To the uninitiated, it sounds horrifying: Toddlers are medicated for ADHD!
To those who understand the range of physical symptoms—and physical risks—associated with ADHD, it sounds reasonable.
The latest “click bait” from The New York Times’ Alan Schwarz: “Thousands of Toddlers are Medicated for ADHD, Report Finds, Raising Worries”.
I held my breath. I knew the reverberations would be horrendous—and immediate.
(Update: The fallout proved worse than I anticipated, with political pressure being applied on the CDC to come out with ridiculous, medication-stigmatizing guidelines. Russell Barkley, PhD, and I wrote about it here: Hey, CDC, Why Promote Misinformation on ADHD?)
A friend wrote to me:
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. 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. I carried him home apologizing to him 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:
Yes, if a toddler were diagnosed and treated on that basis, that would be very wrong.
I agree with your stance on the library situation: Two years old is too young to sit still for 30 minutes. That constitutes cruel and unusual punishment!
It’s a very complex issue, though. 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 in the New York Times. Much was missing in that article.
Here’s how that story came to be.
Schwarz showed up unannounced at a state-wide mental-health conference in Georgia. A CDC researcher presented unpublished data on Georgia children only.
Schwarz took numbers compiled for Georgia and extrapolated them to the rest of the country, without taking any complicating factors into consideration. For example, did these children have other physical health conditions? Were their ADHD symptoms severe enough to cause them to run out into the street and do other dangerous things?
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 it 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.
We know dopamine as the “reward” neurotransmitter. But it affects so much more!
- Dopamine also controls motivation, movement, and emotional regulation.
- Dopamine affects important physiological processes, including respiratory and cardiovascular function.
- ADHD is associated with higher rates of enuresis and encopresis, asthma and allergies, heart arrthymia, and sleep disorders.
- Finally. 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.
This Information Can Be Live-Saving
I am passionate about educating the public about the potentially wide-ranging impact of ADHD. We need to make this known to the various medical specialists who are treating the “downstream effect” of ADHD without treating the sources.
Hence, my two-part blog post, with Part II here.
It’s long. But I promise: It’s worth it. You’ll learn something very important here.
I hope you will pass it around, using the handy social-media icons at the end.
Here is the overview:
- ADHD is often a biomedical issue, not simply a “behavior” problem.
- Stimulant medications improve transmission of the brain chemical called dopamine.
- Dopamine affects far more than “reward” and “focus.” It affects physiological systems, including respiratory and cardiovascular functioning as well as all the senses (touch, hearing, vision, taste, smell).
- Poorly reported stories hurt children (and parents) who are already suffering.
- Please help me to educate the public and the medical community.
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 about ADHD that falls beyond the intuitive grasp of even well-educated people with ADHD. Especially if they’re not thinking of very sick children.
Here’s 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.
Skewed News Harms Children
One thing was clear: The New York Times, The Daily Beast, The Today Show, and other “news outlets” that glommed onto the 10,000 Toddlers meme were interested in ADHD’s medical reality.
They have their own angle: Children with ADHD are out-of-control “brats.” That’s how their graphic designers illustrate the pieces, with photos of screaming, angry children. (I’ve used photos of a different type here.)
These news outlets betrayed their science illiteracy. They implied 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.
Some children with ADHD are extremely impaired. It is up to the evaluating physician as to how to proceed. Sports reporter Alan Schwarz has no place in this equation. No matter how many Pulitzers he hopes to win with his “hard-hitting investigation.”
(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 and creating a name for himself. Especially with his new book, A.D.H.D. Nation, an expanded compilation of his misguided newspaper articles.)
The FDA acknowledges that sometimes stimulant medications can be used for young children, with these guidelines “Stimulant and Related Medications: Use in Pediatric Patients.”
Example: The Insatiable, Sleepless Toddler
Many toddlers and even babies with ADHD are chronically unhappy, about everything. Their distraught parents can do nothing right. That’s because the problem is not on the outside but on the inside, within the neural pathways.
I wrote in my first book about how ADHD can make some adults insatiable. That is, chronically dissatisfied. There’s never enough of anything to make them happy.
Take a minute to think about what insatiability would look like in a baby or a 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 of these babies cannot sit still long enough to nurse. They cannot direct their gaze long enough at their caregiver to form that all-important connection. Uninformed critics are always yammering that the babies “need more than medication.” But what if nothing else will work until medication is in effect?
Their young lives are miserable. Anyone with a heart can clearly see it.
- What kind of start in life is this?
- Who cannot be compassionate to such a child?
- Who wouldn’t want to help instead of inflicting the worst kind of ignorance on the child and family?
Example: Toddler Turns Blue—and Faints
Moms of children with ADHD have told me of a “hyperactive” fetus—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 can and often do grow up to be toddlers who will walk out the front door and into traffic, or crawl out of windows. They 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 witnessed this. I found it horrifying— to feel so helpless at a child’s severe distress. What kind of long-term impact does this feeling have on the child?
I learned about this fainting phenomenon while seeking to help a friend’s child. My friend is an incredibly attentive, empathic, loving, and patient mother. She’d done everything “right.” Still, her baby had hardly ever been happy, hardly smiled, and had tremendous difficulty sleeping. Now that he was walking, the fainting began.
Mothers in my online ADHD communities reported to me the same phenomenon among their ADHD children. Their physicians were clueless. Even at “famous” clinics.
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?
Another friend and her husband (who has severe ADHD, now well-managed) were grief-stricken when their newborn displayed what appeared to be sleep apnea. Little Henry simply stopped breathing. Who wouldn’t be apoplectic?
Let me make this clear to NYT reporter Alan Schwarz: The parents didn’t worry about the baby misbehaving or learning differential equations. They worried about him surviving!
The Lifesaving Role of Dopamine
No one suggests cavalierly giving stimulant medication, which act on dopamine neurotransmitters, to a newborn or baby for ADHD.
Yet, guess what? Vulnerable babies are given dopamine itself (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 complains 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.
When the public blindly reacts to click-bait from The New York Times or some other self-promoter with an agenda, it is not helpful. It is harmful.
“They’ll Grow Out Of It”
Typically, pediatricians didn’t understand these issues when my friends presented them. The physicians would head pat and reassure, “The child will grow out of it.”
Here is what actually happens: 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. On it goes up the developmental ladder. The pediatric syncope (fainting) didn’t go away; it simply moved to a more developmentally advanced mode of expression.
Unfortunately, the ADHD diagnosis comes much later for many of these children. It comes long after so many bad habits and blows to self-esteem have taken root. It comes long after illnesses such as allergies and asthma have further circumscribed their lives.
The mother of a 17-year-old boy told me that he has long had problems with both enuresis (involuntary urinating, as in “bed wetting” and sometimes “pants wetting” at school) and encopresis (involuntary defecation).
Her San Francisco-based pediatrician has explained the problem as a “small bladder” issue and a “bowel disorder.” This same pediatrician dismissed any concerns about ADHD as “mild” and said the greater problem was “auditory processing disorder”—despite APD rarely existing except as a consequence of ADHD.
Yet, 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
How many U.S. toddlers are medicated for ADHD? We don’t have a firm number.
It’s important to understand: That 10,000 figure is only an estimate. Schwartz simply extrapolated to the nation the Georgia state-based figures provided by CDC official Susanna Visser.
Veteran Journalist Takes Issue with Schwarz
This is at least the second time that Schwarz, a sports reporter with no apparent life-science expertise, has acted in a dodgy and unorthodox manner. He reported an amateur analysis of the CDC data, and then attempted 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
Thanks to The New York Times and the worldwide copycat media who picked up the story, readers grabbed their pitchforks. They prepared to hunt down Big Pharma, the doctors doing the prescribing, the lazy parents wanting the “quick fix,” and every other villain involved with “drugging children.
Based on such misinformation.
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 it was children on Medicaid receiving the medication seemed to enrage readers the most. They reacted with fervid blaming of “lazy” parents at the Times’ companion piece (the Motherlode column entitled “The New Inequality for Toddlers: Less Income; More Ritalin”).
NYTimes columnist KJ Dell’Antonia writes about her children in a blog called “Raising Devils” (ahem). These children were being “drugged” only because they were poor, she claimed.
NYTimes’ Blogger 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 in evidence among bloggers such as Dell’Antonia. She 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 such uneducated, unsophisticated individuals get hired?
No News Report Has Examined the Data
You can download Visser’s Georgia presentation here.
Absolutely nothing is 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 often stuck 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. Head Start programs have been cut. Yet, they’ve been shown to be beneficial and cost-effective, not to mention humane. And all the rest.
This fact remains, however: Even with better circumstances, many of these young children will still have ADHD. Their parents will have it. Most likely, their grandparents will have it, too.
Having a “hand up” is important. Improving pre-conception and pre-natal nutrition is important. Yet, 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 those 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.
I welcome your opinions on this topic. It’s easy. No annoying codes to enter.