CCPR: Why is it important for clinicians to know about early childhood mental health and early childhood psychiatry?

Dr. Rowe: Early childhood mental health focuses on the development and behavioral health of children 0–5 years of age. Most of us see kids over 5, and yet their problems frequently started in early childhood (Zeanah CH et al, J Am Acad Child Adolesc Psychiatry 2002;40(2):214–221). If we don’t consider development, we might diagnose “atypical bipolar” in a 10-year-old child who actually has emotional dysregulation, which is a problem with the amount of emotional upset more than the quality of mood. They are explosive and might say, “I’m gonna kill myself. I’m gonna kill other people.” But when they come down, those thoughts go away. I look for their quantity of mood, mood stability, slope of increased intensity, and time it takes to return to baseline. 

CCPR: What percentage of young kids need clinical attention? 

Dr. Rowe: That may depend on the population. Dr. Laurel Leslie and Kristin Gist studied a child welfare population and found that kids under 6 had developmental disabilities 50% of the time while the general population rate was 10%, and 30% had a behavioral health diagnosis while the general population rate was 3% (Leslie L et al, J Dev Behavior Pediatr 2005;26(2):140–151). 

CCPR: What mental health problems occur in young children?

Dr. Rowe: Young children can have challenges in 1) self-regulation, 2) self-advocacy, 3) executive function, and 4) their sense of well-being. These four core areas are usually solid by age 5. If not, the child carries these problems forward, often complicated by DSM-type mental health problems. 

CCPR: Can you describe these four areas? 

Dr. Rowe: Sure. Self-regulation includes sleeping, eating, mood, attention, social interaction, impulse control, and aggression. Self-advocacy reflects a positive sense of self, the sense that their efforts can matter, the ability to use communication, and physical abilities. Executive function involves modulating attention, resisting distractions, holding thoughts in mind, figuring out saliency (what’s important), planning and predicting what could happen next, and learning from experience. A child’s sense of well-being, emotionally and physically, includes experiencing belonging, a purpose of life, a sense of morality (right and wrong), and freedom from physical and emotional pain.

CCPR: Do these give a complete picture of a young child?

Dr. Rowe: There are other areas to consider. A fifth chunk is internal working models— basic assumptions of who they are, what they should or should not do, and who is a safe and nurturing support. A sixth area is the sense of attachment: Who nurtures or encourages the child? Another consideration is interrupted development, particularly before age 5. (Editor’s note: For a list of these areas and factors with examples, see our online resource: www.thecarlatreport.com/EarlyChildhoodPsychCareResources.)

CCPR: What other factors affect neuropsychiatric function in young children?

Dr. Rowe: Genetic anomalies can affect brain structure and function. In utero events include exposure to toxins, drugs, strokes, and infections. Perinatal insultscan occur—infection, trauma, cancer, or surgery. One child I worked with needed bilateral frontal lobe surgery before age 2, had no impulse control or executive function at 5, but by 7 had improved wonderfully. Another factor is complex PTSD from prolonged neglect or physical, sexual, or emotional trauma, often before age 2. 

CCPR: Any other factors to keep in mind?

Dr. Rowe: Autism can result in difficulties with sensory processing, communication difficulties, fixation on routines, and responding to internal scripts. There are also 10 characteristics of temperament that can interfere with everyday function, such as poor adaptability to change and sensory oversensitivity. These impact the child’s relationships with parents, teachers, and peers. There are many other kinds of difficulties, including ADHD, anxiety, and depression.

CCPR: What does a child with these difficulties experience? 

Dr. Rowe: By age 5, children compare themselves with peers and may feel like a failure: “I’m not fast.” “I can’t use scissors.” “I can’t write my name.” Demoralization from problems in the four big areas can cause problems with peers and preschool teachers. Parent struggles with stress, mental illness, or substance use can impact attachment, temperamental mismatch, and responsiveness to their children. Children look for connection, including kids on the spectrum, and without it they suffer traumatizing stress. The excessive cortisol triggers neuropsychologic and neuroendocrine consequences that impact the alert and arousal systems (National Scientific Council on the Developing Child. The Science of Neglect: The Persistent Absence of Responsive Care Disrupts the Developing Brain; 2012: Working Paper 12). 

CCPR: What happens with poor self-regulation?

Dr. Rowe: Dysregulated children are too reactive (with excessive arousal), too underreactive, too quick to escalate, or too slow to recover. The child may feel as though they “might blow up.” They lack a sense of self-advocacy or mastery over their behavior. Parent-child interactions also impact self-regulation, eg, when parents pay too much or too little attention to the child. By age 4 you can have difficulties with mood, anxiety, behavior, and self-management, resulting in kids and caregivers who are really suffering. 

CCPR: How do you organize your assessment?

Dr. Rowe: I use the following 10 questions: 1) In how many areas does a child have problems, and is the case straightforward or complex? 2) When did the problems start? 3) What is the course of the difficulties? 4) What is the child’s chronological age and their developmental age? 5) Are there any heritable conditions present in the family, and do they influence the diagnosis? 6) Did treatments help; if so, which ones, and why were they stopped? 7) Did any stresses make the problems worse? Are there protective factors that are present or that went away? 8) Are recognized complex behavioral health disorders present? 9) What are the needs of the caregiver (concrete, medical, behavioral health)? 10) What are the primary relationships in the home (parent/child, parent/parent, any relationship difficulties)? (Editor’s note: For examples of each, see our online resource: www.thecarlatreport.com/EarlyChildhoodPsychCareResources.)

CCPR: How do social determinants affect assessment of young children?

Dr. Rowe: Dr. Pradeep Gidwani coined the phrase “a culture of one” to reflect how everyone’s social determinants are wide-ranging and unique: socioeconomic status, where they were raised, who raised them, what their family was doing. Did they have an immigration or refugee experience? Has skin color or gender impacted their access to services? Do they have food, housing, transportation, education, a safe and supportive community and home environment? 

CCPR: How do these aspects affect care?

Dr. Rowe: They impact mental health care attitudes and access: “What does your culture think of child psychiatry? Has anybody in your family had therapy? Is anyone in your family similar to your child?” If they don’t have food, shelter, and clothing, or if an abusive or alcoholic person lives in the home, it may be impossible to offer effective help such as psychotherapy. 

CCPR: How do you build rapport with families?

Dr. Rowe: With families from minoritized groups I’ll ask, “Are you okay with having a White psychiatrist from Milwaukee, Wisconsin? Because we’re not all the same either.” They laugh and say, “We’ll see.” This is true for all families. Dr. Gidwani says families want to know: “Does this psychiatrist see us for who we are? Do they care that we have problems? Will they be there when things are difficult?” If not, the therapeutic alliance suffers. You might recommend medication and families don’t try it. If they’re taking the bus, you need to be flexible about their appointment times. Understand the socioeconomic, racial, cultural, and experiential factors related to getting help from you. That’s a culture of one.

CCPR: How do you use medication in young children?

Dr. Rowe: We may need to address excessive arousal so that therapies and school plans can work. This includes sleep-wake cycle, hyperactivity, and flares of temper. I want children to fall asleep, stay asleep, and not be groggy in the morning. A second target is aggression. Look at the frequency, intensity, and duration of the aggression and use medications to cut the frequency down (eg, from 20 times a day to five times a day). If they shift from hitting people with sticks to calling people a bad word, or if the duration drops from 45 minutes of blowups to five minutes, I’ve made progress. 

CCPR: What other areas can you address with medication?

Dr. Rowe: Look at quality of emotion, anxiety, and parent-child interactions. For one complicated 5-year-old girl, we targeted attention, focus, and hyperactivity with methylphenidate. She came back saying, “Dr. Rowe, this medicine is working great.” 

CCPR: What do you do for sleep?

Dr. Rowe: Most kids I see have behavioral dyscontrol during the day and sleep difficulty, so I work with parents to implement sleep hygiene since young children generally cannot engage in cognitive behavioral therapy for insomnia. If necessary, I start with melatonin, then use central alpha-adrenergic agonists. I start with guanfacine, which has a longer half-life than clonidine and less morning sedation. Also, the duration of effect for clonidine is about four hours, so kids may wake up at night. 

CCPR: What do you do for the daytime problems?

Dr. Rowe: I try to avoid using D2-blocking antipsychotic medications if possible due to their serious metabolic and neurologic side effect. However, if the child is severely impulsive, hyperactive, or aggressive and no other nonpharmacologic or medication approaches are working, I’ll use low dosages of second-generation antipsychotic D2 blockers for 24-hour arousal reduction. The sedation is usually in the first eight hours, but the benefit lasts longer. I start with 0.5 mg of risperidone or 2.5–5 mg of aripiprazole. Olanzapine works, but about 30% of the kids have weight gain and glucose metabolism problems, so I don’t use that first. If the antipsychotic causes weight gain or excessive prolactin excretion with breast growth and galactorrhea, I might use ziprasidone at 10–40 mg or quetiapine at 12.5 mg or 25 mg. I occasionally use the antidepressant mirtazapine if a child has both sleep problems and picky appetite.

CCPR: How do you follow the effects of medication and when do you discontinue it?

Dr. Rowe: I developed a 10-item checklist for families. It is not “normed,” but it helps me track symptoms and side effects. I try to stabilize kids, get a good overall plan in place, then gradually discontinue the medication. (Editor’s note: See our online resource: www.thecarlatreport.com/EarlyChildhoodPsychCareResources.)

CCPR: What is the prognosis for young children with mental health difficulties?

Dr. Rowe: You can see rapid improvements within three months of intervention for attachment, behavioral management, sleep, and self-regulation. Brain plasticity peaks from 0 to 2 years, it’s about 80% at 5, and 20% during adolescence. The prognosis is outstanding with the right services. This relies on comprehensive diagnosis: What are the areas of difficulties? What’s the focus of treatment? Should we do child-parent psychotherapy? Should we do speech and language? Should we do OT and PT at the same time? But many localities don’t have those specialty services.

CCPR: What’s the prognosis for older children who did not get early intervention?

Dr. Rowe: If you don’t fix these basic building blocks by age 6, the problems are compounded—lifelong trouble with self-management, teens who cannot sleep or regulate themselves without marijuana or alcohol. Still, intervention at later ages can be helpful. In one study, reading levels of teens in our juvenile hall were at the second-grade level. A judge paid for a reading program, and they rose to eighth grade in four months. The kids were proud that they could read, learn, and remember. This is the kind of developmental thinking that we all need to be doing. (Editor’s note: For a treasure trove of resources related to this article, see: www.thecarlatreport.com/EarlyChildhoodPsychCareResources.)

CCPR: Thank you for your time, Dr. Rowe.