Attention deficit disorders are among the most commonly diagnosed childhood behavioral disorders. Although there are a number of disorder subtypes, as a group these disorders are referred to as Attention Deficit Hyperactivity Disorder (ADHD). Symptoms include hyperactivity, impulsiveness, and inattention. The American Psychiatric Association’s diagnostic manual provides criteria for identifying ADHD; however, there is no agreed upon test to confirm an attention disorder. Estimates of the prevalence of the disorder vary widely. A recent international review of 19 epidemiological studies conducted in various countries since 1980 on the prevalence of ADHD in school-age children reported ranges of 2 percent to 18 percent. The review found that the ADHD prevalence rate varies depending on the diagnostic criteria, the children included in the sample, and how the data were collected. Researchers conducting the review concluded with a “best” estimate of between 5 and 10 percent of children and adolescents having some form of this disorder. Although controversial, stimulants are the most common treatment for attention disorder symptoms and are the only drugs that are approved by the Food and Drug Administration (FDA) for this purpose. Methylphenidate is the most widely used stimulant, but amphetamines have been increasingly prescribed. Antidepressants, including buproprion and velafaxine, are not approved by the FDA for the treatment of ADHD; however, they are sometimes prescribed by physicians for ADHD if stimulant medications are ineffective or inappropriate for a particular patient. ADHD drugs come in generic forms, but are often referred to by their brand names. Methylphenidate brand names include Ritalin (see fig. 1), Concerta, Methylin and Metadate. Brand name amphetamines include Adderall, Dexedrine, and Dextrostat. Both types of stimulants are available in quick acting, but short duration (2 to 6 hours) tablets. Recently, sustained or extended release tablets lasting 8 to 12 hours have become available, and a once-a-day skin patch is under development. Longer acting drugs may reduce the need for some children to take their medications at school. Several companies are testing nonstimulant drugs for ADHD treatment that do not have the potential for abuse or physical dependency associated with stimulant drugs. Methylphenidate and amphetamines are classified under the federal Controlled Substances Act as Schedule II drugs—those with a high potential for abuse and severe psychological or physical dependence if abused. A 1995 Drug Enforcement Administration (DEA) review of methylphenidate concluded that based on studies of laboratory animals and humans, methylphenidate was similar in pharmacological effects to cocaine and amphetamines. The DEA establishes annual production quotas for Schedule II drugs by analyzing data on past sales, inventories, market trends, and anticipated need. The production quotas for methylphenidate and amphetamines have risen considerably since 1990. (See table 1.) A number of factors have contributed to the increase in the quotas, according to researchers. Key factors include (1) the number of people diagnosed as having ADHD has grown with an expansion in the criteria used to diagnose ADHD; (2) longer periods of treatment for the disorder; (3) more girls are receiving medication than in prior years; and (4) a greater public acceptance of psychopharmacologic treatment of youth. According to data obtained by DEA, about 80 percent of the prescriptions for amphetamines and methylphenidate were to treat children with ADHD. Along with the increase in the use of stimulant medications have come concerns that these drugs may be being diverted from their prescribed use, or otherwise abused. School settings are perceived as particularly vulnerable for abuse because schools store attention disorder drugs for students needing medication while at school. DEA interviews in 1997 with schools officials in three states indicated that schools might leave medications in unsecured locations, such as teachers’ desks, making theft possible. A number of anecdotal news accounts of students abusing these drugs at school have heightened concerns. (See app. IV.) However, no studies are available to document the degree to which these medications are diverted at school. There is some evidence from a small number of studies and national data that abuse of these drugs does occur. (See app. V.) For example, the University of Michigan has surveyed a national sample of public and private 8th, 10th, and 12th grade students since 1991. Of 12th graders surveyed in 2000, 2 percent reported using Ritalin without a prescription in the past year. The University of Michigan survey does not specify where drug use occurred. Based on our survey, an estimated 8 percent of principals in public middle schools and high schools in the United States reported at least one incident of diversion or abuse of attention disorder drugs during the current 2000-2001 school year. (See fig. 2.) Most of those principals reported knowing of only one incident at their school. An additional 3 percent of school principals reported at least one possible incident, but were uncertain of the drugs involved. Of the 8 percent reporting an incident of diversion or abuse in the current school year, only methylphenidate was involved at 73 percent of the schools, and only amphetamines were involved at 20 percent of the schools. In the remaining cases, the specific drug could not be determined or both drugs were involved. Using the U.S. Department of Education designations for community, we classified schools as being located in central cities, urban communities, or small towns. We compared incident rates by school and community type. (See fig. 3.) Due to the low number of incidents overall, we were unable to draw any statistical conclusions about possible association between these factors and the incidence rate. Principals reporting any incident at their school were asked to briefly describe the incident for which they had the most information. A content analysis of the 51 incidents described by our sample respondents showed that in 38 cases the student gave or sold pills to other students. For example, “Student brought Adderall to school and attempted to sell it to other students.” A second type of incident (4 cases) involved pills being stolen from other students or the school. The remaining incident descriptions were varied, such as “In all (6) cases, a pill was found outside the entrance to the main building. We aren’t sure if it is a student taking the medication at school or bringing it from home and dropping it outside.” The students involved in the estimated 8 percent of schools with reported diversion or abuse incidents were most often expelled or suspended from school as a consequence of the incident, according to principals. Other measures taken by schools in response to the incident are shown in table 2. An estimated 42 percent of the principals that were aware of an incident did not call police regarding the drug diversion or abuse incident. Consequently, measures of attention disorder diversion or abuse based on official police records may underreport actual occurrences. Most principals did not perceive the diversion or abuse of prescribed attention disorder drugs to be a major problem at their school. An estimated 89 percent reported that it was less of a problem than other illicit drug use, excluding alcohol and marijuana. In general, illicit drug use (excluding alcohol and marijuana) was reported to be not a problem at all or a minor problem by approximately 78 percent of the principals. In addition, the most frequent comments voluntarily written by principals were comments regarding the lack of an ADHD medication abuse problem at their school. For example, one principal stated that “I feel comfortable in stating that there is ‘NO DIVERSION’ of medication that is administered through the office/clinic.” We compared incident rates by the principal’s assessment of the problem, but were unable to draw any statistical conclusions about a possible association due to the low number of incidents overall. Most school officials reported that attention disorder medications are administered to students during the school day, most often by a nurse. However, only a small fraction (less than 2 percent) of a school’s students were reported to receive these drugs. Most schools reported that drugs were stored in locked cabinets or rooms, and that students are observed when they take their medications. Nationally, an estimated 90 percent of schools have school staff administering attention disorder medication to some students on a typical day, according to principals we surveyed. Schools that do not typically administer these drugs may have policies that prohibit dispensing medication, or do not have students currently requiring attention disorder medication during school hours. As shown in figure 4 estimates, statistically more middle school officials (96 percent) administered ADHD medications than did high school officials (83 percent). However, incident estimates by community type were not statistically different. While 90 percent of principals in our study population reported that their schools administer attention disorder medications, a relatively small fraction of students attending these schools were administered attention disorder medications while at school. An estimated 1.1 percent of students (in schools where drugs are administered) were dispensed methylphenidate and an estimated 0.5 percent of students were administered amphetamines, for an overall rate of almost 2 percent. A DEA drug diversion official expressed concern during recent congressional testimony with the volume of methylphenidate on hand at school for student daytime dosing. Our survey found that 6 percent of schools stored 600 pills or more, while over half of the schools stored 100 pills or less. (See fig. 5.) At schools that dispense attention disorder medications, the personnel approved to administer medications varied among schools. Nurses were reported to most often carry out that task, and second to nurses, nonhealthcare professionals, such as secretaries, most often dispense medications. (See table 3.) Lack of a nurse or other trained healthcare professional was noted as a concern by several principals. Of the 107 optional comments written by principals in our survey, 13 comments were about the need for nurses to administer medication to students.