How young is too young? ADHD in Toddlers

The Center for Disease Control (CDC) just came out with a report estimating that more than 10,000 American toddlers are being medicated for ADHD.

Why is this a problem? First of all, guidelines for diagnosing children under three years old do not exist, so diagnoses themselves are purely speculative and subjective. Furthermore, no significant research surrounding stimulant use in this age bracket exists, so both the safety and the effectiveness of the medication are questionable. The American Academy of Pediatrics does not address the diagnosis of toddlers because hyperactivity and impulsivity,  two primary symptoms of ADHD, are developmentally appropriate at that age.

Despite the growing body of research surrounding stimulant medication in toddlers, the consensus among professionals is that behavioral therapy is always preferable in children who are so young. Some doctors do concede that medication in children under four is acceptable under rare circumstances and as a last resort, but the scientific research is inconsistent at best. A couple studies have found that young children are more sensitive to adverse side effects like delayed growth, insomnia, loss of appetite and anxiety. Yet, another review found that stimulants are safe for carefully diagnosed ADHD preschool children three years and older. In terms of effectiveness, one study found that methylphenidate doses significantly reduced symptoms in preschoolers; however, effect sizes were smaller than they were for school-aged children.

Given this conflicting research, it is clear that without large enough sample sizes and differing results, further research is needed for us to safely say that preschool children should be diagnosed and/or medicated for ADHD.

To complicate things further, the data show that toddlers covered by Medicaid are the most likely to be medicated by stimulants. Why is this the case? First, low-income children are simply more likely to be diagnosed with ADHD. Some experts say the difference may be due to low-income parents struggling to provide a consistent and structured home environment. Others say that teachers in low-income schools lack the resources to provide special services to children in the classroom. Still others point to differing diagnostic procedures used by primary care physicians, who are more likely to make the ADHD diagnosis in Medicaid patients (rather than a psychiatrist or psychologist). Also, Medicaid programs often cannot afford to invest in long term therapy treatments, especially given the lack of children’s psychiatrists in rural areas. Dr. Susanna Visser, the CDC’s top ADHD researcher, explains, “It’s hard to take away medications when therapy isn’t readily available.” Some states like Arizona and Illinois have implemented policies in their Medicaid programs to prevent harmful diagnosis and medication of ADHD in young children by requiring all physicians to seek pre-authorization from a panel of peers two weeks before prescribing stimulants to children under six. Other states like Missouri and Vermont may soon adopt similar policies.

It seems urgent that we take a step back and evaluate the rate of diagnosis and medication in toddlers, given the lack of information. While it is important that we catch and address ADHD symptoms early, it is also important not to misdiagnose or mistreat kids at such a vulnerable age. So, how young is too young? How do we close the socioeconomic gap across different treatments? What are the risks of diagnosing too early versus too late? These are the questions that face us, as medicine begins to outpace the science on this important issue.