Why toddlers don't need ADHD medication

At least 10,000 toddlers in the United States are being medicated for attention deficit hyperactivity disorder when they shouldn't be receiving this type of treatment, according to data presented last month by an official at the Centers for Disease Control and Prevention.

Susan Visser, DrPH, MS, presented data at the annual meeting at the Carter Center in Atlanta, on the diagnosis and treatment of ADHD.  Rosalyn Carter began her work in promoting mental health issues in the 1970s when she was First Lady and it continues today, and every year there is a well-attended conference at the Center in Atlanta.

Her data focused on a very close analysis of children in Georgia, and one glaring item stood out near the end of her presentation. She found that over 1,600 children, ages 2 and 3, were being treated for ADHD with stimulant and other psychoactive medications. This was approximately 1 percent of all children of this age in the state of Georgia.  If we applied Georgia's rate to the number of toddlers on Medicaid nationwide, we would expect at least 10,000 of those to be on ADHD medication, said Visser in a New York Times article.

This is a serious problem for four reasons:

1. There are no valid diagnostic criteria for ADHD for children in this age range.

2. Two and 3 year-olds are by nature hyperactive and often non-compliant. Child activity level essentially is at its highest from two to four and then decreases over the years, so children are at their most active phase of life in those years.  Along with that fact, children of this age range have not developed the ability to put on the brakes, follow directions, and easily comply with rules. Now many parents of children diagnosed with ADHD at age 7 say that they knew their child was hyperactive at age 2.  That is true.  However, for every four or five children who look hyperactive at age two, the majority will be within normal limits by age seven. So you cannot predict who will be clinically hyperactive by school age.

3. There is very little research on the impact of psychoactive medicines, particularly the stimulants on very young children. The few studies that have been done have shown that the medicines are not very effective in this age range, have a much higher rate of side effects including appetite suppression, irritability and sleep disruption, and generally just don't work that well.

4. There are effective treatments out there to help these children and families.   Systematically teaching parents to improve their behavior management skills, build in healthy routines for meals and sleep and moderate their own responses to their child's behavior have shown to be remarkably effective.   There are a group of programs that work including Triple P Parenting, the Incredible Years Program, and Parent Child Interaction Therapy. Over the past 20 years in Delaware, many therapists have been trained in one or more of these effective programs, and referral for a family to the appropriate trained therapist is the best solution.  The problem is families often don't get linked to the right therapist.  Another problem is that these programs are expensive in their training, often beyond the means of stressed budgets at mental health agencies.

But there is good news to help both children, parents, and therapists. Over the past several years, the CDC's National Center for Injury Prevention and Control has analyzed all of the effective therapy programs, and determined what makes them effective and their common features.  What Jennifer Kaminsky, PhD, found is that increasing positive interactions between parent and child and learning to effectively discipline without resorting to spanking were two of the most important elements.  The other two are teaching effective communication skills and use of social praise and rewards.  Based on the existing research and this analysis, CDC has just released a set of videos and other materials to teach those effective parenting skills on a new website Essentials for Parenting.

So now, parents do have a free effective option to choose when they find that their child is overly active and hard to manage. Therapists and pediatricians also have additional materials to use to help families.  And perhaps, we can finally dispense the notion that one can diagnose a child with ADHD at age two, and help parents by doing something that is effective, with no side effects.

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