The S.T.A.R.T. Now program was developed in consultation with the following organizations*:

• The Drug Enforcement Administration (DEA)
• The National Association of School Nurses (NASN)
• The National Council for Patient Information and Education (NCPIE)
• The National Institute on Drug Abuse (NIDA)
• The National Institute of Mental Health (NIMH)

Novartis would like to thank each of these organizations for lending their valuable time to this project.

*These organizations do not endorse any particular products or companies.

Introduction
Learning that a child has been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) may evoke different responses in different parents. You may be relieved to learn the cause for your child's difficulties in school and with social relationships; you may be confused about what ADHD is and what it means for your child; or you may be distressed to learn that your child has a medical condition. Regardless of your personal reaction, you probably have a lot of questions.

Important Facts

• One of the first things you need to know is that you are not alone-many other parents are going through the same thing. ADHD is the most commonly diagnosed behavioral disorder in North America. ¹
• ADHD is also the most studied childhood psychiatric disorder and has been recognized for over 40 years.
• There are a variety of treatments such as behavioral therapy, counseling and/or medication available to help manage this condition.
• With appropriate treatment, many children with ADHD overcome the challenges presented by the disorder.

You are visiting this website because your child's doctor has prescribed medication as part of his or her ADHD treatment plan. This information is intended to help ensure that children take their medication responsibly. It is also another resource you can access for important information about ADHD. First we'll discuss ADHD treatment and proper use of medication; then, we'll review some facts about ADHD.

I. Straight Talk About Straight Responsible Treatment
ADHD Treatment
The overall treatment plan for ADHD usually includes more than one type of help. The first treatment step focuses on behavior: parents, teachers and healthcare professionals teach patients how to control some of their inappropriate actions. When a doctor believes it is necessary, the next step involves the use of medication that may help improve the symptoms of ADHD. According to some experts, a combination of medicine, behavior therapy and emotional support leads to great improvement in people with ADHD. A 14-month study involving more than 500 children showed that school-aged children diagnosed with ADHD had a marked reduction in core ADHD symptoms when treated with a combination of medication and behavioral treatment.²

Stimulant Medicines
Since your child's doctor has prescribed a medication as part of his or her ADHD treatment, your child is likely to be taking the kind of medicine known as a "stimulant." Stimulant medications help the brain normalize the activity of certain chemicals that are affected by ADHD (these chemicals are known as neurotransmitters). Stimulant medications include both short- and long-acting treatments. If you are not sure whether the medication your child is taking is a stimulant, ask your child's doctor.

When taken appropriately, stimulant medications can improve symptoms in up to 90% of children with ADHD.³ They help calm children who are hyperactive and help children who have trouble concentrating to focus. Stimulants have been used safely and effectively in the treatment of ADHD for over 40 years. However, like other prescription medications, if stimulant medications are misused, abused or given to kids without ADHD, there may be serious health consequences.

What Can I Do to Help Ensure My Child Only Takes His or Her Medication as it is Supposed to be Taken?

• Maintain open lines of communication with your child and his or her teachers.
• Make sure that your child understands that as with all prescription medications, medications for ADHD should only be taken by him or her, as directed by a physician. They should never be given to friends.
• Kids and teens need to know that if they give away or sell prescription medications, not only are they participating in conduct that could cause serious harm to another individual, they are also engaging in illegal activity.⁴

In the past, all medications for ADHD had to be taken periodically during the day. Today, there are options available that do not need to be taken during school hours. New, longer-acting formulations of the original treatments have been developed and are now available. Keeping your child's medication out of his or her school may decrease the likelihood of diversion. Also, children are sometimes reluctant to take their medication at school because of concern about being singled out as "different" or about peers accusing them of "being on drugs." If your child is currently taking a medication that is given in school you may want to talk to his or her doctor about whether a longer-acting treatment may be appropriate. However, if your child does need to take medicine during school hours, be familiar with the school's policies and procedures for dispensing medication. Procedures vary, so in addition to following the policies of your child's school, you may want to consider some of the following precautions.

Steps to S.T.A.R.T. with if your Child is Taking Medicine During School:

S

• Find out how medications are Stored at the school.

• Take medication to school personally rather than sending it in with your child, and bring written directions about appropriate dosing and dispensing of the medication. You will also be asked to sign a permission form that will allow the school's staff to give your child his or her medication during school hours.

• Know the Amount of medication that should be taken each week and check in regularly with the school nurse (or other school official if your child's school does not have a nurse) to ensure that treatment is going smoothly.

• Report any changes in dosage or dosing schedule to the school nurse (or other school official if your child's school does not have a nurse).

• Try to schedule a meeting between you, your child and school staff who will be responsible for dispensing the medication. During the meeting you can discuss the importance of responsible use of stimulant medications and/or review school policies and procedures with your child. You may also want to request that the school provide periodic reports for your child's doctor on any changes the school staff has noticed since your child started the medication.

It may also help to follow some simple storage guidelines:

• Also, make sure that your child's medication is stored safely in your home and that you or another responsible adult administer it.
• Stimulant medications should not be stored in hot, damp, humid or very cold places.
• Medication should be stored in a safe place where others can't see it or easily get it such as a cabinet or cupboard. It might also be helpful to maintain a log each time the medicine is given so that you will know if any is missing.

Myths about Stimulant Medications
Even though stimulant medications have been around for a long time, there is a lot of misinformation about them. The following are just some of the myths that exist about stimulants and ADHD.

MYTH: Stimulants are safe for anyone to take because they are a prescription medication.	FACT: Stimulant medications are only to be taken as prescribed by qualified healthcare professionals. A prescription medication is only safe for you if you are the person for whom it was prescribed.
MYTH: Stimulants are addictive.	FACT: There is no evidence to suggestthat kids taking stimulant medications as indicated as part of an ADHD treatment program become addicted to the medications.5
MYTH: Taking these medications leads to drug abuse.	FACT: Research has shown that appropriate treatment of ADHD with stimulant medications may in fact decrease the likelihood of drug abuse in later life.6
MYTH: Everyone can benefit fromtaking a stimulant every now and then to improve focus, study or stay alert.	FACT: Stimulants are designed to restore the natural balance of the chemicals in the brain affected by ADHD. They should only be taken as prescribed by qualified healthcare professionals.

Misuse and Abuse of Stimulant Medications

Patterns of misuse and abuse include:

• Taking higher than prescribed doses.
• Frequent episodes of binge use followed by severe depression.
• An overpowering desire to continue inappropriate use of the medication despite serious adverse medical and social consequences.⁷

Stimulant medications are classified as Schedule II by the Drug Enforcement Administration (DEA). Schedule II drugs are medicines of accepted medical value that, if misused or abused, can lead to tolerance and psychological dependence. Codeine is an example of another Schedule II drug. Codeine is found in Tylenol® with Codeine, Robitussin® A-C and other medications commonly given to children. These medications should only be taken by mouth as prescribed by a doctor. Inappropriate use of these medications can be highly dangerous. When used as indicated, these drugs are safe, effective and non-addictive.

As the DEA explains, this does not mean that a child or young adult who is properly diagnosed with ADHD and prescribed a stimulant medication as part of his or her treatment will become "addicted" or become a drug abuser. Low-dose, oral ADHD medication is generally not associated with misuse or addiction when taken as prescribed. In fact, study findings suggest that appropriate use of stimulants in children with ADHD may decrease the likelihood of drug abuse in later life. ⁸, ⁹

What Can Happen When Stimulant Medications are Misused or Abused?

As with other prescription medications, taking stimulants in a way other than intended can have serious consequences. According to the DEA, abuse of stimulant medications may result in the following:

• Short, intense periods of high energy; feelings of nervousness or stress, uncontrollable shaking, rapid beating of the heart, forcible or irregular pulsing of the heart that is noticeable to the person experiencing it, and high blood pressure from very high doses.
• Psychotic episodes, paranoid delusions, hallucinations and bizarre behavior.¹⁰

If your child demonstrates any of these symptoms or behaviors, talk to your child and a healthcare professional immediately.

How Common is Misuse and Diversion of Stimulant Medications?

You may have seen reports about misuse and abuse of stimulant medications on TV or read about this issue in the newspaper or in a magazine. While there has been a lot of media coverage on the topic, until recently there were not any wide-scale studies to determine just how common the problem is. In 2001, the investigative arm of Congress known as the General Accounting Office (GAO) surveyed principals of public middle and high schools across the United States. Eight percent of these principals reported knowing of ADHD medications being given away, stolen or misused/abused at their school. Most of those principals reported knowing of only one incident. The GAO report also stated that increasing use of once-daily medications may reduce the potential for diversion.

The extent of the problem may vary in different schools and your child's experiences might be very different from someone else's. The important thing is to be aware that there is the potential for others to want to experiment with or to gain access to your child's ADHD medication.¹¹

Following the storage and safety guidelines discussed in this brochure may help reduce the likelihood of stimulant abuse and diversion. Nevertheless, it is important to be able to spot warning signs such as the following:

• Withdrawn, depressed, or tired behavior.
• Hostile or uncooperative attitude.
• Strained or changed relationships with family members¹²

II. ADHD Information

What is ADHD?

• ADHD is a medical disorder associated with the balance of chemicals (neurotransmitters) in the brain.
• While researchers continue to investigate the exact cause of ADHD, scientific studies suggest that it is related to disturbances in the transmission of the brain chemical called dopamine and, to a lesser extent, another chemical in the brain called norepinephrine.
• People with ADHD have difficulty paying attention, staying still and controlling their impulses.
• Because there is no one test that identifies ADHD, doctors must uncover the disorder by looking at certain patterns of behavior. While clinical studies using brain imaging technologies have shown differences in the brains of people with ADHD, such technology is not a common diagnostic tool.
• Although there is no genetic test for ADHD, the disorder's tendency to run in families has led researchers to believe that genetics may also play a role.
• Studies show that between 4%-12% of U.S. school-aged children have ADHD, which is about 4 million kids in all.¹³
• About half of those who need medication to control their ADHD when they are children no longer need it when they are adults. However, ADHD symptoms may continue into the teenage years and adulthood.
  • It is estimated that 40% to 80% of children with ADHD still meet the diagnostic criteria in adolescence, and some continue to meet the criteria in late adolescence and young adulthood.
  ¹⁴

ADHD Symptoms
Primary symptoms of ADHD are hyperactivity, inattention and impulsivity. Children with ADHD may demonstrate one, two or all three of the core symptoms. Examples include:

	Hyperactivity	Inattention	Impulsivity
	Roaming around a room Talking incessantly Inability to sit through	Difficulty in filtering out unncessary distractions Getting sidetracked by movements of people or objects.	Acting before thinking Demonstrating a very short temper Yelling or hitting

While children without ADHD may occasionally demonstrate some of these symptoms, children with ADHD exhibit them on a level much greater than that of their peers on an ongoing basis and in more than one setting (such as at school AND at home). When the symptoms stem from ADHD they interfere with the child's ability to function academically or socially on a daily basis.¹⁵

ADHD does not have to stop people from living happy, fulfilling lives because there are effective ways to control its symptoms. However, it is important to know that ADHD can affect learning, behavior, self-esteem, social skills and family relationships. A comprehensive treatment program with specific goals, systematic follow-up and consistent monitoring may lead to improved outcomes for children with ADHD and their families. ADHD is a chronic disorder that has been shown to be best addressed by ongoing treatment and management.

In order to initiate a discussion about ADHD and the importance of appropriate use of medication, click here to access a quiz you can complete with your child.

Other Resources
The Internet has many resources available for you to learn more about ADHD and its appropriate treatment. We encourage you to visit the following sites:

• http://www.add.about.com
• http://www.ADDitudemag.com
• American Academy of Pediatrics
  http://www.aap.org
• Children and Adults with Attention Deficit Hyperactivity Disorder
  http://www.chadd.org
• Drug Enforcement Administration
  http://www.deadiversion.usdoj.gov
• National Attention Deficit Disorder Association -
  http://www.add.org
• National Council on Patient Information and Education
  http://www.talkaboutrx.org
• National Institute on Drug Abuse
  http://www.nida.nih.gov
  http://www.drugabuse.gov
  http://www.sarasquest.org
• National Institute of Mental Health
  http://www.nimh.nih.gov
• Novartis Pharmaceuticals Corporation
  http://www.adhdinfo.com
• U.S. Department of Health & Human Services
  http://www.hhs.gov/kids/

References
S.T.A.R.T Now Parents Brochure

1. Richters, J. et al. MTA Background and Rationale. J. Am Acad. Child and Adolesc. Psych. 1995; 34: 987-1000.

2. MTA Cooperative Group. A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder. Archives of General Psychiatry. Dec. 1999; 56:1073-1086.

3. Goldman, L.S. et al. Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. JAMA. April 8, 1998; 279 (14): p. 1106.

4. What are the dangers in abusing stimulant medications? http://www.deadiversion.usdoj.gov/pubs/brochures/stimulant/stimulant_abuse.htm#e.

5. Goldman, L.S. et al. Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. JAMA. April 8, 1998; 279 (14): p. 1106.

6. Biederman, J. et al. Pharmacotherapy of Attention-Deficit/Hyperactivity Disorder Reduces Risk for Substance Use Disorder. Pediatrics. August 1999, 104(2).

7. How is it being abused? http://www.deadiversion.usdoj.gov/pubs/brochures/stimulant/stimulant_abuse.htm#d.

8. What are the dangers in abusing stimulant medications? http://www.deadiversion.usdoj.gov/pubs/brochures/stimulant/stimulant_abuse.htm#e.

9. How is it being abused? http://www.deadiversion.usdoj.gov/pubs/brochures/stimulant/stimulant_abuse.htm#d.

10. What are the dangers in abusing stimulant medications? http://www.deadiversion.usdoj.gov/pubs/brochures/stimulant/stimulant_abuse.htm#e.

11. United States General Accounting Office Report 01-1011 Attention Disorder Drugs: Few Incidents of Diversion or Abuse Identified by Schools; September 2001.

12. http://www.kidshealth.org/parent/emotions/behavior/using_drugs_p2.html

13. AAP Subcommittee on Attention-Deficit/Hyperactivity Disorder. Clinical Practice Guideline: Treatment of the School-Aged Child with Attention-Deficit/ Hyperactivity Disorder. Pediatrics Vol. 108. October 2001.

14. Zametkin, A.J. and Ernest, M. Current Concepts: Problems in the Management of Attention- Deficit/Hyperactivity Disorder. New England Journal of Medicine. January 7, 1999: 340(1): 40-46.

15. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). Attention-Deficit/Hyperactivity Disorder. American Psychiatric Association. Washington, D.C. 1994. p. 83.