Preschoolers and Drugs: How Young Is Too Young for Ritalin?
The Results Are In
Should a two-year-old be given stimulants like Ritalin? Should a three-year-old be put on an anti-depressant like Prozac?
A new study reported in this week's Journal of the American Medical Association (JAMA) finds the rate at which preschoolers were given such drugs doubled, perhaps even tripled, between 1991 and 1995.Researchers at the University of Maryland School of Pharmacy analyzed 200,000 preschoolers' prescription records from two state Medicaid programs and an HMO in the Northwest over a five-year period. Among the findings:
Although the researchers did not note the conditions children were being treated for, nor the training of the medical staff who prescribed the drugs, the study is being given serious attention because it suggests that nationally, as many as 150,000 children under age five may be taking the drugs. Many are commonly prescribed to older children diagnosed with Attention Deficit Hyperactivity Disorder (ADHD).
Yet few of the medications have been approved by the Food and Drug Administration for use with toddlers and preschoolers. Methylphenidate, the generic form of Ritalin, carries a warning against prescribing the drug to children under six (although it is legal for physicians to do so).
"Unresolved questions involve the long-term safety of psychotropic medications (with this age group)," wrote the study's lead author, Dr. Julie Magno Zito. "The possibility of adverse effects on the developing brain cannot be ruled out."
Prescription for Debate
Some doctors are alarmed by the study's findings. Dr. Joseph Coyle, chairman of psychiatry at Harvard Medical School, warns that even the diagnosis of ADD/ADHD in very young children is considered unreliable, let alone the effects of the drugs on a developing brain. Coyle is among those calling for "much more extensive studies to determine the long-range consequences" of the use of such drugs at young ages.
But Dr. Joseph Biederman, chief of pediatric psychopharmacology at Massachusetts General Hospital in Boston, angrily dismisses the study and accuses its authors of having "an ideological bent."
"The purpose of the study is to alarm the public," Biederman insists. "When you have a three-year-old devastating the household I don't see any reason why the three-year-old should not be treated. We're talking about serious out-of-control behavior with some of these children, not one temper tantrum."
Biederman, who reviewed Zito's research prior to publication, points out that the study does not indicate what, if any, previous treatment the children had received.
"If a child has asthma, would you delay treatment until the child is twenty?" he asks. "If a child has a cavity, it needs to be filled, whether the child is four or ten."
Moira Munns, parent of a child with ADHD, registered pharmacist, and a member of the board of directors of the parent-run ADD Information Network, has mixed feelings about the study.
"I'm a little alarmed," she admits. "I hope parents are working with competent professionals, because anytime you have people who are desperate, they are easily taken advantage of."
Munns advises parents to "proceed cautiously" regarding medication to treat ADD and ADHD in children. Behavior management programs or early intervention programs, she notes, are "frequently very effective."
"Personally, I always feel that medication is not a best first step," Munns says. "Better to try other things first."
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