This is truly a travesty...
ATLANTA — More than 10,000 American toddlers 2 or 3 years old are being medicated for attention deficit hyperactivity disorder outside established pediatric guidelines, according to data presented on Friday by an official at the Centers for Disease Control and Prevention.
The report, which found that toddlers covered by Medicaid are particularly prone to be put on medication such as Ritalin and Adderall, is among the first efforts to gauge the diagnosis of A.D.H.D. in children below age 4. Doctors at the Georgia Mental Health Forum at the Carter Center in Atlanta, where the data was presented, as well as several outside experts strongly criticized the use of medication in so many children that young.
The American Academy of Pediatrics standard practice guidelines for A.D.H.D. do not even address the diagnosis in children 3 and younger — let alone the use of such stimulant medications, because their safety and effectiveness have barely been explored in that age group. “It’s absolutely shocking, and it shouldn’t be happening,” said Anita Zervigon-Hakes, a children’s mental health consultant to the Carter Center. “People are just feeling around in the dark. We obviously don’t have our act together for little children.”
Dr. Lawrence H. Diller, a behavioral pediatrician in Walnut Creek, Calif., said in a telephone interview: “People prescribing to 2-year-olds are just winging it. It is outside the standard of care, and they should be subject to malpractice if something goes wrong with a kid.”
Friday’s report was the latest to raise concerns about A.D.H.D. diagnoses and medications for American children beyond what many experts consider medically justified. Last year, a nationwide C.D.C. survey found that 11 percent of children ages 4 to 17 have received a diagnosis of the disorder, and that about one in five boys will get one during childhood.
A vast majority are put on medications such as methylphenidate (commonly known as Ritalin) or amphetamines like Adderall, which often calm a child’shyperactivity and impulsivity but also carry risks for growth suppression,insomnia and hallucinations.
Only Adderall is approved by the Food and Drug Administration for children below age 6. However, because off-label use of methylphenidate in preschool children had produced some encouraging results, the most recent American Academy of Pediatrics guidelines authorized it in 4- and 5-year-olds — but only after formal training for parents and teachers to improve the child’s environment were unsuccessful.
Children below age 4 are not covered in those guidelines because hyperactivity and impulsivity are developmentally appropriate for toddlers, several experts said, and more time is needed to see if a disorder is truly present.
Susanna N. Visser, who oversees the C.D.C.’s research on the disorder, compiled Friday’s report through two sources: Medicaid claims in Georgia and claims by privately insured families nationwide kept by MarketScan, a research firm. Her report did not directly present a total number of toddlers 2 and 3 years old nationwide being medicated for the disorder, however her data suggested a number of at least 10,000 and perhaps many more.
Dr. Visser’s analysis of Georgia Medicaid claims found about one in 225 toddlers being medicated for A.D.H.D., or 760 cases in that state alone. Dr. Visser said that nationwide Medicaid data were not yet available, but Georgia’s rates of the disorder are very typical of the United States as a whole.
“If we applied Georgia’s rate to the number of toddlers on Medicaid nationwide, we would expect at least 10,000 of those to be on A.D.H.D. medication,” Dr. Visser said in an interview. She added that MarketScan data suggested that an additional 4,000 toddlers covered by private insurance were being medicated for the disorder.
Dr. Visser said that effective nonpharmacological treatments, such as teaching parents and day care workers to provide more structured environments for such children, were often ignored. “Families of toddlers with behavioral problems are coming to the doctor’s office for help, and the help they’re getting too often is a prescription for a Class II controlled substance, which has not been established as safe for that young of a child,” Dr. Visser said. “It puts these children and their developing minds at risk, and their health is at risk.”
Very few scientific studies have examined the use of stimulant medications in young children. A prominent 2006 study found that methylphenidate could mollify A.D.H.D.-like symptoms in preschoolers, but only about a dozen 3-year-olds were included in the study, and no 2-year-olds. Most researchers on that study, sponsored by the National Institute of Mental Health, had significant financial ties to pharmaceutical companies that made A.D.H.D. medications.
Some doctors said in interviews on Friday that they understood the use of stimulant medication in 2- and 3-year-olds under rare circumstances.
Keith Conners, a psychologist and professor emeritus at Duke University who since the 1960s has been one of A.D.H.D.’s most prominent figures, said that he had occasionally recommended it when nothing else would calm a toddler who was a harm to himself or others.
Dr. Doris Greenberg, a behavioral pediatrician in Savannah, Ga., who attended Dr. Visser’s presentation, said that methylphenidate can be a last resort for situations that have become so stressful that the family could be destroyed. She cautioned, however, that there should not be 10,000 such cases in the United States a year.
“Some of these kids are having really legitimate problems,” Dr. Greenberg said. “But you also have overwhelmed parents who can’t cope and the doctor prescribes as a knee-jerk reaction. You have children with depression or anxiety who can present the same way, and these medications can just make those problems worse.”
Dr. Visser said she could offer no firm explanation for why she found toddlers covered by Medicaid to be medicated for the disorder far more often than those covered by private insurance.
Dr. Nancy Rappaport, a child psychiatrist and director of school-based programs at Cambridge Health Alliance outside Boston who specializes in underprivileged youth, said that some home environments can lead to behavior often mistaken for A.D.H.D., particularly in the youngest children.
“In acting out and being hard to control, they’re signaling the chaos in their environment,” Dr. Rappaport said. “Of course only some homes are like this — but if you have a family with domestic violence, drug or alcohol abuse, or a parent neglecting a 2-year-old, the kid might look impulsive or aggressive. And the parent might just want a quick fix, and the easiest thing to do is medicate. It’s a travesty.”
As a group of children walked home together from school in Providence, they held hands and played the "I Spy" guessing game. When they reached a busy intersection, an adult accompanying them prodded, "What's the rule?"
"Behind the line!" they said in unison, as they stepped back from the edge of the curb and waited for the walk signal.
Shortly after, the group stopped in front of 8-year-old Jaiden Guzman's house. He said goodbye to his friends and raced to his front door. His mother waved and the rest of the walking school bus continued on its way.
For a growing number of children in Rhode Island, Iowa and other states, the school day starts and ends in the same way — they walk with their classmates and an adult volunteer to and from school. Walking school buses are catching on in school districts nationwide because they are seen as a way to fight childhood obesity, improve attendance rates and ensure that kids get to school safely.
Ten-year-old Rosanyily Laurenz signed up for the Providence walking school bus this school year. Before, she said, she was sometimes late to school when her grandmother didn't feel well enough to walk with her.
But now, "I get to walk with my friends," Rosanyily said. "Plus, I get snacks."
Many programs across the country are funded by the federal Safe Routes to School program, which pays for infrastructure improvements and initiatives to enable children to walk and bike to school.
Robert Johnson, of the Missouri-based PedNet Coalition, a nonprofit that advocates for transit alternatives, said the success of the programs reflects a growing interest in getting kids more active.
"Every parent is looking for ways to make their child a little healthier, and walking to school is one," he said.
In 2012, about 30 percent of students living within a mile of school walked there in the morning and 35 percent walked home in the afternoon, according to the National Center for Safe Routes to School. Those numbers have increased by about 6 percentage points since 2007.
Organizers in Providence are also motivated by high rates of chronic absenteeism. Thirty-seven percent of Providence students missed 10 percent or more of the 2010-11 school year.
The nonprofit agency Family Service of Rhode Island targeted Mary E. Fogarty Elementary School for its first walking school bus in 2012 because it's located in one of the city's poorest neighborhoods. Children who live within a mile of school don't qualify for the bus.
In Sioux City, Iowa, nearly 1,000 children in 10 elementary schools use walking school buses during the spring and fall, said Alison Benson, spokeswoman for the district. Benson said the program has helped the schools incorporate fitness into the morning routine and build a sense of community.
Elementary schools in Columbia, Missouri, were among the first in the nation to have walking school buses. Piloted in 2003, the program, at its height, involved 450 children, 13 schools and about 200 volunteers. It was canceled this year because of funding issues, according to the PedNet Coalition.
Johnson said he is working with 15 school districts in Kansas on what may become the largest walking school bus project in the United States.
Some districts have been able to cut school bus routes and save money because of the program, he said.
On the milelong route in Providence, the program's manager, Allyson Trenteseaux, and another volunteer recently led Jaiden, Rosanyily and six other children through busy intersections and around broken glass littering the sidewalks.
On the walks, Trenteseaux said, she mends relationships among the kids, builds relationships and intervenes when there are problems. During the winter, a walk leader noticed some of the children were wearing slippers and bought them all boots.
Last year, 11 of the 14 students who participated and completed a survey attended school more often. The program now has a waiting list, and Family Service plans to expand into more schools next year.
No one wants to go to the dentist, but kids need to. A small cavity left to fester can grow into a big health problem. Although the government made pediatric dental care one of the health law's "essential benefits," new data suggest a lot of parents didn't buy dental coverage during the online enrollment period.
About 60% of U.S. children will have had cavities by age 5, according to a report from the American Academy of Pediatric Dentistry. Children with tooth decay are more likely to have ear and sinus infections. The chance of developing other chronic problems, such as obesity, diabetes and even heart disease, also increases.
Paul Reggiardo, chairman of the American Academy of Pediatric Dentistry's Council on Dental Benefit Programs, says early dental problems can affect children's learning, how they interact with other kids and their ability to eat.
"It starts having an impact much more than cavities," he says.
Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a non-profit, non-partisan health policy research and communication organization not affiliated with Kaiser Permanente.
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