(New York Times, March 1, 2000)
The outcry over a recent report showing a dramatic increase in the use of medications like Ritalin for preschoolers reminded me of a patient of mine named Christopher.
In the early 1980's, when I was researching the efficacy of Ritalin in young children, Christopher was 3 l/2. He still slept in a crib to discourage his getting up in the middle of the night and wandering around the house. It didn't work: he often escaped, going to the kitchen and playing with the stove. Babysitters came only once. Nursery schools kept him for just a few days.
We observed Christopher and his mother in our clinic. She kept running after him to catch his attention; he played with 61 toys in one five-minute span. Then we put Christopher on Ritalin. In his mother's words: "He became a different child. He will sit and let me read a book to him. I can take him to a puppet show. We now can enjoy each other."
Christopher is now 20, a high school graduate who describes himself as well adjusted and happy. He also still takes Ritalin twice a day.
I guess I shouldn't be surprised that Attention-Deficit/Hyperactivity Disorder is still so frequently dismissed as childhood exuberance or "just a phase." Most adults do not realize how it differs from behavior that is simply on the active end of normal. Children with the disorder are 10 times as likely as the average child to drop out of high school. They have a higher incidence of drug abuse. This is a real psychiatric disorder and requires treatment.
The latest study, published in the Journal of the American Medical Association, found that between 1991 and 1995, there was a twofold to threefold increase in the use of Ritalin and similar drugs in children aged 2 to 4. About 1 in 100 children received Ritalin in l995. Is 1 percent of children taking such medications too high?
Unfortunately we have no information about the percentage of very young children who meet the criteria for an accurate diagnosis of A.D.H.D. For those who do, medications like Ritalin are the best treatment we have.
Understandably, there is concern that medications may affect brain development. Encouragingly, the evidence we have, although limited and crude, does not suggest that development is compromised by Ritalin.
Critics are also concerned that some medications for psychiatric illness are prescribed for preschoolers without approval by the Food and Drug Administration for use in that age group. But this practice holds true in other areas of medical care. One asthma medication, for example, is frequently given to young kids even though the F.D.A. has not approved it for children. There is ample evidence of Ritalin's effectiveness for school-aged children with A.D.H.D., and some evidence that it helps younger children.
What should be at issue is not the clinical wisdom of giving Ritalin to young children, but who gives it and how the decision is made. Unfortunately, pediatricians and general practitioners are usually not trained to undertake the necessary clinical evaluations to make psychiatric diagnoses and monitor treatment.
Increasing use of Ritalin is not necessary cause for alarm. The real outrage is that an estimated 20 percent of the nearly l0 million American children and teenagers who suffer from diagnosable psychiatric illnesses ever receive help.