Over the weekend, the American Academy of Pediatrics updated its guidelines for diagnosing and treating attention deficit hyperactivity disorder in youngsters and children, and one recommendation is likely to cause some debate. The AAP now suggests that primary care doctors consider prescribing ADHD meds to kids as young as four years old with "moderate to severe dysfunction" if behavior therapy does not work.
“Treating children at a young age is important, because when we can identify them earlier and provide appropriate treatment, we can increase their chances of succeeding in school,” says Mark Wolraich, the lead author, a professor of pediatrics at the University of Oklahoma College of Medicine and a consultant to a few drugmakers, says in a statement. “Because of greater awareness about ADHD and better ways of diagnosing and treating this disorder, more children are being helped.”
The recommendation of an AAP steering committee is part of an effort to update guidelines last issued a decade ago and, simultaneously, expand the age range that was covered previously. Now, the AAP says "emerging evidence" makes it possible to diagnose and manage ADHD in children from ages four to 18 years old, while the last set of guidelines covered children ages six to 12 years old.
The APP recommendation is likely to cause a stir, given what is already a long-standing debate about what some say is an overreliance by school districts on ADHD meds to cope with children who have behavioral issues; concerns about misdiagnosis, and uncertainty about effects on children who take the pills for an extended period. Other issues include effect on growth and suicidal thoughts.
For instance, Strattera, which is a selective norepinephrine reuptake inhibitor, carries a Black Box warning that "some children and teenagers may have a higher chance of having suicidal thoughts or actions. Although no suicides occurred in these studies, four out of every 1,000 patients developed suicidal thoughts." The drug, which is sold by Eli Lilly, is approved for children who are six years old and up.
Anticipating a backlash, the AAP paper acknowledges that "children in whom ADHD is inappropriately diagnosed might be labeled inappropriately, or another condition might be missed, and they might receive treatments that will not benefit them." And preschoolers are unlikely to have a "separate observer if they do not attend a preschool or child care program, and even if they do attend, staff in those programs might be less qualified than certified teachers to provide accurate observations."
The AAP also acknowledges another limitation. Although the AAP provides guidelines for diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders for Primary care, the AAP notes that behavioral descriptions have "not yet been tested in community studies to determine the prevalence or severity of developmental variations and problems in the areas of inattention, hyperactivity, or impulsivity" (you can read the AAP committee paper here).
As for side effects the meds may cause, the AAP paper acknowledges that preschoolers might experience "increased mood lability and dysphoria," which can generally refer to discontent or a form of depression. And mood lability is another way of saying mood changes. The paper notes that only dextroamphetamine - also known as Dexedrine among other names - is approved by the FDA for use in preschoolers.
And the AAP concedes that only one multi-site study has carefully assessed medication use in preschoolers. This involved methylphenidate, also known as Concerta and Ritalin. And there is limited experience and information about the effects. While there were also 10 single-site studies, most of which the paper reports demonstrated significant efficacy as well as moderate safety evidence, use in preschoolers remains off label.
Despite the qualifiers, the AAP maintains there are strong reasons for docs to consider prescribing the meds. For one thing, the AAP cites reports suggesting 8 percent of kids have ADHD. Moreover, the committee argues that the actual number of children with ADHD is far greater than can be managed by the mental health system. "Treatments available have shown good evidence of efficacy, and lack of treatment results in a risk for impaired outcomes," according to the AAP steering committee paper.
Certainly, there are preschoolers whose attention can be improved, although there are also developmental differences to consider when considering their situation with other children. And the AAP does acknowledge some qualifiers before plunging ahead with prescriptions. What do you think?
Should ADHD Meds Be Prescribed To Preschoolers?
- No (96%, 158 Votes)
- Yes (4%, 7 Votes)
Total Voters: 165
23 Comments
The fact is, whether it's recommended or not or FDA approved or not, the kids ARE already getting these meds as preschoolers, and many enter kindergarten on them at age 5. That's not news to ppl with kids in school or teachers, and if the kid acts up in class the teacher will call the parent and ask if the child took their meds for the day. Schools place a huge pressure on parents and kids to conform with medication.
If these kids have ADHD bad enough to require medication they should not be treated by an FP, but require a child psychiatrist experienced in the disease and use of these medications.
The question Should be;
"Should the people committing Felony Assault and Aggravated Battery on these preschoolers be allowed to plead Not Guilty by reason of being too Stupid to be held legally responsible for their conduct?"
Personally, I'd like to see what disclosures the members of this steering committee made with respect to ties to pharma companies offering these drugs.
Hi Karl,
Thanks for writing in and the answer to your question should be visible if you go to the link to the AAP paper, which I've provided, and scroll down toward the bottom. The author disclosures are listed there.
Hope this helps, ed
An ADHD diagnosis and treatment recommendation can qualify a child for Social Security benefits in many states. Dx and prescription #s will only rise as a result.
"“children in whom ADHD is inappropriately diagnosed might be labeled inappropriately, or another condition might be missed, and they might receive treatments that will not benefit them.” .....but this group with when you look at the members with more conflicts than one would hope for says 'start em early' can someone tell me exactly how many studies have been conducted on this age group ? I agree with D Bunker
Medicine has gone to hell in a hand-basket..this assault on children is beyond ludicrous...they are drugging the wrong population.... let's start at the APA and work our way through Washington DC to Wall Street...they have shown without a fragment of doubt to all need very large doses of anti-psychotics....
Putting all the children in a class room (K-12) - and the implications for behavioral expectation - is a very recent development, when viewed in the greater sweep of thousands of years of human history.
So if 5 or 10% of children don't/can't conform to what parents/teachers/society demand, well they get labeled "ADHD" - they are said to have disease or disorder, or exhibit characteristics thereof.
The diagnosis - the condition it represents - is naught but a convenient fiction. A fiction perpetuated by various parties who cannot admit that what is "wrong" is the historically aberrant expectation that Johnny sit in his desk quietly and obey teacher's instructions.
PS: If and when they manage to use fMRI to diagnose ADHD, nothing will have changed. Who is to say what constitutes normal vs pathological variation in brain activity? The data will be what it will be, the interpretation will still be fiction.
I used to work in a school system, and watched the effects of drugging the kids for the pleasure of the teachers. One little boy collapsed and foamed at the mouth and had to be carted off the hospital. Do you think his immigrant parents kept him on a drug? Another little boy forever more looked sad; never smiling. The sparkle was gone from his eyes.
Finally the practice stopped after several of us put our foot down. Children were moved to another class, where a different teacher might be more tolerant or have better behavior management skills.
Maybe the academics would like to comment, but 20% of matriculating college freshman are on at least one mood altering drug, including ADHD meds. My sources tell me that there is ongoing buying, selling and just plain exchanging of these meds that peaks before final exams. Side effects can be difficult when these kids are zooming and crashing, and college counseling centers are completely overwhwelmed and reluctant to notify parents. I don't think that the word epidemic is too strong.
This thread is about children, but it is these same children that ultimately enter college, and there is a 1/5 chance that they will be on a mood stabilizer and/or have a diagnosable DSM-IV mental illness. We are drugging this and future generations of kids.
Whatever happened to NO-DOZ? Seemed to work fine for us for one all nighter at a time, but these kids are using ADHD meds, whether ot not prescribed, and using to stay up 2-3 nights in a row. Don't be surprised to hear about psychotic breaks induced by prolonged sleep depriving meds.
One day this will frowned upon as a horrifying failed experiment - trying to chemically control behavior. Whether you believe in creationism or evolution how does a belief that man altering the brains of our future men is a natural part of the plan?
Professional organizations are not scientific studies.
Guidelines or recommendations from organizations require transparency. If the particular organization doesn't disclose potential conflicts perhaps Ed can lend a hand when he writes up the story.
Nonprofit tax exempt organizations should DISCLOSE when they dictate policy or relinquish their nonprofit status. Anything less is product marketing and nothing more.
Legal disclaimers are not to be confused with disclosures.
http://aappediatricbuyersguide.com/
I suspect 20% is an underestimate. At least by the time students are seniors, studies suggest nearly 50% use "adhd" drugs at least occasionally; some more regularly.
The highest proportions are consistently among the most competitive fields. Ironically, pre-meds have one of the highest rates.
One of my own students interviewed a number of her peers about their own views and use. What was disturbing (among other things) was a number of pre-meds anticipated they would continued to need/use the same drugs once in practice.
And this anecdote: One kid's parents sent a "care package" that included cookies, margarita mix, and a bag of adderall (it had never been rx'd for him).
The phenomenon is probably at least equally the initiative of parents as students. There was a NEJM editorial a few years back about parents' concerns about their kids "getting an edge" through psychotropics.
This is the pharmaceutical industry expanding the market, and has nothing to do with treating a disease, ADD, which may or may not exist. The drugs typically prescribed to treat ADD are very dangerous. Myself, I became addicted to Adderall, and after two years of absence from this drug, I still feel myself recovering from abusing that drug. Ritalin, biochemically, is no different from cocaine. These children may be damaged for life, from these drugs.
Thanks JiM. Several years ago the Accreditation Council for Graduate Medical Education (ACGME) implemented a maximum 80 hour workweek on hospital residents, in part to cut down on mistakes caused by sleep depreivation. Except perhaps for surgeons these rules have largely been followed. 36 hour shifts have been replaced by Hospitalists and night float systems at hospitals.
Even after finishing residency most doctors today become salaried employees rather than solo practioners who were on call 24/7. In short, most doctors are leading structured lives these days with ample time for rest and relaxation. Any future doctor who claims that they will have an ongoing need for Ritalin is already psychologically addicted if not physically addicted IMO
@Ms Piggy
Agree - although I doubt there is any medication to cure their psychosis and sociopathy, best to contain them in an institution, they like institutions.
People actually doing good work in health care do not seem to have a voice on this blog, they must be too busy doing the job of 10 people armed with crappy modern gizmos that feed information to bean counters for immediate profit extraction...
The brain of a human being between the ages of just-born to 5 years old has been well studied by past group of scientists who were interested in making sure the NORMAL process of establishing connections was not damaged or derailed.
It's very disturbing to the psyche to read the comments on this thread - OMG - what kind of competition for *profit* is this tangled web of mechanistic logic?
And doing this ONLY to the children of countries that have some kind of access to these medications....?
Another initial surprise to me....It turns out that a lot of faculty (across disciplines) also use adhd drugs to "keep their edge."
Is this different than in industry, sales, finance or other "high buzz" occupations?
I'd now be surprised if it was.
These kids should not be given ADHD drugs until they are much older. Kids are kids and they act up. Just because a child has a lot of energy and has a hard time calming down doesn't mean he/she has ADHD. They should be sent to a pychiatrist (spelling?) 1st and then see what happens. Then again doctors of all sorts love to pass out medicine like candy so who is out there on our side to protect the children?
I believe that the line from the song goes "leave them kids alone". I agree that we don't need no thought control.
JiM, why do profs need to keep their edge? I thought they were all laid back potheads like the Donald Sutherland character, English Prof. Dave Jennings in "Animal House". After all, how much "edge" do you need to discuss Milton?
Diagnosing ADHD in a 4 year old is sort of like practicing Veterinary-Pediatrics. It's not like diagnosing an ear infection or pneumonia, because unlike other childhood illnesses, there are no blood tests, X-rays, Scans or even reliable physical findings that conclusively allow a doctor to say...yes, your child is ADHD. The problems in diagnosing ADHD in this age group include: 1. the child can't tell whether or not he or she is suffering as a result of their behavior which makes behavioral training difficult to say the least 2. may normal children at age 4 show behaviors that could be mistaken as ADHD, yet still be normal 3. four year old kids can't tell you how they feel about and interact with their surroundings Let's not be hasty to slap a label of ADHD on these children. In my experience, most hyperactive 4 year olds are just normal or have definite reasons for being hyper. A word of caution: just because a child gets better on an ADHD drug does not mean he or she is definitely ADHD. Before labeling your child, find an ADHD doctor who has been trained to look for all of the more than 60 things that can mimic ADHD causing a child to be misdiagnosed as ADHD and possibly mislabeled for life. You just might prevent your child from being a failure in life! Dr. Frank www.mistakenforadhd.com
Dr Frank, on your first point you say "the child can’t tell whether or not he or she is suffering as a result of their behavior which makes behavioral training difficult to say the least."
It seems to me that with ADJD the child's suffering is secondary to the "suffering" of the household or classroom, and that parents and teachers are less concerned about addressing the child's behavioral issues than in maintaining order in the classroom and the home.
The brain of human children under the age of 5 is completely devoted to *learning* - accessing each and every part of the brain and activating its function.
There is no SCIENTIFIC basis for altering this NORMAL *growing up* phase with a molecule that breaks through the blood brain barrier - one day this will be seen in history as hate-based authoritarian savagery - reverse eugenics - eliminating the best and brightest as soon as they are identified.
The Millennial Generation is convinced that the worst thing they could do is send the kids to school in this current authoritative economic climate. It's obvious that competition is going to be managed through the poisoning of minds before Age 5.