To the uninitiated, it sounds horrifying: They’re medicating toddlers for ADHD! To those who understand the range of physical symptoms—and physical risks—associated with ADHD, it sounds reasonable.
All the same, a friend writes to me, below, after the latest “click bait” from The New York Times’ Alan Schwarz. The story is called “Thousands of Toddlers are Medicated for ADHD, Report Finds, Raising Worries.”
My friend, who has ADHD and whose husband has ADHD, writes:
Wait…TODDLERS? That blows my mind. How could anyone even diagnose a toddler with ADHD? I took our 2-year-old to a story time thing at the library where the toddlers were expected—no lie—to sit nicely in one place and listen to songs and stories for over 30 minutes.
I managed to get him to do this somehow, but he had a total meltdown afterward, at which point I carried him home apologizing for not knowing what we were in for and subjecting him to such a developmentally inappropriate activity. He absolutely cannot sit still and be inattentive for any length of time, but my armchair diagnosis for that is “being a toddler.” And that’s with the knowledge that he has two ADHD parents.
Here is my response to my friend:
Yes, if a toddler were diagnosed and treated on that basis, that would be very wrong.
It’s a very complex issue, though, and we cannot view ADHD solely through the reductionist lens of behavior. Nor can we assume we know the facts from reading Alan Schwarz’s so-called reporting. Much was missing in that article.
Essentially, Schwarz showed up unannounced at a state-wide conference in Georgia. A CDC researcher presented unpublished data on Georgia children only. He took numbers compiled for Georgia and extrapolated them to the rest of the country. To say that this is a leap entirely unworthy of what used to be the “paper of record,” The New York Times, is an understatement.
As for treating young children for ADHD, think about it: At its core, ADHD is about problematic dopamine transmission (an oversimplified explanation, but it will have to do for now). That might most obviously manifest in “behavior problems,” but is not limited to that, especially in the more severe presentations and with co-existing conditions. In short, let’s examine this with more logic than sensation.
Dopamine is not only the “reward” neurotransmitter. It also affects many important physiological processes, including those related to respiratory and cardiovascular function. (ADHD is associated with higher rates of enuresis and encopresis, asthma and allergies, and arrthymia.). It also controls motivation, movement, and emotional regulation.
Also, guess what? There are many sick children for whom ADHD is the least of their problems. This includes children with spina bifida and others. Each year, about 1,500 children are born in the U.S. with spina bifida alone, according to the CDC.
Hence, a two-part blog post, with this being Pt. I: The Truth Behind “10,000 Toddlers Medicated for ADHD” Report.
It’s long, but I promise: It’s worth it.
ADHD: A BioMedical Issue, Not A “Behavior Problem”
The friend who made that comment has ADHD. So does her husband. She personally knows the benefits of ADHD medication. But when it comes to children, she has a blind spot.
It’s understandable. There is so much that even well-educated people with ADHD fail to grasp about the condition, especially if they’re not thinking of very sick children.
What the public largely fails to understand: ADHD involves so much more than one’s school performance, behavior, inability to “conform to society,” or whatever preconceived notion one harbors about the condition. ADHD also carries with it a risk of physiological adverse effects, and these can begin very early on.
It is clear that the The New York Times, The Daily Beast, The Today Show, and other “news outlets” that glommed onto the 10,000 Toddlers meme are not interested in the medical reality of ADHD.
They have their own angle: Children with ADHD are “brats,” and that’s how their graphic designers illustrate the pieces, with photos of screaming, angry children. (I’ve used photos of a different type here.)
Betraying their lack of a background in science, they imply that all children that survive birth are somehow mentally healthy. As if the brain, that most vulnerable of organ, is protected from all that can befall heart, lungs, limbs, and every other organ.
Children with ADHD can be extremely impaired, and it is up to the evaluating physician as to how to proceed, not sports reporter Alan Schwarz—no matter how many Pulitzers he hopes to win with his “hard-hitting investigation.” (Because, let’s be honest; it’s not compassion for sick children that’s evident here; it’s pandering to a largely science-illiterate reading public.)
The FDA acknowledges that sometimes stimulant medications can be used for young children, with these guidelines “Stimulant and Related Medications: Use in Pediatric Patients.”
The Insatiable, Sleepless Toddler
For example, many toddlers and even babies with ADHD are chronically unhappy, about everything. Their distraught parents can do nothing right, because the problem is not on the outside but on the inside, in the neural pathways. I wrote in my book about some adults with ADHD being insatiable – there’s never enough of anything to make them happy. So, think about the Insatiable Baby or the Insatiable Toddler.
This is no minor thing.
I’ve met babies whose ADHD makes them chronically unhappy, often crying, and they broke my heart. Imagine being a parent unable to console a child, despite your best efforts.
Moreover, sleep is so difficult for them. They awaken at the slightest noise, when they finally get to sleep (and that can be extremely difficult). They climb out of their cribs and become a danger to themselves. In the crib, they begin the lifelong sleep debt that will plague them for the rest of their lives. I’ve met adults who were these children.
This will come as news to some “attachment theorists”: Some cannot sit still long enough to nurse. Moreover, they cannot direct their gaze long enough at their caregiver to form that all-important connection that uninformed critics are always yammering that the babies “need more than medication.” What if some need both?
Their young lives are miserable, as anyone with a heart can clearly see. What kind of start in life is this? Who cannot be compassionate to such a child and want to understand how to help instead of inflicting the worst kind of ignorance on the child and family?
Only someone aiming for a Pulitzer, high blog ratings in GoogleAnalytics, or a spot on a talk show.
Could You Watch a Toddler Turn Blue—and Faint? Repeatedly?
Many moms of children with ADHD have told me of a “hyperactive” fetus, one constantly kicking. ADHD is also associated with a higher rate of prematurity. In other words, the neurobiology can make itself known early on.
Those babies on the far end of the ADHD spectrum can and often do grow up to be toddlers who will walk out the front door and into traffic, or crawl out of windows. And die or become maimed or brain-injured.
There are even toddlers whose emotional dysregulation is so severe they develop pediatric syncope—that is, they turn blue and faint. I’ve seen this; it is horrifying to feel so helpless when the child is so distressed.
There are other terms for it, including Expiratory Apnea. And while I was researching it for a friend—an incredibly attentive, empathic, loving, and patient mother—many mothers of children with ADHD reported to me the same phenomenon. Their physicians were clueless.
We know that dopamine is involved with adult sleep apnea, which is so common among adults with ADHD. Why would it not also affect newborns, toddlers, and young children?
A friend and her husband (who has severe ADHD, now well-managed) were grief-stricken when their newborn displayed what appeared to be sleep apnea. It simply stopped breathing. Who wouldn’t be apoplectic? The parents weren’t worried about the baby being naughty or not learning differential equations, Alan Schwarz. They were worried about him surviving!
No one is suggesting cavalierly giving neurostimulants to a newborn or baby for ADHD. Yet, guess what? Vulnerable babies are given dopamine (the neurotransmitter targeted by the stimulants) in the hospital! Consider this 2011 tidbit from Nature: Brains Breathe: Dopamine’s Role in Preterm Infants.
A 2009 paper published in the journal Intensive Care Medicine reports that dopamine, widely used to maintain blood pressure in very preterm infants, facilitates flow-metabolism coupling in preterm brain. In other words, dopamine apparently aids in keeping preterm infants’ cerebral oxygen demands in touch with cerebral blood flow.
No one seems to complain about other health interventions for young children—blood transfusions, surgeries to repair holes in the heart, etc.
Unfortunately, the stimulants often don’t even work that well in young children, leaving them with little else.
The point is, dear public, ADHD is about more than “behavior.” It can have very serious physiological effects. Blindly reacting to click-bait from The New York Times or some other self-promoter with an agenda is not helpful to anyone, especially children. And it’s definitely not helpful to a compassionate, public-health-conscious public.
“They’ll Grow Out Of It”
Typically, pediatricians didn’t understand these issues when my friends presented them. They’d head pat and reassure, “The child will grow out of it.”
But what actually can happens is that the behavior changes to a more developmentally appropriate expression of the same problem as the child grew.
In other words, the pre-verbal toddler who got so frustrated that he fainted becomes the verbal four-year-old who yells and screams in frustration—and on it goes up the developmental ladder. The pediatric syncope (fainting) didn’t go away; it simply moved to a more advanced mode of expression.
Unfortunately, the ADHD diagnosis comes much later for many of these children, after so many bad habits and blows to self-esteem have taken root, even after illnesses such as allergies and asthma further circumscribe their lives.
But all it takes is one (more) sensationalistic story from The New York Times‘ Alan Schwarz, quoting low-level clinicians and publicity-hungry fringe players—and suddenly there is the SHOCKING story that 10,000 toddlers are being given ADHD medications.
10,000 is Only A Guesstimate
Yes, that 10,000 figure is only an estimate. Schwartz simply extrapolated to the nation the state-based figures provided by CDC official Susanna Visser.
Side story: This is at least the second time that Schwartz, a sports reporter who has no apparent life-science expertise, has acted in a dodgy and unorthodox manner by reporting an amateur analysis of the CDC data, and attempting to pass it off as as professionally parsed. Veteran journalist Paul Raeburn questioned the first occurrence at the M.I.T.Knight Science Journalism Center’s Tracker (“peer review with science journalism”) on April 3, 2013:
The story, by Alan Schwarz and Sarah Cohen with reporting contributed by Allison Kopicki, did not say that the figures came from an announcement or publication by the CDC. It said that the Times had “obtained the raw data from the agency and compiled the results” itself.
That’s tricky. The CDC could make a mistake compiling and interpreting its own data; such things happen. But for my money, I’d rather have the CDC doing that than entrust the job to Schwarz and Cohen. Where did they get the data? What form was it in? What did they have to do to come up with the figures they report? Did they enlist a scientist from the CDC or elsewhere to check and validate their analysis?
We are not told. The first quote in the story comes from a Yale neurologist who says he is “floored” by the rise in the diagnosis and treatment of ADHD. It’s not a terribly insightful comment; I suspect most readers did not need an expert to tell them that the statistics were remarkable.
The story, published on March 31, now has a string of corrections appended to it. It picked up its first correction on April 1, another yesterday, and another one today. Each of the corrections fixes a misstatement concerning the statistics. If Schwarz had told us more about how he got that data and what it looked like, and if he’d brought in a scientist to help him analyze it, perhaps he would not have made those mistakes.
Back to the Main Story
Never mind the Times‘ known bias and skewed reporting. A host of traffic-hungry sites (The Today Show, The Daily Beast, Boston.com, and various bloggers) picked up the story and added their own purple prose. Readers across the Internet started grabbing their pitchforks, preparing to hunt down Big Pharma, the doctors doing the prescribing, the lazy parents wanting the “quick fix,” and all the rest. Based on such misinformation. Talk about impulsivity.
Without any of these facts, without
knowing exactly how many young children
are diagnosed and treated
vis a vis the estimated prevalence,
without even knowing if the
treatment is working, we know
absolutely nothing at all.
That children on Medicaid were receiving the medication in question seemed to enrage readers the most. There was fervid blaming of “lazy” parents at the Times’ insipid companion piece (the Motherlode column entitled “The New Inequality for Toddlers: Less Income; More Ritalin”).
NYTimes columnist KJ Dell’Antonia, who writes about her children in a blog called “Raising Devils,” hammered home the idea that these children were being “drugged” only because they were poor.
NYTimes’ Blogger Dell’Antonia Questions Basis for ADHD
Neither Dell’Antonia nor the readers commenting (including a self-described pediatrician) seemed to understand one critical point: ADHD is a risk factor for poverty; these children might be suffering from the most severe ADHD symptoms, compounded by their parents’ ADHD and other risk factor such as substance abuse disorders.
Understanding this context would require the kind of sophistication not apparently accessible to bloggers such as Dell’Antonia, who writes: “Particularly given that there is still a debate among practitioners and researchers regarding whether ADHD has a biological basis, or is a label given to a collection of symptoms.”
With so many good journalists out of work, how do uneducated people like this get hired?
Not One News Report Has Examined the Data
You can download Visser’s Georgia presentation here.
Absolutely nothing seems publicly known about what kind and how much medication these alleged children are receiving, and what other services or interventions. Until the CDC decides to share with the tax-paying public, consider these Medicaid enrollment figures from a factsheet on Medicaid published by the American Academy of Pediatrics:
- 30.6M infants and children through age 18 (that represents 50.2% of all Medicaid enrollees, 38.9% of all US children through age 18)
- 2.4M infants (4.0% of all Medicaid enrollees; 56.6% of all US infants)
In light of these huge numbers, 10,000 children being treated medically for ADHD—as having ADHD severe enough to merit treatment at a younger-than-average age—no longer seems so “outrageous,” as one headline put it. Does it?
We know absolutely nothing at all on this topic without knowing critical facts, including:
- How many children are diagnosed and treated vis a vis the estimated prevalence?
- For how many children is the treatment working?
- How many of these children have other health conditions that are highly associated with ADHD, including neural tube defects such as spina bifida?
Yet, the online world is bursting at the seams with the scurrilous headlines. This is what happens when reckless papers and other news outlets self-medicate with provocation, without thinking of consequences.
Newsflash: ADHD Can Create Entrenched Poverty
Left unaddressed over the generations, ADHD can result in miserably entrenched poverty, substance abuse, and more. In other words, the people suffering the most adverse affects of ADHD are those at the lower rungs of society; neurogenetic nature and environmental nurture compound the trauma generation after generation.
Yes, absolutely. No question. Our economic structure is further oppressing these people. Headstart programs have been cut, when they’ve been shown to be beneficial and cost-effective, not to mention humane. And all the rest.
But the fact remains: Even with better circumstances, many of these young children will still have ADHD, their parents will have it, and most likely their grandparents, too. No matter how many “hands up” they are given, a certain percentage will be unlikely to make good use of opportunities until their ADHD and commonly co-existing conditions are managed. This is as true for highly impaired children in the lower rungs of the socioeconomic strata as well as the highest rungs.
The bottom line is this: There are legitimate reasons for treating very young children medically for ADHD, and we simply do not know the particulars behind this story—how many children at what ages are being medically treated and for what reason. We only have Schwarz’s cherry-picked report and intended, ensuing hysteria.
The only thing we know for sure is this: Our most disadvantaged people who have ADHD deserve comprehensive help, including screening the parents and providing treatment for them, too—the “genetic donors”—so they can best help their child and break the generational cycle.
They also deserve that you, me, and the powers that be slow down hair-trigger emotions and make a sincere attempt to comprehend what’s happening instead of making shamefully lame judgments and Olympic-sized leaps to conclusion that lead only to more disastrous consequences.
Mostly, they and we need news outlets who care more about these people than they do their own profits and fame—and reporters who have at some point in their lives taken a biology class.
Alan Schwarz would not dare publicly bully children born with heart defects, malformed lungs and limbs, vision problems, diabetes type I, hemophilia, or asthma. Yet, when it comes to the most vulnerable, delicate organ of all—the brain—and the most documented psychiatric condition of childhood—ADHD—he finds it fair game. Alan, please go back to the sports deck. Your detached flair with “statistics” would be less harmful there.
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