Guidelines Advise MH Treatment for Very Young Children

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.▪