structures within the three factors that may reflect specific parenting practices. In order to do this, each set of items within the three global typologies were analyzed using principal axes factor analysis followed by oblimin rotation. As a result, four factors were identified within the authoritative factor accounting for 47.4% of the variance–(a) warmth and involvement–11 items (b) reasoning/induction–7 items (c) democratic participation–5 items (d) good natured/easy going–4 items. Four factors were extracted from the authoritarian items accounting for 46.8% of the variance, that is, (a)verbal hostility – 4 items, (b) corporal punishment–6 items (c) nonreasoning punitive strategies – 6 items, and (d) directiveness – 4 items. Three factors were extracted from the permissive items accounting for 40.3% of the variance. These factors were labeled–(a) lack of follow through–6 items (b) ignoring misbehavior – 4 items, and (c) self-confidence–5 items. The results of this study indicated that parenting questions consistent with Baumrind’s three major typologies can be derived. Additionally, within each typology additional factors have been identified which may prove to be useful in predicting outcomes. A 32-item version was later developed using confirmatory factor analysis/structural equation modeling, which is the scale that was used for the current study. The scoring key of the PSDQ was used to classify parents into

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one of three parenting styles. The scoring key yielded an overall mean score in each category of parenting style, and based on this score the parents’ particular style was determined. Parenting Scale. The Parenting Scale (see Appendix D) was completed by one of the parents of a preschool child or by a legal guardian of the child. Arnold et al. (1993) designed a rating scale comprised of 30 items measuring dysfunctional discipline practices in parents of young children. The authors identified three stable factors of dysfunctional discipline, or three primary types of mistakes made by mothers of two to four year old children: (a) laxness (b) overreactivity, and (c) hostility. O’Leary (1995) described these three mistakes as follows. Laxness refers to a tendency to give in to one’s children, not enforce rules, and positively reinforce negative behaviors. Overeactivity involves frequent displays of anger, irritability, and meanness. Hostility refers to a parent’s use of physical or verbal force when disciplining, such as physical punishment, cursing, and name-calling Item responses utilize 7-point Likert scales and higher scores indicate dysfunctional discipline practices. Thus, for each of the three mistakes factor scores were computed based on the average of the responses on the items on that factor. Higher factor scores indicated more lax, overreactive, or hostile parenting, depending on the factor being examined. Scores range from 1 to 7 for each of the different factors. A recent study conducted by Rhoades and O’Leary (2007) looked at confirmatory analyses based on the scoring derived from 5 previous studies of the Parenting Scale. In all, 453 parents of 3 to 7 year olds comprised the sample. The three factor scores of lax, overreactive, and hostile disciplining practices correlated significantly with several

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validity measures, including child behavior problems. The validities of the Parenting Scale factors were supported by meaningfully strong correlations between the factors and a variety of other measures for both parents. Therefore, the Parenting Scale is a costeffective self-report measure of parental discipline.

In addition, Coefficient alphas of

factor scores were as follows: (a) Lax, .85 and .82; (b) Overreactive, .80 and .80; and (c) Hostile, .78 and .83. These scores demonstrate strong internal consistency of the scale. Family Adaptability and Cohesion Scales (FACES IV). The FACES-IV (see Appendix C) was completed by one of the parents or by the legal guardian of a preschool child. Olson, Gorall, and Tiesel (2007) developed this paper and pencil questionnaire that is self-administered and contains 62 items that are measured on a 5-point Likert-type scale. The scale includes two balanced scales called balanced cohesion and balanced flexibility. It also includes four unbalanced scales called disengaged and enmeshed for the cohesion dimension and rigid and chaotic for the flexibility dimension. Additionally, there is a family communication scale and a family satisfaction scale. Scoring consists of taking each item response and summing up the item responses for each of the six FACES IV scales, creating a total raw score. Then the total raw score is converted into percentage scores. A percentile score for the following six scales are provided: (a) Balanced Cohesion, (b) Balanced Flexibility, (c) Disengaged, (d) Enmeshed, (e) Rigid and (f) Chaotic. One can also create Cohesion Ratio, Flexibility Ratio, and Total Circumplex Ratio scores that indicate the level of functional versus dysfunctional behavior perceived in the family system. The ratio score is obtained by assessing the Balanced/Average Unbalanced score for each dimension. The lower the ratio score, the more unbalanced the system. Conversely, the higher the ratio score, the

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more balanced the system. There are also dimension scores for cohesion and flexibility which are used for plotting the one location of the family onto the updated graphic representation of the Circumplex Model of Couples and Family Systems. Both ratio scores and dimension scores will be used in the current study. To assess the validity of the FACES-IV scale, Olson, Gorall, and Tiesel (2007) administered a FACES IV item pool (84 items) to 487 individuals. These 87 items were obtained from earlier versions of FACES as well as 24 new items that were developed to identify the high and low extremes of cohesion and flexibility. To assess the criterion validity of the FACES IV scales, three other family assessment measures were used including the Self-Report Family Inventory, Family Assessment Device, and Family Satisfaction Scale. First, an exploratory factor analysis of all 84 items was conducted. Items loading below .30 and those with cross-loading were removed from future analysis. Five factors were identified including (a) balanced cohesion/disengaged, (b) balanced flexibility, (c) enmeshed, (d) rigid and (e) chaos. Subsequently, six scales ((a) balanced cohesion, (b) balanced flexibility, (c) disengaged, (d) enmeshed, (e) rigid, and (f) chaotic) with seven items each (42 items in total) were subjected to confirmatory factor analysis. Results of the confirmatory analysis indicated an acceptable and well-fitted model. Additionally, factor loadings for all 42 items on their respective scales indicated high loadings and a fairly even loading pattern. A differential pattern was revealed for each proposed dimension. For example, balanced cohesion was strongly and negatively correlated with the low unbalanced form of cohesion. Additionally, the balanced scales were very highly correlated with each other.

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An alpha reliability analysis was conducted to examine the internal consistency of the six scales. Reliability of the six scales are all acceptable and are as follows: Enmeshed = .77, Disengaged = .87, Balanced Cohesion = .89, Chaotic = .86, Balanced Flexibility = .84, Rigid = .82. An additional confirmatory factor analysis was conducted with FACES IV and each of the three validation scales. Results of this analysis indicated that the balanced FACES scales of cohesion and flexibility had large positive correlations with the validation scales, while the unbalanced FACES scales of disengaged and chaotic had large negative correlations with the validation scales. In order to determine whether the FACES IV scales can distinguish between problem family systems and non-problem family systems, Olson, Gorall, and Tiesel (2007) ran a discriminant analysis. Analyses that were run demonstrate the discriminant validity of the FACES-IV scales. Craddock (2001) conducted a study with the goal of testing out the predictions of Tiesel and Olson’s (1997) FACES-IV and the Circumplex model using an Australian sample. Results of this investigation indicate that, as Tiesel and Olson predicted, the three measures of family quality on the FACES-IV, namely, family strength, satisfaction, and communication have high positive correlations with each other. Additionally, family strengths, satisfaction, and communication were negatively and significantly correlated with disengagement, rigidity, and chaos. Families classified as generally extreme in their family system type were significantly lower in family quality and higher in family stress than families classified as balanced. The strongest predictors of family quality were family disengagement and family rigidity, and family chaos was the

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strongest predictor of family stress. Thus, FACES-IV has good internal consistency reliability. Validity is demonstrated by the fact that the measure differentiates between functional and dysfunctional families. Preschool Feelings Checklist (PFC). The PFC (see Appendix B) was completed by one of the parents or legal guardian of a preschool child as well as by the teacher of the children whose parents consented to participate in the study. The Preschool Feelings Checklist, developed by Luby, Koenig-McNaught, Brown, and Spitznagel (2004), is a brief and valid screening measure of the child’s behaviors and can be used in a variety of different settings. It consists of sixteen yes/no items about the existence of depressive symptoms in preschool children. The items cover a range of internalizing and externalizing symptoms that show strong associations with independent diagnostic measures of internalizing symptoms and major depressive disorder. The PFC is designed to be scored in a symptom present/absent fashion. If the respondent indicates “Yes,” the child should be given a score of 1 for that item; if the respondent indicates “No,” the child should be given a score of 0 for that item, resulting in a total possible score of 16. A total score of 3 or more indicates the need for a clinical evaluation (Luby et al., 2004). Luby, Heffelfinger, Koenig-McNaught, Brown, and Spitznagel (2004) administered the Preschool Feelings Checklist (PFC) to 174 parents of preschool children. Once all inclusion and exclusion criteria were met, children and their caretakers participated in a 2-to-3 hour assessment in which caregivers were administered a comprehensive structured interview resulting in a diagnosis of either Major Depressive

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Disorder, a psychiatric disorder, or no disorder. The Childhood Behavior Checklist (CBCL) was completed prior to the interview. Results indicated significant correlations between the PFC and the diagnosis of MDD based on the interview as well as between the PFC and the Internalizing T score on the CBCL. Such findings indicate that the PFC is a valid screening measure. Excellent internal consistency was found and scores on the PFC significantly differentiated depressed preschoolers from those with other psychiatric disorders. The measure contained a cutoff point that maintained a high level of sensitivity, which could be used to identify preschoolers who are in need of a more in-depth clinical evaluation. Web based surveys. In recent years there has been rapid development of technology and its ability to offer convenience and efficiency in many different realms of daily life, including conducting research. Administering surveys and questionnaires via the internet is becoming increasingly popular for a variety of different reasons. Denscombe (2006) investigated whether or not people provide different information on a survey depending on the mode of administration. This was done by administering a survey to two near-equal groups who responded to two near-identical questionnaires. One questionnaire was web-based and one was paper-based. Contents of data as well as completion rates were considered. It was concluded that there are no essential differences between responses or completion rates between the different modes of administration. In fact, the completion rate was slightly higher for web-based questionnaires than for paper-based. The indications from this study are that web-based

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questionnaires provide a reliable data collection method as compared to paper based versions. Procedure Preschools listed in the yellow pages were contacted and asked permission to recruit participants from their population of parents. While many schools were contacted, six granted permission recruit participants from the parent body. A faculty member in each school was designated as the one responsible for the distribution of forms. A letter explaining the project and seeking participants was distributed to all parents in the preschool facility. A consent form (see Appendix A) was attached and parents were asked to send back the signed consent form if they agree to participate. A designated box was set up in the main office of each preschool that served as the drop off location for completed forms.

In the consent forms, parents were offered the option of completing

the surveys on the internet. Those who chose this option were asked to provide their email address, and the survey was e-mailed to them. Once the signed consent forms were collected, those parents who agreed were given or e-mailed a brief questionnaire to complete, called the Preschool Feelings Checklist (PFC). Two weeks later, they were given or e-mailed a set of three questionnaires to complete; the Parenting Styles and Dimensions Questionnaire (PSDQ), the Parenting Scale, and the Family Adaptability and Cohesion Scales (FACES-IV). All questionnaires were coded before they were distributed to the parents, so that their name did not appear anywhere on the questionnaire. Those that were done via e-mail were coded when the completed questionnaire was printed from the computer.

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At the same time, teachers of the participants’ children were given or e-mailed the Preschool Feelings Checklist (PFC). The names of the students were written on an attached sheet of paper and only a number code was on the actual checklist. Teachers were instructed to tear off the first page before returning the checklist so that the child’s name was not located on the actual checklist. Parents and teachers returned completed questionnaires and checklists in sealed envelopes and left them in the designated box in the main office. If it was done via e-mail, the name of the child was coded once the completed questionnaire was printed from the computer. Design Several statistical analyses were utilized. Descriptive statistics were used to determine whether or not depressive symptoms were observable in preschool children. Cohen’s Kappa statistics were used to evaluate inter-rater agreement between parent and teacher responses on the PFC. This statistic compares observed and expected agreement to find if the observed agreement is beyond the chance level. Logistic Regression analyses were utilized to determine the relationships between the three independent variables and depressive symptoms in preschool children. Additionally, a receiver operating characteristic curve (ROC curve) was plotted to evaluate the predictive power of the logistic regression model

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Chapter Four Results This chapter describes the results obtained. Descriptive statistics, Cohen’s Kappa statistics, logistic regression analyses and Receiver Operating Characteristic Curves (ROC Curves) were used to address the five hypotheses in this study. The dependent variable in this study was the presence or absence of certain symptoms that characterize a preschool child as either at risk or not at risk for developing depression. These symptoms are represented by the parent and teacher scores on the Preschool Feelings Checklist (PFC) (Luby, Koenig-McNaught, Brown, & Spitznagel,2004), a 16 item screening measure used to identify whether or not preschool

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children are at risk for developing depression. The items cover a range of internalizing and externalizing symptoms that show strong associations with independent diagnostic measures of internalizing symptoms and major depressive disorder. Four categorical variables were created based on parent and teacher PFC scores. Two variables were created based on a clinical definition of at risk as is described by the scoring instructions of the PFC. Using this definition, a score of 3 or more indicates that the child is at risk for developing depression. Two variables were created using a less stringent definition of at risk. The less stringent definition is such that the child is considered at risk for developing depression if he/she exhibits one or more symptoms depicted on the PFC. The two definitions of at risk were created due to the expectation that the clinical definition suggested in the scoring instructions of the PFC would occur too infrequently. Because the N in logistic regression depends on the minimum number of events and the number of events is relatively small using the clinical definition, the power is reduced. One way to address low power is to lower the standard for the number of events. This is what was done by creating the less stringent definition of at risk. As explained above, four categorical variables were created (See Table 15). The Parent At-Risk Clinical (PARC) variable indicates whether or not the parent reported the child to be at risk according to the clinical definition of at risk. The Teacher At-Risk Clinical (TARC) variable indicates whether or not the teacher reported the child to be at risk according to the clinical definition of at risk. The Parent At-Risk Less Stringent (PARLS) variable indicates whether or not the parent reported the child to be at risk according to the less stringent definition of at risk. The Teacher At-Risk Less Stringent

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(TARLS) variable indicates whether or not the parent reported the child to be at risk according to the less stringent definition of at risk. Demographics Age and gender of preschool children. The sample consisted of 35 (58.3 %) girls and 25 (41.7 %) boys. The age of the preschool children ranged from 3 to 5 with a mean of 3.8 years old. One participant in the sample did not report the age of her presschool child. Table 1 Crosstabulation of Gender and Age of Participants Gender Age 3 Age 4 Female 15 12 Male 9 12 Total 24 24

Age 5 8 3 11

Total 35 24 59

Table 2 Gender of Preschool Children in Sample Gender Frequency Female 35 Male 25

Percent 58.3 41.7

Table 3 Age of Preschool Children in Sample Age Frequency 3 4 5

24 24 11

Percent 40.7 40.7 18.6

Ethnicity. For those parents responding to a question on ethnicity there were 4 Asian-Americans (7.1%), 2 Hispanic/Latinos( 3.6 %), 2 respondents of mixed race(.6%) and 48 Caucasians (85.7%).

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Table 4 Ethnic Makeup of Sample Ethnicity Asian American Hispanic/Latino Mixed Race White/Caucasian

Frequency 4 2 2 48

Percent 7.1 3.6 3.6 85.7

Family makeup of children in sample. Fifty-seven (96.6 %) of the children in the sample were living with both their biological parents. One (1.7 %) child was living with adoptive parents, and 1 (1.7 %) was living in a single parent home due to divorce. The number of children in the participating families range from 1 to 6 with 2.5 being the average number of children in the family. The mode number of children was 2, with 22 families having 2 children. Table 5 Number of Children in Family Number of Children in Family 1 2 3 4 5 6

Frequency 9 22 18 9 1 1

Percent 15 36.7 30 15 1.7 1.7

Of the children in the sample, 31 were the oldest, 11 were the youngest and 17 were middle children. Role of PFC respondents. The respondents of the Parent PFC consisted of both mothers and fathers. Fiftyfive of the 60 respondents were mothers (91.7%) and 5 (8.3%) were fathers.

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Age of parent completing parenting scales. The age of the parent completing the Parenting Scales ranged from 25 to 53 with a mean age of 35.7. Education of parent completing parenting scales. Of the parents who completed the parenting scales, 2 parents (3.3%) completed some college, 11 parents (18.3%) completed college and 47 parents (or 78.3%) hold an advanced degree. Income of parents. The income of the parents completing the scale ranged from less than $10,000.00 (3 families) to more than $100,000 (17 families) as is depicted in Table 9. Table 6 Income of Parents Completing Parenting Scale Income Frequency Less than $10,000 3 $10,000 - $20,000 3 $20,000 - $30,000 1 $30,000 - $40,000 2 $40,000 - $50,000 5 $50,000 - $60,000 7 $60,000 - $80,000 8 $80,000 - $100,000 8 $100,000 or more 17

Risk Factors

Percent 5.6 5.6 1.9 3.7 9.3 13 14.8 14.8 31.5

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The two risk factors that have been found to be significant in the development of depression in children are a history of mood disorders in the family as well as the occurrence of a stressful life event in the past year. Of the respondents in the sample, 27 parents (45.8%) reported that there was a history of mood disorders in the family. Thirtytwo (54.2%) respondents reported that there is no history of mood disorders in the family. Twenty-nine respondents (50%) reported that the family experienced a stressful life event within the past year, while 29 respondents (50%) reported that there was no stressful life event experienced within the past year. Logistic regression analyses were conducted with the two risk factors as the independent variables and the four outcome variables (PARC, PARLS, TARC, TARLS) as the dependent variables. The risk factors were not found to be significant predictors of preschoolers who show signs for being at risk for developing depression in this study. Hypothesis #1 The first hypothesis addressed whether or not depressive symptoms are observable in preschool children. It was hypothesized that depressive symptoms are observable in preschool children. Descriptive statistics were calculated for each of the four definitions of at risk and are depicted in Table 7. According to the parent report and the less stringent definition (PARLS) of at risk, 35.1% of the children in the sample were found to be at risk. According to the parent report and the clinical definition (PARC) of at risk, 9.1% of the children in the sample were found to be at risk. According to the teacher report and the less stringent definition, 33.8% of the sample was found to be at risk. According to the teacher report and the clinical definition of at risk, 16.9% of the children in the sample were found to be at risk. The data described above and depicted in

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Table 7 below support the hypothesis that symptoms of depression are observable in preschool children. Table 7 The Observation of Depressive Symptoms in Preschool Children Reporter Definition of At Risk N At Risk Parent Less Stringent 59 27 Parent Clinical 59 7 Teacher Less Stringent 60 26 Teacher Clinical 60 13

Percent At Risk 35.1 9.1 33.8 16.9

The responses on the parent PFC yielded a mean score of .88 and a standard deviation of 1.18. In other words, the mean number of symptoms observed by parents is .88. The responses on the Teacher PFC yielded a mean score of 1.3 and a standard deviation of 1.758. In other words, the average number of symptoms observed by teachers is 1.3. Table 8 Preschool Feelings Checklist – Means and Standard Deviations Scale Parent PFC Teacher PFC

Mean Score .88 1.3

Standard Deviation 1.18 1.758

Hypothesis #2 The second hypothesis in this study stated that there will be a lack of agreement between teacher and parent responses to a behavior checklist regarding the child’s symptoms. Cohen’s kappa statistics were used to evaluate inter-rater agreement. This statistic compares observed and expected agreement to find if the observed agreement is beyond the chance level. The range of scores for the parent-completed PFCs was from zero to four, indicating that the largest number of symptoms reported by parents was four. The range of scores

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for the teacher-completed PFCs was zero to seven, with seven being the maximum number of symptoms reported. According to the clinical definition of at risk, both parent and teachers agreed regarding 43 out of the 51 children, or 84.3% of the children. Parents reported that 5 children exhibited symptoms of being at risk while teachers reported that 9 children exhibited symptoms of being at risk for developing depression. There were 6 cases in which the teacher reported the child to be at risk while the parent did not and 2 cases where the parent reported the child to be at risk and the teacher did not. The magnitude of the kappa value is .346, and there was a significant difference from chance at the .009 significance level. While parents and teachers agree more than chance, they are not seeing the same symptoms. Table 9 Crosstabulation of Parent and Teacher Reports of At Risk Children According to the Clinical Definition Teacher Not At Risk Teacher At Risk Total Parent Not At Risk 40 6 46 Parent At Risk 2 3 5 Total 42 9 51 According to the less stringent definition of at risk, both parent and teachers agreed regarding 33 out of the 51 children, or 64.7% of the children. Parents reported that 23 children exhibited symptoms of being at risk while teachers reported that 21 children exhibited symptoms of being at risk for developing depression. There were 8 cases in which the teacher reported the child to be at risk while the parent did not and 10 cases where the parent reported the child to be at risk and the teacher did not. The magnitude

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of the kappa value is .282 and this indicates that there was a significant difference from chance at the .044 significance level. Table 10 Crosstabulation of Parent and Teacher Reports of At Risk Children According to the Less Stringent Definition Teacher Not At Risk Teacher At Risk Total Parent Not At Risk 20 8 28 Parent At Risk 10 13 23 Total 30 21 51 The data described above support the hypothesis that there will be a lack of agreement between teacher and parent responses on the PFC. Following up on the above findings, the author investigated which items on the PFC were the greatest source of disagreement between parents and teachers. Items 1, 3, 7 and 10 were the greatest sources of disagreement, and all had more than 10 instances where the teacher and parent disagreed regarding the item. Item #1 and item #7 are related to playing with other children while item #3 is about following rules. These 3 items may be particularly observable in a school setting. Item # 10 is about lacking confidence. In general, the teachers reported symptoms more readily than parents did. Hypothesis #3 The third hypothesis in this study was about the relationship between parenting styles and depressive symptomatology in preschool children. More specifically, it was hypothesized that authoritarian and permissive parenting styles would be related to depressive symptomatology in preschool children. Logistic regression analyses were computed on SPSS with the four categorical variables (PARC, PARLS, TARC, TARLS) entered as outcome variables, and authoritarian and permissive parenting entered into the equation as predictors.

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Using the parent report and clinical definition of at risk as the outcome variable, there was no significant relationship between parenting styles and depressive symptomatology. With PARC as outcome variable and authoritarian parenting as the independent variable, the logistic regression analysis yielded a p-value of .365. Using PARC as the outome variable and permissive parenting as the independent variable, the logistic regression analysis yielded a p-value of .248. Using the parent report and the less stringent definition of at risk as the outcome variable, there was no significant relationship between parenting styles and depressive symptomatology. Using PARLS as the outcome variable and authoritarian parenting as the independent variable, the logistic regression analysis yielded a p-value of .865. Using PARLS as the outcome variable and permissive parenting as the independent variable, the logistic regression analysis yielded a p-value of .182. Using the teacher report and the clinical definition of at risk, there was no significant relationship between parenting styles and depressive symptomatology.

The logistic

regression analysis with TARC as the outcome variable and authoritarian parenting as the independent variable yielded a p-value of .244. The logistic regression analysis with TARC as the outcome variable and permissive parenting as the independent variable yielded a p-value of .879. Using the teacher report and the less stringent definition of at risk, the relationship between authoritarian parenting styles and the observation of depressive symptoms yields an a p-value of .053 (<.1) which indicates that there is a significant relationship between the two variables. Taking permissive parenting out of the analysis and centering the authoritarian variable at 1 (as scale responses go from 1 to 5 so 1 becomes 0) the results

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change somewhat. When this is done, authoritarian parenting yields a p-value of .048 (< .05) which indicates that there is a significant relationship between the two variables. Since the constant is .028 and the exponent, or odds are .236, the probability is .19. In other words, a child with authoritarian parenting has a 19% chance of being at risk for depression. Table 11 Logistic Regression Analysis for Relationship between Parenting Styles and Depressive Symptoms using the Teacher Report and the Less Stringent Definition of At Risk Predictor B S.E. Df P Value Exp (B) Authoritarian Parenting 2.090 1.079 1 .053 8.801 Permissive Parenting -.165 .608 1 .786 .848 Table 12 Logistic Regression Analysis for the Relationship between the Centered Authoritarian Parenting Style and Depressive Symptoms using the Teacher Report and the Less Stringent Definition of At Risk Predictor B S.E. df P Value Exp (B) Authoritarian Parenting Centered 1.995 1.00 1 .048 7.353 9 The data described above partially supported the hypothesis that there was a relationship between parenting styles and depressive symptomatology in preschool children. Teacher reports regarding symptoms of depression yielded results indicating that authoritarian parenting was related to the existence of symptoms of depression in preschool children. However, parent reports of symptoms did not indicate a significant relationship. Hypothesis #4 The fourth hypothesis in this study examines the relationship between dysfunctional discipline practices and depressive symptomatology in preschool children.

The

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dysfunctional discipline practices included laxness, overreactivity and hostility. Logistic regression analyses were conducted to determine the significance of these predictors. The analyses were computed on SPSS using the dysfunctional discipline practices as predictor variables in the regression equation and the four categorical variables (PARC, PARLS, TARC, TARLS) as outcome variables in the equation.

None of the

abovementioned predictors yielded significant results. Using PARC as the outcome variable and laxness, overreactivity and hostility as the predictors, the regression analysis yielded p-values of .287, .924, and .987, respectively. Using PARLS as the outcome variable and laxness overreactivity and hostility ast the predictors, the regression analysis yielded p-values of .558, .383, and .285, respectively. Using TARC as the outcome variable and laxness, overreactivity and hostility as the predictors, the regression analysis yielded p-values of .690, .314, and .440, respectively. Using TARLS as the outcome variable and laxness, overreactivity and hostility as predictors, the regression analysis yielded p-values of .546, .354, and .370, respectively. The data do not support the hypothesis that there is a relationship between dysfunctional discipline practices and depressive symptomatology in preschool children. Hypothesis #5 The fifth hypothesis in this research study addressed the relationship between family functioning and symptoms of depression in preschool children. It was hypothesized that families who are less cohesive and less adaptable (more rigid) will have preschool children who show more symptoms of depression. Using PARC, PARLS, and TARC as predictors, neither family cohesion nor adaptability were significant predictors. Using PARC as the outcome variable and family cohesion and flexibility as the independent

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variables, the logistic regression analysis yielded p-values of .168 and .941, respectively. Using PARLS as the outcome variable and family cohesion and flexibility as the independent variables, the regression anaysis yielded p-values of .130 and .656, respectively. Using TARC as the outcome variable and family cohesion and flexibility as the independent variables, the regression analysis yielded p-values of .126 and .136, respectively. Using the teacher report of symptoms and the less stringent definition of at risk (TARLS), flexibility was a significant predictor with a p-value of .063 <.1.

This

indicates that more rigidity in families is a significant predictor of preschool children who show signs of being at risk for depression. Taking cohesive family functioning out of the equation and centering the flexibility score at 1, the results changed somewhat as the regression equation now yields a p value of .003 (<.01).

This further supported the hypothesis that more rigidity in family

functioning was a significant predictor of preschool children who show signs of being at risk for depression. Table 13 Logistic Regression Analysis for the relationship between Family Functioning and Depressive Symptoms using the Teacher Report and the Less Stringent Definition of At Risk Predictor B S.E. Df P Value Exp (B) Cohesive Family Functioning -.295 .188 1 .117 .745 Flexible Family Functioning -.242 .130 1 .063 .785 Table 14 Logistic Regression Analysis for the relationship between the Centered Variable of Flexible Family Functioning and Depressive Symptoms using the Teacher Report and the Less Stringent Definition of At Risk Predictor B S.E. df P Value Exp (B) Flexible Family Functioning (Centered) -.36 .122 1 .003 .694

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5 The data from this study partially supported the hypothesis that family functioning was related to depression in preschool children. Using the teacher report of symptoms, less flexibility in family functioning was a significant predictor of symptoms of depression in preschool children. ROC Curve A Receiver Operating Characteristic curve (ROC curve) is a graphical way to evaluate the predictive power of the logistic regression model. It summarizes proportions of correctly classified cases (true positives) versus the rate of misclassified events (false positives), informing about the overall model value (Peng & So, 2002, Understanding Statistics). An ROC curve was plotted to determine how well a combination of seven independent variables (authoritarian parenting, permissive parenting, laxness, over reactivity, hostility, cohesive family functioning, and flexible family functioning) predicted the “at risk of depression” status of preschoolers, which was determined according to the teacher report with the less stringent “at risk” definition. According to Figure 1, this logistic regression model performed fairly well in classifying students to their “at risk” category, judging by the separation between the model solid line and the no-predictors-model dotted line. The model dotted line indicates what the curve would look like if there was no prediction. The more separation there is between the model solid line and the no predictor dash line, the stronger the predictive power of the model. At the point where the false positive rate was at 20%, the true positive rate exceeded 80%. Thus, based on this model with seven predictors, for every five students classified

Familial Factors as “at risk”, four would be classified correctly, whereas one would be falsely misdiagnosed with “at risk of depression.” In contrast, when the ROC curve was plotted using the seven predictors and the TARC (teacher report and more clinical definition of at risk) the regression model does not perform as well in classifying students as at-risk or not at-risk. One can see from Figure 2, that there is more of a separation between the no predictor dotted line and the model solid line. In order to achieve the true positive rate of 80%, there will be more than 30% of false positives. This curve indicates less predictive power than the curve depicting the full model with with TARLS definition.

Figure 1 ROC Curve using the seven predictor (authoritarian parenting, permissive parenting, laxness, over reactivity, hostility, cohesive family functioning, and flexible family functioning) logistic regression model with the teacher report and the less stringent definition of at risk (TARLS) as the outcome variable

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0.6 0.4 0.0

0.2

True positive rate

0.8

1.0

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0.2

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0.8

1.0

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Figure 2 ROC Curve using the seven predictor (authoritarian parenting, permissive parenting, laxness, over reactivity, hostility, cohesive family functioning, and flexible family functioning) logistic regression model with the teacher report and the clinical definition of at risk (TARC) as the outcome variable

0.8 0.6 0.4 0.2 0.0

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Chapter 5 Discussion

1.0

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This chapter discusses the implications of the results obtained from the statistical analyses. Potential reasons for the findings and limitations of the study are presented. Educational implications for preschools are discussed. This study examined whether depressive symptoms exist in the preschool population and whether teachers and parents agree regarding the existence of the symptoms. It also examined the relationship between certain family-related factors and the existence of depressive symptoms in preschool children. The current study supports and extends existing research on preschoolers and depression by examining the variables associated with preschoolers who show signs of depression. Depressive Symptoms in Preschoolers Prior work, notably by Luby et al. (2002, 2003, 2004) found that preschool children show signs of being at risk for depression, describe what the disorder looks like in young children, and developed a brief and valid screening measure for detecting signs of depression in preschool children. The results from the current study show consistent findings with regard to the observation of symptoms of depression in preschool children. The screening measure developed by Luby et al. was administered to teachers and parents in a mainstream preschool. Parents reported that 35.1% of the sample displayed at least one symptom while teachers reported that 33.8% of the sample displayed at least one symptom of depression. Thus, parents and teachers can identify whether or not preschool students are at risk for developing depression by carefully observing and monitoring their behaviors. The ability to screen students in this way at such an early age is crucial and will have significant impact on treatment effectiveness. The earlier children can be

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identified as depressed, or even at risk for depression, the sooner they can be treated and the greater the likelihood of the treatment being effective. The abovementioned finding is significant because it is often difficult to identify internalizing disorders in young children; more often young children tend to “act out” their symptoms and so those externalizing disorders are reported more frequently. (Webster-Stratton, Kolpacoff, & Hollinsworth, 1998). This study indicates that it is possible to detect signs of internalizing disorders in young children. Agreement between Parents and Teachers The current study confirms previous findings of Achenbach, McConaughty and Howell (1987), Kashani, Holcomb, and Orvaschel (1986) and others that there is limited agreement between parents and teachers reports of symptoms. While parents and teachers agree more than chance, they are not reporting the same behaviors. The range of scores for the parent-completed PFCs was from zero to four, indicating that the largest number of symptoms reported by parents was four. The range of scores for the teachercompleted PFCs was zero to seven, with seven being the maximum number of symptoms reported. In the current study, many of the items on which parents and teachers disagreed were items regarding following rules and playing with other children which may be behaviors that are more readily observable in school. Additionally, parents may have difficulty objectively rating the child’s behavior and might be hesitant to report difficulties that their children are experiencing. This finding is important as it demonstrates that it is never sufficient to collect data regarding symptoms from only one source. We know that there is little agreement between parents and teachers regarding symptoms. Therefore, when assessing preschool

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children, it is important to collect information from multiple sources and recognize that there may be discrepancies between teacher and parent perspectives. Familial Factors Associated With Depression in Preschoolers There were no significant findings with regard to familial factors associated with the development of depression using the parent report (either clinical or less stringent definition of at risk) as the outcome variable. There were also no significant findings using teacher report and the clinical definition of at risk. The only analysis that yielded significant findings involved the teacher report and the less stringent definition of at risk (TARLS). The less stringent definition of at risk yielded the largest number of preschoolers who are at risk. In the parent report and less stringent definition of at risk (PARLS), 27 preschool children were considered at risk while 26 were considered at risk using the TARLS definition. This is compared to 7 and 13 preschoolers who were considered at risk according to the clinical definition. There were simply not enough data regarding children who are at risk using the clinical definition for any of the findings to have been significant. It is unclear why the analyses involving PARLS as the outcome variable did not yield significant findings despite the stronger power. It is possible that the subjectivity of the parents completing both the PFC as well as the parenting scales compromised the findings to some degree. While parents may have been somewhat comfortable reporting that their children display certain symptoms, they may not have been comfortable reporting on their own shortcomings as parents. Most of the parents in the sample are well educated and successful people who undoubtedly have a sense of what good parenting should look like. They may have responded to the questionnaires by reporting

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on what they know is the right way as opposed to what goes on in their household on a consistent basis. Therefore, the self-report format of these questionnaires may not have been ideal. Using the TARLS definition of at risk as the outcome variable, authoritarian parenting appears to be a significant predictor of the preschoolers who show signs of being at risk for depression. Authoritarian parenting refers to a parenting style that is detached and controlling as well as somewhat less warm than other parents. There is no negotiation between parents and children as parents are viewed as the absolute authority. Obedience is considered a virtue and punishments are usually punitive and forceful and are used when there is a conflict between the beliefs or actions of their child and their standard of acceptable conduct (Baumrind, 1989). Such parenting is a predictor for preschool children who show signs of being at risk for depression. This finding is consistent with that of Belden and Luby (2006) who investigated the relationship between preschool depression severity and parental emotional support and found that preschoolers who demonstrated higher depression severity scores experienced parenting strategies that were less emotionally supportive. While the authors do not refer to the term authoritarian parenting, they describe emotional support as a mother’s expression of positive regard, encouragement on novel tasks, a sense of when the child is in need of encouragement, and respecting the child’s need for autonomy. This description clearly describes the antithesis of authoritarian parenting that lacks a parent’s expression of positive regard, encouragement, and providing a sense of autonomy for the child. Rather, it is controlling and does not provide emotional warmth or encouragement.

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Additionally, using TARLS as the outcome variable, the lack of flexible family functioning is a predictor for preschool children who are at risk for developing depression. Family flexibility refers to the degree of change that occurs in terms of its leadership, role relationships, and relationship rules. The focus of flexibility is the quality and expression of leadership and organization, role relationship, and relationship rules and negotiations (Olson, Gorall & Tiesel, 2007). A system that functions at the low extremes of flexibility (i.e., being too rigid) is associated with preschoolers who are at risk for depression. This finding is consistent with that of Kashani et al. (1999) who compared anxious and depressed children and adolescents with respect to their perceptions of their family environments. One of the findings of this study was that poor family functioning and specifically low adaptability was observed in families of depressed children. The authoritarian parenting style and rigid family functioning are consistent in many ways. Controlling parents who demand obedience and do not allow for negotiation create a home environment which is rigid and inflexible. Such a parenting style fosters a home environment that does not adapt to new situations and circumstances in a flexible and functional way. Therefore, it is intuitive that those two variables are both significant predictors for preschoolers who are at risk for developing depression. Preschool children whose emotional needs are not met due to a lack of warmth, emotional support, and feelings of control and independence show signs of being at risk for depression later on in life. Children who spend most of their lives in rigid home environments that are not flexible to the needs of their children, external circumstances, or changes in their own family, are at risk. In order for children to thrive they need to be in a warm and

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emotionally supportive environment that has rules and boundaries but also allows for a healthy amount of autonomy and flexibility. The other parenting style hypothesized to be a predictor in the study was permissive parenting which refers to a parenting style that is noncontrolling, nondemanding, and relatively warm. Permissive parents are accepting of their children’s impulses, demands and desires and are non-punitive. They make few maturity demands. Permissive parents allow their children to regulate their own activities. Parents are present as resources for their children to use as they wish but are not there to alter their children’s current or future behavior. They do not demand that the attitudes or behaviors of their children meet externally defined standards (Baumrind, 1989). While research shows that such parenting is not ideal and will have implications for the way such children learn to function and navigate their social worlds (Baumrind, 1967; 1968), it may not be associated with depressed functioning in children. Findings of the current study demonstrate that depression in young children is associated with home environments that do not offer emotional support to children. Permissive parenting can be thought of as the antithesis of this. Emotional support is too plentiful in such homes, and children get whatever it is that they want or ask for. Their children’s emotions dictate what will happen in the household at any given moment. While such practice is not good parenting and lacks structure, rules, and appropriate boundaries, it was not associated with depression in children. Rather, depression in children was impacted by homes that lack emotional warmth and caring. The dysfunctional discipline practices of laxness, overreactivity and hostility were not found to be significant predictors of preschoolers who show signs of being at risk for

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depression. The literature review cited studies that examined the relationship between discipline techniques and signs of depression in school age children. Research was lacking regarding the relationship between parental discipline techniques and internal disorders in preschool children. According to this study, there was no significant relationship between parental dysfunctional discipline practices and signs of depression in preschool children. It is possible that this is due to the fact that parents do not typically begin disciplining their children until age 2 or 3 or even later in some cases. Therefore, the practices they use in this area may not have such a profound impact during the preschool years. While it may influence a child’s external behaviors, it may take longer for internalizing disorders to emerge as a result of such practices. However, as the children get older and the years of discipline increase, a relationship emerges between dysfunctional discipline practices and signs of depression in school-age children and adolescents. While it was hypothesized that two aspects of family functioning would be associated with depression, only adaptability was found to be a significant predictor and family cohesion was not. There was evidence that a lack of family cohesion is associated with older children diagnosed with depression but such evidence was not found with preschoolers. It is possible that preschool children are not as sensitive to the lack of cohesion in families as are older children and are, therefore, not as impacted by it. It is also possible the families are more cohesive in the early years when the children are younger. However, with time and different stages and challenges, families may have a tendency to become less cohesive so that school-age children and adolescents are more exposed to such family environments.

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While only two of the hypothesized predictors were found to be significantly related to symptoms of depression in preschool children, an additional analysis was conducted to determine if the combination of all the hypothesized variables had any impact on depression in preschoolers. A Receiver Operating Characteristic Curve (ROC Curve) was plotted to determine how well the familial factors predict the outcome of at-risk preschoolers according to the teacher report and the less stringent definition of at risk. The curve in Figure 1 depicts the full model, with authoritarian parenting, permissive parenting, laxness, over reactivity, hostility, cohesive family functioning, and flexible family functioning serving as predictors. Graphical model expression is important for evaluating model accuracy. For instance, if one were to use a spectrum of student background information captured by seven model predictors to assess whether a student is at risk of depression, it would be important to know the extent, to which this information is predictive of student mental health. This graphical summary goes beyond the traditional way of model testing, which primarily relies on the parameter p-values. In the current model, despite the fact that not all variables were found to be statistically significant at the alpha of p<.1, the ROC curve indicates that familial factors can work together to predict preschoolers who are at risk for depression. Based on this model, the true positive rate is counter-balanced by the low false positive rate, which is desirable for good predictions. Erikson’s Stages of Psychosocial Development Erikson’s theory can help explain why authoritarian parenting and rigid family functioning can impact symptoms of depression. In Erikson’s theory of psychosocial

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development, there are eight stages of development in which healthy developing human beings should pass from infancy to late adulthood. In each stage, the individual is confronted with and hopefully masters new conflicts. Each stage builds on the successful completion of earlier stages (Erikson & Erikson, 1981). When stages are not completed successfully, it can lead to future problems. When parental practices impact the child in a way so that the outcome of the conflict is the crisis as opposed to healthy adjustment, symptoms of psychopathology can emerge. When there is a lack of flexibility in the home and authoritarian parenting, especially during the earlier stages of development, maladaptive outcomes such as mistrust and shame and doubt can emerge. Trusting relationships and autonomy are not fostered in such home environments. Therefore, the child has lost the foundation with which to successfully navigate the remainder of the stages and depression can emerge. Risk Factors While Belden, Luby, and Spitznagel (2006) found that a family history of mood disorders and stressful life events were significant risk factors for depression in early childhood, the current study did not yield such findings. This may be due to the fact that the current study utilized a screening measure that identified students as at risk for depression. Belden, Luby, and Spitznagel (2006), on the other hand, conducted extensive interviews utilizing DSM-IV criteria for Major Depressive Disorder (MDD) to determine whether each child met diagnostic criteria for MDD. A family history of mood disorders and stressful life events were found to be risk factors for preschool children who met diagnostic criteria for MDD, but may not be significant risk factors for students who are merely at risk for developing depression later on in life.

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Limitations and Future Research There are several important limitations of the study. The first one is the size of the sample. While the sample size met the minimum requirements indicated by the power analysis, it was still not large enough to include a large number of cases in which children did demonstrate signs of being at risk for depression. In future studies, a larger sample should be included that would ensure enough events for all the various analyses to have as much power as possible. Additionally, it would be ideal for a future research study to use a case control design where data from a number of cases are collected that meet criteria for at risk as well as a number of cases that do not meet criteria for at risk. The two sets of cases should be matched in as many other ways possible. Analyzing the differences in the two sets of data will provide clear implications regarding the impacts of familial factors on the development of depression in young children. Another limitation of the study is the homogeneity of the sample. Most of the sample is comprised of children from middle to upper class families in Queens, Manhattan, and Nassau County. Almost one third of the sample (31.5%) is made up of homes with incomes at or above $100,000. Because it is known that there is a greater likelihood of psychopathology in children from low income homes (Keenan, Shaw, Walsh, Delliquadri, & Giovanelli, 1997) it would be preferable to include a more heterogeneous sample with regard to socioeconomic status. Additionally, 78.3% of the parents completing the surveys held an advanced degree. Therefore, the majority of the sample was very educated and whether or not they practice effective parenting techniques and create a balanced family environment, they

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undoubtedly have knowledge about what these things should look like. Some of their responses may have been a reflection of what they know is the more effective way of parenting as opposed to what their actual parenting practices and family environments are. Future research should include families whose parents have a more heterogeneous range of educational backgrounds. Future research may also want to decrease the subjectivity involved in responses. Perhaps there is a more objective way of collecting data about familial factors instead of utilizing a self-report. An observation technique or video recording of home environments may pose more logistical difficulties but may provide data that is more objective and accurate. Since the current study has shown that authoritarian parenting and rigid family functioning is associated with signs of depression in preschool children, future research should begin to explore potential interventions for these factors. Parent training programs that teach methods of authoritative parenting which have been used to effectively decrease negative externalizing behaviors may also be effective in decreasing symptoms of internalizing disorders. Programs that help parents create home environments that are balanced and adaptable may also be effective. Such programs can be used as prevention techniques for all parents as everyone would undoubtedly benefit. However, they can also be used once a child is identified as being at risk for depression to prevent symptoms from increasing in number and intensity and helping the child function more effectively before they meet criteria for a depressive disorder. Educational Implications

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Findings of the current study have important implications for preschools. First, it is of paramount importance for preschool administrators, teachers, assistants and all other school personnel including therapists, nurses, and bus drivers to be aware that preschoolers do exhibit signs of depression and these symptoms can be identified at an early age. Schools can determine whether or not children are at risk and if they are, they can seek help for such children right away to improve the prognosis. Schools can also work with parents and help them identify symptoms of depression in their children as well as facilitate treatment. Preschools can also offer programming for parents to teach appropriate parenting styles and family functioning. It is incumbent on school psychologists working in preschool settings to be aware that symptoms of depression can exist at such a young age and to know what symptoms look like so that they can work effectively with students, teachers and parents in this regard. School psychologists are in a position to develop awareness programs for parents and teachers as well as to foster a home-school relationship in which symptoms can be detected early and treated effectively. Finally, preschool teachers have the wonderful opportunity of modeling appropriate styles, techniques and environments for parents and caregivers. Preschool parents are often heavily involved in their child’s education, are often in the school building and are usually the ones transporting their children to and from school. Parents and caregivers can learn a tremendous amount by observing a teacher’s daily interactions with students, the way he or she handles transgressions as well as the nurturing but structured environment that is created within the four walls of the classroom. Conclusion

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The purpose of this study was to look at the relationship between symptoms of depression in preschool children and family factors such as parenting styles, discipline practices and family functioning. Results of the study indicate that preschoolers do demonstrate signs of depression, that parents and teachers do not always agree regarding whether or not certain symptoms exist and that there is a relationship between the parenting style of flexibility as well as rigid family functioning. The less flexible the parenting style and the more rigid the family functioning, the greater chance there is of preschoolers showing signs of depression. Additionally, it was found that familial factors can work together to predict preschoolers who are at risk for depression.

These findings

are important in that they demonstrate that early identification of at-risk preschoolers is a possibility and when identifying these youngsters, input from both parents and teachers is important. The findings also demonstrate that prevention and intervention programs can and should be developed which focus on aspects of parenting and family environment.

Dear Parent/Guardian, My name is Malka Ismach and I am student in the School Psychology specialization of the Ph.D. Program in Educational Psychology and Principal Investigator of a research study of the relationship between the way family members interact with each other and the existence of signs of depression in preschool children.

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This is a consent form for participation in the study described above, which has two components. First, I will ask you to complete a brief checklist regarding the typical behaviors of your child. This survey will take 1 or 2 minutes to complete. Several weeks later, I will ask that you complete three surveys regarding your parenting styles and practices and the family functioning in your home. Completing the surveys will take about 15-20 minutes of your time. Your responses will remain confidential and your name will not appear anywhere on the actual survey. A numerical code will be assigned to each child and only this code will appear on the response sheet. The only person with access to the numerical codes will be me. Again, your responses to all questions will remain confidential as I will not ask you to put your name on any of the response sheets. Second, your child’s teacher will complete the same brief checklist regarding the behaviors that he/she typically exhibits in school. Responses to these questions will remain confidential as well. Your child’s teacher will not be asked to put your child’s name on the actual response sheet. He/She will be given a cover sheet with the child’s name on it which he/she will be instructed to tear off prior to returning the checklist. The actual checklist will only contain the child’s assigned numerical code. The risks from participating in this study are no more than encountered in everyday life. The benefits of your participation are that as a result of the research, there will be more information available regarding the relationships between familial factors and signs of depression in young children. These benefits may help in the implementation of effective prevention programs for depression in young children. I am offering a $5.00 Amazon gift card to all participants, which will be distributed once the surveys are collected. If you are willing to complete the surveys via an e-mail based version, a $6.00 gift card will be offered. Taking part in this study is voluntary. You may choose not to take part. Your child’s standing at the school will in no way be affected by the decision to participate or not to participate. If you begin, you may stop at any time. By signing your name below, you are agreeing to participate in the study and a survey packet will be distributed to you in the near future. I agree to participate in this study. ____________________________ ____________ Participant’s signature Date __ I prefer paper based version __ I prefer e-mail based version Please provide e-mail address here: ___________________________________

I may publish results of the study, but names of people, or any identifying characteristics, will not be used in any of the publications. If you would like a copy of a summary of the study, please indicate that in the space provided below. Additionally, please provide me with your address below so that I can send you the gift card once the surveys are collected:

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Name: _______________________ Address: ___________________________________________ ___________________________________________ E-mail: _________________________________ ____ Yes, please send me a copy of the summary of the study If you have any questions about this research, you can contact me at (917) 373-4883 or [email protected], or my advisor, Dr. Marian Fish, at (212) 817-8290 or [email protected]. If you have questions about your rights as a participant in this study, you can contact Kay Powell, IRB Administrator, The Graduate Center/City University of New York, (212) 817-7525, [email protected]. Thank you for your participation in the study. Sincerely, ___________________ Malka Ismach, M.S. Ed Principal Investigator

Washington University In St. Louis

Early Emotional Development Program 18 South Kingshighway, Suite 101 St. Louis, MO 63108 314 – 286 – 2730

SCHOOL OF MEDICINE

Preschool Feelings Checklist Child’s Code ________ Gender F

M Date Checklist Completed ________________

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Name of Person Completing Checklist _________________________________ Relationship to Child _________________________________________ This Student: Is almost always interested in playing with other kids.

Y

N

Frequently appears sad or says he/she feels sad.

Y

N

Has a lot of trouble following simple directions or rules.

Y

N

Seems not to be as excited about play or activities as much as other kids. Y

N

Whines or cries a lot.

Y

N

Can’t pay attention to games or tasks for very long.

Y

N

Keeps to him/herself.

Y

N

Pretend plays about scary or sad things.

Y

N

Blames him/herself for things.

Y

N

Seems to lack confidence.

Y

N

Doesn’t react to things that other children his/her age find exciting or upsetting.

Y

N

Often seems to be very tired and has low energy.

Y

N

Seems to feel overly guilty.

Y

N

Failed to gain weight or has lost weight (without being on a diet.)

Y

N

Used to behave his/her age but now seems to act younger (for example, used to be potty trained but now soiling clothes).

Y

N

Seems more irritable or grouchy than other children his/her age.

Y

N

Luby J., Heffilfinger, A, Mratkotsky C, Hildebrand, T (1999), Preschool Feelings Checklist. St. Louis, MO: Washington University.

FACES IV David H. Olson, Ph.D., Dean M. Gorall, Ph.D., Judy W. Tiesel, Ph.D. Life Innovations P.O. Box 190 Minneapolis, MN 55440 Child’s Code: Parent Information:

Familial Factors Age: ______ Sex: M: ___ F: ___ Date: _________________________ Education: (a)___ Some High School (b) ___ Completed High School (c) ___ Some college (d)___ Completed College (e)___ Advanced Degree Income: (If relevant) (a) ___ Less than $10,000 (b)___ $10-20,000 (c) ___ $20-30,000 (d)___ $30-40,000 (e)___ $40-50,000 (f) ___ $50-60,000 (g)___ $60-80,000 (h)___ $80-100,000 (i) ___ $100,000 or more Ethnic Background: (check all that apply) (a)___ Asian American (d) ___ Hispanic/Latino (g) ___ White/Caucasian (b)___ Black/African American (e) ___ Mixed Race (c)___ Hawaiian or Pacific Islander (f) ___ Native American Current relationship status: (a)___ Single, never married (e) ___ Married, not first marriage (b)___ Single, divorced (f ) ___ Life-partnership (c)___ Single, widowed (g) ___ Living together (d)___ Married, first marriage (h) ___ Separated Current living arrangement: (a)___ Alone (d)___ With Others (b)___ With Parents (e)___ With Children (c)___ With Partner (f )___ With Partner and Children Use Current Family: If no current Family, use Family of Origin Family Structure: (a) ____ Two parents (biological) (d) ___ Two Parent (same sex) (b) ____ Two parents (step family) (e) ___ One Parent (c) ____ Two parents (adoptive) Family Member: (a)___ Father (b)___ Mother Number of Children in Family: (a) ____ None (b) ____ One (c) ___ Two (d) ____ Three (e) ____ Four (f) ____ Five (g) ___ Six or more Is there a family history of mood disorders (depression or anxiety) on either the maternal or paternal side of the family? Y N Has there been a stressful life event during the past year (e.g. loss of job, death of family member or close friend, birth of sibling, divorce etc.)? Y N Comments:__________________________ Child Information (Please provide information regarding the child attending preschool, through which you were recruited for this study): Sex of child: Male __ Female __ Age of Child: _____ Relationship to Child: Mom ___ Dad ___ Legal Guardian___ Number of Child in Birth Order of Family: Oldest ___ Youngest ___ Middle ___ If Child is a Middle Child: Number of children above child ____ Number of children below child ___

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Directions to Family Members: Family members should complete the instrument independently, not consulting or discussing their responses until they have been completed. Fill in the corresponding number in the space. 1 Strongly Disagree

2 Generally Disagree

3 Undecided

4 Generally Agree

5 Strongly Agree

1. Family members are involved in each others’ lives ___ 2. Our family tries new ways of dealing with problems ___ 3. We get along better with people outside our family than inside ___ 4. We spend too much time together ___ 5. There are strict consequences for breaking the rules in our family ___ 6. We never seem to get organized in our family ___ 7. Family members feel very close to each other ___ 8. Parents equally share leadership in our family ___ 9. Family members seem to avoid contact with each other when at home ___ 10. Family members feel pressured to spend most free time together ___ 11. There are clear consequences when a family member does something wrong ___ 12. It is hard to know who the leader is in our family ___ 13. Family members are supportive of each other during difficult times ___ 14. Discipline is fair in our family ___ 15. Family members know very little about the friends of other family members ___ 16. Family members are too dependent on each other ___ 17. Our family has a rule for almost every possible situation ___ 18. Things do not get done in our family ___ 19. Family members consult other family members on important decisions ___ 20. My family is able to adjust to change when necessary ___ 21. Family members are on their own when there is a problem to be solved ___ 22. Family members have little need for friends outside the family ___ 23. Our family is highly organized ___ 24. It is unclear who is responsible for things (chores, activities) in our family ___ 25. Family members like to spend some of their free time with each other ___ 26. We shift household responsibilities from person to person ___ 27. Our family seldom does things together ___ 28. We feel too connected to each other ___ 29. Our family becomes frustrated when there is a change in our plans or routines ___ 30. There is no leadership in our family ___ 31. Although family members have individual interests, they still participate in family activities ___ 32. We have clear rules and roles in our family ___ 33. Family members seldom depend on each other ___ 34. We resent family members doing things outside the family ___ 35. It is important to follow the rules in our family ___

Familial Factors

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36. Our family has a hard time keeping track of who does various household tasks ___ 37. Our family has a good balance of separateness and closeness ___ 38. When problems arise, we compromise ___ 39. Family members mainly operate independently ___ 40. Family members feel guilty if they want to spend time away from the family ___ 41. Once a decision is made, it is very difficult to modify that decision ___ 42. Our family feels hectic and disorganized ___ 1 Strongly Disagree

2 Generally Disagree

3 Undecided

4 Generally Agree

5 Strongly Agree

43. Family members are satisfied with how they communicate with each other ___ 44. Family members are very good listeners ___ 45. Family members express affection to each other ___ 46. Family members are able to ask each other for what they want ___ 47. Family members can calmly discuss problems with each other ___ 48. Family members discuss their ideas and beliefs with each other ___ 49. When family members ask questions of each other, they get honest answers ___ 50. Family members try to understand each other’s feelings ___ 51. When angry, family members seldom say negative things about each other ___ 52. Family members express their true feelings to each other ___ 1 Very Dissatisfied

2 Somewhat Dissatisfied

3 Generally Satisfied

4 Very Satisfied

5 Extremely Satisfied

How satisfied are you with: 53. The degree of closeness between family members ___ 54. Your family’s ability to cope with stress ___ 55. Your family’s ability to be flexible ___ 56. Your family’s ability to share positive experiences ___ 57. The quality of communication between family members ___ 58. Your family’s ability to resolve conflicts ___ 59. The amount of time you spend together as a family ___ 60. The way problems are discussed ___ 61. The fairness of criticism in your family ___ 62. Family members concern for each other ___

Parenting Scale D.S. Arnold, S.G. O’Leary, L.S. Wolff, and M.M. Acker

Please check appropriate boxes below: Instructions: At one time or another, all children misbehave or do things that could be harmful, that are “wrong,” or that parents don’t like. Examples include:

Familial Factors hitting someone forgetting homework having a tantrum

whining throwing food lying

not picking up toys refusing to go to bed wanting a cookie before dinner

94

running into the street arguing back coming home late

Parents have many different ways or styles of dealing with these types of problems. Below are items that describe some styles of parenting. For each item, fill in the circle that best describes your style of parenting during the past two months with your preschool child indicated on the cover page. SAMPLE ITEM: At meal time… I let my child decide how much to eat.

0---0------0---0---0---0

I decide how much my child eats.

1. When my child misbehaves… I do something right away. it later.

0---0---0---0---0---0---0

I do something about

2. Before I do something about a problem… I give my child several reminders or warnings.

0---0---0---0---0---0---0

I use only one reminder or warning.

3. When I’m upset or under stress… I am picky and on my picky child’s back.

0---0---0---0---0---0---0

I am no more than usual.

4. When I tell my child not to do something… I say very little.

0---0---0---0---0---0---0

I say a lot.

0---0---0---0---0---0---0

I can’t ignore pestering.

0---0---0---0---0---0---0

I don’t get into an argument.

0---0---0---0---0---0---0

I know I won’t actually do.

5. When my child pesters me… I can ignore the pestering. 6. When my child misbehaves… I usually get into a long argument with my child. 7. I threaten to do things that… I am sure I can carry out. 8. I am the kind of parent that…

Familial Factors sets limits on what my child is allowed to do.

95

0---0---0---0---0---0---0

lets my child do whatever he/she wants.

0---0---0---0---0---0---0

I keep my talks short and to the point.

0---0---0---0---0---0---0

I speak to my child calmly.

9. When my child misbehaves… I give my child a long lecture. 10. When my child misbehaves… I raise my voice or yell.

11. If saying “No” doesn’t work right away… I take some other kind of action.

0---0---0---0---0---0---0

I keep talking and try to get through to my child.

12. When I want my child to stop doing something… I firmly tell my child to stop. stop.

0---0---0---0---0---0---0

I coax or beg my child to

13. When my child is out of my sight… I often don’t know what my child is doing.

0---0---0---0---0---0---0

I always have a good idea of what my child is doing.

14. After there’s been a problem with my child… I often hold a grudge.

0---0---0---0---0---0---0

Things get back to normal quickly.

0---0---0---0---0---0---0

I let my child get away with a lot more.

15. When we’re not at home… I handle my child the way I do at home.

16. When my child does something I don’t like… I do something about it. every time it happens.

0---0---0---0---0---0---0

I often let itgo.

Familial Factors

96

17. When there is a problem with my child… Things build up and I do

0---0---0---0---0---0---0

Things don’t get out of hand.

things I don’t mean to do. 18. When my child misbehaves, I spank, slap, grab, or hit my child… never or rarely.

0---0---0---0---0---0---0

most of the time.

19. When my child doesn’t do what I ask… I often let it go or end

0---0---0---0---0---0---0

up doing it myself.

I take some other action.

20. When I give a fair threat or warning… I often don’t carry it out. 0---0---0---0---0---0---0

I always do what I said.

21. If saying “No” doesn’t work… I take some other

0---0---0---0---0---0---0

I offer my child something nice so he/she will behave.

0---0---0---0---0---0---0

I get so frustrated or angry that my child can see I’m upset.

0---0---0---0---0---0---0

I say “No” or take some other action.

kind of action. 22. When my child misbehaves… I handle it without getting upset.

23. When my child misbehaves… I make my child tell me why he/she did it.

24. If my child misbehaves and then acts sorry…

Familial Factors I handle the problem

0---0---0---0---0---0---0

I let it go that time

0---0---0---0---0---0---0

I almost always use bad language.

97

like I usually would. 25. When my child misbehaves… I rarely use bad language or curse.

26. When I say my child can’t do something… I let my child

0---0---0---0---0---0---0

I stick to what I said.

do it anyway. 27. When I have to handle a problem… I tell my child I’m sorry.

0---0---0---0---0---0---0

I don’t say I’m sorry about it.

28. When my child does something I don’t like, I insult my child, say mean things, or call my child names… never or rarely.

0---0---0---0---0---0---0

most of the time.

29. If my child talks back or complains when I handle a problem… I ignore the complaining and stick to what I said.

0---0---0---0---0---0---0

I give my child a talk about not complaining.

30. If my child gets upset when I say “No”… I back down and

0---0---0---0---0---0---0

I stick to what I said.

give in to my child.

Parenting Styles and Dimensions Questionnaire

Familial Factors

98

Robinson, C.C., Mandleco, B., Olsen, S.F., & Hart, C.H. (2001). The Parenting Styles and Dimensions Questionnaire (PSDQ). In B.F. Perlmutter, J. Touliatos & G.W. Holden (Eds.), Handbook of family measurement techniques: Volume 3. Instruments & Index (pp. 319 – 321). Thousand Oaks: Sage. For each of the following items, rate how often you exhibit this behavior with your preschool child: 1 – Never 2 – Once in a while 3 – About half of the time 4 – Very often 5 – Always

_____

1.

I am responsive to my child’s feelings and needs.

2.

I use physical punishment as a way of disciplining my child.

3.

I take my child’s desires into account before asking him/her to do something.

4.

When my child asks why he/she has to conform, I state: because I said so, or I am your parent and I want you to.

5.

I explain to my child how I feel about the child’s good and bad behavior.

6.

I spank when my child is disobedient.

7.

I encourage my child to talk about his/her troubles.

8.

I find it difficult to discipline my child.

9.

I encourage my child to freely express (himself)(herself) even when disagreeing with me.

_____

10. I punish by taking privileges away from my child with little if any explanations. 11. I emphasize the reasons for rules. 12. I give comfort and understanding when my child is upset. 13. I yell or shout when my child misbehaves. 14. I give praise when my child is good. 15. I give into my child when the child causes a commotion about something. 16. I explode in anger towards my child. 17. I threaten my child with punishment more often than actually giving it.

_____

18. I take into account my child’s preferences in making plans for the family.

Familial Factors

99

19. I grab my child when being disobedient. 20. I state punishments to my child and do not actually do them. 21. I show respect for my child’s opinions by encouraging my child to express them. 22. I allow my child to give input into family rules. 23. I scold and criticize to make my child improve. _____

24. I spoil my child. 25. I give my child reasons why rules should be obeyed. 26. I use threats as punishment with little or no justification. 27. I have warm and intimate times together with my child.

_____

28. I punish by putting my child off somewhere alone with little if any explanations. 29. I help my child to understand the impact of behavior by encouraging my child to talk about the consequences of his/her own actions.

_____

30. I scold or criticize when my child’s behavior doesn’t meet my expectations.

_____

31. I explain the consequences of my child’s behavior.

_____

32. I slap my child when the child misbehaves.

Table 15

Familial Factors Definitions of At-RiskDefinitions of At-Risk

Construct PARC

TARC

PARLS

Word Definition At-risk according to the

Measured As 3 or more symptoms

parent report and the

reported by parent

clinical definition of at risk At-risk according to the

3 or more symptoms

teacher report and the

reported by teacher

clinical definition of at risk At-risk according to the

1 or more symptoms

parent report and the less

reported by parent

stringent definition of at TARLS

risk At-risk according to the

1 or more symptoms

teacher report and the less

reported by teacher

stringent definition of at risk

References

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Achenbach, T.M., McConaughty, S.H., & Howell, C.T. (1987) Child/Adolescent behavioral and emotional problems: Implications of cross-informant correlations for situational specificity. Psychological Bulletin, 101, 2, 213–232. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, D.C.: Author. American Psychiatric Association (1987). Diagnostic and Statistical Manual of Mental Disorders (3rd ed. Revised). Washington, D.C.: Author. Arieti, S. & Bemporad, J.S. (1980). The psychological organization of depression. American Journal of Psychiatry, 137, 11, 1360–1365. Arnold, D.S., O’Leary, S.G., Wolff, L.S., & Acker, M.A. (1993). The Parenting Scale: A measure of dysfunctional parenting in discipline situations. Psychological Assessment, 5, 137–144. Asarnow, J.R., Goldstein, M.J., Tomspon, M., & Guthrie, D. (1993). One-year outcomes of depressive disorders in child psychiatric in-patients: Evaluation of the prognostic power of a brief measure of expressed emotion. Journal of Child Psychology and Psychiatry, 34, 2, 129–137. Baumrind, D. (1967). Socialization practices associated with dimensions of competence in preschool boys and girls. Child Development, 38, 2, 291–327. Baumrind, D. (1968). Authoritarian vs. authoritative parental control. Adolescent, 3, 255 272. Baumrind, D. (1971). Current patterns of parental authority. Developmental Psychology Monograph, 4, 1, 1-103. Baumrind, D. (1971). Harmonious parents and their preschool children. Developmental Psychology, 4, 1, 99-102. Baumrind, D. (1989). Rearing competent children. In W. Damon (Ed.), Child Development Today and Tomorrow, (pp. 349–378). San Francisco: Jossey-Bass. Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford. Belden, A.C. & Luby, J.C. (2006). Preschoolers’ depression severity and behaviors during dyadic interactions: The mediating role of parental support. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 2, 213–222. Buri, J.R., Louiselle, P.A., Misukanis, T.M., & Mueller, R.A. (1988). Effects of parental

Familial Factors

102

authoritarianism and authoritativeness on self-esteem. Personality and Social Psychology Bulletin, 14, 271–282. Craddock, A.E. (2001). Family system and family functioning: Circumplex model and FACES IV. Journal of Family Studies, 7, 1, 29–39. Denscombe, M. (2006). Web-based questionnaires and the mode effect. Social Science Computer Review, 24, 2, 246–254. Erikson, E.H., & Erikson J.H. (1981). On generativity and identity: From a conversation with Erik and Joan Erikson. Harvard Educational Review, 51, 249-269. Gallimore, M., & Kurdek, L.A. (1992). Parent depression and parent authoritative discipline as correlates of young adolescents’ depression. Journal of Early Adolescence, 12, 2, 187–196. Garber, J., Robinson, N.S., & Valentiner, D. (1997). The relation between parenting and adolescent depression: Self-worth a mediator. Journal of Adolescent Research, 12, 1, 12–33. Hartman, C.A., Rhee, S.H., Willcutt, E.G., & Pennington, B.F. (2007). Modeling rater disagreement for ADHD: Are parents or teachers biased? Journal of Abnormal Child Psychology, 35, 536–542. Jaffee, S.R., Moffitt, T.E., Caspi, A., Fombonne, E., Poulton, R., & Martin, J. (2002). Differences in early childhood risk factors for juvenile-onset and adult-onset depression. Archives of General Psychiatry, 59, 215–222. Junttila, N., Voeten, M., Kaukiainen, A., & Vauras, M. (2006). Multisource assessment of children’s social competence. Educational and Psychological Measurement, 66, 5, 874–895. Kashani, J.H., Allan, W.D., Dahlmeier, J.M., Rezvani, M., & Reid, J.C. (1995). An examination of family functioning utilizing the circumplex model in psychiatrically hospitalized children with depression. Journal of Affective Disorders, 35, 65–73. Kashani, J.H., Holcolmb, W.R., & Orvaschel, H. (1986). Depression and depressive symptoms in preschool children from the general population. American Journal of Psychiatry, 143, 1138-1143. Kashani, J.H. & Ray, J.S. (1983) Depressive symptoms among preschool-age children. Child Psychiatry and Human Development, 13, 233-238. Kashani, J.H., Ray, J.S., & Carlson, G.A. (1984). Depression and depression like states in preschool age children in a child development unit. American Journal of

Familial Factors

103

Psychiatry, 141, 11, 1397–1402. Kashani, J.H., Suarez, L., & Jones, M.R. (1999). Perceived family characteristics and differences between depressed and anxious children and adolescents. Journal of Affective Disorders, 52, 269–274. Kaslow, N.J., Tannenbaum, R.I., & Seligman, M.E.P. (1978). The KASTAN-R: A Children’s Attributional Style Questionnaire (KASTAN-R:CASQ). Unpublished manuscript. Department of Psychology, University of Pennsylvania, Philadelphia. Kovacs, M. (1983). The Children’s Depression Inventory: A self rated depression scale for school-aged youngsters. Unpublished manuscript, University of Pittsburg School of Medicine. Kovacs, M. (1985). The Children’s Depression Inventory (CDI). Psychopharmacology Bulletin, 21, 995–998. Kovacs, M. (1996). The course of childhood onset depressive disorders. Psychiatric Annals, 26, 6, 326–330. Keenan, K., Shaw, D.S., Walsh, B., Delliquadri, E. & Giovannelli, J. (1997) DSM-III-R disorders in preschool children from low-income families. Journal of the American Academy of Child And Adolescent Psychiatry, 36, 5, 620-627. Kovacs, M., & Beck, A.T. (1977). An empirical-clinical approach toward a definition of childhood depression. In J.G. Schulterbrandt & A. Raskin (Eds.), Depression in childhood. (pp. 1-25). New York: Raven. Laidra, K., Allik, J., Harro, M., Merenakk, L., & Harro, J. (2006). Agreement among adolescents, parents, and teachers on adolescent personality. Assessment, 13, 2, 187–196. Leve, L.D., Kim, H.K., & Pears, K.C. (2005) Childhood temperament and family environment as predictors of internalizing and externalizing trajectories from ages 5 to 17. Journal of Abnormal Child Psychology,33, 5, 505–520. Luby, J.L., Belden, A.C., & Spitznagel, E. (2006). Risk factors for preschool depression: the mediating role of early stressful life events. Journal of Child Psychology and Psychiatry, 47, 12, 1292–1298.

Luby, J.L., Heffelfinger, A., Koenig-McNaught, A.L., Brown, K., & Spitznagel, E.

Familial Factors

104

(2004) The Preschool Feelings Checklist: A brief and sensitive screening measure for depression in young children. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 6, 708-717. Luby, J.L., Heffelfinger, A.K., Mrakotsky, C., Hessler, M.J., Brown, T.H., & Hilderbrand, T. (2002). Preschool major depressive disorder: preliminary validation for developmentally modified DSM-IV criteria. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 8, 928-938. 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. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 3, 340-349. Milner, J.S. The Child Abuse Potential Inventory: Manual: (2nd ed.). Webster, NC: psyctec. Mol, L.A., De Wit, C.A.M., & De Bruyn, E.E.J (2000). Depression and play in early childhood: Play behavior of depressed and nondepressed 3 to 6 year olds in various play situations. Journal of Emotional and Behavioral Disorders, 8, 249– 260. Normura, Y., Wickramaratne, P.J., Warner, V., & Weissman, M. (2002). Family discord, parental depression, and psychopathology in offspring: Ten year follow up. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 402409. O’Leary, S.G. (1995). Parental discipline mistakes. Current Directions in Psychological Science, 11–13. Olson, D.H., & Gorall, D.M. (2003). Circumplex model of marital and family systems. In F. Walsh (Ed.), Normal Family Processes: Growing Diversity and Complexity, 3rd ed. (pp. 514-544). Olson, Gorall, D.M. & Tiesel, J.W. (2007). FACES IV and the circumplex model: Validation study. Retrieved February 20, 2008, from FACES IV, Family Adaptability and Cohesion Evaluation Scale, Web site, http://www.facesiv.com/secure/. Peng, C. & So, T. (2002). Logistic regression analysis and reporting: A primer. Understanding Statistics, 1, 31-70. Pfiffner, L.J., & O’Leary, S.G. (1989). Effects of maternal discipline and nurturance on toddlers’ behaviors and affect. Journal of Abnormal Child Psychology, 17, 527– 540. Reynolds, C.R., & Richmond, B.O. (1985). Revised Children Manifest Anxiety Scale

Familial Factors

105

(CMAS) Manual. Los Angeles: Western Psychological Services. Rhoades, K.A., & O’Leary, S.G. (2007). Factor structure and validity of the parenting scale. Journal of Clinical Child and Adolescent Psychology, 36, 2, 137 – 146. Robinson, C.C., Mandleco, B., Frost Olsen, S., & Hart, C.H. (1995). Authoritative, authoritarian, and permissive parenting practices: Development of a new measure. Psychological Reports, 77, 819–830. Rodriguez, C.M. (2003). Parental discipline and abuse potential affects on child depression, anxiety and attributions. Journal of Marriage and Family, 65, 809817. Rodriguez, C.M. (2006). Attributional style as a mediator between parental abuse risk and child internalizing symptomatology. Child Maltreatment, 11, 2, 121–130. Sander, J.B., & McCarty, C.A. (2005). Youth depression in the family context: Familial risk factors and models of treatment. Clinical Child and Family Psychology Review ,8, 3, 203–219. Shiner, R.L. (1998). Family environments of adolescents with lifetime depression: Associations with maternal depression. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 11, 1152–1160. Stark, K.D. (1990). The treatment of depression during childhood: A school based program. New York: Guilford. Stark, K.D., Humphrey, L.L., Crook, K., & Lewis, K. (1990). Perceived family environments of depressed and anxious children: Child’s and maternal figure’s perspectives. Journal of Abnormal Child Psychology, 18, 527-547. Sullivan, J., & Belden, A.C. (2006). An observational analysis of behavior in depressed preschoolers: Further validation of early-onset depression. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 2, 203–212. Walsh, F. (2003). Changing families in a changing world: Reconstructing family normality. In F. Walsh (Ed.), Normal Family Processes: Growing Diversity and Complexity, 3rd ed. (pp. 3-26). Webster-Stratton, C., Kolpacoff, M., & Hollinsworth, T. (1988). Self-administered videotape therapy for families with conduct-problem children: Comparison with two cost-effective treatments and a control group. Journal of consulting and clinical psychology, 56, 558–566. Zito, J., Safer, D., DosReis, S., Gardner, J., Boles, M., & Lynch, F. (2000). Trends in the

Familial Factors prescribing of psychotropic medications to preschoolers. Journal of the American Medical Association, 283, 1025–1030.

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