The Washington Post

Wednesday, February 23, 2000

Behavioral Drug Use In Toddlers Up Sharply

By Susan Okie

Doctors are prescribing stimulants such as Ritalin and antidepressants such as Prozac for preschoolers at rates that appear to be rising rapidly, according to a study released yesterday.

The study, covering children age 2 to 4 in three large health systems in different parts of the United States, found the use of such drugs had doubled or even tripled from 1991 to 1995.

The rapid increase occurred despite the fact that none of the most commonly used of these drugs has been approved for children under 6 and little research has been done on the medicines' effects on children so young.

"The knowledge base that we have to support the effectiveness and safety of these medicines in preschool-age children is certainly insufficient," said Julie Magno Zito of the University of Maryland School of Pharmacy, the study's principal author. "There's no dosing information for these children. . . . Are we satisfied that it's appropriate?"

Although previous studies have documented a rapid increase in Ritalin use among older children in recent years, the new study is the most comprehensive effort so far to examine the use of such drugs in preschoolers. Experts said yesterday that they believe the findings--published in today's issue of the Journal of the American Medical Association--reflect a national trend.

The study analyzed data from two state Medicaid programs and a health maintenance organization and found that as many as 1.5 percent of children 2 to 4 years old were receiving stimulants, antidepressants or antipsychotic drugs--a group that includes "major tranquilizers" such as thorazine.

The findings suggest that, nationally, as many as 150,000 children in this age group were taking such medicines in 1995, up from about 100,000 in 1991, Zito said. The use of antidepressants almost doubled and the use of stimulants almost tripled in the programs studied.

The study does not describe what conditions the children were being treated for, or whether the drugs were prescribed by pediatricians, family practitioners or psychiatrists. Zito and other experts said, however, that the growing use of stimulants and antidepressants in preschoolers is undoubtedly related to a recent national increase in the use of such drugs to treat attention deficit hyperactivity disorder (ADHD) in older children. As many as 2 million elementary school children in the United States are thought to have ADHD, and during the 1990s the number receiving Ritalin, amphetamines and other stimulants has almost tripled.

Doctors' increasing use of stimulants and antidepressants in very young children may also reflect the inadequacy of mental health services available to many children with severe psychiatric or developmental problems, several experts said yesterday. "Many insurance companies will not pay for a physician and a psychologist on the same day," said Marsha D. Rappley of Michigan State University's College of Human Medicine. "As a profession, we need to do more about finding better ways to help these families."

The study examined data on more than 200,000 children age 2 to 4 who were enrolled in one of three health systems--a Medicaid program in a mid-Atlantic state, a Medicaid program in the Midwest and an HMO in the Pacific Northwest. It found that from 1991 to 1995, the use of stimulants, antidepressants and clonidine in this age group increased substantially, while the use of antipsychotic drugs increased only slightly.

Stimulants (primarily Ritalin) were the category of drugs most commonly prescribed, but there was considerable geographic variation. For instance, in 1995, about 11 of every 1,000 children age 2 to 4 in the midwestern Medicaid program received Ritalin, versus about 4 of every 1,000 in the HMO. When antidepressants were used, an older family of drugs called tricyclic antidepressants was most often chosen, but use of the newer class that includes Prozac increased dramatically from 1991 to 1995 at the two Medicaid programs.

In an editorial accompanying the study, Joseph T. Coyle of the Harvard Medical School in Boston sharply criticized the growing use of stimulant and antidepressant drugs in preschool-age children. This age "is a time of extraordinary, unprecedented changes in the brain," Coyle said in a telephone interview. "We have very little information about the long-term impact of treatment with these drugs early in development."

Stimulants such as Ritalin have been tested in preschoolers and are considered safe, but they don't work as well in this age group as in older children and are more likely to produce side effects such as sleeplessness and loss of appetite, said Judith Rapoport of the National Institute of Mental Health. She said antidepressants such as Prozac have not been studied in preschoolers.

Rappley expressed concern about the use of clonidine, a blood pressure medicine with sedative effects that some doctors have prescribed for ADHD in older children.

"There have been reports of children who've been taking this medicine along with a stimulant who had a sudden, unexplained death," she said. "There are places that won't use this medicine anymore because of that."

Mark A. Stein of Children's National Medical Center said that children are being treated for ADHD at younger ages than in the past. A few years ago, they typically began taking stimulants at age 7 or 8.

Now, he said, doctors often start them on Ritalin at 5 or 6. "As we hurry kids along and put more expectations on them, they're going to display more symptoms of ADHD and I think there's a tendency to start treating them younger," he said.