Update on Screening, Referring, and Treating the

Curr Treat Options Peds DOI 10.1007/s40746-017-0076-x

Mental Health (WF Njoroge and TD Benton, Section Editors)

Update on Screening, Referring, and Treating the Behavioral, Social, and Mental Health Problems of Very Young Children Shannon Bekman, PhD, IMH-E®(IV)1,* Celeste St. John-Larkin, MD2 Jennifer J. Paul, PhD3 Amanda Millar, BA3 Karen Frankel, PhD, IMH-E®(IV)3 Address *,1 Mental Health Center of Denver, 3401 Eudora Street, Denver, CO, 80207, USA Email: [email protected] 2 Pediatric Mental Health Institute, Children’s Hospital Colorado, University of Colorado School of Medicine, Box 130, 13123 East 16th Avenue, Aurora, CO, 80045, USA 3 Department of Psychiatry, Irving Harris Program in Child Development and Infant Mental Health, University of Colorado School of Medicine, Anschutz Medical Campus, 13001 E. 17th Place, Box F546, Aurora, CO, 80045, USA

* Springer International Publishing AG 2017

This article is part of the Topical Collection on Mental Health Keywords Infant mental health interventions I Early childhood evidence-based treatments I Young child mental health screening, preschool I Treatment I Psychopharmacology

Opinion statement Very young children can experience a wide range of mental health disorders including posttraumatic stress disorder, anxiety disorders, depression, and parent-child relationship disorders, among others. These disorders cause young children true psychological suffering and family stress and often do not resolve without treatment. Pediatricians have a pivotal role in routinely screening all young children for mental health concerns and referring to specialized early childhood mental health providers when concerns are present. A Bwatchful waiting^ approach is strongly discouraged. There are a number of highly effective evidence-based practices that exist to treat most mental health problems in young children. We strongly espouse dyadic mental health services that focus clinical interventions on the parent-child relationship, which is seen as the vehicle of change at

Mental Health (WF Njoroge and TD Benton, Section Editors) these developmental stages. The conservative use of psychiatric medications should be reserved for preschoolers ages 3 and over, should occur only after a course of psychotherapy has been unsuccessful in ameliorating severe symptoms, and should be managed under the supervision of a child and adolescent psychiatrist.

Introduction As the field of early childhood mental health continues to expand in both recognition and scientific merit, the role of pediatricians in linking young children with necessary mental health care grows. A mounting literature indicates the incidence and prevalence of emotional and behavioral health disorders in very young children is on the rise. While prevalence data of psychopathology in infants is scarce, epidemiological studies show the rate of psychiatric disorders in community samples of preschoolers ranges from 10–27%, rates comparable to those found for older children and adults [1, 2]. These concerns often present to the pediatrician and referral to clinical assessment, and intervention is the next necessary step. Although there has been debate about the desirability of diagnosing psychiatric disorders in very young children (for a review see [3–5]), it is increasingly accepted that young children can and do experience a host of mental health disorders including: posttraumatic stress disorder, anxiety disorders, depression and other mood disorders, regulatory disorders, and parent-child relationship disorders [6]. This acceptance has prompted the development of a specific diagnostic system to be used with children under the age of 6: DC:0–5™ Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood [7]. Emotional and behavioral problems in young children often are not transient [8, 9] and do not remit on their own [10]. Years of research demonstrate that early-onset emotional and behavioral problems,

when left untreated, are associated with a variety of negative sequelae including poor peer relationships [11] adolescent and adult mental health disorders, juvenile delinquency, and school dropout [12]. Thus, the importance of early identification and intervention before disorders become entrenched is paramount. Recent evidence supports active intervention before disorders become entrenched and cautions against managing emotional disorders in the early years with a Bwatchful waiting^ approach [13••]. Luby cites the developmental neuroplasticity characteristic of early childhood and the substantial literature that suggests clinical treatments are likely to be most effective when provided in the earliest of years [14]. While it can be distressing to acknowledge the psychological suffering of very young children, these problems are identifiable and treatable. This paper provides a roadmap for pediatricians to become conversant in the mental health screening tools and various evidence-based treatments available for the 0–5 population, so that appropriate and timely referrals can be made when problems first manifest. The interventions detailed below focus heavily on the parent-child relationship and dyadic approaches to treatment where the primary relationship is the agent of change. We also review the use of psychiatric medications in very young children.

Perinatal and early childhood mental health screening Perinatal depression screening The literature suggests that child psychopathology is impacted by maternal depression (for a review see [15]). The US Preventative Services Task Force (USPSTF) recommends screening all adults for depression. In 2016, USPSTF expanded these guidelines to include the routine, universal screening of pregnant/postpartum women by health care providers, including pediatric primary care practitioners [16••]. The American Academy of Pediatrics (AAP) recommends screening for maternal depression over the course of the first year of a child’s life (e.g., 1, 2, 4, and 6-month well-child visits) in its Clinical Report:

Update on Screening, Referring and Treating Mental Health

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Table 1. Developmental and mental health screening/assessment for use in pediatric settings for children ages birth–5 years

Instrument name

Age range

Administration time

Key reference

1 month–5½ years

[39]

18 months–5 years

10–15 min Scoring 2–3 min 10–20 min

[40]

0–18 months

5–10 min

[41]

16–30 months

5 min (first stage) 5–10 min (F/U) 10–20 min

[42]

General Developmental Ages and Stages Questionnaire—Third Edition (ASQ-3TM)a Child Development Review—Parent Questionnaire (CDR-PQ) Infant Development Inventory (IDI) Autism Modified Checklist for Autism in Toddlers—Revised with Follow-up (MCHAT-R/F)a Pervasive Developmental Disorders Screening Test-II (PPDST-II), Stage 1—Primary Care Screener (PSC) Psychosocial/behavioral/mental health

12–18 months

[43] [44]

3–5 years

10–15 min Scoring 1–3 min 10 min

[46]

2–21 years

10–20 min

[47]

4–17 years

10 min

[48]

12–36 months

7–10 min

[49]

10–20 min

[50]

Early Childhood Screening Assessment (ESCA)

18 months – 5 years 18–60 months

[51]

Pediatric Symptom Checklist-17 (PSC-17)a

4–18 years

10–15 min Scoring 1–2 min 3–5 min

The Preschool Anxiety Scale of SCAC

2.5–6.5 years

5–10 min

[53]

Strengths and Difficulties Questionnaire (SDQ) early years; (2014)a, b Trauma Symptom Checklist for Young Children (TSCYC)

2–4 years

5–10 min

[54]

3–12 years

15–20 min

[55]

Ages and Stages Questionnaire: Social Emotional—Second Edition (ASQ:SE-2 TM); (2015)a, b ADHD Rating Scale—IV Preschool Version Behavior Assessment System for Children (BASC-3); (2015)b Brief Impairment Scale (BIS) Brief Infant-Toddler Social and Emotional Assessment (BITSEA) Child Behavior Checklist (CBCL) 1.5–5

1 month–6 years

[45]

[52]

a

Listed in California Evidence-Based Clearing House (CEBC) tools used for screening mental health needs Year noted for updates within the past 5 years

b

Incorporating Recognition and Management of Perinatal and Postpartum Depression into Pediatric Practice [17••]. Per the USPSTF, screening measures such as the Edinburgh Postnatal Depression Scale (EPDS) [18, 19] and Patient Health Questionnaire-9 (PHQ-9) [20] are suggested. My Mood Monitor (M3) has also been validated in primary care settings and specifically screens for anxiety, OCD, and PTSD, in addition to depression [21]. Increasing evidence suggests that screening for paternal depression is also needed [22–25]. Healthy fathers may serve as protective factors for babies whose mothers are suffering from PMADs, but when fathers are also suffering from emotional challenges, they compound the risks to the infant [26–28]. The Gotland Male Depression

Mental Health (WF Njoroge and TD Benton, Section Editors) Scale [29] and the Masculine Depression Scale [30] include both the more traditional internalizing depressive symptoms and the externalizing depressive symptoms theorized to be more prominent in male depression, though improved tools for identifying paternal depression [31, 32] as well as routine screening guidelines [33] are needed.

Pediatric screening and assessment The AAP recommends routine screening and assessment at well-child visits from birth through age 21 years, including mental health screening in early childhood [34••]. The October 2015 update of the Bright Futures/AAP Recommendations for Preventive Pediatric Health Care Periodicity Schedule recommends monitoring in the following subdomains for young children through 5 years at minimum: developmental screening (9, 18, and 30 months), developmental surveillance (all well-child visits excluding 9, 18, and 30 months when developmental screening is completed), psychosocial/behavioral assessment (all well-child visits), and autism screening (18 and 24 months) [35••]. Some pediatric practices screen at every contact [36] or utilize integrated behavioral health clinicians [37]. In 2010, the Centers for Medicare & Medicaid Services made many screenings and assessments utilized within primary care reimbursable; The AAP released a fact sheet about coding for developmental screening and testing [38]. A growing body of literature exists regarding screening and assessment tools within pediatric primary care settings (for a review see [34••]), including those related to early childhood mental health [56] (see Table 1). The second edition of the Ages and Stages Questionnaire: Social-Emotional (ASQ:SE-2) examines selfregulation, compliance, communication, adaptive behaviors, autonomy, affect, and interaction with people, and allows for social-emotional screening of children as young as 1 month [45]. In 2011, the AAP released new guidelines to include diagnosis and treatment of ADHD in children as young as 4 years old [57]. While the AD/HD Rating Scale-IV Preschool Version is available as an ADHD-specific screener for children ages 3–6 years [46], national surveys suggest providers typically utilize broader psychosocial/behavioral scales or checklists to identify ADHD in preschool children [58] (e.g., Child Behavior Checklist 1.5–5). Once the pediatrician has determined the probable need for additional assessment or treatment, the next step is referral. Fortunately, evidence-based and promising practices exist to address most early childhood mental health challenges. These should be delivered by specially trained infant and early childhood mental health specialists. There are endorsements (e.g., The MI-AIMH Endorsement for Culturally Sensitive, Relationship-focused Practice Promoting Infant Mental Health [IMH-E®] [59, 60] and the Transdisciplinary Infant-Family and Early Childhood Mental Health Practitioners [61]) which certify clinicians’ competency to treat this special population. Pediatricians are encouraged to seek out mental health providers with this expertise and endorsement whenever possible. The World Association for Infant Mental Health (WAIMH) [62] has affiliates in 26 states in the USA which can provide information on qualified professionals. We acknowledge that in some areas, there is a shortage of qualified child mental health providers, especially Child and Adolescent Psychiatrists. The use of telehealth and innovative telephone consultation programs have increased access to this expertise in many states across the country [63]. The National Network of Child Psychiatry Access Programs [64] lists programs in 28 states, with contact information available.


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Once providers are identified, families can be referred for office-based, homebased, or childcare-based treatment. Treatments can be focused on the individual child, the caregiver-child pair (dyadic therapy), or on parent training. Parent training can occur individually or in groups.

Evidence-based treatments Child Parent Psychotherapy Child Parent Psychotherapy (CPP) is a relationship-based intervention for children ages 0–5 who have experienced a traumatic event (e.g., physical or sexual abuse, neglect, exposure to domestic violence, accidental injury) and are experiencing problems including PTSD or other manifestations of traumatic stress including externalizing problems (i.e., aggression, defiance, tantrums, noncompliance) and internalizing problems (i.e., separation anxiety, sleeping difficulties, and social/emotional withdrawal). CPP is a dyadic treatment that views promotion of the parent-child relationship as the most expedient and enduring path to the healing of young children. Families are seen in weekly joint parentchild sessions either in the family home or clinic, typically for a 12-month course; individual sessions with the parent are scheduled when indicated. CPP focuses on promoting emotion regulation in both the child and parent; the resolution of child trauma-related symptoms and maladaptive parent-child interaction; supporting developmentally appropriate interactions; co-creation of a trauma narrative and re-establishing the child’s trust in the parent as a source of safety and protection. CPP uses several treatment modalities including (1) promoting developmental momentum through play, physical contact, and language (2) provision of unstructured developmental guidance, (3) modeling appropriate protective behavior for the parent (3) interpreting feelings and actions, (4) providing emotional support and empathic communication, and (5) providing crisis intervention, case management, and concrete assistance with problems of living [65]. CPP has strong empirical support and is listed in the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-Based Programs and Practices [66] as an evidence-based treatment. Clinical trials demonstrate numerous positive outcomes including improved attachment security [67, 68]; improvements in children’s behavior problems, traumatic stress symptoms, and diagnostic status of PTSD [69]; increases in children’s cognitive performance [68]; and improvements in self and maternal representations [70].

Parent-Child Interaction Therapy Parent-Child Interaction Therapy (PCIT) is an evidence-based behavioral parent training program that treats disruptive behavioral problems in children ages 2– 7 [71]. It targets disruptive, noncompliant, oppositional, defiant, and aggressive behaviors. PCIT has been shown to be effective with a number of special populations including physically abusive/maltreating parents [72, 73], children with intellectual disability [74], and child witnesses to domestic violence [75]. In addition, a modified version of PCIT delivered in the home has shown promising effects for infants from high-risk families who scored high on screens of behavior problems during a pediatric primary care visit [76].

Mental Health (WF Njoroge and TD Benton, Section Editors) Table 2. Summary of evidence-based and promising interventions for children ages birth–5 years Intervention

Targets of treatment

Targeted ages (years)

Format

Length of treatment

Child Parent Psychotherapy (CPP)a

PTSD, child witnesses to domestic violence and exposure to other traumas

0-5

On average 12 months of weekly sessions

Parent-Child Interaction Therapy (PCIT)a

Externalizing behavior problems (disruptive behaviors, non-compliance, aggression) Physically abusive parenting. Newer adaptations target anxiety and depressive disorders. PTSD symptoms

2-7

Predominantly dyadic caregiver-child sessions with individual parent or child sessions as needed. Dyadic caregiver-child sessions with 2 caregiver only teaching sessions.

Incredible Years-BASIC Parent Traininga

Parenting skills, children’s disruptive behavior

Caregivers of children 0-12

Circle of Security Intervention (20-week protocol)

Caregiver sensitivity, children’s attachment security, caregiver mental representations of child

Caregivers of children 0-5

Mother-Infant Therapy Group (M-ITG)

Caregiver perinatal mood and anxiety disorders, caregiver-infant interactions

Caregivers of infants

Preschool PTSD treatment (TF-CBT)a

3-6

Predominantly individual child sessions, with some conjoint parent-child sessions and individual parenting sessions. Group parent training with protocols grouped by child age (babies, toddlers, preschool and school age) Small group treatment with 5–6 caregivers; treatment incorporates video clips of dyadic caregiver- child interactions. Group sessions that consist of a mother’s group ran concurrent with an Infant Developmental Stimulation Group, followed by Mother-Infant Dyadic Group

12–20 weekly sessions, but can vary based on caregiver skill acquisition and child’s symptoms

12 weekly sessions

10–20 weekly group sessions of 2-3 h (time and length vary by child age) 20 75-min weekly group sessions

12 weekly group sessions

a

evidence-based treatment per SAMHSA’s National Registry of Evidence-Based Programs and Practices

What makes PCIT unique is its method of delivery: PCIT uses a Bbug in the ear^ approach where caregivers are coached while playing with their child. The clinician provides behavioral parent coaching in real time, usually from behind a one-way mirror, to help parents have successful, positive interactions with their young children. Treatment is delivered in two sequential phases: child directed interaction (CDI) and parent-directed interaction (PDI). CDI, known as the relationship enhancement phase, teaches parents to follow their child’s lead, praise, describe, and imitate the child’s appropriate behaviors and reflect their child’s positive language to create a strong, warm, mutually enjoyable parent-child relationship [77]. PDI, the discipline portion of PCIT, teaches parents effective behavior management strategies to promote children’s compliance with parental commands and decrease aggressive/disruptive behaviors. While originally developed to treat externalizing behavior disorders, there have been recent adaptations of PCIT to treat anxiety and mood disorders in young children (for a review see [78]), such as separation anxiety [79], preschool depression [80], and selective mutism [81].


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Trauma-Focused Cognitive Behavioral Therapy TF-CBT/Preschool PTSD Treatment Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an evidence-based treatment for children ages 3–18 that treats posttraumatic stress disorder and other trauma-related symptoms [82]. TF-CBT is the most well-established trauma treatment for children, with randomized clinical trials consistently demonstrating large effect sizes in treating symptomatology related to a wide variety of traumas (e.g., sexual or physical abuse, exposure to domestic violence, medical trauma, war, etc.). Scheeringa and colleagues have shown TF-CBT’s feasibility and efficacy with preschoolers (ages 3–6 years; [83]). Their randomized controlled trial demonstrated a large posttreatment improvement in PTSD symptoms as compared to a waitlist control, with additional gains seen at a 6-month follow-up. Primary caregivers are incorporated into several sessions, and when not in the treatment room with the child, caregivers observe the child’s sessions (i.e., via one-way mirror or TV) to promote attunement (see [84] for full treatment protocol).

Incredible years Incredible years (IY) is a widely researched set of three complementary, developmentally based group training curricula for parents, teachers, and young children that are effective in promoting positive parenting practices and treating young children’s disruptive behavior problems. The programs have been disseminated both nationally and internationally and are included in SAMHSA’s National Registry of Evidence-Based Programs and Practices. At the heart of IY are the BASIC parent training programs. These parenting programs are available for caregivers of children ages 0–12 years and are grouped according to age: babies (0–12 months), toddlers (1–3 years), preschoolers (3–6 years) and school age (6–12 years). Groups are delivered in 10–20 weekly group sessions, typically at mental health centers or child care, and rely heavily on the use of videotaped vignettes of real-life situations that demonstrate targeted skills. Sessions focus on strengthening parent-child interactions, providing nurturance, reducing harsh discipline practices, strengthening parents’ ability to promote their children’s social, emotional, and language development, and reducing conduct problems [85]. Child programs include the Classroom Dinosaur curriculum that is a prevention program for use by teachers of children ages 3–8 years. There is also the Small Group Dinosaur Therapy for children ages 4–8 with clinical disorders including oppositional defiant disorder, ADHD, and internalizing problems. A recent meta-analysis (reviewing 50 studies) of the parent training program deemed the parent training program to be effective in reducing disruptive child behavior and increasing prosocial skills in a diverse range of families [86]. Furthermore, a study by Seabra-Santos et al. [87] also demonstrated caregiver improvements in parenting practices and self-confidence.

Evidence-informed treatments Circle of Security Circle of Security (COS) is an attachment-based group intervention for caregivers of children ages 0–5 designed to promote children’s attachment security by increasing caregivers’ sensitivity and responsiveness to young children’s emotional needs [88]. The original COS intervention is comprised of 20 small

Mental Health (WF Njoroge and TD Benton, Section Editors) group sessions in which 5–6 caregivers meet weekly with a clinician. The intervention is organized around the use of the BCOS graphic^ which depicts children’s attachment and exploratory needs (i.e., secure base/safe haven phenomenon) in a user friendly way that promotes parental understanding of attachment theory. The intervention includes use of individualized video clips of caregivers interacting with their young children to increase caregivers’ awareness of their children’s emotional cues. Although the COS intervention is firmly grounded in well-established theory, it is currently not considered an evidence-based treatment by SAMHSA’s National Registry of Evidence-based Programs and Practices. However, several recently published studies lend support to the intervention’s efficacy in improving caregiver-child relationships [89, 90], with randomized controlled trials underway [91]. The creators of COS have more recently condensed the content of the original 20-week intervention into two other abbreviated protocols: the COS-parenting DVD and COS-HV4 (i.e., four home visiting sessions). Empirical research of these protocols remains limited at this time.

Mother-Infant Therapy Group Mother-Infant Therapy Group (M-ITG) is a manualized group therapy treatment for mothers experiencing postpartum depression that utilizes Cognitive Behavioral Therapy (CBT; [92, 93]) and Interpersonal Psychotherapy (IPT; [94]) combined with reflective process through a psychodynamic lens [95]. While a number of treatment interventions are available for women experiencing Perinatal Mood or Anxiety Disorders (PMADs), M-ITG is one of the few treatments that intentionally intervenes with the mother individually, the baby individually, and the mother-baby relationship. Dyadic therapy is a critical component of this model given evidence that even effective individual treatment of mothers’ postpartum depressive symptoms does not subsequently improve the mother-infant relationship [96] or mitigate negative outcomes for the child [97]. The M-ITG model consists of a series of individual evaluations followed by 12 weekly group sessions. Parenting partners attend two of the group therapy sessions focused on increasing partners’ understanding of postpartum depression and improving communication and problem-solving skills and the coparenting relationship. Following M-ITG, mothers not only experience significant reduction in depressive symptoms, but also demonstrate improved interactions with their babies [98]. Although M-ITG is not listed on SAMHSA’s National Registry of Evidence-Based Programs and Practices, it is grounded in well-established evidence-based treatments (e.g., CBT and IPT). Table 2 presents a summary of available evidence-based treatments and other promising interventions for the 0–5 population.

Considerations regarding the use of psychotropic medications for preschoolers Many mental health concerns are initially brought to primary care providers by parents seeking help for behavioral and emotional problems in their young children. However, research is limited in preschool psychopharmacology, creating a dilemma for the pediatrician and the family. Caution is advised in psychopharmacologic medication treatment for youth ages 5 and younger, due to the period of rapid brain development, considerations of the context of the family and other caregiving environments, and lack of strong evidence for efficacy


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Table 3. Adverse drug events increased in preschoolers and young children

Medication class

Adverse drug events commonly seen in preschoolers and young children

Simulants

Decrease in height and weight percentile growth velocity More decreased appetite and upper abdominal pain (children in general vs. adults) Tearfulness, irritability and anxiety (school-age children may experience improvement in anxiety) Tics (especially in younger children) Hallucinations (rare 1 in 1200)

Atomoxetine

Greater decrease in growth velocity in preschoolers and children under 7 Vomiting Somnolence

SSRIs

Activation—much more common in preschoolers One small study on fluoxetine showed lower growth in height and weight gain than placebo Youth under 25: increased risk of suicidal thoughts and behavior—unknown for preschoolers

Atypical antipsychotics

Sedation Withdrawal dyskinesia Dystonia—can be responsive to anticholinergic prophylaxis Weight gain—especially olanzapine for preschoolers, and all ages. Weight gain is increased in youth for quetiapine, risperidone and aripiprazole also. Sialorrhea is higher in children with ASD (29–35% vs 4% baseline, and 2% in risperidone-treated patients without ASD) Metabolic and laboratory changes, such as abnormal LFTs, prolactin, fasting glucose, cholesterol and triglycerides.

of psychotropic medications in young children. Treatment with medications for behavioral and emotional concerns in young children should be the exception and not the rule and occur after thorough assessment and therapeutic interventions have failed to alleviate the symptoms. This section will discuss a variety of medications organized by the evidence for each disorder being treated. This varies across the spectrum of symptoms, with the most studies supporting medication in the treatment of ADHD and irritability related to Autism Spectrum Disorders. The American Academy of Child and Adolescent Psychiatry published guidelines on the Psychopharmacological Treatment of Very Young Children in 2007 [99••] which can be very helpful in choosing the best treatment options. The guidelines include algorithms for assessment and treatment of disorders in preschoolers, including ADHD, disruptive behavior disorders, depression, bipolar disorder, anxiety, OCD, pervasive developmental disorders, and primary sleep disorders. Recent literature reviews demonstrate that while open label and case studies may show efficacy for medications in children ages 3–5, they have also a greater risk of side effects in this age group [13••]. Consultation with, or referral to a child and adolescent psychiatrist with early childhood expertise is recommended before prescribing any medication for very young children. Prior to initiating medication, these guidelines recommend adequate trials of therapy for each disorder, which range from 8 weeks in ADHD, between 3 and 6 months for depression, and up to 6 months for CPP and play-based therapy for

Mental Health (WF Njoroge and TD Benton, Section Editors) PTSD [99••]. For cognitive behavioral-based therapies for anxiety disorders, OCD, and PTSD, the minimum treatment should be 12 weeks. PCIT for disruptive behavior problems, as described above, should be continued for a trial of 10 to 20 weeks. In all cases, if parental psychopathology is affecting the child’s presentation, there is evidence that treatment for parents can improve child outcomes and this should be recommended by the child’s medical provider [99••].

Attention-deficit/Hyperactivity Disorder Recently updated guidelines from the AAP [57] and The National Institute for Health and Care Excellence (NICE) in the UK [100], recommend behavioral interventions prior to medication (per above). If symptoms are not improving after 8 weeks, and there is persistent significant functional impairment in more than one setting, then a medication trial is reasonable. Currently, the strongest evidence supports the use of methylphenidate in preschool-age children, based on an NIMH funded, six-site randomized controlled trial, The Preschool ADHD Treatment Study (PATS), which demonstrated methylphenidate’s safety, tolerability, and efficacy [101–103•]. Effect sizes were lower than in older children and preschoolers experienced more mood lability. Doses of immediate release methylphenidate ranged from 7.5 to 30 mg per day, divided three times per day. Twice-daily dosing is often utilized in clinical practice. Amphetamine formulations (mixed amphetamine salts, dextroamphetamine) are second line, if methylphenidate is ineffective or not tolerated. Although FDA indicated for children ages 3–5 for ADHD, amphetamine formulation use is not supported by an RCT. An open label, naturalistic, prospective study of 28 preschoolers found that mixed amphetamine salts showed improvement similar to methylphenidate, though the sample size was not large enough to differentiate between medications [104]. Doses of both medications ranged from 5 to 10 mg twice per day for the short-acting formulations. Amphetamine formulations are more potent than methylphenidate, and initial doses may be as low as 2.5 mg twice per day. Extended-release stimulants have not been studied in preschoolers, but may be used if the immediate release is tolerated at the lowest effective dose. Third-line medications for ADHD include alpha-agonists and atomoxetine. Guanfacine and clonidine have been used in young children, despite lack of RCTs. Ghuman reports on two case studies of five patients under the age of 5 who responded well to clonidine and guanfacine [105]. Extended-release guanfacine and clonidine are FDA approved for monotherapy or in combination with stimulants but have only been studied in children 6 years and older. When stimulants are not tolerated or are contraindicated due to potential side effects, immediate-release, rather than extended-release, alpha agonists should be used in preschoolers, beginning with low doses, 0.025 up to 0.05 mg for clonidine and 0.5 mg for guanfacine. Atomoxetine has been evaluated in an open-label pilot study of 12 preschoolers. ADHD symptoms improved significantly over the 8-week treatment; however, more than 66% of patients experienced side effects, most commonly gastrointestinal complaints, but defiance, tantrums, aggression, and irritability were more concerning to parents [106]. Dosing started with 10 mg at bedtime, increasing weekly up to a maximum of 40 mg, which could be moved to morning if there is difficulty sleeping, or divided twice daily to decrease side effects.


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Autism Spectrum Disorder Primary care providers are often first line in screening and referral for Autism Spectrum Disorder (ASD). While behavioral treatments for ASD are beyond the scope of this review, early intervention with evidence-based treatments, including multidisciplinary, behavioral intervention is critical. Medications may be helpful for severe irritability and aggression in preschoolers, as risperidone (ages 5–16) and aripiprazole (ages 6–17) are FDA approved for irritability related to autism. Two randomized controlled trials with 24 children ages 2.5–6, and 39 children ages 2–6 years demonstrated efficacy and tolerability for risperidone, with improvement in core autism symptoms [107, 108]. Weight gain, sedation, and hypersalivation were the most common side effects. Doses started at 0.5 mg once at bedtime and increased up to 1.5 mg per day; however, smaller doses of 0.25 mg one to three times per day are also helpful in this population. Aripiprazole has not been studied in an RCT in preschoolers, but may be considered as a second-line agent, if risperidone is not tolerated. In clinical experience, weight gain and sedation can be less frequent with aripiprazole than risperidone, although a recent review of naturalistic treatment with risperidone and aripiprazole, which included some children as young as age 3 with ASD, found elevations in BMI z-score to be equal in both treatment groups [109]. The use of SSRIs in preschoolers with ASD is not recommended [99••]. SSRIs have been evaluated in two RCTs with children 5 and above for repetitive behaviors in autism. While a smaller trial of low-dose fluoxetine showed positive results [110], a subsequent study of citalopram in 145 subjects did not show efficacy greater than placebo, and 97% of patients experienced a side effect. These included most commonly increased energy level, impulsiveness, decreased concentration, hyperactivity, stereotypy, diarrhea, and insomnia [111].

Anxiety and depression Psychopharmacologic treatment of preschoolers with anxiety and depression should only be considered after an adequate trial of therapy, as described above. Therapy should be ongoing during medication treatment, which allows for additional monitoring of tolerability and progress. There are no FDA-approved medications for depression or anxiety in children under 6 years. A 2014 review found 11 treatment studies for preschool anxiety disorders, but none for depression [112]. Most were small case studies of one to three patients. Fluoxetine was most common, with doses between 5-20 mg per day. There were only two cases of sertraline reported, and none using other SSRIs. Although positive results were reported, behavioral activation was common. An open-label trial of fluoxetine (N = 6) for OCD in preschoolers found significant improvement in CGI scores [113]. Although only one participant discontinued the medication due to lack of efficacy and behavioral disinhibition, five out of six subjects experienced this side effect. A retrospective chart review of children under 7 on SSRIs suggested efficacy, but also a 28% rate of adverse events: 18% of subjects discontinued the medication due to side effects [114].

Side effects in very young children It is evident that young children experience more adverse effects than adolescents and adults, making informed consent from parents of preschoolers

Mental Health (WF Njoroge and TD Benton, Section Editors) especially important for psychotropic medications. Benefits of the medication may still outweigh the risks in cases of significant impairment. In a national analysis, preschoolers (under age 5) were found to be twice as susceptible to adverse drug events (from all medications) [115]. A 2011 review by Safer examined psychotropic drug adverse events across the age span [116]. Table 3 below was summarized from information reviewed in this article to highlight some specific reactions which may be more common in younger children.

Conclusions Early childhood mental health problems are common and treatable. Screening for and detecting these problems early can have long lasting positive impacts for the child and family. Ongoing symptoms place very young children at increased risk for impaired family and peer relationships, educational problems, high-risk behaviors, and future mental health problems [99••]. Screening can begin at newborn and well-baby visits by screening for perinatal depression in the parents and continue through early childhood with a variety of measures outlined in Table 1. There are evidence-based and promising psychotherapy treatments available for the birth-to-5 population, and familiarity with these options will help primary care providers recommend the best treatment for their young patients and families. A trial of psychotherapy is always recommended prior to initiating psychopharmacology in children 5 and younger, given the limited evidence for using medications in preschool children, as well as increased risk of adverse effects. It is important for primary care providers to balance the risks and benefits of medications, with the risk of not treating in difficult cases that are not responding to psychotherapeutic interventions. When considering pharmacotherapy, primary care providers are encouraged to refer to child psychiatrists when possible for treatment of this very young population. When this is not possible, resources exist to assist primary care providers including the American Academy of Child and Adolescent Psychiatry’s practice parameters [117] and telepsychiatry options. Primary care and early childhood mental health providers can increase collaboration to help improve the health and lives of these vulnerable patients.

Compliance with Ethical Standards Conflict of Interest Shannon Bekman declares that she has no conflict of interest. Celeste St. John-Larkin declares that she has no conflict of interest. Jennifer J. Paul declares that she has no conflict of interest. Amanda Millar declares that she has no conflict of interest. Karen Frankel declares that she has no conflict of interest. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.


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References and Recommended Reading Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance 1.

Egger HL, Angold A. Common emotional and behavioral disorders in preschool children: presentation, nosology, and epidemiology. J Child Psychol Psychiatry. 2006;47(3‐4):313–37. 2. Bufferd SJ, Dougherty LR, Carlson GA, Klein DN. Parent-reported mental health in preschoolers: findings using a diagnostic interview. Compr Psychiatry. 2011;52(4):359–69.v. 3. Angold A, Egger HL. Psychiatric diagnosis in preschool children. In: DelCarmen-Wiggins R, Carter A, editors. Handbook of infant, toddler, and preschool mental health assessment. New York: Oxford University Press; 2004. p. 123–39. 4. Carter AS, Briggs-Gowan MJ, Davis NO. Assessment of young children’s social-emotional development and psychopathology: recent advances and recommendations for practice. J Child Psychol and Psychiatry. 2004;45:109–34. 5. Egger HL, Emde RN. Developmentally sensitive diagnostic criteria for mental health disorders in early childhood: the diagnostic and statistical manual of mental disorders—IV, the research diagnostic criteria-preschool age, and the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood—Revised. Am Psychol. 2011;66:95–106. 6. Zeanah CH. Handbook of infant mental health. 3rd ed. New York: Guilford; 2009. 7. Zero To Three. DC:0-5™ Diagnostic classification of mental health and developmental disorders of infancy and early childhood. Washington, DC: Author; 2016. 8. Bufferd SJ, Dougherty LR, Carlson GA, Rose S, Klein DN. Psychiatric disorders in preschoolers: continuity from ages 3 to 6. Am J Psychiatry. 2012;169(11):1157–64. 9. Briggs-Gowan MJ, Carter AS, Bosson-Heenan J, Guyer AE, Horwitz SM. Are infant-toddler social-emotional and behavioral problems transient? J Am Acad Child Adolesc Psychiatry. 2006;45(7):849–58. 10. Mathiesen KS, Sanson A. Dimensions of early childhood behavior problems: stability and predictors of change from 18 to 30 months. J Abnorm Child Psychol. 2000;28:15–31. 11. Danzig AP, Bufferd SJ, Dougherty LR, Carlson GA, Olino TM, Klein DN. Longitudinal associations between preschool psychopathology and school-age peer functioning. Child Psychiatry Hum Dev. 2013;44:621–32. 12. Caspi A, Moffitt TE, Newman DL, Silva PA. Behavioral observations at age 3 years predict adult psychiatric disorders: longitudinal evidence from a birth cohort. Arch Gen Psychiatry. 1996;53(11):1033–9. 13.•• Luby JL. Treatment of anxiety and depression in the preschool period. J Am Acad Child Adolesc Psychiatry. 2013;52(4):346–58. doi:10.1016/j.jaac.2013.01.011.

Offers a comprehensive clinical review of treatments for anxiety and depression in preschoolers. 14. Luby JL. Dispelling the Bthey’ll grow out of it^ myth: implications for intervention. Am J Psychiatry. 2012;169:1127–9. 15. Goodman SH, Rouse MH, Connell AM, Broth MH, Hall CM, Heyward D. Maternal depression and child psychopathology: a meta-analytic review. Clin Child Fam Psychol Rev. 2011;14(1):1–27. 16.•• Siu AL. US Preventive Services Task Force, screening for depression in adults: US preventive services task force recommendation statement. JAMA. 2016;315(4):380–7. This article issues recommendations for screening depression in adults in primary care settings. 17.•• Earls MF. Clinical Report: Incorporating recognition and management of perinatal and postpartum depression into practice. Pediatrics.2010;126(5). Reaffirmed December 2014. This article provides recommendations for the screening of postpartum depression in pepdiatricpractices. 18. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression, development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782–6. 19. Cox JL, Holden JM. Perinatal mental health: a guide to the Edinburgh Postnatal Depression Scale (EPDS). London: Gaskell; 2003. 20. Kroenke K, Spitzer R, Williams J. The PHQ-9 validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606. 21. Gaynes BN, DeVeaugh-Geiss J, Weir S, Gu H, MacPherson C, Schulberg H, et al. Feasibility and diagnostic value of the M-3 Checklist: a brief, self-rated screen for depressive, bipolar, anxiety and post traumatic stress disorders. Ann Family Med. 2010;8(2):160–69. 22. Paulson JF, Bazemore SD, Goodman JH, Leiferman JA. The course and interrelationship of maternal and paternal perinatal depression. Arch Women Ment Health. 2016;19(4):655–63. 23. Freitas CJ, Williams-Reade J, Distelberg B, Fox CA, Lister Z. Paternal depression during pregnancy and postpartum: an international Delphi study. J Affect Disord. 2016;202:128–36. 24. Cameron EE, Sedov ID, Tomfohr-Madsen LM. Prevalence of paternal depression in pregnancy and the postpartum: an updated meta-analysis. J Affect Disord. 2016;206:189–203. 25. Edward KL, Castle D, Mills C, Davis L, Casey J. An integrative review of paternal depression. Am J Mens Health. 2015;9(1):26–34.

Mental Health (WF Njoroge and TD Benton, Section Editors) 26.

Philpott LF. Paternal postnatal depression: how midwives can support families. Br J Midwifery. 2016;24(7):470–6. 27. Wee KY, Skouteris H, Pier C, Richardson B, Milgrom J. Correlates of ante- and postnatal depression in fathers: a systematic review. J Affect Disord. 2011;130(3):358–77. 28. Ramchandani PG, Phil D, Stein A, Connor TGO, Murray L. Depression in men in the postnatal period and later child psychopathology: a population cohort study. J Am Acad Child Adolesc Psychiatry. 2008;47(4):390–8. 29. Zierau F, Bille A, Rutz W, Bech P. The Gotland Male Depression Scale: a validity study in patients with alcohol use disorder. Nordic J Psychiatry. 2002;56:265–71. 30. Magovcevic M, Addis ME. The Masculine Depression Scale: development and psychometric evaluation. Psychol Men Masculinity. 2008;9(3):117–32. 31. Madsen SA, Tina J. Paternal depression in the postnatal period assessed with traditional and male depression scales. J Mens Health. 2013;4(1):26–31. 32. Goodman JH. Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health. J Adv Nurs. 2004;45(1):26–35. 33. Edmondson OJ, Psychogiou L, Vlachos H, Netsi E, Ramchandani PG. Depression in fathers in the postnatal period: assessment of the Edinburgh PND Scale as a screening measure. J Affect Disord. 2010;125:365–8. 34.•• AAP Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee, Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Policy statement: identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006;118:405–20. This article details AAP's recommendations for developmental screening of infants and young children. 35.•• AAP Committee on Practice and Ambulatory Medicine and Bright Futures Periodicity Schedule Workgroup. 2016 Recommendations for Preventive Pediatric Health Care. Pediatrics. 2016:137. This article provides an update of AAP's recommended timeline for developmental screening and assessment. 36. Porter A, Qureshi R, Caldwell BA, Echevarria M, Dubbs W, Sullivan MW. Developmental surveillance and screening practices by pediatric primary care providers: Implications for early intervention professionals. Infant Young Child. 2016;29:91–101. 37. Talmi A, Muther EF, Margolis K, Buchholz M, Asherin R, Bunik M. The scope of behavioral health integration in a pediatric primary care setting. J Ped Psych. 2016;113. doi:10.1093/jpepsy/jsw065 38. AAP. Developmental screening and testing coding sheet for primary care clinicians. In: Addressing mental health concerns in primary care: A clinician’s toolkit. 2010. 39. Squires J, Twombly MS, Bricker D, Potter L. ASQ-3TM User’s Guide. Baltimore: Paul H. Brookes Publishing CO; 2009.

40. 41.

42. 43.

44. 45.

46.

47. 48.

49. 50. 51.

52.

53. 54.

55.

Ireton H. Child Development Review Manual. Minneapolis, MN: Behavior Science Systems; 2004. Creighton DE, Suave RS. The Minnesota Infant Development Inventory in the developmental screening of high-risk infants at 8 months. Can J Behav Sci. 1998;20:424–33. Robins D, Fein D, Barton M. Modified checklist for autism in toddlers, revised with follow-up. 2009. Available at: http://www.mchatscreen.com. Siegel B. Pervasive Developmental Disorders Screening Test-II (PDDST-II): Early Childhood Screener for Autistic Spectrum Disorders. San Antonio: Harcourt Assessment, Inc.; 2004. AAP. Mental health screening and assessment tools for primary care. In: Addressing mental health concerns in primary care: A clinician’s toolkit. 2010. Squires J, Bricker D, Twombly E, et al. Ages & Stages Questionnaires®: Social-Emotional, Second Edition (ASQ :SE-2™): A Parent-Completed Child Monitoring System for Social-Emotional Behaviors. Baltimore: Paul H. Brookes Publishing Co.; 2015. McGoey KE, DuPaul GJ, Haley E, Shelton TL. Parent and teacher ratings of attention-deficit/hyperactivity disorder in preschool: The ADHD Rating Scale-IV Preschool Version. J Psychopath Behav Assess. 2007;29:269–76. Reynolds CR, Kamphaus RW. Behavior assessment system for children, Third Edition (BASC-3). Pearson Education, Inc; 2015. Bird HR, Canino GJ, Davies M, et al. The Brief Impairment Scale (BIS): a multidimensional scale of functional impairment for children and adolescents. J Am Acad Child Adolesc Psychiatry. 2005;44:699–707. Carter AS, Briggs-Gowan M. ITSEA BITSEA: The InfantToddler and Brief Infant Toddler Social Emotional Assessment. San Antonio: PsychCorp; 2005. Achenbach TM, Rescoria LA. Manual for the ASEBA Preschool forms and Profiles. Burlington: University of Vermont Department of Psychiatry; 2000. Gleason MM, Zeanah CH, Dickstein S. Recognizing young children in need of mental health assessment: Development and preliminary validity of the Early Childhood Screening Assessment. Infant Mental Health J. 2010;31(3):335–57. Blucker RT, Jackson D, Gillaspy JA, Hale J, Wolraich M, Gillaspy SR. Pediatric behavioral health screening in primary care a preliminary analysis of the Pediatric Symptom Checklist-17 with functional impairment items. Clin Pediatr. 2014;53(5):449–55. Spence SH. Structure of anxiety symptoms among children: a confirmatory factor-analytic study. J Abnorm Psychol. 1997;106(2):280–97. Mellor D. Furthering the use of the Strength and Difficulties Questionnaire: reliability with younger child respondents. Psychol Assess. 2004;16(4):396–401. Brier J. Trauma Symptom Checklist for Young Children (TSCYC): Professional Manual. Odessa: Psychological Assessment Resources, Inc; 2005.

Update on Screening, Referring and Treating Mental Health 56.

57.

58.

59. 60.

61.

62. 63.

64. 65.

66.

67. 68.

Ringwalt S. Developmental screening and assessment instruments with an emphasis on social and emotional development for young children ages birth through five. Chapel Hill: The University of North Carolina, FPG Child Development Institute, National Early Childhood Technical Assistance Center; 2008. AAP, Management Steering Committee on Quality Improvement and Subcommittee on AttentionDeficity/Hyperactivity Disorder. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. 2011. www. pediatrics.org/cgi/doi/10.1542/peds.2011-2654. doi:10.1542/peds.2011-2654 Visser SN, Zablotsky B, Holbrook JR, Danielson ML, Bitsko RH. Diagnostic experiences of children with attention-deficit/hyperactivity disorder. Natl Health Stat Rep. 2015;81:1–7. Weatherston DJ, Paradis N. Defining professional competency in the infant mental health field. Zero Three J. 2011;32(1):37–43. Michigan Association for Infant Mental Health: Endorsement Registry. http://mi-aimh.org/for-imhprofessionals/endorsement/endorsement-registry/. 2016. Accessed 20 Oct 2016. California Center for Infant-Family and Early Childhood Mental Health. http://cacenter-ecmh.org/wp/ professional-development/california-compendium-oftraining-guidelines-personnel-competencies-andprofessional-endorsement-criteria-for-infant-familyand-early-childhood-mental-health/(2012). Accessed 20 Oct 2016. World Association of Infant Mental Health: Affiliates. http://www.waimh.org/i4a/pages/index.cfm?pageid= 3278) (2016). Accessed 20 Oct 2016. Sarvet B, Gold J, Straus JH. Bridging the divide between child psychiatry and primary care: The use of telephone consultation within a population-based collaborative system. Child Adolesc Psychiatr Clin N Am. 2011;20(1):41–53. National Network of Child Psychiatry Access Programs. 2016. http://nncpap.org/existing-programs. html. Accessed 5 Dec 2016. Lieberman A, Ghosh Ippen C, Van Horn P. Don’t hit my mommy!: A manual for child-parent psychotherapy with young children exposed to violence and other trauma. 2nd ed. Washington: Zero to Three Press; 2015. Substance Abuse and Mental Health Services Administration. SAMHSA’s National Registry of EvidenceBased Programs and Practices. 2016. http://nrepp. samhsa.gov. Accessed 14 Oct 2016. Lieberman AF, Weston DR, Pawl JH. Preventive intervention with anxiously attached dyads. Child Dev. 1991;62:199–209. Toth SL, Rogosch FA, Manly JT, Cicchetti D. The efficacy of toddler-parent psychotherapy to reorganize attachment in the young offspring of mothers with major depressive disorder: a randomized preventive trial. J Consult Clin Psychol. 2006;74:1006–16.

69.

70.

71.

72. 73. 74.

75.

76.

77. 78.

79.

80.

81.

82. 83.

Bekman et al.

Lieberman AF, Van Horn PJ, Ghosh Ippen C. Toward evidence-based treatment: child-parent psychotherapy with preschoolers exposed to marital violence. J Am Acad Child Adolesc Psychiatry. 2005;44:1241–8. Toth SL, Maughan A, Manly JT, Spagnola M, Cicchetti D. The relative efficacy of two interventions in altering maltreated preschool children’s representational models: implications for attachment theory. Dev Psychopathol. 2002;14:877–908. Eyberg SM, Nelson MM, Boggs SR. Evidence-based psychosocial treatments for children and adolescents with disruptive behavior. J Clin Child Adolesc Psychol. 2008;37:215–37. Thomas R, Zimmer-Gembeck MJ. Parent-child interaction therapy: an evidence-based treatment for child maltreatment. Child Maltreat. 2012;17(3):253–66. Thomas R, Herschell AD. Parent–child interaction therapy: a manualized intervention for the therapeutic child welfare sector. Child Abuse Negl. 2013;37:578–84. Bagner DM, Eyberg SM. Parent–child interaction therapy for disruptive behavior in children with mental retardation: a randomized controlled trial. J Clin Child Adolesc Psychol. 2007;36:418–29. doi:10.1080/ 15374410701448448. Timmer SG, Ware W, Urquiza A, Zebell NM. The effectiveness of parent–child interaction therapy for victims of interparental violence. Violence Vict. 2010;25:486–503. Bagner DM, Coxe S, Hungerford GM, Garcia D, Barroso NE, Hernandez J, et al. Behavioral parent training in infancy: a window of opportunity for high-risk families. J Abnorm Child Psychol. 2016;44:901–12. Eyberg S. PCIT: integration of traditional and behavioral concern. Child Fam Behav Ther. 1988;10:33–46. Carpenter AL, Puliafico AC, Kurtz SM, Pincus DB, Comer JS. Extending parent-child interaction therapy for early childhood internalizing problems: new advances for an overlooked population. Clin Child Fam Psychol Rev. 2014;17:340–56. Pincus DB, Santucci LC, Ehrenreich JT, Eyberg SM. The implementation of modified parent-child interaction therapy for youth with separation anxiety disorder. Cogn Behav Pract. 2008;15:118–25. Luby JL, Lenze S, Tillman R. A novel early intervention for preschool depression: findings from a pilot randomized controlled trial. J Child Psychol Psychiatry. 2012;53:313–22. Mele CM, Kurtz SMS. Parent–child interactions in behavioral treatment of selective mutism: a case study. Poster presented at the meeting of the Anxiety Disorders Association of America, La Jolla, CA; 2013. Cohen JA, Mannarino AP, Deblinger E. Treating trauma and traumatic grief in children and adolescents. New York: Guilford Press; 2006. Scheeringa MS, Weems CF, Cohen JA, Amaya‐Jackson L, Guthrie D. Trauma‐focused cognitive‐behavioral therapy for posttraumatic stress disorder in three‐ through six year‐old children: a randomized clinical trial. J Child Psychol Psychiatry. 2011;52(8):853–60.

Mental Health (WF Njoroge and TD Benton, Section Editors) 84. 85.

86.

87.

88.

89.

90. 91.

92.

93.

94.

95. 96.

97.

Scheeringa MS. Treating PTSD in preschoolers: a clinical guide. New York: Guilford Publications; 2015. Webster-Stratton C. The Incredible Years parents, teachers, and children’s training series: program content, methods, research and dissemination 1980-2011. Seattle: Incredible Years Inc; 2011. Menting ATA, de Castro BO, Mattys W. Effectiveness of the Incredible Years parenting training to modify disruptive and prosocial child behavior: a meta-analytic review. Clin Psychol Rev. 2013;33:901–13. Seabra-Santos MJ, Gaspar MF, Azevedo AF, Homem TC, Guerra J, Martins V, et al. Incredible Years parent training: What changes, for whom, how, for how long? J Appl Dev Psychol. 2016;44:93–104. Powell B, Cooper G, Hoffman K, Marvin B. The Circle of Security intervention: enhancing attachment in early parent-child relationships. New York: Guilford Press; 2014. Huber A, McMahon CA, Sweller N. Efficacy of the 20week circle of security intervention: changes in caregiver reflective functioning, representations, and child attachment in an Australian clinical sample. Infant Ment Health J. 2015;36:556–74. Yaholkoski A, Hurl K, Theule J. Efficacy of the Circle of Security intervention: a meta-analysis. J Infant Child Adolesc Psychother. 2016;15:95–103. Ramsauer B, Lotzin A, Mühlhan C, Romer G, Nolte T, Fonagy P, et al. A randomized controlled trial comparing Circle of Security Intervention and treatment as usual as interventions to increase attachment security in infants of mentally ill mothers: Study Protocol. BMC Psychiatry. 2014;14(1):1–11. Cristea IA, Huibers MJ, David D, Hollon SD, Andersson G, Cuijpers P. The effects of cognitive behavior therapy for adult depression on dysfunctional thinking: a meta-analysis. Clin Psychol Rev. 2015;42:62–71. Cuijpers P, van Straten A, Andersson G, van Oppen P. Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies. J Consult Clin Psychol. 2008;76(6):909–22. Cuijpers P, Geraedts AS, van Oppen P, Andersson G, Markowitz JC, van Straten A. Interpersonal psychotherapy for depression: a meta-analysis. Am J Psychiatry. 2011;168(6):581–92. Clark R, Tluczek A, Wenzel A. Psychotherapy for postpartum depression: a preliminary report. Am J Orthopsychiatry. 2003;73(4):441–54. Forman DR, O’Hara MW, Stuart S, Gorman LL, Larsen KE, Coy KC. Effective treatment for postpartum depression is not sufficient to improve the developing mother-child relationship. Dev Psychopathol. 2007;19:585–602. Murray L, Cooper PJ, Wilson A, Romaniuk H. Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression: impact on the mother—child relationship and child outcome. Br J Psychiatry. 2003;182(5):420–7.

98.

Clark R, Tlucek A, Brown R. A mother-infant therapy group model for postpartum depression. Infant Ment Health J. 2008;29(5):514–36. 99.•• Gleason MM, Egger HL, Emslie GJ, Greenhill LL, Kowatch RA, Lieberman AF, et al. Psychopharmacological treatment for very young children: contexts and guidelines. J Am Acad Child Adolesc Psychiatry. 2007;46(12):1532–72. Expert consensus resource covering all diagnoses in preschool children. 100. National Institute for Health and Care Excellence (NICE). Attention deficit hyperactivity disorder: diagnosis and management of ADHD in children, young people and adults [NICE guidelines CG72]. London: NICE; 2008. Revised March 2013. 101. Greenhill L, Kollins S, Abikoff H, Mccracken J, Riddle M, Swanson J, et al. Efficacy and safety of immediaterelease methylphenidate treatment for preschoolers with ADHD. J Am Acad Child Adolesc Psychiatry. 2006;45(11):1284–93. 102. Wigal T, Greenhill L, Chuang S, McGough J, Vitiello B, Skrobala A, et al. Safety and tolerability of methylphenidate in preschool children with ADHD. J Am Acad Child Adolesc Psychiatry. 2006;45(11):1294– 303. 103.• Vitiello B, Lazzaretto D, Yershova K, Abikoff H, Paykina N, McCracken JT, et al. Pharmacotherapy of the Preschool ADHD Treatment Study (PATS) children growing up. J Am Acad Child Adolesc Psychiatry. 2015;54(7):550–6. Systematic 3- and 6-year follow up study of naturalistic treatment of children enrolled in the PATS study for methylphenidate treatment in preschoolers. 104. Short EJ, Manos MJ, Findling RL, Schubel EA. A prospective study of stimulant response in preschool children: insights from ROC analyses. J Am Acad Child Adolesc Psychiatry. 2004;43(3):251–9. 105. Ghuman JK, Arnold LE, Anthony BJ. Psychopharmacological and other treatments in preschool children with attention-deficit/hyperactivity disorder: current evidence and practice. J Child Adolescent Psychopharmacol. 2008;18(5):413–47. 106. Ghuman JK, Aman MG, Ghuman HS, Reichenbacher T, Gelenberg A, Wright R, et al. Prospective, naturalistic, pilot study of open-label atomoxetine treatment in preschool children with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 2009;19(2):155–66. doi:10.1089/cap.2008.054. 107. Luby JL, Mrakotsky C, Stalets MM, Belden A, Heffelfinger A, Williams M, et al. Risperidone in preschool children with autistic spectrum disorders: an investigation of safety and efficacy. J Child Adolesc Psychopharmacol. 2006;16(5):575–87. 108. Nagaraj R, Singhi P, Malhi P. Risperidone in children with autism: randomized, placebo-controlled, double-blind study. J Child Neurol. 2006;21(6):450–5. 109. Wink LK, Early M, Schaefer T, Pottenger A, Horn P, McDougle CJ, et al. Body mass index change in


110.

111.

112.

113.

autism spectrum disorders: comparison of treatment with risperidone and aripiprazole. J Child Adolesc Psychopharmacol. 2014;24(2):78–82. Hollander E, Phillips A, Chaplin W, Zagursky K, Novotny S, Wasserman S, et al. A placebo controlled crossover trial of liquid fluoxetine on repetitive behaviors in childhood and adolescent autism. Neuropsychopharmacology. 2004;30(3):582–9. King BH, Hollander E, Sikich L, et al. Lack of efficacy of citalopram in children with autism spectrum disorders and high levels of repetitive behavior: citalopram ineffective in children with autism. Arch Gen Psychiatry. 2009;66(6):583–90. Barterian JA, Rappuhn E, Seif EL, Watson G, Ham H, Carlson JS. Current state of evidence for medication treatment of preschool internalizing disorders. Sci World J. 2014;286085. doi:10.1155/2014/286085. Coskun M, Zoroglu S. Efficacy and safety of fluoxetine in preschool children with obsessive compulsive

114.

115.

116. 117.

Bekman et al.

disorder. J Child Adolesc Psychopharmacol. 2009;19:297–300. Zuckerman ML, Vaughan BL, Whitney J, Dodds A, Yakhkind A, MacMillan C, et al. Tolerability of selective serotonin reuptake inhibitors in thirty-nine children under age seven: a retrospective chart review. J Child Adolesc Psychopharmacol. 2007;17:165–74. Bourgeois FT, Mandl KD, Valim C, Shannon MW. Pediatric adverse drug events in the outpatient setting; an 11-year national analysis. Pediatrics. 2009;124(4):e744–50. Safer DJ. Age-grouped differences in adverse drug events from psychotropic medication. J Child Adolesc Psychopharmacol. 2011;21(4):299–309. American Academy of Child & Adolescent Psychiatry Practice Parameters and Resource Centers. 2016. http://www.aacap.org/AACAP/Resources_for_ Primary_Care/Practice_Parameters_and_Resource_ Centers/Home Accessed 6 Dec 2016.