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What's New - Preschoolers' Prescriptions

Study shows most Northwest preschoolers cared for by Kaiser Permanente who get psychiatric medication have severe behavioral problems

Kaiser Permanente's Center for Health Research is First to Link Preschoolers' Prescriptions with Their Mental Helath Diagnoses

(PORTLAND, Ore.) - Researchers at Kaiser Permanente's Center for Health Research in Portland have found that 2 percent of Northwest preschoolers ages 2 to 5 enrolled in Kaiser Permanente had been diagnosed with symptoms of one or more emotional or behavioral disorders. Of the 743 youngsters with such a diagnosis, one in six (120) had been prescribed a psychiatric medication, such as Ritalin.

"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," says Lynn DeBar, PhD, lead author and principal investigator for the study.

The study was funded by Kaiser Permanente's Center for Health Research. It appears in the February 10th issue of the Archives of Pediatrics and Adolescent Medicine. The study follows on the heels of research documenting an increase in the prescribing of psychiatric drugs among school-age and younger children. The Kaiser Permanente study examined whether psychiatric drugs are prescribed appropriately.

Researchers analyzed the medical and pharmacy records of all children between ages 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 one percent) had been prescribed a psychiatric medication.

On average, the time between a child's first diagnosis of a behavioral or emotional health problem and a child receiving a medication was six months. This suggests, says DeBar, that drug treatment was rarely, if ever, the first line of treatment.

ADHD the most common problem
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. The medication they were prescribed most often was consistent with that diagnosis, namely a stimulant, such as Ritalin, which helps control impulsive and aggressive behaviors. Nearly half 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 (a medicine used increasingly in children to control aggressive behavior and sleep problems). Less frequently used were antidepressants 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," says DeBar, who is 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 says the study also showed that children on medication were from homes less equipped to cope with their disruptive behavior. More than three fourths (77 percent) had some kind of instability in the home, including sexual or 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," says pediatrician Jim Powell, MD, 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. The physicians work to determine the cause of difficult behaviors by collecting lots of information over time. Based on our findings, we can say that the 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."

Most also receive other mental health care
For example, Dr. Powell says the vast majority (82 percent) of children and families received some form of mental health or behavioral management/parenting services from Kaiser Permanente Northwest or outside agencies. The researchers also examined a number of treatment procedures that are associated with prescribing psychiatric drugs. A follow-up appointment was scheduled and attended within 12 weeks of an initial prescription for 93 percent of the children to assess medication effectiveness and possible adverse effects. Medical records also showed that 53 percent received some form of psychological testing, ranging from full psychological and/or neurological assessments to behavioral rating scales administered to children's parent or caregivers.

Dr. Powell cautions that, although children across the nation are prescribed psychiatric drugs, because no other health care organizations have published such precise data on diagnosis and medication, there's no way to make comparisons. He says that further research is needed to find out what the experience of children in other health care settings is.

About Kaiser Permanente
Kaiser Permanente's Center for Health Research, founded in 1964, is a not-for-profit research institute that conducts research in the public domain. Its mission is to advance knowledge to improve health.

Kaiser Permanente (Oakland, Calif.) is America's leading integrated health care organization. Founded in 1945, it is a non-profit, group-practice prepayment program. Kaiser Permanente serves the health care needs of 8.4 million members in nine states and the District of Columbia. Nationwide, Kaiser Permanente includes approximately 90,000 technical, administrative, and clerical employees and 11,000 physicians representing all specialties.

Kaiser Permanente's Center for Health Research is a not-for-profit research insitute dedicated to discovering and advancing knowledge to improve health. Kaiser Permanente is a group practice health care organization serving the health care needs of about 455,000 people in Northwest Oregon and Southwest Washington.

For more infomation contact:
Terry Fitzpatrick (503) 335-6602 or
Jim Gersbach (503) 831-4820

Released: February 10, 2003