Report Finds Thousands Of Toddlers Are Being Medicated For ADHD At Alarming Rates
There is something seriously wrong with the way attention deficit hyperactivity disorder (ADHD) is diagnosed in young children in the US, with over 1 million kids being potentially misdiagnosed just because they are the youngest in their kindergarten year, with the youngest in class twice as likely to be on stimulant medication. More than 10,000 American toddlers 2 or 3 years old are being medicated for ADHD outside established pediatric guidelines, according to data presented on by an official at the Centers for Disease Control and Prevention.
The report, which found that toddlers covered by Medicaid are particularly prone to be put on medication such as Ritalin and Adderall, is among the first efforts to gauge the diagnosis of ADHD in children below age 4. Doctors at the Georgia Mental Health Forum at the Carter Center in Atlanta, where the data was presented, as well as several outside experts strongly criticized the use of medication in so many children that young.
The American Academy of Pediatrics standard practice guidelines for ADHD do not even address the diagnosis in children 3 and younger -- let alone the use of such stimulant medications, because their safety and effectiveness have barely been explored in that age group. "It's absolutely shocking, and it shouldn't be happening," said Anita Zervigon-Hakes, a children's mental health consultant to the Carter Center. "People are just feeling around in the dark. We obviously don't have our act together for little children."
Children Being Targeted In Schools
Dr Todd Elder, assistant professor of economics at Michigan State University, looked at a sample of nearly 12,000 children from the Early Childhood Longitudinal Study Kindergarten Cohort, which is funded by the National Center for Education Statistics. He analysed the difference in ADHD diagnosis and medication rates between the youngest and the oldest children in a kindergarten grade.
He found that the youngest children were significantly more likely to be diagnosed with ADHD and to be prescribed behavior-modifying stimulants such as Ritalin than their older classmates. He told the press that the "smoking gun" was that the diagnoses depended on the children's age relative to classmates and the teacher's perceptions of whether they had symptoms.
Elder said medicating such children inappropriately was a cause for concern not just because of the effect of long term stimulant use on their health but also because it costs a lot of money: he estimated about 320 to 500 million US dollars is being wasted on unnecessary medication of young children for ADHD, of which 80 to 90 million is funded by Medicaid.
From his analysis, Elder found that the youngest kindergarten kids were 60 per cent more likely to be diagnosed with ADHD than the oldest in the same grade, and also, by the time those groups reached the fifth and eighth grades, the youngest were more than twice as likely to be on prescription stimulants.
Prescribing Toddlers With Psychoactive Drugs
Dr. Lawrence H. Diller, a behavioral pediatrician in Walnut Creek, Calif., said in a telephone interview: "People prescribing to 2-year-olds are just winging it. It is outside the standard of care, and they should be subject to malpractice if something goes wrong with a kid."
Friday's report was the latest to raise concerns about ADHD diagnoses and medications for American children beyond what many experts consider medically justified. Last year, a nationwide C.D.C. survey found that 11 percent of children ages 4 to 17 have received a diagnosis of the disorder, and that about one in five boys will get one during childhood.
A vast majority are put on medications such as methylphenidate (commonly known as Ritalin) or amphetamines like Adderall, which often calm a child's hyperactivity and impulsivity but also carry risks for growth suppression, insomnia and hallucinations.
Only Adderall is approved by the Food and Drug Administration for children below age 6. However, because off-label use of methylphenidate in preschool children had produced some encouraging results, the most recent American Academy of Pediatrics guidelines authorized it in 4- and 5-year-olds -- but only after formal training for parents and teachers to improve the child's environment were unsuccessful.
Children below age 4 are not covered in those guidelines because hyperactivity and impulsivity are developmentally appropriate for toddlers, several experts said, and more time is needed to see if a disorder is truly present.
Susanna N. Visser, who oversees the C.D.C.'s research on the disorder, compiled Friday's report through two sources: Medicaid claims in Georgia and claims by privately insured families nationwide kept by MarketScan, a research firm. Her report did not directly present a total number of toddlers 2 and 3 years old nationwide being medicated for the disorder, however her data suggested a number of at least 10,000 and perhaps many more.
Dr. Visser's analysis of Georgia Medicaid claims found about one in 225 toddlers being medicated for ADHD, or 760 cases in that state alone. Dr. Visser said that nationwide Medicaid data were not yet available, but Georgia's rates of the disorder are very typical of the United States as a whole.
"If we applied Georgia's rate to the number of toddlers on Medicaid nationwide, we would expect at least 10,000 of those to be on ADHD medication," Dr. Visser said in an interview. She added that MarketScan data suggested that an additional 4,000 toddlers covered by private insurance were being medicated for the disorder.
Toddlers Being Put At Risk
Dr. Visser said that effective nonpharmacological treatments, such as teaching parents and day care workers to provide more structured environments for such children, were often ignored. "Families of toddlers with behavioral problems are coming to the doctor's office for help, and the help they're getting too often is a prescription for a Class II controlled substance, which has not been established as safe for that young of a child," Dr. Visser said. "It puts these children and their developing minds at risk, and their health is at risk."
Very few scientific studies have examined the use of stimulant medications in young children. A prominent 2006 study found that methylphenidate could mollify ADHD-like symptoms in preschoolers, but only about a dozen 3-year-olds were included in the study, and no 2-year-olds. Most researchers on that study, sponsored by the National Institute of Mental Health, had significant financial ties to pharmaceutical companies that made ADHD medications.
In the early 1990s, several reports of sudden, unexplained death in children taking these medications began to raise concerns. But the rarity of reports of such deaths made them difficult to study. In 2006, the U.S. Food and Drug Administration requested that the prescribing information on these medications warn physicians against ordering the drugs for children with any known cardiac abnormalities. Current prescribing information also suggests that physicians request a thorough family history of heart problems and sudden deaths and perform a physical exam before starting youngsters on these medications.
The increasing use of anti-psychotics since the mid-1990s corresponds with the introduction of costly and heavily marketed medications such as Zyprexa and Risperdal. The packaging information for both says their safety and effectiveness in children have not been established.
However, attention deficit disorder is sometimes accompanied by temper outbursts and other disruptive behavior. As a result, some doctors prescribe anti-psychotics to these children to calm them down -- a strategy some doctors and parents say is irresponsible.
Keith Conners, a psychologist and professor emeritus at Duke University who since the 1960s has been one of ADHD's most prominent figures, said that he had occasionally recommended it when nothing else would calm a toddler who was a harm to himself or others.
Dr. Doris Greenberg, a behavioral pediatrician in Savannah, Ga., who attended Dr. Visser's presentation, said that methylphenidate can be a last resort for situations that have become so stressful that the family could be destroyed. She cautioned, however, that there should not be 10,000 such cases in the United States a year.
"Some of these kids are having really legitimate problems," Dr. Greenberg said. "But you also have overwhelmed parents who can't cope and the doctor prescribes as a knee-jerk reaction. You have children with depression or anxiety who can present the same way, and these medications can just make those problems worse."
Dr. Visser said she could offer no firm explanation for why she found toddlers covered by Medicaid to be medicated for the disorder far more often than those covered by private insurance.
Dr. Nancy Rappaport, a child psychiatrist and director of school-based programs at Cambridge Health Alliance outside Boston who specializes in underprivileged youth, said that some home environments can lead to behavior often mistaken for ADHD, particularly in the youngest children.
"In acting out and being hard to control, they're signaling the chaos in their environment," Dr. Rappaport said. "Of course only some homes are like this -- but if you have a family with domestic violence, drug or alcohol abuse, or a parent neglecting a 2-year-old, the kid might look impulsive or aggressive. And the parent might just want a quick fix, and the easiest thing to do is medicate. It's a travesty."