Historically there has been little to no research in the mental health field on very young children. Parents and professionals alike find themselves wondering what is the best path to take in safely healing our littlest population?

Fortunately long awaited evidence-based treatment guidelines are now available for your pre-schooler. A group of experts in early childhood psychiatry, psychology, and neurology have joined forces to publish clinical guidelines to treat psychological and behavioral problems in very young children. The guidelines include algorithms for managing conditions such as ADHD, depression, anxiety, bipolar disorder, and sleep disorders.

The experts highlighted the need to perform a thorough assessment of very young patients - and their home environment - before making diagnostic and treatment recommendations. First line treatment in very young children should be “evidence-supported psychosocial treatments” advised the group, even when medication is prescribed. For ADHD, family caregivers should be involved in every aspect of the therapy process including behavioral techniques and parent training. The guidelines strongly encourage physicians to try discontinuing medications over time and focus on family interventions.

You can review a copy of the published guidelines in the Journal of the American Academy of Child and Adolescent Psychiatry, Dec 2007 issue. Go to www.jaacap.com/pt/re/jaacap/home, click on “Archive”, Dec 2007.

Consider bringing this information to your provider to encourage an integrated, best-practices approach in treatment. The collaboration of care will be helpful to everyone, most importantly to your child.

A recent study at Harvard Medical School in Boston showed - surprisingly - that the use of stimulant medication in the past year was not associated with sleep problems in children and adolescents with ADHD. There were 225 children with and without ADHD in the study followed for one year. The children with ADHD (ages 6 to 17) were indeed much more likely to have insomnia than other children their age, but the sleep problems were occuring equally in those ADHD kids who took medication and those that did not.

Investigators did find a significant increase in behavioral problems among children who have ADHD and insomnia. Intuitively parents know that lack of sleep worsens behavioral problems for their children and this study strongly supports that not sleeping is truly a major risk factor for bad behavior. In fact this Harvard study reports that kids with ADHD who have sleep problems have significantly higher levels of behavioral difficulties than those non-ADHD kids with insomnia.

The message to all parents is that sleep is a major factor in reducing behavioral problems, but especially for those children with ADHD!

Try melatonin as a natural supplement known to improve sleep quality for children with ADHD. Prior research shows a 45 min earlier onset of sleep in ADHD kids who also took melatonin.

Many children with ADHD have difficulty with transitions, especially very young children. A five year long study out of Lehigh University reviews the benefits of counting down the time before switching activities and found that at least in children, youngsters are better able to control outbursts spurred by ADHD. The five-year study, paid for by the National Institutes of Health, provided a range of behavioral-only therapies to 135 preschoolers with severe ADHD. Families were given either parent-education classes only, or parenting classes plus home and preschool visits by researchers who customized techniques for each child. After a year, aggression and other problem behaviors had dropped, and learning improved, by about 30 percent, the researchers report this month in a journal of the National Association of School Psychologists.

What helped? Stressing consistent rules and routines, and more praise for good behavior than punishment for bad. Surprisingly, both groups fared equally well, raising questions about how to tell which children need more intense aid. Preschoolers with ADHD learn best through repeated practice so the study stressed role-playing things like how to ask to share a toy. Parents were taught to reserve stronger punishments for worst cases, and to try reward systems where children gain or lose “points” for behavior instead. Even the time-out standby was to be used sparingly.

Teaching children from a young age to eat a low-fat diet can be effective — even as they reach their teens and begin eating more meals away from home, according to a new study. The study of children in Finland found that those who were taught to focus on healthy fats — those found in fish, nuts, seeds and oils from plants — had slightly lower cholesterol levels compared to those who ate an unrestricted diet. The researchers have been following the 1,062 children since the age of 7 months. About half of the children and their families were counseled to shift fat intake from animal-based saturated fats to healthier unsaturated fats. The rest did not get specific diet advice. The new study reported the results on the children at age 14. Dr. Harri Niinikoski, lead author of the study done at the University of Turku in Finland, said children begin forming their eating and lifestyle habits in childhood. “The earlier you intervene, the more likely you are going to be successful,” she said. 

A study published in the American Heart Association Journal recently compared 540 children assigned to a dietary counseling group to 522 who did not get special diet advice, starting from seven months of age and found that regular counseling of families and children about the benefits of avoiding saturated fats in their diet led to diets lower in fat and saturated fat, and reduced blood cholesterol levels in children up to the age of 14. There were no differences in stature between counseled children and those who were not, suggesting a low-fat diet can pay dividends from the start without affecting growth.  Among the findings, counseling seemed to have a bigger impact on the cholesterol level of boys than girls. The researchers were not sure why. The counseled children also ate more protein and carbohydrates than those who received no dietary advice. “At age 14, the dietary group had a small but statistically significant lower median cholesterol level,” the Heart Association said in a statement. Families in the counseling group received regular advice from a nutritionist and the children were counseled directly from the age of seven. 

Approximately 60% of children under the age of 11 experience some kind of sleep difficulty at least a few nights a week. A recent study conducted by published in the journal Sleep found that more than 80 percent of American children who visit a doctor because they have difficulty sleeping are given some form of prescription medication, even though no sleeping pills are currently approved for use in kids. The research was conducted at the Ohio State University College of Pharmacy in Columbus and complement a 2004 National Sleep Foundation poll that revealed that sleep difficulties are extremely widespread among the young. Specific medications included: about a third were prescribed antihistamines, a quarter alpha-2 agonists, 15% were offered benzodiazepines, and 6% antidepressants.
81% of these children and teens were prescribed medication for their sleep issues. Other recommendations included: 7% were recommended diet and nutritional counseling, 22 % were offered behavioral therapy, and 17% were offered mental health and stress management treatment. A combined regimen of medication plus behavioral therapy was prescribed in just under a fifth of cases. Patients who sought care from a psychiatrist were more than three times as likely to be prescribed a drug for their sleep trouble than those who visited a general practice physician.
Children having difficulty sleeping isn’t “normal”. Rather than simply treat the symptom it is important to figure out the cause – then we can more effectively correct the problem. Antidotally, my experiences as a psychologist have proven to me that therapy for sleep difficulties is very effective. It is critical to approach difficulties from a holistic perspective. In other words, assessing a child’s:
-          Diet: With particular focus on the level of caffeine intake as well as how close to bedtime he eating.
-          Exercise: How much physical exercise does the child engage in and when in the day is she most active.
-          Well-being: Areas to consider include what his school day like, anything new happening at home, is she being bullied or is he worried about upcoming tests, etc…? Often parents are surprised by the worries of a young person since to an adult they are not realistic. Without thoughtful discussion in a safe and relaxed environment, some kids never talk about their concerns and continue to have sleepless nights for long periods of time.
-          Home Life: How comfortable does the child feel in his room? Is the light and noise level appropriate for REM sleeping? Are parents fighting in the other room? How comfortable is the mattress?
-          Relaxation Techniques: Learning simple breathing techniques or body scanning strategies are a useful non-medication approach to falling asleep. 

A study published in this month’s American Journal of Clinical Nutrition reveals more evidence that Omega-3 fatty acids are critical in brain development. The study reports that children whose mothers get enough omega-3 fatty acid during pregnancy may have stronger cognitive skills in infancy. Specifically, researchers found that 9-month-olds whose mothers had eaten DHA-fortified bars during pregnancy performed better on a test of problem-solving abilities than infants whose mothers had not added DHA to their diets.