New psychiatric medication treatment guidelines for preschoolers

Dec 4 2007

The number of preschool-age children being treated with stimulants, antidepressants and other psychiatric drugs is on the rise, despite limited research and a lack of clinical practice guidelines.

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 who are considering medications for children ages 3 to 6.

These guidelines from the Preschool Psychopharmacology Working Group – which includes clinicians and researchers in early childhood psychiatric disorders, psychopharmacology, general and behavioral pediatrics, neurodevelopmental processes, and clinical psychology – are published in the December issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

“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,” said lead author Mary Margaret Gleason, M.D., of the Bradley Hasbro Children's Research Center.

“Our goal was to begin 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,” added Gleason, who's also a clinical assistant professor of psychiatry at The Warren Alpert Medical School of Brown University.

Gleason and colleagues developed treatment algorithms for nine common mental health disorders 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.

The algorithms guide the clinician through recommended assessment and treatment steps. The first step in each algorithm is 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 is confirmed, the authors recommend clinicians start with family-focused psychotherapy – such as parent management training or dyadic (parent-child) psychotherapy – before considering medication. However, if the child is not responding and medication is deemed necessary, they suggest it be used in conjunction with psychotherapy.

Treatment algorithms were established for attention deficit and hyperactivity disorder, disruptive behavior disorders, major depressive disorder, bipolar disorder, anxiety disorders, posttraumatic stress disorder, obsessive-compulsive disorder, pervasive developmental disorders (such as autism), and primary sleep disorders.

“These guidelines emphasize the importance of a family-focused assessment by clinicians with experience 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,” said Gleason. “They are not intended to promote the use of medications; rather, we anticipate that application of these guidelines may actually reduce the number of preschoolers who are taking psychiatric drugs.”

The algorithms share five common factors:

• Assessment and diagnosis at every decision point in order to reassess the diagnosis and formulation – both of which are critical, given the rapid development of preschoolers
• Psychotherapeutic interventions
• Each step is marked by the “level of evidence” supporting the recommendation, allowing clinicians to consider the body of evidence and apply it to the individual patient
• Recommendations for a discontinuation trial after successful medication treatment to reassess the child's symptoms and appropriate treatment
• Consultation with an expert in child psychiatry if the physician arrives at the end of the algorithm with ongoing impairment and distress

The authors stress that the algorithms represent their best attempt to integrate data and clinical experience; however, clinicians may determine that an alternative approach is indicated in a particular clinical situation.

“We hope this information will be useful for clinical practice, highlight opportunities to advocate for the well-being of young children, and encourage future clinical research in treating very young children with both medication and therapy – something that's urgently needed in this preschool population,” said Gleason.