SPECIAL COMMUNICATION
Psychopharmacological Treatment for Very Young Children: Contexts and Guidelines

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ABSTRACT

Systematic research and practice guidelines addressing preschool psychopharmacological treatment in very young children are limited, despite evidence of increasing clinical use of medications in this population. The Preschool Psychopharmacology Working Group (PPWG) was developed to review existing literature relevant to preschool psychopharmacology treatment and to develop treatment recommendations to guide clinicians considering psychopharmacological treatment in very young children. This article reviews the developmental considerations related to preschool psychopharmacological treatment, presents current evidence bases for specific disorders in early childhood, and describes the recommended algorithms for medication use. The purpose of this effort is to promote responsible treatment of young children, recognizing that this will sometimes involve the use of medications.

Section snippets

WORKING GROUP METHODS

The Preschool Psychopharmacology Working Group (PPWG) was established in response to the clinical needs of preschoolers being treated with psychopharmacological agents and the absence of systematic practice guidelines for this age group. The central aim of this working group is to develop best practice algorithms for the use of psychopharmacological agents in preschool children based upon literature review, clinical experience, and expert consensus. This discussion of psychopharmacological

OVERVIEW OF PRESCRIBING PRACTICES

Of preschoolers with psychiatric disorders, only a small proportion are referred for mental health treatment, and the primary treatment modality for most very young children is psychotherapeutic rather than psychopharmacological (AACAP, 1997b, Egger and Angold, 2006, Lavigne et al., 1993). Studies using varied methods yielded estimates that 3 to 9/1,000 U.S. preschoolers received prescriptions for psychotropic medications in the 1990s (DeBar et al., 2003, Zito et al., 2000). Rates of stimulants

SPECIAL CONTEXTS OF PRESCHOOL PSYCHOPHARMACOLOGY

Treatment decisions involving young children include consideration of developmentally specific assessments and diagnosis, attention to neurodevelopmental and ethical factors, and the existing evidence base.

CONSIDERING PSYCHOPHARMACOLOGICAL TREATMENT

The contextual factors reviewed here render rational prescribing considerably more challenging for preschool children compared to older children. Jensen has argued, however, that these diagnostic, neurodevelopmental, metabolic, and regulatory considerations do not “comprise a universal proscription against the use of medication in young children” (Jensen, 1998, p. 588). A child with moderate to severe symptoms and functional impairment that persist despite appropriate psychotherapeutic

ALGORITHMS

The algorithms share five common factors. Assessment and diagnosis are important components in any clinical practice. These steps are included in the algorithm to highlight the importance in young children for whom the diagnostic process can be more complex than for older children. At every treatment initiation point, we recommend reassessment of the diagnosis and clinical formulation in recognition of young children's rapid development. Second, psychotherapeutic intervention steps are included

Stage 0: Diagnostic Assessment and Psychotherapeutic Trial

Hyperactivity in the preschool period has a broad differential diagnosis. The diagnosis of ADHD, therefore, should include assessment and consideration of other causes of behavioral dysregulation including family contextual patterns, anxiety processes, and medical problems (see Fig. 1). Reports from child care providers or teachers allow a clinician to assess the symptoms in more than one setting. Structured baseline assessments of symptoms and level of functioning can guide treatment and

Stage 0: Diagnostic Assessment

Although the validity of the DSM-IV diagnoses of oppositional defiant disorder (ODD) and conduct disorder have been the focus of some debate, a growing body of evidence demonstrates the existence of a group of preschoolers with severe and sustained impairment associated with the symptoms of DSM-IV disruptive behavior disorders (DBD; Egger and Angold, 2006, Keenan and Wakschlag, 2002). Because of the prevalence of behavioral dysregulation in preschoolers with psychopathology, careful assessment

Stage 0: Diagnostic Assessment

Preschool major depressive disorder (MDD) is a serious and impairing disorder. In preschoolers MDD can be validly diagnosed using slight modifications to the DSM-IV criteria, including a change in the duration criteria to reflect developmental variability in mood presentation and inclusion of play-specific observations (Luby et al., 2002, Luby et al., 2003b, Luby et al., 2003c). A review of the current state of preschool MDD diagnosis and assessment provides a comprehensive approach to this

Stage 0: Diagnostic Assessment

The diagnosis of BPD in preschoolers has not been the focus of significant empirical research. The limited literature may be related to the ongoing controversy about the diagnosis and its definition in older school-age children and adolescents, a phenomenon that only adds to skepticism about the application of the diagnosis to younger children (AACAP, 2007). In fact, there is no clear consensus that young children with severe emotional dysregulation have a bipolar disorder. Within the PPWG,

Stage 0: Diagnostic Assessment

This section reviews the treatment of a group of anxiety disorders: separation anxiety disorder (SAD), GAD, selective mutism (SM), and specific phobia (SP; Fig. 5). These disorders are addressed together because the psychopharmacological approaches for these disorders are similar in older children with SAD, GAD, SM, and SP (e.g., RUPP Anxiety Study, 2001). Panic disorder is not included because there is insufficient evidence that this disorder presents in the preschool age (AACAP Task Force on

Stage 0: Diagnostic Assessment

Assessment of PTSD is a more complicated task compared to most other disorders. Whereas much of the symptomatology of other common disorders of childhood are easy to understand and directly observable, identifying the key symptomatology of PTSD requires that the clinician recognize the link between a child's observable behaviors and a traumatic experience. It is not uncommon for children to respond to triggers that adults do not identify as reminders of the trauma. In the early childhood

Stage 0: Diagnostic Assessment

Like PTSD, OCD has a unique evidence base warranting individual attention. OCD in preschoolers has received little attention in the literature, in spite of the attention on developmental processes in OCD (Freeman et al., 2003, Geller et al., 1998, Scahill et al., 2003, Tobias and Walitza, 2006). The differential diagnosis of OCD includes SAD or other anxiety disorders, tic disorders, PDD, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, or movement

Stage 0: Diagnostic Assessment

By the DSM-IV definition, autism must present before age 3 years, and other PDDs are typically recognized by parents in the first 3 years of life (reviewed in Chawarska and Volkmar, 2005). These disorders presents with severe delay in socialization, as well as delayed and deviant language and/or repetitive behaviors. Minimum assessment of children with PDD includes testing IQ and adaptive behavior, language and hearing, structured, categorical and dimensional validated measures of symptoms of

Stage 0: Diagnostic Assessment

The sleep algorithm was derived primarily from recently published young children's sleep practice guidelines developed by the American Academy of Sleep Medicine (Morgenthaler et al., 2006, Owens et al., 2006). The diagnostic assessment of a child presenting with a sleep disturbance includes three components: thorough evaluation for primary sleep disorders that may present with neurobehavioral and mood impairments, inventory of possible contributing/exacerbating factors, and detailed assessment

CONCLUSIONS

It is encouraging to see that young children have more access to mental health care than in the past, but studies showing a rise in use of medication, including multiple medications in the preschool age group raise some concerns, especially given the limited body of evidence (e.g. DeBar et al., 2003, Rappley et al., 2002, Zito et al., 2000). The PPWG has responded to the gap between practice and evidence by clearly defining the current state of preschool psychopharmacological treatment,

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    Dr. Gleason is with the Bradley Hasbro Research Center and the Tulane Institute of Infant and Early Childhood Mental Health; Dr. Egger is with the Center for Developmental Epidemiology, Duke University Medical School; Dr. Emslie is with the University of Texas Southwestern Medical Center; Dr. Greenhill is with the New York State Psychiatric Institute; Dr. Kowatch is with the Department of Psychiatry, Cincinnati Children's Hospital Medical Center; Dr. Lieberman is with the Department of Psychiatry, University of California, San Francisco; Dr. Luby is with the Department of Psychiatry, Washington University School of Medicine; Dr. Owens is with the Department of Pediatrics, Brown University Medical School; Dr. Scahill is with the Child Study Center at Yale University; Dr. Scheeringa is with the Division of Child and Adolescent Psychiatry at the Tulane University Health Sciences Center; Dr. Stafford is with the Departments of Pediatrics and Psychiatry at the Children's Hospital, Denver; Dr. Wise is with the University of Colorado Health Sciences Center; Dr. Zeanah is with the Division of Child and Adolescent Psychiatry at Tulane University Health Sciences Center.

    This project was supported by a grant from the AACAP Abramson Fund.

    Disclosure: Dr. Emslie receives research support from Eli Lilly, Organon, and Forest Laboratories; is a consultant to Eli Lilly, GlaxoSmithKline, Wyeth-Ayerst, and Biobehavioral Diagnostics Inc.; and serves on the speakers' bureau of McNeil. Dr. Greenhill receives support from Eli Lilly, Novartis, Forest, Pfizer, and Otsukan. Dr. Kowatch receives research support from Bristol-Myers Squibb, serves as a consultant to Creative Educational Concepts and Abbott, is the editor of Current Psychiatry, and is on the speakers' bureau of Astra-Zeneca and Abbott. Dr. Owens receives research support from Lilly, Shire, Sepracor and serves as a consultant to Cephalon, Shire, Lilly, Sanofi-Aventis, and Boehringer-Ingelheim. Dr. Scahill is a consultant for Janssen, Supernus, Bristol-Myers Squibb, and Neutropharm and serves on the speakers' bureau of Janssen. The other authors have no financial relationships to disclose.

    The authors would like to acknowledge the important contributions of the young children and families with whom we work, and the valuable feedback received from the Early Childhood Clinical Research team at Bradley Hospital.

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