Central stimulant treatment of childhood attention deficit hyperactivity disorder. Issues and recommendations from a US perspective

The use of CNS stimulants for the treatment of attention deficit hyperactivity disorder (ADHD) in children has steadily increased in most areas of the world over the last 30 years. In mid-1995, at least 1.5 million US children were receiving methylphenidate or dexamphetamine (dextroamphetamine). However, in other countries these agents are not used as widely. Specific stimulant-induced benefits for children with ADHD include: improved school grades, more completed classroom work, fewer reprimands for disruptive behaviour, improved handwriting, and improved behaviour at home and in social situations. Stimulants benefit at least 75% of children with ADHD and are remarkably well tolerated, having few (for the most part minor and temporary) adverse effects. However, the benefits of stimulants that are obvious in most patients with ADHD during a brief clinical trial are primarily symptomatic. Although the behavioural benefits of stimulants are generally present during each period of treatment for as long as the ADHD condition exists (and children with ADHD are now often staying on stimulant medication into their mid-teens), the treatment has not been shown to change the long term outcome of the disorder. Before prescribing stimulants, paediatric physicians need to perform a careful diagnostic assessment for ADHD using multiple sources of information, including detailed ratings of the child's behaviour from his/her teachers and from a parent. If at baseline, the child's academic and behavioural adjustment in the classroom is good, stimulant medication would be inappropriate. However, if the child's pattern of ADHD has consistently and seriously interfered with his/her classroom and home adjustment, stimulant treatment should be actively considered. Should stimulant therapy be initiated, knowledgeable medical follow-up is required.