What is ADD? What is the difference between an Attention-Deficit Disorder and an Attention-Deficit/Hyperactivity Disorder? What are some signs of inattention? What are some signs of overactivity-impulsivity? How prevalent is ADD? What Conditions Might Be Confused With ADD? What Conditions Commonly Co-Exist With ADD? How can you tell if a child is having trouble because of problems such as stress or family problems or if it's really ADD? How can you tell if a child with learning disabilities also has ADD? What is attention deficit hyperactivity disorder (ADHD)? What is the cause of ADHD? What are the symptoms of ADHD? How is ADHD diagnosed? How are schools involved in diagnosing, assessing, and treating ADHD? Patient Discussions: Attention Deficit Hyperactivity Disorder - Tests and Diagnosis Is ADHD inherited? Is ADHD on the increase? If so, why? Can ADHD be seen in brain scans of children with the disorder? Can a preschool-aged child be diagnosed with ADHD? What is the impact of ADHD on children and their families? What is the role of alternative therapies in ADHD? What are behavioral treatments? Which educational interventions have been studied and shown to be effective in the treatment of ADHD? What medications are currently being used to treat ADHD? Are there standard doses for these medications? How long are children on these medications? Hasn't the use of stimulant medication become excessive? Are there differences in stimulant use across racial and ethnic groups? Why are stimulants used when the problem is overactivity? What are the risks of the use of stimulant medication and other treatments? Will children taking these medications for ADHD become drug addicts? What is the relationship between ADHD and other disorders, such as learning disabilities, anxiety disorders, bipolar disorder, or depression? What is the prognosis for individuals with ADHD? What is the history of ADHD? How is it related to ADD? What are the future research directions for ADHD? Attention Deficit Hyperactivity Disorder (ADHD) (ADD) At A Glance What is ADD? An attention-deficit disorder (ADD) is a developmental disorder characterized by developmentally inappropriate degrees of inattention, overactivity, and impulsivity. Symptoms are neurologically-based, arise in early childhood, and are chronic in nature in most cases. Symptoms are not due to gross neurological impairment, sensory impairment, language or motor impairment, mental retardation, or emotional disturbance. Three main traits characterize ADD: (1) poor sustained attention or vigilance; (2) impulsivity or difficulty delaying gratification; and (3) hyperactivity or poorly regulated activity. Increased variability of task performance and problems complying with rules are often key features. What is the difference between an Attention-Deficit Disorder and an Attention-Deficit/Hyperactivity Disorder? ADD with and without hyperactivity are separate and unique childhood disorders. They are not subtypes of an identical attention disturbance. It has been noted that children with ADD/-H are more frequently described as depressed, learning disabled, or "lazy" while children with ADD/+H are more frequently labeled as conduct or behavior disordered. What are some signs of inattention? * Difficulty following instructions * Difficulty sustaining attention * Loses things necessary for tasks * Insufficient attention to details * Appears disorganized * Makes careless mistakes * Appears sluggish/drowsy * Appears forgetful * Often engages in daydreaming rather than attending * Appears apathetic, unmotivated to complete tasks * Appears "spacey," preoccupied * Appears confused, lost in thought What are some signs of overactivity-impulsivity? * Difficulty awaiting turn * Interrupts/intrudes * Blurts out answers * Difficulty playing quietly * Difficulty remaining seated * Excessive writhing or squirming * Fidgeting * Excessive talking How prevalent is ADD? Attention-deficit disorders affect approximately 3-5% of the childhood population. It has been estimated that 50-80% continue some degree of symptomatology into adulthood. What Conditions Might Be Confused With ADD? The purpose of a comprehensive diagnostic evaluation is to rule-out other conditions which may present with symptoms that can look identical to the symptoms of ADD. Through careful questioning, observation, and objective testing these conditions can either be ruled out or described as co-existing with ADD. The following conditions are commonly confused with ADD. Oppositional-Defiant Disorder These children display a pattern of negativistic, hostile and defiant behavior. They tend to be argumentative, lose their temper frequently, and deliberately annoy or blame others. However, they typically lack the developmental delays and the pattern of impulsive, disinhibited behavior characteristic of children with ADD. They also do not display a marked degree of restlessness and inattentiveness. This syndrome is often associated with parental difficulties with child management, a dysfunctional family setting or a history of depression in one or both parents. Learning Disabilities Children with learning disabilities must demonstrate a significant discrepancy between intellectual potential and academic achievement. They tend to lack the early childhood history of hyperactivity characteristic of ADD. Problems staying focused may arise when schoolwork becomes difficult, often in second or third grade. These attention problems are typically task-specific as opposed to the more global attention problems seen in children with ADD. Anxiety/Panic Disorders Rather than appearing impulsive, children with anxiety are frequently over-inhibited and shy. Although they may appear restless, this may look like fretful, worrisome behavior as opposed to hyperactivity. They may have difficulty focusing attention at specific times but can sustain attention if sufficiently relaxed. There tends to be a strong family history of anxiety. Interview information typically reveals no history of hyperactivity during early childhood. Thought Disorders Children with psychotic features display very atypical patterns of thinking. Parents may notice odd fascinations, strange aversions, unusual mannerisms and postures, and peculiar sensory reactions. They may appear labile and display unpredictable moods not tied to reality. Social aloofness and disinterest in others may be present. These children often have extreme difficulties relating to others and may have poor perception of the meaningfulness of events. Other Psychiatric Disorders A psychiatric evaluation or use of psychological tests which assess personality and mood may be necessary to differentiate ADD from the following conditions: * Affective disorders with manic characteristics * Major depression * Adjustment disorder with disturbance of behavior * Personality disorder * Obsesive-compulsive disorder Organic/Medical Disorders A medical examination and thorough health history should be included in the diagnostic process, as ADD--like symptoms can sometimes be attributed to physical causes besides ADD. The conditions which should be considered are: * Lead toxicity * Sensory disorders, especially hearing impairment * Medication-induced attentional difficulties (e.g., antihistamines) * Substance abuse * Attentional difficulties resulting from sleep disorders * Mental retardation * Seizure disorder * Hypothyroidism * Iron-deficiency anemia * Tourette's disorder/multiple tic disorder Inappropriate Envirionment/Expectations In young children, inattention or overactivity may be age-appropriate. Inappropriate school placement or curriculum (i.e., a gifted child who is bored with the classroom work) may lead to ADD-like behaviors. Similarly, a chaotic home setting, abuse or neglect may result in behavioral symptoms. What Conditions Commonly Co-Exist With ADD? Differential diagnosis is often difficult because many conditions tend to co-exist with ADD. This is particularly true when evaluating older children, adolescents and adults, as the longer ADD remains untreated, the higher the potential for developing additional problems. The following are common co-existing problems: Academic performance problems * Underachievement * Erratic or inconsistent academic performance * Learning disabilities Emotional problems * Over-reaction to situations * Low frustration tolerance * Poor self-esteem Social skills problems * May appear selfish or self-centered * Intrudes on others or too aggressive * Impulsively "blurts out" inappropriate comments to others * May not pay attention to social consequences of actions or speech * Immature play/social interests * Poor self-awareness Conduct problems * Oppositional/defiant behavior * Temper tantrums/angry outbursts * Destructiveness * Verbal and physical aggression * Lying and stealing * Gets in trouble with the law * Substance abuse problems Developmental/medical * Immature motor coordination * Greater incidence of enuresis * Increased sleep disturbances What is attention deficit hyperactivity disorder (ADHD)? ADHD refers to a chronic disorder that initially manifests in childhood and is characterized by hyperactivity, impulsivity, and/or inattention. Not all of those affected by ADHD manifest all three behavioral categories. These symptoms can lead to difficulty in academic, emotional, and social functioning. The diagnosis is established by satisfying specific criteria and may be associated with other neurological, significant behavioral, and/or developmental/learning disabilities. Therapy may consider the use of medication, behavioral therapy, and adjustments in day-to-day lifestyle activities. Studies in the United States indicates approximately 8%-10% of children satisfy diagnostic criteria for ADHD. ADHD is, therefore, one of the most common disorders of childhood. ADHD occurs two to four times more commonly in boys than girls (male to female ratio 4:1 for the predominantly hyperactive type vs. 2:1 for the predominantly inattentive type). While previously believed to be "outgrown" by adulthood, current opinion indicates that many children will continue throughout life with symptoms that may affect both occupational and social functioning. What is the cause of ADHD? The cause of ADHD has not been fully defined. One theory springs from observations regarding variation in functional brain imagining studies between those with and without symptoms. Similar variations have been shown in studies of the structure of the brain of affected and non-affected individuals. Animal studies have demonstrated differences in the chemistry of brain transmitters involved with judgment, impulse control, alertness, planning, and mental flexibility. A genetic predisposition has been demonstrated in (identical) twin and sibling studies. If one identical twin is diagnosed with ADHD, there is at 92% probability of diagnosis with the twin sibling. When comparing nonidentical twin sibling subjects, the probability falls to 33%. (Overall population incidence is 8%-10% in the U.S., as described above.) Attention Deficit Hyperactivity Disorder (ADHD) (cont.) What are the symptoms of ADHD? The diagnostic criteria for ADHD are outlined in the Diagnostic and Statistical Manual of Mental Health, 4th ed. (DSM-IV). All of the symptoms of inattention, hyperactivity, and impulsivity must have persisted for at least six months to a degree that is maladaptive and inconsistent with the developmental level of the child. Inattention: * The child often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities. * The child often has difficulty sustaining attention in tasks or play activities. * The child often does not seem to listen when spoken to directly. * The child 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). * The child often has difficulty organizing tasks and activities. * The child often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework). * The child often loses things necessary for tasks or activities (for example, toys, school assignments, pencils, books, or tools). * The child is often easily distracted by extraneous stimuli. * The child is often forgetful in daily activities. Hyperactivity: * The child often fidgets with his/her hands or feet or squirms in his/her seat . * The child often leaves his/her seat in the classroom or in other situations in which remaining seated is expected. * The child often runs about or climbs excessively in situations in which it is inappropriate. * The child often has difficulty playing or engaging in leisure activities quietly . * The child often talks excessively. Impulsivity: * The child often blurts out answers before questions have been completed. * The child often has difficulty awaiting his/her turn . * The child often interrupts or intrudes on others (for example, butts into conversations or games). In addition, some hyperactive, impulsive, or inattention symptoms that cause present difficulties were present before 7 years of age and are present in two or more settings (at school [or work] or at home). There must be clear evidence of significant impairment in social, academic, or occupational functioning. And the symptoms are not entirely caused by another severe physical disorder (for example, severe illness associated with chronic pain) or mental disorder (for example, schizophrenia, other psychotic disorders, severe disabling mood disorders, etc.). Inattention symptoms are most likely to manifest about at 8 to 9 years of age and commonly are lifelong. The "delay" in onset of inattentive symptoms may reflect its more subtle nature (vs. hyperactivity) and/or variability in the maturation of cognitive development. Hyperactivity symptoms are usually obvious by 5 years of age and peak in severity between 7 to 8 years of age. With maturation, these behaviors progressively decline and often have been "outgrown" by adolescence. Impulsive behaviors are commonly linked to hyperactivity and also peak about 7 to 8 years of age; however, unlike their hyperactive counterpart, impulsivity issues remain well into adulthood. Impulsive adolescents are more likely to experiment with high-risk behaviors (drugs, sexual, driving, etc). Impulsive adults have a higher rate of financial mismanagement (impulse buying, gambling, etc.) How is ADHD diagnosed? The evaluation of a child suspected of having ADHD involves many disciplines to include comprehensive medical, developmental, educational, and psychosocial evaluations. Interviewing parents and the child along with contact with the child's teacher(s) is crucial. Investigation regarding the family history for behavioral and/or social problems is helpful. While direct person-to-person contact is considered vital at the outset of an investigation, follow-up studies may be guided by comparing standardized questionnaires (parental and teacher) completed prior to intervention and subsequent to medication, behavioral therapy, or other approaches. While there is no unique finding on physical exam in patients with ADHD, unusual physical features should prompt consideration of consultation with a geneticist due to the high association with ADHD behavioral patterns and well-recognized congenital syndromes (for example, fetal alcohol syndrome). How are schools involved in diagnosing, assessing, and treating ADHD? Physicians and parents should be aware that schools are federally mandated to perform an appropriate evaluation if a child is suspected of having a disability that impairs academic functioning. This policy was recently strengthened by regulations implementing the 1997 reauthorization of the Individuals with Disabilities Act (IDEA), which guarantees appropriate services and a public education to children with disabilities from ages 3 to 21. If the assessment performed by the school is inadequate or inappropriate, parents may request that an independent evaluation be conducted at the school's expense. Furthermore, some children with ADHD qualify for special-education services within the public schools, under the category of "Other Health Impaired." In these cases, the special-education teacher, school psychologist, school administrators, classroom teachers, along with parents, must assess the child's strengths and weaknesses and design an Individualized Education Program. These special-education services for children with ADHD are available though IDEA. Despite this "federal mandate," the reality is that many school districts, because of underfunding or understaffing, are unable to perform "an appropriate evaluation" for all children suspected of having ADHD. The districts have the latitude to define the degree of "impairment of academic functioning" necessary to approve "appropriate evaluation." This usually means the children who are failing or near-failing in their academic performance. A very large segment of the ADHD-affected children will be "getting by" (not failing) academically (at least for their early years of school), but they are usually achieving well below their potential and getting more and more behind each year on the academic prerequisite skills necessary for later school success. Thereafter, further educational testing may be requested from the school district. Unfortunately, some families will have to assume the financial burden of an independent educational evaluation. These evaluations are commonly done by an educational psychologist and may involve approximately eight to 10 hours of testing and observation spread out over several sessions. A primary goal of an educational evaluation is to exclude/include the possibility of learning disorders (such as dyslexia, language disorders, etc.). Is ADHD inherited? Research has shown that ADHD does seem to cluster in families. Several investigations have demonstrated that children who have ADHD usually have at least one close relative (child or adult) that also has ADHD. At least one-third of all fathers who have ADHD will produce a child with ADHD. With the newer realization that adults may also experience ADHD symptoms, it is not unheard of to have a parent's "problem at my job" be credited to ADHD -- often at the same time their child's diagnosis is being established! Lastly, several studies have demonstrated a number of genes that may reflect a role in altered brain neurochemistry that provide a physiologic basis for this disorder and inheritance pattern. Is ADHD on the increase? If so, why? No one knows for sure whether the prevalence of ADHD per se has risen, but it is very clear that the number of children identified with the disorder and who obtain treatment has risen over the past decade. Some of this increased identification and increased treatment seeking is due in part to greater media interest, heightened consumer awareness, and the availability of effective treatments. Teachers are better trained to recognize the condition and suggest that the family seek help, especially in the more mild to moderate cases. The condition itself is so much more clearly defined and more concisely diagnosed now. The diagnosis of ADHD is less of a social stigma than in the past. This more enlightened perspective reflects the understanding that ADHD is a biochemical disorder and not merely an "out of control child," as such more parents are receptive to medical therapy for the condition rather than resorting to less effective home/school discipline techniques. Interestingly, the increase in prevalence of ADHD is not solely an American phenomenon but has been noted also in other countries. Whether the number of patients with ADHD has truly increased or rather that better recognition and acceptance of ADHD as a diagnosis has "increased," the number of patients diagnosed remains to be further defined. Can ADHD be seen in brain scans of children with the disorder? Neuroimaging research has shown that the brains of children with ADHD differ fairly consistently from those of children without the disorder in that several brain regions and structures tend to be smaller. There is also a lack of expected symmetry between the right and left hemispheres. Overall, brain size is generally 5% smaller in affected children than children without ADHD. While this average difference is observed consistently, it is too small to be useful in making the diagnosis of ADHD in a particular individual. In addition, there appears to be a link between a person's ability to pay continued attention and measures that reflect brain activity. In people with ADHD, the brain areas that control attention appear to be less active, suggesting that a lower level of activity in some parts of the brain may be related to difficulties sustaining attention. It is important to reiterate that these laboratory observations are not yet sufficiently sensitive or specific enough to use to establish or confirm the diagnosis of ADHD or to monitor the effectiveness of treatment. Can a preschool-aged child be diagnosed with ADHD? The diagnosis of ADHD in the preschool-aged (under 5 years old) child is possible, but it can be difficult and should be made cautiously by experts well trained in childhood neurobehavioral disorders. A variety of physical problems, emotional problems, developmental problems (especially language delays), and adjustment problems can sometimes imitate ADHD in this age group. It is certainly not mandatory that the preschool-aged child showing ADHD-suggestive symptoms be placed in a preschool. The first line of therapy for children of this age showing ADHD-like symptoms is not stimulant medication therapy but rather environmental or behavioral therapy. This type of therapy can certainly be carried out in the home with appropriate training supplied to the parents. If the child is to be placed in a preschool, the caretakers must be equally trained in the techniques of behavioral therapy. Stimulant therapy can reduce oppositional behavior and improve mother-child interaction, but it's usually reserved for severe cases or when a child does not respond to environmental or behavioral interventions. What is the impact of ADHD on children and their families? Life can be hard for children with ADHD. They are often in trouble at school, can't finish a game, and have trouble making friends. They may spend agonizing hours each night struggling to keep their mind on their homework, only to forget to bring it to school. Family conflict can increase, placing added stress on exhausted parents and frustrated children. Adolescents are at increased risk for poor self-esteem, motor-vehicle accidents, tobacco and other drug use, early pregnancy, and lower educational attainment. School programs to help children with problems often connected to ADHD (social skills and behavior training) are not available in many schools. In addition, not all children with ADHD qualify for special-education services. To overcome these barriers, parents may want to look for school-based programs that have a team approach involving parents, teachers, school psychologists, other mental-health specialists, and physicians. What is the role of alternative therapies in ADHD? CAM (complementary and alternative medicine) therapies are considered and/or tried in over half of patients with ADHD. Many times, these modalities are used covertly and it is important for the treating physician to inquire about CAM to encourage open communication and review risks vs. benefits of such an approach. CAM treatment modalities incorporating vision training, special diets and megavitamin therapy, herbal and mineral supplements, EEG biofeedback and applied kinesiology have all been advocated. The benefits of these approaches, however, have not been confirmed in double-blind controlled research studies. Families should be aware that such programs might require a long-term financial commitment that may not have insurance reimbursement as an option. What are behavioral treatments? In 2001, the American Academy of Pediatrics (AAP), in their Clinical Practice Guideline, suggested that when treating target ADHD symptoms, "clinicians should recommend stimulant medication and/or behavior therapy, as appropriate." Several forms of behavioral intervention have been found to show little or no effectiveness in treating ADHD patients. These included individual or play therapy, long-term psychotherapy, psychoanalysis, sensory-integration training, and cognitive behavioral therapy. But one form of a non-medication approach, behavioral therapy, has been demonstrated to be somewhat effective with ADHD children. The therapy sessions are conducted by a mental-health professional (for example, a psychologist or social worker) and consist of parent and teacher training in child behavior management. The parents and teachers are taught to consider their child's behavior as a function of the disorder, rather than "bad behavior" or the result of failed parenting/teaching skills. The sessions then go on to teach the adults to pay attention to appropriate behavior, ignore minor inappropriate behavior, to give clear and concise directions, and to establish effective incentive programs, such as token or point reward systems. The adults manage misbehavior by applying immediate, specific, and consistent consequences (removal of privileges). Basically, the three principles of behavior therapy are 1. set specific goals, 2. provide rewards and consequences, and 3. keep using the rewards and consequences for a long time. Parents can help their child's behavior with specific goals such as: (1) maintaining a daily schedule, (2) keeping distractions to a minimum, (3) setting small and reasonable goals, (4) rewarding positive behavior, (5) using charts and checklists to keep a child "on task", and (6) finding activities in which the child will succeed (sports, hobbies). Many feel that behavior therapy can be an appropriate first-level treatment in several scenarios: 1. the milder ADHD patient, 2. for the preschool-aged child with ADHD-suspicious symptoms, and 3. when the family prefers this approach vs. medication. What educational interventions have been studied and shown to be effective in the treatment of ADHD? Children with ADHD may require adjustments in the structure of their educational experience, including tutorial assistance and the use of a resource room. Many children function well throughout the entire school day with their peers. However, some patients with ADHD will benefit from a "pull out session" to complete tasks, review specific homework assignments, and develop "management" skills necessary for higher education. Extended time for class work/tests may be necessary as well as assignments written on the board and preferential seating near the teacher. An IEP (individualized educational program) should be developed and reviewed periodically with the parents. ADHD is considered a disability falling under U.S. Public Law 101-476 (Individuals with Disabilities Education Act, "IDEA"). As such individuals with ADHD may qualify for "appropriate accommodations within the regular classroom." within the public-school system. In addition, the Americans with Disabilities Act ("ADA") indicates that secular private schools may be required to provide similar "appropriate accommodations" in their institutions. What medications are currently being used to treat ADHD? Psychostimulant medications, including methylphenidate (Ritalin, Metadate, and Concerta), amphetamine (Dexedrine, Dextrostat, and Adderall), and a newer drug, atomoxetine (Strattera, marketed as a "non-stimulant," although its mechanism of action and potential side effects are essentially equivalent to the "psychostimulant" medications), are by far the most widely researched and commonly prescribed treatments for ADHD. Numerous short-term studies have established the safety and effectiveness of stimulants and psychosocial (behavioral therapy) treatments for not only alleviating the symptoms of ADHD but also improving the child's ability to follow rules and improve relationships with peers and parents. National Institute of Mental Health (NIMH) research has indicated that the two most effective treatment modalities for elementary-school children with ADHD are a closely monitored medication treatment or a program that combines medication with intensive behavioral interventions (behavior therapy). In the NIMH Multimodal Treatment Study for Children with ADHD (MTA), which included nearly 600 elementary-school children across multiple sites, nine out of 10 children improved substantially on one of these treatment programs. Two types of antidepressant medications, the "tricyclic antidepressants" (TCA) (imipramine, desipramine, and nortriptyline) and bupropion (Wellbutrin) have also been shown to have a positive effect on all three of the major components of ADHD: inattention, impulsivity, and hyperactivity. They tend, though, to be considered as second options for the children who have shown inadequate response to stimulant medication or who experience unacceptable side effects from stimulant medication such as tics (uncontrolled movement disorders) or insomnia. The antidepressants, however, have a greater potential for side effects of their own, such as heart-rate and rhythm changes, dry mouth, headaches, and drowsiness, to name a few. If higher doses are required, bupropion may bring on seizures. The antidepressants, therefore, require more careful monitoring. For the child who has a combination of ADHD and comorbid conditions such as depression, anxiety disorders, or mood disorders, stimulant medications can be combined with an antidepressant medication very successfully. Are there standard doses for these medications? For most children, stimulant medications are very safe and extremely effective. Research has shown that up to 80% of ADHD children show very good to excellent response to these medications. Improvements in the delivery systems for these medications in the last few years that have allowed the child to frequently only require one dose per day, alleviating the embarrassing "trip to the nurse's office" for a midday dose at school. Recently, a skin patch (Daytrana, a methylphenidate transdermal system) that, when applied daily, delivers the medication at a carefully controlled rate. The doctor will work with the child and his family to find the best medication, dosage, schedule, and delivery system. This requires careful individualization, since some children respond to one type of stimulant much better than another and each child's daily needs and schedules are so variable. How long are children on these medications? The expected duration of treatment has lengthened during this past decade as evidence has accumulated that benefits extend into adolescence and adulthood. Medication usage during the teen years can become problematic. The natural rebellion and desire for independence can make the adolescent protest against taking a medication. The need for a medication may reinforce anxiety that is common during the teen years in that it reinforces the notion of "I am different" to an age range that craves "fitting in." As such, parents and physicians must empower the teen to become a partner rather than a mere participant in his/her health. In some circumstances, it may even be necessary to allow the teenager to suffer the effects (academic and social) should he refuse to take medication. It is frequently the case that medication will be required into adulthood, and these years are critically important ones for the adolescent to begin to learn self-management of medication and other issues related to ADHD. Hasn't the use of stimulant medication become excessive? While it is certainly true that the prescribing of stimulant medication has increased sharply in the last 15 years, the statistics indicate that this increase coincides with the number of legitimately diagnosed cases of ADHD worldwide. Physicians, and the population in general, have achieved a much greater degree of awareness of and acceptance of the biological nature of ADHD, as well as the dramatic effectiveness of treatment protocols. Are there differences in stimulant use across racial and ethnic groups? There are significant differences in access to mental-health services between children of different racial groups; and consequently, there are differences in medication use. In particular, African-American children are much less likely than Caucasian children to receive psychotropic medications, including stimulants, for treatment of mental disorders. Why are stimulants used when the problem is overactivity? Recall that the three key components in ADHD are inattention, impulsiveness, and hyperactivity. While the exact nature of the disorder at the brain-cell level is not completely understood, it is felt that the medications work by stimulating the brain cells to make more of the chemicals (neurotransmitters) available that send messages from one brain cell to another. This improved message-sending system enhances the brains ability to pay attention, control behavior and impulses, plan actions, and follow through on schedules. What are the risks of the use of stimulant medication and other treatments? Stimulant medications have been successfully used to treat patients with ADHD for more than 50 years. This class of medication, when used under proper medical supervision, has an excellent safety record in patients with ADHD. In general, the side effects of the stimulant class of medications are mild, often temporary, and reversible with adjustment in dosage amount or interval of administration. The incidence of side effects is highest when administered to preschool-aged children. Common side effects include appetite suppression, sleep disturbances, and weight loss. Less common side effects include an increase in heart rate/blood pressure, headache, and emotional changes (social withdrawal, nervousness, and moodiness). Patients treated with the methylphenidate patch (Daytrana) may develop a skin sensitization at the site of application. Approximately 15%-30% of children treated with stimulant medication develop minor motor tics (involuntary rapid twitching of facial and/or neck and shoulder muscles). These are almost always short-lived and resolve without stopping the use of medication. A recent investigation studied the possibility of stimulant medication used to treat ADHD and cardiovascular side effects. Concern focused on a possible association with heart attack, heart-rate and rhythm disturbances and stroke. At the time of the writing of this article, there is no certainty as to the relationship to these event (including sudden death) when medication is used in a pediatric population screened for prior cardiovascular symptoms or structural pathology. A positive family history for certain conditions (such as unusual heart-rhythm patterns) may be considered a risk factor. The current position of the American Academy of Pediatrics is that a screening EKG is not indicated before initiation of stimulant medication in a patient without risk factors. Will children taking these medications for ADHD become drug addicts? Although an increased risk of drug abuse and cigarette smoking is associated with childhood ADHD, this risk appears due to the ADHD condition itself, rather than its treatment. In a study jointly funded by the NIMH and the National Institute on Drug Abuse, boys with ADHD who were treated with stimulants were significantly less likely to abuse drugs and alcohol when they got older. Caution is warranted, nonetheless, as the overall evidence suggests that people with ADHD (particularly untreated ADHD) are indeed at greater risk for later alcohol or substance abuse. Because some studies have come to conflicting conclusions, more research is needed to understand these phenomena. Regardless, in view of the substantial, well-established findings of the harmful effects of inadequate treatment or no treatment for a child with ADHD, parents should not be dissuaded from seeking effective treatments because of misconstrued or exaggerated claims about substance-abuse risks. "Diversion" is the transfer of medication from the patient for whom it was prescribed to another individual. Several large studies have indicated that 5%-9% of grade and high-school students and 5%-35% of college-age individuals reported use of non-prescribed stimulant medication. Approximately 16%-29% of students for whom stimulant medications were prescribed reported being approached to give, trade, or sell their medication. Misuse was more frequently seen in whites, members of fraternities and sororities, and students with a lower GPA. Diversion was more likely with the short-acting preparations. The most common reasons cited for use on non-prescribed stimulants were they "helped with studying," improved alertness, drug experimentation, and "getting high."