Introduction

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

3. What Are the Effective Treatments for ADHD?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

6. What Are the Directions for Future Research?

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

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

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

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

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

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

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

Conclusions

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

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

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

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

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

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

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

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

Consensus Development Panel

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

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

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

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

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

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

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

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

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

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

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

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

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

Speakers

• Howard Abikoff, Ph.D.
• Professor of Clinical Psychiatry
• Director of Research
• NYU Child Study Center
• New York University School of Medicine
• New York, New York

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

• L. Eugene Arnold, M.D., M.Ed.
• Professor Emeritus of Psychiatry
• Ohio State University, Columbus
• Sunbury, Ohio

• Russell A. Barkley, Ph.D.
• Director of Psychology
• Department of Psychiatry
• University of Massachusetts Medical Center
• Worcester, Massachusetts

• Joseph Biederman, M.D.
• Professor of Psychiatry, Harvard Medical School
• Chief, Joint Program in Pediatric Psychopharmacology
• Massachusetts and McLean General Hospitals
• Boston, Massachusetts

• Hector R. Bird, M.D.
• Professor
• Clinical Psychiatry
• Columbia University
• Deputy Director
• Child Psychiatry
• New York State Psychiatric Institute
• New York, New York

• Peter R. Breggin, M.D.
• Director
• Center for the Study of Psychiatry and Psychology
• Bethesda, Maryland

• William B. Carey, M.D.
• Clinical Professor of Pediatrics
• University of Pennsylvania School of Medicine
• Division of General Pediatrics
• Children's Hospital of Philadelphia
• Philadelphia, Pennsylvania

• Betty Chemers, M.A.
• Director of Research and Program Development
• Office of Juvenile Justice and Delinquency Prevention
• Washington, D.C.

• C. Keith Conners, Ph.D., M.A.
• Director, ADHD Program
• Department of Psychiatry
• Duke University Medical Center
• Durham, North Carolina

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

• Louis Danielson, Ph.D.
• Director, Division of Research to Practice
• Office of Special Education Programs
• Office of Special Education and Rehabilitative Services
• U.S. Department of Education
• Washington, D.C.

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

• Steven R. Forness, Ed.D.
• Professor of Psychiatry and Biobehavioral Sciences
• Neuropsychiatric Hospital
• University of California, Los Angeles
• Los Angeles, California

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

• Stephen P. Hinshaw, Ph.D.
• Professor of Psychology
• Director of Clinical Psychology Training Program
• Department of Psychology
• University of California, Berkeley
• Berkeley, California

• Kimberly Hoagwood, Ph.D.
• Chief of Child and Adolescent Services Research
• Services Research Branch
• National Institute of Mental Health
• National Institutes of Health
• Bethesda, Maryland

• Peter S. Jensen, M.D.
• Associate Director for Child and Adolescent Research
• National Institute of Mental Health
• National Institutes of Health
• Bethesda, Maryland

• Charlotte Johnston, Ph.D.
• Associate Professor
• Department of Psychology
• University of British Columbia
• Vancouver, British Columbia
• Canada

• Peter W. Kalivas, Ph.D.
• Professor and Chair
• Department of Physiology and Neuroscience
• Medical University of South Carolina
• Charleston, South Carolina

• Kelly J. Kelleher, M.D., M.P.H.
• Staunton Professor of Pediatrics and Psychiatry
• Child Services Research and Development Program
• University of Pittsburgh
• Pittsburgh, Pennsylvania

• Rachel G. Klein, Ph.D.
• Director of Clinical Psychology
• Department of Psychology
• New York State Psychiatric Institute
• New York, New York

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

• Nadine M. Lambert, Ph.D.
• Professor
• Cognition and Development Area
• Director, School Psychology Program
• Graduate School of Education
• University of California, Berkeley
• Berkeley, California

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

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

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

• James Swanson, Ph.D.
• Professor of Pediatrics
• Department of Pediatrics
• University of California, Irvine
• Irvine, California

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

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

• Mark L. Wolraich, M.D.
• Professor of Pediatrics
• Director, Division of Child Development
• Department of Pediatrics
• Vanderbilt University
• Nashville, Tennessee

Planning Committee

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lead Organizations

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

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

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

Supporting Organizations

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

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

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

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

Bibliography

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

Overview and Introduction

1. Conners CK, Erhardt D. Hersen M, Bellack A, editors. New York: Elsevier Science. 1998. Attention-deficit hyperactivity disorder in children and adolescents: clinical formulation and treatment.
2. Goldman LS, Genel M, Bezman RJ, Slanetz PJ. Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs, American Medical Association. JAMA . 1998;;279:1100-7 [PubMed: 9546570]
3. Richters JE, Arnold LE, Jensen PS, Abikoff H, Conners CK, Greenhill LL, et al. NIMH collaborative multisite multimodal treatment study of children with ADHD: I. Background and rationale. J Am Acad Child Adolesc Psychiatry . 1995;;34:987-1000 [PubMed: 7665456]
4. Weiss G, Hechtman L. Hyperactive children grown up: ADHD in children, adolescents, and adults. 1993.

ADHD as a Disorder in Children, Adolescents, and Adults

1. Applegate B, Lahey BB, Hart EL, Biederman J, Hynd GW, Barkley RA, et al. Validity of the age-of-onset criterion for ADHD: a report from the DSM-IV field trials. J Am Acad Child Adolesc Psychiatry . 1997;;36:1211-21 [PubMed: 9291722]
2. Carey WB, McDevitt SC. Coping with children's temperament. 1995.
3. Castellanos FX, Giedd JN, March Wl, Hamburger SD, Vaituzis AC, Dickstein DP, et al. Quantitative brain magnetic resonance imaging in attention-deficit hyperactivity disorder. Arch Gen Psychiatry . 1996;;53:607-16 [PubMed: 8660127]
4. Diller LH. Running on Ritalin. 1998.
5. Lahey BB, Applegate B, McBurnett K, Biederman J, Greenhill L, Hynd GW, et al. DSM-IV field trials for attention deficit/hyperactivity disorder in children and adolescents. Am J Psychiatry . 1994;;151:1673-85 [PubMed: 7943460]
6. Lahey BB, Pelham WE, Stein MA, Loney J, Trapani C, Nugent K, et al. Validity of DSM-IV attention-deficit/hyperactivity disorder for younger children. J Am Acad Child Adolesc Psychiatry. . In press [PubMed: 9666624]
7. Lahey BB, Carlson CL, Frick PJ. In: Widiger TA, Frances AJ, Davis W, First M, editors. DSM-IV sourcebook, Vol 1. Washington (DC): American Psychiatric Press. 1997. Attention deficit disorder without hyperactivity: a review of research relevant to DSM-IV.
8. Levine MD. In: Levine MD, Carey WB, Crocker AC, editors. Developmental-behavioral pediatrics. 3rd ed. Philadelphia: Saunders. 1998. Neurodevelopmental variation and dysfunction among school children.
9. Lou HC. Etiology and pathogenesis of attention-deficit hyperactivity disorder (ADHD): significance of prematurity and perinatal hypoxic-haemodynamic encephalopathy. Acta Paediatr . 1996;;85:1266-71 [PubMed: 8955450]
10. Maziade M. Should adverse temperament matter to the clinician? An empirically based answer. 1989.
11. Oosterlaan J, Logan GD, Sergeant JA. Response inhibition in AD/HD, CD, comorbid AD/HD+CD, anxious and control children: a meta-analysis of studies with the stop task. J Child Psychol Psychiatry . 1998;;39:411-26 [PubMed: 9670096]
12. Pennington BF, Ozonoff S. Executive functions and developmental psychopathology. J Child Psychol Psychiatry . 1996;;37:51-87 [PubMed: 8655658]
13. Seidman LJ, Biederman J, Faraone SV, Weber W, Ouellette C. Toward defining a neuropsychology of attention deficit-hyperactivity disorder: performance of children and adolescents from a large clinically referred sample. J Consul and Clin Psychol . 1997;;65:150-60 [PubMed: 9103744]
14. Swanson JM, Sunohara GA, Kennedy JL, Regino R, Fineberg E, Wigal T, et al. Association of the dopamine receptor D4 (DRD4) gene with a refined phenotype of attention deficit hyperactivity disorder (ADHD): a family-based approach. Mol Psychiatry . 1998;;3:38-41 [PubMed: 9491811]
15. Tannock R. Attention deficit hyperactivity disorder: advances in cognitive, neurobiological, and genetic research. J Child Psychol Psychiatry . 1998;;39:65-99 [PubMed: 9534087]
16. Volkow ND, Ding YS, Fowler JS, Wang GJ, Logan J, Gatley JS, et al. Is methylphenidate like cocaine? Studies on their pharmacokinetics and distribution in human brain. Arch Gen Psychiatry . 1995;;52:456-63 [PubMed: 7771915]

Impact

1. Barkley RA, Fischer M, Edelbrock CS, Smallish L. The adolescent outcome of hyperactive children diagnosed by research criteria: I. An 8-year prospective follow-up study. Am Acad Child Adolesc Psychiatry . 1990;;29:546-57 [PubMed: 2387789]
2. Barkley RA. In: Barkley RA, Attention deficit hyperactivity disorder. 2nd ed. New York: Guilford Press. 1998. Developmental course, adult outcome, and clinic-referred ADHD adults.
3. Biederman J, Faraone SV, Spencer T, Wilens T, Norman D, Lapey KA, et al. Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder. Am J Psychiatry . 1993;;150:1792-8 [PubMed: 8238632]
4. Biederman J, Faraone S, Milberger S, Guite J, Mick E, Chen L, et al. A prospective 4-year follow-up study of attention-deficit hyperactivity and related disorders. Arch Gen Psychiatry . 1996;;53:437-46 [PubMed: 8624187]
5. Bird H. Epidemiology of childhood disorders in a cross-cultural context. J Child Psychol Psychiatry . 1996;;37(1):35-49 [PubMed: 8655657]
6. Bussing R, Zima BT, Belin TR, Forness SR. Children who qualify for LD and SED programs: do they differ in level of ADHD symptoms and comorbid psychiatric conditions? J Emot Beh Disord . 1998;;22:88-97
7. Cocozza JJ, editor. Responding to the mental health needs of youth in the juvenile justice system. 1992.
8. Danckaerts M, Taylor EJ. In: Verhulst FC, Koot HM, editors. The epidemiology of child and adolescent psychopathology. New York: Oxford University Press. 1995. The epidemiology of childhood hyperactivity.
9. DuPaul GJ, Eckert TL. The effects of school-based interventions for attention deficit hyperactivity disorder: a meta-analysis. Sch Psych Rev . 1997;;26:5-27
10. Forness SR, Walker HM. Special education and children with ADD/ADHD. 1994.
11. Greene R, Biederman J, Faraone SV, Sienna M, Garcia-Jetton J. Adolescent outcome of boys with attention-deficit/hyperactivity disorder and social disability: results from a 4-year follow-up study. J Consult Clin Psychol . 1997;;65:758-67 [PubMed: 9337495]
12. Hinshaw SP, Melnick SM. Peer relationships in children with attention-deficit hyperactivity disorder with and without comorbid aggression. Dev Psychopathol . 1995;;7:627-47
13. Lahey BB, Pelham WE, Stein MA, Loney J, Trapani C, Nugent K, et al. Validity of DSM-IV attention-deficity/hyperactivity disorder for younger children. J Am Acad Child Adolesc Psychiatry . 1998;;37:435-42 [PubMed: 9666624]
14. Leung PW, Luk SL, Ho TP, Taylor E, Mak FL, Bacon-Shone J. The diagnosis and prevalence of hyperactivity in Chinese schoolboys. Br J Psychiatry . 1996;;168(4):486-96 [PubMed: 8730946]
15. Loeber R, Farrington D, editors. Serious and violent juvenile offenders: risk factors and successful interventions. 1998.
16. Mann EM, Ikeda Y, Mueller CW, Takahashi A, Tao KT, Humris E, et al. Cross-cultural differences in rating hyperactive-disruptive behaviors in children. Am J Psychiatry . 1992;;149(11):1539-42 [PubMed: 1415822]
17. Mannuzza S, Klein R, Bessler A, Malloy P, LaPadula M. Adult outcome of hyperactive boys. Educational achievement, occupational rank, and psychiatric status. Arch Gen Psychiatry . 1993;;50:565-76 [PubMed: 8317950]
18. Mannuzza S, Klein RG, Bessler A, Malloy P, Hynes ME. Educational and occupational outcome of hyperactive boys grown up. J Am Acad Child Adolesc Psychiatry . 1997;;36:1222-7 [PubMed: 9291723]
19. Reid R, Maag JW, Vasa SF, Wright G. Who are the children with attention deficit-hyperactivity disorder? A school-based survey. J Spec Ed . 1994;;28:117-37
20. Slomkowski C, Klein RG, Mannuzza S. Is self-esteem an important outcome in hyperactive children? J Abnorm Child Psychol . 1995;;23:303-15 [PubMed: 7642839]
21. Snyder HN. Juvenile arrests 1996. 1997.
22. Stahl AL. Delinquency cases in juvenile courts, 1995. OJJDP fact sheet #79. 1998.
23. Weiss G, Hechtman LT. New York: Guilford Press. 1993. Hyperactive children grown up. 2nd ed.

Safety and Efficacy of Treatments -- Short and Long Term

1. Arnold L, Abikoff H, Cantwell D, Conners C, Elliott G, Greenhill L, et al. NIMH collaborative multimodal treatment study of children with ADHD (MTA): design challenges and choices. Arch Gen Psychiatry . 1997;;54:865-70 [PubMed: 9294378]
2. Biederman J, Thisted R, Greenhill L, Ryan N. Estimation of the association between desipramine and the risk for sudden death in 5- to 14-year-old children. J Clin Psychiatry . 1995;;56:87-93 [PubMed: 7883735]
3. Biederman J, Baldessarini RJ, Wright V, Keenan K, Faraone S. A double-blind placebo controlled study of desipramine in the treatment of attention deficit disorder: III. Lack of impact of comorbidity and family history on clinical response. J Am Acad Child Adolesc Psychiatry . 1993;;32:199-204 [PubMed: 8428872]
4. Borcherding BG, Keysor CS, Rapoport JL, Elia J, Amass J. Motor/vocal tics and compulsive behaviors on stimulant drugs: is there a common vulnerability? Psychiatry Res . 1990;;33:83-94 [PubMed: 2217661]
5. Breggin PR. Monroe (ME): Common Courage Press. 1998. Talking back to Ritalin.
6. Carlson CL, Pelham WE, Milich R, Dixon J. Single and combined effects of methylphenidate and behavior therapy on the classroom performance of children with ADHD. J Abnorm Child Psychol . 1992;;20:213-32 [PubMed: 1593027]
7. Dunnick JK, Hailey JR. Experimental studies on the long-term effects of methylphenidate hydrochloride. Toxicology . 1995;;103:77-84 [PubMed: 8545847]
8. Klein GR, Landa B, Mattes JA, et al. Methylphenidate and growth in hyperactive children. Arch Gen Psychiatry . 1988;;45:1127-30 [PubMed: 3058088]
9. Goldman LS, Genel M, Bezman RJ, Slanetz PJ. Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs. American Medical Association. JAMA . 1998;;279:1100-7 [PubMed: 9546570]
10. Hechtman L, Abikoff H. Multimodal treatment plus stimulants vs. stimulant treatment in ADHD children: results from a two-year comparative treatment study. October 1995.
11. Hinshaw SP. Stimulant medication and the treatment of aggression in children with attentional deficits. J Clin Child Psychol . 1991;;20:301-12
12. Horn WF, Ialongo NS, Pascoe JM, Greenberg G, Packard T, Lopez M, et al. Additive effects of psychostimulants, parent training, and self-control therapy with ADHD children. J Am Acad Child Adolesc Psychiatry . 1991;;30:233-40 [PubMed: 2016227]
13. Jensen PJ, Abikoff H. In: Brown T, editor. Attention deficit disorders and comorbidities in children, adolescents, and adults. American Psychiatric Press. In press. Tailoring treatment interventions for individuals with ADDs.
14. Klein RG, Abikoff H. Behavior therapy and methylphenidate in the treatment of children with ADHD. J Attention Disord . 1997;;2:89-114
15. Klein RG, Abikoff H, Klass E, Ganeles D, Seese LM, Pollack S. Clinical efficacy of methylphenidate in conduct disorder with and without attention deficit hyperactivity disorder. Arch Gen Psychiatry . 1997;;54:1073-80 [PubMed: 9400342]
16. Marotta PJ, Roberts EA. Pemoline hepatotoxicity in children. J Pediatr . 1998;;132:894-7 [PubMed: 9602211]
17. McMaster University Evidence-Based Practice Center. The treatment of attention-deficit/hyperactivity disorder: an evidence report. Contract no. 290-97-0017. 1998.
18. Melega WP, Raleigh MJ, Stout DB, Lacan G, Huang SC, Phelps ME. Recovery of striatal dopamine function after acute amphetamine- and methamphetamine-induced neurotoxicity in the vervet monkey. Brain Res . 1997;;766:113-20 [PubMed: 9359594]
19. Nasrallah H, Loney J, Olson S, McCalley-Whitters M, Kramer J, Jacoby C. Cortical atrophy in young adults with a history of hyperactivity in childhood. Psychiatry Res . 1986;;17:241-6 [PubMed: 3704030]
20. Pelham WE, Wheeler T, Chronis A. Empirically supported psychosocial treatments for attention deficit hyperactivity disorder. J Clin Child Psychol . 1998;;27:189-204 [PubMed: 9648036]
21. Pelham WE, Murphy HA. Attention deficit and conduct disorder. 1986
22. Pelham WE, Hoza B. In: Hibbs E, Jensen P, editors. Psychosocial treatments for child and adolescent disorders: empirically based strategies for clinical practice. New York: APA Press. p. 311-40. 1996. . Intensive treatment: a summer treatment program for children with ADHD.
23. Pliszka S. Effect of anxiety on cognition, behavior, and stimulant response in ADHD. J Amer Acad Child Adolesc Psychiatry . 1989;;28:882-7 [PubMed: 2808258]
24. Safer DJ, Zito JM, Fine EM. Increased methylphenidate usage for attention deficit disorder in the 1990s. Pediatrics . 1996;;98:1084-8 [PubMed: 8951257]
25. Spencer T, Biederman J, Wilens T, Harding M, O'Donnell D, Griffin S. Pharmacotherapy of attention-deficit hyperactivity disorder across the life cycle. J Am Acad Child Adolesc Psychiatry . 1996;;35:409-32 [PubMed: 8919704]
26. Swanson JM, Flockhart D, Udrea D, Cantwell DP, Connor DF, Williams L. Clonidine in the treatment of ADHD: questions about safety and efficacy. J Child Adolesc Psychopharmacol . 1995;;5:301-4
27. Wilens TE, Biederman J. Stimulants. 1992. [PubMed: 1347939]

Substance Abuse Risks of Stimulant Treatments

1. Beck L, Langford W, MacKay M, Sum G. Childhood chemotherapy and later drug abuse and growth curve: a follow-up study of 30 adolescents. Am J Psychiatry . 1975;;132:436-8 [PubMed: 1119596]
2. Biederman J, Wilens TE, Mick E, Milberger S, Spencer TJ, Faraone SV. Psychoactive substance use disorders in adults with attention deficit hyperactivity disorder (ADHD): effects of ADHD and psychiatric comorbidity. Am J Psychiatry . 1995;;152:1652-8 [PubMed: 7485630]
3. Carroll KM, Rounsaville BJ. History and significance of childhood attention deficit disorder in treatment-seeking cocaine abusers. Compr Psychiatry . 1993;;34:75-82 [PubMed: 8485984]
4. Drug Enforcement Administration, Office of Diversion Control. Methylphenidate review: eight factor analysis. 1995.
5. Drug Enforcement Administration, Office of Diversion Control. Conference report: stimulant use in the treatment of ADHD. 1996.
6. Gaytan O, al-Rahim S, Swann A, Dafny N. Sensitization to locomotor effects of methylphenidate in the rat. Life Sci . 1997;;61:101-7 [PubMed: 9275016]
7. Hartsough CS, Lambert NM. Pattern and progression of drug use among hyperactives and controls: a prospective short-term longitudinal study. J Child Psychol Psychiatry . 1987;;28:543-53 [PubMed: 3654806]
8. Hechtman L. Adolescent outcome of hyperactive children treated with stimulants in childhood: a review. Psychopharmacol Bull . 1985;;21:178-91 [PubMed: 2860690]
9. Herrero ME, Hechtman L, Weiss G. Antisocial disorders in hyperactive subjects from childhood to adulthood: predictive factors and characterization of subgroups. Am J Orthopsychiatry . 1994;;64:510-21 [PubMed: 7847567]
10. Jaffe SL. Intranasal abuse of prescribed methylphenidate by an alcohol and drug abusing adolescent with ADHD. J Am Acad Child Adolesc Psychiatry . 1991;;30:773-5 [PubMed: 1938793]
11. Klein RG, Mannuzza S. The importance of childhood hyperactivity in the development of substance use disorders. In press.
12. Kramer J, Loney J. In: Gadow KD, Bialer I, editors. Advances in learning and behavioral disabilities. Greenwich (CT): Jai Press. 1982. Childhood hyperactivity and substance abuse: a review of the literature.
13. Lambert NM, Hartsough CS. Prospective study of tobacco smoking and substance dependence among samples of ADHD and non-ADHD subjects. J Learn Disabil . 1998;;31:533-44 [PubMed: 9813951]
14. Lambert NM, Sandoval J, Sassone D. Prevalence of hyperactivity in elementary school children as a function of social system definers. Am J Orthopsychiatry . 1978;;48:446-63 [PubMed: 307912]
15. Lambert NM. Adolescent outcomes for hyperactive children: perspectives on general and specific patterns of childhood risk for adolescent educational, social, and mental health problems. Am Psychol . 1988;;43:786-99 [PubMed: 3195797]
16. Lambert NM, Hartsough CS, Sandoval J. Children's attention and adjustment survey—home and school versions. 1990.
17. Levin FR, Kleber HD. Attention deficit hyperactivity disorder and substance abuse: relationships and implications for treatment. Harv Rev Psychiatry . 1995;;2:246-58 [PubMed: 9384909]
18. Loney J, Kramer J, Salisbury H. Medicated vs. unmedicated hyperactive boys as adults: attitudes toward and use of substances. 1998.
19. Lynskey MT, Fergusson DM. Childhood conduct problems, attention deficit behaviors, and adolescent alcohol, tobacco, and illicit drug use. J Abnorm Child Psychol . 1995;;23:281-302 [PubMed: 7642838]
20. McDougall SA, Duke MA, Bolanos CA, Crawford CA. Ontogeny of behavioral sensitization in the rat: effects of direct and indirect dopamine agonists. Psychopharmacology . 1994;;116:483-90 [PubMed: 7701053]
21. Milberger S, Biederman J, Faraone S, Chen L, Jones J. ADHD is associated with early initiation of cigarette smoking in children and adolescents. J Am Acad Child Adolesc Psychiatry . 1997;;36:37-43 [PubMed: 9000779]
22. Piazza PV, Deroche V, Rouge-Pont F, Le Moal M. Behavioral and biological factors associated with individual vulnerability to psychostimulant abuse. 1997 [PubMed: 9686413]
23. Pierce RC, Kalivas PW. A circuitry model of the expression of behavioral sensitization to amphetamine-like psychostimulants. Brain Res Brain Res Rev . 1997;;25:192-216 [PubMed: 9403138]
24. Post RM. Intermittent versus continuous stimulation: effect of time interval on the development of sensitization or tolerance. Life Sci . 1980;;26:1275-82 [PubMed: 6991841]
25. Report of the International Narcotics Control Board for 1996.
26. Wilens TE, Biederman J, Mick E, Faraone SV, Spencer T. Attention deficit hyperactivity disorder (ADHD) is associated with early onset substance use disorders. J Nerv Ment Dis . 1997;;185:475-82 [PubMed: 9284860]

Existing Practices and Barriers Regarding Assessment and Treatment

1. Costello EJ, Edelbrock C, Costello AJ, Dulcan MK, Barne BJ, Brent, D. Psychopathology in pediatric primary care: the new hidden morbidity. Pediatrics . 1988;;81:415-24 [PubMed: 3405677]
2. Diller LH. The run on Ritalin: attention deficit disorder and stimulant treatment in the 1990's. Hastings Cent Rep . 1996;;26:12 [PubMed: 8722521]
3. Horwitz SM, Leaf PJ, Leventhal JM, Forsyth B, Speechley KN. Identification and management of psychosocial and developmental problems in community-based primary care pediatric practices. Pediatrics . 1992;;89:480-5 [PubMed: 1371342]
4. Jensen PS, Kettle L, Roper MT, Sloan MT, Dulcan MK, Hoven CW, et al. Are stimulants over-prescribed? Treatment of ADHD in four U.S. communities. J Am Acad Child Adolesc Psychiatry. In press [PubMed: 10405496]
5. Kelleher KJ, Childs GE, Wasserman RC, McInerny TK, Nutting PA, Gardner WP. Insurance status and recognition of psychosocial problems: a report from pediatric research in office settings and the ambulatory sentinel practice networks. Arch Pediatr Adolesc Med . 1997;;151:1109-15 [PubMed: 9369872]
6. Knapp M. Economic evaluations and interventions for children and adolescents with mental health problems. J Child Psychol Psychiatry . 1997;;38(1):3-25 [PubMed: 9232456]
7. Leaf PJ, Alegria M, Cohen P, Goodman SH, Horwitz SM, Hoven CW, et al. Mental health service use in the community and schools: results from the four-community MECA study. J Am Acad Child Adolesc Psychiatry . 1996;;35:889-97 [PubMed: 8768348]
8. Offord DR, Boyle MH, Szatmari P, Rae-Grant NI, Links PS, Cadman DT, et al. Ontario Child Health Study. II. Six-month prevalence of disorder and rates of service utilization. Arch Gen Psychiatry . 1987;;44:832-6 [PubMed: 3498458]
9. Rappley MD, Gardiner JC, Jetton JR, Houang RT. The use of methylphenidate in Michigan. Arch Pediatr Adolesc Med . 1995;;149:675-9 [PubMed: 7767425]
10. Wolraich ML, Hannah JN, Pinnock TY, Baumgaertel A, Brown J. Comparison of diagnostic criteria for attention deficit hyperactivity disorder in a county-wide sample. J Am Acad Child Adolesc Psychiatry . 1996;;35:319-24 [PubMed: 8714320]
11. Wolraich ML, Lindgren S, Stromquist A, Milich R, Davis C, Watson D. Stimulant medication use by primary care physicians in the treatment of attention deficit hyperactivity disorder. Pediatrics . 1990;;86:95-101 [PubMed: 2359688]

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

For making bibliographic reference to consensus statement no. 110 in the electronic form displayed here, it is recommended that the following format be used: Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder. NIH Consens Statement Online 1998 Nov 16-18; In press. [cited year, month, day]; 16(2): In press. [PubMed: 10868163]

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