Increasing Use of Stimulant Medication Treatment for Preschoolers

As you may already be aware, stimulant medication has been back in the news recently in regards to the increasing frequency with which it is being prescribed for preschool children. Hillary Clinton herself has become involved in this important issue and has expressed what I believe are some appropriate concerns about the use of stimulants and other medications with preschool-age children.

The research that has promoted this emerging debate was published last month in the Journal of the American Medical Association (Zito, J.M., et al., (2000). Trends in the prescribing of psychotropic medications to preschoolers. JAMA, 283(8), 1025-1031). In this important study, the authors examined the prescription records from 2 state Medicaid programs as well as a large HMO. Specifically, they looked at the use of stimulant medications, clonidine (often prescribed for treating ADHD), and antidepressants with children between the ages of 2 and 4. Data from 3 different years - 1991, 1993, and 1995 was examined so that they could look at trends in the use of these medications with young children that may have emerged over time.

At each year, over 200,000 children in the 2 to 4-year-old age range comprised their sample. The data were examined separately within the 2 state Medicaid programs and the HMO to look at possible differential usage in these different health systems. Because this was such a large and representative group of children, it is quite reasonable to believe that the results provide an accurate reflection of changes in medication use for preschoolers that have occurred throughout the nation during this time, although the possibility of important regional variation can not be overlooked.

Results

The authors' report results that provide clear indication of increasing use of all 3 types of medications - stimulants, clonidine, and antidepressants - between 1991 and 1995. Below are what appear to be the most important findings:

Within All 3 Systems, There Was A Significant Increase In The Use Of Each Medication For Preschool Children Between 1991 And 1995.

The rate of increase ranged from just under 200% at one site to about 300% at the others. Percent increases in the use of clonidine were even more dramatic - as high as 2300% in one of the sites. The increases in the use of antidepressants were more modest, but also showed considerable variability between the 3 different insurance system populations.

Although The Increase In The Use Of These Medications Was Large, The Absolute Usage Of Each Medication Type Remained Relatively Small.

An important point that seems to be missing from media coverage of this study so far is that the absolute usage of these medications - although it increased substantially - remained relatively modest in an absolute sense. (Of course, what constitutes "relatively modest" is a judgment call.)

For example, the actual rate of stimulant medication usage in the 1995 data ranged from about .05% of children per year at one site to about 1.2% at the highest use site. In other words, even though the rate of prescribing to preschoolers had increased dramatically between 1991 and 1995, there remained relatively few 2-4 year olds who were receiving such prescriptions during the highest use year. The percentage of children who were prescribed clonidine or antidepressants was far lower - well less than 1 child per 100 at all 3 sites.

In contrast, the percentage of 5-9 year old children who were prescribed stimulant medication during 1995 was much higher - representing about 6% of this population.

There Was A Greater Proportional Increase In The Number Of Preschool Age-girls Receiving Stimulant Medication Treatment.

Once again, this varied substantially across the 3 sites. Overall, however, the ratio of boys to girls who received stimulant medication treatment between 1991 and 1995 decreased.

Implications

These data tell an important story in changes that are occurring in how the medical community is responding to the emotional and behavioral difficulties in young children that they are often asked to address. As these data make clear, the use of medication to address these issues is becoming an increasingly frequent method used to try and help children with such problems. Although I am not sure if anyone knows whether the trends that were identified between 1991 and 1995 have continued, it would not be surprising to me if they have, and this would mean that an even larger percentage of young children are currently being treated with stimulants and other medications. These data also suggest that this may be particularly true for young girls, although this is not completely clear and is likely to vary from region to region.

In light of these facts, it is instructive to review what is currently known about the efficacy of such medications for this age group, and what national professional associations have suggested about the appropriateness of such treatment in young children. Regarding the use of stimulant meds such as Ritalin with preschoolers, there is considerably less data available than there is to support the use of such meds with older children. Those studies that have been published have reported results that are positive, but the need for additional research with this age group is clearly recognized. In addition, a number of professionals have expressed concerns about possible adverse effects of long-term treatment with stimulants that is initiated at such a young age, and the authors of this study identify the important need to carefully study this issue.

In the practice guidelines for ADHD published by the American Academy of Child and Adolescent Psychiatry in October of 1997, important cautions about the use of stimulant medication for preschool children were raised. These guidelines stressed the need to carefully consider the presence of alternative explanations of a young child's symptoms before making a diagnosis of ADHD in a preschool age child. This, of course, is important to do at all ages but is especially critical in young children who may show behaviors that lead one to wonder about the possibility of ADHD for a variety of reasons. In addition, such behaviors will tend to be less stable in young children than in school-age children because of the important maturational differences that characterize children of this age.

The guidelines also stressed that "stimulants should be used in this age group only in the more severe cases or when parent training and placement in a highly structured, well-staffed preschool program have been unsuccessful or are not possible." If medications are used, the recommendation was to exercise more caution, to use lower doses, and to monitor the child's response more frequently. In addition, it was noted that dietary interventions should be considered as an alternative to try with this age group.

Unfortunately, the data in this study do not provide any indication as to whether any such appropriate cautions were typically heeded. Based on other data that has been presented about problems in how stimulant medication is often prescribed even among older children, it would certainly not be surprising if such important guidelines were often not incorporated into a young child's treatment.

One possible adverse consequence of all the good research that has been done to document the efficacy and - as far as we know - safety of stimulant medications for children with ADHD, is that it may be leading some physicians to be less cautious about prescribing it. If this were the case, it could extend to the more frequent use in very young children - as an initial option rather than as something to consider after a variety of alternative interventions have been attempted.

One very positive outcome of the debate that seems to be emerging in response to this study would be a shift in the focus from is the use of medication to treat ADHD "good" or "bad", but rather, how can medication treatment be used most appropriately to produce the greatest possible benefits for children. Careful attention to this issue would be likely to result in outcomes that would be of greater benefit to children and families.

Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.

Reproduced with permission of David Rabiner, Ph.D. - HelpforADD.com