Concern about the rising number of preschool-age children receiving atypical antipsychotics, α-agonists, or other psychotherapeutic medications recently motivated pediatric mental health professionals to develop best-practice algorithms for psycho-pharmacological treatment of young children. It also prompted some states and mental health providers to initiate medication monitoring and consultation programs.
In a 7-state medicaid study, Zito and colleagues1 found that 2.3% of 274,518 continuously enrolled preschoolers received one or more psychotherapeutic medications in 2001. The prevalence was 0.96% for those aged 2 years, 2.08% at age 3 years, and 3.99% at age 4 years. The study also showed an estimated doubling of usage of some medications in a 6-year period.
To address concerns about the growing use of psychiatric medications in preschoolers, the Preschool Psychopharmacology Working Group (PPWG) of the American Academy of Child and Adolescent Psychiatry developed algorithms based on extensive literature reviews, clinical experience, and expert consensus.2
"Our first goal was to review the current state of the preschool psychiatric field for clinicians, and the second... was to provide a set of guidelines to help clinicians," explained lead author Mary Margaret Gleason, MD, of the Bradley Hasbro Research Center and the Tulane Institute of Infant and Early Childhood Mental Health, and clinical assistant professor of psychiatry at Brown University.
The algorithms, Gleason emphasized, address treatment of young children with severe psychiatric symptoms who meet DSM-IV criteria. Such children include those who have been expelled from child care facilities multiple times, those who are unable to interact with other children, or those who are unable to develop trusting relationships with their parents because of their psychiatric symptoms, as well as those who are so anxious that they will not talk to anyone outside their immediate family.
In their report, Gleason and her coauthors caution that preschool psychopathology and treatment must be considered within developmental, clinical, regulatory, and ethical contexts. For example, the impact of early and/or prolonged exposure to psychotherapeutic medications during the preschool period has not been systematically studied, but research highlights the sensitivity of the developing brain. What's more, few psychotherapeutic medications are approved for use in pediatric populations; most are used off-label.
To provide guidance, the PPWG established algorithms for attention-deficit/hyperactivity disorder; disruptive behavior disorders; major depressive disorder; bipolar disorder; anxiety disorders, such as separation anxiety disorder, selective mutism and specific phobia; posttraumatic stress disorder (PTSD); obsessive-compulsive disorder; pervasive developmental disorders, including autism; and primary sleep disorders.
The first step in each algorithm is a comprehensive diagnostic assessment of the child's emotional and behavioral symptoms, relationship patterns, medical and developmental history, and psychiatric status.
"The ingredients that are most useful for an assessment," Gleason said, "are the multiples—multiple visits, information from multiple caregivers, and using multiple modalities, including interview, informal observations, and structured interaction assessments. Young children are sensitive to context and don't have the ability to describe their internal emotional state in a way that an adult might."
If a clinician is considering pharmacological treatment for a young child, Gleason said her first recommendation is "to assess the adequacy of interventions that have already been tried and to determine whether there are other psychotherapeutic or other nonpharmacological interventions that could help reduce the symptoms."
Such psychotherapeutic interventions can include behavioral therapy, cognitive-behavioral therapy, parent management training, or dynamic psychotherapy. Should these prove ineffective, Gleason offered further recommendations, which include discussing with parents the level of evidence supporting the recommended pharmacological treatment and "really go[ing] through the informed consent process in a meticulous way." The algorithms article includes published preschool psychopharmacology studies for specific diagnoses.
Clinicians and parents should start by discussing the target symptoms expected to be addressed by the medication, and the need for discontinuation trials. Such trials permit reassessment of the child's underlying symptoms off medication after a period when developmental, contextual, and therapeutic processes may have impacted the child's psychiatric presentation, according to Gleason.
"We want to know whether the child's current psychiatric status warrants the medication being prescribed," she added.
Gleason also urged clinicians to continue obtaining information from caregivers and to monitor symptoms with structured instruments throughout the treatment process. Some structured tools useful for assessing and monitoring young children, such as the Preschool Feelings Checklist for depression and the Child Behavior Checklist PTSD scale, are discussed in the algorithms article.
However, "nothing takes the place of careful clinical judgment in [treating] young children," Gleason added. Even though the algorithms discuss psychopharmacological interventions, they are not intended to promote the use of medications, she said. "We anticipate that application of these guidelines may actually reduce the number of preschoolers who are taking psychiatric drugs," she added. The PTSD algorithm, for instance, does not even include the use of psychopharmacological interventions.
We looked for randomized controlled trials on pharmacological treatments to help guide us, Gleason said, but there were none in preschool PTSD and none in child and adolescent PTSD. The PPWG felt that extrapolating from adult trials to preschoolers was too great a leap.