Attention Deficit Disorder -- The Invented Disease

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Official Description of ADD

U.S. Surgeon General's Description of ADD

National Institutes of Health Consensus Development Conference Statement

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Attention-Deficit Hyperactivity Disorder

American Description

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Diagnostic Criteria

  1. Either (1) or (2):
    1. six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
      1. often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
      2. often has difficulty sustaining attention in tasks or play activities
      3. often does not seem to listen when spoken to directly
      4. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
      5. often has difficulty organizing tasks and activities
      6. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
      7. often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
      8. is often easily distracted by extraneous stimuli
      9. is often forgetful in daily activities
    2. six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

      Hyperactivity

      1. often fidgets with hands or feet or squirms in seat
      2. often leaves seat in classroom or in other situations in which remaining seated is expected
      3. often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
      4. often has difficulty playing or engaging in leisure activities quietly
      5. is often "on the go" or often acts as if "driven by a motor"
      6. often talks excessively

      Impulsivity

      1. often blurts out answers before questions have been completed
      2. often has difficulty awaiting turn
      3. often interrupts or intrudes on others (e.g., butts into conversations or games)
  2. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
  3. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
  4. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
  5. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Specify Type:

Note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, "In Partial Remission" should be specified.

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Differential Diagnosis

Age-appropriate behaviors in active children; Mental Retardation; understimulating environments; oppositional behavior; another mental disorder; Pervasive Developmental Disorder; Psychotic Disorder; Other Substance-Related Disorder Not Otherwise Specified.

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Internet Mental Health (www.mentalhealth.com) copyright © 1995-2003 by Phillip W. Long, M.D.

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Chapter 3
Children and Mental Health

Normal Development

Overview of Risk Factors and Prevention

Overview of Mental Disorders in Children

Attention-Deficit/Hyperactivity Disorder

Depression and Suicide in Children and Adolescents

Other Mental Disorders in Children and Adolescents

Services Interventions

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Service Delivery

Conclusions

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References
Figure 3-2. Grading The Level of Evidence for Efficacy of Psychotropic Drugs in Children


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Attention-Deficit/Hyperactivity Disorder

As its name implies, attention-deficit/hyperactivity disorder (ADHD) is characterized by two distinct sets of symptoms: inattention and hyperactivity-impulsivity (see Table 3-3). Although these problems usually occur together, one may be present without the other to qualify for a diagnosis (DSM-IV). Inattention or attention deficit may not become apparent until a child enters the challenging environment of elementary school. Such children then have difficulty paying attention to details and are easily distracted by other events that are occurring at the same time; they find it difficult and unpleasant to finish their schoolwork; they put off anything that requires a sustained mental effort; they are prone to make careless mistakes, and are disorganized, losing their school books and assignments; they appear not to listen when spoken to and often fail to follow through on tasks (DSM-IV; Waslick & Greenhill, 1997).

The symptoms of hyperactivity may be apparent in very young preschoolers and are nearly always present before the age of 7 (Halperin et al., 1993; Waslick & Greenhill, 1997). Such symptoms include fidgeting, squirming around when seated, and having to get up frequently to walk or run around. Hyperactive children have difficulty playing quietly, and they may talk excessively. They often behave in an inappropriate and uninhibited way, blurting out answers in class before the teacher’s question has been completed, not waiting their turn, and interrupting often or intruding on others’ conversations or games (Waslick & Greenhill, 1997).

Many of these symptoms occur from time to time in normal children. However, in children with ADHD they occur very frequently and in several settings, at home and at school, or when visiting with friends, and they interfere with the child’s functioning. Children suffering from ADHD may perform poorly at school; they may be unpopular with their peers, if other children perceive them as being unusual or a nuisance; and their behavior can present significant challenges for parents, leading some to be overly harsh (DSM-IV).

Inattention tends to persist through childhood and adolescence into adulthood, while the symptoms of motor hyperactivity and impulsivity tend to diminish with age. Many children with ADHD develop learning difficulties that may not improve with treatment (Mannuzza et al., 1993). Hyperactive behavior is often associated with the development of other disruptive disorders, particularly conduct and oppositional-defiant disorder (see Disruptive Disorders). The reason for the relationship is not known. Some believe that the impulsivity and heedlessness associated with ADHD interfere with social learning or with close social bonds with parents in a way that predisposes to the development of behavior disorders (Barkley, 1998).

Even though a great many children with this disorder ultimately adjust (Mannuzza et al., 1998), some—especially those with an associated conduct or oppositional-defiant disorder—are more likely to drop out of school and fare more poorly in their later careers than children without ADHD. As they grow older, some teens who have had severe ADHD since middle childhood experience periods of anxiety or depression. This seems to be especially common in children whose predominant symptom is inattention (Morgan et al., 1996). Excellent reviews of ADHD can be found in DSM-IV and other sources5.

Table 3-3. DSM-IV criteria for Attention-Deficit/Hyperactivity Disorder

 

  1. Either (1) or (2):

     
    1. six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Inattention

       
      1. often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
      2. often has difficulty sustaining attention in tasks or play activities
      3. often does not seem to listen when spoken to directly
      4. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
      5. often has difficulty organizing tasks and activities
      6. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
      7. often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
      8. is often easily distracted by extraneous stimuli
      9. is often forgetful in daily activities

         
    2. six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

                Hyperactivity

       
      1. often fidgets with hands or feet or squirms in seat
      2. often leaves seat in classroom or in other situations in which remaining seated is expected
      3. often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
      4. often has difficulty playing or engaging in leisure activities quietly
      5. is often “on the go” or often acts as if “driven by a motor”
      6. often talks excessively

        Impulsivity

         
      7. often blurts out answers before questions have been completed
      8. often has difficulty awaiting turn
      9. often interrupts or intrudes on others (e.g., butts into conversations or games)

         
  2. Some hyperactive-impulsive or inattentive symptoms that cause impairment were present before age 7 years.

     
  3. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).

     
  4. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

     
  5. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

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Prevalence
ADHD, which is the most commonly diagnosed behavioral disorder of childhood, occurs in 3 to 5 percent of school-age children in a 6-month period (Anderson et al., 1987; Bird et al., 1988; Esser et al., 1990; Pelham et al., 1992; Shaffer et al., 1996c; Wolraich et al., 1996). Pediatricians report that approximately 4 percent of their patients have ADHD (Wolraich et al., 1990), but in practice the diagnosis is often made in children who meet some, but not all, of the criteria recommended in DSM-IV (Wolraich et al., 1990) (see also Treatment later in this section). Boys are four times more likely to have the illness than girls are (Ross & Ross, 1982). The disorder is found in all cultures, although prevalences differ; differences are thought to stem more from differences in diagnostic criteria than from differences in presentation (DSM-IV).

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Causes
The exact etiology of ADHD is unknown, although neurotransmitter deficits, genetics, and perinatal complications have been implicated. In the early post-World War II years, a number of pediatricians, neurologists, and child psychiatrists noted that brain-damaged children were often hyperactive (Strauss & Lehtinen, 1947; Eisenberg, 1957; Laufer & Denhoff, 1957). These observations led to the diagnostic concept of“minimal brain damage” (Wender, 1971), which was thought to be characterized by hyperactivity, inattention, learning difficulties, and a wide variety of behavior problems. However, large epidemiological studies (Rutter & Quinton, 1977) of grossly brain-damaged children with cerebral palsy, epilepsy, and so forth, did not find an excess of hyperactivity, and more recent imaging studies have found no evidence of gross brain damage in children with ADHD (Swanson et al., 1998). The past view that ADHD is a form of minimal brain damage has therefore been abandoned by experts. Many brain-damaged children are, if anything, significantly underactive.

In the late 1970s, it was postulated that the core problem in hyperkinetic children was one of inattention (Douglas & Peters, 1979). This view led, in 1980, to the adoption, in the official DSM-III (American Psychiatric Association, 1980) nomenclature, of the new diagnostic label attention-deficit disorder.

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Because the symptoms of ADHD respond well to treatment with stimulants, and because stimulants increase the availability of the neurotransmitter dopamine, the“dopamine hypothesis” has gained a wide following. The dopamine hypothesis posits that ADHD is due to inadequate availability of dopamine in the central nervous system. The neurotransmitter dopamine plays a key role in initiating purposive movement, increasing motivation and alertness, reducing appetite, and inducing insomnia, effects that are often seen when a child responds well to methylphenidate. The dopamine hypothesis has thus driven much of the recent research into the causes of ADHD.

The fact that ADHD runs in families suggests that inheritance is an important risk factor. Between 10 and 35 percent of children with ADHD have a first-degree relative with past or present ADHD. Approximately one-half of parents who had ADHD have a child with the disorder (Biederman et al., 1995). Over the past decade, a large number of twin studies have shown that, when ADHD is present in one twin, it is significantly more likely also to be present in an identical twin than in a fraternal twin (Goodman & Stevenson, 1989). These findings have led geneticists to estimate that genes are important in a high proportion of children with ADHD.

Research to pinpoint abnormal genes is honing in on two genes: a dopamine-receptor (DRD) gene on chromosome 11 and the dopamine-transporter gene (DAT1) on chromosome 5 (Cook et al., 1995; Smalley et al., 1998). Several studies have found evidence that children with ADHD have genetic variations in one of the dopamine-receptor genes (DRD4), although the largest of these studies suggests that the presence of such a variation is associated with only a modest increase in the risk of developing ADHD (Smalley et al., 1998). Several other studies have found evidence for abnormalities of the dopamine-transporter gene (DAT1) in children with very severe forms of ADHD (Cook et al., 1995; Gill et al., 1997; Waldman et al., 1998).

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Yet for most children with ADHD, the overall effects of these gene abnormalities appear small, suggesting that nongenetic factors also are important. Although none of the many imaging studies have found evidence of gross brain damage, some investigators have suggested that exposure to toxins, such as lead, or episodes of oxygen deprivation for the fetus, as may occur during some complications of pregnancy, may adversely affect dopamine-rich areas of the brain. These theories support observations that hyperactivity and inattention are more common in children whose mothers smoked during pregnancy (Nichols & Chen, 1981), in children who have been exposed to high quantities of lead (Needleman et al., 1990), and in children who had a lack of oxygen in the neonatal period (Whittaker et al., 1997).

Some investigators have noted that the parents of hyperactive children are often overintrusive and overcontrolling (Carlson et al., 1995). It has therefore been suggested that such parental behavior is another possible risk factor for ADHD. However, others have noted that, when children are treated with methylphenidate, there is a reduction in parental negativity and intrusiveness. This suggests that the observed overintrusive and overcontrolling behavior of the parent is a response to the child’s behavior rather than the cause (Barkley et al., 1985).

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Treatment

The American Academy of Child and Adolescent Psychiatry (AACAP) published “practice parameters” (i.e., guidelines for clinical practice) on the diagnosis and treatment of ADHD. The AACAP parameters include an extensive literature review, detailed descriptions of the clinical presentation of the disorder, and recommendations for treatment. The practice parameters state that“the cornerstones of treatment are support and education of parents, appropriate school placement, and pharmacology” (AACAP, 1991). These practice parameters evolved out of research relating to two major types of treatment: pharmacological treatment and psychosocial treatment, particularly behavioral modification, as well as multimodal treatment, the combination of psychosocial and pharmacological treatments.

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Pharmacological Treatment
Psychostimulants
Pharmacological treatment with psychostimulants is the most widely studied treatment for ADHD. Stimulant treatment has been used for childhood behavioral disorders since the 1930s (Bradley, 1937). Psychostimulants are highly effective for 75 to 90 percent of children with ADHD. At least four separate psychostimulant medications consistently reduce the core features of ADHD in literally hundreds of randomized controlled trials: methylphenidate, dextroamphetamine, pemoline, and a mixture of amphetamine salts (Spencer et al., 1995; Greenhill, 1998a, 1998b; Greenhill et al., 1998).

These medications are metabolized, leave the body fairly quickly, and work for 1 to 4 hours. Administration is timed to meet the child’s school schedule, to help the child pay attention and meet his or her academic demands, and to mitigate side effects. These medications have their greatest effects on symptoms of hyperactivity, impulsivity, and inattention and the associated features of defiance, aggression, and oppositionality. They also improve classroom performance and behavior and promote increased interaction with teachers, parents, and peers. Small effects were found on learning and school achievement (see reviews by Barkley, 1990; Pelham, 1993; Swanson et al.,1993, 1995b; Greenhill et al., 1998; Cantwell, 1996a; Spencer et al., 1996.) However, psychostimulants do not appear to achieve long-term changes in outcomes such as peer relationships, social or academic skills, or school achievement (Pelham et al., 1998).

Children who do not respond to one stimulant may respond to another (Elia et al., 1991; Elia & Rapoport, 1991). Children should be reevaluated without the medication to see if stimulant treatment is still indicated. Many families choose to have their child take a“drug holiday” on weekends and vacations to reduce overall exposure, but the utility of this strategy has not been demonstrated (AACAP, 1991).

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Dosing
Stimulants are usually started at a low dose and adjusted weekly (AACAP, 1991). A recent study demonstrated that the practice of dosing methylphenidate on the basis of body weight fails to predict the optimal dose of medication (Rapport & Denney, 1997). One of the goals of the recently completed NIMH Multimodal Treatment Study of ADHD (described more fully below) was to develop medication strategies to guide“best dose,” dose changes, management of side effects, and integration with other treatments (Greenhill et al., 1996).

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Side Effects
Common stimulant side effects include insomnia, decreased appetite, stomach aches, headaches, and jitteriness. Some children may develop tics, but a recent study suggests that they disappear with continued treatment (Gadow et al., 1995). Rebound activation (i.e., a sudden increase in attention deficit and hyperactivity) has been noted anecdotally after the child’s last dose of medication wears off (Johnston et al., 1988). Most of the side effects are mild, recede over time, and respond to dose changes. Children rarely experience cognitive impairment, which, if it does occur, can be resolved with reduction or cessation of the drug (Cantwell, 1996). A few cases of psychosis have been reported. Pemoline has been associated with hepatotoxicity, so monitoring of liver function is necessary. Two studies have shown no long-term effects of stimulants on later height or weight (Klein & Mannuzza, 1988; Vincent et al., 1990). Nonetheless, regular precautionary monitoring of weight and height for children on stimulants is recommended.

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Other Medications
For children with ADHD who do not respond to stimulants (10 to 30 percent) or cannot tolerate the side effects, there are other useful medications. The antidepressant bupropion has been found to be superior to placebo, although the response is not as strong as that found with stimulants (Cantwell, 1998). Bupropion can also be used as an adjunct to augment stimulant treatment. Well-controlled trials have shown tricyclic antidepressants to be superior to placebo but less effective than stimulants (Elia et al., 1991; Elia & Rapoport, 1991). Reports of sudden death of a few children in the early 1990s on the tricyclic compound desipramine led to great caution with the use of tricyclics in children (Riddle et al., 1991).

Considerable controversy surrounds the use of central alpha-adrenergic blocking drugs, such as clonidine and guanfacine, to treat ADHD. There is some evidence that clonidine is effective for ADHD when it occurs with a tic disorder (Hunt, 1987; Hunt et al., 1990, 1995). Caution is warranted in view of the four cases of sudden death that have been reported in children taking methylphenidate and clonidine together and of a number of reports of nonfatal cardiac side effects in children taking clonidine alone or in combination (Swanson et al., 1995a).

Neuroleptics have been found to be occasionally effective (Green, 1995), yet the risk of movements disorders, such as tardive dyskinesia, makes their use problematic. Lithium, fenfluramine, or benzodiazapines have not been found to be effective treatments for ADHD (Cantwell, 1996a; Green, 1995), nor have SSRIs, such as fluoxetine (Goldman et al., 1998). Furthermore, more than 20 studies have shown that dietary manipulation (e.g., the Feingold diet) is not efficacious (Mattes & Gittelman, 1981), and controlled studies failed to demonstrate that sugar exacerbates the symptoms of children with ADHD (Milich & Pelham, 1986).

Psychosocial Treatment
Important options for the management of ADHD are psychosocial treatments, particularly in the form of training in behavioral techniques for parents and teachers. Behavioral techniques, which are described more fully below, typically employ“time-out,” point systems and contingent attention (adults reinforcing appropriate behavior by paying attention to it). Psychosocial treatments are useful for the child who does not respond to medication at all or for whom the therapeutic benefits of the medication have worn off and for the child who responds only partially to medication or cannot tolerate medication. In addition, some families express a strong preference not to use medication. Even children who are receiving medication may continue to have residual ADHD symptoms or symptoms from other disorders, such as oppositional defiant disorder or depression, which make specialized child management skills necessary and helpful (see next section, Multimodal Treatments). Furthermore, children with ADHD can present a challenge that puts significant stress on the family. Skills training for parents can help reduce this stress on parents and siblings.

Behavioral Approaches
The main psychosocial treatments for ADHD are behavioral training for parent and teacher, as well as systematic programs of contingency management (this behavioral technique is described in more detail in the Treatment section later in this chapter). Of these options, systematic programs of intensive contingency management conducted in specialized classrooms or summer camps with the setting controlled by highly trained individuals is the most effective (Abramowitz et al., 1992; Carlson et al., 1992; Pelham & Hoza, 1996). The efficacy of behavioral training of teachers is well-established, while the evidence for parent training is less solid, according to the criteria, noted earlier, promulgated by the American Psychological Association Task Force (Pelham et al., 1998). There is, however, indirect support for the effectiveness of parent training in the literature, demonstrating the efficacy of parent training for children with oppositional defiant disorder who share many characteristics with children who have ADHD (see section on Disruptive Disorders).

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A number of studies have compared parent training (Gittelman et al., 1980; Firestone et al., 1986; Horn et al., 1987, 1990, 1991; Pelham et al., 1988) or school-based behavioral modification (Gittelman et al., 1980; Pelham et al., 1988) with the use of stimulants. Most of the studies are of outpatient behavioral therapy programs in which parents meet in groups and are taught behavioral techniques such as time out, point systems, and contingent attention. Teachers are taught similar classroom strategies, as well as the use of a daily report card for parents that evaluates the child’s in-school behavior. The improvements in the symptoms of ADHD achieved with psychosocial treatments are not as large as those found with psychostimulants (Pelham et al., 1998). Behavioral interventions tend to improve targeted behaviors or skills but are not as helpful in reducing the core symptoms of inattention, hyperactivity, or impulsivity. Questions remain about the effectiveness of these treatments in other settings. To be fully effective, treatments for ADHD need to be conducted across settings (school, home, community) and by different people (e.g., parents, teachers, therapists)—a consistency and comprehensiveness that can be hard to achieve.

Cognitive-Behavioral Therapy
Cognitive-behavioral therapy (CBT), primarily training in problem solving and social skills, has not been shown to provide clinically important changes in behavior and academic performance of children with ADHD (Pelham et al., 1998). However, CBT might be helpful in treating symptoms of accompanying disorders such as oppositional defiant disorder, depression, or anxiety disorders (Abikoff, 1985; Hinshaw & Ehardt, 1991; Lochman, 1992).

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Psychoeducation
Although there are no studies evaluating the efficacy of psychoeducation as a treatment modality for ADHD, providing information to parents, children, and teachers about ADHD and treatment options is considered critical in the development of a comprehensive treatment plan (AACAP, 1991). Educational accommodations for children with ADHD are federally mandated, and mental health providers are required to ensure that patients and families have access to adequate and appropriate educational resources. Organizations such as Children and Adults with Attention Deficit Disorder (CHADD) and the National Attention Deficit Disorder Association can be helpful sources of information and support for families.

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Multimodal Treatments
Many researchers and families have long suspected that multimodal treatment—medication used together with multiple psychosocial interventions in multiple settings—should be more effective than medication alone. Multimodal treatment has thus been used in the absence of empirical support (Hechtman, 1993). To determine whether multimodal treatment is indeed effective, the recent NIMH Multimodal Treatment Study of ADHD (called the MTA Study) examined three experimental conditions: medication management alone, behavioral treatment alone, or a combination of medication and behavioral treatments. The study compared the effectiveness of these three treatment modes with each other and with standard care provided in the community (the control group). The behavioral treatment condition consisted of parent training, a school intervention, and a summer treatment program. The MTA Study was also designed to determine the relative benefits of these treatments over time (Richters et al., 1995). All subjects were treated for 14 months and then followed for an additional 22 months.

Results of the MTA Study comparing the 14-month outcomes of 579 children randomly assigned to one of the four treatment conditions were presented in the fall of 1998 (MTA Cooperative Group, 1998). At 14 months, medication and the combination treatment were generally more effective than the behavioral treatment alone or the control treatment. Notably, the combined treatment resulted in significant improvement over the control condition in six outcome areas—social skills, parent child relations, internalizing (e.g., anxiety) symptoms, reading achievement, oppositional and/or aggressive symptoms, and parent and/or consumer satisfaction—whereas the single forms of treatment (medication or behavior therapy) were each superior to the control condition in only one to two of these domains. The conclusions from this major study are that carefully managed and monitored stimulant medication, alone or combined with behavioral treatment, is effective for ADHD over a period of 14 months. Addition of behavioral treatment yields no additional benefits for core ADHD symptoms but appears to provide some additional benefits for non-ADHD-symptom outcomes.

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Treatment Controversies

Overprescription of Stimulants
Concerns have been raised that children, particularly active boys, are being overdiagnosed with ADHD and thus are receiving psychostimulants unnecessarily. However, recent reports found little evidence of overdiagnosis of ADHD or overprescription of stimulant medications (Goldman et al., 1998; Jensen et al., 1999). Indeed, fewer children (2 to 3 percent of school-aged children) are being treated for ADHD than suffer from it. Treatment rates are much lower for selected groups such as girls, minorities, and children receiving care though public service systems (Bussing et al., 1998a, 1998b). However, there have been major increases in the number of stimulant prescriptions since 1989 (Hoagwood et al., 1998), and methylphenidate is being manufactured at 2.5 times the rate of a decade ago (Goldman et al., 1998). Most researchers believe that much of the increased use of stimulants reflects better diagnosis and more effective treatment of a prevalent disorder. Medical and public awareness of the problem of ADHD has grown considerably, leading to longer treatment, fewer interruptions in treatment, and increased treatment of adults. Adolescents and younger girls with ADHD, who were underdiagnosed in the past, are being identified and treated.

Nonetheless, some of the increase in use may reflect inappropriate diagnosis and treatment. In one study, the rate of stimulant treatment was twice the rate of parent-reported ADHD, based on a standardized psychiatric interview (Angold & Costello, 1998). While many children who do meet the full criteria for ADHD are not being treated, the majority of children and adolescents who are receiving stimulants did not fully meet the criteria. These findings may reflect a failure of proper, comprehensive evaluation and diagnosis rather than a failure of the diagnostic criteria, which are clear and validated by research (Angold & Costello, 1998). A diagnosis of ADHD requires the presence of impairing ADHD symptoms in multiple settings for at least 6 months. Although fidgeting and not paying attention are normal, common childhood behaviors, DSM-IV criteria reserve a diagnosis of ADHD for children in whom such frequent behavior produces persistent and pervasive dysfunction. An adequate diagnostic evaluation requires histories to be taken from multiple sources (parents, child, teachers), a medical evaluation of general and neurological health, a full cognitive assessment including school history, use of parent and teacher rating scales, and all necessary adjunct evaluation (such as assessment of speech, language). These evaluations take time and require multiple clinical skills. Regrettably, there is a dearth of appropriately trained professionals.

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Family practitioners are more likely than either pediatricians or psychiatrists to prescribe stimulants and less likely to use diagnostic services, provide mental health counseling, or provide followup care (Hoagwood et al., 1998). The American Academy of Pediatrics published a policy statement in 1996 on the use of medication for children with attentional disorders, concluding that use of medication should not be considered the complete treatment program for children with ADHD and should be prescribed only after a careful evaluation (American Academy of Pediatrics Committee on Children With Disabilities and Committee on Drugs, 1996).

Safety of Long-Term Stimulant Use
Even though the MTA Study found no safety issues over a 14-month period (Greenhill et al., 1998), concerns have been raised about the longer term safety of stimulant treatment. Since ADHD has an early onset and requires an extended course of treatment, research is needed to examine the long-term safety of treatment and to investigate whether other forms of treatment could be combined with psychostimulants to lower their dose as well as to reduce other problem behaviors found with ADHD. Such combined treatments could be targeted for symptoms of disorders that often accompany ADHD, such as conduct disorder, substance abuse, and learning disabilities, and could be targeted to improve overall functioning (Laufer, 1971; Gittelman et al., 1985).

Because stimulants are also drugs of abuse and because children with ADHD are at increased risk for a substance abuse disorder, concerns have also been raised about the potential for abuse of stimulants by children taking the medication or diversion of the drug to others. While stimulants clearly have abuse potential, the rate of lifetime nonmedical methylphenidate use has not significantly increased since methylphenidate was introduced as a treatment for ADHD, suggesting that abuse is not a major problem (Goldman et al., 1998). Case reports describing abuse by children prescribed stimulants for ADHD are rare (Hechtman, 1985).

 

5 Taylor, 1994; Cantwell, 1996; Waslick & Greenhill, 1997; Barkley, 1998; and NIH Consensus Statement 110, 1998.

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Consensus Statements
 


 

110. Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder
 

National Institutes of Health
Consensus Development Conference Statement
November 16-18, 1998


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This statement was originally published as:

Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder. NIH Consens Statement 1998 Nov 16-18; 16(2): 1-37.

For making bibliographic reference to consensus statement no. 110 in the electronic form displayed here, it is recommended that the following format be used:

Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder. NIH Consens Statement Online 1998 Nov 16-18; [cited year, month, day]; 16(2): 1-37.

NIH Consensus Statements are prepared by a nonadvocate, non-Federal panel of experts, based on (1) presentations by investigators working in areas relevant to the consensus questions during a 2-day public session; (2) questions and statements from conference attendees during open discussion periods that are part of the public session; and (3) closed deliberations by the panel during the remainder of the second day and morning of the third. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government.

The statement reflects the panel’s assessment of medical knowledge available at the time the statement was written. Thus, it provides a "snapshot in time" of the state of knowledge on the conference topic. When reading the statement, keep in mind that new knowledge is inevitably accumulating through medical research.

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 Abstract
 Introduction
 1. What Is the Scientific Evidence To Support ADHD as a Disorder?
 2. What Is the Impact of ADHD on Individuals, Families, and Society?
 3. What Are the Effective Treatments for ADHD?
 4. What Are the Risks of the Use of Stimulant Medication and Other Treatments?
 5. What Are the Existing Diagnostic and Treatment Practices, and What Are the Barriers to Appropriate Identification, Evaluation, and Intervention?
 6. What Are the Directions for Future Research?
 Conclusions
 Consensus Development Panel
 Speakers
 Planning Committee
 Lead Organizations
 Supporting Organizations
 Bibliography
 

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Abstract

Objective

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The objective of this NIH Consensus Statement is to inform the biomedical research and clinical practice communities of the results of the NIH Consensus Development Conference on Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder (ADHD). The statement provides state-of-the-art information regarding effective treatments for ADHD and presents the conclusions and recommendations of the consensus panel regarding these issues. In addition, the statement identifies those areas of study that deserve further investigation. Upon completion of this educational activity, the reader should possess a clear working clinical knowledge of the state of the art regarding this topic. The target audience of clinicians for this statement includes, but is not limited to, psychiatrists, family practitioners, pediatricians, internists, neurologists, psychologists, and behavioral medicine specialists.

Participants

Participants were a non-Federal, nonadvocate, 13-member panel representing the fields of psychology, psychiatry, neurology, pediatrics, epidemiology, biostatistics, education, and the public. In addition, 31 experts from these same fields presented data to the panel and a conference audience of 1215.

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Evidence

The literature was searched through Medline, and an extensive bibliography of references was provided to the panel and the conference audience. Experts prepared abstracts with relevant citations from the literature. Scientific evidence was given precedence over clinical anecdotal experience.

Consensus Process

The panel, answering predefined questions, developed their conclusions based on the scientific evidence presented in open forum and the scientific literature. The panel composed a draft statement that was read in its entirety and circulated to the experts and the audience for comment. Thereafter, the panel resolved conflicting recommendations and released a revised statement at the end of the conference. The panel finalized the revisions within a few weeks after the conference. The draft statement was made available on the World Wide Web immediately following its release at the conference and was updated with the panel's final revisions.

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Conclusions

Attention deficit hyperactivity disorder or ADHD is a commonly diagnosed behavioral disorder of childhood that represents a costly major public health problem. Children with ADHD have pronounced impairments and can experience long-term adverse effects on academic performance, vocational success, and social-emotional development which have a profound impact on individuals, families, schools, and society. Despite progress in the assessment, diagnosis, and treatment of ADHD, this disorder and its treatment have remained controversial, especially the use of psychostimulants for both short- and long-term treatment.

Although an independent diagnostic test for ADHD does not exist, there is evidence supporting the validity of the disorder. Further research is needed on the dimensional aspects of ADHD, as well as the comorbid (coexisting) conditions present in both childhood and adult forms.

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Studies (primarily short term, approximately 3 months), including randomized clinical trials, have established the efficacy of stimulants and psychosocial treatments for alleviating the symptoms of ADHD and associated aggressiveness and have indicated that stimulants are more effective than psychosocial therapies in treating these symptoms. Because of the lack of consistent improvement beyond the core symptoms and the paucity of long-term studies (beyond 14 months), there is a need for longer term studies with drugs and behavioral modalities and their combination. Although trials are under way, conclusive recommendations concerning treatment for the long term cannot be made presently.

There are wide variations in the use of psychostimulants across communities and physicians, suggesting no consensus regarding which ADHD patients should be treated with psychostimulants. These problems point to the need for improved assessment, treatment, and followup of patients with ADHD. A more consistent set of diagnostic procedures and practice guidelines is of utmost importance. Furthermore, the lack of insurance coverage preventing the appropriate diagnosis and treatment of ADHD and the lack of integration with educational services are substantial barriers and represent considerable long-term costs for society.

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Finally, after years of clinical research and experience with ADHD, our knowledge about the cause or causes of ADHD remains largely speculative. Consequently, we have no documented strategies for the prevention of ADHD.


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Introduction

Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed behavioral disorder of childhood, estimated to affect 3 to 5 percent of school-age children. Its core symptoms include developmentally inappropriate levels of attention, concentration, activity, distractibility, and impulsivity. Children with ADHD usually have functional impairment across multiple settings including home, school, and peer relationships. ADHD has also been shown to have long-term adverse effects on academic performance, vocational success, and social-emotional development.

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Despite the progress in the assessment, diagnosis, and treatment of children and adults with ADHD, the disorder has remained controversial. The diverse and conflicting opinions about ADHD have resulted in confusion for families, care providers, educators, and policymakers. The controversy raises questions concerning the literal existence of the disorder, whether it can be reliably diagnosed, and, if treated, what interventions are the most effective.

One of the major controversies regarding ADHD concerns the use of psychostimulants to treat the condition. Psychostimulants, including amphetamine, methylphenidate, and pemoline, are by far the most widely researched and commonly prescribed treatments for ADHD. Because psychostimulants are more readily available and are being prescribed more frequently, concerns have intensified over their potential overuse and abuse.

This 2 1/2 day conference brought together national and international experts in the fields of relevant medical research and health care as well as representatives from the public.

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After 1 1/2 days of presentations and audience discussion, an independent, non-Federal consensus panel chaired by Dr. David J. Kupfer, Thomas Detre Professor and Chair, Department of Psychiatry, University of Pittsburgh, weighed the scientific evidence and wrote a draft statement that was presented to the audience on the third day. The consensus statement addressed the following key questions:

  • What is the scientific evidence to support ADHD as a disorder?
  • What is the impact of ADHD on individuals, families, and society?
  • What are the effective treatments for ADHD?
  • What are the risks of the use of stimulant medication and other treatments?
  • What are the existing diagnostic and treatment practices, and what are the barriers to appropriate identification, evaluation, and intervention?
  • What are the directions for future research?

 

The primary sponsors of this conference were the National Institute on Drug Abuse, the National Institute of Mental Health, and the National Institutes of Health (NIH) Office of Medical Applications of Research. The conference was cosponsored by the National Institute of Environmental Health Sciences, the National Institute of Child Health and Human Development, the U.S. Food and Drug Administration, and the Office of Special Education Programs, U.S. Department of Education.


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1. What Is the Scientific Evidence To Support ADHD as a Disorder?

The diagnosis of ADHD can be made reliably using well-tested diagnostic interview methods. However, as of yet, there is no independent valid test for ADHD. Although research has suggested a central nervous system basis for ADHD, further research is necessary to firmly establish ADHD as a brain disorder. This is not unique to ADHD, but applies as well to most psychiatric disorders, including disabling diseases such as schizophrenia. Evidence supporting the validity of ADHD includes the long-term developmental course of ADHD over time, cross-national studies revealing similar risk factors, familial aggregation of ADHD (which may be genetic or environmental), and heritability.

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Additional efforts to validate the disorder are needed: careful description of the cases, use of specific diagnostic criteria, repeated followup studies, family studies (including twin and adoption studies), epidemiologic studies, and long-term treatment studies. To the maximum extent possible, such studies should include various controls, including normal subjects and those with other clinical disorders. Such studies may provide suggestions about subgrouping of patients that will turn out to be associated with different outcomes, responses to different treatment, and varying patterns of familial characteristics and illnesses.

Certain issues about the diagnosis of ADHD have been raised that indicate the need for further research to validate diagnostic methods.

  1. Clinicians who diagnose this disorder have been criticized for merely taking a percentage of the normal population who have the most evidence of inattention and continuous activity and labeling them as having a disease. In fact, it is unclear whether the signs of ADHD represent a bimodal distribution in the population or one end of a continuum of characteristics. This is not unique to ADHD as other medical diagnoses, such as essential hypertension and hyperlipidemia, are continuous in the general population, yet the utility of diagnosis and treatment have been proven. Nevertheless, related problems of diagnosis include differentiating this entity from other behavioral problems and determining the appropriate boundary between the normal population and those with ADHD.
  2. ADHD often does not present as an isolated disorder, and comorbidities (coexisting conditions) may complicate research studies, which may account for some of the inconsistencies in research findings.
  3. Although the prevalence of ADHD in the United States has been estimated at about 3 to 5 percent, a wider range of prevalence has been reported across studies. The reported rate in some other countries is much lower. This indicates a need for a more thorough study of ADHD in different populations and better definition of the disorder.
  4. All formal diagnostic criteria for ADHD were designed for diagnosing young children and have not been adjusted for older children and adults. Therefore, appropriate revision of these criteria to aid in the diagnosis of these individuals is encouraged.
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  6. In summary, there is validity in the diagnosis of ADHD as a disorder with broadly accepted symptoms and behavioral characteristics that define the disorder.

 


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2. What Is the Impact of ADHD on Individuals, Families, and Society?

Children with ADHD experience an inability to sit still and pay attention in class and the negative consequences of such behavior. They experience peer rejection and engage in a broad array of disruptive behaviors. Their academic and social difficulties have far-reaching and long-term consequences. These children have higher injury rates. As they grow older, children with untreated ADHD in combination with conduct disorders experience drug abuse, antisocial behavior, and injuries of all sorts. For many individuals, the impact of ADHD continues into adulthood.

Families who have children with ADHD, as with other behavioral disorders and chronic diseases, experience increased levels of parental frustration, marital discord, and divorce. In addition, the direct costs of medical care for children and youth with ADHD are substantial. These costs represent a serious burden for many families because they frequently are not covered by health insurance.

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In the larger world, these individuals consume a disproportionate share of resources and attention from the health care system, criminal justice system, schools, and other social service agencies. Methodological problems preclude precise estimates of the cost of ADHD to society. However, these costs are large. For example, additional national public school expenditures on behalf of students with ADHD may have exceeded $3 billion in 1995. Moreover, ADHD, often in conjunction with coexisting conduct disorders, contributes to societal problems such as violent crime and teenage pregnancy.

Families of children impaired by the symptoms of ADHD are in a very difficult position. The painful decision-making process to determine appropriate treatment for these children is often made substantially worse by the media war between those who overstate the benefits of treatment and those who overstate the dangers of treatment.


 
 

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3. What Are the Effective Treatments for ADHD?

A wide variety of treatments have been used for ADHD including, but not limited to, various psychotropic medications, psychosocial treatment, dietary management, herbal and homeopathic treatments, biofeedback, meditation, and perceptual stimulation/training. Of these treatment strategies, stimulant medications and psychosocial interventions have been the major foci of research. Studies on the efficacy of medication and psychosocial treatments for ADHD have focused primarily on a condition equivalent to DSM-IV combined type, meeting criteria for Inattention and Hyperactivity/Impulsivity. Until recently, most randomized clinical trials have been short term, up to approximately 3 months. Overall, these studies support the efficacy of stimulants and psychosocial treatments for ADHD and the superiority of stimulants relative to psychosocial treatments. However, there are no long-term studies testing stimulants or psychosocial treatments lasting several years. There is no information on the long-term outcomes of medication-treated ADHD individuals in terms of educational and occupational achievements, involvement with the police, or other areas of social functioning.

Short-term trials of stimulants have supported the efficacy of methylphenidate (MPH) dextroamphetamine and pemoline in children with ADHD. Few, if any, differences have been found among these stimulants on average. However, MPH is the most studied and the most often used of the stimulants. These short-term trials have found beneficial effects on the defining symptoms of ADHD and associated aggressiveness as long as medication is taken. However, stimulant treatments may not “normalize” the entire range of behavior problems, and children under treatment may still manifest a higher level of some behavior problems than normal children. Of concern are the consistent findings that despite the improvement in core symptoms, there is little improvement in academic achievement or social skills.

Several short-term studies of antidepressants show that desipramine produces improvements over placebo in parent and teacher ratings of ADHD symptoms. Results from studies examining the efficacy of imipramine are inconsistent. Although a number of other psychotropic medications have been used to treat ADHD, the extant outcome data from these studies do not allow for conclusions regarding their efficacy.

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Psychosocial treatment of ADHD has included a number of behavioral strategies such as contingency management (e.g., point/token reward systems, timeout, response cost) that typically is conducted in the classroom, parent training (where the parent is taught child management skills), clinical behavior therapy (parent, teacher, or both are taught to use contingency management procedures), and cognitive-behavioral treatment (e.g., self-monitoring, verbal self-instruction, problem-solving strategies, self-reinforcement). Cognitive-behavioral treatment has not been found to yield beneficial effects in children with ADHD. In contrast, clinical behavior therapy, parent training, and contingency management have produced beneficial effects. Intensive direct interventions in children with ADHD have produced improvements in key areas of functioning. However, no randomized control trials have been conducted on some of these intensive interventions alone or in combination with medication. Studies that compared stimulants with psychosocial treatment consistently reported greater efficacy of stimulants.

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Emerging data suggest that medication using systematic titration and intensive monitoring methods over a period of approximately 1 year is superior to an intensive set of behavioral treatments on core ADHD symptoms (inattention, hyperactivity/impulsivity, aggression). Combined medication and behavioral treatment added little advantage overall, over medication alone, but combined treatment did result in more improved social skills, and parents and teachers judged this treatment more favorably. Both systematically applied medication (monitored regularly) and combined treatment were superior to routine community care, which often involved the use of stimulants. An important potential advantage for behavioral treatment is the possibility of improving functioning with reduced dose of stimulants. This possibility was not tested.

There is a long history of a number of other interventions for ADHD. These include dietary replacement, exclusion, or supplementation; various vitamin, mineral, or herbal regimens; biofeedback; perceptual stimulation; and a host of others. Although these interventions have generated considerable interest and there are some controlled and uncontrolled studies using various strategies, the state of the empirical evidence regarding these interventions is uneven, ranging from no data to well-controlled trials. Some of the dietary elimination strategies showed intriguing results suggesting the need for future research.

The current state of the empirical literature regarding the treatment of ADHD is such that at least five important questions cannot be answered. First, it cannot be determined if the combination of stimulants and psychosocial treatments can improve functioning with reduced dose of stimulants. Second, there are no data on the treatment of ADHD, Inattentive type, which might include a high percentage of girls. Third, there are no conclusive data on treatment in adolescents and adults with ADHD. Fourth, there is no information on the effects of long-term treatment (treatment lasting more than 1 year), which is indicated in this persistent disorder. Finally, given the evidence about the cognitive problems associated with ADHD, such as deficiencies in working memory and language processing deficits, and the demonstrated ineffectiveness of current treatments in enhancing academic achievement, there is a need for application and development of methods targeted to these weaknesses.


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4. What Are the Risks of the Use of Stimulant Medication and Other Treatments?

Although little information exists concerning the long-term effects of psychostimulants, there is no conclusive evidence that careful therapeutic use is harmful. When adverse drug reactions do occur, they are usually related to dose. Effects associated with moderate doses may include decreased appetite and insomnia. These effects occur early in treatment and may decrease with continued dosing. There may be negative effects on growth rate, but ultimate height appears not to be affected.

It is well known that psychostimulants have abuse potential. Very high doses of psychostimulants, particularly of amphetamines, may cause central nervous system damage, cardiovascular damage, and hypertension. In addition, high doses have been associated with compulsive behaviors and, in certain vulnerable individuals, movement disorders. There is a rare percentage of children and adults treated at high doses who have hallucinogenic responses. Drugs used for ADHD other than psychostimulants have their own adverse reactions: tricyclic antidepressants may induce cardiac arrhythmias, bupropion at high doses can cause seizures, and pemoline is associated with liver damage.

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The degree of assessment and followup by primary care physicians varies significantly. This variance may contribute to the marked differences in appropriate prescribing practices. Adequate followup is required for any prescribed medications, especially for higher doses of psychostimulants.

Although an increased risk of drug abuse and cigarette smoking is associated with childhood ADHD (see Question 2), existing studies come to conflicting conclusions as to whether use of psychostimulants increases or decreases the risk of abuse. A major limitation of inferences from observational databases is the inability to examine independently the use of stimulant medication, the diagnosis and severity of ADHD, and the effect of coexisting conditions.

The increased availability of stimulant medications may pose risks for society. The threshold of drug availability that can lead to oversupply and consequent illicit use is unknown. There is little evidence that current levels of production have had a substantial effect on abuse. However, there is a need to be vigilant in monitoring the national indices of use and abuse of stimulants among high school seniors. One of the indices is the Drug Abuse Warning Network (DAWN).


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5. What Are the Existing Diagnostic and Treatment Practices, and What Are the Barriers to Appropriate Identification, Evaluation, and Intervention?

The American Academy of Child and Adolescent Psychiatry has published practice parameters for the assessment and treatment of ADHD. The American Academy of Pediatrics has formed a subcommittee to establish parameters for pediatricians, but those guidelines are not available at this time. Primary care and developmental pediatricians, family practitioners, (child) neurologists, psychologists, and psychiatrists are the providers responsible for assessment, diagnosis, and treatment of most children with ADHD. There is wide variation among types of practitioners with respect to frequency of diagnosis of ADHD. Data indicate that family practitioners diagnose more quickly and prescribe medication more frequently than psychiatrists or pediatricians. This may be due in part to the limited time spent making the diagnosis. Some practitioners invalidly use response to medication as a diagnostic criterion, and primary care practitioners are less likely to recognize comorbid (coexisting) disorders. The quickness with which some practitioners prescribe medications may decrease the likelihood that more educationally relevant interventions will be sought.

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Diagnoses may be made in an inconsistent manner with children sometimes being overdiagnosed and sometimes underdiagnosed. However, this does not affect the validity of the diagnosis when appropriate guidelines are used. Some practitioners do not use structured parent questionnaires, rating scales, or teacher or school input. Pediatricians, family practitioners, and psychiatrists tend to rely on parent rather than teacher input. There appears to be a “disconnect” between developmental or educational (school-based) assessments and health-related (medical practice-based) services. There is often poor communication between diagnosticians and those who implement and monitor treatment in schools. In addition, followup may be inadequate and fragmented. This is particularly important to ensure monitoring and early detection of any adverse effect of therapy. School-based clinics with a team approach that includes parents, teachers, school psychologists, and other mental health specialists may be a means to remove these barriers and improve access to assessment and treatment. Ideally, primary care practitioners with adequate time for consultation with such school teams should be able to make an appropriate assessment and diagnosis, but they should also be able to refer to mental health and other specialists when deemed necessary.

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What are the barriers to appropriate identification, evaluation, and intervention?

Studies identify a number of barriers to appropriate identification, evaluation, and treatment. Barriers to identification and evaluation arise when central screening programs limit access to mental health services. The lack of insurance coverage for psychiatric or psychological evaluations, behavior modification programs, school consultation, parent management training, and other specialized programs presents a major barrier to accurate classification, diagnosis, and management of ADHD. Substantial cost barriers exist in that diagnosis results in out-of-pocket costs to families for services not covered by managed care or other health insurance. Mental health benefits are carved out of many policies offered to families, and thus access to treatment other than medication might be severely limited. Parity for mental health conditions in insurance plans is essential. Another cost implication lies in the fact that there is no funded special education category specifically for ADHD, which leaves these students underserved, and there is currently no tracking or monitoring of children with ADHD who are served outside of special education. This results in educational and mental health service sources disputing responsibility for coverage of special educational services.

Barriers exist in relationship to gender, race, socioeconomic factors, and geographical distribution of physicians who identify and evaluate patients with ADHD.

Other important barriers include those perceived by patients, families, and clinicians. These include lack of information, concerns about risks of medications, loss of parental rights, fear of professionals, social stigma, negative pressures from families and friends against seeking treatment, and jeopardizing jobs and military service. For health care providers, the lack of specialists and difficulties obtaining insurance coverage as outlined above present significant obstacles to care.


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6. What Are the Directions for Future Research?

Basic research is needed to better define ADHD. This research includes the following: (1) studies of cognitive development, cognitive processing, and attention/inattention in ADHD and (2) brain imaging studies before the initiation of medication and following the individual through young adulthood and middle age.

Further research should be conducted with respect to the dimensional aspects of this disorder, as well as the comorbid (coexisting) conditions present in both childhood and adult ADHD. Therefore, an important research need is the investigation of standardized age- and gender-specific diagnostic criteria.

The impact of ADHD should be determined. Studies in this regard include (1) the nature and severity of the impact on individuals, families, and society of adults with ADHD beyond the age of 20 and (2) determination of the financial costs related to diagnosis and care of children with ADHD.

Additional studies are needed to develop a more systematized treatment strategy. These include:

  • Studies of the Inattentive type of ADHD, especially since it might include a higher proportion of girls than the subtypes with hyperactivity/impulsivity.
  • Studies of long-term treatment (treatment lasting longer than 1 year), which are needed because of the persistence of the disorder.
  • Prospective controlled studies, up to adulthood, of the risks and benefits associated with childhood treatment with psychostimulants.
  • Studies to determine the effects of psychotropic therapy on cognitive function and school performance.
  • Studies of the effects of instructional treatments on the academic achievement of children with ADHD.
  • Studies to determine whether the combination of stimulants and psychosocial treatments can improve functioning with a reduced dose of stimulants.
  • Studies to determine the risks and benefits associated with treating children younger than age 5 with stimulants.
  • Studies of the effects of various stimulants in adolescents and adults.

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Greater attention should be given to developing integrated programs for diagnosis and treatment. These include:

  • Model projects to demonstrate methods of training teachers to recognize and provide appropriate special programs for children with ADHD.
  • Incorporation of classroom strategies to effectively serve a greater variety of students and thereby reduce the need for ADHD referral and diagnosis.
  • Determination of the extent to which individuals with ADHD are being served in postsecondary education and, if so, where they are being served, with what types of accommodations, and with what level of success.

 


 

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Conclusions

Attention deficit hyperactivity disorder or ADHD is a commonly diagnosed behavioral disorder of childhood that represents a major public health problem. Children with ADHD usually have pronounced difficulties and impairments resulting from the disorder across multiple settings. They can also experience long-term adverse effects on academic performance, vocational success, and social-emotional development.

Despite progress in the assessment, diagnosis, and treatment of ADHD, this disorder and its treatment have remained controversial in many public and private sectors. The major controversy regarding ADHD continues to be the use of psychostimulants both for short-term and long-term treatment.

Although an independent diagnostic test for ADHD does not exist, evidence supporting the validity of the disorder can be found. Further research will need to be conducted with respect to the dimensional aspects of ADHD, as well as the comorbid (coexisting) conditions present in both childhood and adult ADHD. Therefore, an important research need is the investigation of standardized age- and gender-specific diagnostic criteria.

The impact of ADHD on individuals, families, schools, and society is profound and necessitates immediate attention. A considerable share of resources from the health care system and various social service agencies is currently devoted to individuals with ADHD. Often the services are delivered in a nonintegrated manner. Resource allocation based on better cost data leading to integrated care models needs to be developed for individuals with ADHD.

Effective treatments for ADHD have been evaluated primarily for the short term (approximately 3 months). These studies have included randomized clinical trials that have established the efficacy of stimulants and psychosocial treatments for alleviating the symptoms of ADHD and associated aggressiveness and have indicated that stimulants are more effective than psychosocial therapies in treating these symptoms. Lack of consistent improvement beyond the core symptoms leads to the need for treatment strategies that utilize combined approaches. At the present time, there is a paucity of data providing information on long-term treatment beyond 14 months. Although trials combining drugs and behavioral modalities are under way, conclusive recommendations concerning treatment for the long term cannot be made easily.

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The risks of treatment, particularly the use of stimulant medication, are of considerable interest. Substantial evidence exists of wide variations in the use of psychostimulants across communities and physicians, suggesting no consensus among practitioners regarding which ADHD patients should be treated with psychostimulants. As measured by attention/activity indices, patients with varying levels and types of problems (and even possibly unaffected individuals) may benefit from stimulant therapy. However, there is no evidence regarding the appropriate ADHD diagnostic threshold above which the benefits of psychostimulant therapy outweigh the risks.

Existing diagnostic and treatment practices, in combination with the potential risks associated with medication, point to the need for improved awareness by the health service sector concerning an appropriate assessment, treatment, and followup. A more consistent set of diagnostic procedures and practice guidelines is of utmost importance. Current barriers to evaluation and intervention exist across the health and education sectors. The cost barriers and lack of coverage preventing the appropriate diagnosis and treatment of ADHD and the lack of integration with educational services represent considerable long-term cost for society. The lack of information and education about accessibility and affordability of services must be remedied.

Finally, after years of clinical research and experience with ADHD, our knowledge about the cause or causes of ADHD remains speculative. Consequently, we have no strategies for the prevention of ADHD.


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Consensus Development Panel

David J. Kupfer, M.D.
Panel and Conference Chairperson
Thomas Detre Professor and Chair of Psychiatry
Western Psychiatric Institute and Clinic
Department of Psychiatry
University of Pittsburgh
Pittsburgh, Pennsylvania

Robert S. Baltimore, M.D.
Professor of Pediatrics, Epidemiology, and Public Health
Division of Infectious Diseases
Department of Pediatrics
Yale University School of Medicine
New Haven, Connecticut

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Donald A. Berry, Ph.D.
Professor
Institute of Statistics and Decision Sciences
Duke University Medical Center
Durham, North Carolina

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Naomi Breslau, Ph.D.
Director of Research
Department of Psychiatry
Henry Ford Health System
Detroit, Michigan

Everett H. Ellinwood, M.D.
Professor of Psychiatry and Pharmacology
Duke University Medical Center
Durham, North Carolina

Janis Ferre
Past Chair
Utah Governor's Council for People With Disabilities
Salt Lake City, Utah

Donna M. Ferriero, M.D.
Associate Professor of Neurology
Division of Child Neurology
Department of Neurology
University of California, San Francisco
San Francisco, California

Lynn S. Fuchs, Ph.D.
Professor
Department of Special Education
Peabody College
Vanderbilt University
Nashville, Tennessee

Samuel B. Guze, M.D.
Spencer T. Olin Professor of Psychiatry
Department of Psychiatry
Washington University School of Medicine
St. Louis, Missouri

Beatrix A. Hamburg, M.D.
Visiting Professor
Department of Psychiatry
Cornell University Medical College
New York, New York

Jane McGlothlin, Ph.D.
Assistant Superintendent for Curriculum and Instruction
Scottsdale Unified School District
Phoenix, Arizona

Samuel M. Turner, Ph.D., ABPP
Professor of Psychology
Director of Clinical Training
Department of Psychology
University of Maryland
College Park, Maryland

Mark Vonnegut, M.D.
Pediatrician
Milton Pediatrics
Quincy, Massachusetts


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Speakers

Howard Abikoff, Ph.D.
"Matching Patients to Treatments"
Professor of Clinical Psychiatry
Director of Research
NYU Child Study Center
New York University School of Medicine
New York, New York

Sheila Anderson
"Individual and Family Barriers"
Immediate Past National President
Children and Adults With Attention Deficit Disorders
Plantation, Florida

L. Eugene Arnold, M.D., M.Ed.
"Treatment Alternatives for ADHD"
Professor Emeritus of Psychiatry
Ohio State University, Columbus
Sunbury, Ohio

Russell A. Barkley, Ph.D.
"ADHD: Long-Term Course, Adult Outcome, and Comorbid Disorders"
Director of Psychology
Department of Psychiatry
University of Massachusetts Medical Center
Worcester, Massachusetts

Joseph Biederman, M.D.
"Pharmacotherapy of ADHD: Nonstimulant Treatments"
Professor of Psychiatry, Harvard Medical School
Chief, Joint Program in Pediatric Psychopharmacology
Massachusetts and McLean General Hospitals
Boston, Massachusetts

Hector R. Bird, M.D.
"The Prevalence and Cross-Cultural Validity of ADHD"
Professor
Clinical Psychiatry
Columbia University
Deputy Director
Child Psychiatry
New York State Psychiatric Institute
New York, New York

Peter R. Breggin, M.D.
"Risks and Mechanism of Action of Stimulants"
Director
Center for the Study of Psychiatry and Psychology
Bethesda, Maryland

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William B. Carey, M.D.
"Is ADHD a Valid Disorder?"
Clinical Professor of Pediatrics
University of Pennsylvania School of Medicine
Division of General Pediatrics
Children's Hospital of Philadelphia
Philadelphia, Pennsylvania

Betty Chemers, M.A.
"The Impact of ADHD on the Juvenile Justice System"
Director of Research and Program Development
Office of Juvenile Justice and Delinquency Prevention
Washington, D.C.

C. Keith Conners, Ph.D., M.A.
"Overview of Attention Deficit Hyperactivity Disorder (ADHD)"
Director, ADHD Program
Department of Psychiatry
Duke University Medical Center
Durham, North Carolina

James R. Cooper, M.D.
"Availability of Stimulant Medications: Nature and Extent of Abuse and Associated Harm"
Associate Director for Medical Affairs
Division of Clinical and Services Research
National Institute on Drug Abuse
National Institutes of Health
Bethesda, Maryland

Louis Danielson, Ph.D.
"Educational Policy: Educating Children With Attention Deficit Disorders"
Director, Division of Research to Practice
Office of Special Education Programs
Office of Special Education and Rehabilitative Services
U.S. Department of Education
Washington, D.C.

Gretchen Feussner
"Diversion, Trafficking, and Abuse of Methylphenidate"
Pharmacologist
Drug and Chemical Evaluation Section
Office of Diversion Control
Drug Enforcement Administration
Arlington, Virginia

Steven R. Forness, Ed.D.
"The Impact of ADHD on School Systems"
Professor of Psychiatry and Biobehavioral Sciences
Neuropsychiatric Hospital
University of California, Los Angeles
Los Angeles, California

Laurence L. Greenhill, M.D.
"Stimulant Medications"
Research Psychiatrist II
New York State Psychiatric Institute
Columbia University
New York, New York

Stephen P. Hinshaw, Ph.D.
"Impairment: Childhood and Adolescence"
Professor of Psychology
Director of Clinical Psychology Training Program
Department of Psychology
University of California, Berkeley
Berkeley, California

Kimberly Hoagwood, Ph.D.
"A National Perspective on Treatments and Services for Children With ADHD"
Chief of Child and Adolescent Services Research
Services Research Branch
National Institute of Mental Health
National Institutes of Health
Bethesda, Maryland

Peter S. Jensen, M.D.
"Behavioral and Medication Treatments for ADHD: Comparisons and Combinations"
Associate Director for Child and Adolescent Research
National Institute of Mental Health
National Institutes of Health
Bethesda, Maryland

Charlotte Johnston, Ph.D.
"The Impact of ADHD on Social and Vocational Functioning in Adults"
Associate Professor
Department of Psychology
University of British Columbia
Vancouver, British Columbia
Canada

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Peter W. Kalivas, Ph.D.
"Sensitization and the Risk of Exposure to Stimulant Medications"
Professor and Chair
Department of Physiology and Neuroscience
Medical University of South Carolina
Charleston, South Carolina

Kelly J. Kelleher, M.D., M.P.H.
"Use of Services and Costs for Youth With ADHD and Related Conditions"
Staunton Professor of Pediatrics and Psychiatry
Child Services Research and Development Program
University of Pittsburgh
Pittsburgh, Pennsylvania

Rachel G. Klein, Ph.D.
"Alcohol, Nicotine, Stimulants, and Other Drugs"
Director of Clinical Psychology
Department of Psychology
New York State Psychiatric Institute
New York, New York

Benjamin B. Lahey, Ph.D.
"Current Diagnostic Schema/Core Dimensions"
Professor of Psychiatry
Chief of Psychology
Department of Psychiatry
University of Chicago
Chicago, Illinois

Nadine M. Lambert, Ph.D.
"Stimulant Treatment as a Risk Factor for Nicotine Use and Substance Abuse"
Professor
Cognition and Development Area
Director, School Psychology Program
Graduate School of Education
University of California, Berkeley
Berkeley, California

Jan Loney, Ph.D.
"Risk of Treatment Versus Nontreatment"
Professor
Department of Psychiatry
State University of New York at Stony Brook
Stony Brook, New York

William E. Pelham, Jr., Ph.D.
"Psychosocial Interventions"
Professor and Director of Clinical Training
Department of Psychology
State University of New York at Buffalo
Buffalo, New York

Andrew S. Rowland, Ph.D.
"Public Health Perspectives and Toxicological Issues Concerning Stimulant Medications"
Epidemiologist
Epidemiology Branch
National Institute of Environmental Health Sciences
National Institutes of Health
Research Triangle Park, North Carolina

James Swanson, Ph.D.
"Biological Bases of ADHD: Neuroanatomy, Genetics, and Pathophysiology"
Professor of Pediatrics
Department of Pediatrics
University of California, Irvine
Irvine, California

Rosemary Tannock, Ph.D.
"Cognitive and Behavioral Correlates"
Scientist
Associate Professor of Psychiatry
Brain and Behavior Program
Research Institute for the Hospital for Sick Children
University of Toronto
Toronto, Ontario
Canada

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Timothy E. Wilens, M.D.
"ADHD and Risk for Substance Use Disorders"
Associate Professor of Psychiatry
Harvard Medical School
Massachusetts General Hospital
Boston, Massachusetts

Mark L. Wolraich, M.D.
"Current Assessment and Treatment Practices"
Professor of Pediatrics
Director, Division of Child Development
Department of Pediatrics
Vanderbilt University
Nashville, Tennessee


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Planning Committee

James R. Cooper, M.D.
Planning Committee Co-Chairperson
Associate Director for Medical Affairs
Division of Clinical and Services Research
National Institute on Drug Abuse
National Institutes of Health
Bethesda, Maryland

Peter S. Jensen, M.D.
Planning Committee Co-Chairperson
Associate Director for Child and Adolescent Research
National Institute of Mental Health
National Institutes of Health
Bethesda, Maryland

Sheila Anderson
Immediate Past National President
Children and Adults With Attention Deficit Disorders
Plantation, Florida

Elaine Baldwin
Chief, Public Affairs and Science Reports Branch
Office of Scientific Information
National Institute of Mental Health
National Institutes of Health
Bethesda, Maryland

Cheryl Boyce, Ph.D.
Society for Research in Child Development Fellow
Developmental Psychopathology Research Branch
National Institute of Mental Health
National Institutes of Health
Bethesda, Maryland

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Sarah Broman, Ph.D.
Health Science Administrator
Division of Fundamental Neuroscience and Developmental Disorders
National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, Maryland

J.A. Costa e Silva, M.D.
Director
Division of Mental Health and Prevention of Substance Abuse
World Health Organization
Geneva, Switzerland

Dorynne J. Czechowicz, M.D.
Medical Officer
Division of Clinical and Services Research
National Institute on Drug Abuse
National Institutes of Health
Bethesda, Maryland

Jerry M. Elliott
Program Analysis and Management Officer
Office of Medical Applications of Research
National Institutes of Health
Bethesda, Maryland

John H. Ferguson, M.D.
Director
Office of Medical Applications of Research
National Institutes of Health
Bethesda, Maryland

Gretchen Feussner
Pharmacologist
Drug and Chemical Evaluation Section
Office of Diversion Control
Drug Enforcement Administration
Arlington, Virginia

Laurence L. Greenhill, M.D.
Research Psychiatrist II
New York State Psychiatric Institute
Columbia University
New York, New York

William H. Hall
Director of Communications
Office of Medical Applications of Research
National Institutes of Health
Bethesda, Maryland

John King
Deputy Assistant Administrator
Office of Diversion Control
Drug Enforcement Administration
Arlington, Virginia

David J. Kupfer, M.D.
Panel and Conference Chairperson
Thomas Detre Professor and Chair of Psychiatry
Western Psychiatric Institute and Clinic
Department of Psychiatry
University of Pittsburgh
Pittsburgh, Pennsylvania

Benjamin B. Lahey, Ph.D.
Professor of Psychiatry
Chief of Psychology
Department of Psychiatry
University of Chicago
Chicago, Illinois

Jan Loney, Ph.D.
Professor
Department of Psychiatry
State University of New York at Stony Brook
Stony Brook, New York

Reid Lyon, Ph.D.
Chief
Child Development and Behavior Branch
National Institute of Child Health and Human Development
National Institutes of Health
Bethesda, Maryland

Stuart L. Nightingale, M.D.
Associate Commissioner for Health Affairs
Food and Drug Administration
Rockville, Maryland

William E. Pelham, Jr., Ph.D.
Professor and Director of Clinical Training
Department of Psychology
State University of New York at Buffalo
Buffalo, New York

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Elizabeth Rahdert, Ph.D.
Research Psychologist
Treatment Research Branch
Division of Clinical and Services Research
National Institute on Drug Abuse
National Institutes of Health
Bethesda, Maryland

Andrew S. Rowland, Ph.D.
Epidemiologist
Epidemiology Branch
National Institute of Environmental Health Sciences
National Institutes of Health
Research Triangle Park, North Carolina

Ellen Schiller, Ph.D.
Special Assistant
Division of Research to Practice
Office of Special Education Programs
U.S. Department of Education
Washington, D.C.

Bennett Shaywitz, M.D.
Professor of Pediatrics and Neurology
Department of Pediatrics
Yale University School of Medicine
New Haven, Connecticut

Charles R. Sherman, Ph.D.
Deputy Director
Office of Medical Applications of Research
National Institutes of Health
Bethesda, Maryland

Benedetto Vitiello, M.D.
Chief
Child and Adolescent Treatment and Preventive Intervention Research Branch
Division of Services and Intervention Research
National Institute of Mental Health
National Institutes of Health
Bethesda, Maryland

Timothy E. Wilens, M.D.
Associate Professor of Psychiatry
Harvard Medical School
Massachusetts General Hospital
Boston, Massachusetts


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Lead Organizations

Office of Medical Applications of Research
John H. Ferguson, M.D.
Director

National Institute on Drug Abuse
Alan I. Leshner, Ph.D.
Director

National Institute of Mental Health
Steven E. Hyman, M.D.
Director


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Supporting Organizations

National Institute of Environmental Health Sciences
Kenneth Olden, Ph.D.
Director

National Institute of Child Health and Human Development
Duane Alexander, M.D.
Director

U.S. Food and Drug Administration
Michael A. Friedman, M.D.
Acting Commissioner

Office of Special Education Programs
U.S. Department of Education
Thomas Hehir, Ed.D.
Director



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Bibliography

The speakers listed above identified the following key references in developing their presentations for the consensus conference. A more complete bibliography prepared by the National Library of Medicine (NLM) at NIH, along with the references below, was provided to the consensus panel for their consideration. The full NLM bibliography is available at the following Web site: http://www.nlm.nih.gov/pubs/cbm/adhd.html.

OVERVIEW AND INTRODUCTION

Conners CK, Erhardt D.
Attention-deficit hyperactivity disorder in children and adolescents: clinical formulation and treatment. Hersen M, Bellack A, editors. New York: Elsevier Science; 1998.

Goldman LS, Genel M, Bezman RJ, Slanetz PJ.
Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs, American Medical Association. JAMA 1998;279:1100-7.

Richters JE, Arnold LE, Jensen PS, Abikoff H, Conners CK, Greenhill LL, et al.
NIMH collaborative multisite multimodal treatment study of children with ADHD: I. Background and rationale. J Am Acad Child Adolesc Psychiatry 1995;34:987-1000.

Weiss G, Hechtman L.
Hyperactive children grown up: ADHD in children, adolescents, and adults. New York: Guilford; 1993.

ADHD AS A DISORDER IN CHILDREN, ADOLESCENTS, AND ADULTS

Applegate B, Lahey BB, Hart EL, Biederman J, Hynd GW, Barkley RA, et al.
Validity of the age-of-onset criterion for attention-deficit/hyperactivity disorder: a report from the DSM-IV field trials. J Am Acad Child Adolesc Psychiatry 1997;36:1211-21.

Carey WB, McDevitt SC.
Coping with childrenís temperament. New York: Basic Books; 1995.

Castellanos FX, Giedd JN, March Wl, Hamburger SD, Vaituzis AC, Dickstein DP, et al.
Quantitative brain magnetic resonance imaging in attention-deficit hyperactivity disorder. Arch Gen Psychiatry 1996;53:607-16.

Diller LH.
Running on Ritalin. New York: Bantam; 1998.

Lahey BB, Applegate B, McBurnett K, Biederman J, Greenhill L, Hynd GW, et al.
DSM-IV field trials for attention deficit/hyperactivity disorder in children and adolescents. Am J Psychiatry 1994;151:1673-85.

Lahey BB, Pelham WE, Stein MA, Loney J, Trapani C, Nugent K, et al.
Validity of DSM-IV attention-deficit/hyperactivity disorder for younger children. J Am Acad Child Adolesc Psychiatry. In press.

Lahey BB, Carlson CL, Frick PJ.
Attention deficit disorder without hyperactivity: a review of research relevant to DSM-IV. In: Widiger TA, Frances AJ, Davis W, First M, editors. DSM-IV sourcebook, Vol 1. Washington (DC): American Psychiatric Press; 1997.

Levine MD.
Neurodevelopmental variation and dysfunction among school children. In: Levine MD, Carey WB, Crocker AC, editors. Developmental-behavioral pediatrics. 3rd ed. Philadelphia: Saunders; 1998.

Lou HC.
Etiology and pathogenesis of attention-deficit hyperactivity disorder (ADHD): significance of prematurity and perinatal hypoxic-haemodynamic encephalopathy. Acta Paediatr 1996;85:1266-71.

Maziade M.
Should adverse temperament matter to the clinician? An empirically based answer. In: Kohnstamm GA, Bates JE, Rothbart MK, editors. Temperament in childhood. New York: Wiley; 1989.

Oosterlaan J, Logan GD, Sergeant JA.
Response inhibition in AD/HD, CD, comorbid AD/HD+CD, anxious and control children: a meta-analysis of studies with the stop task. J Child Psychol Psychiatry 1998;39:411-26.

Pennington BF, Ozonoff S.
Executive functions and developmental psychopathology. J Child Psychol Psychiatry 1996;37:51-87.

Seidman LJ, Biederman J, Faraone SV, Weber W, Ouellette C.
Toward defining a neuropsychology of attention deficit-hyperactivity disorder: performance of children and adolescents from a large clinically referred sample. J Consul and Clin Psychol 1997;65:150-60.

Swanson JM, Sunohara GA, Kennedy JL, Regino R, Fineberg E, Wigal T, et al.
Association of the dopamine receptor D4 (DRD4) gene with a refined phenotype of attention deficit hyperactivity disorder (ADHD): a family-based approach. Mol Psychiatry 1998;3:38-41.

Tannock R.
Attention deficit hyperactivity disorder: advances in cognitive, neurobiological, and genetic research. J Child Psychol Psychiatry 1998;39:65-99.

Volkow ND, Ding YS, Fowler JS, Wang GJ, Logan J, Gatley JS, et al.
Is methylphenidate like cocaine? Studies on their pharmacokinetics and distribution in human brain. Arch Gen Psychiatry 1995;52:456-63.

IMPACT

Barkley RA, Fischer M, Edelbrock CS, Smallish L.
The adolescent outcome of hyperactive children diagnosed by research criteria: I. An 8-year prospective follow-up study. Am Acad Child Adolesc Psychiatry 1990;29:546-57.

Barkley RA.
Developmental course, adult outcome, and clinic-referred ADHD adults. In: Barkley RA, Attention deficit hyperactivity disorder. 2nd ed. New York: Guilford Press; 1998.

Biederman J, Faraone SV, Spencer T, Wilens T, Norman D, Lapey KA, et al.
Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder. Am J Psychiatry 1993;150:1792-8.

Biederman J, Faraone S, Milberger S, Guite J, Mick E, Chen L, et al.
A prospective 4-year follow-up study of attention-deficit hyperactivity and related disorders. Arch Gen Psychiatry 1996;53:437-46.

Bird H.
Epidemiology of childhood disorders in a cross-cultural context. J Child Psychol Psychiatry 1996;37(1):35-49.

Bussing R, Zima BT, Belin TR, Forness SR.
Children who qualify for LD and SED programs: do they differ in level of ADHD symptoms and comorbid psychiatric conditions? J Emot Beh Disord 1998;22:88-97.

Cocozza JJ, editor.
Responding to the mental health needs of youth in the juvenile justice system. Seattle: The National Coalition for the Mentally Ill in the Criminal Justice System; 1992.

Danckaerts M, Taylor EJ.
The epidemiology of childhood hyperactivity. In: Verhulst FC, Koot HM, editors. The epidemiology of child and adolescent psychopathology. New York: Oxford University Press; 1995.

DuPaul GJ, Eckert TL.
The effects of school-based interventions for attention deficit hyperactivity disorder: a meta-analysis. Sch Psych Rev 1997;26:5-27.

Forness SR, Walker HM.
Special education and children with ADD/ADHD. Mentor (OH): National Attention Deficit Disorder Association; 1994.

Greene R, Biederman J, Faraone SV, Sienna M, Garcia-Jetton J.
Adolescent outcome of boys with attention-deficit/hyperactivity disorder and social disability: results from a 4-year follow-up study. J Consult Clin Psychol 1997;65:758-67.

Hinshaw SP, Melnick SM.
Peer relationships in children with attention-deficit hyperactivity disorder with and without comorbid aggression. Dev Psychopathol 1995;7:627-47.

Lahey BB, Pelham WE, Stein MA, Loney J, Trapani C, Nugent K, et al.
Validity of DSM-IV attention-deficity/hyperactivity disorder for younger children. J Am Acad Child Adolesc Psychiatry 1998;37:435-42.

Leung PW, Luk SL, Ho TP, Taylor E, Mak FL, Bacon-Shone J.
The diagnosis and prevalence of hyperactivity in Chinese schoolboys. Br J Psychiatry 1996;168(4):486-96.

Loeber R, Farrington D, editors.
Serious and violent juvenile offenders: risk factors and successful interventions. Thousand Oaks: Sage Publications; 1998.

Mann EM, Ikeda Y, Mueller CW, Takahashi A, Tao KT, Humris E, et al.
Cross-cultural differences in rating hyperactive-disruptive behaviors in children. Am J Psychiatry 1992;149(11):1539-42.

Mannuzza S, Klein R, Bessler A, Malloy P, LaPadula M.
Adult outcome of hyperactive boys. Educational achievement, occupational rank, and psychiatric status. Arch Gen Psychiatry 1993;50:565-76.

Mannuzza S, Klein RG, Bessler A, Malloy P, Hynes ME.
Educational and occupational outcome of hyperactive boys grown up. J Am Acad Child Adolesc Psychiatry 1997;36:1222-7.

Reid R, Maag JW, Vasa SF, Wright G.
Who are the children with attention deficit-hyperactivity disorder? A school-based survey. J Spec Ed 1994;28:117-37.

Slomkowski C, Klein RG, Mannuzza S.
Is self-esteem an important outcome in hyperactive children? J Abnorm Child Psychol 1995;23:303-15.

Snyder HN.
Juvenile arrests 1996. Washington, DC: U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention; 1997.

Stahl AL.
Delinquency cases in juvenile courts, 1995. OJJDP fact sheet #79. Washington, DC: U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention; 1998.

Weiss G, Hechtman LT.
Hyperactive children grown up. 2nd ed. New York: Guilford Press; 1993.

SAFETY AND EFFICACY OF TREATMENTS -- SHORT AND LONG TERM

Arnold L, Abikoff H, Cantwell D, Conners C, Elliott G, Greenhill L, et al.
NIMH collaborative multimodal treatment study of children with ADHD (MTA): design challenges and choices. Arch Gen Psychiatry 1997;54:865-70.

Biederman J, Thisted R, Greenhill L, Ryan N.
Estimation of the association between desipramine and the risk for sudden death in 5- to 14-year-old children. J Clin Psychiatry 1995;56:87-93.

Biederman J, Baldessarini RJ, Wright V, Keenan K, Faraone S.
A double-blind placebo controlled study of desipramine in the treatment of attention deficit disorder: III. Lack of impact of comorbidity and family history on clinical response. J Am Acad Child Adolesc Psychiatry 1993;32:199-204.

Borcherding BG, Keysor CS, Rapoport JL, Elia J, Amass J.
Motor/vocal tics and compulsive behaviors on stimulant drugs: is there a common vulnerability? Psychiatry Res 1990;33:83-94.

Breggin PR.
Talking back to Ritalin. Monroe (ME): Common Courage Press; 1998.

Carlson CL, Pelham WE, Milich R, Dixon J.
Single and combined effects of methylphenidate and behavior therapy on the classroom performance of children with ADHD. J Abnorm Child Psychol 1992;20:213-32.

Dunnick JK, Hailey JR.
Experimental studies on the long-term effects of methylphenidate hydrochloride. Toxicology 1995;103:77-84.

Klein GR, Landa B, Mattes JA, et al.
Methylphenidate and growth in hyperactive children. Arch Gen Psychiatry 1988;45:1127-30.

Goldman LS, Genel M, Bezman RJ, Slanetz PJ.
Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs. American Medical Association. JAMA 1998;279:1100-7.

Hechtman L, Abikoff H.
Multimodal treatment plus stimulants vs. stimulant treatment in ADHD children: results from a two-year comparative treatment study. Paper presented at the Annual Meeting of the American Academy of Child and Adolescent Psychiatry; October 1995; New Orleans, Louisiana.

Hinshaw SP.
Stimulant medication and the treatment of aggression in children with attentional deficits. J Clin Child Psychol 1991;20:301-12.

Horn WF, Ialongo NS, Pascoe JM, Greenberg G, Packard T, Lopez M, et al.
Additive effects of psychostimulants, parent training, and self-control therapy with ADHD children. J Am Acad Child Adolesc Psychiatry 1991;30:233-40.

Jensen PJ, Abikoff H.
Tailoring treatment interventions for individuals with ADDs. In: Brown T, editor. Attention deficit disorders and comorbidities in children, adolescents, and adults. American Psychiatric Press. In press.

Klein RG, Abikoff H.
Behavior therapy and methylphenidate in the treatment of children with ADHD. J Attention Disord 1997;2:89-114.

Klein RG, Abikoff H, Klass E, Ganeles D, Seese LM, Pollack S.
Clinical efficacy of methylphenidate in conduct disorder with and without attention deficit hyperactivity disorder. Arch Gen Psychiatry 1997;54:1073-80.

Marotta PJ, Roberts EA.
Pemoline hepatotoxicity in children. J Pediatr 1998;132:894-7.

McMaster University Evidence-Based Practice Center.
The treatment of attention-deficit/hyperactivity disorder: an evidence report. Contract no. 290-97-0017. Agency for Health Care Policy and Research; 1998.

Melega WP, Raleigh MJ, Stout DB, Lacan G, Huang SC, Phelps ME.
Recovery of striatal dopamine function after acute amphetamine- and methamphetamine-induced neurotoxicity in the vervet monkey. Brain Res 1997;766:113-20.

Nasrallah H, Loney J, Olson S, McCalley-Whitters M, Kramer J, Jacoby C.
Cortical atrophy in young adults with a history of hyperactivity in childhood. Psychiatry Res 1986;17:241-6.

Pelham WE, Wheeler T, Chronis A.
Empirically supported psychosocial treatments for attention deficit hyperactivity disorder. J Clin Child Psychol 1998;27:189-204.

Pelham WE,Murphy HA.
Attention deficit and conduct disorder. In: Hersen M, editor. Pharmacological and behavioral treatment: an integrative approach. New York: John Wiley & Sons; 1986. p. 108-48.

Pelham WE, Hoza B.
Intensive treatment: a summer treatment program for children with ADHD. In: Hibbs E, Jensen P, editors. Psychosocial treatments for child and adolescent disorders: empirically based strategies for clinical practice. New York: APA Press; 1996. p. 311-40.

Pliszka S.
Effect of anxiety on cognition, behavior, and stimulant response in ADHD. J Amer Acad Child Adolesc Psychiatry 1989;28:882-7.

Safer DJ, Zito JM, Fine EM.
Increased methylphenidate usage for attention deficit disorder in the 1990s. Pediatrics 1996;98:1084-8.

Spencer T, Biederman J, Wilens T, Harding M, OíDonnell D, Griffin S.
Pharmacotherapy of attention-deficit hyperactivity disorder across the life cycle. J Am Acad Child Adolesc Psychiatry 1996;35:409-32.

Swanson JM, Flockhart D, Udrea D, Cantwell DP, Connor DF, Williams L.
Clonidine in the treatment of ADHD: questions about safety and efficacy. J Child Adolesc Psychopharmacol 1995;5:301-4.

Wilens TE, Biederman J.
Stimulants. In: Schaffer D, editor. Psychiatric Clinics of North America. Philadelphia: W.B. Saunders; 1992. p. 191-222.

SUBSTANCE ABUSE RISKS OF STIMULANT TREATMENTS

Beck L, Langford W, MacKay M, Sum G.
Childhood chemotherapy and later drug abuse and growth curve: a follow-up study of 30 adolescents. Am J Psychiatry 1975;132:436-8.

Biederman J, Wilens TE, Mick E, Milberger S, Spencer TJ, Faraone SV.
Psychoactive substance use disorders in adults with attention deficit hyperactivity disorder (ADHD): effects of ADHD and psychiatric comorbidity. Am J Psychiatry 1995;152:1652-8.

Carroll KM, Rounsaville BJ.
History and significance of childhood attention deficit disorder in treatment-seeking cocaine abusers. Compr Psychiatry 1993;34:75-82.

Drug Enforcement Administration, Office of Diversion Control.
Methylphenidate review: eight factor analysis. Washington (DC); 1995.

Drug Enforcement Administration, Office of Diversion Control.
Conference report: stimulant use in the treatment of ADHD. Washington (DC); 1996.

Gaytan O, al-Rahim S, Swann A, Dafny N.
Sensitization to locomotor effects of methylphenidate in the rat. Life Sci 1997;61:101-7.

Hartsough CS, Lambert NM.
Pattern and progression of drug use among hyperactives and controls: a prospective short-term longitudinal study. J Child Psychol Psychiatry 1987;28:543-53.

Hechtman L.
Adolescent outcome of hyperactive children treated with stimulants in childhood: a review. Psychopharmacol Bull 1985;21:178-91.

Herrero ME, Hechtman L, Weiss G.
Antisocial disorders in hyperactive subjects from childhood to adulthood: predictive factors and characterization of subgroups. Am J Orthopsychiatry 1994;64:510-21.

Jaffe SL.
Intranasal abuse of prescribed methylphenidate by an alcohol and drug abusing adolescent with ADHD. J Am Acad Child Adolesc Psychiatry 1991;30:773-5.

Klein RG, Mannuzza S.
The importance of childhood hyperactivity in the development of substance use disorders. In: Bailly D, editor. Addictions et Psychiatrie. Paris (France): Editions Masson. In press.

Kramer J, Loney J.
Childhood hyperactivity and substance abuse: a review of the literature. In: Gadow KD, Bialer I, editors. Advances in learning and behavioral disabilities. Greenwich (CT): Jai Press; 1982.

Lambert NM, Hartsough CS.
Prospective study of tobacco smoking and substance dependence among samples of ADHD and non-ADHD subjects. J Learn Disabil 1998;31:533-44.

Lambert NM, Sandoval J, Sassone D.
Prevalence of hyperactivity in elementary school children as a function of social system definers. Am J Orthopsychiatry 1978;48:446-63.

Lambert NM.
Adolescent outcomes for hyperactive children: perspectives on general and specific patterns of childhood risk for adolescent educational, social, and mental health problems. Am Psychol 1988;43:786-99.

Lambert NM, Hartsough CS, Sandoval J.
Childrenís attention and adjustment survey -- home and school versions. Circle Pines (MN): American Guidance Service; 1990.

Levin FR, Kleber HD.
Attention deficit hyperactivity disorder and substance abuse: relationships and implications for treatment. Harv Rev Psychiatry 1995;2:246-58.

Loney J, Kramer J, Salisbury H.
Medicated vs. unmedicated hyperactive boys as adults: attitudes toward and use of substances. Stony Brook: State University of New York; 1998.

Lynskey MT, Fergusson DM.
Childhood conduct problems, attention deficit behaviors, and adolescent alcohol, tobacco, and illicit drug use. J Abnorm Child Psychol 1995;23:281-302.

McDougall SA, Duke MA, Bolanos CA, Crawford CA.
Ontogeny of behavioral sensitization in the rat: effects of direct and indirect dopamine agonists. Psychopharmacology 1994;116:483-90.

Milberger S, Biederman J, Faraone S, Chen L, Jones J.
ADHD is associated with early initiation of cigarette smoking in children and adolescents. J Am Acad Child Adolesc Psychiatry 1997;36:37-43.

Piazza PV, Deroche V, Rouge-Pont F, Le Moal M.
Behavioral and biological factors associated with individual vulnerability to psychostimulant abuse. NIDA monograph #169. National Institutes of Health, Laboratory Behavioral Studies of Vulnerability to Drug Abuse; 1997. p. 105-33.

Pierce RC, Kalivas PW.
A circuitry model of the expression of behavioral sensitization to amphetamine-like psychostimulants. Brain Res Brain Res Rev 1997;25:192-216.

Post RM.
Intermittent versus continuous stimulation: effect of time interval on the development of sensitization or tolerance. Life Sci 1980;26:1275-82.

Report of the International Narcotics Control Board for 1996.
(E/INCB/1996/1)

Wilens TE, Biederman J, Mick E, Faraone SV, Spencer T.
Attention deficit hyperactivity disorder (ADHD) is associated with early onset substance use disorders. J Nerv Ment Dis 1997;185:475-82.

EXISTING PRACTICES AND BARRIERS REGARDING ASSESSMENT AND TREATMENT

Costello EJ, Edelbrock C, Costello AJ, Dulcan MK, Barne BJ, Brent, D.
Psychopathology in pediatric primary care: the new hidden morbidity. Pediatrics 1988;81:415-24.

Diller LH.
The run on Ritalin: attention deficit disorder and stimulant treatment in the 1990ís. Hastings Cent Rep 1996;26:12.

Horwitz SM, Leaf PJ, Leventhal JM, Forsyth B, Speechley KN.
Identification and management of psychosocial and developmental problems in community-based primary care pediatric practices. Pediatrics 1992;89:480-5.

Jensen PS, Kettle L, Roper MT, Sloan MT, Dulcan MK, Hoven CW, et al.
Are stimulants over-prescribed? Treatment of ADHD in four U.S. communities. J Am Acad Child Adolesc Psychiatry. In press.

Kelleher KJ, Childs GE, Wasserman RC, McInerny TK, Nutting PA, Gardner WP.
Insurance status and recognition of psychosocial problems: a report from pediatric research in office settings and the ambulatory sentinel practice networks. Arch Pediatr Adolesc Med 1997;151:1109-15.

Knapp M.
Economic evaluations and interventions for children and adolescents with mental health problems. J Child Psychol Psychiatry 1997;38(1):3-25.

Leaf PJ, Alegria M, Cohen P, Goodman SH, Horwitz SM, Hoven CW, et al.
Mental health service use in the community and schools: results from the four-community MECA study. J Am Acad Child Adolesc Psychiatry 1996;35:889-97.

Offord DR, Boyle MH, Szatmari P, Rae-Grant NI, Links PS, Cadman DT, et al.
Ontario Child Health Study. II. Six-month prevalence of disorder and rates of service utilization. Arch Gen Psychiatry 1987;44:832-6.

Rappley MD, Gardiner JC, Jetton JR, Houang RT.
The use of methylphenidate in Michigan. Arch Pediatr Adolesc Med 1995;149:675-9.

Wolraich ML, Hannah JN, Pinnock TY, Baumgaertel A, Brown J.
Comparison of diagnostic criteria for attention deficit hyperactivity disorder in a county-wide sample. J Am Acad Child Adolesc Psychiatry 1996;35:319-24.

Wolraich ML, Lindgren S, Stromquist A, Milich R, Davis C, Watson D.
Stimulant medication use by primary care physicians in the treatment of attention deficit hyperactivity disorder. Pediatrics 1990;86:95-101.

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