There is an urgent need for more research on psychotropic drug use in very young children, says Henrietta Leonard, M.D., a practicing child and adolescent psychiatrist and a professor of psychiatry and human behavior in the School of Medicine. In fact, no research results support psychotropic drug treatment in preschoolers, she says.
Last February, a study in the Journal of the American Medical Association (JAMA) described a seemingly dramatic increase in the prescribing of psychiatric drugs to preschoolers. Between 1991 and 1995, the number of 2- to 4-year-olds receiving stimulants such as Ritalin or antidepressants such as Prozac increased two- to threefold. An even sharper increase was found for Clonidine, which is used to treat insomnia in hyperactive children.
The study did not include reasons for the increase or for regional differences in prescriptions, nor was information on diagnoses or physician specialty gathered.
"Other data allow us to be pretty sure that most of the prescribing of medication is taking place in primary care, rather than psychiatric, settings," said study leader Julie Zito, associate professor of pharmacy and medicine, University of Maryland. Most of the medications described in the study were not labeled for use among preschoolers. Moreover, there is little or no monitoring of this drug use in young children, she said.
"What's missing is information on the status of the children; their length of time in treatment; the extent of treatment, and whether or not there are improvements in symptoms," Zito said. "In short, there is a great need for information on outcomes. Also missing is information on what home, academic and social factors are involved. Fundamentally absent is population-based information for understanding how well drug therapies work in preschoolers."
There is an urgent need for more research on psychotropic drug use in very young children, said Henrietta Leonard, M.D., a practicing child and adolescent psychiatrist and a professor of psychiatry and human behavior in the School of Medicine.
In fact, no research results support psychotropic drug treatment in preschoolers, said Leonard, who runs research trials of medications in children and adolescents and is a member of the scientific committee of the federally funded Research Units in Pediatric Psychopharmacology. "We have little information to know what the effects may be on the developing brain," she said.
It used to be that an experienced multidisciplinary team would carefully and thoughtfully evaluate a child, before prescribing medication, Leonard said.
"We don't know if the pre-schoolers in the [JAMA] study were receiving adequate assessments and treatments, but we can guess that they probably were not," said Leonard, who has talked and written extensively on scientific and ethical issues in prescribing medications in children. "And if there were assessments and treatments, who was doing them? You want someone who is well trained and if that individual is prescribing medications, that they are specifically trained in that expertise, such as someone who was trained in child psychiatry."
What may be interpreted as hyperactivity or attention deficit disorder may actually be normal behavior in a preschooler, Leonard said. A seeming reliance on drugs suggests insufficient use of behavioral and counseling approaches when a problem is suspected, she said.
"There are occasional times when it is appropriate to use psychotropic medications to treat 2- to 4-year-olds but only after psychotherapies have been tried, are ongoing, and have been assessed," she said. "The fear is that this is not occurring and that psychosocial stresses in the homes of these children, which may underlay or complicate these cases, are not being addressed."
Last spring, the National Institute of Mental Health launched a nationwide study of Ritalin use in children under the age of 6. A White House Conference on Mental Health will convene this fall.
The JAMA findings suggest a crisis in mental health services in children, said Leonard, who serves on the editorial board of the Journal of Child and Adolescent Psychopharmacology and is editor of the Brown University Child and Adolescent Psychopharmacology Update. She wrote a feature article for the Update last April titled "Are Psychotropic Drugs Being Overprescribed in Preschoolers?"
Money cutbacks for health care ration psychotherapy and force a focus on the quick fix, Leonard said. The trend among third-party payers is to place increasing and impossibly difficult obstacles to approving and receiving reimbursement for psychotherapy and for combined psychotherapy and drug treatments. This increases the chances that only drugs will be used, she said.
"There have been dramatic changes in the health care world, such as severe time restrictions imposed on taking care of patients, which affects how we do a comprehensive evaluation and provide appropriate treatment," Leonard said. "I have to write a 12-page treatment plan on why I want to talk with a child and family members or caretakers for 45 minutes. But if I put that child on medication, I can see him or her for a 15-minute follow-up, and I don't have to jump through any hoops."
Discussion of the expanded use of psychotropic drugs in young children is accompanied by a tendency to assess blame, said David Lewis, M.D., director of the Center for Alcohol and Addiction Studies. Lewis, editor of the Brown University Digest of Addiction Theory and Application, wrote in the April issue that down the line, assessing blame, whether to parents, schools, or physicians, may lead to a decrease in the prescribing of drugs before the findings from new studies or mental-health gatherings are known.
In the absence of long-term monitoring and "serious" assessment of medications in preschoolers, Zito suggests that families avoid viewing a child's behavior as a purely medical problem.
"Look at the child in the context of social, school, and home life," she said. "Then consult people who can analyze the situation in that context, such as a psychiatric social worker, behavioral pediatrician or child psychiatrist.
"A child may be hyperactive or inattentive, or the youngster may be getting C's in school and the parents are just not happy about it. You go a long way toward a particular solution depending on how you define the problem. There is a lot of pressure on kids these days to achieve academically. We may be losing some of our common sense about this. Maybe at the end of the day we can accept fewer would-be scholars and more happy-go-lucky car dealers."