Psychiatric Treatment for Preschoolers

Several studies have confirmed what many observers have suspected: The number of medications prescribed to children ages two to four to treat psychiatric disorders has increased dramatically in the past two decades.

Consider the following:

• In one study, a team of researchers from the University of Maryland, Johns Hopkins University and Kaiser Permanente 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 two to four increased dramatically. Prescriptions for stimulants tripled during this period in two of the programs, while antidepressant prescriptions doubled in two programs.

• Another study from the mid-1990s documented a 10-fold increase in the number of prescriptions for selective serotonin reuptake inhibitor (SSRI) antidepressants for children ages five and younger in the United States.

• A study based on Michigan Medicaid claims reported that nearly 60 percent of children ages three and younger who were diagnosed with attention deficit hyperactivity disorder were prescribed at least one medication, while only 25 percent received psychotherapy.

Partly in response to these trends, The American Academy of Child and Adolescent Psychiatry (AACAP) has developed and published guidelines for evaluating and treating nine mental health conditions diagnosed in young children. Some of their recommendations are summarized below.

A delicate balance

As any parent can attest, the preschool years are a time of tremendous brain development. Between the ages of two and five, children learn to talk, develop hand and eye coordination, and learn how to interact with others.

Brain changes underlie these developments. The number of synapses (connections between brain cells) and neurotransmitter receptors reach their peak at age three, while the brain's metabolic rate peaks between ages three and four.

Clinicians and parents thus face a delicate balancing act when it comes to treating psychiatric disorders, especially in the youngest children. There are risks associated with giving medications, because we don't know exactly what effects psychiatric drugs may have on the developing brain. But there can also be significant risk from not giving medications, because mental disorders also have a negative effect on brain development.

Mental disorders can lead to impaired peer and family relationships and poor school performance. Untreated childhood problems may give way to continuing mental health problems when the child when he or she grows up. And there is evidence that many lifelong psychiatric disorders begin early. A Harvard study published in 2005 estimated that half of all disorders that meet standard criteria for a diagnosis start by age 14.

There is no simple way to tell a normal variations in temperament or development from the beginnings of a mental health problem. In practical terms, a child's problems may require medication to ease suffering and help him or her develop normally. Medications may be worth trying especially if non-drug treatments haven't been effective.

Applying the guidelines to three disorders

Here is a brief summary of what AACAP suggested for attention deficit disorder, anxiety disorders and developmental disorders.

Attention deficit hyperactivity disorder

Experts recommend a thorough evaluation to define the problem. This requires reports from parents, teachers and child care providers so that the clinician can assess the child's symptoms in multiple settings. Parents can be taught the best ways to help their children. Whether a child needs medication or not, he or she will probably do better if the parents become comfortable with skills for setting limits and rewarding positive behavior. If parent guidance and psychotherapy are not sufficient to control symptoms, AACAP recommends trying methylphenidate (Ritalin) for six months. At that time, the doctor can stop the medication to see if the child still needs it, either for controlling symptoms or functioning in school. Numerous other medications are available if methylphenidate does not work.

Anxiety disorders (separation anxiety, selective mutism, specific phobias)

Again, experts recommend that, in addition to making their own observations, clinicians will have an easier time defining the problem if they can get information from parents, teachers and other caregivers. Sometimes formal rating scales and questionnaires are used during the evaluation. The clinician should also remain alert to co-existing problems, like depression or behavior problems. Available research suggests that psychotherapy may teach a child to better control behavior while also improving self-esteem, so AACAP recommends trying it for at least 12 weeks to see if it is effective. If psychotherapy does not provide relief and anxiety symptoms continue to impair the child's functioning, a low dose of fluoxetine (Prozac) may be given. After six to nine months, the clinician can stop fluoxetine to see if it is needed any longer.

Developmental disorders, such as autism

AACAP recommends formal intelligence tests, plus tests of hearing and language skills. They suggest using instruments such as the Childhood Autism Rating Scale or the Aberrant Behavior Checklist to evaluate the child. Before thinking about medication, a team of helpers may be necessary to help a child improve language skills, enhance social development, and reduce repetitive behavior and aggression. Medication may eventually be necessary for children who have severe behavioral problems that interfere with functioning. As with anxiety disorders, the clinician can stop the medication after about six months to see whether it is still necessary.

Maximize help and minimize harm

The AACAP also provided some principles that are useful for evaluating and treating any problem that comes up in a young child.

• Address diagnostic challenges. Preschoolers vary in terms of development, personality, and communication skills. Diagnostic criteria for adults and older children may not be relevant to preschoolers. To address these challenges, the AACAP working group advises making a diagnosis only after getting information from multiple sources (the child, parents, teachers, other clinicians) over multiple visits.

• Track symptoms and impairment. Before starting any treatment, develop a way to identify symptoms and any functional impairment, so these can be tracked over time. This will help clinicians and parents to assess whether a particular treatment is working.

• Try psychotherapy first. The group advises trying various types of psychological interventions first, and for a sufficient time, before adding a medication to the mix.

• Monitor medications. If a child's symptoms do not improve after trying medication, stop the medication. Even when a medication works, plan on discontinuing it for a time to see if the drug is still necessary. (A child's ongoing brain development may correct the underlying problem.) The working group recommends against prescribing medications to alleviate side effects of other medications.

• Clinicians should invite parents to stay involved. Parents are important partners in care. If parents need help in handling stress, learning better parenting skills or dealing with their own mental health issues, they should be referred to an appropriate practitioner.

When a child has significant mental or behavior trouble, it places a strain on them, the parents, siblings and classmates. Relying on these basic principles won't necessarily make life easy. But following systematic treatment guidelines will improve the chances your child will avoid unnecessary troubles, and have the best chance to get needed help.