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Preschoolers on Drugs
Not all hyperactive kids need to be medicated.
By Rochelle Jones
WedMD Feature
May 22, 2000 -- Nicholas Hill was an obstinate and defiant 4-year-old. He
exploded into violent rages. He yelled, screamed, and threw his toys. When his
parents made reasonable requests, he seemed to take perverse pleasure in
ignoring their wishes and doing exactly the opposite.
"He was a 4-year-old but he was still acting like a 2-year-old," says his
mother, Sue, a special education teacher in Durand, Mich. "It was taxing for
him and for us."
Frustrated, his parents took him to the local hospital, where doctors evaluated
Nicholas and diagnosed him with attention deficit hyperactivity disorder
(ADHD), a condition that affects some 4.8 million American children, according
to the American Academy of Pediatrics. Like most children with ADHD, Nicholas
was prescribed medication to help control his symptoms.
While the drugs helped, Hill still did not feel like Nicholas?s behavior was
under control. Not wanting to place her son on yet another medication, she
began researching nondrug options and stumbled upon Ross Greene's book, The
Explosive Child. Hill began using Greene?s behavior modification techniques
with Nicholas and found they made a huge difference in managing his outbursts.
Greene, PhD, director of cognitive-behavioral psychology at Massachusetts
General Hospital and assistant professor of psychology at Harvard Medical
School, has developed a drug-free approach to parenting children who are easily
frustrated and chronically inflexible, including those with ADHD. Greene's
method teaches parents to intervene before their children explode and helps
kids develop the skills to handle frustration constructively.
Growing Numbers of Preschoolers on Drugs
Greene, who has discussed his approach on Oprah and other programs, is gaining
a following among parents of kids with ADHD. The Journal of the American
Medical Association reported in February that the number of preschoolers being
prescribed stimulants for disorders such as ADHD tripled between 1991 and 1995;
those on antidepressants doubled during the same period. The long-term safety
of these drugs, researchers say, is unknown, and many parents are seeking
non-drug alternatives.
No one knows just how many children are being medicated unnecessarily, but some
experts suspect that doctors are reaching for their prescription pads far too
often. Mark Stein, MD, director of the Hyperactivity, Attention, and Learning
Problems Program at Children's National Medical Center in Washington, says 40%
of the ADHD children referred to him for further evaluation have been diagnosed
incorrectly. Conditions that can be confused with ADHD, he says, include mental
retardation and autism; and some children have personality characteristics
similar to symptoms of ADHD without having the disorder itself.
"There is enormous pressure on primary care physicians in HMOs to diagnose
conditions in 10 minutes -- conditions about which they know very little," says
Stein, who spends 3 to 6 hours doing a comprehensive physical and psychological
exam on any child suspected of having ADHD.
A New Approach
Based on his research at Massachusetts General, Greene's strategy involves two
steps. The first step is for parents to identify and avoid situations that
habitually frustrate their child. For example, a kid who becomes
over-stimulated in the supermarket can be left at home with a babysitter.
The second step is for parents to teach the child to accept a compromise when
his demands can't be granted immediately. A child can be given permission to
sleep over at a friend's house on the weekend, instead of during the week when
homework needs to be completed.
Prioritizing for Parents
In addition, Greene says parents need to prioritize their demands, and he
suggests using a system of "baskets" A, B, and C. Parents should put behaviors
that relate to a child's health and safety (such as wearing a helmet when
bicycling) in a nonnegotiable Basket A. These rules are important to enforce
even if the child becomes angry and out of control.
Behaviors that are desirable (such as eating a variety of foods) but are not
worth daily mealtime tantrums can be put in Basket C and assigned a lower
priority for enforcement.
And in Basket B parents can put behaviors that are important but not essential
and that can be negotiated with a compromise. For instance, a child who doesn't
want to come into the house might be allowed to play outside for an extra 15
minutes.
Greene says that while these kids may want to obey, they lack critical skills
such as flexibility and problem solving that would allow them to comply. With
his techniques, parents can reduce the demands on their children and intervene
before the kids become irrational.
"I have to sell this approach on a daily basis to skeptical parents," Greene
acknowledges. "It seems simplistic but it really works."
Nicholas Hill's mother agrees. A year after starting to follow Greene's
techniques, Nicholas, now 8, is a calmer, happier, more confident child.
Although he remains on some medications, the doses have been dramatically
reduced. "The negative mood over the whole household has lifted," says Hill.
As she talks on her kitchen telephone, she watches Nicholas dash out the back
door and chase his brother up a tree. "At one time that would have been an 'A,'
but now it's a 'C,' " she says. "I've learned."