Role of Ritalin in Preschoolers

JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGYVolume 10, Number 2, 2000Mary Ann Liebert, Inc.Pp. 53-54

Editorial

Role of Ritalin in Preschoolers

It's hard to believe that a medication commonly known as Ritalin still makes headlines, even the frontpage of the New York Times as on January 23, 2000. Our nation continues to believe in myths and mis-

conceptions about child psychiatric illness. Just as adults do, children suffer from real and impairing psy-chiatric disorders that require effective treatments, which often means medication.In the early 1980s, I examined the benefits of Ritalin in preschoolers with attention-deficit/hyperactivity

disorder (ADHD). Nicholas was 3'/2 years old but still slept in his high-walled crib to discourage wander-ing around in the middle of the night. During the day, Nicholas was in constant motion, surrounded by ac-

cidents and destruction. Babysitters came only once. Nursery schools lasted just a few days. Nicholas re-

quired constant supervision, causing neglect of his siblings and havoc in his parents' relationship. Theordinary pleasures of childhood were impossible for Nicholas—having a book read, sharing a TV programwith the family, playing with children.During clinical observation, Nicholas ran around wildly, played with 61 toys over a 5-min span, and

never engaged with his affectionate but harassed mother, who vainly tried to catch his attention. Nicholaswas placed on Ritalin. In his mother's words, "He is a different child. He will sit and let me read a bookto him. He can have a meal at McDonalds. I can take him to a puppet show. We now enjoy each other."Clinic observations corroborated these reports. We now know that a majority of such young children willhave significant maladjustments later on, and that dismissing their difficulties as childish exuberance or

"just a phase" does a disservice to these needy children.A recent Journal of the American Medical Association article reports that, between 1991 and 1995, there

was a two- to threefold increase in Ritalin use in 2-5-year-olds, the increase is actually restricted to 4-year-olds. About one in 500 received Ritalin in 1991, whereas in 1995 one in 100 did. Is a 1% rate alarminglyhigh or, perhaps, too low? We don't know since we have no information about the proportion of preschoolchildren with sufficiently severe behavior problems to warrant treatment for ADHD. Among those with in-tractable behavioral hyperactivity, medications such as Ritalin are the best treatment we have, and there are

no alternative interventions with demonstrated efficacy. Studies of psychosocial treatments have alwaysshown medication to be distinctly more effective.Understandably, there is concern that medications may affect brain development. However, stress and

illness also affect brain development. In fact, all human experiences do. Only further research can provideinformed opinion on the relative merits of giving or withholding treatment to ill individuals. Encouragingly,the limited evidence we have, does not suggest that compromised brain development is caused by Ritalintreatment.Another concern is that medications for emotional and behavior problems are prescribed "off-label" for

preschool age children in the absence of FDA approval for such use. This practice is not surprising sinceit holds true for most of medical care. Asthma medications are used frequently in children without FDAapproval. Even more striking, multiple surgical procedures are routinely performed without having had thebenefit of systematic evaluation. The use of medication in certain patients often cannot be delayed untilFDA approval. However, usually there is a rational basis for the "off-label" use of medications, such as

knowledge established through scientific inquiry, or clinical observations that strongly suggest efficacy. InRitalin's case, there is more than overwhelming evidence that it is effective in school age children with

As originally published in The New York Times, January 23, 2000.

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EDITORIAL

ADHD. There is some limited documentation that younger children may also benefit. Therefore, it is notunreasonable to medicate young children with severe intractable behavior problems.What is at issue is not whether or not it is ever wise to do so, but who should diagnose and treat. Judi-

cious treatment requires expert diagnosis, which often is unavailable. Pediatricians and general practition-ers are usually not trained, nor do they have the time, to undertake the lengthy clinical evaluations neces-

sary to establish psychiatric diagnoses, or to monitor treatment response. Unfortunately, current economicallydriven trends in care delivery work against better psychiatric care for young children, resulting in patternsof use that defy rational explanation. The answer is not a knee jerk condemnation of often essential med-ications but rather a focus on how to fund improved child research and build quality in professional care.

Harold S. Koplewicz, M.D.Editor- in-Chief

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