Psychiatric Medication Guidelines Set for Preschoolers

Concern about the rising number of preschool-age children receiving atypical antipsychotics, α-agonists, or other psychotherapeutic medications recently motivated pediatric mental health professionals to develop best-practice algorithms for psycho-pharmacological treatment of young children. It also prompted some states and mental health providers to initiate medication monitoring and consultation programs.

In a 7-state medicaid study, Zito and colleagues¹ found that 2.3% of 274,518 continuously enrolled preschoolers received one or more psychotherapeutic medications in 2001. The prevalence was 0.96% for those aged 2 years, 2.08% at age 3 years, and 3.99% at age 4 years. The study also showed an estimated doubling of usage of some medications in a 6-year period.

To address concerns about the growing use of psychiatric medications in preschoolers, the Preschool Psychopharmacology Working Group (PPWG) of the American Academy of Child and Adolescent Psychiatry developed algorithms based on extensive literature reviews, clinical experience, and expert consensus.²

"Our first goal was to review the current state of the preschool psychiatric field for clinicians, and the second... was to provide a set of guidelines to help clinicians," explained lead author Mary Margaret Gleason, MD, of the Bradley Hasbro Research Center and the Tulane Institute of Infant and Early Childhood Mental Health, and clinical assistant professor of psychiatry at Brown University.

The algorithms, Gleason emphasized, address treatment of young children with severe psychiatric symptoms who meet DSM-IV criteria. Such children include those who have been expelled from child care facilities multiple times, those who are unable to interact with other children, or those who are unable to develop trusting relationships with their parents because of their psychiatric symptoms, as well as those who are so anxious that they will not talk to anyone outside their immediate family.

In their report, Gleason and her coauthors caution that preschool psychopathology and treatment must be considered within developmental, clinical, regulatory, and ethical contexts. For example, the impact of early and/or prolonged exposure to psychotherapeutic medications during the preschool period has not been systematically studied, but research highlights the sensitivity of the developing brain. What's more, few psychotherapeutic medications are approved for use in pediatric populations; most are used off-label.

To provide guidance, the PPWG established algorithms for attention-deficit/hyperactivity disorder; disruptive behavior disorders; major depressive disorder; bipolar disorder; anxiety disorders, such as separation anxiety disorder, selective mutism and specific phobia; posttraumatic stress disorder (PTSD); obsessive-compulsive disorder; pervasive developmental disorders, including autism; and primary sleep disorders.

The first step in each algorithm is a comprehensive diagnostic assessment of the child's emotional and behavioral symptoms, relationship patterns, medical and developmental history, and psychiatric status.

"The ingredients that are most useful for an assessment," Gleason said, "are the multiples-multiple visits, information from multiple caregivers, and using multiple modalities, including interview, informal observations, and structured interaction assessments. Young children are sensitive to context and don't have the ability to describe their internal emotional state in a way that an adult might."

If a clinician is considering pharmacological treatment for a young child, Gleason said her first recommendation is "to assess the adequacy of interventions that have already been tried and to determine whether there are other psychotherapeutic or other nonpharmacological interventions that could help reduce the symptoms."

Such psychotherapeutic interventions can include behavioral therapy, cognitive-behavioral therapy, parent management training, or dynamic psychotherapy. Should these prove ineffective, Gleason offered further recommendations, which include discussing with parents the level of evidence supporting the recommended pharmacological treatment and "really go[ing] through the informed consent process in a meticulous way." The algorithms article includes published preschool psychopharmacology studies for specific diagnoses.

Clinicians and parents should start by discussing the target symptoms expected to be addressed by the medication, and the need for discontinuation trials. Such trials permit reassessment of the child's underlying symptoms off medication after a period when developmental, contextual, and therapeutic processes may have impacted the child's psychiatric presentation, according to Gleason.

"We want to know whether the child's current psychiatric status warrants the medication being prescribed," she added.

Gleason also urged clinicians to continue obtaining information from caregivers and to monitor symptoms with structured instruments throughout the treatment process. Some structured tools useful for assessing and monitoring young children, such as the Preschool Feelings Checklist for depression and the Child Behavior Checklist PTSD scale, are discussed in the algorithms article.

However, "nothing takes the place of careful clinical judgment in [treating] young children," Gleason added. Even though the algorithms discuss psychopharmacological interventions, they are not intended to promote the use of medications, she said. "We anticipate that application of these guidelines may actually reduce the number of preschoolers who are taking psychiatric drugs," she added. The PTSD algorithm, for instance, does not even include the use of psychopharmacological interventions.

We looked for randomized controlled trials on pharmacological treatments to help guide us, Gleason said, but there were none in preschool PTSD and none in child and adolescent PTSD. The PPWG felt that extrapolating from adult trials to preschoolers was too great a leap.

Research and screening

By publishing the algorithms, Gleason said the PPWG seeks to encourage further research. Studies looking at the long-term effects of psycho- therapeutic medications in young children are desperately needed, she noted, as well as independently funded studies on all areas of early childhood mental health problems, including assessment and treatment.

Because of her interest in identification of young children with psychiatric problems, Gleason has developed the Early Childhood Screening Assessment, a brief screen for social, emotional, and behavioral problems in children aged 18 to 60 months. She has tested it in primary care settings in Louisiana and Rhode Island.

Focus on primary care

Several studies indicate that primary care physicians are the main prescribers of psychiatric medications in young children, according to Gleason. Because there is a severe shortage of pediatric mental health providers and, in particular, a shortage of child psychiatrists in many parts of the country, primary care providers are often left to care for young children with psychiatric disorders, she pointed out.

Massachusetts is one state that has begun multiple efforts to assist pediatric primary care providers through the Massachusetts Child Psychiatry Access Project (MCPAP) and the Children's Behavioral Health Initiative of the Executive Office of Health and Human Services and MassHealth. MassHealth encompasses the state's Medicaid program and the State Children's Health Insurance Plan.

Massachusetts' Behavioral Health Partnership, a ValueOptions company responsible for mental health and substance abuse services for MassHealth recipients, helped develop the MCPAP. The MCPAP consists of 6 mental health teams, including child psychiatrists and therapists, working under the supervision of child psychiatry divisions of academic medical centers across the state. Each team seeks to enroll all of the pediatric primary care practices in its catchment area. Once enrolled, the primary care providers have access to several services for their patients regardless of insurance status, including informal telephone consultations, timely psychiatric diagnostic evaluations, and interim psychotherapy.

The MCPAP "stands ready to help any primary care provider in the state who has a question about the need for psychotherapeutic medication with any child, especially one less than 5 years of age," said John Straus, MD, Behavioral Health Partnership's vice president for medical affairs.

On December 31, 2007, MassHealth also started requiring that providers use standardized behavioral health screening as part of the Early Periodic Screening, Diagnosis, and Treatment services. Information on MassHealth-approved standardized behavioral health screening tools for patients younger than 21 years as well as a list of resources for referring those with positive screen results is available at the MCPAP Web site, http://www. mcpap.org/.

Monitoring efforts

Following the death of a 4-year-old girl from an overdose of psychiatric drugs in 2006, Massachusetts' health officials established an early warning system to identify preschoolers who might be receiving excessive or inappropriate medication for their psychiatric illnesses.

Under the system, managed care organizations, such as the Massachusetts Behavioral Health Partnership, are reviewing prescription records for all children younger than 5 years whose mental health treatment is paid for by MassHealth. Straus said that in the first quarter of 2007, Massachusetts Behavioral Health Partnership identified 137 preschoolers receiving at least one psychotherapeutic medication; 18 were receiving an antipsychotic and 8 were receiving 3 or more psychotherapeutic medications.

Straus believes the monitoring of psychotherapeutic medications for preschoolers has resulted in a decrease in prescribing. In the most recent quarter (July through September of 2007), 71 of 32,722 children younger than 5 years were receiving at least one psychotherapeutic medication; 9 were receiving antipsychotics and 3 were receiving 3 or more psychotherapeutic medications.

"We are working with prescribers to ensure that treatment is based on behaviors observed by individuals other than the family, such as day-care providers, and we are also working to ensure that prescribers are fully using nonmedication modalities," he said.

Other states, such as Louisiana, also have early-warning programs, Gleason continued. She said that she finds such programs useful because they provide extra levels of risk assessment and consideration for a vulnerable population.

For Gleason, however, the most important goal of all the efforts described is that "these children have access to comprehensive assessments and safe, effective, evidence-supported treatment that would allow them to develop in a healthy way."

References:

References

1.

Zito JM, Safer DJ, Valluri S, et al. Psychotherapeutic medication prevalence in Medicaid-insured preschoolers.

J Child Adolesc Psychopharmacol.

2007; 17:195-203.

2.

Gleason MM, Egger HL, Emslie GJ, et al. Psychopharmacological treatment for very young children: contexts and guidelines.

J Am Acad Child Adolesc Psychiatry.

2007;46:1532-1572.