Treating Preschoolers With Psychiatric Disorders

In 2000, in an editorial published in the Journal of the American Medical Association, Harvard psychiatrist Joseph Coyle warned that psychiatrists were prescribing medications to children as a quick fix, rather than offering the type of multidisciplinary therapy that improves outcomes. The same year, the American Academy of Child and Adolescent Psychiatry (AACAP) recommended that guidelines be developed for drug treatment of preschoolers with psychiatric disorders.

As a first step in that direction, a working group of experts from 12 medical schools and institutions, convened by the AACAP, has published treatment algorithms for nine mental health conditions diagnosed in young children.

One of the reasons the algorithms took so long to develop is that treatment decisions, which are always complicated, are especially difficult when it comes to preschoolers. Children mature at different rates, so it's sometimes hard to distinguish normal variations in temperament or development from burgeoning mental health problems. And while any medication involves risks in preschoolers, not treating psychiatric disorders also has consequences—which means that clinicians and parents face a delicate balancing act in deciding upon treatment.

Prescribing patterns and trends

The study Dr. Coyle was commenting about, which is still cited frequently, was conducted by a team of researchers from the University of Maryland, Johns Hopkins University, and Kaiser Permanente. They analyzed outpatient prescription records at two Medicaid programs and a health maintenance organization. From 1991 to 1995, the number of psychiatric medications prescribed to children ages 2 to 4 increased dramatically. Prescriptions for stimulants tripled during this period in two of the programs, for example, while antidepressant prescriptions doubled in two programs.

Other studies provide additional evidence that psychiatric prescriptions for preschoolers rose during the 1990s. For example, one study of prescribing practices between 1993 and 1997 documented a 10-fold increase in the number of prescriptions for selective serotonin reuptake inhibitors (SSRIs) for children ages 5 and younger in the United States. Another study based on Michigan Medicaid claims reported that nearly 60 percent of children ages 3 and younger who were diagnosed with attention deficit hyperactivity disorder were prescribed at least one medication, while only 25 percent received psychotherapy.