We thought toddlers had it easy. No bills to pay, no bosses to please--just ice cream and a little mischief on the brain. But America's tiniest citizens, some still in diapers, are now the newest members of the Ritalin and Prozac nation. The numbers are small, but in a study published in The Journal of the American Medical Association last week, researchers reported that the use of certain psychotropic drugs, like antidepressants and stimulants, in 2- to 4-year-olds doubled or even tripled between 1991 and 1995.
The study gave no reasons for the increase, but experts say frustrated parents, agitated day-care workers and 10-minute pediatric visits all contribute to quick fixes for emotional and behavioral problems. Even with the best of intentions, says Julie Magno Zito of the University of Maryland and the study's lead author, "you have a confluence of social forces together who collectively say, 'I don't have time for anything else'."
The new data raises serious questions about how doctors are making diagnoses and why they are prescribing powerful drugs that have not been fully evaluated for safety or efficacy in such young children. Unsurprisingly, Ritalin, given to tens of thousands of school-age kids to treat attention deficit hyperactivity disorder (ADHD), topped the preschoolers' list. But ADHD can be extremely difficult, if not impossible, to diagnose with any confidence in kids younger than 5. Symptoms like restlessness and inattentiveness may simply be toddler rambunctiousness, "the terrible twos and trying threes," says psychologist Susan B. Campbell of the University of Pittsburgh. Or a child might be acting out in response to serious stressors like divorce, neglect or poor child care. Experts worry that some doctors are making diagnoses based on symptom checklists rather than on thorough evaluations of a child's life both in and out of the home.
As for Ritalin, while it is known to help some school-age kids, the label warns against dispensing it to children under 6. Doctors are allowed to prescribe drugs "off label," but many experts worry that they are taking far too great a risk with toddlers--not just because of potential side effects (nervousness and insomnia are the most common with Ritalin) but because there is no data on how psycho-tropic drugs affect long-term brain development. "The period between birth and 4 is a time of tremendous change in the maturation of the brain," says Dr. Joseph Coyle, chair of Harvard Medical School's department of psychiatry. "We need to be very cautious."
The number of other drugs prescribed for toddlers in the study (which looked at two Medicaid programs and one HMO) was far smaller. But Dr. Steven Hyman, director of the National Institute of Mental Health, says he was shocked that either clonidine, an adult blood-pressure drug that appears to be increasingly used to treat ADHD symptoms or insomnia, or the older generation of tricyclic antidepressants were being given at all to preschoolers. Clonidine in combination with stimulants has been associated with heart problems in children. And there's no evidence that tricyclics, which can also have serious side effects, even work for depression in kids. Tricyclics are also used to control impulses and treat bed-wetting, which could have accounted for many of the toddler prescriptions. But in children so young, says Hyman, "I don't see a justification for using them."
More information about drug safety and efficacy in preschoolers could be a few years away. Researchers are hoping to launch a nationwide trial of Ritalin in 3- to 5-year-olds as early as this summer. But more scientific conclusions will do little to mollify those who believe the drugging of America has reached a new low.