Preschoolers on meds: Too much too soon?

Doctors have been prescribing drugs to treat attention deficits and depression in very young children for more than a decade.

Story highlights

  • More than a quarter of U.S. kids and teens now take regular medication
  • About 1 in 5 children ages 13 to 18 has some sort of mental disorder
  • These medicines are not meant to be a quick solution for stressed-out families
As the sun rises over Phoenix, 4-year-old Shelby wakes. She sleepily uses the potty, dutifully washes her hands, and then accepts a white capsule from her mother, Victoria*. (*Last name has been withheld.)
The blond-haired, blue-eyed little girl swallows the medicine easily. "And then she's off—to take care of the pets, play with play dough, and just be Shelby," says Victoria.
The capsule contains 20 milligrams (mg) of Ritalin (methylphenidate), the prescription stimulant used to calm and focus children with attention deficit hyperactivity disorder (ADHD). After dinner, Shelby takes more meds -- 2.5 mg of Abilify and .05 mg of clonidine. The preschooler has been on daily medication since she was 2, when she slept only about four hours a night and threw frequent, violent temper tantrums that sometimes left her mother with bruises and bite marks.
A psychiatrist at the local children's hospital diagnosed bipolar disorder. For a year, Shelby was on increasingly potent doses of Risperdal (risperidone), an antipsychotic, and Depakote (divalproex), an antiseizure drug that's also used to reduce mania.
But as her outbursts gave way to medication side effects including slurred speech, tremors, weight gain, and an inability to walk without stumbling, her mother sought another opinion. This psychologist disagreed with the initial diagnosis, suggesting that Shelby didn't have bipolar disorder but rather a combination of ADHD and oppositional defiant disorder (ODD). He prescribed Ritalin.
Two-year-olds being diagnosed with bipolar disorder and put on psychiatric meds? It sounds incredible, but across the country children are learning to swallow pills before they can tie their shoelaces.
A 2007 study found about one preschooler in 70 was taking a psychiatric drug, such as a stimulant, an antidepressant, a mood stabilizer, an antipsychotic, or an antianxiety drug, says Mark Olfson, M.D., a Columbia University psychiatrist and researcher.
While some doctors have been prescribing drugs to treat attention deficits and depression in very young children for more than a decade now, the use of antipsychotics to counter irritability and aggression in this age group is new.
The change may be part of a larger trend of prescribing drugs -- for any condition -- to children. More than a quarter of U.S. kids and teens now take regular medication, according to Medco Health Solutions, Inc., the biggest U.S. pharmacy-benefit manager.
In spite of the growing number of young kids taking psychiatric drugs, these medications (with a few exceptions) are not specifically approved by the Food and Drug Administration for use in children under age 6. Why? Because little is known about how they affect the tiny brains and bodies of young children.
"We have very little research to show how psychiatric medications affect the developing nervous system, for instance," says Dr. Olfson. "This is a concern."
What is known: Some medications carry significant side effects. Stimulants may be associated with a slower rate of growth when used consistently over several years. Antipsychotics are linked to rapid weight gain and metabolic and endocrine abnormalities.
In one study, kids ages 2 to 6 gained an average of 19 pounds in less than 12 weeks on one antipsychotic-drug regimen. But even with these side effects, doctors defend the drugs' use in the most severe cases.
"This doesn't mean children shouldn't be on these medications -- many have benefits that outweigh the risk of side effects," says Rachel Klein, M.D., director of the Anita Saltz Institute for Anxiety and Mood Disorders at New York University. "It does mean you need to be really careful to monitor kids who are on these drugs."
For parents whose lives have been turned upside down by intensely moody or rebellious toddlers and preschoolers, the psychiatric drugs can seem heaven-sent.
"My son used to be a ticking time bomb -- he'd find a screwdriver and poke a hole in the screen door, then stuff a toy down the toilet in a matter of minutes," says Theresa Newfield of Raynham, MA, whose son Dayson was diagnosed with ODD when he was 3. Now on the stimulant Adderall (amphetamine and dextroamphetamine) by day and an antidepressant before bed,
"Dayson can actually focus on what you're saying and reply with a sensible thought," she says.
Last year The New York Times reported on a boy named Kyle who started taking an antipsychotic drug when he was just 18 months old, prescribed by a physician trying to control the boy's severe temper tantrums. The article documented the child's journey from doctor to doctor, diagnosis to diagnosis, until, by the time he was 3, he was taking an antipsychotic, an antidepressant, two sleeping medicines, and a drug for attention deficit hyperactivity disorder. Now 7, the boy was finally weaned off all meds but one -- for ADHD -- through a program administered by the state of Louisiana in partnership with Tulane clinicians.
"The rate that children are being medicated is increasing out of proportion to research showing that it's safe and effective," says Mary Margaret Gleason, M.D., assistant professor of psychiatry and behavioral sciences at Tulane University School of Medicine. "At the same time, we know that kids need help." Dr. Gleason, who treated Kyle as he was weaned off the heavy medications, said there was no valid reason to give antipsychotic drugs to the boy...or virtually any other 2-year-old.
About 1 in 5 children ages 13 to 18 has some sort of mental disorder, be it an anxiety, mood, or disruptive behavior disorder, according to researchers at the National Institutes of Health. The rate of problems in preschoolers is not much less than that of teens, says Dr. Gleason. That means there are a lot of children who desperately need help. But are these medications the best way for them to get it?