Harvard Mental Health Letter

Treating preschoolers with psychiatric disorders

Experts develop treatment algorithms for nine 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% of children ages 3 and younger who were diagnosed with attention deficit hyperactivity disorder were prescribed at least one medication, while only 25% received psychotherapy.

Disorders, drugs, and the developing brain

The brain takes longer than any other organ to develop, and it does not fully mature until early adulthood. And there is evidence that many lifelong psychiatric disorders get started early. A Harvard study published in 2005 estimated that half of all disorders that meet Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria start by age 14.

On the one hand, symptoms that prompt a medical visit may be caused by alterations in brain function that are so exaggerated that medication is necessary to ease suffering and help the child achieve normal development. On the other hand, for ethical and practical reasons, no one has systematically studied the effect that early psychiatric medications have on young children, whose brains are developing in critical and rapid ways. This forces clinicians and parents to make high-stakes decisions with few solid findings to guide them.

As any parent can attest, the preschool years are a time of tremendous brain development. Between the ages of 2 and 5, children learn to talk, develop hand and eye coordination, and learn how to interact with others. Brain changes underlie these behaviors. The numbers of synapses (connections between brain cells) and neurotransmitter receptors reach their peak at the age of 3, while the brain's metabolic rate peaks between ages 3 and 4.

Animal studies suggest that psychiatric drugs affect crucial brain processes such as the formation of new brain cells (neurons), migration of neurons to their proper location in the brain, and the formation of synaptic connections between neurons. Animal studies have also shown that changes in serotonin concentration (as might occur when taking an SSRI) early in life can change the pattern of synaptic connections, altering later memory function. Antipsychotic drugs given early on may transform the development of dopamine receptors in unpredictable ways.

Other organs are also developing in childhood, including the liver and kidneys, which are both involved in processing drugs in the body. Because children metabolize medication differently from adults, they often need higher doses of a particular medication to achieve therapeutic blood levels. Preschoolers also tend to experience more side effects than older children or adults.

But all these risks must be weighed against the likelihood that mental disorders also adversely affect brain development. The outward consequences of illness, such as serious problems at home and school, make things worse in both the short- and long-term. The risk of injury or developmental delay may be significantly greater than the risks posed by drugs — especially if psychosocial interventions have been tried but haven't worked sufficiently. Impaired peer and family relationships and poor school performance can breed adult mental health problems.

Treatment advice from the American Academy of Child and Adolescent Psychiatry

This is just a sampling; for complete details on all nine algorithms, see Journal of the American Academy of Child and Adolescent Psychiatry, December 2007.

Diagnosis

Means of diagnosis

Psychotherapy options

Medication options

Attention deficit hyperactivity disorder

Use reports from parents, teachers, and child care providers to assess symptoms in multiple settings.

Help parents learn how to manage child's behavior as productively as possible by learning practical skills for setting limits and rewarding positive behavior.

If therapy is not sufficient to control symptoms, consider methylphenidate (Ritalin) first. Discontinue after six months and reassess need. Try other medications if methylphenidate does not work.

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

Combine parent input, child report and observations, and clinical evaluation measures. Comorbid disorders, such as depression or other anxiety disorders, are common.

Published research is limited, but case reports suggest that behavioral therapy and cognitive behavioral therapy may help. Try for at least 12 weeks to see if therapy is effective before trying something else.

If psychotherapy is not sufficient to provide relief and anxiety symptoms are severe enough to impair the child's functioning, consider fluoxetine (Prozac). Start at a low dose. Plan to discontinue after six to nine months to determine if medication is still necessary.

Pervasive developmental disorders (PDD)

Test IQ and hearing, assess language skills, and assess PDD, using instruments such as the Childhood Autism Rating Scale or the Aberrant Behavior Checklist.

Multidisciplinary options include interventions to improve language skills, enhance social development, and reduce repetitive behavior and aggression.

Medication may be necessary for children who have severe behavioral problems that interfere with functioning. Monitor side effects carefully; plan discontinuation trial after six months.

Balancing risks and benefits

The AACAP algorithms are quite detailed and discuss how much evidence supports the options offered. They also include practical advice about how long to try one option before considering another (see table for examples). Some general advice applies to all treatment decisions involving preschoolers.

Address diagnostic challenges. Preschoolers vary in terms of development, personality, and communication skills. To complicate matters further, the DSM-IV does not include criteria for diagnosing some disorders in preschoolers, and using adult criteria to diagnose children remains controversial. To address these challenges, the AACAP working group advises making a diagnosis only after obtaining information from multiple sources (the child, parents, teachers, other clinicians) over multiple visits. Specific advice about which diagnostic instruments might be useful are provided in each of the algorithms.

Track symptoms and impairment. Before starting any treatment, develop a system to identify symptoms and any functional impairment, so these can be tracked over time. This will enable 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 an adequate amount of time, before adding a medication to the mix.

Monitor medications. A clinical diagnosis and evidence of significant impairment in a child's functioning might indicate that psychotherapy has not worked sufficiently, and therefore that a medication is necessary. If symptoms do not improve after drug treatment, discontinue 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.) And the working group recommends against prescribing medications to alleviate side effects of other medications.

Involve parents. Preschoolers are particularly dependent on parents, so parents are important partners in care. If parents need help in handling stress, learning productive parenting styles, or dealing with their own mental health issues, they should receive referrals to appropriate practitioners.

Coyle JT. "Psychotropic Drug Use in Very Young Children," Journal of the American Medical Association (Feb. 23, 2000), Vol. 283, No. 8, pp. 1059–60.

Gleason MM, et al. "Psychopharmacological Treatment for Very Young Children: Contexts and Guidelines," Journal of the American Academy of Child and Adolescent Psychiatry (Dec. 2007), Vol. 46, No. 12, pp. 1532–72.

For more references, please see www.health.harvard.edu/mentalextra.