• Should very young children be taking stimulants?

    preschoolersThe use of psychiatric medications with young children has increased greatly in the US over the last 25 years, including 0.3% of US children under 6 (perhaps 100,000 kids) who take stimulants such as Ritalin. These children are given these drugs because they have or are thought to be at risk for attention/deficit hyperactivity disorder (ADHD). They get this diagnosis largely because they are aggressive or unruly, or at least are not being successfully managed by their parents or caregivers.

    Is it a good idea to give these drugs to preschoolers? There are reasons to think not. The drugs are expensive. More importantly, we should not expose developing brains and bodies to powerful medications without a very good reason. So it’s important to ask whether these drugs benefit such young children.

    In Pediatrics, Alice Charach and her colleagues review current evidence on ways to help preschoolers judged to be at risk for ADHD. The two primary treatments are programs that train parents in how to manage difficult kids and stimulant medications. Charach et al. searched the literature and found 55 empirical studies of ADHD treatments for preschoolers. But after applying rigorous criteria they found only eight ‘good’ quality studies that looked at parent behavior training. These studies consistently showed that parent behavior training leads to a moderate improvement in child behavior for many children.

    Charach et al. found only five ‘fair’ and one ‘good’ quality studies of methylphenidate (Ritalin). These studies reported a mix of benefits and harms for children.

    All studies noted improved ADHD behaviors (ie, inattention, hyperactivity, impulsivity) on active treatment… Adverse events were more common and of greater intensity at high than low doses. Poor appetite, social withdrawal, lack of alertness, stomach ache, irritability, and rebound were increased on medication relative to placebo.

    In the one ‘good’ study of Ritalin, whether children benefited depended on whom you asked.

    methylphenidate resulted in a small positive effect for teacher- but not parent-rated ADHD symptoms and social competence, no improvement in parental stress, and moderate worsening of parent-rated child mood. In contrast, clinicians rated children as improved with moderate to large effect size.

    So, I don’t think that treating preschoolers with stimulants is a good idea. There is no strong evidence that stimulants help very young kids, whereas there is good evidence that parent behavior training can help.

    The Charach literature review is another example of what Aaron calls “comparative effectiveness goodness.” But the not-so-good thing about this example is that after Charach purged out the weak studies, the eight remaining strong studies on parent behavior training included only 424 children. And the single strong study on Ritalin involved only 124 kids! This is a shallow evidence base for treatment decisions that affect tens of thousands of children. This will sound trite, but we need both more research and higher standards for research in this area.

    @Bill_Gardner

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    • Reading carefully, I can see you’re talking about a relatively benign set of behavioral disorders – ‘at risk for adhd’.

      Still, one should be cautious about generalizations like this. Ritalin is a relatively non-toxic drug compared to the antipsychotics, and both are generally preferable to institutionalization. There’s a big spectrum of behavioral disorders in children, and “behavior training” is perhaps not as simple as you may be implying.

      Greenes ‘The Explosive Child’ is a good introduction to a challenging domain only a handful of psychiatrists and therapists are willing to tackle.

    • And what about stimulant use for ADD in college students? Not much strong evidence there, either, and stimulant use/overuse is rampant on campuses.

    • it’d be interesting to see how those kids on ritalin today function as adults 20-30 years hence..

    • As a general pediatrician this is helpful. I’ve never treated a preschooler with a stimulant. However the 2011 change in age for diagnosis of ADHD (to include preschoolers) and this report from AAP has confused many parents and pediatricians, in my opinion:
      http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/AAP-Expands-Ages-for-Diagnosis-and-Treatment-of-ADHD-in-Children.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token

      My one question is—in your opinion to whom should we send patients and their parents for behavior parent training?

      Who typically has that training in a community?? Behavior health specialists aren’t advertising those services with those terms that I know of…

      • There are parenting books. 1-2-3 Magic being one. It’s hated by many ultra liberal parents, but worked for me.

      • Parent training programs like The Incredible Years and Triple P have excellent scientific support for efficacy and effectiveness. Strongest Families is a newer one that has only one RCT, but which showed excellent results. This uses parent coaching by phone, so living in a rural area or not having transportation is not a problem. Mental health agencies, Psychiatry departments, behavioral health departments, and some community agencies usually run these programs.

    • I’d like to see a chart on ADHD increase compared to spanking decrease. In liberal parenting circles on the web, in books, and in life, the mantra is time-out and very few discuss what to do when your kid refuses to cooperate with a time-out.

      Often, the result is an undisciplined kid. I’ve listened to parents react in horror at the violence implicit in a few firm swats on their kid’s bum when said kid is in danger of getting kicked out of pre-school or stuck on amphetamines because he’s learned that hitting, kicking and biting are effective ways to get his way and the only consequence is being asked to sit in a time-out that he refuses to sit in.

      The parents either shrug and say, at least they aren’t committing the worst of parenting, they aren’t spanking their kid. And he’s basically good. Most are. A few end up hated by their peers and don’t understand why.

    • The point being, I think no kid should be put on drugs before the parents have classes in managing challenging kids. What to do if your kid refuses to cooperate with a time out.

    • FYI, prior TIE coverage of ADHD with a link to a review of the evidence by CEPAC here: http://theincidentaleconomist.com/wordpress/comparative-effectiveness-of-adhd-treatments/

    • It makes sense that teachers would prefer it, when you take stimulants you are agreeing to 4-8 hours of focus at a time you have chosen in return for a flat-lined brain for the rest of the day.

      Maybe there are cases where the fallout from not performing well, or being a disciplinary case, in preschool is so bad that anything that improves performance during school hours is worth it, but even leaving aside brain development, is sitting quietly in school really THAT important at that age that you gotta sacrifice everything else?

    • I have very mixed feelings about this subject. On one hand, I believe very strongly that Ritalin was a life-changing intervention for my nephew. He went from a likely high-school-dropout to a successful graduate of Cornell’s vet school.

      On the other hand, I have recently been re-reading “Tom Sawyer.” The behaviors that Twain describes would be immediately suppressed, either by medication or by incarceration. But they were deemed pretty normal in the 19th century.

    • I think there is a reasonable prima facie argument that stimulants could be helpful in some young children. I’ll start by saying that I think diagnostic creep of ADHD is harmful and I bet the majority of kids on ADHD medication right now would do as well or better without it.

      So why would I ever support these medications? Because humans are constantly learning, and children learn faster than most. A much more feared condition, schizophrenia, is often not diagnosed until it reaches a late stage. By the time that anti-psychotic medications are started on a 21 year old the brain has grown into a schizophrenic brain. By this I mean that there can be delusions, hallucinations and social withdrawal symptoms that have been recurring again and again. The brain is plastic and it slowly becomes more and more convinced that these hallucinations/delusions are real and you reach a point that you can’t UNlearn the brain pathology – it becomes almost set in stone. Evidence shows that if you can get ahead of these symptoms and target patients when they are first becoming psychotic you can keep the brain from ever “tipping over” into the frankly psychotic state. You can read more and come to your own conclusions by starting here: http://en.wikipedia.org/wiki/Early_intervention_in_psychosis

      So what does this have to do with ADHD? The fear is that a child who is unable to function in school in kindergarten thru 3rd grade will slowly “tip over” to a child who learns that school is useless, horrible, impossible and not worth the effort. I work with kids in a psychiatry unit and you see these kids – the ones who have “learned” that they will never be able to succeed in school so why bother? The fear is if you condition a kid to fail at school, even if they are slowly growing out of ADHD as they mature, they still have absorbed the lesson of futility. If a stimulant medication can artificially make a kid succeed at school in this critical period, the benefits can last for years and years. We don’t have perfect ways of identifying which kids fit under this category but I assure you they exist. And I also assure you, a lot of these kids have parents with ADHD/cognitive impairment/poor social skills. As much as I wish we could give every kid the ideal psycho-social support to develop skills of attention and sustained effort – it just isn’t going to happen with some of these kids.

      So, I would say the answer is no, MOST young children should use better ways to treat ADHD symptoms. But some children are at risk of tipping into a life time of never trying, never learning, never developing self-esteem. And I would try almost anything to help them, including stimulants.

    • Thanks to everyone for these thoughtful comments! Let me restate that my post was specifically on the use of stimulant meds with very young children. These are kids who are not yet at risk of school failure, about which Will is rightly concerned.