Treating preschoolers with psychiatric disorders

The Family Health Guide

Recently a working group of experts from 12 medical schools and institutions, convened by the American Academy of Child and Adolescent Psychiatry (AACAP), has published treatment guidelines for nine mental health conditions diagnosed in young children.

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.

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.

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.

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. 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.

Balancing risks and benefits

The AACAP guidelines 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. 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.

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.

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.

Involve parents. Preschoolers are particularly dependent on parents, so parents are important partners in care.

May 2008 update

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