By publishing the algorithms, Gleason said the PPWG seeks to encourage further research. Studies looking at the long-term effects of psycho- therapeutic medications in young children are desperately needed, she noted, as well as independently funded studies on all areas of early childhood mental health problems, including assessment and treatment.
Because of her interest in identification of young children with psychiatric problems, Gleason has developed the Early Childhood Screening Assessment, a brief screen for social, emotional, and behavioral problems in children aged 18 to 60 months. She has tested it in primary care settings in Louisiana and Rhode Island.Focus on primary care
Several studies indicate that primary care physicians are the main prescribers of psychiatric medications in young children, according to Gleason. Because there is a severe shortage of pediatric mental health providers and, in particular, a shortage of child psychiatrists in many parts of the country, primary care providers are often left to care for young children with psychiatric disorders, she pointed out.
Massachusetts is one state that has begun multiple efforts to assist pediatric primary care providers through the Massachusetts Child Psychiatry Access Project (MCPAP) and the Children's Behavioral Health Initiative of the Executive Office of Health and Human Services and MassHealth. MassHealth encompasses the state's Medicaid program and the State Children's Health Insurance Plan.
Massachusetts' Behavioral Health Partnership, a ValueOptions company responsible for mental health and substance abuse services for MassHealth recipients, helped develop the MCPAP. The MCPAP consists of 6 mental health teams, including child psychiatrists and therapists, working under the supervision of child psychiatry divisions of academic medical centers across the state. Each team seeks to enroll all of the pediatric primary care practices in its catchment area. Once enrolled, the primary care providers have access to several services for their patients regardless of insurance status, including informal telephone consultations, timely psychiatric diagnostic evaluations, and interim psychotherapy.
The MCPAP "stands ready to help any primary care provider in the state who has a question about the need for psychotherapeutic medication with any child, especially one less than 5 years of age," said John Straus, MD, Behavioral Health Partnership's vice president for medical affairs.
On December 31, 2007, MassHealth also started requiring that providers use standardized behavioral health screening as part of the Early Periodic Screening, Diagnosis, and Treatment services. Information on MassHealth-approved standardized behavioral health screening tools for patients younger than 21 years as well as a list of resources for referring those with positive screen results is available at the MCPAP Web site, http://www. mcpap.org/.Monitoring efforts
Following the death of a 4-year-old girl from an overdose of psychiatric drugs in 2006, Massachusetts' health officials established an early warning system to identify preschoolers who might be receiving excessive or inappropriate medication for their psychiatric illnesses.
Under the system, managed care organizations, such as the Massachusetts Behavioral Health Partnership, are reviewing prescription records for all children younger than 5 years whose mental health treatment is paid for by MassHealth. Straus said that in the first quarter of 2007, Massachusetts Behavioral Health Partnership identified 137 preschoolers receiving at least one psychotherapeutic medication; 18 were receiving an antipsychotic and 8 were receiving 3 or more psychotherapeutic medications.
Straus believes the monitoring of psychotherapeutic medications for preschoolers has resulted in a decrease in prescribing. In the most recent quarter (July through September of 2007), 71 of 32,722 children younger than 5 years were receiving at least one psychotherapeutic medication; 9 were receiving antipsychotics and 3 were receiving 3 or more psychotherapeutic medications.
"We are working with prescribers to ensure that treatment is based on behaviors observed by individuals other than the family, such as day-care providers, and we are also working to ensure that prescribers are fully using nonmedication modalities," he said.
Other states, such as Louisiana, also have early-warning programs, Gleason continued. She said that she finds such programs useful because they provide extra levels of risk assessment and consideration for a vulnerable population.
For Gleason, however, the most important goal of all the efforts described is that "these children have access to comprehensive assessments and safe, effective, evidence-supported treatment that would allow them to develop in a healthy way."