The number of U.S. preschoolers diagnosed with attention-deficit hyperactivity disorder (ADHD) jumped 56 percent between 2007–08 and 2011–12, according to data from the National Survey of Children's Health.
Perhaps even more stunning: The number of children ages 2 to 5 taking a psychoactive medication to treat ADHD doubled, the survey found.
In addition, nearly half of preschoolers with ADHD are not getting behavioral therapy, the first-line treatment the American Academy of Pediatrics has recommended for the condition since 2011.
Such findings highlight a problem that concerns many psychologists: Preschoolers are getting more medication for ADHD, anxiety disorders and depression, although many of these drugs haven't been tested with young children.
Even among those that have, evidence suggests that preschoolers who use them may experience side effects and health risks, including irritability, sleep problems and lethargy, says Susanna Visser, DrPH, an epidemiologist with the U.S. Centers for Disease Control and Prevention. Plus, she adds, little is known about how these drugs may affect a young child's developing brain.
Where are the behavioral interventions?
The increase in prescribing medications to young children comes at a time when a growing body of research is showing that evidence-based behavioral intervention programs for ADHD, anxiety and depression are very effective among preschoolers, says Mary Margaret Gleason, MD, professor of psychiatry, behavioral sciences and pediatrics at Tulane University School of Medicine.
The problem, Gleason notes, is that, particularly among primary-care physicians in non-urban, non-academic areas, those formal interventions aren't always readily available — nor are qualified mental health professionals to assess and treat these young children.
"Primary-care providers are in the position of feeling like they need to do something, and I think that, unfortunately, leads to some of what we see in terms of prescribing medications," says Gleason.
She and other experts say that medications can be necessary — and effective — for young children, but that can only be determined after a thorough, careful clinical assessment has been done.
"The first step for any child when someone is considering treatment is really knowing what's going on, and that means diagnostically, but also thinking about the family context and thinking about the developmental context of the children," Gleason says.
Unfortunately, such thorough exams don't happen often enough, research suggests. In 2010, Columbia University psychiatrist Mark Olfson, MD, found that the rates of antipsychotic use among privately insured young children more than doubled from 1999 to 2007, but fewer than half of these children received a mental health assessment, had a psychotherapy visit or visited a psychiatrist (Journal of the American Academy of Child & Adolescent Psychiatry, 2010opens in new window).
Another study led by Ohio State University's Cynthia Fontanella, PhD, found that of the children treated with psychotropic medications from 2002 to 2008, only 29 percent received a mental health assessment, 24 percent saw a psychiatrist and 30 percent had a psychotherapy visit (Journal of Child and Family Studies, 2014opens in new window).
Psychologists are particularly concerned that these children are being prescribed antipsychotics, since only one rigorous study has explored the safety or efficacy of this class of medications among preschoolers — and even that study only looked at using antipsychotics to treat autism.
"Antipsychotics are associated with very serious side effects, so practitioners need to be very cautious when prescribing, especially since these effects might be even greater in younger children," says Jonathan Comer, PhD, professor of psychology and psychiatry at Florida International University. Some of the more serious side effects include weight gain, diabetes, high cholesterol, cardiovascular disease and tardive dyskinesia, a neurological disorder resulting in compulsive movement. Comer's own research found that from 1996 to 2007, the use of these drugs for anxiety disorders more than doubled among adults and children age 6 and up, with the most pronounced increases among new patients (American Journal of Psychiatryopens in new window, 2011opens in new window).
In an ideal world, parents and doctors would try behavioral interventions before medication. However, it can be difficult to refer these kids to behavioral therapy with a qualified mental health professional, says William Pelham Jr., PhD, chair of the psychology department at Florida International University.
"Neither pediatricians nor psychiatrists have training in offering psychosocial or psychological approaches to mental health treatment," Pelham says. "All they have in their toolkit is medication."
Outside of urban areas, in particular, psychological treatments can be hard to standardize, says Comer. "If you're filling a prescription at a CVS in Los Angeles or a Wal-Mart in Nebraska or a Duane Reade in New York City, you're getting the same medication," he explains. "But if you're referring someone for a well-supported psychological treatment across different providers, there's not that same guarantee in consistency across providers."
Comer calls on psychologists to do a better job at getting treatments disseminated to front-line practice settings. "The amazing research that's happening in clinical trials is not having any impact because it's not making its way into front-line clinical settings."
Effective interventions
How can psychologists more broadly disseminate evidence-based psychological interventions for preschoolers?
When it comes to ADHD, Visser points to research-based interventions in a 2011 reportopens in new window by the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality. It found that formal parenting interventions — known as parent behavior training, or PBT — are effective for children under age 6, with no reports of complications or harm. In particular, the report identifies four programs that have the most empirical support — Triple Popens in new window, Parent-Child Interaction Therapy (PCIT)opens in new window, Incredible Yearsopens in new window and the New Forest Parenting Programmeopens in new window.
All of these programs focus on positive parenting strategies, including positive reinforcement for good behaviors and the importance of having a consistent discipline style, Visser says. Pelham says that the manuals for these programs are available for free or for a very small fee, for psychologists interested in learning more about the programs and some of the strategies they advise.
Gleason also notes that several studies point to the effectiveness of cognitive-behavioral therapy (CBT) for children experiencing post-traumatic stress disorder (PTSD) and anxiety disorders. Research shows not only that children as young as age 4 can learn the skills of CBT, but that the treatment can help them better understand their feelings and reduce symptoms of PTSD and anxiety. For example, a study led by Michael Scheeringa, MD, a professor of child psychiatry at Tulane University, found that 12 weeks of trauma-focused CBT significantly improved symptoms of PTSD in 3- to- 6-year-old children compared with a control group that was waitlisted 12 weeks for treatment (Journal of Child Psychology and Psychiatry, 2011opens in new window). The effects were actually stronger at the six-month follow-up, the authors note, suggesting that the treatment can continue to be effective even after formal therapy has ended.
Another promising psychosocial intervention for young children with depression is a parent-child psychotherapy program called PCIT-ED, developed by Joan Luby, MD of Washington University School of Medicine. The program focuses on emotion development, but specifically targets depression in young children. A 2011 pilot study with 54 depressed 3- to- 7-year-olds who participated in the program found that it improved the children's executive functioning and emotion recognition skills compared with a control group whose members received psychoeducational training, findings that suggest it could be an early intervention for depression. The researchers are continuing to test the program, Luby says.
Psychologists can help improve awareness about the effectiveness of these treatments among pediatricians and psychiatrists by continuing to take part in integrated care and co-location opportunities with primary-care providers, Comer says. Visser also notes that the CDC is working closely with the American Academy of Pediatrics to educate physicians about the fact that for these very young children, behavioral therapy is the recommended first-line treatment. Comer and Visser are also encouraging parents who have concerns about their child's behavior to seek a psychologist first, who can help them understand and apply parenting and behavioral strategies.
Pelham suggests that more direct-to-consumer education around parenting tips for dealing with a child showing symptoms for ADHD could help reduce the number of young children receiving unnecessary medication.
"Right now, all that gets advertised is medication," he says.
Comer also points to electronic communication and telecommunications technologies for help in overcoming disparities in care and helping families who may not have local access to quality providers of behavioral therapy for their preschool-age children.
"Telehealth offers a potentially game-changing way to extend the reach of supported care," he says. But most important, he adds, "we need to think harder about how psychological and mental health care can be better integrated and coordinated with pediatrics, rather than viewed as a separate health care discipline."
