The understanding of internalizing disorders in young children has lagged behind advances in our understanding of other areas of psychopathology in this age group. One factor contributing to the relatively slower progress in this domain might be that, as a group, internalizing disorders tend to be viewed as less problematic by parents, teachers, and other caregivers. This may be related to the fact that such disorders are most often characterized by quiet, internal distress sometimes referred to as "intropunitive," rather than overtly, socially negative, or disruptive behavior. Such features may also make these disorders more difficult to detect in the very young who have less well-developed verbal skills in general and specifically an even more limited capacity to describe internal feeling states.Despite these impediments, a major shift, and advance in this area, has been the study of more discrete differentiated disorders instead of lumping of all internalizing symptoms into one broad category of the two-dimensional internalizing versus externalizing taxonomy of childhood psychopathology. This shift in the conceptualization and categorization of psychopathology, although still an area of considerable debate, has allowed systematic investigation of diagnostic nosologic classifications used in older children and adults and has contributed to our understanding of the differentiation between mood and anxiety disorders in early childhood and differences between preschoolers and school-age children. In older children, some investigations have provided data that dispute this distinction, suggesting that some anxiety disorders (eg, generalized anxiety disorder) should be categorized with major depressive disorder (MDD).1 , 2 However, several investigations in young children have supported a meaningful distinction between mood and anxiety disorders in general.3 , 4 The question of whether to lump or split mood and anxiety disorders, and how to split them in early childhood, remains a relatively empirically unexplored area in need of further study.The shift to a categorical and more differentiated view of mood and anxiety disorders in early childhood has also created a gap in our ability to link this newer literature to the large and rich older body of literature on young children that used these broader dimensional measures of psychopathology.5 -7 As in other areas of young child psychopathology, the recent development of age-appropriate measures of psychopathology has catalyzed this area of research, with findings moving beyond the traditional two-dimensional taxonomy as offered by the widely used Child Behavior Checklist (CBCL). In addition to the

Context Childhood depression is a serious and relapsing psychiatric disorder. However, to date studies have focused mostly on children aged 6 years and older. Validation for depression in preschool children has been provided by 2 independent study samples. While several studies have demonstrated stability and poor outcomes of internalizing symptoms in preschoolers, there has not yet been longitudinal data available to inform the course of preschool depression and whether it shows homotypic continuity into early childhood. Objective To examine the 24-month course of preschool depression and whether it showed homotypic vs heterotypic continuity or was a developmentally transient phenomenon. Design Blindly rated, prospective, 24-month, longitudinal follow-up study. Setting Community sites. Patients Three hundred six preschoolers aged 3 to 6 years recruited from community sites and oversampled for symptoms of depression. Main Outcome Measure Recurrence/stability of depression and predictors of course. Results Preschoolers with depression at baseline had the highest likelihood of subsequent depression 12 and/or 24 months later compared with preschoolers with no baseline disorder and with those who had other psychiatric disorders. Preschoolers with depression at baseline were more likely to have later depression rather than other psychiatric disorders. Findings from a logistic regression analysis indicated that when controlling for demographic variables, risk factors, and comorbid disorders, depression during the preschool period and family history of affective disorders were the most robust and significant predictors of later depression. Conclusions Preschool depression, similar to childhood depression, is not a developmentally transient syndrome but rather shows chronicity and/or recurrence. Homotypic continuity of preschool MDD during a 24-month period was found. These results underscore the clinical and public health importance of identification of depression as early as preschool. Further follow-up of preschoolers with depression is warranted to inform the longitudinal course throughout childhood.

Objective: The present study examined the course of ADHD over 24 months in a preschool population. Method: n = 48 preschoolers with ADHD, aged 3.0-5.11 years, subjects included in a larger sample of preschoolers with depression and other disorders (n = 306) were comprehensively assessed at 3 annual time points over 24 months in a prospective longitudinal follow-up study. Results: Baseline diagnoses of preschool MDD, ODD, and CD were risk factors for ADHD diagnosis over 24 months in this preschool population. Among older preschoolers and after controlling for key demographic variables, ADHD predicted later ADHD diagnosis, along with other significant risk factors -baseline diagnosis of ODD, and/or family history of disruptive disorders, and stressful life events. Conclusions: ADHD showed greater homotypic continuity at later rather than earlier preschool ages. Other disruptive comorbidities also emerged as key predictors of stable ADHD course. Study findings may help to inform which preschool ADHD populations to target for early intervention. Larger sample sizes are needed to confirm these findings and to further explore the stability, course, and predictors of outcome of preschool onset ADHD.

IntroductionDespite significant progress over the last decade in the characterization and validation of numerous forms of preschool psychopathology, the area of bipolar disorder remains perhaps the most controversial. The difficulty of distinguishing normative extremes in mood intensity and lability known to characterize early childhood from those emotions and behaviors that cross the threshold into clinically significant psychopathology is a central issue. Further, another fundamental problem is the ongoing lack of clarity about the diagnostic criteria and validity of the diagnosis in older children as phenotypes in older children are a key source for the downward extension of nosologies in the preschool period. Along this line, contrasting definitions of bipolar disorder in children and adolescents have been proposed and tested. This definitional debate remains a salient issue in the existing literature. Questions about the basic validity of the diagnosis in children, its temporal features and continuity into adulthood, as well as treatment are only a few key areas debated in both the psychiatric literature and in public forums [1].While a growing body of empirical research is available to inform these issues in older children, studies in preschoolers remain scarce. Along this line, the studies that are available in preschoolers with suspected bipolar disorder are limited predominantly to case reports and chart reviews. There is a smaller body of systematic literature but many of these studies are limited by retrospective designs with small sample size. More recently, for example Danielyan et al [2] reviewed 26 outpatient charts of preschoolers referred to a psychiatric clinic and found high recovery and relapse rates. Similarly, Ferreira Maia et al [3] also retrospectively reviewed outpatient charts in a mood disorders clinic and found preschoolers to have classic symptoms of mania, but the reports were also limited by the small sample size of preschoolers who met DSMIV bipolar disorder criteria (n=8). Classic features of mania such as elation, grandiosity, psychomotor agitation and decreased need for sleep were also observed by Dilsaver & Akiskal [4] over two years and a family history notable for affective illness was described. Three presumptive cases of preschool bipolar disorder were also described as having classic symptoms or "cardinal features" by Luby et al [5], but these cases were from a specialty preschool mood disorders clinic and with potentially limited generalizability. One larger systematic investigation of preschoolers in a community-based sample investigated the presence of age adjusted mania symptoms [6]. Ironically, there is a somewhat larger body of literature on treatment in preschoolers although this is limited to case reports and retrospective chart reviews with only a couple of open label investigations available to date.

Home visitation (HV) interventions may hold promise to improve parenting and prevent child maltreatment recidivism in families reported to child protective services (CPS) with young children, but this has rarely been studied. Findings are presented from an 18-month randomized controlled trial in which intact families ( N = 122) with at least one CPS report were provided with a facilitated connection to a paraprofessional evidence-based HV program or usual care services from child protection. Results are reported for changes in maternal stress, depression, and social support outcomes and repeat reports to CPS. No significant changes were found in maternal outcomes by group. Among nondepressed mothers or families without multiple CPS reports prior to study enrollment, HV was associated with a significantly lower likelihood of CPS report recidivism. These results indicate potential for HV to prevent maltreatment recidivism but suggest that higher intensity intervention is warranted for mothers exhibiting significant depressive symptoms or families with extensive CPS histories.