The number of preschool-age children being treated with stimulants, antidepressants, and other psychiatric drugs is on the rise. Many of these psychiatric drugs carry a risk of serious side effects, and their safety in young children has not been thoroughly researched. Furthermore, the medical community has lacked clinical practice guidelines for the use of psychiatric medications in preschoolers. In a first step toward standardizing treatment approaches, child mental health professionals from the Bradley Hasbro Children’s Research Center and 11 other institutions have developed recommendations for specific disorders to help clinicians considering medications for children ages three to six. These guidelines from the Preschool Psychopharmacology Working Group include data from clinicians and researchers in early childhood psychiatric disorders, psychopharmacology, general and behavioral pediatrics, neurodevelopmental processes, and clinical psychology.
Without established treatment guidelines, clinicians and families face a delicate balancing process. If child continues to have severe or dangerous symptoms after non-medication treatments, the physicians and families must weigh the potential risks of medications with the risks of not intervening in complex clinical situations. Researchers are hoping to close the gap between practice and evidence by clearly defining the current state of psychopharmacological treatment of preschoolers, encouraging judicious practice, and using existing evidence and clinical consensus to provide treatment guidelines for these young children and their families.
Treatment algorithms for nine common mental health disorders were developed based on a review of existing literature on the use of psychiatric medications in preschoolers, knowledge about preschoolers’ development, available data on school-age children and adolescents, and expert clinical experience. Algorithms were established for attention deficit and hyperactivity disorder (ADHD), disruptive behavior disorders, major depressive disorder, bipolar disorder, anxiety disorders, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), pervasive developmental disorders (such as autism), and primary sleep disorders. Algorithms serve to guide clinicians through assessment and treatment steps with the first step always being a comprehensive diagnostic assessment, taking into consideration the child’s emotional and behavioral symptoms, relationship patterns, medical history, and developmental history and status. If a psychiatric diagnosis exists, clinicians are prompted to initiate family-focused psychotherapy-parent management training or dyadic (parent-child) psychotherapy-before considering medication. If the child does not respond and medication is needed, it is recommended it be prescribed in conjunction with psychotherapy.
Guidelines emphasize: The importance of a family-focused assessment by clinicians with who are experienced working with young children, the use of psychotherapy as the first line treatment for young children with severe psychiatric disorders, and the value of careful monitoring of symptoms and side effects when treating young children. Guidelines are not intended to promote the use of medications; rather, it is hoped that use of these guidelines will reduce the number of preschoolers taking psychiatric drugs.
The algorithms share five common factors. Essentially, the algorithms suggest: Assessment and diagnosis at every step, critical given the rapid development of preschoolers; psychotherapeutic interventions; data supporting recommendations so clinicians can consider and apply treatment; recommendations for a discontinuation trial once successful medication treatment is realized so that the child’s symptoms and treatment can be reassessed; and expert child psychiatric consultation if the physician arrives at the end of the algorithm with a continued need for treatment.
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