Preschool is no longer just about jungle gyms, finger painting and snack time for a growing percentage of kids barely out of their diapers. Many of them are getting Ritalin, Prozac and other mind-bending drugs along with their juice and crackers, according to a study in Tuesday's Journal of the American Medical Association.
The study by Julie Magno Zito, a University of Maryland pharmacy professor, and several colleagues, detected a three-fold increase in the prescription of psychotropic drugs in the population they studied -- 200,000 kids age 2 to 4, most of them Medicaid enrollees -- between 1991 and 1995.
The wholesale sedation of American youth is no secret. A study last summer found that one-fifth of the fifth-graders in Virginia Beach, Va., were on Ritalin, an amphetamine that calms them down, and so are 3 million other American kids -- Ritalin production is up 700 percent in the past decade. But the data Zito gathered shows how these drugs are increasingly being administered to the very young.
Zito estimates that around the country at least 150,000 preschoolers -- a tenth of them 2-year-olds -- were on psychotropic drugs in 1995. This is up from 100,000 in 1991. About 90 percent of the children were getting Ritalin or other stimulants, with the others on anti-depressants, anti-psychotics and other psychoactive drugs. Nearly all such prescriptions are "off-label" -- they aren't recommended by the FDA because there's no data on safety or efficacy for children so young.
Among the drugs being given to these young children is clonidine -- even though there have been reports that it causes fainting and depression. Commonly used to fight hypertension in adults, clonidine is increasingly being used to fight insomnia in kids who are taking Ritalin.
"Without sounding alarmist," says Zito, "I think it's reasonable to be concerned. We have no data on how these drugs effect the developing brain, the heart, the kidney, the liver. Off-label use is common practice. But it's not common practice in preschoolers."
Ritalin, of course, has been used for decades, long enough to be considered generally safe and effective -- at least in older children. It use has skyrocketed since psychiatrists in the early 1980s broadened the terms under which they considered that a kid could be diagnosed with Attention Deficit/Hyperactivity Disorder.
In August, the journal Pediatrics published a small study indicating that kids with ADHD who were treated with Ritalin are significantly less likely to abuse drugs and alcohol when they become teenagers. "Treating the underlying disorder," NIH drug abuse chief Alan Leshner said at the time, "significantly reduces the probability they will use drugs later on."
Many psychiatrists say that psychotropic drugs may be appropriate even for small children, though probably not in the numbers they are currently prescribed. "The point is, these children are sick and they need some treatment," says Harold Koplewicz, head of the Child Study Center at New York University.
But most experts believe the massive increase in prescription of Ritalin and other psychotropic drugs must at least partly be explained by social forces -- the need to "fit octagonal children into round holes," as one pediatrician explains -- and by medical economics.
Once upon a time, children with behavioral problems got work-ups in multidisciplinary clinics where they could be seen by a variety of specialists. But, as Harvard Medical School's Joseph T. Coyle writes in a JAMA editorial accompanying Zito's study, unless they've got lots of money or awfully good health plans, "behaviorally disturbed children are now increasingly subjected to quick and inexpensive pharmacologic fixes ... These disturbing prescription practices suggest a growing crisis in mental health services to children and demand more thorough investigation."
The average pediatrician sees a child for seven and a half minutes. A good diagnosis of a behavioral problem requires at least one and a half hours, says Koplewicz.
"I'm less worried about what Ritalin does than what it means," says California pediatrician Lawrence Diller, author of the critical 1998 book "Running on Ritalin." And Ritalin, in general, works. "It allows us to stick to things we find boring and difficult," he says, "but I don't see it as substitute for effective parenting and better schools for kids."
Mary, a former day-care worker and preschool teacher who asked that her last name not be used, struggled with the medication problem when her son Logan, now 9, was a 3-year-old in a Head Start program in North Carolina. Logan was extremely sensitive to noise and would crawl under the teacher's desk or walk out of the classroom when he felt threatened. His teacher said he was ADHD. Others described him as "high-end autistic."
"They were telling us we needed to do something and Ritalin was one thing we could do," she says. She and her husband resisted drugs and eventually home-schooled Logan for a year. They have since moved to Seattle, where Logan is enrolled in public school and doing well.
"I've worked in day care a long time. In all those years I only met two children I really thought, 'Thank God they're on something.' The rest of them -- they're all boys, and they seemed angry, not neurological problems. We were asking way too much of them to sit in a classroom all day. And at 3 years old -- it's insane. You don't know what a person is like at that age."
The rationale for treating children with psychotropic drugs is that behavior is primarily biological. Yet so is hypertension, say critics of the medications route, but the first line of treatment for it is exercise, stress reduction and modifications of diet -- not drugs. "Aspirin relieves headache but we don't talk about headache as an aspirin deficiency," Diller says.
In Diller's experience, young children respond to immediate and consistent discipline as well and as quickly as they do to drugs. "So for this younger age group especially," he says, "prescriptions seem like jumping the gun."
In addition, from a purely biological standpoint, nobody knows how these drugs affect the brains of kids under 3, whose brains are still changing rapidly. A 1998 study in the Journal of Child and Adolescent Psychopharmacology that looked at adverse events in children ages 4 to 6 who took Ritalin found the most pronounced effects were in the youngest in the group.
Zito also worries that many of the children taking these medications may be taking more than one, with even less predictable outcomes.
"Let's say I put this boy on stimulants because he's running around the classroom too much and he's too impulsive and in everyone's face," Zito says as she explains a conundrum she believes may already be too common. "Three months later, it looks like the treatment works, but he needs medication to go to sleep. Enter clonidine. Now we've gone from one drug to two. I have to worry about interactions, a wider spectrum of side effects. Then you say after a couple months it becomes apparent that he cries more easily, he's more sensitive. Now somebody says, well, I think he's depressed. He needs an antidepressive ... You can't just keep treating symptom by symptom, because you end up with multidrug regimens in which all bets are off in terms of efficacy and safety."