Administration of methylphenidate(Drug information on methylphenidate) to young rodents resulted in alterations in neurotransmitter receptor densities, particularly dopamine(Drug information on dopamine).22,23 Behavioral studies have demonstrated alterations in motivation, reward pathways, and spatial memory in juvenile normal rodents following early exposure.24 However, caution is warranted when extrapolating these data to children with psychiatric diagnoses such as ADHD. In these children, there is increasing evidence of neurodevelopmental differences independently associated with psychiatric diagnoses. When 2 medications are combined, the risks to the developing brain likely increase exponentially, with unknown impacts on neurodevelopment. Thus, extreme caution is warranted with the use of multiple psychotropic medications because of the limited evidence base for efficacy of single medications in young children and the complete lack of efficacy for multiple medications in young children.25, 26
Ethical implications: a call for change
The ethical implications of the current state of use of psychotropic medications in young children are many and represent a call to arms. The key ethical principles of nonmaleficence, justice, and beneficence are all relevant to this discussion.27 As physicians, we began our service to patients with the Hippocratic Oath primum non nocere (at first do no harm). Given the lack of efficacy data for the use of psychotropic medications in children and the significant known adverse effects, the principle of nonmaleficence is applicable.
However, the disconnect between the implementation of evidence-based interventions and the elevated use of psychotropic agents high-lights the principles of beneficence and justice. Justice requires that all young children be able to access effective and appropriate clinical care. Currently, inadequate insurance reimbursement for developmentally appropriate assessment of and psychotherapy for young children,17 the critical shortage of mental health providers trained in the care of young children, the absence of federal support for the needed intervention research, and the lack of funding to implement the existing evidence-based treatments all conspire against justice in the mental health treatment of very young children. Specifically, clinicians who serve young children do so with substantially less information, fewer proven treatment options, and more limited access to psychotherapeutic first-line treatments than those who serve older children and adults. The increasing evidence that the use of atypical antipsychotics and other psychotropic medications is occurring at higher rates in certain ethnic populations and in children in the child welfare system highlights a failure to apply the principle of justice that demands that all groups be equally treated.14,28
Consideration of beneficence in mental health treatment of young children is critical. Families that have children with significant mental health issues are in crisis. Often they have struggled for years before seeking assistance. Withholding all medications in young children is in direct opposition to the principle of beneficence. Beneficence requires that clinicians use their best clinical judgment, incorporating parents’ goals and values and the current evidence, to alleviate suffering, enhance safety, and balance the potential benefits with the risks of untreated or undertreated psychopathology. Until we have sufficient evidence, these decisions will continue to be fraught with uncertainty. The issue is controversial: some suggest that psychopharmacological agents may be neuroprotective in children with mental illness, while others view the use of medications in preschoolers as universally unacceptable. To date, we do not have the data to resolve this controversy.