(Compilation of All Information)

Quality of Life
Children with ADHD have even a worse quality of life than children with asthma, according to a 2005 study in Pediatrics। The study evaluated children who had recently been diagnosed with ADHD and who had not yet received treatment. Compared to children with asthma and healthy children, ADHD had a more negative impact on the daily lives and activities of patients and their families.

Adults with ADHD have more problems staying employed and lose more days from work than healthy adults, according to research presented at the 2005 meeting of the American Psychiatric Association। ADHD interferes with educational and professional achievements and can significantly lower earning potential. Experts estimate that ADHD costs the US more than $77 billion in annual lost income.

Introduction
According to the U.S. National Institutes of Mental Health, attention-deficit hyperactivity disorder (ADHD) is a legitimate psychologic condition.
ADHD is a syndrome generally characterized by the following symptoms:
Inattention
Distractibility
Impulsivity
Hyperactivity

Some experts categorize ADHD into three subtypes:
Behavior marked by hyperactivity and impulsivity, but not inattentiveness
Behavior marked by inattentiveness, but not hyperactivity and impulsivity
A combination of the above two

General Description of a Child with ADHD
Symptoms of ADHD usually occur before the age of seven. Studies indicate that ADHD symptoms in preschool children with ADHD do not differ significantly from older children.
The classic ADHD symptoms do not always adequately describe the child's behavior, nor do they describe what is actually happening in the child's mind. Some experts are focusing on deficits in "executive functions" of the brain to understand and describe all ADHD behaviors. Such impaired executive functions in ADHD children can cause the following problems:
Inability to hold information in short-term memory
Impaired organization and planning skills
Difficulty in establishing and using goals to guide behavior, such as selecting strategies and monitoring tasks
Inability to keep emotions from becoming overpowering
Inability to shift efficiently from one mental activity to another
Hyperactivity. The term hyperactive is often confusing since, for some, it suggests a child racing around non-stop. A boy with ADHD playing a game, for instance, may have the same level of activity as another child without the syndrome. But when a high demand is placed on the ADHD child's attention, his brain motor activity intensifies beyond the levels of the other children. In a busy environment, such as a classroom or a crowded store, ADHD children often become distracted and react by pulling items off the shelves, hitting people, or spinning out of control into erratic, silly, or strange behavior.
Impulsivity and Temper Explosions. Even before the "terrible two's," impulsive behavior is often apparent. The toddler may gleefully make erratic and aggressive gestures, such as hair pulling, pinching, and hitting. Temper tantrums, normal in children after two, are usually exaggerated and not necessarily linked to a specific negative event in the life of an ADHD child. One of the most painful events a parent may experience is an abrupt and aggressive attack that may occur after cuddling a young ADHD child. Often this reaction seems to be caused not by anger, but by the child's apparent inability to endure overstimulation or displays of physical affection.
Attention and Concentration. ADHD children are usually distracted and made inattentive by an overstimulating environment (such as a large classroom). They are also inattentive when a situation is low-key or dull. Some experts believe that certain parts of the brain in ADHD children may be underactive, so the children fail to be aroused by nonstimulating activities. In contrast, they may exhibit a kind of "super concentration" to a highly stimulating activity (such as a video game or a highly specific interest). Such children may even become over-attentive -- so absorbed in a project that they cannot modify or change the direction of their attention.
Impaired Short-Term Memory. Many experts now believe that an essential feature in ADHD, as well as in learning disabilities, is an impaired working (also called short-term) memory. People with ADHD can't hold groups of sentences and images in their mind long enough to extract organized thoughts. They are not necessarily inattentive. Instead, an ADHA patient may be unable to remember a full explanation (such as a homework assignment), or unable to complete processes that require remembering sequences, such as model building. In general, children with ADHD are often attracted to activities (e.g., television, computer games, or active individual sports) that do not tax the working memory, or produce distractions. Children with ADHD have no differences in long-term memory compared with other children.
Inability to Manage Time. Studies suggest that children with ADHD have difficulties being on time and planning the correct amount of time to complete tasks. (This may coincide with short-term memory problems.) In one study, although children with probable ADHD were able to self-report many ADHD symptoms, they tended to believe they used their time wisely, in contrast to reports by their teacher.
Lack of Adaptability. ADHD children have a very difficult time adapting to even minor changes in routines, such as getting up in the morning, putting on shoes, eating new foods, or going to bed. Any shift in a situation can precipitate a strong and noisy negative response. Even when they are in a good mood, they may suddenly shift into a tantrum if met with an unexpected change or frustration. In one experiment, ADHD children could closely focus their attention when directly cued to a specific location, but they had difficulty shifting their attention to an alternative location.
Hypersensitivity and Sleep Problems. ADHD children are often hypersensitive to sights, sounds, and touch. They usually complain excessively about stimuli that seem low key or bland to others. Sleeping problems usually occur well after the point when most small children sleep through the night. In one study, 63% of children with ADHD had trouble sleeping.

Risk Factors
In the U.S., the diagnosis of ADHD in children increased from 1990 to 1996, from nearly 950,000 to over 2,400,000 cases.
The prevalence of ADHD ranges from 2 - 18% of the population, depending on where and how the studies were conducted. ADHD is a genuine disorder, but it should be strongly noted that the U.S. accounts for 90% of worldwide prescriptions for stimulants for ADHD. It is not known whether this reflects a real increase in ADHD, or a better ability to recognize it. Some say it may be an indication of a culture that places excessive value on normalcy and academic achievement at the expense of more frequent diagnoses.

Gender and ADHD
ADHD is most often diagnosed in boys. However, there is some evidence that it is underdiagnosed in girls. Until recently, all major studies were conducted using boys as subjects. Important studies on girls with ADHD are now underway. A major study is reporting that girls with the condition experience the same multiple impairments as boys do.
Adults with ADHD
Although ADHD is primarily thought of as a childhood disorder, diagnoses of attention-deficit disorder in adults are on the rise. Methylphenidate (Ritalin) was prescribed for nearly 800,000 adults in the U.S. in 1997, nearly three times the number in 1992.
How Is ADHD Identified in Adults?
Some research suggests that ADHD affects between 2 - 6% of the adult population, assuming that one- to two-thirds of cases persist into adulthood. ADHD in adults always occurs as a continuum of the childhood condition. Adult-onset symptoms are likely to be due to other factors. Diagnosing adult ADHD can be a difficult problem since hyperactivity typically wanes as children get older, while attention and organizational problems may develop in older people. Some experts believe, then, that the number of adults with ADHD is underestimated.
A rating scale using four factors has been developed that may prove to be useful in identifying adults with ADHD:
Inattention and memory problems. (Examples: losing or forgetting things, being absent-minded, not finishing things, misjudging time, depending on others for order, having trouble getting started, changing jobs or projects in the middle.)
Hyperactivity and restlessness. (Examples: always being on the go, fidgety, easily bored, taking risks, liking active and fast paced jobs and activities, such as being a sales representative or stockbroker.)
Impulsivity and emotional instability. (Examples: saying things without thinking first, interrupting others, being annoying to others, easily frustrated, easily angered, having unpredictable moods, driving recklessly, having high relationship and job turnover.)
Problems with self worth. (Examples: Avoids new challenges, appears confident to others but not to oneself.)
How Serious Is Attention Deficit Disorder in Adults?
Accompanying Emotional, Personality, and Learning Disorders. Between 19 - 37% of adults with ADHD have depression or bipolar disorder. Between 25 - 50% have an anxiety disorder. Bipolar disorder plus ADHD, in fact, may be very difficult to differentiate from ADHD alone in adults.
Accompanying Learning Disorders. About 20% of adults with ADHD have learning disorders, usually dyslexia and auditory processing problems. These problems should be considered in any treatment plan.
Effect on Work. Compared to adults without ADHD, those with the condition tend to reach lower educational levels, earn less money, and be fired more often. In fact, one article reported that by the time they are in their 30s, about 35% of ADHD adults are self-employed..
Substance Abuse. According to a 2003 study, the incidence of ADHD is 5 to 10 times higher among alcoholics than in the general public. Other studies have reported that between 32% and 53% of adults with ADHD abuse alcohol, and between 8 - 32% smoke marijuana or take cocaine. An important 2003 study suggested that young people and adults with the highest risk for substance abuse were who had inattention-related ADHD and conduct disorders as a child.
Sleep Disorders. Sleep disorders, especially restless legs syndrome and sleep apnea, are common in adults and children with ADHD. Sleep apnea is a disorder in which a person temporarily stops breathing during sleep, perhaps hundreds of times. In most cases the person is unaware of it, although sometimes they awaken and gasp for breath. It is usually accompanied by snoring. One report suggested that treating sleep apnea in adults with both conditions may help reduce ADHD symptoms. [See In-Depth Report #65: Sleep Apnea.]
How Is Adult Attention Deficit Disorder Treated?
Atomoxetine (Strattera is the first drug approved for adults with ADHD. It is a non-stimulant. In two well-conducted 2003 studies, atomoxetine significantly reduced symptoms of inattention, hyperactivity, and impulsivity in adult patients. Side effects were generally mild. However, several cases of atomoxetine-associated liver injury have been reported. As a result, the FDA has warned doctors that the drug should be discontinued at the first signs of jaundice or liver problems, and has asked the manufacturer to include a warning on its label. Although atomoxetine may increase the risk of suicidal thinking in children and adolescents, it does not appear to pose a risk for adults.
Antidepressants. Specific antidepressants, such as bupropion (Wellbutrin) and venlafaxine (Effexor), may be useful for adults with ADHD. Studies report response rates with these drugs of 50 - 78%. Bupropion may be a particularly good choice for certain ADHD adults, including those who also have bipolar disorder or a history of substance abuse. Tricyclic antidepressants, such as desipramine, may also be very effective, particularly in adults with both ADHD and depression. (Adderall XR has been linked to sudden death in children.)
Psychostimulants. The standard psychostimulants, methylphenidate (Ritalin) and Adderall, are also effective in adults. The newer, longer acting forms of methylphenidate (Concerta, Ritalin-LA, Metadate CD) and Adderall (Adderall XR) may offer further advantages.
Nicotine Replacement. Nicotine improves ADHD symptoms and appears to have effects in the brain that are similar to those of stimulants. Although such findings should certainly not encourage anyone to smoke, some studies are focusing on benefits of nicotine therapy in adults with ADHD.

Causes
Brain Structures. Increasingly, research using advanced imaging techniques shows there is a difference in the size of certain parts of the brain of ADHD children compared to children who do not have ADHD. The areas showing change include:
The prefrontal cortex. The prefrontal cortex is located in the front of the brain. It is thought to be the brain's command center. It regulates the brain’s ability to block certain responses. A number of imaging studies have indicated that the prefrontal cortex of the brain in people with ADHD may be less active than in those without the disorder.
The caudate nucleus and the globus pallidus. The caudate nucleus and globus pallidus, located near the center of the brain, speed up or stop orders coming from the prefrontal cortex. A major 2002 study reported that it was smaller than average in young children with ADHD, but tended to normalize as children got older. Abnormalities in these areas may impair a person's ability to stop certain actions, resulting in the impulsivity typical of people with ADHD.
The cerebellum. The cerebellum is the area above the brain stem. This area helps control muscle tone and balance, and synchronizes muscle activity. An important 2002 study reported that this area tends to be smaller in children with ADHD compared to those without the condition.
Genetic Factors
Genetic factors may play the most important role in ADHD. The relatives of ADHD children (both boys and girls) have much higher rates of ADHD, antisocial, mood, anxiety, and substance abuse disorders than the families of non-ADHD children. A study reported that 90% of children with a diagnosis of ADHD shared it with their twin.

Pregnancy and ADHD
ADHD is often associated with problem pregnancies and difficult deliveries. If a women smokes during pregnancy, a genetically susceptible child is at higher risk for ADHD. One study indicated that an increased risk also existed in children of women who were exposed during pregnancy to environmental toxins, including dioxins and polychlorinated biphenyls (PCBs).

Diagnosis
The American Academy of Pediatrics issued its first guidelines for diagnosing attention-deficit hyperactivity disorder (ADHD) in children in 2002. They include the following:
Children between ages 6 and 12 should first be evaluated for ADHD if they show symptoms of inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems in at least two settings. Such behaviors should have been harmful for the child academically or socially for at least 6 months.
The child should meet the official symptom guidelines.
A diagnosis requires detailed reports by parents or caregivers. It should be noted that a mother's description of her child's behavior is a very accurate and reliable guide for diagnosing ADHD. Parents should not be shy about insisting on further evaluation if their experience does not match a doctor's single observation of their child.
Guidelines for primary care doctors emphasize the importance of obtaining direct evidence from the classroom teacher or other school-based professionals about the child's symptoms and their duration, and evidence of functional impairment in the school setting.
The child should be assessed for accompanying conditions (such as learning difficulties).

Difficulties in Identifying Children with ADHD
There are currently no laboratory or imaging tests to reliably diagnose ADHD. A diagnosis relies only on behavioral symptoms and ruling out other disorders. Many experts believe that the disorder is both over- and underdiagnosed. Diagnosis of attention-deficit hyperactivity disorder is difficult for some of the following reasons:
Arguments that ADHD is Overdiagnosed in Some Children.
The popularity methylphenidate (Ritalin) has encouraged some parents and teachers to pressure doctors into prescribing this standard ADHD drug for children who are aggressive or who have poor grades. In one study of fifth graders in two different cities, 18% and 20% of Caucasian boys were being treated with medications. In one center, after careful testing, ADHD was the actual diagnosis in only 11% of children referred for ADHD, and 18% had no disability. Others were simply poorer learners or had no problems at all.
In one study, children more likely to receive medication were young for their grade, indicating they may have been socially and intellectually immature, rather than behaviorally impaired.
Being poor and growing up in a single parent household contribute to emotional and behavioral problems. The significant increase in these problems has also paralleled an increase in the diagnosis of ADHD children, who may simply be responding to social and economic problems.
Arguments that ADHD is Underdiagnosed in Some Children.
Some evidence suggests that many girls with ADHD may go underdiagnosed. Research indicates that girls with ADHD are often inattentive but not hyperactive or impulsive. In fact, older girls with ADHD tend to have social problems due to withdrawal and internalized emotions, showing symptoms of anxiety and depression. The inattentive subtype, in any case, may first show up in older children and adolescents. However, according to the criteria, ADHD is not diagnosed in people whose symptoms appear after age seven.
Doctors may fail to diagnose children with ADHD because they often behave normally in the quiet doctor's office where there are no distractions to trigger symptoms.
In spite of the fact that there seems to be no differences in response to treatment among population groups, African American, Hispanic, and Asian children with ADHD are half as likely to be diagnosed and treated as Caucasian children. By high school, the racial disparity increases to the level that the medication rate for blacks is one-fifth of that for whites.
ADHD may also be underdiagnosed in adults. Some experts, in fact, believe that ADHD may be the most common chronic undiagnosed psychiatric disorder in adults.
Other Disorders Associated with ADHD
A number of disorders may mimic or accompany attention-deficit disorder. ADHD exists alone in only about one-third of children. Many professionals object to the use of the single term “attention-deficit hyperactivity disorder” to encompass such a wide spectrum of behaviors, which they believe should be categorized into subgroups. Many of these problems require other modes of treatment and should be diagnosed separately, even if they accompany ADHD.
Attention-Deficit Disorder without Hyperactivity
Attention-deficit disorder can appear without hyperactivity, in which case the child's primary symptoms are distractibility and an inability to persist in tasks.

Oppositional-Defiant Disorder
About 35% of children diagnosed with ADHD also have oppositional-defiant disorder (ODD). The most common symptom for this disorder is a pattern of negative, defiant, and hostile behavior toward authority figures that lasts more than 6 months. In addition to displaying inattentive and impulsive behavior, these children demonstrate aggression, have frequent temper tantrums, and display antisocial behavior. Up to 25% of children with ODD have phobias and other anxiety disorders, which should be treated separately.
Conduct Disorder
Some children with ADHD also have conduct disorder, which describes a complex group of behavioral and emotional disturbances seen in children. It includes aggression towards people and animals, destruction of property, deceitfulness, lying, or stealing, and general violation of rules.
Pervasive Developmental Disorder
Pervasive developmental disorder (PDD) is rare and usually marked by autistic-type behavior, hand-flapping, repetitive statements, slow social development, and speech and motor problems. If a child who has been diagnosed with ADHD does not respond to treatment, the parents might inquire about PDD, which often responds to antidepressants. Preliminary research also suggests that children with PDD may benefit from stimulants such as methylphenidate (Ritalin, Concerta). A 2005 study reported that methylphenidate worked better than placebo in treating hyperactivity in children with PDD. However, these children did not respond as well to methylphenidate as children with ADHD. The drug also caused side effects in many of the children with PDD.
Primary Disorder of Vigilance
Primary disorder of vigilance is a term for a syndrome that includes poor attention and concentration as well as difficulties staying awake. The term is not recognized as an official diagnosis by the American Psychiatric Association, but some experts believe it represents a fairly well defined set of behaviors. People with vigilance disorder tend to fidget, yawn and stretch, and appear to be hyperactive in order to remain alert; they typically have kind and affectionate temperaments. The condition appears to be inherited and gets worse with age. It it is treatable with stimulants.
Central Auditory Processing Disorder and Hearing Problems
Children with ADHD often have difficulties with tasks that involve listening or hearing. Research is indicating that symptoms of the two disorders often overlap but may actually be two distinct disorders. Hearing problems themselves may cause ADHD symptoms.
Bipolar Disorder (Manic Depression)
One study found that as many as 25% of children diagnosed with attention-deficit disorder may also have bipolar disorder, commonly called manic depression. Indications of this problem include episodes of depression and mania (with symptoms of irritability, rapid speech, and disconnected thoughts), sometimes occurring at the same time. [See In-Depth Report #66: Bipolar Disorder.] Both disorders often cause inattention and distractibility and may be difficult to distinguish, particularly in children. Children with mania and ADHD may have more aggression, behavioral problems, and emotional disorders than those with ADHD alone. In some cases, ADHD in children or adolescents can even be a marker for an emerging bipolar disorder. The primary way to differentiate bipolar disorder from ADHD is by the presence of a manic or hypomanic episode, which occurs in patients with bipolar disorder but not with ADHD. Most children with bipolar will also respond to the drug valproate, which does not typically work for ADHD in children.
Anxiety Disorders
Anxiety disorders commonly accompany ADHD. Obsessive-compulsive disorder is a specific anxiety disorder that shares many characteristics with ADHD and may share a genetic component. Young children who have experienced traumatic events, including sexual or physical abuse or neglect, exhibit characteristics of ADHD, including impulsivity, emotional outbursts, and oppositional behavior.

Sleep Disorders
Sleep disorders or disturbances are very common with ADHD patients. Insomnia is common. In addition, specific sleep disorders--restless legs syndrome and sleep-disordered breathing--have been identified with hyperactivity and conduct disorder.
Restless Legs Syndrome (RLS
Some experts believe RLS and periodic limb movement disorder are strongly associated with ADHD in some children. One theory is that the two are linked by a common mechanism. The disorders have much in common, including poor sleep habits, twitching, and the need to get up suddenly and walk about frequently. They may even be genetically linked. For example, both have been associated with lower levels of dopamine in the brain, which is associated with faulty motor control, a common problem in both disorders.
Sleep-Disorder Breathing and Sleep Apnea
Some research has shown an association between mild symptoms of ADHD and sleep-disordered breathing, including snoring and obstructive sleep apnea in children and adults. Treating the sleep-related breathing disorders may improve the attention disorder in some children. (One study indicated that such problems are unlikely to be associated with children with moderate to severe ADHD.) [See In-Depth Report #65: Sleep Apnea.]
Complications
Emotional Disorders
More than half of children with attention-deficit disorder have accompanying disorders, including anxiety, depression, and conduct disorders. Children with ADHD who experience anxiety or depression are also more likely to suffer from low self-esteem. One study found that 25% of children with ADHD have or develop bipolar disorder (commonly called manic depression).
Social Problems
Anti-Social Behavior. Even if these emotional disorders are absent in childhood, the ADHD child's relationship with others is volatile, and he or she is often unhappy from a very young age. Research indicates that any ADHD boy or girl, particularly an aggressive child, has trouble getting along with others, and is less liked by his or her peers.
ADHD children with the inattentive subtype are more likely to be picked on and to spend time alone.
Children with the combined subtypes tend to have different problems. A best friend can turn into an enemy overnight when, for example, an ADHD boy does not perceive his friend's fearful response to over-aggressive roughhousing and fails to let up. The next day the ADHD child has forgotten the event; the ex-friend hasn't. This is a classic situation repeated time and again. When an ADHD child hurts someone, the child either may go into a state of denial or blame himself excessively. As ostracism, fear, and ridicule from peers persist from year to year, the unstable behavior, originally neurologic, becomes emotionally based. Unless this cycle is broken, serious adult problems can evolve.
A 2000 study found that boys with ADHD are less likely than others to empathize with people in difficult circumstances. One speculative explanation is that this is a self-protective reaction to prevent negative feelings, which ADHD children are highly prone to all the time.
Substance Abuse in Young People. Studies consistently report that ADHD young people--in particularly those with conduct or mood disorders--have a higher than average risk for substance abuse and that it starts in younger ages. In one study, for example, by age 11 nearly 20% of children with ADHD had tried smoking cigarettes, drinking alcohol, or both. Biologic factors associated with ADHD may make these individuals susceptible to substance abuse. Many of these young people are self-medicating their condition. In fact, according to a major analysis, Ritalin or other stimulants used to treat ADHD may help protect such patients against substance abuse. (Boys with ADHD and conduct disorder, however, still face a high risk for substance abuse. Girls with ADHD and emotional disorders may also still have a higher risk.)
High-Risk Behavior. Impulsivity in ADHD young people can certainly cause them to take chances before thinking them through, putting them in situations where the consequences become clear only after the action has been taken. ADHD children with high levels of aggression are at higher risk for delinquent behavior in adolescents and criminal activity in adulthood. It should be strongly noted that ADHD children who are not aggressive have a lower and even normal risk for dangerous activities. Even in aggressive ADHD children, close parental attention and early treatment can limit the risk considerably.
Learning Problems
Although speech and learning disorders are common in children with ADHD, the disorder does not affect intelligence. People with ADHD span the same IQ range as the general population.
One study suggested, however, that 90% of ADHD children were underachievers, and that half were held back at least once. Some evidence suggests that inattention may be a major factor in low academic performance in these children. About 20% also have reading difficulties and 60% have serious handwriting problems. Adults with ADHD are also at very high risk for these conditions.

Persistence of ADHD into Adulthood
Some research suggests that ADHD persists in one- to two-thirds of those diagnosed with the condition in childhood. Many experts, in fact, describe the pattern of ADHD as they would a chronic illness, in terms of whether it goes into remission or not. They define this remission in three categories of severity:
Effect on Family
Mothers generally get the brunt of the emotional and physical abuse that an ADHD child can produce, which is sadly ironic because the ADHD child tends to love the mother intensely and feel safe with her.
Parents may have to give up on the idea of an immaculate house and a hot meal every night. (One advantage of an ADHD child in the family is that the parents learn that they are not perfect, nor do they have to be. In fact, striving for perfection is among the most counterproductive goals to pursue in raising an ADHD, or any, child.)
Parents must face the hostility and anger of other parents and see their own child rejected. It is very easy to fall into an emotional black hole, and feel alone, inadequate, and helpless.
Marriages are often stressed to the breaking point because of exhaustion and disagreements between the husband and wife on how to raise the ADHD child.
Arguments For and Against Psychostimulants
Many parents are very disturbed by the idea of putting their children on intensive stimulant drug regimens, possibly for years, particularly given the uncertainties in diagnosis and the negative publicity surrounding the use of these drugs. Although the decision to use these drugs should not be made lightly, the negative social and emotional effects of the disorder itself for many children with ADHD are far more severe and long-lasting than the use of these drugs. For some parents and children, medication seems like a miracle and can provide desperate families with a quality of life for which they had almost given up hope.
Still, there are a number of questions, particularly for taking psychostimulants alone without additional behavioral therapy. Of great concern is the dramatic increase in prescriptions for psychostimulants among preschool children, not only in the US but also in some European countries. There is evidence the drugs may be over-prescribed, and parents should discuss the question of medications very carefully with their doctors. ADHD represents a growing market for pharmaceutical companies. Although psychostimulants and alternative drugs are proving to be helpful for many families, no one should underestimate the influence of the economic issues involved.
It should be noted that a major study reported that children with ADHD will benefit to some degree from any treatment, whether behavioral therapies, medication, or simple mental health intervention. Combinations of behavioral therapy and medications appear to be best, however. Stimulants are not a cure-all, and children should not grow up believing that taking a pill will solve life's problems without their having to make self-efforts.
Ritalin and Other Psychostimulants for ADHD: Pros and Cons

Arguments For Medications
Arguments Against Medications
Effect on ADHD Symptoms
The effectiveness of Ritalin in improving ADHD symptoms has been established by more than 160 controlled studies, the largest amount of evidence on any subject involved with childhood behavioral disorders. They are equally effective in boys and girls with ADHD.
Positive results in many studies are most evident in children with severe symptoms, particularly those who suffer from aggression. The benefits with less severe conditions tend not to be as pronounced.
Effect on Intelligence and Academic Achievement
Some studies suggest that medications raise intelligence test scores, even in children who have accompanying disorders, such as autism, pervasive developmental disorder, and mental retardation.
There is no definite proof that drugs improve academic achievement. Psychostimulants, for example, do not improve a child's ability to memorize facts by rote. In fact, in a major study there was no difference in academic achievement between children taking medications and those being given behavioral therapies. A 2001 study reported that only low doses improved academic functioning in adolescents. In some young people higher doses was associated with worse performance.
Effect on Social Functioning
A 2000 study reported that medications had some positive effect on self-esteem, which was greatest in highest doses. (Presumably, then, children with the most severe symptoms felt the greatest improvement in self-confidence.)
One of the few long-term studies on ADHD children reported that patients who were effectively treated and responded well were more likely to be living independently as adults, to be either married or to be engaged. They had higher IQs and were less likely to have substance abuse problems or have attempted suicide. (Patients who were closely monitored for treatments as children, however, may also have had more positive parenting, which could also account for the better outcome.)
A child may still have social problems after taking psychostimulants. Medication alone rarely helps aggressive children with ADHD. And a major study found no difference in oppositional behavior or relationships with peers between children taking psychostimulants and those being given behavioral therapies.
Side Effects
Most young people report mild side effects, most often loss of appetite.
Some children report distressing side effects that include a "zombie" like effect, tics, and moodiness. Weight loss may be a problem for some children. Even in young people who abuse Ritalin, however, less than 1% experience severe side effects (rapid heart rate, hypertension).
Effect on Bone Loss and Growth
The drugs do not cause bone loss, as some people have feared.
These drugs may affect growth, although most studies suggest the impact is not significant and that children catch up later on.
Effect on the Brain
There is some recent evidence to suggest that medication may enhance growth of brain white matter--which consists of insulated nerve fibers that make up the core of the cerebral hemispheres.
No major studies have been conducted on the long-term effects of stimulant use in preschool children. Studies on animals being given such drugs during equivalent developmental periods report negative effects on memory, on important neurotransmitters, and other adverse effects.
Risk for Addiction
Studies on both animals and humans suggest that Ritalin lacks the properties that create addiction, particularly in doses used for treating ADHD. Furthermore, a major 2003 analysis of six studies suggested that the use of stimulants may protect against drug abuse in ADHD young people.
An emerging and serious problem is the sale of stimulants to non-ADHD peers, who are in danger of over-use and severe side effects. It should be noted that crushing the pills and inhaling them nasally can also provide a euphoric state.
Choosing Candidates for Drug Treatment
When used correctly, questionnaires and other screening tests for ADHD symptoms are proving to be very accurate for determining the best candidates for drug treatments.
There are no objective tests for diagnosing ADHD, so it is unclear if the appropriate people are being treated or not treated.

Medications
There are an increasing number of medications available to treat ADHD.
Pyschostimulants: Methylphenidate (Ritalin) and Similar Drugs
Psychostimulants, to date, are the primary drugs used to treat ADHD. Methylphenidate (Ritalin, Metadate, Concerta) is the most commonly used psychostimulant for ADHD. Its positive benefits for improving ADHD symptoms appear to be due to its actions in increasing dopamine, a neurotransmitter important for motor control. This drug is effective in both children and adults. A similar drug dexmethylphenidate (Focalin) has been approved. It is similar to in methylphenidate in effectiveness and side effects. At the time of this report, the FDA was also considering approving a new skin patch for ADHD. The patch, Daytrana, delivers a 9-hour dose of methylphenidate. It is designed for children who cannot take pills.
Regimen. The older form of Ritalin is short acting, and needs to be taken several times a day, including during school hours. As it wears off, a rebound effect can occur and ADHD symptoms intensify. Longer-acting forms (Concerta, Ritalin LA, Ritalin SR, Metadate) are now available.
Concerta is now the most commonly prescribed drug for ADHD and uses a special pump action that releases the medication gradually into the body and can be effective for 12 hours. Ritalin LA and Metadate also only need to be taken once during the entire school day. (Ritalin SR can still can wear off by early afternoon.) A patch form of methylphenidate (MethylPatch) is awaiting approval. A 4-week trial in 2002 reported that it was very effective in improving attention and improving behavior.
A 2003 study of Concerta indicated that depending on the ADHD subtype, children may require different doses. In the study, children with the inattentive type responded to lower doses than those with the combined type.
Side Effects. All stimulants have a number of side effects:
The most common side effects of any stimulant are nervousness and sleeplessness, although some parents have reported improved sleep patterns in their children after taking stimulants.
Children may lose weight.
Tics or jerky, disordered movements occur in about 9% of children. Some studies indicate they are not caused by standard doses of Ritalin. In any case, low doses are often effective in controlling impulsivity without causing tics, even in some children who also have mild to moderate Tourette's syndrome.
Other side effects include irritability, withdrawal, stomach pain, headache, depression, hallucinations, hair loss, and lack of spontaneity.
Concerns for Abuse. Studies on both animals and humans suggest that that Ritalin lacks the properties that create addiction, particularly in doses used for treating ADHD. Although methylphenidates have properties similar to amphetamines, their drug levels rise very slowly in the brain at the oral doses given for ADHD. This slow rise prevents a so-called "high" and subsequent addiction to the drug.
A major analysis in 2003, in fact, indicated that methylphenidate treatment may even protect young people with ADHD from abusing alcohol or other drugs. In such cases, methylphenidates may reduce the need to self-medicate ADHD symptoms using nicotine, alcohol, or illegal drugs. (Ritalin does not protect against substance abuse in young people with ADHD and conduct disorder, however.)
Dependence has not been reported in children who have taken this drug for long periods in appropriate dosages. It should be noted, however, that crushing the pills and inhaling them nasally can provide a euphoric state. The primary danger for drug abuse from stimulants appears to occur in non-ADHD young people who purchase these drugs illegally. In one study, for instance, 16% of ADHD children reported pressure from their fellow students to sell or give them their medication.
Managing Aggression. Some useful tips for managing aggression include the following:
Parents should try to give little attention to mildly disruptive behaviors that allow this energetic child to let off some harmless steam. The parent will also be wasting energy that will be needed when the negative behavior becomes destructive, abusive, or intentional.
The use of "time-out," isolating the child immediately for a short period of time, is an effective measure for allowing both the caregiver and the child to cool down. The child should immediately (and without emotion) be removed from a situation in which he or she is endangered or is endangering others. The child should view time out as a way of cooling off and getting a distance on their behavior, not as isolation from others.
To channel physical aggression and impulsivity in the ADHD toddler, the parents must teach them to use verbal responses. (A parent may need to allow verbal responses that would be unacceptable in another child.)
When the ADHD child becomes older and if the verbal responses become intentionally abusive and socially undesirable, then the parent must redirect this form of aggression into more acceptable activities, such as competitive one-on-one sports, energetic music, video games, or big colorful paintings. Competitive video games, such sports games, may also be an option. (Some studies, including one in 2001, suggest that reducing watching of TV or playing video games will reduce aggressive behavior in all children. The 2001 study, however, did not explore the nature of the content and did not study ADHD children specifically. Patents should gauge for themselves what activities will reduce aggressive behavior.)
Sometimes a parent can anticipate situations when an ADHD child is likely to misbehave, but all too often the child explodes for no apparent reason. If the blow-up occurs in public, the parents should complete their activities and leave as quickly as possible.

Establishing a Reward System. Children with ADHD respond particularly well to reward systems. One study reported that they performed equally well when encouraged either by a direct reward for a correct response or with the use of a system called response-cost. With this system, the child is given the reward first and allowed to keep it if their behavior remains appropriate.
Some suggested tips for rewarding the ADHD child are as follows:
Create charts with points or stars for good behavior or for completed tasks. It is important to give points for even simple positive behaviors, which may be taken for granted in other children (e.g., responding happily to a change in plans, changing an obscenity to a more acceptable expletive).
Rewards for any child can include playing a favorite game with the child, extending bedtime by an hour, or allowing an extra half-hour of TV.
Rewards of food or gifts should be used infrequently, if at all. They can create other problems, such as being overweight, having a bad diet, or making continuous demands for objects.
A reward system should rotate different types of rewards, because such children are easily bored.
ADHD children respond better with small rewards promised in the short-term than large rewards offered in the future. One approach that employs both short- and long-term rewards uses a system that gives the child points for specific positive behaviors. As the children accumulate points, they can use them for larger tangible rewards, such as a favorite video game or CD.
Rewards should be promised only when caregivers are fairly certain they can follow through. ADHD children respond with much greater frustration than non-ADHD children to disappointment, and are likely to have a strong (and noisy) negative reaction. A parent must remember that this response is part of the ADHD child's make-up and not necessarily in their control.
Food Allergies. Evidence suggests that children with behavioral difficulties may be sensitive to certain chemicals in foods. Studies vary widely, however, on how many cases of ADHD may be associated with sensitivities or allergies to food chemicals or additives, with results ranging widely from 5 - 62%. Among the suspected additives and foods that parents and studies report as inciting behavioral changes are the following:
Any artificial colorings (particularly yellow, red, or green)
Other chemical additives -- for example, BHT or BHA
Milk
Chocolate
Eggs
Wheat
Foods containing salicylates, including all berries, chili powder, apples and cider, cloves, grapes, oranges, peaches, peppers (bell & chili), plums, prunes, tomatoes.
In one small study, 62% of children who were given only rice, turkey, pears, and lettuce to eat for two weeks experienced at least a 50% improvement in symptoms. Nevertheless, about a quarter of the children pulled out because they could not stick with diet or they became ill.

ADHD, Ritalin, and Big Brother
Alan L. Miller
Two recent cases in New York are eerily similar to the above example. In Albany, New York, a couple who had taken their son off Ritalin agreed to put him back on the drug after a family court threatened them with child abuse charges. Another New York couple was contacted by child protective services, who were investigating possible medical neglect, after they took their son off Ritalin and other drugs, contrary to a school-endorsed psychiatrist's recommendation.
It is estimated that 3-5 percent of school-aged children in the United States are now diagnosed with attention deficit hyperactivity disorder (ADHD), equaling about 2 million kids on Ritalin (methylphenidate), the drug most commonly prescribed for this disorder. However, these estimates might be low. In a 1999 study of 30,000 grade school kids in Virginia, published in the American Journal of Public Health, researchers found 17 percent of Caucasian boys, 9 percent of African-American boys, 7 percent of Caucasian girls, and 3 percent of African-American girls were diagnosed with ADHD. This would lead one to believe that, at least in this area of Virginia, and probably in other areas of the country, ADHD is overdiagnosed.

ADHD therapy to be applied transdermally
Heidi Belden, Pharm.D.
A drug that came onto the market as Ritalin over 50 years ago has been redeveloped into a new treatment option for the 4.4 million children in the United States who have been diagnosed with attention deficit/hyperactivity disorder (ADHD). The Food & Drug Administration recently approved Daytrana (methylphenidate transdermal system), from Shire Plc., giving clinicians the first non-oral alternative to help manage the condition.

Antidepressants for Children Soar!
Sarah Boseley, Health editor
In the UK, prescriptions have risen from around 400,000 in 2000 to more than 700,000 in 2002, an increase of 68%. The rise in the UK is higher than in the US, Canada, France, Germany, Spain, Argentinia, Brazil or Mexico. The second study looks at the growing use of antidepressants for children in the UK over the 10 years from January 1992 to December 2001. The rate at which the drugs were being prescribed to children rose by 70%.


Are Stimulants Overprescribed for Youths with ADHD?
Daniel J Safer
Abstract Critics of stimulant treatment for youths with attention deficit hyperactivity disorder (ADHD) have increased their rhetoric of late, contending that the leading medication for it, Ritalin®, is vastly overprescribed. Additionally, they claim that Ritalin (methylphenidate) is inherently dangerous and that the entire system of the diagnosis and treatment of ADHD is seriously flawed. The critics view the underlying reason for the epidemic as societal, due to our modern pace of living, our competitive society, and our consumer emphasis. Rejoinders to and clarifications of the more tangible points of the critics are presented, followed by a discussion of some more practical and legitimate concerns for researchers in this area. These concerns include changes within the ADHD category, the clinical need for multiple sources of diagnostic data, infrequent teacher–physician communication, problematic ADHD/conduct disorder comorbidity in adolescence, and the limited amount of community-based research.
Consumers Union: ADHD Drugs Overprescribed
Todd Zwillich
Sept. 27, 2005 -- Stimulant drugs used to treat attention deficit hyperactivity disorder in millions of American children are effective but are probably being prescribed to many youths who do not have the disorder. CDC data show that 4 million American children aged 3 to 17 have been diagnosed with ADD, comprising about 6.5% of the population. Boys are much more likely than girls to have the disorder. Close to 65% of diagnosed children take stimulant drugs as treatment, though many others without an official diagnosis may also use it, according to federal figures.
Diagnosing ADHD
Novartis Pharmaceuticals Corporation
ADHD contains subtypes with predominant traits. Therefore, a child without hyperactivity can still be affected by the disorder. The subtypes include:
An inattentive subtype
A hyperactive-impulsive subtype
A combined subtype

1.
Hyperactivity

Roaming around a room
Talking incessantly
Inability to sit through a lesson

2.
Inattention

Difficulty in filtering out unnecessary distractions
Being distracted or sidetracked by the movement of people or of objects

3.
Impulsivity

Acting before thinking
Demonstrating a very short temper
Behavior that includes yelling or hitting


The American Academy of Pediatrics guidelines for diagnosing ADHD include:1
Evaluate any child 6 to 12 years of age who shows signs of school difficulties, academic underachievement, troublesome relationships with teachers, family members, peers, and other behavioral problems.
Use DSM-IV criteria; these require that ADHD symptoms be present in 2 or more of a child's settings, and that the symptoms adversely affect the child's academic or social functioning for at least 6 months.
Requires information from parents or caregivers and a teacher or other school professional regarding core symptoms of ADHD in various settings, age of onset, duration of symptoms, and degree of impairment.
Assessment for co-existing conditions: learning and language problems, aggression, disruptive behavior, depression or anxiety.
Children with ADHD often suffer from co-existing conditions, such as:
Conduct disorders, described by the DSM-IV as "repetitive and persistent pattern(s) of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated (30%-50%)6
Oppositional defiant disorder, defined by the DSM-IV as "a recurrent of negativistic, defiant, disobedient, and hostile behavior toward authority figures that persists for at least 6 months" (up to 40%)7
Mood disorders (15%-20%)8
Anxiety disorders (20%-25%)9

Why is getting a correct diagnosis for ADD / ADHD difficult? Why can a diagnosis of ADHD go undetected?
Thomas E. Brown, Ph.D.
 Lack of a standard laboratory test. No laboratory or imaging tests can indicate reliably whether a child does or does not have ADHD. A diagnosis relies only on behavioral symptoms and ruling out other disorders. The experienced clinician needs to rely on clinical judgment.
 Other disorders cause ADHD-like symptoms or co-occur with AD/HD.
 Official guidelines for evaluating ADD symptoms are vague and open to interpretation – yet they lead to an all-or-nothing diagnosis.
 Pressure to prescribe medications. Sometimes parents are pressured by schools, or schools are pressured by parents to prescribe medications. In response, parents and teachers sometimes pressure physicians into prescribing Ritalin or similar drugs (primarily for Caucasian boys) because the children are aggressive or have poor grades. Many might just be poorer learners who don’t have ADHD.
 Fewer girls get diagnosed. According to the University of Maryland Medical Center (UMMC), “Some evidence suggests that many girls with ADHD may go underdiagnosed. Research indicates that girls with ADHD are often inattentive but not hyperactive or impulsive. In fact, older girls with ADHD tend to have social problems due to withdrawal and internalized emotions, showing symptoms of anxiety and depression. The inattentive subtype, in any case, may first show up in older children and adolescents. However, according to the criteria, ADHD is not diagnosed in people whose symptoms appear after age seven.”
 Fewer non-Caucasians get diagnosed. In spite of the fact that there seems to be no difference in the disorder among population groups, African-American, Hispanic, and Asian children with ADHD are half as likely to be diagnosed and treated as Caucasian children. By high school, the racial disparity increases to the level that the medication rate for blacks is one-fifth of that for whites. (Source: UMMC)
 Immaturity. Children who are young for their grade may be socially and intellectually impaired rather than behaviorally impaired.
 Testing is performed in a different setting. Physicians may fail to diagnose children with ADHD because they often behave normally in the quiet physician's office where there are no distractions to trigger symptoms.





Drug is Another Part of School By Victoria Brett
At Sea Road, 23 of the 450 students take Ritalin. Others take psychotropic drugs such as Prozac and Zoloft to control depression or obsessive compulsive disorders. "We have a lot of kids on heavy duty medication," LaPointe said. "I hope it slows down. I don't like the quick fix." Although critics have suggested that Ritalin is overprescribed for children, a study last December found that doctors use about 2ｽ times more Ritalin for hyperactive and inattentive children than in 1990—a much smaller increase than feared. The research, reported in the December issue of Pediatrics, said some 1.5 million young people ages 5 through 18, or 2.8 percent of the nation's school-age children, take the drug. The National Association of School Nurses, based in Scarborough, Maine, said the number is more like 3 million.
Drugging Our Children: Parents Look For Altnernative to RitalinYou
Cameron Woodworth
One day early in 2000, Michael and Jill Carroll of West Byrne, New York, got a knock on their door from Child Protective Services. Their alleged crime wasn't abusing drugs, beating their child or withholding love. Rather, they were accused of refusing to give their 7-year-old son, Kyle, the popular-yet-controversial drug, Ritalin.


Evaluating Health Warnings
Lawrence Diller
In my own practice, many teenagers and young adults have told me they had already tried a stimulant, usually Adderall, which is an amphetamine, on their own. They liked the effects and wondered if they had ADHD? One high-school senior told me he had been able to buy or trade for Adderall for the last two years, taking the pills before important exams, like the SAT, and for big projects. He never saw a doctor until meeting with me.
What About Ritalin?
Tina Blue
The simple fact that Ritalin is equivalent to what is, after all, a form of "speed," and that these drugs are routinely offered to children, is enough to shock and horrify many people. But such drugs are administered in microdosages (typically between 5mg and 20mg, three to four times daily), and both of them have a long history (about sixty years' worth) of use in treating ADD. The therapeutic effects of the drugs have been extensively studied, as have their potential side effects.
Nevertheless, there are many troubling issues surrounding the use of Ritalin and other psychoactive drugs to treat ADD in children--recently even children as young as two and three years old
Is ADD overdiagnosed? Is Ritalin overprescribed?
Tagged As: Adhd DiagnosedQuestion:Is ADD overdiagnosed? Is Ritalin overprescribed?
Answer:To answer the question, is this condition overdiagnosed (as I believe it is), there are quite a few questions to consider. EVEN IF we agree that ADD/ADHD is a legitimate neurological disorder (note I have not stated that it doesn't or couldn't exist, although that too could be-- and is-- debated), it is not a simple matter to say that the disorder is being accurately diagnosed and treated. This is because: * The diagnosis is subjective, based on observation of behaviors over time * Behaviors associated with ADHD may only be abnormal in their intensity, frequency or duration * The behaviors, regardless of intensity or frequency, would not necessarily be perceived abnormal in other cultural groups, among children of different social or family circumstances, or in children of another age or sex * The disorder often occurs-- or is believed to occur-- in conjunction with learning disabilities which could themselves be the the partial or sole cause of the behaviors * The behaviors could occur as a result of other medical conditions (mental illnesses, allergies, tyroid disease, depression, etc.) * There is not yet any standard, generally accepted medical test in place to lend support to the diagnosis * The behaviors associated with ADD/ADHD seems to end in the teen years or early adulthood for some-- leading some experts to question the validity of the diagnosis, and of the disorder in general (e.g. Is a developmental disorder really a disorder?) * The diagnosis is relatively new in the society, yet the number of children diagnosed has exploded in a short time * The medication most commonly used to treat ADHD is increasingly abused by non-sufferers who can experience the same effects sufferers do by taking equivalent doses * The emphasis on school achievement places pressure on parents whose children do not succeed at school, increasing the possibility they will seek medical explanation, medical assistance, and special privileges (testing accomodations, etc.) for their children, whether or not the children have a disorder. * There is significant and increasing concern at all levels of society about the accuracy and prevalence of the diagnosis and the appropriateness of the treatment. But there are lots of questions unanswered. Is ADD like LD-- more likely to be diagnosed among middle and upper-class whites than others? Has the lack of a generally accepted medical test for ADD lead to overdiagnosis? I believe the answer to both questions is yes. For example: According to a research study by pediatric psychologist Gretchen LeFever nearly 30% of fifth graders in the upper-middle class Virginia Beach community are being medicated for ADD, as compared with the estimated 3-5% of elementary aged children believed to have ADD. She claims this is 30% figure is normal in wealthy communities. [source: Psychology Today] I read an article from the Minneapolis Star-Tribune which (like other articles from other publications) reported on a cross-cultural study at the University of Massachusetts. The study compared two groups of English children, one diagnosed with ADHD, the other not. The researcher observed the children for 35 behaviors called symptoms of ADHD, and found no significant differences between the groups. I would like to see more information on WHO is most likely to be diagnosed ADD/ADHD, because I believe that while the disorder may not be overdiagnosed in the overall population, it could be shown overdiagnosed among Anglo-Saxon US children, and especially middle- to upper-class Anglo-Saxon children, for whom academic success is a cultural mandate. Writing in the Harvard Mental Health Letter, Dennis Donovan states that although there is no accepted medical test for ADD/ADHD, and although theories about genetic causes of brain dysfunctions or abnormalities have not been proven, these unproven theories on ADD/ADHD are being used to justify the present regimen of drugs and environmental accommodations in schools. However since it is known that certain physical or biochemical brain abnormalities change behavior in predictable ways, a reliable medical test for ADD/ADHD must be possible. In one study I read about, a team of psychiatrists led by Dr. Martin Teicher administered an attention test to 17 boys between 6 and 12 years old. Eleven of the boys were previously diagnosed ADHD, and the remaining 6 were normal. The attention test required the boys to press a key on a computer keyboard each time they saw a specified image. An infrared tracking device monitored their movements and their performance on the test. Interestingly enough, the test identified only **six** of the 11 ADHD-diagnosed participants as correctly diagnosed. Later, MRI technology was used to image the brains of the 11 ADHD-diagnosed participants. The images showed that the worse students did on the attention test, the less activity could be seen in a brain region called the putamen, which regulates attention and body movements. When given Ritalin, the 6 ADHD-diagnosed boys whose diagnosis had been confirmed by the attention test had this in common: once given Ritalin, their brains showed increased activity in the putamen, and they performed better on the attention test. After receiving Ritalin, the 5 ADHD-diagnosed boys eliminated by the attention test showed even less putamen activity than before, and they showed no improvement in test performance. [source: Nature Medicine] While this small study group may or may not be representative of the general population of ADHD students, it is frightening to think that such a high percentage of ADHD diagnoses could be wrong, even among such a small group. This is especially troubling since (according to various sources I have read) as many as 75% of ADD/ADHD diagnoses result in prescribed medicines. I predict that the widespread adoption of diagnostic tests like these will eliminate a large percentage of the currently diagnosed population, and result in hard criticism and litigation over the methods now used in diagnosis. Various causes of ADD disorder have been proposed, including fetal brain injury due to drug or lead exposure, and genetic inheritance of ADD traits. There is evidence to support these theories, but according to pediatrician and clinical researcher Dr. Lawrence Greenberg, heredity plays an important role in ADHD but does not appear to account for the majority of cases. [source: The Clearinghouse] [note: Dr. Greenberg developed one of the first continuous performance tests (CPTs) designed for clinical use, known as the TOVA, or Test of Variables of Attention. He has written over 100 articles and lectured extensively on the diagnosis and treatment of ADD/ADHD.] The publication Public Interest notes that in studies of fraternal and identical twins, the diagnosis of one led to a 51% likelihood that the idemtical twin is also diagnosed. The probability among fraternal twins was 33%. The studies support a genetic factor but it seems odd that the percentage among identical twins would not be higher. The popularity of the ADD/ADHD diagnosis has certainly increased from dramatically in the United States. The American Academy of Pediatrics estimates that about 1.5 million 5 to 18 year olds, or 2.8 percent of U.S. school-age children, take ritalin for ADD. The number of presciptions for legal uses such as treatment of ADD have increased substantially in recent years, according to the Drug Enforcement Agency by 600% during the last five years. [source: WellWeb.com] As for the overprescription of Ritalin, the journal Pediatrics describes the data now available as insufficient to settle the matter I agree, because I believe (as I stated earlier) that information is needed as to WHO is most likely to be diagnosed ADD/ADHD, and WHY. Cross-cultural studies are also needed to help determine what role society's expectations play in the diagnosis and treatment of ADD/ADHD. But it is clear that drug administration has increased dramatically. In February 2000 the Journal of the American Medical Association (JAMA) reported dramatic increases in the numbers of psychiatric and stimulant drugs prescribed to children. Now, 1.5% of children only two to four years old are medicated. JAMA reports that Ritalin and other stimulants have tripled in use, and antidepressant use has doubled. According to a 1999 survey of doctors by the University of North Carolina at Chapel Hill, 72% had prescribed Prozac or a similar drug to children under 18 years old. It is known that the US consumes more than ***90 percent of all the Ritalin made worldwide***, even though it has only about ***5% of the world population***. [source: Harvard Mental Health Letter] The International Narcotics Control Board of the United Nations has publicly criticized the United States for overprescribing stimulants such as Ritalin to children. [Chicago Sun-Times] American critics see the irony of prescribing the drug at this astounding rate while advocating a just say no ethic for drug use. Ritalin is known to have both short- and long-term side effects even in normal dosages (examples cited in my reading: slowed body growth, nervousness, insomnia, dizziness, heart palpitations, headache, heightened blood pressure, rashes, itching, loss of appetite and weight loss, nausea, vomiting, psychotic episodes, and depression). A 1995 Brookhaven National Laboratory study indicated that cocaine and Ritalin had a similar effect on the brain [source: Archives of General Psychiatry] Studies conducted over 40 years conclude the drug is safe, and that it does reduce the ADHD behaviors in most people who take it, but some studies have shown Ritalin is ineffective and even dangerous for some and that its use has led to cancer in mice. [source: Psychology Today] Ritalin is labeled for use in children six and older only, and its effects have not been ... This is completely incorrect. The diagnosis is *NOT* based upon observation of behaviors; observation of behaviors is merely what suggests the existence of the symptoms. A sore foot is not diagnosed by observation of limping; observing limping leads you to suspect it, and other testing is then performed to verify it. Note that a sore foot is entirely subjective, based upon self-reporting. Everyone coughs once in a while; a cough due to a cold is abnormal only in the intensity, frequency, and duration of coughing. Absolutely and totally incorrect. A child who can't sit still without fidgetting will be perceived as abnormal in the sense that most children can sit still without fidgetting. The child might not be looked down upon for this fidgetting; another culture might even have a proud parent saying Of *COURSE* my child is too energetic to sit still like most children, but it will be clear that this child is still outside of the norm in ability to sit without fidgetting. The assumption that ADHD is a disorder of behavior is a very silly one, unless and until you make *EVERYTHING* into behavior. Note the use of the word often. . .it's a completely meaningless term without a relative measure. How often? What percentage of cases of ADHD have these other disabilities? When those disabilities aren't there, do you state that the child has a disability anyway, but it's just not ADHD? Note that this is the silliest argument of the bunch. You don't diagnose ADHD until you've ruled out the other possible causes. Nor is there any such test for just about anything in the DSM-IV. Are you now claiming that depression is as questionable as ADHD? The diagnostic method is the exact same thing: look at the symptoms, eliminate other causes, then assume a tentative diagnosis of depression (or ADHD). Schizophrenia suffers from the same problems as listed above. Shrug. And here is exactly why the use of behavior as a criteria is so silly. It might well be that the symptoms of ADHD always persist into adulthood (though an adult might have better coping skills than a child, and hence, show less abnormal 'behavior'). No, it's not. The formalization and study of the disorder is relatively new. Is it surprising that, when you learn more about what a disorder is, you can spot more cases of it? This is interesting. Somehow, the fact that the medication is abusable casts doubt upon the diagnosis? Some people are taking viagra in hopes that it's an aphrodisiac; does this cast doubt upon erectile difficulties (another thing that is diagnosed subjectively and has no universal medical test)? School achievement is generally only used as a criteria for ADHD when you see that a child is clearly performing below his or her abilities due to attention-type problems. This is a standard fallacy known as argumentum ad populum. If a lot of people question something, it must be questionable. Of course, are these people well informed? I'd bet that *EVERYTHING* is more likely to be diagnosed in the middle-to-upper class due to better medical care. (Okay, let's ignore things like malnutrition, etc..) And the question is, does that belief have *ANY* basis in reality? Was this researcher a trained psychologist? What criteria were used to try to determine the differences? Was the observation blinded as best as possible? Were the 35 behaviors grouped or addressed singly? Many would use the word might in place of the word could. I could do that says something very different from I might do that. And. . .? THere are no useful conclusions that can be drawn from that. You could get suspicious. . . but you can be as suspicious that the test isn't good as about the diagnosis. And if the test didn't suggest any of the 6 had ADHD, well, that's likely a significant difference; over half of one group versus non of the other? Which is great, except we have, as yet, no evidence, at all, that this is the case. Unless, of course, you can prove that the test is perfect in diagnosing ADHD. How would you do that, though? You just claimed there is no ...
Is Ritalin Overprescribed? Yes
This article is from drkoop.com
The problem
Ritalin is being dispensed with a speed and nonchalance compatible with our drive-through culture, yet entirely at odds with good medicine and common sense. The drug does help some people pay attention and function better; some of my own patients have benefited from it. But too many children, and more and more adults, are being given Ritalin inappropriately.
Psychiatry has devised careful guidelines for prescribing and monitoring this sometimes-useful drug. But the five-fold jump in Ritalin production in the past five years clearly suggests that these guidelines are being ignored and that Ritalin is being vastly overprescribed.
The problem has finally been recognized by medical groups such as the American Academy of Child and Adolescent Psychiatry, the American Psychiatric Association, the American Academy of Pediatrics, and even by Ciba, the primary manufacturer of Ritalin. These organizations have written or are developing guidelines for diagnosing ADHD, and Ciba issued similar guidelines to doctors last summer.
Why Ritalin is overprescribed
Under the pressure of managed care, physicians are diagnosing ADHD in patients and prescribing them Ritalin after interviews as short as 15 minutes. And given Ritalin's quick action (it can "calm" children within days after treatment starts), some doctors even rely on the drug as a diagnostic tool, interpreting improvements in behavior or attention as proof of an underlying ADHD -- and justification for continued drug use.
Studies show that Ritalin prescribing fluctuates dramatically depending on how parents and teachers perceive "misbehavior" and how tolerant they are of it. I know of children who have been given Ritalin more to subdue them than to meet their needs -- a practice that recalls the opium syrups used to soothe noisy infants in London a century ago. When a drug is prescribed because one person is bothering another -- a disruptive child upsetting a teacher, for example -- there is clearly a danger that the drug will be abused. That danger only increases when the problem being treated is so vaguely defined.
Why ADHD exists
ADHD exists as a disorder primarily because a committee of psychiatrists voted it so. In a valiant effort, they squeezed a laundry list of disparate symptoms into a neat package that can be handled and treated. But while attention is an essential aspect of our functioning, it's certainly not the only one. Why not bestow the label of "disorder" on other problems common to people diagnosed with ADHD -- such as Easily Frustrated Disorder (EFD) or Nothing Makes Me Happy Disorder (NMMHD)?
Once known as Minimal Brain Dysfunction and Hyperkinetic Syndrome, ADHD is considered a neurological disorder. Certainly, some people diagnosed with ADHD are neurologically impaired and need medication. But nervous system glitches account for the disruptive behavior of only a small minority of people who are vulnerable to distraction or impulsive behavior -- perhaps 1 or 2 percent of the general population. Yet many more people have ADHD symptoms that have nothing to do with their nervous systems and result instead from emotional distress, depression, anxiety, obsessions, or learning disabilities.
For these people, who exhibit the symptoms of ADHD but suffer from some other problem, Ritalin will likely be useless as a treatment. Taking it may postpone more effective treatment. And it may even be harmful.

Ritalin
No one knows how Ritalin works. Some miracle drugs, of course, have helped people for decades or even centuries before their mechanisms of action were understood. But we need to know more about the possible effects of a drug used mainly on children.
People are willing to overlook side effects when it comes to treating a life-threatening disease. But with a less-weighty disorder like ADHD, therapeutic rewards must be weighed against possible adverse reactions. In a drug targeted for children, there is concern that harmful effects may crop up decades after treatment stops. Since Ritalin is a relatively new drug, in use for about 30 years, we still don't know whether long-term side effects await its young users. But we do know that more immediate problems can occur.
It's already clear that Ritalin can worsen underlying anxiety, depression, psychosis, and seizures. More common but milder side effects include nervousness and sleeplessness. Some studies suggest that the drug may interfere with bone growth. And last February, the United Nation's International Narcotics Control Board reported an increase in teenagers who were inhaling this stimulant drug, which is chemically similar to cocaine but not nearly as potent.
While Ritalin's mode of action isn't clear, the drug is known to affect the brain's most ancient and basic structures, which control arousal and attention. I question the wisdom of tampering with such a crucially important part of the brain, particularly with a drug whose possible long-term side effects remain to be discovered.
Society's role
The surge in both ADHD diagnoses and Ritalin prescriptions is yet another sign of a society suffering from a colossal lack of personal responsibility. By telling patients that their failures, misbehavior, and unhappiness are caused by a disorder, we risk colluding with their all-too-human belief that their actions are beyond their control and weaken their motivation to change on their own. And in the many cases where ADHD is misdiagnosed in children, we give parents the illusion that their child's problems have nothing to do with the home environment or with their performance as parents.
It must be true that bad biology accounts for some people's distracted and impulsive lifestyles. But random violence, drugs, alcohol, domestic trauma, and (less horrifically) indulgent and chaotic homes are more obvious reasons for the ADHD-like restlessness that plagues America. We urgently need to address these problems. To do that, we need legislators who will provide support for good parenting, especially in the early years of childhood when the foundations for handling feelings, self-control, and concentration are biologically and psychologically laid down.
Some people who can't concentrate probably do merit the diagnosis of ADHD and a prescription for Ritalin to treat it. But the brain, the neurological seat of the soul and the self, must be treated with the utmost respect. With the demand for Ritalin growing, we must be increasingly wary about doling out a drug that can be beneficial but is more often useless or even harmful.
Dr. Richard BromfieldAmerican Council on Science and Healthhttp://www.acsh.org/
Founded in 1978, and directed and advised by the world's leading scientists, physicians, and policy advisors -- ACSH is is a nonprofit, consumer education organization dedicated to providing the public with mainstream scientific information on issues related to food, nutrition, chemicals, pharmaceuticals, lifestyle, the environment and health.
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