The number of medications prescribed to children ages two to four to treat psychiatric disorders increased dramatically after the early 1990s.
A Delicate Balance
As any parent can attest, the preschool years are a time of tremendous brain development. Between the ages of two and five, children learn to talk, develop hand and eye coordination, and learn how to interact with others.
Brain changes underlie these developments. The number of synapses (connections between brain cells) and neurotransmitter receptors reach their peak at age three, while the brain's metabolic rate peaks between ages three and four.
Clinicians and parents thus face a delicate balancing act when it comes to treating psychiatric disorders, especially in the youngest children. There are risks associated with giving medications, because we don't know exactly what effects psychiatric drugs may have on the developing brain. But there can also be significant risk from not giving medications, because mental disorders also have a negative effect on brain development.
Mental disorders can lead to impaired peer and family relationships and poor school performance. Untreated childhood problems may give way to continuing mental health problems when the child when he or she grows up. And there is evidence that many lifelong psychiatric disorders begin early. A Harvard study published in 2005 estimated that half of all disorders that meet standard criteria for a diagnosis start by age 14.
There is no simple way to tell normal variations in temperament or development from the beginnings of a mental health problem. In practical terms, a child's problems may require medication to ease suffering and help him or her develop normally. Medications may be worth trying especially if non-drug treatments haven't been effective. But it is worth emphasizing that these decisions are almost always very difficult to make in the youngest children.
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Guidance for Three Disorders
Attention deficit hyperactivity disorder
Experts recommend a thorough evaluation to define the problem. This requires reports from parents, teachers and child care providers so that the clinician can assess the child's symptoms in multiple settings. Parents can be taught the best ways to help their children. Whether a child needs medication or not, he or she will probably do better if the parents become comfortable with skills for setting limits and rewarding positive behavior. If parent guidance and psychotherapy are not sufficient to control symptoms, a trial of methylphenidate (Ritalin) or another related drug for six months may be considered. After six months, the doctor can stop the medication to see if the child still needs it, either for controlling symptoms or improving functioning in school. Numerous other medications are available if methylphenidate does not work.
Anxiety disorders (separation anxiety, selective mutism, specific phobia)
In addition to making their own observations, clinicians will have an easier time defining the problem if they can get information from parents, teachers and other caregivers. Sometimes formal rating scales and questionnaires are used during the evaluation. The clinician should also remain alert to co-existing problems, like depression or behavior problems. Available research suggests that psychotherapy may teach a child to better control behavior while also improving self-esteem. So, a course of at least 12 weeks is usually the first intervention to try. If psychotherapy does not provide relief and anxiety symptoms continue to impair the child's functioning, a low dose of fluoxetine (Prozac) or a similar drug can be considered. After six to nine months, the clinician may be able to taper and then stop medication.
Developmental disorders, such as Autism
These children should have formal intelligence tests, plus tests of hearing and language skills. Useful evaluation instruments are the Childhood Autism Rating Scale and the Aberrant Behavior Checklist. Before thinking about medication, a team of helpers may be necessary to coach a child to improve language skills, enhance social development, and reduce repetitive behavior and aggression. Medication may eventually be necessary for children who have severe behavioral problems that interfere with functioning. As with anxiety disorders, the clinician can assess if medication is still needed after six to nine months.
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Maximize Help and Minimize Harm
Here are some useful principles to guide the evaluation and treatment of any problem that comes up in a young child.
- Address diagnostic challenges. Preschoolers vary in terms of development, personality, and communication skills. Diagnostic criteria for adults and older children may not be relevant to preschoolers. When possible, a diagnosis should be made after several visits with the child and only after multiple sources have provided information about the child's progress (the child, parents, teachers, other clinicians).
- Track symptoms and impairment. Before starting any treatment, the clinician and family should work together to define symptoms and any functional impairment, so these can be tracked over time. This will help in assessing whether a particular treatment is working.
- Try psychotherapy first. Various types of psychological interventions are worth trying first, and for a sufficient time, before adding a medication to the mix.
- Once medication has been started, monitor the response. If a child's symptoms do not improve after trying medication, stop the medication. Even when a medication works, plan on discontinuing it for a time to see if the drug is still necessary. (A child's ongoing brain development may correct the underlying problem.) Avoid adding medications to alleviate side effects of other medications.
- Clinicians should invite parents to stay involved. Parents are important partners in care. If parents need help in handling stress, learning better parenting skills or dealing with their own mental health issues, they should be referred to an appropriate practitioner.
When a child has significant mental or behavior trouble, it places a strain on them, the parents, siblings and classmates. Basic principles don't necessarily make life easy. But taking a systematic approach will improve the chances your child will avoid unnecessary troubles, and have the best chance to get needed help.
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Michael Craig Miller, M.D. is editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 25 years.