PBJ and Prozac

By Lindsey Townsend

Four-year-old Zachary was a problem. He wouldn’t follow directions. He refused to sit in a circle and sing the ABCs. He fidgeted, interrupted the teacher, and had difficulty waiting his turn.

It didn’t take the daycare teachers long to tell Zachary’s parents they suspected he was suffering from Attention Deficit-Hyperactive Disorder, or ADHD. His doctor put him on Ritalin, an amphetamine that typically starts working within a couple of days. But three weeks later, Zachary was worse.

Unfortunately, Zachary is not the only toddler popping pills with a swig from his Sippie cup. According to a report published this year in the Journal of the American Medical Association, use of Ritalin among U.S. preschoolers between 1991 and 1995 increased 150%, and use of antidepressants such as Prozac went up more than 200%. Does this mean that a problem is being taken care of, or a problem is being created?

Many health professionals are troubled by the trend. Dr. Joseph Coyle of Harvard Medical School’s psychiatry department has expressed concern about the study’s findings, pointing out that there is no evidence to support the use of psychotropic drug treatments in young children. Other experts agree. “When it comes to toddlers and drugs, we don’t know what we’re doing. In fact, we don’t know for sure that the number of behavioral problems is increasing. All we do know is that the use of medication is increasing,” says Aaron Kipnis, Ph.D., a professor of clinical psychology with Pacifica Graduate Institute in Santa Barbara, CA (www.malepsych.com).

Most disturbing is the fact that while not many drugs have been tested on children under age 12, none have been tested on children under age 6. In fact, the only medication that has been studied to date is the use of Ritalin in school-aged children. And even if it can be proved that Ritalin is safe for older children, that doesn’t automatically translate to the toddler crowd. “There have been no long-term studies whatsoever involving preschoolers and psychiatric drug use. People will say that a well-known drug such as Ritalin is safe because it has been around for years, but the truth is they have no idea what the long-term effects are on a very young child with a developing brain and a developing body,” says Dr. Mary Ann Block, medical director of The Block Center in Hurst, TX and author of No More Ritalin: Treating ADHD Without Drugs (www.blockcenter.com.)

Dr. Block recently treated a 5-year-old boy who had already been on at least six different medications, including Ritalin, Prozac, and clonidine, a blood pressure drug now being used to treat insomnia in hyperactive children. “But what was most amazing to me is that he, along with most of the other kids that I see, had never had a complete physical exam before the drugs were prescribed.”

What’s behind this penchant for prescriptions? Experts point to an increased awareness about behavioral problems among childcare workers, along with the fact that many children now spend long hours in structured daycare situations. Because no definitive tests exist for ADHD or other psychological problems such as depression, medication may sometimes be prescribed as a “quick fix.”

When Jennifer Willis* brought her three-year-old son Kyle* to the doctor last year because he was having trouble sitting still at daycare, the doctor told her “boys will be boys.” He prescribed Tofranil, a tricyclic antidepressant. Although the drug’s numerous side effects can include nervousness, sleep problems, and stomach and intestinal disorders, Willis says these possibilities weren’t even discussed.

While the medication did calm her son down, Willis wasn’t satisfied. “I didn’t feel comfortable with Kyle being on a drug,” she says. She later discovered through The Block Center that her son had numerous food allergies, including dairy, corn, and wheat. He’s now off medication and on a special diet that seems to be working. “I’ve seen the change in him. His teachers can even tell the difference from when he’s on his allergic foods and when he’s off them.”

According to Dr. Block, it’s totally absurd to label a child aged 2-4 ADHD or pathological in some way. “You do these children a disservice if you don’t look for the underlying cause of the problem while they’re young,” she says. Dr. Michael Barber, assistant professor of pharmacy at the University of Houston College of Pharmacy, agrees. “There is incredible data to show that ADHD is a brain-based biological disorder. If a school-aged child is suffering from it to the point where it’s limiting their ability to succeed, almost everyone would agree that medication is sometimes necessary,” he says. “But a 2-4-year old child cannot possibly be expected to have a sustained attention span. So how can you say that the benefits of medicating a toddler outweigh the risks when you can’t be sure that he or she truly has a problem?”

Perhaps it’s our society that needs to be “fixed” instead, suggests Dr. Leslie Rubin, a developmental psychologist with The Marcus Behavior Center at the Marcus Institute in Atlanta, GA. “One question that must be answered definitively before making the decision to medicate a toddler is determining what is “normal” behavior and what is truly pathological,” he says. “Children, particularly boys, have an incredible need to move, to tumble, to explore, and from a very young age we expect them to sit still for long periods of time. In my opinion, we as a society are creating this epidemic, by taking normal kids and subjecting them to unreasonable conditions.”

Much is still unknown about the long-term risks of psychiatric drugs. Dr. Kipnis points out that Ritalin is very similar pharmacologically to cocaine and might establish a risk of later addiction. “We’re teaching our kids that taking drugs like cocaine is the way to solve their problems,” he says. The short-term side effects of Ritalin and other amphetamine-type drugs can include a “zombie-like” flattening of mood, insomnia, depression, and loss of appetite. Long-term effects may include cardiac arrhythmia, mood disorders, and the possibility of psychotic events. Short-term side effects of Prozac and the other SSRI drugs, meanwhile, might include nausea, diarrhea, loss of appetite, and sleep disturbances. “The SSRIs are believed to be a fairly safe class of drugs, but because they are relatively new, we barely know the short-term, let along the long-term data,” remarks Dr. Barber.

The bottom line is, if your preschooler is having difficulties, don’t be too quick to let anyone label him ADHD. He or she may be suffering from many other conditions, including emotional problems, hearing disorders, allergies, nutritional deficiencies, or food sensitivities. Many options to medication exist such as behavioral therapy, play therapy, and counseling. One therapy showing great promise in treating behavioral problems is the use of neurofeedback training. It can be a viable alternative to treating a number of problems in pre-school age children, including attentional and hyperactivity disorders, anxiety, and depression, according to John Millerman, Ph.D., clinical director of Precision Neurofeedback Centers in Plano, TX.

If you need help, you might look for a developmental pediatrician to help evaluate your child, “because they understand child development-and variations in development-better than anyone,” says Dr. Rubin. “If you’re uncomfortable with a physician’s recommendation, always get a second opinion…Making an accurate diagnosis is probably the most important factor that makes a difference between appropriate and inappropriate use of medication.”

Finally, be sure to read every bit of information that’s available, and never feel pressured into a course of action that doesn’t feel right. After all, when it comes to the welfare of your child, it’s worth turning over every stone to find the best solution. “There are many ways to help children at risk. Most of the time medication is the crudest, cheapest, and quickest option-but by no means the most effective one,” says Dr. Kipnis.

*Names have been changed.

For More Information:

National Attention Deficit Disorder Association
Information on diagnosis of ADD and contact information to support groups

Children and Adults with Attention Deficit-Hyperactivity Disorders
Articles: Treating a Child with Attention Deficit Disorder and Attention Deficit Disorders in the Classroom

American Academy of Child and Adolescent Psychiatry
Questions and Answers about Child and Adolescent Psychiatry