Psychiatr News January 18, 2008
Volume 43, Number 2, page 6
© 2008 American Psychiatric Association
Guidelines Advise MH Treatment for Very Young Children
Jun Yan
Treating preschool-aged children with psychoactive medications is
fraught with safety risks and complexities. New guidelines call for a more
step-by-step intervention.
Attempting to bridge the chasm between the lack of research data and
the need to treat severely disturbed young children, a group of experts in
early childhood psychiatry, psychopharmacology, clinical psychology, general
and behavioral pediatrics, and neurological development have published
pharmacological treatment guidelines for psychiatric disorders in very young
children in the December 2007 Journal of the American Academy of Child and
Adolescent Psychiatry.
The experts formed the Preschool Psychopharmacology Working Group (PPWG)
and mapped out nine algorithms for the management of
attention-deficit/hyperactivity disorder (ADHD), disruptive behavior
disorders, major depressive disorder, bipolar disorder, anxiety disorders,
posttraumatic stress disorder (PTSD), obsessive-compulsive disorder, pervasive
developmental disorders, and primary sleep disorders in preschool-aged
children. The algorithms provide step-by-step guidance—from diagnosis to
treatment—for physicians and note the level of available evidence-based
research for each step and treatment option.
"These are the first comprehensive guidelines, as far as we know, on
treating very young children that involve the expertise across multiple
disciplines and areas in child mental health," Mary Gleason, M.D., the
lead author and a clinical assistant professor of psychiatry at Brown
University's medical school, told Psychiatric News. She
practices child psychiatry at the Bradley Hasbro Children's Research Center in
Rhode Island.
"We had three main goals in compiling this document," she said.
"The first was to review and present the current state of evidence for
treatment for preschoolers and provide some resource for
physicians."
The second goal, she said, was to formulate evidence-based guidelines for
both mental health providers and children and families in terms of
pharmacologic options and present rational algorithms for treatment.
Finally, this document is intended to be used as "a springboard and
advocacy for more independently funded research in this area." Gleason
stressed that the child psychiatric community urgently needs the resources for
more studies, more specialized training, and more financial support, such as
reimbursement for psychotherapy, for the diagnosis and treatment of
psychiatric problems in preschool-aged children.
Because it is risky and difficult to conduct medical research on very young
children, safety and efficacy data on medication use in this population are
woefully inadequate, and regulatory approval nearly nonexistent. In addition
to the limited literature on these children, the PPWG reviewed the scientific
evidence in older children, which is more abundant, and obtained consensus
from practicing clinicians, through a survey; their recommendations were also
based on the expertise among the PPWG members. The initiative was funded by
the American Academy of Child and Adolescent Psychiatry.
The work group highlighted the need to perform a thorough assessment of
very young patients—and their home environment—before forming
treatment strategies. "It is very important to get a family-focused,
developmentally appropriate diagnosis," said Gleason. "The
clinician should gather information from multiple appointments and multiple
sources." She recommended using various methods, including observation,
interviews, structured examinations, and informal assessments, to form a clear
and complete impression of the patient. "That is the critical first
step." The guidelines ask clinicians to pay attention to each child's
particular developmental, family, and community context of the symptoms during
evaluation.
The group recommended that "evidence-supported psychosocial
treatments" be applied as a first-line treatment for preschool-aged
children and continued even if medications are prescribed. In addition, they
suggested that family caregivers should be involved in psychotherapy as much
as possible. For example, the group recommended parent-management training or
other behavioral techniques as first-line interventions for ADHD in
preschoolers.
"It is important to work with the family and together identify
realistic treatment goals, discuss side effects, and plan for the time when
medications may be discontinued," Gleason said. "Then reassess the
child often." Also, "help the family understand the risks and
benefits of the medications prescribed through informed consent," she
recommended.
The guidelines encourage physicians to anticipate and try discontinuation
of medications over time, depending on patient's response and development.
"[The guidelines are] not intended to promote the use of
medications," the PPWG pointed out. Rather, they "anticipate that
application of these algorithms will result in a reduction in the use of
psychopharmacological agents for young children."
An abstract of "Psychopharmacological Treatment for Very Young
Children: Contexts and Guidelines" can be accessed at
<www.jaacap.com/pt/re/jaacap/home>
by clicking on "Archive" and the December 2007 issue.
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