Tuesday, April 3, 2012

Psychostimulants in preschoolers: Panacea or Pandora's Box?

Victoria became pregnant at a young age. During her pregnancy, she was unable to consistently make responsible choices for herself and her developing child, often indulging in alcohol and drugs. As a result, her son Brian was born prematurely at 7 months. By the time Brian entered preschool, he became increasingly difficult for Victoria and his teachers to control, his interactions with other children at times violent and aggressive. Desperately trying to manage Brian’s outbursts, Victoria confides in a child psychiatrist who puts Brian on Ritalin. Within a couple of months, Brian’s outbursts subside, and much to everyone’s relief (Brian’s included), he is now able to sit through his preschool classes with limited distraction. He begins to enjoy relating with other kids and no longer receives negative attention at school. Several years later, Brian, now a very diminutive 9 year-old, writes a paper for a class assignment in which he suggests that everyone should have treatment like him to “make them behave,” and that “all kids with broken brains should have them fixed, too.” When Victoria learns of this, she speaks with Brian, who says he is confused why some kids can “be good without pills,” and wonders if people would “still love him if he stopped taking his.”1 

To some, this story tells of the triumph of administering drugs like Ritalin to children with certain behavioral profiles, such as attention-deficit/hyperactivity disorder (ADHD). Before being treated, Brian is uncooperative, anti-social, and unresponsive to linguistic persuasion. His behavioral disposition persisted and continued to worsen before treatment, and his prenatal exposure to toxins suggests that Brian may have suffered neurodevelopmental abnormalities that contributed to his social dysfunction. By comparison, Brian’s treatment is a successful attempt to bring him “up to speed” with his peers: he now exhibits self-control, can develop meaningful relationships, and attends to his schoolwork.

However, to others, this story highlights concerns about identity formation, self-worth, and growth retardation in drug-treated children. The issue is that Brian has begun to realize how he acts, what he thinks, and how he feels are all in some way a result of the treatment, and that this sets him apart from his “good” peers. Brian’s perception of himself in relation to the world around him has been changed in a fundamental way that will shape his identity as he matures. The hope is that Brian’s caretakers will support his healthy exploration of these concepts and reassure him that his worthiness does not depend on drugs. Also of concern is Brian’s stunted growth, which may be a result of long-term Ritalin treatment.

As a whole, Brian’s story illustrates both the successes and perils of psychopharmacological treatment in very young children. With respect to social functioning, there may be clear, long-lasting improvements for some with ADHD; others may fail to respond, or worse, experience adverse side effects. This brings up the issue of safety, which has been studied to a very limited extent in young children and begs the following question: “Despite their psychosocial benefits, how safe are these drugs for the vulnerable brains and growing bodies of preschoolers?” In order to address this question, I’ll provide an overview of the current body of research into the safety and efficacy of these drugs, along with current trends in ADHD diagnosis and treatment.

Methylphenidate, often referred to by its trademark name Ritalin, and amphetamine (trademark Adderall) are by far the most commonly prescribed drugs used to treat ADHD in preschoolers 4-5 years of age. Both drugs are psychostimulants, meaning they can enhance alertness, and have been shown to reduce classical ADHD symptoms of hyperactivity and inattention. While the exact data on how many prescriptions have been issued to preschoolers alone are unclear, the CDC estimates that just over 4% of all children aged 4-10 took psychostimulants as of 20072. Trends have been increasing since the early 1990’s and can be expected to continue. Aligned with this expectation is the American Academy of Pediatrics’ (AAP) October 2011 release of new clinical practice guidelines supporting the use of psychostimulants in 4 and 5 year-olds3, which the CDC also endorses4. The AAP claims, “there is now emerging evidence to [prescribe to] preschool-aged children.” What is this emerging evidence, exactly?

Of the two psychostimulant drugs most commonly prescribed to preschoolers (and there are a handful of others), only Adderall has received Food and Drug Administration (FDA) approval for use in children this young (also keep in mind that a clinician may prescribe an FDA-approved medication to treat basically any condition in any person, a practice known as “off-label” usage; so, prescribing almost any drug on the market to preschoolers is fair game). One might expect that FDA approval would be based on studies illustrating that Adderall is safe for preschoolers; however it is worth noting that no double-blind, placebo-controlled clinical trial of Adderall in preschoolers has ever been conducted. This basically means that tens if not hundreds of thousands of children are currently taking a drug without most stringent science to back it up, which even the AAP notes has “little evidence to support its safety and efficacy.” On the other hand, Adderall has been studied and deemed safe for older children (6+ years); however, studies have shown decreased drug metabolism and clearance in preschoolers, making the FDA’s extrapolation problematic5.

Ritalin’s effects in preschoolers are better characterized, though the FDA has not officially approved its use in children this young. While a dozen or so studies have examined the effects of Ritalin in preschoolers, only one double-blind, placebo-controlled trial has been carried out. This study, known as the Preschool ADHD Treatment Study (PATS) was completed in 2006 and forms the basis for the AAP’s statement that “methylphenidate is safe and efficacious for children in this age group.” The findings of PATS are encouraging and corroborate the AAP’s claims of efficacy: nearly 2/3 of the 140 children who received 10 months of continual treatment had improvements in ADHD symptomatology6. However, some safety concerns were raised. A small number of subjects dropped out of the study due to adverse side effects, but more concerning was that the Ritalin-treated group experienced 20% less than expected height gain, and 55% less than expected weight gain compared to their unmedicated peers. A similar study in older children suggested that growth-suppressed children never catch up to their unmedicated peers7, and this effect could be even more pronounced when medication is begun earlier in development.

It is clear that additional research studies are necessary. The aforementioned trials only begin to address issues of safety and efficacy, and given the (increasing) prevalence of ADHD diagnoses, the AAP’s recommendation to its 60,000 clinicians to provide drug treatment seems premature. It is important to mention that the AAP recommends Ritalin as a secondary treatment option; behavioral therapy is first, and ideally combines parent, teacher, and peer-based programs. However, the CDC indicates that over 2/3 of children with ADHD currently receive drug treatment8, and a recent study found a 4.9-fold increase in the rate of doctor’s office visits resulting in both an ADHD diagnosis and psychostimulant prescription over the past 18 years9. So, either the behavioral therapy isn’t working, or is being bypassed altogether in favor of pills. Keep in mind that behavioral therapy requires a large time commitment by parents and teachers, and the benefits are often not seen for months. In contrast, pharmacotherapy requires relatively little time and energy, and the effects on a child’s behavior may be seen within days. Obviously, the latter option is far more accessible and alluring.

For Brian, we can only hope that his caretakers will continue to closely monitor his behavior and make the best possible decisions with respect to his course of treatment, whether or not that necessitates the use of Ritalin. But not all kids are so fortunate. The reality is that many children are not surrounded by engaged parents and educators willing to put forth the time, effort, and patience required for behavioral therapy. These children, such as those in foster care or from underserved communities, may be particularly vulnerable to being unnecessarily medicated, over-medicated, or both. Evidence for this comes as early as 1999, where data from the Michigan Medicaid system showed that 57% of children aged 3 and younger with ADHD were treated with as many as 22 different medications in 30 combinations and monitored less than every 3 months10. Although most prescriptions written for preschoolers are psychostimulants, off-label use of antidepressants and antipsychotics is prevalent, and these drugs often have never been tested in young children.

We all want our children and adolescents to thrive and develop into well-balanced, happy adults. This motivation has driven more than two decades of research into ADHD diagnosis and treatment. But it is exceedingly important that we proceed with caution and not be clouded by delusions that a drug, whether now or in the future, will act as panacea. The neurobiological underpinnings of ADHD are complex and vary greatly across individuals. As we have seen, considerable variation also exists in terms of drug sensitivity and metabolism. So while some children have and will continue to benefit greatly from psychostimulants, others will not. Consequently, it is imperative that as ADHD research progresses, scientists and clinicians devote time and resources to developing multimodal treatment strategies that blend behavioral therapy with pharmacotherapy and can be tailored to the individual needs of the child. Multimodal strategies are recognized as the most effective form of treatment for ADHD in children11. On the social level, we must have adequate safeguards in place to advocate on behalf of children most vulnerable to overmedication. We should also be prepared to confidently address the inevitable questions of identity and self-worth that our children will quarrel with, as well as to retrospectively defend our decision to medicate them.

--Jordan Kohn
Emory University
Neuroscience Graduate Program

Want to cite this post?
Kohn, J. (2012). Psychostimulants in preschoolers: Panacea or Pandora's Box? The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2012/04/psychostimulants-in-preschoolers.html

1. This story was adapted from Stein Z, Chiesa BD, Hinton C, Fischer KW. “Ethical issues in educational neuroscience: Raising children in a brave new world.” The Oxford Handbook of Neuroethics. Ed. Illes J and Sahakian BJ. New York: Oxford University Press, 2011. 803-819.  

2. Visser SN, Bitsko RH, Danielson ML, Perou R, and Blumberg SJ. (2010) Increasing prevalence of parent-reported attention-deficit/hyperactivity disorder among children – United States, 2003 and 2007. Morbidity and Mortality Weekly Report. 59(44): 1439-1443. 

3. Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M, Stein MT, Visser S. (2011) Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 128(5): 1007-1022.

4.Recommendations from the American Academy of Pediatrics (AAP). http://www.cdc.gov/ncbddd/adhd/guidelines.html. Accessed 28 Mar 2012.

5. Wigal SB, Gupta S, Greenhill L, Posner K, Lerner M, Steinhoff K, Wigal T, Kapelinski A, Martinez J, Modi NB, Stehli A, Swanson J. (2007). Pharmacokinetics of methylphenidate in preschoolers with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 17 (2): 153-164.

6. Greenhill L, Kollins S, Abikoff H, McCracken J, Riddle M, Swanson J, McGough J, Wigal S, Wigal T, Vitiello B, Skrobala A, Posner K, Ghuman J, Cunningham C, Davies M, Chuang S, Cooper T. (2006) Efficacy and Safety of Immediate-Release Methylphenidate Treatment for Preschoolers with ADHD. J Am. Acad. Child Adolesc. Psychiatry. 45(11):1284-1293.

7. Swanson JM, Elliott GR, Greenhill LL, Wigal T, Arnold LE, Vitiello B, Hechtman L, Epstein JN, Pelham WE, Abikoff HB, Newcorn JH, Molina BS, Hinshaw SP, Wells KC, Hoza B, Jensen PS, Gibbons RD, Hur K, Stehli A, Davies M, March JS, Conners CK, Caron M, Volkow ND. (2007) Effects of stimulant medication on growth rates across 3 years in the MTA follow-up. J Am Acad Child Adolesc Psychiatry. 46(8):1015-27.

8. Attention Deficit/Hyperactivity Disorder: Data & Statistics in the United States. http://www.cdc.gov/ncbddd/adhd/data.html. Accessed 1 April 2012.

9. Sclar DA, Robison LM, Bowen KA, Schmidt JM, Castillo LV, Oganov AM. (2012). Clinical Pediatrics. E-pub ahead of print. Accessed 1 April 2012.

10. Rappley MD, Mullan PB, Alvarez FJ, Eneli IU, Wang J, Gardiner JC. (1999). Diagnosis of attention-deficit/hyperactivity disorder and use of psychotropic medication in very young children. Arch Pediatr Adolesc Med. 153(10): 1039-1045.

11. National Resource Center on ADHD: Diagnosis & Treatment. http://www.help4adhd.org/en/treatment/treatmentoverview. Accessed 1 April 2012.


Anonymous said...

~As described in your blog, the number of ADHD diagnoses have increased over the past decade and thus prescriptions written to treat this 'disease' have also increased. Let's look at what has occurred in the last decade in the environment of the average child. Computers, video games, iPhones, iPads and other technological gadgets are readily available and are widely used by the preschool population. This is correct, iPads/Pods are now being used by preschoolers. In addition, many children use a computer on a daily basis at home and before entering school to play learning games for example. This technological wave has not been reflected in the school curriculum, meaning that tech savvy kids are still being instructed with a curriculum devised generations ego prior to the technology wave.

~Someone I know works as a field engineer for a construction company. His job entails being on the construction site directing contractors and making sure all components of the project are handled properly. He was put into an office for a month in between projects and could not pay attention to his work. He ended up getting a prescription for Adderall to maintain focus. Once he was sent back out into the field, he quit taking the meds because he no longer needed them and could very well pay attention and do his job without drugs.

~How do these two ideas relate? Well, the point I am trying to make is that the environment is the problem for these children. The curriculum needs to be adjusted from archaic to modern in order to reflect our busy technologically advanced lives. Such proposed fast paced teaching will engage children and they will no longer need to even consider taking drugs in order to adjust to an environment that is not stimulating for them (just like the environment was not stimulating for the person in Hawaii. He's rather be outside engaged than behind a computer doing paper pushing). Following the same logic, children rather be involved in a more updated curriculum than the dull 19 century level instruction.

In your blog, the suggested mode of action is to involve parents and therapists instead of handing out amphetamines to kids like candy. This is part of the solution and perhaps this part isn't happening because the parents themselves are too busy living their hectic life answering texts, emails, conference calls and whatever else and don't have as much time for their kids, which is in itself detrimental to a child's emotional and behavioral development. Another part of the solution is renovating the school curriculum to better engage our evolved, fast paced children.

Jordan Kohn said...

Thanks for your comments, Anonymous.

It's difficult to conclusively link the rise of technology use among young children to the increasing prevalence of ADHD. While the correlation is strong, causality is impossible to prove using these epidemiological data. I'd like to point out that other factors also play a role in ADHD prevalence, such as increased awareness of the disorder and decreased stigmatization. Perhaps most importantly, ADHD did not become an official diagnosis until 1987, when the Diagnostic and Statistical Manual of Mental Disorders released revisions to its 3rd edition. It's also worth noting that these trends also began before the advent of iPods, iPads, and social media.

Your suggestion to create a more technologically stimulating, "fast-paced" educational environment for children raises several concerns. A host of recent research suggests that multi-tasking, mind-wandering, and decision fatigue correlate with increased stress and reductions in self-reported well-being. Several prominent theories and empirical studies in psychology assert that complete absorption in a single activity best facilitates one's happiness. Surely some of you have had the experience of reading a captivating work of fiction for hours on end, completely losing track of time or space in the process. Precious moments like those may be rare for those afflicted with ADHD, and creating a curriculum like the one you're suggesting may make them even rarer.

I agree that the education system needs improvements, especially more case-based and inquiry-driven learning programs. Perhaps these would be preferable ways to engage our children, rather than further fragmenting their attention spans with more and more digital stimulation.

izza said...

It's not easy to take care of a child like this. But, I never loose hope cos There's always a perfect time for them to develop their minds. Thanks for sharing your knowledge, reading your post gave me so much understanding about my child's differences. I am also thankful on the fast development through Language Education learning.

Anonymous said...

Surely immersing oneself in an activity is most enjoyable however, to be successful in our current society, we simply don't have the luxury of doing so as often as we would like. We have to keep track of time as our lives are fast paced and on the go.

I believe that the school system curriculum needs to reflect the lifestyle of our kids outside of school. They are moving 100/mph when not at school and when at school, they simply feel bored and disinterested.

I believe that the solution to this problem is multi-factorial and you bring up valid points.

However, I have to stick to my original view that the school system needs to be drastically changed in order to keep up with kids' lives outside of school. Of course, it would be fine and necessary to immerse our children in an activity that requires full attention. However, let's not bore them all day then feed them pills because they aren't paying attention and instead thinking about what to twitter about or how to beat that level in the video game later when they get home. I agree that inquiry based programs would in part solve this issue as long as the curriculum is more interesting than text messages and facebook.

Marília said...

Understanding the excessive medicalization inside western society.

To understand the phenomena of medicalization on young children is required a further study about the thought structures of western society. How we understand the human body and mind (and the separation of them), or further, how we understand nature and culture permeates our scientific production and guide us toward what we have been calling truth. My answer has no intention to delegitimize the work and finds of any field, but show that the process of "medicalyzing" people has consonance with some enlightenment ideas of what we call Men.

Gueertz has a lot to offer when we want to acquire an overview of what means to say “Nature” and “Culture” in our society. The way we see men will guide the way our researches are made and will propitiate a reaffirmation of an old philosophical creation.

In “The Interpretation of Culture” Gueertz discriminates some ideas which part of scientists of every field have been using to base their researches. First I will explain his point of view very briefly, and secondly I´m going to associate his point with the problematic I want to threat in my exposition: the thought that medicines which actuates biologically on human body can solve the human suffering.

Gueertz show us that during centuries the idea of what composes men had changed but incorporates still the concept of pure human nature, without the interference of culture. For Enlightenment philosophers the Human nature was composed in more numbers by immutable laws that could be reached withdrawing the cultural influences. This idea defend that Human nature is uniform, yet, not changed by where people live, the time and the circumstances they are. So, this view defends that the nude men can be reached by blowing the smokescreen that confuses our analysis.

Another theory that Gueertz talks about, that came to substitutes the enlightenment one, is the “stratigraphic” conception of human. It considers that humans are like an onion, composed by layers that can be stripped off. So, in this case, human would have the biological, social, psychological and cultural layers (not in this order), and, to achieve one of them the observer would have to “… peels off layer after layer, each such layer being complete and irreducible in itself …”(1973:37).

These layers follow an order, so when you want to achieve the more profound one, you have to start peeling off the cultural layer, then social, then psychological to finally get to the biological and nude clarity of human nature, with no other influences. His question is, finally: is that really possible?
Part 1

Marília said...

He enters in the hominid evolution defending that culture, since Australopcines, was part of what these apes could count on to survive, showing that can not exist such a thing as human nature separated from culture because the plasticity of Homo Sapiens Sapiens was a product of environmental pressure. He does not believe in the magical shift that made Homo Sapiens a complex ape, claiming that culture was, during centuries, influencing and helping the survival of the species that could better take advantage from the genetics gifts. Taking advantage of the genetic gifts, like tong transformation, was extremely important to allow some apes to survive during Ice Era with production of helpful technologies, like cloths, developing haunt techniques and so on.

My intention is, under all this information, not claim the inexistence of a “nude” Men, but understand how this idea is influencing scientific world and creating some specific phenomena as the increasing number of children under Ritalin medication; or the excessive medicalization of mental diseases on homeless people in Brazil, my actual research.

Clearly biology was, over nineteen and twenty century, one strong base for scientific ideas of human nature, and the tendency to discover the real composition of men grew until the biotechnology, the most financially supported field by private companies. But with the advent of Second Grand War and the sublevation of Epigenetic ideas, the idea of human nature went back to the bases of Enlightenment claiming the equality of human body. Interestingly enough, with Cultural Neuroscience we have an old paradigm and discussion being placed (my second research topic).

Returning to the well exposed Ritalin problem, by Jordan. As Ortega and Vidal demonstrate, the continuum effort to explain men suffering as part of a brain issues (rising plenty discussions about what would strong neuroscience call subjectivity since we are our brains), the problem is proposed: is neuroscience the key to explain and solve the human suffering? Because, if is the brain the main cause, only in the brain people might try to solve their problems, since our society lakes time to submerge in profound themes and self discovering processes. A pill to solve my lack of interest or attention is more simple than reach a deep knowledge about what creates, inside my own universe, my problems.

The medicalization parts from the presupposition that everybody is biologically equal and the problems are just the same, locates in the same area, following the same equation (even if we can find one million of equations), because, always, as Gueertz will shows us in the end of his second chapter, science (including Social Science) wants to find the formula that can be universalized, one which can be applied for almost everybody: seeking to explain with one formula a whole gamma of problems.
part 2

Marília said...

And what about the pharmaceutical industry and all these ideas above explained? The idea of universalizing processes fits as a glove in the interests of Pharmaceutical industry because medicines are created to reach more than a person.

I hope this discussion doesn’t stop here, because its becoming a real problem since private companies in association with politicians are taking advantage of public problems to enrich themselves and claim they are solving a real issue. Brazilian public health is promoting excessive medicalization not because it will solve the problem of thousands of people, but because the pharmaceutical industry offers money to the politicians that have the power to choose what companies they are buying the medicines from. Even more, I hope that neuroscientist can help anthropologist like me to discuss and construct with more consistency the structure of our arguments.

Gratefully, and sorry about the grammar mistakes.

Marilia Xavier Assumpcao


GUEERTz, C. The Interpretation of Cultures. Basic Books, 1973.

ORTEGA, VIDAl. Mapping the cerebral subject in contemporary culture.

Marília said...

Epigenetic is not the right word, change it for eugenics

Sorry about the mistake

Marília said...

So, honestly, I´m not claiming that the education system is not consonant with our children needs, but I want to scream that our real problem is based on how we understand human nature and culture, and how we educate our children inside this symbolic system that maintains the assumption that children has to be socialized in our terms of understanding everything. We don´t allow creation anymore, we don´t allow anything that is outside of the box we all created.

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