MEDICATING OUR CHILDREN

April 2000
		Are we overmedicating our children? When should doctors prescribe psychiatric drugs for kids? Should there be restrictions imposed for younger children? Experts answer your questions.

Forum introduction Ritalin for children under 5. Diagnosing ADHD Diet and ADHD Is our definition of 'normal' accurate? Adults and medication Additional Comments     Health Spotlight: Attention Deficit Hyperactivity Disorder March 24, 2000: Treating ADHD The NewsHour's Health Spotlight. More NewsHour health coverage.	Gerry Sligar of Groveland, MA asks: I have heard that Ritalin was originally approved for children over 5 years old. What is the impact of prescribing it to children under 5? Should parents and doctors be more careful of including this age cutoff when making a decision to medicate a child under 5?   Dr. Diller responds: The recent furor over the use of stimulants and psychiatric drugs in the toddler age group highlights issues relevant to the use of these medications for all age groups. In particular how do we distinguish between variations of extreme "normal" behavior in a young child versus that of a disorder requiring a medication? There are no "tests" for ADHD (as with all psychiatric conditions) and the diagnosis is essentially the judgment of the evaluator. Ritalin is approved by the FDA for use in children six and over for the treatment of ADHD. This is actually more an endorsement for use by the FDA, based upon much data supporting Ritalin's short term effectiveness and relative safety. Once a drug is "approved" however, it can be prescribed by any licensed physician for any purpose. The doctor is restrained only by his practical and ethical judgment. We have much less information about the benefits and safety of stimulants in this younger age group. Anecdotal report suggests these younger children experience more frequent side effects and that rates of improvement are somewhat lower compared to school age children. Notwithstanding, based upon my experience, these children are highly responsive to changes in their environment (both positively and negatively). If one can work with the parents and preschool to develop a form of parenting that is most suited to these children's personalities and behavior, one can see changes as dramatically positive as if they were taking Ritalin. In the long term I believe these children and their families will be better served by developing strategies within the home than depending on medication. It should be a very rare child that requires medication below age five.   Dr. Jensen responds: Of course, parents and doctors should ALWAYS be careful when considering the use of methylphenidate (Ritalin) or other psychiatric medication, whatever the child's age. However, despite the current hoopla about the use of medications in very young children, we don't know whether the current levels of use are warranted or not. In considering whether a medication is warranted or not, two considerations are paramount: a. Other than the fact that the use of psychiatric medications has risen in recent years, nothing in the recent media reports has clarified how carefully these children had been assessed and diagnosed, and what other interventions had been tried BEFORE the medications were prescribed. So assumptions that these medications are being used inappropriately may be erroneous. b. In my view, such medications should never be the first or only intervention, particularly in this age group. Behavioral, family, or other interventions can be powerful and effective tools in addressing children's behavioral problems at any age, and should also be considered as a first line of defense. c. For some children, however, behavioral interventions will be insufficient, and careful use of medication may be indicated. Given the fact that approximately 5-8% of children do in fact have severe behavioral and emotional disorders even at young ages, we should not then be shocked that prescribing rates have risen, now at 1% And for some children, these medications may be truly lifesaving, and are being used as a last step by parents and physicians after other options have been exhausted. d. So we should not be shocked that such medications are being used. But we should be concerned that sufficient data are not available to indicate whether these medications are safe and effective, and to guide prescribing practices as to WHEN AND UNDER WHAT CONDITIONS THEY SHOULD BE USED. Gathering such data is the responsibility of the federal government, such as the FDA and the National Institutes of Health. Encouraging the federal government to be more proactive in filling these knowledge gaps is critical. e. The current situation with psychiatric medications has parallels in all the rest of pediatric medicine. Unfortunately, then, in the great majority of instances in pediatric medicine children are "scientific orphans," in that 4 of 5 of ALL medications (from antibiotics to allergy medications to anesthetics) have NOT been tested for safety and efficacy...not just in children under 6, but in children of all ages. Drug companies often do not want to assume the liability of testing medications in children, preferring instead to test the agents in adults only, where potential liability is lower and public support is greater. This leaves doctors in the lurch, having to rely on studies of adults to guide pediatric practices.