Drugging Toddlers for Inattention, Impulsivity, and Hyperactivity

On May 16, the New York Times ran an article titled Thousands of Toddlers Are Medicated for A.D.H.D., Report Finds, Raising Worries, by Alan Schwarz.  Here is the opening sentence:

“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 CDC official is Susanna Visser, MS, DrPh, Acting Associate Director of Science for the Division of Human Development and Disability, and she was speaking at the annual Rosalyn Carter Georgia Mental Health Forum.  I have not been able to find the text of Ms. Visser’s speech.  (It will probably be published later.)  Meanwhile, there is a good deal of information in Alan Schwarz’s article.  Here are some more quotes:

“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.'”

“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.'”

But there was also some support for the practice, albeit cautiously worded:

“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.”

The article finishes with quotes from Nancy Rappaport, MD:

“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.'”

ADHD IN THE DSM

ADHD is listed in the DSM and is widely promoted by psychiatry as a brain illness which causes children and adults to be excessively inattentive, hyperactive, and/or impulsive.

DSM-III-R specified that the onset of this “illness” had to be prior to age seven, but set no lower age limit.  In fact, in this edition of the APA’s manual, the assignment of this “diagnosis” to preschool children is clearly endorsed.

“In preschool children, the most prominent features are generally signs of gross motor overactivity, such as excessive running or climbing.  The child is often described as being on the go and ‘always having his motor running.’  Inattention and impulsiveness are likely to be shown by frequent shifting from one activity to another.” [Emphasis added] (p 50)

and

“In approximately half of the cases, onset of the disorder is before age four.” [Emphases added] (p 51)

DSM-IV-TR states:

“It is difficult to establish this diagnosis in children younger than age 4 or 5 years, because their characteristic behavior is much more variable than that of older children and may include features that are similar to symptoms of Attention-Deficit/Hyperactivity Disorder.  Furthermore, symptoms of inattention in toddlers or preschool children are often not readily observed because young children typically experience few demands for sustained attention.  However, even the attention of toddlers can be held in a variety of situations (e.g., the average 2- or 3-year-old child can typically sit with an adult looking through picture books).  Young children with Attention-Deficit/Hyperactivity Disorder move excessively and typically are difficult to contain.  Inquiring about a wide variety of behaviors in a young child may be helpful in ensuring that a full clinical picture has been obtained.  Substantial impairment has been demonstrated in preschool-age children with Attention-Deficit/Hyperactivity Disorder.” (p 89)

DSM-5 is briefer but just as clear:

“In preschool, the main manifestation is hyperactivity.” (p 62)

So, as far as the APA is concerned, children of preschool age can, and do, “get” ADHD.

But what is ADHD?  Here again, the APA’s position, in their fact sheet titled “ADHD,” (2014) is  brief and clear:

“Attention-deficit/hyperactivity disorder (ADHD) is one of the most common mental disorders affecting children. ADHD is a brain condition that is often first identified in school-aged children when it causes disruption in the classroom or problems with schoolwork.” [Emphasis added]

Note, incidentally, the assertion of causality.  ADHD is a brain condition that causes classroom disruption and problems with school work.  In reality, the causal connection is spurious, and is just one more example of psychiatric “logic.”  To illustrate this, imagine a conversation between a parent and a psychiatrist:

Parent:  Why is my child so disruptive in class?  Why won’t he concentrate on his schoolwork?
Psychiatrist:  Because he has ADHD.  ADHD causes these problems.
Parent:  But how do you know he has ADHD?
Psychiatrist:  Because he is so disruptive in class and doesn’t concentrate on his school work.

Psychiatry defines ADHD by the presence of an assortment of vaguely-defined behaviors and then adduces this construct as the cause of these behaviors.  In other words, a child has ADHD because he is disruptive; and he is disruptive because he has ADHD!  This particular piece of psychiatric sophistry has been identified and highlighted, at one time or another, by virtually everyone on this side of the “mental illness” debate.  But I have never seen an attempt at rebuttal from any proponent of psychiatric orthodoxy.

But back to the question: what is ADHD?  There is a document titled ADHD: Parents Medication Guide published jointly by the APA and the American Academy of Child and Adolescent Psychiatry in July 2013.  Here’s a quote:

“Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by difficulty paying attention, excessive activity, and impulsivity (acting before you think). ADHD is usually identified when children are in grade school but can be diagnosed at any time from preschool to adulthood.” [Emphases added]

This document also stresses that:

“Early identification of ADHD is advisable…”

and lists the dire consequences if “ADHD is left untreated”:

• “Increased risk for school failure and dropout in both high school and college
• Behavior and discipline problems
• Social difficulties and family strife
• Accidental injury
• Alcohol and drug abuse
• Depression, anxiety and other mental health disorders
• Employment problems
• Driving accidents
• Unplanned pregnancy and sexually transmitted diseases
• Delinquency, criminality, and arrest”

The NIMH document Attention Deficit Hyperactivity Disorder (2012) states:

“Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood brain disorders and can continue through adolescence and adulthood.” [Emphasis added]

So it’s pretty clear that organized psychiatry, as represented by the APA, AACAP, and NIMH, endorses the notion that preschool children can “get” ADHD, and that ADHD is a brain illness.  It is also widely promoted that ADHD should not be left “untreated.”

RESEARCH

In 2006, Greenhill L. et al. published Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD, in the Journal of the American Academy of Child and Adolescent Psychiatry.  Here’s their conclusion:

“MPH-IR [methylphenidate-instant release], delivered in 2.5-, 5-, and 7.5-mg doses t.i.d., produced significant reductions on ADHD symptom scales in preschoolers compared to placebo, although effect sizes (0.4-0.8) were smaller than those cited for school-age children on the same medication.”

The paper lists 17 authors.  The lead author is Laurence Greenhill, MD.  Dr. Greenhill is a very eminent psychiatrist.  At present he is a professor of Psychiatry and Pediatric Psychopharmacology at Columbia University.  He is also Director of the Research Unit of Pediatric Psychopharmacology at the New York State Psychiatric Institute.  Dr. Greenhill has served as principal investigator on several NIMH studies, and on 14 pharma-funded studies.  He has also served as President of the American Academy of Child and Adolescent Psychiatry (2009-2011).

His 2008 conflict of interest statement which is on file with the AACAP, states that during the period when he was president-elect, he was spending 50% of his work time “…dedicated to the private practice treatment of toddlers, adolescents, and adults mostly with ADHD.” [Emphasis added]

Incidentally, according to the disclosure section at the end of the 2006 article, 11 of the 17 authors had ties to pharma.  (In addition, a twelfth author disclosed links in a 2009 paper that will be discussed below.)

This study was funded by the NIMH, and on October 16, 2006, NIMH issued a press release in which they described the study as:

“The first long-term, large-scale study designed to determine the safety and effectiveness of treating preschoolers who have attention deficit/hyperactivity disorder (ADHD) with methylphenidate (Ritalin) has found that overall, low doses of this medication are effective and safe.  However, the study found that children this age are more sensitive than older children to the medication’s side effects and therefore should be closely monitored.” [Emphasis added]

Thomas Insel, MD, Director of NIMH, provided a quote for the press release:

“‘The Preschool ADHD Treatment Study, or PATS, provides us with the best information to date about treating very young children diagnosed with ADHD,’ said NIMH Director Thomas R. Insel, MD. “‘The results show that preschoolers may benefit from low doses of medication when it is closely monitored, but the positive effects are less evident and side-effects are somewhat greater than previous reports in older children.'”

The press release concluded with a quote from Laurence Greenhill, MD, the lead author:

“‘The study shows that preschoolers with severe ADHD symptoms can benefit from the medication, but doctors should weigh that benefit against the potential for these very young children to be more sensitive than older children to the medication’s side effects, and monitor use closely,’ concluded Dr. Greenhill.”

MORE RESEARCH

There’s another piece of research by Abikoff, et al. published in the journal Advances in Preschool Psychopharmacology in 2009.  It’s titled Methylphenidate Effects on Functional Outcomes in the Preschoolers with Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS).    Here’s the conclusion:

“Preschoolers with ADHD treated with MPH [methylphenidate] for 4 weeks improve in some aspects of functioning.  Additional improvements might require longer treatment, higher doses, and/or intensive behavioral treatment in combination with medication.” 

This paper lists as authors most of those who are also shown in the Greenhill et al. study cited above.

So, according to the best psychiatric authorities, the condition known as ADHD

• Is a brain illness;
• Can and does occur in children of preschool age;
• Causes severe problems if left untreated;
• Can be safely and effectively treated with stimulant drugs (with the caveat that children of preschool age should be closely monitored for adverse effects).

Against this well-orchestrated and heavily promoted background, it is easy to see how the drug-prescribing is drifting into the lower age range.  In fact, if one buys the psychiatry line, wouldn’t it be tantamount to criminal to deprive these preschoolers of “treatment” for their “brain illness”?  Wouldn’t it be unconscionable to expose them to the risks outlined earlier?  Surely the risk of taking a few pills – that have been proven safe and effective anyway – is justified when weighed against the dangers of “untreated ADHD.”

Besides, in their booklet on Mental Health Medication (2008), the NIMH state unambiguously:  “Stimulant medications are safe when given under a doctor’s supervision.”  I kid you not.

DISCUSSION

The critical issue here is that the loose cluster of vaguely defined behaviors that psychiatry calls ADHD is not an illness.  Rather, it is, in the vast majority of cases, a reflection of inadequate discipline and training on the part of the parents.

In former times, parents accepted, as an intrinsic part of their role, training their children: to sit still when required; to pay attention to authority figures; to be obedient; to complete chores; to stay focused when needed; to be quiet when needed; to wait his/her turn; not to interrupt when others were speaking; to respect other children’s property; etc…

But today, psychiatry tells us that children who have not acquired these habits are ill.  This is emphatically not something that psychiatry has discovered in the normal scientific manner.  Rather, it is something that psychiatry has decided.  Psychiatry has decided that all significant problems of thinking, feeling, and/or behaving are mental illnesses.  So, children who have not been trained in the skills listed above are ill – by definition.

And because they are “ill,” they must take “medicine.”

Despite the protestations and the expressions of outrage, the expansion of the ADHD “diagnosis,” and consequent drugging, into the preschool population is an inevitable consequence of psychiatry’s spurious medicalization of every conceivable human problem, and their eagerness to prescribe drugs to “treat” these problems.

Protesting that the drugs have not been approved for children under the age of four misses the point, for two reasons.  Firstly, because the approval process is intrinsically flawed, and secondly because drugs are not an appropriate response to these problems, for preschoolers or for older children.

Debates as to whether the preschoolers in question “really” have ADHD are meaningless.  ADHD is defined by the presence of certain vaguely-defined behaviors.  If a two-year-old is engaging in these behaviors, then he “has” ADHD.  This is the travesty that the APA has created.  There is no test or reality against which the child’s presentation can be compared to confirm or refute the “diagnosis.”  All that’s needed is the subjective opinion of a mental health professional that the child displays the misbehaviors in question to a degree that is “inconsistent with [his/her] developmental level and that negatively impacts on social and academic…activities.” (DSM-5, p 59).

And there is no lower age limit for this “diagnosis.”  Well, that’s not absolutely true.  The “symptoms” must have been present for at least six months, so I suppose 6 months is effectively the lower limit!  So the babies are still safe – at least until DSM 5.1!

Psychiatry’s primary agenda for the past fifty years has been the expansion of its “diagnostic” net, and the prescribing of more and more pills to more and more people.  Psychiatry promises joy, happiness, and a trouble-free life from a pill bottle, and tragically our society and our political leadership have bought it.  Today, no group is safe from psychiatry’s depredations.  Their net embraces people of all ages, all walks of life, and all circumstances.  There is truly no human problem that cannot be “diagnosed” as a “mental illness,” and for which psychiatry doesn’t have a pill.

Ten thousand American toddlers taking stimulants for ADHD is just business as usual.  By all means, let us speak out against this psychiatric assault on our toddlers, but let’s not lose sight of the greater tragedy – that this kind of approach has become the norm.  Feeding children psychoactive drugs as a substitute for instilling age-appropriate habits of discipline, self-control, and interpersonal respect is a tragedy beyond description.  If street-dealers were promoting their products to toddlers and their parents in this way, there would be outrage – and rightly so.  But psychiatrists, dressed in nice suits, and with their image polished by an international PR firm, are accepted.
As a society, as a culture, we have truly lost our way.

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This article first appeared on Philip Hickey’s website
Behaviorism and Mental Health