December 05, 2007

New Treatment Guidelines for Mental Health Problems in Pre-School Children

A statement by a child psychiatry research group today announced that even though little research supports it, recently, there has been a rise in the numbers of children being prescribed stimulants and psychiatric drugs including, antidepressants. In hopes of providing the best treatment for young children, mental health professionals at the Bradley Hasbro Children's Research Center (a teaching hospital affiliated with Brown Medical School) in Rhode Island are combining their efforts with other mental health professionals from 11 other mental health institutions to create recommendations for clinicians planning on prescribing medications to children aged 3 to 6 years.

The treatment guidelines appear in this month’s issue of the Journal of the American Academy of Child and Adolescent Psychiatry. The group of mental professionals developing the guidelines, known as the Preschool Psychopharmacology Working Group, hope to, as one of the authors states, "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."

The group created the guidelines by reviewing past literature relevant to the prescription of psychiatric medications to preschoolers on topics such as the development of preschoolers. They then created instructions on treatment of nine commonly treated mental disorders among preschool children. The instructions, or algorithms provide the prescribing clinician with recommendations on which kinds of assessments and treatments to provide step-by-step. They suggest that clinicians first begin by performing a diagnostic assessment that considers "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.

Some of the disorders covered in these guidelines include: bipolar disorder, pervasive developmental disorders—an example of this is autism, major depressive disorder, attention deficit and hyperactivity disorder (ADHD), disruptive behavior disorders and anxiety disorders.

The guidelines stress the value of family-focused assessments in young children and encourage the use of psychotherapy prior to prescription of any medications, among other things. The authors state that the guidelines should reduce the numbers of preschoolers being prescribed psychiatric drugs.

The algorithms provided in the guidelines focus on five factors. These include:

  • 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 also state what they believe is immediately needed in the preschool population, more research efforts that examine the effects of therapy and medication based treatments for young children.

    See Abstract of Guidelines: Psychopharmacological Treatment for Very Young Children: Contexts and Guidelines. (Journal of the American Academy of Child and Adolescent Psychiatry)


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