Ritalin for Toddlers

By Ian K. Smith, MD

Attention-deficit/Hyperactivity disorder (ADHD), as anybody who has been within shouting distance of a schoolyard in the past 10 years knows, was the pediatric diagnosis of the decade. According to one estimate, some 2 million American children are bouncing off the walls with it. For parents and teachers driven to distraction by a hyperactive kid, psychotropic stimulants like Ritalin have been a godsend; thousands of students who couldn't sit still long enough to learn have been able to calm down, pay attention and get the job done, thanks to Ritalin.

For many critics, however, Ritalin has become a symbol of everything that is wrong with our overdiagnosed and overprescribed society. Having ants in your pants is part of a healthy, normal childhood, they say. Why are we drugging our kids at younger and younger ages?

But even Ritalin's critics weren't prepared for the study in last week's Journal of the American Medical Association. A review of HMO and Medicaid prescription records shows that over the five-year period from 1991 to 1995, the number of stimulant prescriptions written for preschoolers (ages 2 to 4) increased twofold to threefold. That's a jump of 200% to 300%. Next we will be prescribing Ritalin for toddlers!

This is almost certainly not a good thing. Although Ritalin is a relatively mild drug with well-known side effects, nobody is sure what it does to the rapidly developing brain of the very young child. There are no good studies. That's why manufacturers warn against its use in children under 6. It says so right on the label. Doctors, of course, can prescribe drugs for so-called off-label use, but they usually do it when the diagnosis is clear and there are no alternatives.

There is nothing clear about ADHD. The diagnosis is based on a checklist of subjective judgments--rating a child's inattention, distractibility, impulsivity and so on. It's hard enough for doctors to distinguish between an energetic teenager and one who has a behavior disorder. How can they make those judgments when the patient is still learning how to talk?

Moreover, there are alternatives--the most popular being some sort of behavior therapy. Such therapies are not well tested and are reportedly less effective than drugs, but their biggest advantage is that there are no side effects--or at least, no bad ones.

Many experts recommend that parents begin by taking a close look at what might be upsetting or stressing their child. Has there been a disruption in the daily routine? A move to a new house? The arrival of a new sibling? Understanding what is causing the stress is the first step to resolving the problem. Family counseling can also be helpful, although in the case of very young children the counseling often seems to be more for the parents than for the toddler. If nothing else, it may buy you enough time to determine whether your child is truly hyperactive and whether he or she will benefit from medication.

ADHD is a tough disorder, not only for the child, but also for family and friends. The first step in treatment is to be as certain as possible of the diagnosis. Then, if you decide to use medications, proceed with caution until researchers figure out what effect these drugs might have on young, developing bodies and brains.

For more information about ADHD visit time.com/personal Questions for Dr. Ian? You can e-mail him at [email protected]