TODDLERS GIVEN BEHAVIOR DRUGS

Medical Journal Calls Practice Disturbing

Growing numbers of preschoolers as young as age 2 are being treated
with Ritalin and other behavior-altering drugs, new research shows.

The practice is disturbing and has the possibility of damaging
youngsters' developing brains, according to the authors of the report
and an accompanying editorial published in Tuesday's Journal of the
American Medical Association.

The findings that 1 to 1.5 percent of children in the study between
ages 2 and 4 were receiving stimulants, antidepressants or
antipsychotic medications shocked some Bay Area pediatricians and day
care providers. Hyperactive toddlers, they suggested, might be better
served by a rousing game of ring-around-the-rosy.

``Gosh, preschoolers. I don't know how they would differentiate a
spirited child with a hyperactive one at that age,'' said Dr.
Jacquelynn Tsu, a San Jose pediatrician who also has a degree in
elementary education.

The study of 2,000 young children revealed the number of prescriptions
written for such drugs increased by 1.3 to 3 times in three different
parts of the country between the years 1991 and 1995.

Overall, use of all these medications remains relatively rare:
Children between the ages of 2 and 4 years were treated at one-tenth
the rate of their 5- to 14-year-old counterparts.

Some Bay Area mental health experts said use of these drugs may not be
intrinsically harmful -- and can, in fact, offer important therapeutic
relief to troubled children.

``Kids do develop psychiatric problems, early on, that can interfere
with their social and academic development,'' said Dr. Mark Levy, a
Mill Valley psychotherapist. ``If they can't focus, for instance,
they're identified as stupid -- and they find school traumatic. They
quickly go off track.''

Use of the drugs was considerably higher among children in the state
Medicaid programs than children who belonged to private HMOs. Children
in Medicaid, uniformly poor, are known to be at greater risk of
emotional disability and major social stressors.

Words of caution

Some therapists cautioned that the wholesale use of medications might
be a quick-and-easy solution by health insurers to solve what might be
more deeply rooted social problems. Even in appropriate cases, such
medication should be used in tandem with family therapy or behavior
modification, they said.

While previous research has documented an increase in treatment with
psychotherapeutic drugs among school-age children, this is the most
definitive study of medication trends in this 2- to 4-year-old age
group.

``These findings are remarkable in light of the limited knowledge base
that underlies psychotropic medication use in very young children . .
. The possibility of adverse effects on the developing brain cannot be
ruled out,'' wrote lead researcher Julie Magno Zito of the University
of Maryland in Baltimore.

In an accompanying editorial in the same issue of JAMA, Dr. Joseph T.
Coyle of Harvard Medical School, Boston, urged that ``the reasons for
these troubling changes in practice need to be identified . . . These
disturbing prescription practices demand more thorough
investigation.''

The usual reasons for prescribing such medicines to children include
pain relief, anxiety caused by medical and dental procedures, bed
wetting, attention-deficit/hyperactivity disorder and depression.

Stimulants lead way

Stimulants were the leading treatment among all children, with the
drug Ritalin (methylphenidate) representing 9 out of 10 stimulant
prescriptions. Ritalin is used to treat attention-deficit
hyperactivity disorder by increasing attention and decreasing
restlessness in children who are overactive, impulsive and cannot
concentrate.

Still, child care providers wonder about the need to use it with very
young children.

``Most of the hyperness is from behavior and needing redirection,''
said Sunshine Mitchell, assistant director of a Kindercare Learning
Center in Campbell. ``They need to have outside time every morning and
afternoon. You need to sing songs and dance -- anything you can for
them to let off energy.''

Saul Wasserman, a San Jose child psychiatrist, said, ``You have to
make sure the child is the one with the problem.

``If you have a poor day care arrangement and the child is bored,
unattended and gets into things, that's not a reason for medication.
It's a reason to improve the day care situation.''

Critics say that public attitudes have changed expectations of
childhood behavior. Over the past two decades, the pressure on
children to perform has increased -- while the support needed to help
improve performance has declined.

Community programs such as Head Start and television shows such as
``Sesame Street,'' while benefiting millions, also have led to
expectations that children can concentrate enough to learn numbers and
the alphabet at an earlier age.

Yet at the same time, poverty rates for children have climbed, and
more families are requiring two incomes to maintain their standard of
living. So very young children are taken from the household and
introduced to pre-academic learning and a more demanding social structure.

Testing criticized

Zito and her colleagues concluded that the vast majority of
psychotropic medications prescribed for preschoolers have not been
thoroughly tested for children this young and so lack product labeling
information approved by the U.S. Food and Drug Administration.

46urther testing of these drugs is needed to assure their safety,
said Dr. Nanette Orman, a psychiatrist in private practice in Los
Altos and a clinical instructor at Stanford University School of
Medicine. ``Children are a different species than adults, so measures
of safety and efficacy that apply to adults can't be used for
children,'' she said.

The researchers analyzed data from 1991, 1993 and 1995 from medical
records of children in a Medicaid program in a Midwestern state, a
second Medicaid program in a mid-Atlantic state and a health
maintenance organization in the northwest United States. The specific
locations of the children were not disclosed.

The study does not provide the diagnoses of the children or the
professional identities or specialties of the prescribers, which could
shed some light on the reason for these prescribing patterns.

Contact Lisa M. Krieger at lkrieger@sjmercury.com or (408)920-5565.
Contact Julia Prodis Sulek at jsulek@sjmercury.com or (408) 278-3409.