https://doi.org/10.1177/0009922817706148 Clinical Pediatrics 2017, Vol. 56(9) 805–810 © The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922817706148 journals.sagepub.com/home/cpj Commentary The prognosis of attention deficit hyperactivity disorder (ADHD) continues to “show heightened risk of multiple mental health and social difficulties as well as premature mortality in adult life” after nearly 50 years of primary pharmacological treatment. 1 If the prognosis of ADHD is not changed by stimulants, then 2016 research that stimulants may cause cardiac arrhythmia and myocar- dial infarction associated with subsequent death in chil- dren younger than 17 years prescribed methylphenidate (MPH) 2 raises the question of whether stimulants should be used. Furthermore, a 2015 Cochran Review found 98·6% of ADHD randomized clinical trials were consid- ered high risk for bias and the remaining trials could also have been considered high risk by using a stricter defini- tion. 3 Has medicalization and marketing of the diagnosis and treatment of ADHD become the basis of putting children at risk by using stimulants, especially in the United States? 4,5 History of ADHD Attention deficit hyperactivity disorder, which today is the most common neurobehavioral disorder of child- hood, was historically considered to be within the nor- mal range of childhood behaviors. 6 The 1954 edition of Nelson’s Textbook of Pediatrics stated that children entering school are “naturally restless and overactive . . . inattentive and noisy” recommending that there “not be unduly long periods of work or sitting quietly in one place.” 7 The 1975 edition of Nelson’s introduced the term hyperkinetic syndrome and stated, difficulties in managing the active toddler mostly reflect inconsistent discipline by the parents . . . the normally exuberant activity of young grade school boys may present problems for teachers in the early school years . . . as a general principle, it may be wise not to have boys begin their first grade experience before the age of six, or at times closer to seven. 8 Medication, dextroamphetamine or methylphenidate (MPH), was recommended, “at times to be a helpful adjunct in the management of children with learning disabilities.” 8 By 1979, Nelson’s brought up a concern related to the use of psychoactive medication, stating, “ethical issues are being raised regarding the ‘behavioral control’ of young children.” 9 The 2004 edition of Nelson’s stated that ADHD, diagnosed with symptoms of increased activity, decreased attention, and impulsiv- ity, is the most common neurobehavioral disorder of childhood, with 80% of affected children continuing with symptoms into adolescence and adulthood. 6 Prevalence of ADHD and Stimulant Use A dramatic increase in the daily use of stimulants, higher stimulant dose, and longer-acting formulations leading to increased adherence has occurred with the increase in prevalence of ADHD and its comorbidities. 10 It is note- worthy that the prevalence of ADHD increased by an average of 4% per year from 1997 to 2006. 11,12 This increase was found in children 12 to 17 years old with no significant increase in children 6 to 11 years old, sug- gesting that earlier exposures to stimulants may have been related to the increased prevalence. 11,12 There was a 7-fold increase in the number of prescriptions written for ADHD treatment between 1987 and 2008. 13 Forty- nine percent of young children with ADHD in the United States are being treated only with medications. 14 In a report reviewing prescriptions for more than 15 million insured patients, 9% of boys between the ages of 12 and18 years were using stimulant medication in 2012, 706148CPJ XX X 10.1177/0009922817706148Clinical PediatricsStern et al research-article 2017 1 Developmental-Behavioral Pediatrician (Retired), Telford, TN, USA 2 Neuroscience Consulting, Inc, Unicoi, TN, USA 3 Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA 4 Harvard Medical School, Boston, MA, USA 5 McLean Hospital, Belmont, MA, USA 6 Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, USA Corresponding Author: James C. Thigpen, Bill Gatton College of Pharmacy, East Tennessee State University, Box 70657, Johnson City, TN 37614-1704, USA. Email: thigpen@etsu.edu Risks of Stimulant Use for Attention Deficit Hyperactivity Disorder on the Developing Brain: Primum non nocere H. Patrick Stern, MD 1 , Jonathan Lipman, PhD 2,3 , Susan L. Andersen, PhD 4,5 , John B. Bossaer, PharmD, BCPS, BCOP 6 , and Jim Thigpen, PharmD, BCPS 6