Why Are America’s Poorest Toddlers Being Overprescribed ADHD Drugs?

Thousands of the nation’s poorest children under the age of four are being prescribed stimulants like Ritalin and Adderall for ailments they’re too young to even have. A first-ever CDC study estimates that under the Medicaid healthcare program, doctors have given some 10,000 American toddlers a diagnosis of ADHD and treated them with ADHD drugs that have not been shown to be effective or safe in children that young. The news that amphetamine-based drugs like Adderall and the methylphenidate Ritalin are being used to medicate, at a minimum, one out of every 225 toddlers nationwide outraged some medical professionals when it was first announced in May at the Georgia Mental Health Forum.

“It’s absolutely shocking, and it shouldn’t be happening,” Anita Zervigon-Hakes, a children’s consultant to the Carter Center, which sponsored the forum, told the New York Times. “[Doctors] are just feeling around in the dark. We obviously don’t have our act together for little children.”

Prescribing ADHD drugs to toddlers against the recommendations of experts may be a new practice, but it is part of a much larger trend of prescribing psychoactive drugs to children who are in foster care, juvenile detention or just living in poverty. (The practice also extends to elderly people in nursing homes.) Impulsive, aggressive behavior is common in such settings, and may be a symptom of ADHD or other medical conditions requiring medication.

“I’ve put several three-year-olds on it [as a last resort] and, with the medication, it’s like night and day,” said Max Wiznitzer, MD, a pediatric neurologist at University Hospitals Rainbow Babies & Children’s Hospitals. “These are very challenging children. We’ve made sure they do have ADHD features, that their behavior is occurring in multiple settings, that it’s not due to poor parenting, it’s not due to poor teaching, it’s not some other medical condition.”

Yet critics ask if the practice is doing more harm than good. They say that the high rates of use of these drugs amount to gross overprescribing.

Susanna Visser, who heads ADHD research at the CDC and who presented the report, said, “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. It puts these children and their developing minds at risk, and their health is at risk.”

Visser was also involved in drafting the American Academy of Pediatrics’ most recent guidelines for treating children with ADHD. After concluding that no child under the age of four could be properly diagnosed with ADHD, the group advised against doctors prescribing stimulants for kids aged two or three. Of all the ADHD drugs on the market, only Adderall is FDA approved for children under age six.

In a recent phone conversation, Visser was quick to defend the legitimacy of prescribing stimulants to treat ADHD (within the recommended guidelines), but she also expressed concern that too many doctors may be taking this route instead of pursuing behavioral therapy, which has been shown to be an effective alternative to medication.

“These stimulants for ADHD have known side-effects and health risks for children, and there are some unique risks for preschoolers,” she said. “They’re more likely to be irritable and emotional, [and to experience] elevations of heart rate and blood pressure, which can extend into disrupting their sleep. And these are the short-term effects. We don’t know what the long-term impacts will be.” Other side effects may include growth suppression, insomnia and hallucinations.

The Controversial Rise in ADHD Diagnoses and Drug Treatment

The expansion of both ADHD diagnoses and prescription drugs to two- and three-year-olds is the latest development in a trend that has been on a meteoric rise for several decades. In the 1970s an estimated 1% of American schoolchildren were diagnosed with an attention disorder. By 2013, 11% of children aged 4 to 17 were being diagnosed with ADHD, including one in five boys, and 69% were on an ADHD drug, according to a 2013 CDC report.

A confluence of factors triggered this dramatic uptick. Direct-to-consumer advertising of prescription drugs saw a seismic increase in the late 1990s, thanks to the FDA Modernization Act of 1997 lifting restrictions on drug companies marketing to the public. With ads for ADHD drugs on TV and other media, many more parents became aware of the condition, leading them to wonder if their child’s troublesome behavior could be a medical diagnosis treatable with a pill. This legislation also granted Big Pharma permission to promote its studies of “off-label” uses for drugs, leading doctors to engage in much more “off-label” prescribing of drugs for symptoms and conditions not approved by the FDA.

Together, these liberalizations in industry’s promotion have helped encourage a spike in ADHD diagnoses and drug prescriptions(as well as in the general practice of off-label prescribing). Now if a doctor wants to give Ritalin to a child before he or she is even potty trained, there’s nothing to stop it. Not surprisingly, the number of children prescribed stimulants increased by 700% from 2000 to 2010.

Drug industry promotion has helped encourage a spike in ADHD diagnoses and drug prescriptions. Not surprisingly, the number of children prescribed stimulants increased by 700% from 2000 to 2010.

Over the years, many critics have argued not only that ADHD is overdiagnosed but that it may not even be an actual medical condition. In his 2013 book, Back to Normal: Why Ordinary Childhood Behavior Is Mistaken for ADHD, Bipolar Disorder and Autism Spectrum Disorder, psychologist Enrico Gnaulati asserts that “we can see shades of all children in the core symptoms of ADHD: distractibility, forgetfulness, problems with follow-through, not listening, talking excessively, fidgetiness, and difficulty waiting one’s turn….A National Institute of Mental Health study even shows that three-quarters of ADHD children outgrow their condition by the time they reach their mid-twenties.”

Similarly, in 2013 New York Times journalist Maggie Koerth-Baker (diagnosed with ADHD herself) wrote about a potential link between the dramatic rise in stimulant drugs in children and the implementation of the No Child Left Behind Act of 2001 and standards-based educational reform.

To be clear: Those are correlations, not causal links. But ADHD, education policies, disability protections and advertising freedoms all appear to wink suggestively at one another. From parents’ and teachers’ perspectives, the diagnosis is considered a success if the medication improves kids’ ability to perform on tests and calms them down enough so that they’re not a distraction to others. (In some school districts, an ADHD diagnosis also results in that child’s test score being removed from the school’s official average.) Writ large, [UC Berkeley psychology professor Stephen] Hinshaw says, these incentives conspire to boost the diagnosis of the disorder, regardless of its biological prevalence.”

The Confounding Cofactors of Poverty and Dysfunction

In addition to the 10,000 toddlers being issued stimulants under Medicaid (available to families and individuals who make up to 133% of the poverty line), Visser’s study also shows that 4,000 children with private insurance were being given similar treatment over the same 12-month period.

The glaring disparity between the numbers of diagnoses in the poor group and those in the more affluent one raise questions about the potential link between poverty and an increase in labeling very young kids with ADHD and giving them an unproven pill treatment.

“When you have children living in poverty, they’re exposed to a number of factors that negatively impact their behavior [and] therefore you’re going to see more ADHD diagnosis and treatment,” Visser said. These factors include substance misuse and addiction, domestic violence and parental neglect in the home as well as stress-inducing conditions in their community.

But Nancy Rappaport, a child psychiatrist who specializes in underprivileged youth, argues that the most accurate analysis of these behaviors is not as symptoms of ADHD but as relatively normal responses to stress and even trauma. “In acting out and being hard to control, they’re signaling the chaos in their environment,” she told The New York Times. “If you have a family with [these problems], 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.”

The CDC’s Visser believes that the doctors prescribing stimulants to toddlers have the best intentions, although she emphasizes that teaching parents proper communication techniques with their children, along with possibly getting the child into behavioral therapy, is a much preferred method of treatment for these problems (which can’t officially even be called ADHD, since there is no recognized diagnosis for children of that age).

The problem is, many American families have little access to psychological and behavioral treatment.

“If you live in a rural area and there is no child behavior therapist available, and you know that medication treatment is effective, and the child and family are in crisis, you’re going to gravitate toward that treatment.”

“We have infrastructure barriers in getting behavioral treatment to families,” Visser said. “If you live in a rural area and there is no child behavior therapist available within 150 miles, and you know that medication treatment is effective, and the child and family are in crisis, you’re going to gravitate toward that treatment.”

In addition, many public and private insurance companies offer only minimal psychological and behavioral therapy, which tends to require an ongoing investment of time and other resources from families.

The idea that social factors, like parental addiction or abuse, and economic ones, like poverty, play a role in the development of ADHD in children throws a wrench into the medical approach to the condition. Recent studies show evidence that ADHD-affected brains are visibly impaired in the left prefrontal cortex when observed under an MRI scanner. Other studies suggest that ADHD may be a genetic disorder passed down from parent to child. Chemical or genetic interventions may eventually greatly improve the prevention and treatment of ADHD. Many individual children with the condition stand to benefit. But unless non-medical cofactors are addressed, it is unlikely that the condition, and its serious consequences, will be controlled.

From Juvenile Detention Center to Nursing Homes, a Similar Trend

Amphetamines have long been overprescribed and used nonmedically in the US. During and after World War II, the widespread use of uppers like Dexedrine and Benzedrine to treat a variety of symptoms like depression, low energy and weight loss. This led to misuse, which played a role in the class of drugs being classified as a controlled substance in 1970. Similarly, critics of the ADHD diagnosis and treatment point to the widespread nonmedical use of Adderall and other ADHD drugs.

The motive behind administering stimulant medication as a first response (as opposed to behavioral therapy) is no mystery: The drugs can be effective, fast working, easy to take, relatively cheap and manufactured by pharmaceutical companies with large marketing and lobbying budgets. For poorly behaved children living below the poverty line — possibly under the care of parents with addiction, say, and mental illness preventing them from giving adequate care — it’s little wonder that a doctor is more likely to scribble off a prescription than attempt to unravel the complex issues of a difficult home environment.

And for those children with no home at all, a whole rainbow of drugs are often administered blindly by government agencies looking for a quick pacifier. In August, the Colorado Division of Youth Corrections received a scathing audit from the state that chastised the juvenile prisons for administering sleeping pills, powerful anti-psychotics and anti-depressants, all with no basic monitoring of the inmates’ vital signs or even evidence of a mental health diagnosis.

For poorly behaved children living below the poverty line, a doctor is more likely to scribble off a prescription than attempt to unravel the complex issues of a difficult home environment.

Similarly, children in foster-care homes have been found to be upward of ten times more likely to be prescribed anti-psychotics than children in permanent homes. Medical oversight comes from state and local government agencies, which have been criticized for over-prescribing these medicines without enough engagement with the child patients (some in infancy), and often in doses too large and in combinations considered risky even for adults.

Government agencies aren’t the only ones taking heat for our nation’s drugged up babies; sometimes they’re the ones wagging the finger. Over the past decade, drug companies have paid billions of dollars to federal and state governments to settle lawsuits for marketing psychoactive drugs for illnesses they haven’t been approved to treat.

Similarly, a recent NPR piece revealed that nursing homes across the country are over-medicating their elderly patients with antipsychotics, despite a lack of a relevant diagnosis and the potential for dangerous side-effects.

What nursing homes, foster care, juvenile detention and poorly behaved, academically challenged schoolchildren all have in common is that they present a complicated, and downright depressing, social problem. Lacking the resources to effectively “treat” the social dysfunction that contributes to the symptoms if not the condition itself, officials are addressing that problem with a one-size-fits-all chemical template of a solution. Babies on speed and teenage zombies are apparently the best society can do.

Josiah M. Hesse is a Denver-based journalist who covers marijuana, politics, entertainment and pop culture. His work has appeared in Westword, Colorado Public Radio, Out Front Colorado and Vice magazine. His previous piece for Substance.com was about the clash in Colorado between grass-roots legal marijuana growers and sellers and the big-time investors and entrepreneurs as the industry grows.

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