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Response to Dr Wagner's Methylphenidate Treatment of ADHD in Preschoolers".
As I read Dr Wagner's piece, "Methylphenidate Treatment of ADHD in Preschoolers" (Psychiatric Times, March 2007, page 47), I wondered if perhaps psychiatry is missing the proverbial forest for the trees. The ever-expanding treatment of school-aged children with amphetamines is enough of a point of controversy, but when we begin treating preschoolers who are "3 to 5.5 years," it would seem that it is time for a sit-down discussion of the goals of psychiatry and how it should fit in society. While I am happy to discover that overall safety concerns in the short term are apparently minimal, I am not sure that "emotional outbursts, difficulty in falling asleep, repetitive behavior/thoughts, decreased appetite, and irritability" (much less the case of the apparent induced seizure) are minor concerns. A half-inch decrease in growth and a 3-lb weight decrease per year seems concerning as well, especially when we are discussing 3-year-olds.
It might also be worthwhile to consider the possible long-term consequences of treating a child who is that young with an amphetamine. Given the opportunity, perhaps some of these children could learn how to assuage the symptoms of attention-deficit/hyperactivity disorder (ADHD) without medication. Moreover, the tendency to overdiagnose ADHD and to treat "problem" children for ADHD will no doubt lead to dubious prescribing of methylphenidate and similar medications, while ignoring the family and psychosocial issues that often underlie these behaviors. Just a few decades ago, such practices were the stuff of dystopian science fiction novels.
Stephen J. Pittelli, MD San Luis Obispo, Calif
Dr Wagner responds:
The comments by Dr Pittelli call attention to the importance of determining whether a preschooler fulfills the diagnostic criteria for ADHD; if so, clinicians should consider nonmedication treatments. In the Preschool ADHD Treatment Study, the preschoolers who were eligible to enter the medication treatment phase were those who continued to fulfill ADHD severity criteria after 10 weeks of parent training.1
Karen Dineen Wagner, MD, PhD
Greenhill L, Kollins S, Abikoff H, et al. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD.
J Am Acad Child Adolesc Psychiatry.