In the spring, Riana Shaw Robinson learned that her 11-year-old son, Madison, had sprinted out of class to chase a squirrel through his school’s courtyard in Berkeley, Calif.

It’s not how her sixth grader would typically behave. But that day Madison hadn’t taken his Adderall — the medication that, in his words, helps his brain slow down, “from 100 miles per hour — like a car — to 70 miles per hour.”

Ms. Robinson said Adderall worked better for her son than the other medications they had used to treat his attention deficit hyperactivity disorder. With Adderall, he was calmer and better able to focus.

“He actually had a taste for what relief could look like,” Ms. Robinson said.

But for nearly a year now the medication — Madison takes the generic version — has been difficult to find. He has had to skip doses, sometimes for up to two weeks, because nearby pharmacies have been out of stock.

The family is rationing his pills this summer so that Madison, who recently turned 12, will have them during the school year.

“We try to manage with a couple of caffeine drinks during the day and soccer in the afternoons,” Ms. Robinson said, strategies that she said have helped her son regulate his emotions.

In July, the Food and Drug Administration posted more shortages in A.D.H.D medications, adding generic versions of Concerta and two types of Vyvanse capsules to the list. And in August, the F.D.A. and the Drug Enforcement Administration took the rare step of issuing a joint public letter acknowledging the shortage and asking manufacturers to increase production.

A representative from Takeda Pharmaceuticals, which makes Vyvanse, said in an email that a “manufacturing delay, which we are actively working to resolve,” had created a temporary disruption in the supply of certain Vyvanse capsules, adding that “we expect this to continue into September 2023.”

Parents and caregivers across the country are spending hours each month hunting down pharmacies with A.D.H.D. medication in stock and asking their doctors to either transfer or rewrite prescriptions, a process many equate to having a second job. Others pay hundreds of dollars out of pocket for name-brand drugs that are sometimes more readily available but, unlike generics, are not covered by their insurance. Some children end up taking similar but less effective medications or go without medication for months at a time because their families do not have the extra time or cash.

A.D.H.D., which is often characterized by inattention, disorganization, hyperactivity and impulsivity, is one of the most common childhood neurodevelopmental disorders. Because of the medication shortage, children across the country with the condition fell behind in their schoolwork over the spring, and their relationships often suffered as they struggled to regulate their emotions, according to interviews with multiple doctors and parents. Meanwhile, they all wonder: Why is this happening, and when will it end?

‘She couldn’t catch up’

One of the cruelest aspects of the A.D.H.D. medication shortage, some parents have said, has been the collateral damage to their children’s self-esteem.

Kari Debbink, who lives in Bowie, Md., said her daughter, who is about to enter her senior year of high school, would lose motivation to do her school work when her A.D.H.D. medication, Concerta, was not available in either the brand name or the generic version. Her grades, which had typically been B’s, plummeted — and so did her confidence.

“Once she got behind, she couldn’t catch up,” Ms. Debbink said. “By the end of the year, we were just trying to prevent her from failing classes.”

Drew Tolliver, 12, who lives in DeKalb, Ill., typically takes the generic version of Concerta, but since February, his family has had difficulty finding it.

When taking the medication regularly, Drew said, “I felt like I knew myself.”

“I felt like a better me,” he added, “like how ‘myself’ should be.”

His mother Amy Tolliver recently located the medicine — but she had to pick it up 40 minutes away from the gas company where she works 10-hour shifts, six days a week.

In the spring, Drew would refuse to go to class when he didn’t have his medication, said Michelle Tolliver, Amy’s wife and Drew’s second parent. She and Amy sometimes relented and allowed him to stay home.

“I hated to see him feel like he failed,” Michelle Tolliver said.

‘I was on hold for 50 minutes’

Because A.D.H.D. medications are considered controlled substances, patients are required to get a new prescription for each 30-day supply.

“I was on hold for 50 minutes waiting to talk to a pharmacist,” Dr. David Grunwald, a child and adolescent psychiatrist in Berkeley, Calif., said of a recent call to track down A.D.H.D. medication for a child whose mother has a chronic illness and cannot spend hours on the phone.

In his practice, he said, long hold times with large pharmacy chains are becoming the norm.

“It feels like a game where you don’t know which stimulant is going to be in short supply each week or month,” he said. “It’s very frustrating.”

Dr. Kali Cyrus, a psychiatrist with a private practice in Washington, D.C., has had to call pharmacies so often that she is planning to hire someone to help her check availability. Right now she tries to squeeze in calls throughout the day, including in the morning, when she is making breakfast or walking her dog.

In her sessions with patients, she said, she sometimes has to decide “how to combine different strengths or formulations to get my patient their normal dose — or as close as we can,” or switch to another stimulant that is more available.

Changing medications can result in a less effective treatment, doctors say, because certain stimulants work better for some people than others. Even switching from name-brand drugs to generic versions can be problematic. Generic versions of Concerta, for example, may not release their drugs over time in the same way as the original.

Because of the shortage, Paige and Leo, who live in Northern California, are now giving their 7-year-old son, Andy, the drug Metadate, which they say lasts only six hours. (The family asked to be referred to by their middle names to protect their privacy.)

This means that Andy then requires an additional dose in the afternoon, administered during his after-school program. Sometimes the staff would forget, Paige said.

When that happened, “we would get a call like, ‘Your kid’s out of control,’” Leo said.

Demand for stimulants has soared

For children with A.D.H.D. who have trouble functioning in daily life, stimulant medications like amphetamines (Adderall) and methylphenidate (including Ritalin and Concerta), have long been considered the gold standard of treatment by psychiatrists and pediatricians.

“They are one of our most effective treatments in psychiatry — period,” said Dr. Alecia Vogel-Hammen, an assistant professor of psychiatry at the Washington University School of Medicine. “They have been life-changing.”

In recent years, these drugs have been in high demand. The use of prescription stimulants to treat A.D.H.D. doubled from 2006 to 2016. And between the pandemic years 2020 and 2021, the percentage of people who had a prescription filled for a stimulant rose by more than 10 percent among some adults and teens, according to an analysis from the Centers for Disease Control and Prevention.

The growing numbers — and the ease of being evaluated via telehealth — have raised concerns that some people are being misdiagnosed and that stimulants for A.D.H.D. are being overprescribed, or abused by people who do not have A.D.H.D. but who use the drug to be more productive in school or at work. But this is not the case across the board. Studies have found that girls, people of color and those who identify as L.G.B.T.Q. are often underdiagnosed and undertreated for A.D.H.D.

Doctors say demand for A.D.H.D. medications has also risen because of increasing awareness about the condition in both children and adults.

Why is the shortage happening?

The disruption in A.D.H.D. medications mirrors the shortage of hundreds of other types of drugs, including generic forms of chemotherapy, that have fallen victim to a faltering pharmaceutical supply chain.

Typically, drug shortages are tied to a single manufacturing facility, said Michael Ganio, an expert in drug shortages at the American Society of Health-System Pharmacists.

But in this case, according to the F.D.A.’s online drug database, the A.D.H.D. medication shortage now involves several manufacturers — mostly those who make generic drugs — and has been ongoing since the fall of last year. On the F.D.A.’s website, the reasons offered by each manufacturer are sometimes as opaque as “regulatory delay” or “other.” Others say “shortage of active ingredient” or “increased demand.”

Some manufacturers have given specific time frames for when the issues might be resolved, such as “mid-August.” But it is unclear when that will translate to restocked pharmacy shelves.

Because controlled substances have a high potential for abuse, the D.E.A. sets limits on how many of these drugs can be produced. But in 2022, the manufacturers of amphetamine medications produced about 1 billion fewer doses than they were permitted to make, according to government records. They did not fully meet their quotas in 2020 or 2021 either.

When asked for more specifics about which companies were not meeting the quotas or whether any companies had asked to increase their quotas, a D.E.A. official responded that details about each company’s quotas are considered confidential.

“The fact that there’s no information is just that much more frustrating,” Dr. Ganio said.

Emails to the drug manufacturers currently described as having a shortage of A.D.H.D. medications provided little clarity as to when the problems might be resolved. A representative from Teva Pharmaceuticals, which manufactures Adderall, said it was continuing to see “unprecedented demand” that may cause “intermittent delays” but that it planned to produce the full amount of doses it was permitted to make. Granules Pharmaceuticals, which makes the generic equivalent of Adderall XR and Adderall IR, said it had requested to raise its D.E.A. quota.

Another factor potentially driving the shortage: a $21 billion settlement brokered between three pharmaceutical distributors and most states that placed new requirements on pharmaceutical companies to help stem the flow of controlled substances like prescription painkillers. It has resulted in tens of thousands of drug orders being canceled, including those for A.D.H.D. drugs.

“There is a higher level of scrutiny on all controlled-substance ordering by pharmacies,” said Ilisa Bernstein, a senior vice president at the American Pharmacists Association. “It’s created a perfect storm.”

Suzana, who lives in Tennessee and asked to be referred to by her first name to protect her family’s privacy, described the shortage as a “nightmare.”

This year, she said, her 16-year-old son’s extended release generic Focalin became difficult to find. And because they couldn’t get it consistently, his fourth quarter played out like a “roller coaster.”

“One week he will have a 100 in the class and next week multiple zeros,” she said.

Over the summer, Suzana said, he was on and off his medication so they could save his pills for the school year, which began Monday. That meant she would have extra time to find a refill for his medication.

“This morning I actually counted pills to see how many he had left,” she said.

Now that her son has his driver’s license, she plans to limit his driving, but she worries: “If he doesn’t take a dose and he drives — will he be OK?”

After years of litigation to hold the pharmaceutical industry accountable for the deadly abuse of prescription painkillers, payments from what could amount to more than $50 billion in court settlements have started to flow to states and communities to address the nation’s continuing opioid crisis.

But though the payments come with stacks of guidance outlining core strategies for drug prevention and addiction treatment, the first wave of awards is setting off heated debates over the best use of the money, including the role that law enforcement should play in grappling with a public health disaster.

States and local governments are designating millions of dollars for overdose reversal drugs, addiction treatment medication, and wound care vans for people with infections from injecting drugs. But law enforcement departments are receiving opioid settlement money for policing resources like new cruisers, overtime pay for narcotics investigators, phone-hacking equipment, body scanners to detect drugs on inmates and restraint devices.

“I have a great deal of ambivalence towards the use of the opioid money for that purpose,” said Chester Cedars, chairman of Louisiana’s advisory opioid task force and president of St. Martin Parish. The state’s directives say only “law enforcement expenditures related to the opioid epidemic,” added Mr. Cedars, a retired prosecutor. “That is wide open as to what that exactly means.”

On Monday, 133 addiction medicine specialists, legal aid groups, street outreach groups and other organizations released a list of suggested priorities for the funds. Their recommendations include housing for people in recovery and expanding access to syringe exchange programs, personal use testing strips for fentanyl and xylazine, and medication that treats addiction.

They expressly stated that no funds “should be spent on law enforcement personnel, overtime or equipment.”

“Law enforcement already gets a lot of funding, and I’m sure they would say it’s never enough,” said Tricia Christensen, an author of the proposed priorities, who is the policy director at Community Education Group, which has been tracking opioid settlement money across Appalachia. But the opioid money, she said, “is really unique.”

Groups that monitor opioid settlements use various criteria to estimate the total payout. But even employing the most conservative tabulation, the final amount could well be north of $50 billion when pending lawsuits are resolved, notably the multibillion-dollar Purdue bankruptcy plan, which the Supreme Court temporarily paused last week.

At first glance, that looks like a fabulous trove of money. In reality, it will be parceled out over 18 years and is already dwarfed by the behemoth dimensions of the opioid crisis, now dominated by illicit fentanyl and other drugs.

The spectacle of states as well as thousands of cities, counties and towns all struggling to determine the most effective uses of these desperately needed funds is raising many questions.

Underlying the wrangling is a push for greater transparency in awarding the money and a determination not to repeat the mistakes of the Big Tobacco settlement 25 years ago. State governments have used most of the $246 billion from tobacco companies to plug budget holes and pay for other projects, and reserved relatively little to redress nicotine-related problems.

Now, states and local governments have committees to determine appropriate allocation of the opioid money. Sheriffs and police officials comprise less than a fifth of the members on those task forces, according to a recent analysis by KFF Health News, Johns Hopkins University and Shatterproof, a national nonprofit that focuses on addiction.

But public sentiment in many communities favors ridding the streets of drug dealers as a means of abating the crisis.

When Samuel Sanguedolce, the district attorney of Luzerne County in Pennsylvania, presented his budget to the County Council in November, he made a pitch for some of the county’s settlement money, about $3.4 million so far.

“With 10 more detectives, I could arrest those cases around the clock,” he said, referring to drug dealers. “I think this is a good way to use money that resulted from this opioid crisis to assist those detectives without putting it on the taxpayers.”

“And I’ve asked not just for detectives,” he continued. “But hiring people, of course, costs money, in the way that they need guns and vests and computers and cars.”

In many areas of the country, the lines between law enforcement and health care can be somewhat blurred: Police and sheriffs’ departments are also emergency responders, trained to administer overdose reversal drugs. Louisiana is dedicating 20 percent of its opioid money to parish sheriffs.

Sheriff K.P. Gibson of Acadia Parish, who represents sheriffs on Louisiana’s opioid task force, said that he intended to use the $100,000 his department is set to receive for “medical needs” of people in the jail, including various opioid treatments and counseling. The goal, he said, is to help inmates become “productive citizens within our community,” once they are released.

Public health officials and addiction treatment specialists are also concerned about another use of the money: grants for faith-based rehab programs that prohibit federally approved medications like Suboxone and methadone, which blunt cravings for opioids.

“I would be open to a faith-based cancer program, but not one that doesn’t let you take effective medicines to treat the cancer,” said Dr. Joshua Sharfstein, a professor at Johns Hopkins Bloomberg School of Public Health, which has released its own guidance principles for the settlement funds.

Throughout the years of negotiating opioid settlements, lawyers for states, tribes and local governments and those defending drug distributors, manufacturers and pharmacy chains struggled to avoid the pitfalls that emerged from the Big Tobacco litigation.

This time, local governments have struck agreements with state attorneys general over the allocation of the money. Legislatures are largely excluded from most of the funds.

Johns Hopkins praised Rock County, Wis., as a jurisdiction that strove to get a full picture of local needs for the money: It put together a working group to review evidence-based literature and conducted surveys and meetings to elicit community suggestions.

In North Carolina, county governments receive 85 percent of the funds, which have reached nearly $161 million so far. Having signed onto the core principles worked up with the attorney general, the counties have great discretion in spending their allotments.

“When you look at who addresses the issues of the opioid epidemic, it’s addressed locally by E.M.S., social services and jails. Those are all county functions in North Carolina, so that’s why it made sense for them to get the bulk of the resources,” said Josh Stein, the North Carolina attorney general, who helped negotiate the national opioid settlements.

Each county is establishing its own priorities. Stanly County, he said, is setting up teams to reach people who have just survived overdoses, hoping to connect them with services. Mecklenburg County has directed some of its funding for post-recovery education and job-training programs.

Such uses can help to lift a community stricken by addiction, said Ms. Christensen, whose group monitors opioid settlements for 13 states. “I really subscribe to the idea that overdoses are often ‘deaths of despair’ — that the reason many folks spiral into chaotic drug use has a lot to do with what has happened to them and their lack of opportunities,” she said. “So how can we invest in the community to prevent that from happening generation after generation? That’s why I think community input is so important in this process.”

The groups that released the new set of priorities cited examples of promising use of the funds. Michigan’s plans include adding rooms in hospitals so that new mothers can stay with infants born with neonatal abstinence syndrome. Kentucky is giving $1 million to four legal aid groups to represent people with opioid-related cases.

“I was blown away by that,” said Shameka Parrish-Wright, executive director of VOCAL-KY, a community group that worked on the priorities documents. Ms. Parrish-Wright, a former candidate for Louisville mayor who had been addicted to drugs, homeless and incarcerated, added: “Those legal entities are really helpful in making sure we deal with paraphernalia charges and evictions. People coming out of treatment are sometimes discriminated against because of those charges and can’t get housing or jobs.”

VOCAL-KY has not applied for settlement money but works closely with groups that do. Its members attend meetings held by Kentucky’s opioid task force. “Knowing that Black and brown and poor white communities are dealing with it the worst, we pushed them to have another town hall in those communities,” Ms. Parrish-Wright said.

With Big Tobacco’s cautionary tale shadowing these debates, the issue of accountability looms. Who ensures that grantees spend their money appropriately? What sanctions will befall those who color outside the lines of their grants?

So far, the answers remain to be seen. Christine Minhee, a lawyer who runs the Opioid Settlement Tracker, which analyzes state approaches to spending the funds, noted that on that question, the voluminous legal agreements could be opaque.

“But between the lines, the settlement agreements themselves imply that the political process, rather than the courts, will bear the actual enforcement burden,” she said. “This means that the task of enforcing the spirit of the agreement — making sure that settlements are spent in ways that maximize lives saved — is left to the rest of us.”