22. Meds for preschoolers?

"Help! My preschooler has been kicked out of child-care and no one in our area can evaluate and treat young kids!" When and how should you prescribe medication for preschoolers with emotional and behavioral problems? Dr. Elise Fallucco shares her thoughts and suggestions on evaluating and treating these children. In cases where children have failed or are unable to access parent-child interaction therapy, she walks you through how to diagnose and understand these problems.  In cases of preschool ADHD, she discusses an evidence-based approach to judicial use of methylphenidate and amphetamine salts, and challenges the use of alpha-agonists in this age group. 

Dr. Elise Fallucco is a child psychiatrist, mom, and host of PsychEd4Peds.  She is a Professor of Pediatrics and Child and Adolescent Psychiatry with over 14 years experience in training pediatric clinicians to identify and treat mental health problems.

Check out our website PsychEd4Peds.com for more resources.
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Transcript

Dr. Elise Fallucco: 0:21

welcome back to psyched for paeds, the child mental health podcast for pediatric clinicians, helping you help kids. I'm your host, Dr. Elise Fallucco, child psychiatrist and mom. Today. I want to start out by thanking all of our friends and colleagues for your comments and your questions and suggestions for future episodes. It's really helpful to hear from our psyched for paeds community and to learn about what's working in your practices and also about what you're interested in learning more about. I had a chance to talk with a group of pediatricians who asked several questions. And I wanted to share one of them because it ties in very nicely with our recent series on helping preschoolers with emotional and behavior problems. So this is Dr. Chanley from Florida.

Dr. Chanley Dudley: 1:08

One of the things that we run across a lot are the little kids who are getting kicked out of preschool. And they're the ones who are bouncing off the walls. They bite their siblings or other kids at school and their parents are about to pull their hair out. And these kids are just aggressive. And it could be from ADHD. It could be from anxiety. We definitely try to get these kids into therapy and have them cognitively evaluated by the neuro psychologists, as best we can, but then they're the ones who do need help sometimes from medications. And I'd like some guidance on that. Do you have some suggestions on obviously off-label usage for treatment of children who are under the age of six, specifically? Like your four-year-olds or maybe even your five-year-olds?

Dr. Elise Fallucco: 1:48

This is a great question. And before we start talking about meds and treatment in this group, it's really helpful to first do an evaluation to try to better understand what's going on, what's driving the behavior problems so that we know what we're treating. I'd like to start with thinking about a broad differential diagnosis. So these young kids with behavioral problems and aggression could have so many different things going on. Thinking back to episode 20 with Dr. Joyce Harrison on preschool behavior problems, we have the alphabetized differential diagnosis. Instead of ABCs, we have ACDs, and starting with the A's. A would be ADHD, anxiety, both of which you mentioned, but it also could be autism. And then we skip B and move to C's communication difficulties. D developmental delay. And then finally the S part of the ACDs are scary or traumatic events or traumatic stress. In your clinical interview, you could use Dr. Harrison's eight S framework to ask the questions To really try to tease out, is this something developmental that's going on or do we think that this may be something more like anxiety or ADHD or trauma? And if you suspect developmental concerns, whether it's autism communication difficulties. Or possible developmental delay. Great call to refer for further cognitive and developmental evaluation by a psychologist. Or you mentioned a neuropsychologist, by a developmental behavioral pediatrician or an autism center, if you are lucky to have these resources in your area. And shifting from evaluation to treatment. You also mentioned that you try to refer these kids for therapy as a first-line which is so important. First-line treatment for preschoolers, is parent- child therapy And also to have a ideally a evaluation to try to better understand what's really driving the behaviors because we know the behavior is just a symptom of them not feeling well on the inside or something not going right. And in an ideal world, each child would have quick, easy access to all of these evidence-based therapies and evaluations. So the only kids in your office would be the ones who had failed therapy. However we know in the real world that access to therapy especially for really young kids is limited. There's not a lot of places that do therapy with preschoolers. And so if you're able to find one that takes your family's insurance, oftentimes there's a wait. And so a lot of families don't even get that trial. And so in the real world, you've made these referrals, but in the meantime, the parents and kids end up waiting indefinitely. And their symptoms are not getting better. And so what we can do is obviously share the parenting tips that we learned about in episode 21 with the families. And then we try to access the referral resources. We also talked about in the previous episode. But the kids in your office and now we're really back to thinking about medications. And so the tricky part is, we want to be really judicious in using medication in this population because of their developing brains and because they are so sensitive to side effects. Effects when you do try to start medications. What I will tell you clinically is you do your absolute best to get them a trial of therapy. And the right type of evidence-based therapy. And if we're getting kicked out of preschool and completely disruptive and, or a danger to self or others, then I think we really are. Doing well to consider. Medication in those cases. Going back to the case, you presented Dr. Dudley of the child who's hitting lots of people and getting kicked out of preschool. You would want to think about assessing for ADHD, anxiety, and trauma. We know an easy way to assess for trauma would be to use the parent report of the pediatric traumatic stress screening tool. It's really for kids who are a little bit older, but it could potentially help rule out the possibility of trauma or traumatic stress being responsible for the symptoms. And then you'd want to ask a couple questions to assess for anxiety. The parent could probably tell you whether the child is particularly worried or again, you could use the eight S framework to see if there's sort of a pattern of symptoms occurring around a specific trigger that could be anxiety provoking. But let's say, for the sake of the case that there's no trauma involved and we're not concerned about anxiety. And it really does seem like ADHD in the absence of any clear, obvious developmental delay or concern for developmental disorder. And so in that case, then we'd be thinking about medications for ADHD in a preschool aged kid. I really think about two classes of medications- so the stimulants or the alpha agonists like guanfacine or Clonidine Stimulants can be really effective. However, preschoolers are so incredibly sensitive to stimulant side effects. And so it can make them more dis-inhibited or they can have behavioral activation or they can have major mood changes. So you would start on very baby doses. And sometimes I'll just. I really want them to be as close to six years old as we possibly can before doing that. And here is the three step approach that I would take. The first step is a little bit of a paradoxical choice. Although the amphetamine salts have FDA approval for kids three and older. The methylphenidate stimulants are the ones that we actually use clinically for preschoolers, because we have a number of large trials showing safety and efficacy of methylphenidate in this population, even though they're off label and only have the FDA approval for kids six and older. Basically step one would be the low dose short acting methylphenidate. And when I say low dose methylphenidate, I'm thinking something like. 1.25 to 2.5 milligrams in the morning, and then that same dose again, around lunch. and potentially you could dose it again after school, if you need, until you can find the target dose, but I would really start with something 2.5 milligrams. Or potentially smaller if you've got a very, very young slash tiny kid, once daily in the morning, make sure that they tolerate it and don't develop side effects. And then you can add another baby dose of 2.5 milligrams around lunchtime. See how they do for a couple of weeks and titrate up if needed. And then the second choice, if they don't tolerate low dose methylphenidate. Would be to consider the amphetamine salts One option that has two recent good trials. In preschoolers is Vyvanse, and you could start at five or 10 milligrams. It can be used in preschoolers and this one's nice because it has a really long half-life and stays in their system longer. So to briefly recap this process for choosing meds for preschool ADHD. First choice would be short acting methylphenidate. Second choice would be amphetamine salts. And finally the third choice if they fail both of these stimulant trials you could consider alpha agonists things like guanfacine or Clonidine at really low doses, carefully monitoring blood pressure. And I know a lot of clinicians prefer alpha agonist to stimulants in this population. But again, we really do not have sufficient data for safety or effectiveness of alpha agonists in preschoolers. So these are very much off-label. And I just want to reemphasize the fact that first-line treatment for preschoolers is evidence-based therapy. And in these particular cases of extreme behavior, Where children have either failed a trial of therapy or have such severe symptoms that they're causing major impairment or danger to themselves or others. Then this is how I would think about approaching things. So as a brief recap, when you got a child with extreme behavior in your office and you've referred them to therapy and they've either failed or they're unable to access it. Really think about ruling out potential trauma using the pediatric traumatic stress tool. Look for anxiety and then think about ADHD and developmental issues. And for a child with ADHD, who's under the age of six. First-line would be to consider low dose short acting methylphenidate products. Second choice would be the amphetamine salts. And then third choice would be to consider the alpha agonist, which really don't have a lot of evidence-base for this. Young age group. Wrapping up this somewhat controversial issue. I just want to say thank you for listening. If you have any other questions we'd really love to hear from you and to find out what's working in your community. And what questions do you have about some of the patients in cases in your office? So please send a chat on the website. Send a message through Instagram or email us at info at site. The number four paeds.com. See you next time.