Should Preschoolers Take Ritalin and Other Stimulants?

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Diagnosis of attention deficit hyperactivity disorder (ADHD) has been steadily on the rise in the past few decades, and so has the use of drugs to treat it. But now even younger children might be considered prime targets for prescriptions of the drugs, an idea that is sparking persistent concerns about the long-term effects of giving stimulants such as Ritalin and Adderall to children.

“We don’t have enough information to know the long-term effects of these medications on young developing brains,” said Rahil Briggs, director of Healthy Steps program at Children’s Hospital at Montefiore Medical Center in New York City. “Young brains are like a sponge, they’ll soak up anything. Serious medication of this sort might affect them disproportionately as well.”

A September survey published in the American Journal of Psychiatry found that use of stimulant medications to treat ADHD had risen in the past 15 years, and the number of children between 13 and 18 taking the drugs had risen 6.5 percent each year since 1996.

The American Academy of Pediatrics released new guidelines  last week recommending that children as young as 4 should be screened for ADHD. The guidelines also endorsed prescribing ADHD medications such as Ritalin for preschool-aged kids who have moderate to severe symptoms and who don’t seem to benefit from behavioral therapy.

The use of methylphenidate, the active ingredient in ADHD drugs such as Ritalin and Concerta, in preschool-aged kids is an off-label use of the drug because the U.S. Food and Drug Administration has approved the drug only for children 6 and older.

The idea of giving powerful stimulants to young children gives many parents and pediatricians pause. But the American Academy of Pediatrics’ new guidelines are particularly cautious when it comes to recommending drugs for preschoolers.

“This issue of over-diagnosing has people in a tither because many believe that if we diagnose we will automatically treat with medicine. That is not the case and, in fact, the guidelines suggest using behavioral methods first in young children, not medicine,” said Dr. Michael Manos, head of the Center for Behavioral Health at the Cleveland Clinic.

For preschoolers who do wind up taking the drugs, scientists know fairly little about how the medications affect them. Only one large study, conducted by the National Institutes of Mental Health, has investigated how these drugs affect preschool-aged kids. The Preschool ADHD Treatment Study looked at 303 kids between 3 and 5 being treated for ADHD. If behavioral interventions failed, the children took daily doses of methylphenidate.

The study’s results showed that preschoolers who took the drug didn’t benefit from it as much as older children do, and they were also more likely to experience adverse side effects. One out of 10 kids who took the drug had to drop out of the study because the drug’s side effects were so intolerable.

Despite these results, some experts note that medication can offer relief to parents and children for whom all other approaches have failed.

“ADHD is common disorder that can lead to significant impairment,” said Dr. Chris Kratochvil, professor of psychiatry and pediatrics at the University of Nebraska Medical Center. “The concern is that if clinicians don’t take the time to do really evaluate the child or don’t understand what ADHD would look like in a preschool child, that might lead to inappropriate use of these medications.”

Ultimately, child development experts say parents and doctors should always take a cautious approach when it comes to prescribing ADHD drugs for young children.

“It’s got to be the very last solution we turn to after exhausting everything else that we know works really well,” Montefiore’s Briggs said.

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