The child, who requires all of a parent’s attention, cannot sit still, and constantly interrupts, may have ADHD. Similarly, the child who is the dreamer, always struggling to pay attention in school, and having difficulty following instructions, may also have ADHD. Children with ADHD are easily bored, distracted by sights and sounds in the environment, and flit from one activity to another. They may fail in school, have difficulty with family and peer relationships, and suffer from low self-esteem. These difficulties persist into adolescence and adulthood. Thus, the impact of ADHD for children and families has a devastating and long-lasting effect.
Among school-age children, ADHD has a three to five percent prevalence rate. Boys tend to exhibit hyperactive symptoms, whereas, girls more frequently have attention deficit behaviors.
For many years, most clinicians believed that children outgrew ADHD. Now, however, there is growing recognition (Secnik, et al. 2005; McGough and Barkley 2004) that ADHD often continues into and throughout adulthood. And, ADHD often exists in the presence of a psychiatric co-morbidity. The difficulties associated with diagnosis and treatment of adults will be discussed along with how adult ADHD affects employment, health care costs, relationships, etc.
Formerly known as “minimal brain dysfunction”, ADHD was thought to be caused by birth trauma, neurological infections, minor head injuries, and bad parenting. Although the root cause of ADHD remains unknown, scientists now know that ADHD has a neurobiological basis involving a chemical imbalance in the brain that affects the neurotransmitters. Neurotransmitters, such as dopamine, norepinephrine, and serotonin, help convey messages across the neural gap. When these chemicals are not available in the necessary amounts, messages are sent incorrectly resulting in behaviors characteristic of ADHD.
Studies of twins have uncovered some genetic links involving the dopamine transporter locus; these studies reveal a dysfunction within frontal intentional networks that are critical to prepare us to act. Scientists conclude that ADHD children lack appropriate transmitters to help them prepare a response to stimuli they encounter. Consequently, the child selects abnormal responses, including impulsive and hyperactive behaviors, randomly (Mostofsky and Denckla 1999). The same deficits and dysfunctions are thought to continue in adults with ADHD.
The task of correctly identifying ADHD frequently falls to the health care team in the primary care setting. ADHD is the third most common chronic disorder seen in primary care practice; the other two are asthma and chronic otitis media with effusion. Like other chronic illnesses, ADHD causes significant impairment in children’s lives. Normal developmental milestones may not be achieved; children with ADHD are behind in fine motor, social, and adaptive skills. Because ADHD causes interference with the child’s ability to “fit in”, a social stigma often is associated with this condition. Children with ADHD who make it into adulthood without being diagnosed have usually developed good coping mechanisms to mask behavior. The difficulties experienced in childhood also impact functioning of adults with ADHD.
Current practice guidelines advocate that any child who presents with symptoms of ADHD or school underachievement should be evaluated for ADHD. In addition to noting the presence of ADHD symptoms, which are specifically discussed in the next section, other assessment tools should be used to gather complete information from the child, parents, and teachers. The three most commonly used assessment tools specifically designed to identify ADHD are 1) the Vanderbilt ADHD Diagnostic Parent and Teacher Scales (VADPRS and VADTRS), 2) the Conners’ Parent and Teacher Rating Scales (CPRS-R and CTRS-R) and 3) the Swanson, Nolan and Pelham Questionnaire IV Rating Scale (SNAP-IV) (Leslie, 2002). Other tests such as the Achenbach Child Behavior Checklist (CBCL) or the Conners’ Global Problem Index (CGI-P) are not recommended to diagnose ADHD, but are useful to diagnose other behavioral problems and rule out ADHD.
Some pediatric practices take a pro-active approach to the identification of ADHD. Whenever a parent schedules a well-child visit for a 6 to 12 year old, a screening questionnaire is given to the parent for completion before the visit. Some practices send the VADPRS and VADTRS to the parent and ask that it be completed and returned before the well-child visit. The pediatric nurse conducts interviews with the child and parentcaregiver, scores the questionnaires, and documents observations of the child’s behavior during the interview and visit. The nurse’s role continues throughout treatment as the parent educator, parent encourager, and child advocate with the school. More about these aspects of treatment is discussed later.
ADHD in adults may manifest itself as poor work history, difficulty with social interactions, and substance abuse (Secnik, et al. 2005). Unfortunately, adult ADHD may be overlooked or dismissed even though between 10 and 60 percent of adults diagnosed with ADHD as children continue to exhibit behaviors consistent with ADHD (Secnik, et al. 2005).
The accurate diagnosis of ADHD requires a comprehensive evaluation that involves determining the child’s developmental level, academic ability, social skills, and emotional functioning. The parentsprimary caregiver must also be involved in the evaluation. The diagnosis of ADHD in adults is far more elusive as the diagnostic criteria are not specifically delineated and tools for measurement are considered non-specific.
Many children remain undiagnosed and carry the symptoms of ADHD into adulthood without receiving treatment. A study of a community-based sample of children found that only one in eight of children with ADHD was diagnosed and treated with appropriate medication while half of the children treated with ADHD medications did not meet the diagnostic criteria for ADHD (Wolraich, 2002).
To standardize the ADHD diagnostic process, the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV-TR) lists specific symptoms as criteria for a diagnosis of ADHD. The symptoms related to inattention, hyperactivity, and impulsivity are further subdivided according to the ADHD behaviors exhibited by the child. There are three resulting diagnostic categories 1) inattentive type, 2) hyperactive-impulsive, and 3) combined type that is a combination of inattentive and hyperactive-impulsive types. Further diagnostic criteria are that a child must exhibit symptoms for more that 6 months and experience significant problems in at least two of the following settings-home, school, or social. While the criteria also say evidence of these symptoms should have been seen before age 7, many physicians feel that inattentive ADHD is often overlooked because those symptoms are not disruptive and may not have been obvious prior to age 7.
Children diagnosed as predominately inattentive ADHD must exhibit six or more of the following symptoms
Children diagnosed with hyperactive-impulsive ADHD must exhibit six or more of the following symptoms
According to CHADD, the organization for children and adults with attention-deficithyperactivity disorder, a diagnostic evaluation is not complete without these additional components physical examination, completion of parent and teacher rated behavior scales, interviews with parents and the child, psychological tests, intelligence testing, parent self-report measures, and a review of prior school and medical records.
What makes the diagnosis even more difficult is that many other conditions can mimic ADHD symptoms and must be ruled out to be sure that the child is correctly diagnosed. Things like impaired vision and hearing can interfere with paying close attention and being able to understand and follow directions. Some epileptic seizures present as inattention. Further, psychiatric conditions can confound making an accurate ADHD diagnosis. Some of these conditions may exist as co-morbid diagnoses, making the diagnosis and treatment of ADHD more complicated. Depressive and anxiety disorders are both common. Depressive conditions may appear as a lack of interest in activities. Weight gain or loss; and too much or too little sleep also symptoms of depression. Anxiety disorders may present as obsessive-compulsive symptoms, panic attacks, extraordinary fear, and phobias. Bi-polar disorder, formerly called manic-depressive, may appear in children with ADHD as frequent cycles of agitation and depression.
Learning disorders very commonly accompany ADHD. The criteria for a learning disorder is that the child scores substantially lower on standardized tests in reading, math, or written expression than is expected for the age, schooling, and level of intelligence of the child. When a learning disorder co-exists with ADHD, treatment for the learning disorder must also be prescribed. Some of the psychosocial treatments involved in ADHD will benefit children with learning disabilities; however, specific interventions are also needed.
Oppositional defiant behavior and conduct disorder also commonly co-exist with ADHD. Both of these disorders include anti-social behaviors. Children are belligerent, hostile, set fires, engage in cruelty. These behaviors serve to isolate the child and make implementation of a comprehensive treatment regimen a challenge. The primary care health team can serve as guides, advocates, and stabilizers for families and children with oppositional defiant behavior and conduct disorder.
McGough and Barkley (2004) explore the difficulties associated with diagnosing ADHD in adults. Despite growing recognition that ADHD persists into adulthood, the lack of good diagnostic tools and corresponding DSM-III codes often force clinicians to rely on a diagnosis in childhood with residual effects lasting into adulthood. Research completed in the last decade indicate that childhood ADHD persists into adulthood in 60 – 70 percent of cases based on comparisons with same-age peers and, when DSM-III criteria are used in conjunction with parental report, as many as 58 percent exhibit symptoms (McGough and Barkley 2004).
Researchers in Utah developed the Wender Utah Rating Scale after working with adults exhibiting minimal brain dysfunction and tying that diagnosis to ADHD in childhood (McGough and Barkley 2004). The Wender is specifically designed to uncover, retrospectively, an ADHD disorder in childhood. Examinations of its sensitivity, specificity and internal factor structure reveal high correlation with parental reports of childhood behavior (McGough and Barkley 2004, p. 3). Validation of the instrument has led to its translation into Spanish, German, and Italian.
The Wender contains subsets of behavior characteristics that cluster around inattentiveness, hyperactivity, mood lability, irritability and hot temper, impaired stress tolerance, disorganization, and impulsivity which then are used to define and describe adult ADHD (McGough and Barkley 2004). Shortcomings of the Wender include a focus on individuals with lifelong inattention and hyperactivity to the exclusion of individuals with inattentive ADHD.
DSM criteria for diagnosis also rely on an established diagnosis of childhood ADHD. Unfortunately, DSM-IV criteria for ADHD were developed by a work group mainly interested in children so that the behaviors associated with the criteria are not related to adult behavior ,i.e., “has difficulty playing quietly” (McGough and Barkley 2004). Unfortunately, at this point clinicians are forced to extrapolate from either the Wender or DSM criteria to diagnose adult ADHD.
Secnik and colleagues (2005) explored co-morbidities and costs associated with adult ADHD. This national study involving 4504 subjects revealed that adults with ADHD were more likely to have a co-morbid illness including asthma, depression, substance abuse, bipolar disorder, antisocial disorder or oppositional disorder. Inpatient, out-patient, and pharmaceutical costs were also significantly higher for the ADHD group (Secnik, et al. 2005).
The treatment of ADHD is multi-faceted and must involve the child, the family, the pediatrician, pediatric nurse, school personnel, peers, and specialists as needed. Each component of the treatment plan is necessary to maximize the child’s therapeutic response. Evidenced-based treatment guidelines have been developed by an American Academy of Pediatrics (AAP) task force and provide a compass for providing effective intervention. Three key elements delineate the AAP plan. First, a partnership among parents, clinicians, and the child must work collaboratively with school personnel throughout the treatment plan. Second, the guidelines use evidence-based practice plans that must be followed to maximize effectiveness. Third, the AAP uses an outcomes approach so clinicians, children and families can monitor the impact of therapy and make adjustments when outcomes are not achieved.
The importance of the primary care team as active participants cannot be over emphasized. Children with ADHD and their families need ongoing support to stick with the treatment protocol and weather the inevitable storms that arise as the child grows and develops. Further, use of stimulant medication is recommended by the AAP. Many rigorous studies suggest that carefully monitored medication use is the single most efficacious treatment for ADHD.
A new drug is now available for treatment of ADHD. Atomoxetine (Strattera) fills a void felt by those children who could not tolerate the usual stimulant medications. Atomoxetine is classified as a selective norepinephrine reuptake inhibitor. Studies indicate that a 1.2 mgkgday significantly improved symptoms (Wimett and Laustsen 2005). Advantages of amotoxetine include not a controlled substance, not a stimulant, unlikely to be abused or cause psychological dependence.
Psychostimulants were found useful more than 60 years ago and now they are considered the most effective therapy for children with ADHD. Many of the prescribed drugs contain methylphenidate (MPH) that is classified as a cerebral stimulant. Methylphenidate increases the release of norepinephrine and dopamine in cerebral cortex to stimulate the reticular activating system. Many varieties of methylphenidate are manufactured; the newer drugs have long acting or extended-release features to provide continuous dosing without making the child take a medication during school hours. Because children seem to do better when their MPH is rising, the drug Concerta contains two drug compartments each with different drug concentrations so that drug levels do not fall during the afternoon (Adesman, 2002).
Following is a chart of some of the methylphenidate medications used to treat children with ADHD. Most studies demonstrate that 70 percent of children do better on stimulant medication and the percentage rises to 90 if an alternative is tried after the first one fails (Leslie, 2003). Children are usually started on a low dose which is titrated upward slowly to achieve maximum effectiveness.
Typical Duration (hours)
6 to 8
6 to 8
6 to 8
6 to 8
Adderall XR capsules
10 to 12
May be single dose or divided equally throughout the day
Start with 40 mg/day; target is 80 mg/day
Dosing based on symptoms; may increase to 100 mg/day
Adderall XR contains amphetamine as the stimulant. This relatively new compound works like Ritalin LA in that it contains two equal compartments of beads. Fifty percent of the beads are immediate release and the rest release approximately four hours later to provide a once a day treatment with longer effective duration.
The neurobiologic effect of these drugs is essentially the same. The main differences are in the duration of action, strength of action, and necessity for mid-day dosing. General consensus is that children with ADHD should be treated with stimulant medications along with psychosocial measures. Research demonstrates that children treated with medication alone do not do as well as children treated with medication and psychosocial interventions Adesman, 2002).
Some short-acting psychostimulants have a rebound effect wherein the child becomes more active, inattentive, and impulsive as the drug wears off. Rebound typically occurs in the afternoon, when the child returns home. It is important to inform parents about the possibility of rebound so that if it does occur they will recognize it for what it is and, ask for a longer-acting medication. If additional medication is needed, it must be administered in a dosage and at a time that will not interfere with the child’s sleep.
Desipramine is a tricyclic antidepressant that has been used to treat the symptoms of ADHD. Some clinicians thought it was the drug of choice until recent reports of sudden death related to its cardiac effects were documented in the literature. A cardiology consult is advised before placing a child on Desipramine.
Some non-stimulant medications have been used to treat ADHD. None is approved by the federal drug administration, yet some have achieved some success in children who are refractory to stimulant therapy. Guanfacine, an alpha-2 agonist similar to Clonidine, has been useful to treat the hyperactivity of ADHD. Bupropion, an anti-depressant with indirect dopamine agonist and noradrenergic effects, was effective in adolescents with a co-morbidity of depression.
Response to medication is varied. General improvements include decrease in excessive talking and classroom disruption, improved fine motor control, decreased anger, bossiness and aggression, improved attention span and short-term memory, and reduced impulsivity. Most children show some improvement in symptoms and clinicians are urged to try different drugs to achieve maximum therapy.
Parents of a child with ADHD are faced with daily challenges. They do well to recruit grandparents, friends, coworkers, and neighbors to help them directly or indirectly with their child’s care. Parents are advised to educate as many people as possible about ADHD, including the bus driver, clerk in the corner store, baby-sitters, etc. The more people who interact with the child understand about ADHD, the more beneficial they can be to the overall treatment plan.
Building self-esteem is a basic and very important step in the overall treatment plan for ADHD.
Parents can promote a child’s self-esteem by doing the following
All children want to feel as if they have something of value to offer to their family, friends, siblings; children need positive recognition. Perhaps a good place for parents to start is by enlisting the child in hisher own care; children have both the need and the right to know about their condition and the treatment plan. By helping the child understand, resistance to aspects of treatment may be lessened.
Other actions the parent can use to help the child include giving simple, one-step directions, ignoring negative behavior, and avoiding blaming. The use of time-out and loss of privileges are usually the most effective reinforcements of negative behavior. Some parents establish a token economy system whereby the child earns tokens for positive behavior and loses them for negative behavior. The economy system must be clearly defined and used consistently to be effective.
Siblings too must be included in the treatment plan. It is often difficult for them to understand why the child with ADHD receives special treatment. And, it is important for the siblings to participate in the behavior modification program. ADHD is a family affair and all family members are needed to provide the optimal therapeutic environment.
School-age children spend much of their day in the school setting; cooperation and support from the teacher and entire school district is necessary to provide the appropriate environment for children with ADHD. Although most teachers are willing to deal with ADHD in the classroom, they often feel unprepared, lacking knowledge, and overwhelmed. Parents must educate the teacher about ADHD so that an appropriate learning environment can be established.
Section 504 of the Rehabilitation Act of 1973 and the Individuals with Disabilities Education Act (IDEA), as amended in 1997 both guarantee a free appropriate public education for children with disabilities. These laws require that children with disabilities receive comparable, not necessarily equal, opportunities as received by children without disabilities. IDEA requires that a student require special education whereas Section 504 means that a child requires some consideration, i.e., more time to take the test that the other children are taking. Section 504, in most school districts, allows for flexibility to establish a customized individualized education plan for the child with ADHD.
Success in school enhances the child’s self-esteem, so helping the child organize studies and school material can improve hisher chances for success. For example, if the child is forgetful, ask for two textbooks, one for home and one for school. Parents often can receive study and homework assignments in advance so they can help the child organize time and space for home study. Some children have difficulty with homework because their medication level is dwindling; parents can ask the clinician to recommend a long-acting drug to provide effective coverage at home.
Successful relationships with peers are fundamental to growing up. Social skills training can be a useful tool and can be tailored to help hyperactive and inattentive children learn how to relate to peers in positive ways. Schoolmates may be asked to help with reinforcing positive behavior and ignoring negative behavior. Children with ADHD do not intuitively incorporate socially acceptable behavior into the peer interactions. Parents, other family members, teachers, and clinicians can teach appropriate behavior through overt instruction and modeling.
An analysis of treatment programs for children with ADHD and oppositional and defiant behavior revealed that continue stimulant medication is efficacious. Other effective programs involved parent and teaching training programs, teaching children skills for coping with anger and solving problems, and improving social skills (Farley, et al. 2005).
Untreated, ADHD carried into adulthood often results in academic underachievement, low self-esteem, poor peer relations, and erratic work records. Further, risk-taking behavior in adolescents increases and the consequences of risk are greater. For example, adolescents with ADHD have more accidents, receive far more driving tickets, and are more likely to have a confrontation with the law.
Helping the child form a supportive therapeutic relationship with a teacher or coach is often beneficial. Sometimes taking part in a team activity, particularly with adult supervision, helps the teen learn impulse control and fosters development of positive peer relationships. Parents may be advised to hire a coach who specializes in behavior modification techniques to help with goal-setting and self-esteem building.
Although the manifestations of ADHD in boys and girls are basically similar, girls tend to be under diagnosed and under-treated. Girls typically exhibit more inattentive symptoms, which means they are less disruptive, and attention demanding. As a result, ADHD is often not recognized in girls. Hyperactivity in girls may be attributed to “tom-boy” behavior or girls may be very chatty so the behavior is overlooked, a diagnosis is not made, and the symptoms not treated. Girls are, however, at the same risk as boys for long-term negative consequences of social, educational, and psychological problems.
Treatment regimens remain the same as in childhood with stimulants and the new drug atomoxetine as standard. Behavior modification, parental involvement, structured environment are also used to mange ADHD in adolescents. Unfortunately, in a study to examine illicit use of stimulants and other drugs, researcher found that college-age students admit to using ADHD stimulants to enhance concentration, increase alertness, and provide a high (Teter, et al. 2005).
Some children with ADHD make it all the way into adulthood without being diagnosed. Most of these children are highly intelligent, charming, and have developed coping skills that allow them to manage ADHD symptoms. Eventually a level of responsibility is reached that overwhelms native charm and coping ability.
In follow-up studies of children with ADHD, about half function well as adults (ADHD and the Family, 2003). The remainder continues to have difficulty with self-esteem, problem-solving ability, peer and marital relations, impulse control, work record, and attention. Many self-help resources are available through support groups such as, Children and Adults with attention-DeficitHyperactivity Disorder (CHADD) www.chadd.org and the National Attention Deficit Disorder Association (ADDA) www.add.org.
Treatment interventions for adults involve medications, psychological counseling, management of co-morbidities, and life skills training. Atomoxetine, by increasing norepinephrine which “is believed to influence attention, impulse control, and organization of thoughts” may be particularly useful for adults with inattentive ADHD (Quillen 2005).
Nurses working with children and families can serve as teachers to families, support systems to the children, and advocates to member of the school system. When families develop a good rapport with nurses, they tend to seek advice from them and rely on them to provide guidance as they manage the child’s symptoms while trying to maintain a healthy, happy family life.
Nurses have an important role to increase community awareness about adult ADHD. Those who work in emergency rooms and employee health may be able to intervene on behalf of ADHD adults by providing education and insight to others in the environment.
ADHD is a frequently occurring disorder that interrupts a child’s life experience in fundamental ways. Children with ADHD exhibit behaviors of impulsivity, inattention, and hyperactivity that occurs more frequently and with greater severity than is usually observed in children of comparable developmental level and age. Daydreaming, fidgeting, and blurting out answers are commonly seen in children with ADHD. Learning, interacting with family and friends, developing competence in school and achieving self-esteem are all negatively impacted for children with ADHD. A comprehensive plan of care involving all aspects of the child growth and development must be part of the treatment for the child with ADHD.
Stimulant medications are successful in helping children with ADHD control symptoms and modify behavior. If an initial medication is not successful, clinicians are well-advised to try another one as some children respond differently to different medication compounds. Parents and teachers need to know how to judge the effectiveness of the medication so that doses can be regulated to provide appropriate symptom relief in school and after school to complete homework assignments.
Parents and other family members as well as friends can play instrumental roles in helping children with ADHD. Experts advise families to enlist as many helpers and advocates as possible. Further, parents have a key role in helping the child with ADHD develop a strong sense of self and high self-esteem. Often a key to developing self-esteem involves teaching the child specific behaviors to enhance hisher ability to get along with peers.
Educators are also important members of the team caring for children with ADHD. The school system as well as individual teachers can learn how to establish a learning environment to maximize success for children with ADHD. Federal law provides that reasonable consideration be given so that children with ADHD can have the same opportunities as non-ADHD children. Teachers may require information about how to help the child maximize hisher learning opportunities. Limiting distractions in the classroom helps as does providing clear, simple directions for tasks that must be completed.
Adolescents who have not been diagnosed or treated are at higher risk for engaging in risky behaviors. They are apt to take chances while driving, which results in increased traffic violations. They are also more likely to challenge authority figures. Similarly, adults may have gone undiagnosed and may no longer be able to use old coping behaviors to manage adult experiences.
Adults with ADHD may require assistance to stabilize relationships and employment experiences. Symptoms occur more visibly during times of stress and periods that require substantial life adjustments. Programs that increase the knowledge of health care workers, law enforcement personnel, and human resource staff may help avoid crises, job loss, and altercations for adults with ADHD.
Listed below are some resources that are available to families and individuals with ADHD.
Children and Adults with Attention-DeficitHyperactivity Disorder (CHADD
8181 Professional Place
Landover, Maryland 20785
Learning Disabilities Association of America (LDA)
4156 Library Road
Pittsburgh, Pennsylvania 15234
National Attention Deficit Disorder Association (ADDA)
1788 Second Street
Highland Park, Illinois 60035
American Coaching Association
P.O. Box 353
Lafayette Hill, Pennsylvania 19144
National Center for Learning Disabilities
381 Park Avenue South
New York, New York 10016
Adesman, A. R. (2002). New medications for treatment of children with attention-deficithyperactivity disorder. Pediatric Annals. 31, (8), 514-522.
ADHD and the Family A blueprint for success. (2002). Shire US, Inc. Florence, KY Shire Resources.
Building self-esteem in your child. (2003). Focus on ADHD. 2, (1).
Farley, S.E.; Lutton, M.E.; Scoville, C. (2005). The Journal of Family Medicine. 31, (2), 62-65
Hannah, J.N. (2002). The role of schools in attention-deficithyperactivity disorder. Pediatric Annals. 31, (8), 507-513.
Johnson, L. A. and Safranek, S. (2005). The Journal of Family Practice. 54, (2), 166-168
Leslie, L.K. (2002). The role of primary care physicians in attention-deficithyperactivity disorder. Pediatric Annals. 31, (8), 475-484.
McGough, J.J. and Barkley, R.A. (2004). Diagnostic Controversies in Adult Attention Deficit Hyperactivity Disorder. 161, 1948-1956.
Mostofsky, S. H. and Denckla, M. B. (1999). School difficulties. In McMillian, J. A, DeAngelis, C.D., Feigin, R. D., Warshaw, J. B. Oski’s Pediatrics Principles and Practice. Philadelphia Lippincott. Williams and Wilkins.
Quillan, T.F. (2005). Nursing 2005. 35, (2), 1-13.
Robin, A. L. (2002). Attention-deficithyperactivity disorder in adolescents. Pediatric Annals. (31, (8), 485-491.
Secnik, K.; Swensen, A.; Lange, M.J. (2005). Co-morbidities and costs of adult patients diagnosed with attention-deficit hyperactivity disorder. Pharmacoeconomics. 23, (1), 93-102.
Teter, C.J.; McCabe, S.E.; Cranford, J.A.; Boyd, C.J.; Guthrie, S.K. (2005). Prevalence and motives for illicit use of prescription stimulants in an undergraduate student sample. Journal of American College Health. 53, (6), 253-262.