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Kaiser Study Refutes Notion That Young Children Are Over-Prescribed

from http://www.medscape.com/viewpublication/422
Posted 02/28/2003

In a study released in this month's issue of the Archives of Pediatrics and Adolescent Medicine, researchers at Kaiser Permanente's Center for Health Research in Portland, Ore., found that most preschoolers cared for by Kaiser Permanente who receive psychiatric medication have severe behavioral problems.

Researchers analyzed the medical and pharmacy records of all children between the ages of 2 and 5 who received care from Kaiser Permanente Northwest physicians from January 1997 through December 1998. Of these 38,664 children, about one in 300 (three-tenths of 1 percent) had been prescribed a psychiatric medication.

Two percent of the preschoolers had been diagnosed with one or more emotional or behavioral disorders. Of these 743 children, only one in six had been prescribed a psychiatric medication.

"To my knowledge, this is the first study that directly links medications received by preschool children with their mental health diagnoses and behavioral symptoms, and with the kinds of treatment they received," said Lynn DeBar, Ph.D., lead author and principal investigator of the study.
On average, the time between a child's first diagnosis of a behavioral or emotional problem and the child receiving a medication was six months. This suggests that drug treatment was rarely, if ever, the first line of treatment, said DeBar.

Nearly 90 percent of the children on medication had received a diagnosis of attention-deficit/hyperactivity disorder (ADHD) alone or in combination with another condition. According to the researchers, the medications they were prescribed most often were stimulants, such as Ritalin (methylphenidate).

Nearly half of the children (48 percent) received a stimulant only. The next most common prescription (23 percent) was for a stimulant in combination with an alpha-adrenergic agent (used to control aggressive behavior and sleep problems).

Less frequently used were anti-depressants alone or in combination with either a stimulant or one of the alpha-adrenergic agents (12.5 percent).

"The children who were prescribed medication had severe behavior problems that seriously impacted their families," said  DeBar, a clinical  psychologist. "

"For example, almost half (45 percent) had difficulty remaining in child care due to extreme aggressive or impulsive behavior. In some cases, they had been asked to leave three or four preschools, and even grandparents no longer felt capable of caring for them."

DeBar said the study showed that children on medication were from homes less equipped to cope with their disruptive behavior. More than three-fourths had some kind of instability in the home, including sexual abuse; physical abuse or neglect; having a parent with current or past emotional or substance abuse problems; and children's removal from the home because of parents' inability to care for them.

"What happens early in a child's life matters a great deal," said pediatrician Jim Powell, M.D., co-author of the study and head of Kaiser Permanente Northwest's Neurodevelopmental Clinic. "In my experience, parents of children with these behavior problems typically don't demand medication and physicians don't push the use of drugs. 

Based on our findings, we can say that physicians in the study were cautious about prescribing psychiatric medications, recommending their use as a trial if the disruptive symptoms are severe. Typically, other kinds of interventions are recommended as well."

Powell said that the vast majority (82 percent) of children and families receiving medications also received some form of mental health or behavioral management/parenting services from Kaiser Permanente Northwest or outside agencies. Follow-up visits were scheduled within 12 weeks to assess medication effectivenessand possible adverse effects.

Medical records showed that 53 percent received some form of psychological testing, ranging from full assessments to behavioral rating scales given to parents or caregivers.

Mental Health Weekly 13(7):5, 2003. 2003 Manisses Communications Group, Inc.

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