Pre-school children and Ritalin: Boon or Bust?
There are usually two aspects to the controversy:
- Is it safe and effective to use them?
- And even if it is, should we do so anyway?
In this blog I'll discuss the first question, which this new study addresses. In my next blog, I'll discuss the "should" question.
This new study is by far the largest and the best to examine the safety and side effects of using methylphenidate (trade names such as Ritalin, Concerta, Metadate) for the treatment of ADHD in preschool children, ages 3-5 years.
The study
- 183 children with a diagnosis of ADHD participated over the course of a year.
- This was the best kind of study: a prospective study lasting almost a year with side effects ("adverse events") compiled by investigators who did not know the child's medication history.
What the study found
- 70% of the children experienced no significant side effects to methylphenidate.
- 30% reported moderate to severe side effects.
- 11% discontinued the medication due to unacceptable side effects. The most common reasons were emotional outbursts and irritability.
- The following side effects were reported (which tended to diminish over the course of the year): Crabby/irritable (44% initially dropping to 24% after 10 months); Prone to crying (37% dropping to 27%); Tearful/sad/depressed (24% dropping to 9%); Listless/tired (12% dropping to 3%).
- Other side effects remained relatively constant over the year: Appetite loss (42%); Skin picking (37%); Trouble sleeping (29%); Worried/anxious (28%); Social withdrawal (17%); Headaches (3%).
The authors conclude:
- There are more side effects when using methyphenidate in preschool children, compared to school age children. 11% discontinued the medication due to side effects, compared to about 1% in school-age kids.
- The side effects in preschool children tended to differ from school age children, with more emotional outbursts, irritability, sleep problems and repetitive behaviors.
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So them's the facts.
This is an extremely useful study for clinicians. It tells us that side effects of methylphenidate are more common and somewhat different in preschoolers, compared to school-age kids. It cautions us to watch carefully for emotional outbursts, for crabbiness, for repetitive type behaviors.
And, of course, everyone agrees that any worrisome side effects should prompt a discontinuation of the medication, after which the side effects inevitably go away. Additionally, we can anticipate that 2/3 of young kids will experience no significant side effects over a year.
Are you horrified or relieved by this study? The answer, I suspect, has more to do with your pre-existing opinion about the use of ADHD meds than it does with the actual statistics: is the glass 2/3 full or 1/3 empty? Or should there not even be a glass for pre-school children?
Here's my question to you: What about the 4 year old who has ADHD and whose life is a misery? Should I recommend using methylphenidate to treat his ADHD? What about in a 3 year old? A 2 year old? These are questions I agonize about regularly in my development and behavior clinic.
Which will be the topic of my next blog. In the meantime, let me know what you think.
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*Article cited:
"Safety and tolerability of methylphenidate in preschool children with ADHD."
Wigal T, et al. Journal of the American Academy of Child and Adolescent Psychiatry. November, 2006.
Related Topics: FDA Okays Treatment Patch for Kids, Choosing the Right ADHD Medication for Your Child
Technorati Tags: ADHD, Ritalin, preschool, child development
16 Comments:
First, a few points of order:
"This blog", to which you refer, is called "Healthy Children". Unless you plan to launch a new blog, your next post will also appear at Healthy Children.
With respect, a prospective study, even though it is blinded, is not the "best kind of study". That would be a randomized, placebo-controlled, multi-center trial. A meta-analysis of several such trials would be even better. The link leads to a summary, not to primary source material, so we can't judge the methodology independently.
I'm more interested to know what Dr. Parker would think had this study shown no increased incidence of side-effects in pre-schoolers. Would he become even more stimulant-friendly than he already appears to be?
best,
Flea
Hello,
As a parent who has ADHD, has a 7 yo with ADHD(wasn't diagnosed till age 5) though we knew there was a mental disorder of some sort since she was diagnosed with an unknown mood disorder at age 2. I also have a stepson who has ADHD and I am 99% sure that my 3 yo has ADHD but I cannot get her preschool teachers to believe me. Anyhow I digress off the topic. I would gladly take a chance with medication if it would make the difference that it did with my other children. I have lived with the side effects and I know that it comes down to fine tuning dosages and learning what works. Why have a miserible child if you can have a child with an easier life?
Just my personal opinion
DW
Dear DW,
Who do you REALLY want the easier life for, your children or YOURSELF. Looks like many around you have been "tagged" with ADHD. Maybe YOU just need a lesson in child rearing; it's not always an easy thing. Best to suck it up and deal with the cards you've been dealt. Not ALL children are easy! Listen to your pre-school teachers, they've had experience with MANY different types of children and they are EDUCATED in REAL child development; which does not come in the form of a pill.
If my child could have been treated for her myriad of learning disabilities/ADHD, it would have given her more time to learn effictivly, efficiently, and willingly.
Children are reading in Kindergarten now, and need the tools to help them progress. Perhaps the problems are not "bad parents of children with ADHD", but society pushing our kids to do more at younger ages. Look at most sports; children start at 3,4,5, in order to become "great". Our kids don't climb trees and build forts, play dolls or bake pies with their grandma's any more. They are in accellerated programs for sports, academics, and the arts.
We are medicating our children to help them survive in this cut-throat society. It is not about lazy parenting, it's about survival for the child.
Medication is a tool, another tool in the evolution of tools we have created to make life easier (computers, cell phones, plows, hammers, refrigeraters) Ritalin is technology designed to make some children's lives easier. Technology and tools, our society embraces them, so why not Ritalin, ...it has been proven to make lives easier.
Another note, it is not always the parents pushing for medication. It is often principles and coaches and teachers, pushing and pushing. It is unfair to place the entire blame on parents, who are filtering information from several sources, and trying to do what is best for their family.
Hi, I am an Italian mother of two kids. In Italy we would NEVER give Ritalin or any kind of drugs to a child under 5, and we are always extremely cautious when it comes to giving medicines to children or teen-agers. Have Americans ever doubted if they are giving too many medicines to their kids?
I have a 14 yr old, HS freshman, who has been hyper-active since she was two. However, she does not have total ADHD. I made the decision not to mention it to her doctors when she was young unless her teachers told me she her behavior was causing problems in class. We did take her to see a pediatric neurologist when she was 10 due to a nervous behavior and he said he could medicate her, but we probably wouldn't like her as much. He suggested getting her invovled in sports as a way to release her excess energy. She no longer does what we termed "her excited thing" and she is in all honor classes in HS.
I realize each child is different, but to ask for medication without first trying to work with the child is just taking the easy way out. I also know it is easier for girls to deal with ADHD than boys. She is still a ball of energy and talks my ear off to tell me about her day. But I would rather have that than the sluggishness that comes from medication.
It is always so interesting to see the almost immediate polarization of opinion that happens when people differ in opinion. We've gotten to the point where we presume that if you'don't agree with what I think, then you're wrong and furthermore, I'm going to do my best to make your opinion (perhaps even you if I have to) look stupid. jeeezz folks- stimulant-friendly? poor parenting skills? hello? I wonder how many who make presumptions like this, live with ADD or ADHD? I do. I also live with a recently diagnosed 18 yo daughter as well. Thinking, concentrating, focusing, organizing, socializing, getting ready for work etc etc is harder for people with ADD/ADHD. Harder because our brains work differentlly and thats ok. 30 years ago, its not likely anybody would have noticed problems like mine- the consensus of my teachers (all educated, intelligent and generally well meaning people) was that I was not the sharpest tool in the shed- hey, I believed it! All my other siblings were beyond average bright- MIT etc type people. IQ tests administered at the insistence of my mother proved teachers wrong- my IQ testing in the significantly higher than the average bear range. My daughter was not diagnosed with ADD until 11th grade- none of her well educated and I assume well meaning teachers saw enough behavioral problems at an early enough age to suspect ADHD- pursue testing and perhaps sugggest medication- not uncommon outcome of course for the girl population. By 11th grade however her poor academic performance, depression issues, truancy etc finally caught the attention of the school system. Essentially, schools answer was to withhold her diploma due to excessive absentieeism. Absenteeism which likely is directly correlated to her ADD. Inability to focus, attend, organize etc are critical components to learning and thus to one's education. If one cannot attend sufficiently to learn, one doesn't learn- at least not what they want you to learn. Now, you probably will learn that you're stupid according to the school system. You'll learn that as you sit stupidly looking around the classroom at the smart kids, you don't really like sitting there feeling stupid and there are days when the smart kids are bored with the less than stellar teaching skills of the math teacher and they decide to entertain themselves (within the teenage prescribed guidelines of torment) with making sure the stupid kids know how stupid they are. If you're a girl with ADD likely you beleive all this stuff and you suffer from all the many self esteem issues that go along with this kind of childhood. Boys with ADHD are likely to take a more active role in dealing with their academic failures, the derision of their peers, the condescension of their teachers (who of course believe that if this boys parent/s would just do a better job parenting this kid wouldn't be acting like this and would no doubt get good grades as well)- the boys reactive response most likely accesses that H component of their supposed disorder. No doubt the impulsive component will drive their response to the failure of those around them to recognize that there is a problem that has a significant impact on ALL aspects of their lives. ADD/ADHD is a brain disorder. Parents who have children with this problem have as much right not to mention responsiblity to ascertain what the problem is AND in conjunction with their pediatrician make the decisions that will best serve their child. I find it hard to believe that anyone actually believes that a parent chooses to use medication for their ADD/ADHD child because caregiving for that child is "hard". If my child had been diagnosed with a blood clotting disorder, if she had severe allergies etc- would we consider withholding medication? Why? The study that questions the satifactory use of medication for preschool children vs elementary aged children, is small and there are some questions I had based on the information I read. That does not negate the relevance of the question of course it just means I would reserve judgement and study the matter further. As parents we find there are way more things involved in each decision we must make regarding the care and well being of our children. Being well informed about as many aspects of an issue as possible is important. Knowing when the opinions of others is important and when it is not is also critical- it's one of the basic lessons we try to teach our children about being swayed by the opinions of their peers. I have spent most of my adult life teaching children from early childhood to college age. I am convinced that our children need all of us to carefully weigh all sides of any issue before we give guidance. Our children need us to support them AND to be supportive of each other in the hard work of raising our children- it's hard work for all of us but well worth the effort. There is no job as important as this one and we all need to help.
I am always amused/frustrated by the various debates about ADHD/ADD. I think that many of my fellow commenters are missing the point - the question (for me) is not so much "Should we medicate ADD/ADHD," but rather "Does this child/adult/extra-terrestrial have an accurate diagnosis?" As a family therapist, I have worked with many families where somebody was accurately diagnosed with ADD/ADHD and medication worked wonders. I have seen many more families where a child has been labeled or misdiagnosed with ADD/ADHD, which only contributes to the child's/family's difficulties. Every time I go to a doctor, when s/he finds out I'm a therapist and we talk about ADD/ADHD, s/he tells me about how many diagnoses are actually something else. For example, my optometrist talks about how a lot of "ADD" is actually a vision problem. 7x7sides talked about how his daughter had "depression issues" before she got an ADD diagnosis. Obviously I don't know enough about her to make my own diagnosis, but I wonder if her issue was depression all along (of course, we must consider that it could be both - again, I dont' know her well enough to say).
Also consider family context - not necessarily "bad" or "lazy" parents, but the environment of the family - do mom and dad fight? Are they violent, are there other mental health issues in the family? Are mom & dad divorced or divorcing? These and many other circumstances can elicit "problem behaviors" in children (and adults) that are misdiagnosed as ADD/ADHD.
Soooo... my thought is that the "problem" isn't over-medication, but over-diagnosis. I urge Dr. P and others in the medical field to be VERY mindful of the family environment when considering any mental health diagnosis - especially ADD/ADHD.
$.02
Matt
msmutchler@yahoo.com
People, please, before you medicate your children, look to see if their behavior is linked to their diet! Food colors, preservatives, diets full of sugar, food intolerance and food allergies can all have strong effects on the behavior of children, especially boys! Do your research before you waste your children's potential!!
I agree with some people but to be honest most don't agree with me. Who's life are you making it easier for you or your children. I think medication is a bunch of crap. I think in giving medication your not teaching your child how to deal with the energy he/she was given. My brother had ADHD they realized when he was very young i'm guessing 2 or 3. My mom put him on medication 1 time. She didn't agree with it because when she put him on it he changed. YES exactly what you would like huh? A child that is easier to handle... huh? that's great for the parents. But the child is in term oil trying to understand why it is he has to take medication to be in a room of peers (in some cases are doing exactly what he was doing... being an active child) If you consider this active child hard to deal with maybe you shouldn't have had children. Children are BORN with this energy so they can learn... some more than others. (as they say your born with a purpose) You need this energy to do what your type of person wants to do in his/her life. The children that have this energy are the ones who become something later in life that requires all this energy. You shouldn't take it away you should TEACH them to control it and harnes it to do good things with. If you don't want to spend your time doing this maybe you should rethink having children.
I think your just teaching your children they're not good enough they way they were born. Also in giving medication and giving them this name your giving them excuses for acting like what ever they want to act like when they please. (just like saying Sugar makes you hyper, if you say that and than give your child a cookie they will automaticly act like a monister)
I am a school social worker and parent.
I think the study is important to give us one more bit of information on the safety of medication. But that is just one piece of the puzzle.
If parents who have concerns about their children's hyperactivity and attention issues do research, they will hear about all kinds of different diagnoses, and different ways to treat. For example, they will read about sleep disorders, depression, anxiety, learning disabilities. The various treatments will include sleep clinics, therapy, anti-depressants, Omega-3 supplements, diet changes, on and on. The point is, it's just additional information and the more informed parents can be regarding concerns about their kids, the better.
We shouldn't be judging here, just gathering information.
L
It is our culture to cure things with pills: head aches, heart burn, depression, impotents, sleep problems, poor child’s behavior. Watch the evening news commercials and a pill is available (that works fast) for everything. There are people who are truly in need of these medications, however the vast majority are treating the symptoms and not treating the cause of their ailment.
As an adult, I am aware that red dye, high sugar, and nutrient poor foods changes my behavior undesirably, less than 8 hours of sleep lessens my productivity at work, less than 5 hours of activity each week changes my disposition. Behavior for all ages is a delicate balance between diet, sleep, physical activity, and intellectual challenge. Our culture promotes pills, not a better balance. A doctor of psychology should exhaust all other means of establishing this balance with the parents and child before writing a prescription, and only is a parent “bad” when they choose heedlessness. If this were the traditional approach, there would be far less folks considering the question: should a child be medicated for bad behavior.
I am a preschool teacher who has ADD. I didn't start meds until college and I can distinctly remember how I felt when I started taking the meds. I felt like my brain put on the brakes and I was thinking in slow motion. This fades to more normal as your body gets used to the meds. I worry how a small child would feel if this happened to them and could they understand that the meds help and that it will get better. As a teacher and parent I look at all other factors of behavior before suggesting to meet with a doctor about meds. However, if the child is diagnosed and is clearly becoming frustrated then I would certainly use the meds. I remember how frustrated I felt in school and how it affected my self esteem. Just this weekend I discovered new information about women and ADD and I can't tell you the relief I feel to be reminded that I am normal.
The key to a child's success in school and life is confidence. It is easy to lose confidence when you just can't achieve like your peers no matter how hard you try. If my own children were diagnosed with ADD and were becoming frustrated and disheartened I wouldn't hesitate with the meds if I had exhausted all other factors.
My son was recently diagnosed with ADHD and he is 4 years old. I had suspected this condition was present since he was 2 years old, however i did not believe he needed medicine til he regularly needed stitches in his head, got kicked out of 3 daycares, and stayed at a language level of a 2 year old. I am very happy with the results! He is a happier child who does not constantly fall, is constantly talking, and of course able to sleep at night restfully. I hope other parents have such good results as we have.
I think people sound so idiotic when they say lazy parents give their children medicaiton for ADHD. My son has had problems earlier then age 2. I have been to so many doctors, years of weekly speech therapy sessions at the hospital, even special education classes including occupational and physical therapy as well. Once my son started receiving ritalin life changed for him. He is now 9 years old and is a wonderful student and eager to learn. Before medication, he could barely sit still to write his name. Ritalin has been a wonder drug for him. Once his medication does start to wear off I can not expect him to sit still and want to read books or try to teach him anything. During school I think it is absolutely necessary that he takes medication so he does have a chance to succeed in life and learn. So when you write your statements to a whole audience you really should do some research first. I did mine for years prior to giving my son medication, and fought back and fourth with myself on what I should do as far as medicating my child. Every child is different and yes, I do agree some parents use medication for the wrong reasons, but not all of us do. PLEASE - if you are thinking about putting your child on medication follow your own opinion and professionals. DO NOT listen to people that run their mouths just because they don't believe in a certain issue. Do what is right for your child. Every situation is unique, but my child is wonderful on Ritalin!
just a mom--------
I do think that medication should be a last resort. Diet and behavioral modification and a complete medical history should be done to rule out anything else...one should look for a qualified physician that is willing to be honest about any and all other existing treatments and/or programs before reccomending drug therapy for young children. Any drug comes with risks and side effects and caution should be used.
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