Pre-school children and Ritalin (Part 2)

In my last blog I discussed an important new study that looked at the use of methylphenidate ("Ritalin", etc.) in preschool age children.

The data were reassuring: although, compared to its use in older children, side effects occurred more often and it was effective in fewer kids, the majority of children appeared to benefit and only a minority (11%) stopped the medication due to significant side effects (which resolved when the medication was discontinued). Best of all, no really bad events occurred.

********************

But this study does not really answer the question "should we use stimulant medications in children this young?" - a topic some of you addressed in your comments and, as promised, the topic of today's blog.

This is an important and legitimate question. Few trends have provoked more heated controversy and passionate opinions than has the surge in the use of psychiatric medications in children, and especially in those who are less than 6 years old.

********************

Dr. P's view
As a developmental pediatrician getting long in the tooth, I have prescribed stimulant medications to lots of children. While I have seen their clear benefit, I too wonder and worry if starting such a medication in a young child whose brain is still actively shaping itself could have a long term effect - bad or good - on the final architecture and chemistry of that brain. Since this phenomenon is relatively recent, we simply don't know if this could happen and, frankly, we are unlikely to for another decade or two, when these kids grow up and are studied.

Given this unresolved concern, why then do I continue to prescribe stimulant medications to young children? It has evolved out of my clinical work.

I had been trained not to use medications (this, of course, when dinosaurs roamed the earth). It took me many years and many failures of recommending improved limit-setting and time-out and other environmental interventions which seemed to have no effect before I finally screwed up my courage and prescribed a stimulant for ADHD.

Kids with ADHD who need and benefit from medications are those who had been having serious problems in their lives: abysmal school performance, no friends, disrupted family relationships, poor self-esteem...the list is always long and heartbreaking. And I saw stimulant medications in many cases providing benefits that were so far superior to what I had been previously recommending, so gratifying for the child and parents, that it seemed like malpractice not to offer the child and family this way to relieve the child's suffering.

So, despite the unknown potential for long term side effects, the short term benefits are so undeniable and the side effects, when they occur, so manageable, that I recommend these medications without apology.

********************

But, of course, some beg to differ. I have followed the objections to using stimulants for ADHD with interest. Generally they boil down to the following:

• It's a conspiracy by psychiatry and other nefarious elements (I suppose like me) to control and shape the minds of children, and/or it's an abominable practice fostered by unscrupulous physicians on the payroll of the drug companies. This is a time-honored ad hominen objection: if you have no coherent argument or evidence on your side, criticize the motives and honesty of the clinicians.
• It somehow just doesn't sit right. The implicit prejudice is that behavior problems must be managed by environmental engineering, not by tinkering with brain chemistry (even if it's clear that a difference in brain chemistry and not an inappropriate environment causes ADHD in most kids).
• These meds are a crutch, used by lazy, ineffective parents (and professionals) who want to chemically restrain their normal, active kids. In fact, they often argue, ADHD doesn't even really exist.

(Of the three, I find this last the most egregious. It unfairly damns parents of kids with ADHD as the cause of the problem, as maliciously using medications for their own selfish interests and not to benefit their child, and as not knowing or caring what is best for their kid. Aside from the fact that I've never met such a parent, it is a boneheaded and mean-spirited trifecta: self-righteous insensitivity to the real suffering experienced by kids with ADHD; the unconscionable accusation that parents are lazy and selfish and incompetent (with the self-righteous implication that "if I were this child's parent I would cure it beautifully without the need for medications. Why can't you?" This inevitably comes from someone who never raised a child with ADHD themselves.); and a stunning lack of insight into the complicated forces of both nature and nurture that guide human development and behavior.

********************

OK, that's my rant and I'm sticking to it. What about the use of stimulants in pre-school kids? Here's my take:

• By age 4 - but not before - good clinicians can be reasonably accurate in making a diagnosis of ADHD. If a child is experiencing signficant problems in the important aspects of his life (learning, relationships, self-esteem, etc.) then medications can be incredibly helpful - just as they often are in older kids - and should be considered.
• The diagnosis of ADHD can't really be made (although sometimes suspected) in two-year-olds. Let's face it, all two-year-olds have ADHD (and a touch of psychosis while we're at it). Stimulant medications at this age are a no-no.
• The same goes for three-year-olds. Although, occasionally a child is in such trouble (e.g., the child I saw who was being expelled from his 3rd child care site, who had all the hallmarks of ADHD, and whose mom was going to have to leave her much-needed job to care for him) that, in desperation, I have tried stimulants - with variable success.

Bottom line: If you are parent of a child 4 years or older whom you and the professionals are convinced really has ADHD and who is having a real hard time in his life, don't be afraid to engage in a 'therapeutic trial' of stimulant medications. Trust yourself. You'll know if it is helping your child or not. You'll recognize side effects that might warrant discontinuation. You'll know if the stimulants are a boon or bust for your child. Don't let the self-serving, self-righteous sneeries make you feel like a bad parent for doing so.


Related Topics: ADHD: An Update on Diagnosis and Treatment for Kids, ADHD: Boys Vs Girls

Technorati Tags: ADHD, Ritalin, preschool, child development