We're Medicating Four-Year-Old Hunters Before We Even Know Who They Are

I want to talk about the four-year-old, because the four-year-old is the one who can’t speak for himself in any of this.

Image by Hanin Abouzeid from Pixabay

My son was 12 years old when we first started seriously wondering whether something was going on with him. 12. And even at 12, even after the testing and the conversations with psychologists and the stacks of papers I collected from university libraries and medical schools, I was cautious about what story I told him about himself.

Because the story you tell a child about who they are has a way of becoming true, in the best and worst senses of that word. At 12, he was old enough to start building an identity. Old enough to hear “there is something different about how your brain works” and make something of it, for good or ill.

He was not four.

A study led by researchers at Stanford Medicine, published in JAMA Network Open, looked at electronic health records from more than 700,000 children between the ages of three and five, seen at primary care practices affiliated with eight major academic medical centers across the United States.

Of the children who received an ADHD diagnosis, 42 percent were prescribed stimulant medication within thirty days.

Not within thirty days of finishing a recommended course of behavioral therapy. Within thirty days of the diagnosis itself.

The American Academy of Pediatrics is not a radical organization. It doesn’t traffic in alternative frameworks or evolutionary hypotheses. It’s about as mainstream as medicine gets, and its guidelines say plainly that children this young should try six months of behavioral therapy before anyone considers medication. Six months.

Nonetheless, the researchers found that only 14 percent of diagnosed preschoolers waited that long before receiving a prescription.

Here is the part that stopped me cold. Among preschoolers whose charts noted some ADHD symptoms but who had not yet received a formal diagnosis, nearly one in four still received medication within thirty days. Children who hadn’t even been formally diagnosed yet were being put on stimulants.

I want to be precise about what I am and am not saying here.

I am not saying that every one of those prescriptions was wrong, or that every one of those physicians was careless. Medicine is practiced in the real world, where waiting lists are long and appointments are short and parents are exhausted and desperate for something that will help their child and their family right now. I understand that desperation. I lived it.

And the researchers who conducted this study understand it too. When they asked physicians informally why they prescribed so quickly, the answer that kept coming up wasn’t impatience or laziness. It was access. There aren’t enough therapists trained in behavioral treatment for young children. Insurance often won’t cover it even when a therapist exists. So the doctor writes a prescription because a prescription is what they can actually provide.

That is a systems failure, and the physicians caught inside it are not the villains of this story.

But I want to talk about the four-year-old, because the four-year-old is the one who can’t speak for himself in any of this.

A four-year-old Hunter is one of the most purely alive human beings on the planet. He is in motion. He is loud. He is curious about seventeen things simultaneously and committed to exactly none of them for more than four minutes at a stretch. He touches everything. He interrupts. He has strong opinions about which direction the walk should go and he will not be easily redirected.

He’s exhausting to be around if you’re a Farmer adult who’s spent twenty years learning to sit still and follow instructions, and yet he is absolutely magical if you can step back far enough to see what you’re actually looking at.

What you are looking at is a brain that is doing precisely what it was designed to do. Not a broken brain. Not a disordered brain. A four-year-old brain that happens to be wired for exploration, novelty, movement, and immediate reward. Farmers call this ADHD. For most of human history, the tribe called it Tuesday.

The diagnosis of ADHD before the age of six is, to put it charitably, an uncertain science. The traits that define ADHD in a clinical setting — inattention, hyperactivity, impulsivity — are also the defining traits of being a young child.

Separating the two requires time, observation, multiple settings, and a clinician who has seen enough children to know the difference between a Hunter and a four-year-old who hasn’t had enough sleep. It requires exactly the kind of careful, unhurried assessment that a fifteen-minute primary care appointment can’t possibly provide.

And yet primary care is where most of these diagnoses are being made, and made quickly, because that is where families end up when they can’t access anything else.

What behavioral therapy actually does, when it’s given the chance to work, is teach skills. It teaches the child’s parents how to structure an environment that works with a Hunter brain rather than against it. It teaches the child, in age-appropriate ways, how to manage transitions and frustration and the gap between what they want to do and what the situation requires.

These are skills that last a lifetime. A prescription doesn’t teach anyone anything. It changes the neurochemical environment inside the child’s brain, and when the pill wears off, the child still doesn’t have the skills, because no one taught them.

There’s also the question of what we’re communicating to a four-year-old when we medicate him. Children that age don’t understand pharmacology. What they understand is that they were a certain way, the adults around them were unhappy about it, and now they take a pill every morning.

The story that writes itself from that sequence of events is not a story about evolutionary heritage and Hunter traits and a mismatch between ancient wiring and modern classrooms. It is a much simpler and much darker story: I was born broken, and the pill makes me less broken.

I spent years trying to give my son a different story than that. Not a story that denied the realities of his situation, because he deserved honesty about the challenges he faced. But a story that started from the premise that he was not broken.

That the friction between how he was wired and how school was structured was real, but that the friction said something about the structure too, not only about him. That the same traits that made fourth grade hard for him and me had made entire civilizations possible, and that if he could learn some new skills and find the right environments, those traits would be among the best things about him.

He was seven when we started building that story. I am genuinely uncertain what version of it can be told to a four-year-old, or how a four-year-old metabolizes a daily pill in terms of self-understanding.

What I am certain of is that we owe it to these children to try to find out before we start medicating them.

Six months of behavioral therapy isn’t a bureaucratic hurdle the Academy of Pediatrics invented to make everyone’s lives harder. It is the minimum amount of time needed to find out who this child actually is, what they actually need, and whether the answer is really a controlled substance or whether it might be a parent who has learned some new tools, a teacher who understands how Hunter brains work, and a little more room to run.

The study found that the families least likely to access behavioral therapy first were the families least able to navigate a complicated, underfunded mental health system.

Which means the children most likely to be medicated before anyone teaches them anything are the children who most need someone in their corner.

That’s not a coincidence: it’s a policy failure with a face on it, and the face is four years old.