Use of Psychotropic Agents in Preschool Children: Associated Symptoms, Diagnoses, and Health Care Services in a Health Maintenance Organization

Background  Recent pharmacoepidemiological reports have contributed to concerns about frequent and perhaps indiscriminate psychopharmacotherapy for very young children.

Objective  To examine the diagnoses, symptoms, and health care services associated with preschool children receiving psychotropic medication.

Design  Population-based pharmacoepidemiological analysis of electronic medical records, paper medical and mental health charts, and pharmacy records from 1997 and 1998.

Setting  A large Pacific Northwest health maintenance organization.

Participants  Preschool children receiving psychotropic medication (psychostimulants, antidepressants, neuroleptics, or α₂-adrenergic agonists).

Measures  Physician-reported mental health diagnoses and related symptoms, functional impairment, family and participant characteristics, and the types and level of associated medical and mental health services.

Results  Of 743 preschool children who clinicians identified as having behavioral or emotional problems, 120 (16%) received psychotropic medication; 57 children (48%) were prescribed a stimulant medication only, and 60 (50%) received a diagnosis of attention-deficit/hyperactivity disorder. Most children had substantial psychosocial risk factors, including parents with psychiatric or substance abuse problems (71%; n = 85), documented histories of abuse (29%; n = 35), and out-of-home placement (31%; n = 37). Four of 5 children or families (83%; n = 99) received psychosocial services in addition to pharmacotherapy. On average, children received psychotropic medication at least 6 months after initial identification of a behavioral or mental health problem.

Conclusions  Despite commentary by the popular media about widespread psychopharmacotherapy for very young children, such treatment was only infrequently received in this health plan. Most children receiving psychopharmacotherapy had substantial additional risk factors and were receiving psychosocial services for mental health or behavioral management.

GIVEN THE number of recent media reports that have expressed concern about the increasing exposure of children to psychotropic medications, further scientific study of this issue is warranted. The majority of scientific publications examining rates and types of pharmacotherapy for mental disorders in childhood have focused on school-aged children or aggregated results for all youth younger than 18 years.^1-3 More recently, however, several reports have suggested that these increases in psychopharmacotherapy extend to preschool children.^4-6 A recent well-publicized report by Zito et al⁶ examined trends in prescribing psychotropic medication to preschool children across 3 populations in different regions of the United States. From 1991 through 1995, they found a 1.7-fold to 3.1-fold increase in psychostimulant use, a 1.3-fold to 2.2-fold increase in the use of antidepressants, and a 6.8-fold to 28.2-fold increase in the use of clonidine. Only modest increases (1.2-fold to 1.5-fold) were found in the use of neuroleptic medications among preschool children.

Other recent reports have also documented the increase in pharmacotherapy in very young children. A recent review of findings from the Intercontinental Medical Statistics Study describes a 3-fold increase in methylphenidate prescriptions to children younger than 5 years in Canada (although there was almost no increase in the United States) and an 11-fold increase in the prescription of selective serotonin reuptake inhibitors in the United States from 1993 through 1997.⁴ This review also summarized findings from Kopferschmitt et al⁷ who examined the use of psychotropic medications among 11 595 children in the Strasbourg region of France who had undergone mandatory medical examinations for primary school enrollment. These researchers found that 12% of children in their study were receiving psychotropic medications at the time of school entry, and 76% began taking medication by age 4 years. Finally, Rappley et al⁵ used Michigan Medicaid claims data to examine the use of psychotropic medication among very young children (aged 3 years and younger) diagnosed with attention-deficit/hyperactivity disorder (ADHD). Among the 223 children included in the study, more than half (57%) received psychotropic medications, whereas significantly fewer children (27%) received psychological services.

These studies and several editorial and review articles published in academic journals^1,8-12 and lay publications^13-18 have outlined several concerns about pharmacotherapy in very young children. These concerns focus on 3 major domains: the short- and long-term safety of these agents for very young children, particularly their possible effects on the developing brain; the lack of efficacious data demonstrating that these medications attenuate the behavioral and emotional symptoms targeted in these young children; and the context in which these medications are prescribed (eg, characteristics of the children, their families, and the prescribing clinician; accompanying medical and psychosocial services). Although these safety and efficacy concerns are important,^12,19-21 the focus of this report is the third domain, the context of prescribing.

Although numerous editorial articles in academic and lay journals have speculated about the context in which psychotropic medications are prescribed to very young children, few empirical reports describe this context. To date, we do not know much about who these children are, including their presenting diagnoses and symptoms, characteristic impairment, and family factors. We also know little about the context in which medication is prescribed, such as the medical specialty of the clinician; whether the medication is given after a thorough assessment, with explanations of risks and benefits, and with adequate follow-up; and whether the medication is the first line of treatment or is only given after or in conjunction with broader psychosocial services.

This study examined the associated symptoms, diagnoses, and health care services received by preschool children receiving psychotropic medication (psychostimulants, antidepressants, neuroleptics, and α₂-adrenergic agonists) during a recent 2-year period at a large Pacific Northwest health maintenance organization (HMO). We reviewed electronic medical records, paper medical and mental health charts, and pharmacy records to determine associated diagnoses and reported symptoms, functional impairment,¹ family and child characteristics, and the types and level of associated medical and mental health services provided.

We collected data on clinical diagnoses and health services for all children younger than 5 years who received care from clinicians at a large HMO in the northwestern United States from January 1, 1997, through December 31, 1998. We included only children who were treated by clinicians who were part of the Northwest Permanente Medical Group. A few children were treated by clinicians who work with the health plan exclusively through subcontracts. These contract clinicians do not use the health plan's electronic medical record system; therefore, no information regarding diagnoses, symptoms, and use of psychosocial services is available for children under their care.

The sample included privately insured children and children whose health care was covered by Medicaid. We collected data on clinical diagnoses, behavioral and emotional symptoms, and health services for children who received 1 or more of 3 types of psychotropic medication: stimulants (methylphenidate or other stimulants); neuroleptics; and antidepressants (selective serotonin reuptake inhibitors, tricyclic antidepressants, and other antidepressants). We also included preschool children who received α₂-adrenergic agonists (clonidine and guanfacine) because their use alone or as combined psychopharmacological treatment has increased substantially since the early 1990s. Although other medications are used for psychiatric treatment in young children, we limited the medications examined for two reasons. First, we could not cleanly examine the use of other medications for psychiatric purposes because many of these medications are used primarily for nonpsychiatric reasons in young children (eg, anticonvulsants for seizure disorders or minor tranquilizers for minor surgical procedures). Second, we were interested in following up on the study by Zito et al⁶ and providing context for the reported increase in psychotropic medication; therefore, we examined the medications reported on in that study. Hereafter, we describe children who received psychotropic medications as the "medication group."

We also performed initial analyses including all preschool children in the HMO who had a mental health diagnosis or associated emotional or behavioral symptoms during the study period. We created a subgroup who received no psychotropic medication and hereafter describe this group as the "no medication group."

The research setting was Kaiser Permanente Northwest, a nonprofit group-model HMO that serves more than 440 000 members in the Pacific Northwest. The demographic characteristics of HMO members are similar to those of the larger community. Prepaid health plan benefits include complete coverage for physician, hospital, laboratory, and radiology services. The HMO provides primary and specialty medical and surgical care and specialty mental health care, covering a broad range of educational, screening, diagnostic, treatment, and rehabilitation services.

Covered services may vary among health plan members. All privately insured groups have medical, surgical, and integrated mental health benefits, and 90% of members have coverage for prescription drugs. Medication is available at a reduced charge to all privately insured members. In contrast, Medicaid recipients have comprehensive medical and drug benefits that are similar to the benefits of privately insured members, but, as is required by state law, coverage for specialty mental health services is provided through separate community-based organizations (ie, "carved out"). However, a number of mental health–related services, such as medication management, diagnosis, and consultation, are provided under the physical health contract with the HMO. Any mental health services provided through primary care clinicians are available to all Medicaid enrollees.

We used the comprehensive electronic medical record (EMR) system of the HMO to collect information on medications dispensed and services received, presenting symptoms and assigned diagnoses, and child and family characteristics. For the medication group, the EMR was augmented by review of any existing health plan paper charts. Comprehensive chart reviews were only conducted for the medication group because these children were the primary focus of this study. Paper charts were used at the health plan before 1996, and many records of mental health and social services received outside the health plan were included in these paper charts. We developed a structured chart review form and re-reviewed 10% of charts to establish reliability (89% agreement across data fields). Medical records for all subjects were reviewed from their birth or entry into the health care system through services and medications received during their fifth year of age. Comprehensive chart review included detailed analysis of all chart notes, reports, and administrative correspondence for each contact with the HMO. Although we limited case identification to children younger than 5 years receiving psychotropic medication, we collected information on services and medication through the fifth year of age to ensure a more complete representation of health services received in association with psychopharmacological treatment. To preserve anonymity, we aggregated all reported results when there were fewer than 3 subjects per condition.

The Committee for the Protection of Human Subjects for the HMO monitored and approved all study procedures. Health plan members' contracts with the HMO provide consent for use of their data in HMO-sponsored research studies. The study research center is located within the HMO but conducts independent, public-domain, nonproprietary research.

Data were collected in 4 principal domains: child demographics and family characteristics, medication information, symptom and diagnostic information, and service use information. Child demographics and family characteristics are shown in Table 1.

Medication-related information included all dispensing of study medications to subjects through 5 years of age, the target symptoms of the treatment, indications of quality procedures for prescribing (eg, discussion of medication risks and treatment options and timely follow-up visits), and the time from initial identification of a behavioral or psychiatric problem to receipt of psychotropic medication. In addition, we examined the simultaneous and consecutive use of more than one psychotropic medication. Similar to Rappley et al,⁵ we defined "simultaneous use" as more than 1 medication received within 7 days or a pattern of more than 1 medication in recurrent use over time. Consecutive treatment was defined as the sequential use of different medications throughout the study window.

Symptom and diagnostic-related information included all International Classification of Diseases, Ninth Revision (ICD-9) diagnoses related to a psychiatric or behavioral condition, all reported behavioral and psychiatric symptoms, information on speech and language-related disorders, and information on functional impairment. In addition, other medical diagnoses and symptoms were recorded when they were explicitly linked with a psychotropic medication examined in this study. For the no medication group, we limited diagnoses to 5 ICD-9 categories and 2 emotional/behavioral symptoms: ADHD and its variants, oppositional defiant disorder, posttraumatic stress disorder and acute stress reactions, mood and anxiety disorders, adjustment disorders, "aggressive behavior," and "unspecified behavioral disturbance." We included these nondiagnostic categories because pediatric clinicians in this HMO often use symptom codes to indicate emotional and behavioral disturbances in very young children if there is any uncertainty about a definitive diagnosis. The pediatric department guidelines of the HMO strongly suggest that emotional or behavioral symptoms be assigned rather than diagnoses when there is uncertainty about whether children meet full ICD criteria.

Service use information collected included the medical specialty of the prescribing clinician, mental health and social services received (type and associated clinicians), and assessment procedures conducted (eg, psychological or neuropsychological testing and developmental and social/behavioral assessments).

From 1997 through 1998, 9% of health plan members (N = 38 664) were children younger than 5 years; 743 (2%) of these children had emotional or behavioral diagnoses or significant symptoms according to the EMR. This does not include children who had a presenting complaint of behavioral or emotional problems but whose clinicians failed to confirm these complaints by recording a clinical diagnosis or symptom.

During the study period, 128 preschool children who met our inclusion criteria were dispensed a psychotropic medication at an HMO pharmacy. Eight of these children received psychotropic medication for agitation or behavioral disturbance associated with major medical morbidity (eg, cerebral palsy, severe head injury, or near drowning) and were thus dropped from further analyses.

We next examined the intersection between behavioral or emotional diagnoses or symptoms and receipt of psychotropic medication. With the health data recorded in the EMR, we found associated diagnoses or emotional or behavioral symptoms for 105 (88%) of 120 children in the medication group. However, when we included additional data obtained in a thorough chart review, we found associated diagnoses or emotional or behavioral symptoms for 100% of children in the medication group. Therefore, 120 (16%) of 743 children with clinically identified emotional or behavioral problems in the EMR received psychotropic medication during the study window. Demographic information displayed in Table 1 was collected from the EMR, but diagnostic data were from all sources (EMR and chart review). All further analyses involved the medication group only (n = 120).

Consistent with many reports on behavioral and emotional problems in young children, most children (71%) were male (Table 1). Half the children in the medication group did not receive psychotropic medication until age 4. The proportion of Medicaid recipients in the medication group (45%) was substantially higher than was Medicaid enrollment in the health plan overall (approximately 25%). Data on family characteristics suggest that more than three quarters (77%) of children had some type of instability in the home. One or both parents of most children (71%) had a history of emotional or substance abuse disorders significant enough to be noted in the child's medical records. A sizable minority of these children (29%) had also experienced 1 or more forms of abuse (sexual abuse, physical abuse, and/or neglect). Finally, 31% of children had been removed from the home after birth because of their parents' inability to care for them and were in the foster care system or living with a relative at the time of their treatment.

Information was collected on all psychotropic medications dispensed to subjects through age 5 years. Most children (48%; n = 57) were dispensed a stimulant only. Stimulants in combination with an α₂-adrenergic agonist (clonidine or guanfacine) was the next most common category (23%; n = 27) followed by antidepressants alone or combined with either stimulants or an α₂-adrenergic agonist (12.5%; n = 15); α₂-adrenergic agonist only (9%; n = 11); and neuroleptics in combination with another psychotropic medications (8%; n = 10). Most antidepressants used, regardless of other psychotropics given, were tricyclic antidepressants (12 [52%]of 23). Of the 57 children receiving more than 1 type of psychotropic medication, simultaneous medication use was evident in 46 (81%). The relative proportion of children receiving these psychotropic agents is depicted in Figure 1.

We also examined mental health diagnoses received by children prescribed psychotropic medications any time before their fifth birthday (Figure 2). The most common diagnosis was ADHD only (50%; n = 60), followed by ADHD and oppositional defiant disorder (20%; n = 24), ADHD and posttraumatic stress disorder (10%; n = 12), pervasive developmental disorder (9%; n = 11), or other diagnoses, including mood and adjustment disorders in combination with ADHD (8%; n = 9). Four children (3%) did not have a recorded mental health diagnosis, although aggressive behavior problems were noted in their charts. In addition to these formal mental health diagnoses, 48 subjects (40%) had speech or language disorders, 29 (24%) had significant developmental delays, and 14 (12%) had evidence or suspicion of drug or alcohol effects prenatally or at birth. More than one third (37%; n = 44) of subjects in the medication group received 2 or more mental health diagnoses simultaneously, indicating that there was a substantial amount of comorbidity among this population. Finally, 29 children (24%) had been removed from or refused day-care or home-care services because of their behavior, and significant behavior-related child-care problems were noted for an additional 25 (21%). Thus, for almost half the sample (45%; n = 54), behavioral disturbance was consistent with significant functional impairment.

We also examined the association between the initial psychotropic medication given and the mental health diagnoses and symptoms that prompted pharmacotherapy (Table 2). Stimulant prescriptions were most often associated with either an ADHD diagnosis or the behavioral symptoms of aggression and overactivity. α₂-Adrenergic agonists (clonidine and guanfacine) were only infrequently associated with the diagnosis of a specific mental health condition and were most often given in association with aggression or sleep disturbance. It was uncommon for an antidepressant to be given as the initial psychotropic medication; no prototypical pattern of associated mental health diagnoses or behavioral symptoms could be discerned for these children. A neuroleptic medication was never prescribed as the initial psychotropic medication. Overall, psychotropic medications were prescribed without an associated mental health diagnosis or behavioral symptoms recorded in the medical record for only 5 subjects (4%).

Finally, we examined the medical specialties of clinicians who prescribed psychotropic medications and found that 89 (74%) were pediatricians and 22 (18%) were psychiatrists or behavioral neurologists. In 9 cases (8%), the clinician's medical specialty was not specified. Of those children whose medication was prescribed by a pediatrician, 29 (33%) were also seen by a psychiatrist at some point during their care.

We also examined how medication status relates to services received by children (Table 3). In general, the more complex the medication regime (eg, polypharmacy or psychotropic agents less commonly used in young children), the more likely children were to receive specialty mental health services. Relatively few families (18%; n = 21) received no mental health or behavioral management/parenting services from the HMO or other public agencies, and for just 8 children (7%) were such services not at least recommended. We found no significant differences between the proportions of Medicaid and non-Medicaid enrollees receiving these services.

In addition, we examined a number of medication management procedures associated with prescribing psychotropic medications. For 70 children (58%), their medical chart indicated that the clinician discussed various treatment options and the relative risks and benefits with the child's caregiver. For 112 children (93%), a follow-up appointment to assess treatment effectiveness and possible adverse effects was scheduled and attended within 12 weeks of the initial prescription. Medical charts indicated that 64 children (53%) received some form of formal psychological testing. This ranged from full psychological and/or neuropsychological assessments to behavioral rating scales administered to the child's caregiver. For 83 children (69%), communication or coordination was noted between the health plan clinician and outside educational and/or social service agencies.

Finally, we examined the time between the initial identification of a behavioral or mental health problem and the receipt of psychotropic medication. On average, children received psychotropic medication 6 months after a behavioral or mental health problem had initially been identified (mean [SD], 6.1 [7.4] months; range, 0-32 months).

Preschool children in this health plan who received psychotropic medication represented a relatively small proportion (16%) of children with identified behavioral or emotional problems. Furthermore, in addition to identified behavioral or emotional problems, most of these children had substantial psychosocial risk factors; three quarters had parents with psychiatric or substance abuse problems significant enough to be noted in the child's medical chart, approximately one third had documented histories of abuse, and one third had been removed from their homes because their parents could not care for them adequately. Finally, 83% of children or families received psychosocial services, which were focused on managing children's behavioral or emotional problems, in addition to pharmacotherapy. Based on the 6-month mean delay between the initial identification of behavioral or emotional problems and psychopharmacotherapy, medication did not appear to be an early response to the identification of such problems for these very young children. Our findings suggest that, in this health plan, pharmacotherapy for very young children was infrequently prescribed and generally was given in the context of substantial additional risk factors and in conjunction with psychosocial services for mental health or behavioral management. Based solely on information available in the electronic medical record, preschool children with identified behavioral or emotional problems who received psychotropic medication were much more likely to be given a diagnosis of ADHD (74%) than were children with such problems who did not receive medication (11%).

To our knowledge, this is the first published report directly linking medications received by preschool children with behavioral symptoms and/or mental health diagnoses. Although Rappley et al⁵ reported on the use of psychotropic medications in very young children diagnosed with ADHD, they acknowledged that their reliance on Medicaid claims data precluded directly linking the two. In this report, the most frequently prescribed psychotropic medications were psychostimulants, which were most often associated with an ADHD diagnosis. However, psychostimulants were also frequently linked to specific behavioral symptoms, including overactivity and aggression. That psychostimulants were the most frequently prescribed medication is consistent with the relatively greater clinical research support for their efficacious and safe use in very young children. α₂-Adrenergic agonists, the next most frequently prescribed initial medication, were most often linked to aggression or sleep disturbance. Because of the infrequency with which the other classes of medications were initially prescribed (n = 6 for antidepressants and no cases of initial use of a neuroleptic), we can say little about modal-associated diagnoses or behavioral symptoms for these medication classes.

In addition to mental health diagnoses and behavioral symptoms linked specifically to the initiation of psychopharmacotherapy, further problems were documented among 78% of the sample (ie, comorbid psychiatric conditions, developmental delays, speech or language problems, or documented refusal of child-care services because of behavior), suggesting that subjects had complicated clinical presentations and multiple domains of difficulties.

Several things should be kept in mind when interpreting the information in this report. First, reported behavioral symptoms are limited to those recorded in subjects' medical charts. This is not a comprehensive representation of all symptoms experienced but rather is limited to the problems and symptoms that the treating clinician decided were most pertinent to document and/or those specifically reported by caregivers. These diagnoses may or may not closely correspond to a diagnosis based on a full research assessment. Despite this limitation, these symptoms and diagnoses are what routinely guide clinicians' treatment decisions in naturalistic settings and, thus, are important to discern. As has been discussed in previous reports,^5,12 diagnosing mental health conditions for very young children is controversial and acknowledged by experts to be extremely difficult.

We were limited in our ability to analyze medication management practices, such as timely follow-up, assessment procedures employed, or discussion of the risks or benefits of various treatment options, by the known variance across clinicians in what is routinely recorded in the medical chart. For example, our investigation suggests that treatment risks, benefits, and options were discussed with families or caregivers for only 58% of cases. If accurate, this is an important area for possible improvement. However, this finding may be an artifact of charting practices. Future studies that assess clinicians' practices directly could more accurately examine medication management practices within this population.

In this report, we present aggregated data rather than directly describing the pathways of care. We elected to describe our findings in this manner because it was more parsimonious but also to preserve the confidentiality of the preschool children included in this report. The relatively small number of children receiving psychotropic medications during the preschool years makes it difficult to discern prototypical trends in treatment and also suggests caution in interpreting the data presented in this report.

Because this report is based on information from a nonprofit group-model HMO, these findings may not be generalizable to other treatment settings, including differently structured managed care organizations. However, our study included both children on Medicaid (45%) and children with private health insurance (55%). Therefore, despite the possible regional differences in practice patterns and differences across health care systems, this study represents a broader cross-section of children than is often described in published studies,²² many of which have focused exclusively on mental health services within the public sector.

Finally, our study focused primarily on preschool children who received psychotropic medication for their behavioral or emotional problems. We were able to make only limited comparisons to children with such problems who did not receive pharmacotherapy. When and with whom pharmacotherapy is used is an important area for further research.

This study represents a first step in understanding the context of psychopharmacotherapy for very young children. Future studies could pursue several important directions. First, the factors we examined in this study should be examined among different health care systems in different regions of the country to determine if similar patterns are found. Second, studies should examine the characteristics that distinguish children, families, and treatment settings in which pharmacotherapy is used from those in which other treatment approaches (eg, psychosocial interventions) are used exclusively. Finally, prospective studies for which comprehensive assessment data are collected from children, families, and clinicians would significantly enhance our understanding of the context of pharmacotherapy. Such prospective studies would also enable an examination of the longer-term trajectory of such care (eg, behavioral outcomes, family satisfaction with treatment, and incidence of adverse reactions to medication) and the decision process of both clinicians and families that lead to different trajectories of care.

The paucity of information about the efficacy and safety of psychotropic medications for very young children suggests extreme caution in using pharmacotherapy with this population. Although concerns have been raised in lay and professional literature about frequent and perhaps indiscriminate psychopharmacotherapy for very young children,^8,10,15,16 our findings suggest that in this setting such treatment was only infrequently received, was generally provided in the context of substantial additional risk factors, and was provided most often in conjunction with psychosocial services for mental health or behavioral management.

Although there is little specific information about the rates of behavioral and emotional disorders in very young children, epidemiological research indicates that there may be an increase in the overall prevalence of child and adolescent psychiatric disorders²³; 14% to 20% of American children have moderate to severe psychiatric disorders,²⁴ and as many as half of all pediatric visits reflect behavioral, psychosocial, and educational concerns.²⁵ If this recent increase in prevalence extends to very young children, and is an actual prevalence increase rather than a reflection of improved case identification or revised diagnostic criteria, the recent reports of increased use of psychotropic medications in this population⁶ may be at least partly the result of an epidemiological trend rather than a true increase in pharmacotherapy.²⁶

Finally, we were struck by the domestic instability and high-risk circumstances in which many of these children lived. We feel strongly that social and domestic instability alone should never be grounds for the use of psychopharmacotherapy to treat young children with behavioral or emotional problems. However, substantial family instability and/or caregiver psychiatric impairment may interfere with the substantial amounts of training and caregiver commitment often required for psychosocial treatments in school-aged or younger children. This suggests that researchers and clinicians might need to rethink how best to deliver many of the psychosocial treatments available to young children when stable caregivers may be unavailable or not sufficiently able to participate fully in such treatment. Although several psychotherapeutic interventions are effective for young children with behavioral problems (see Hibbs and Jensen²⁷ for an extensive review of research-based psychosocial treatments), multimodal treatment, including pharmacotherapy, may be important for improving both immediate and longer-term functioning and prognosis for very young children with complex mental health conditions and severe psychosocial risk factors. In the face of the compelling needs of these children and families, continued research is imperative to better understand the circumstances in which psychotropic medications are prescribed as well as the behavioral outcomes and possible adverse events associated with their use.

Article

Corresponding author and reprints: Lynn L. DeBar, PhD, MPH, Kaiser Permanente Center for Health Research, 3800 N Interstate Ave, Portland, OR 97227 (e-mail: lynn.debar@kpchr.org).

Accepted for publication October 17, 2002.

We thank Jennifer Coury, MALS, and Gregory N. Clarke, PhD, for their helpful comments on previous versions of this article. We also thank Paula Wagenbach, PsyD, Lynette Currie, MA, Alison Firemark, MA, and Gail Morgan, without whom this study could not have been conducted.

Recent reports have documented the increase in pharmacotherapy in young children.⁶ However, few empirical reports describe the context in which psychotropic medications are prescribed to very young children. To fill this gap, this study examined the diagnoses, symptoms, and health care services associated with preschool children who received psychotropic medication in a group-model HMO. Our findings suggest that, in this setting, pharmacotherapy for very young children was infrequently received, was generally provided in the context of additional risk factors, and was provided most often in conjunction with psychosocial services for mental health or behavior management. In addition, the domestic instability and high-risk circumstances in which many of these children lived suggests that researchers and clinicians might need to rethink how best to deliver psychosocial treatments to young children when stable caregivers may be unavailable or not sufficiently able to participate fully in such treatment.