What is a quick screen for prior to stimulant prescription for Attention Deficit Hyperactivity Disorder (ADHD)?

Quick Screen Prior to Stimulant Prescription for ADHD

Before prescribing stimulant medications for ADHD, clinicians should perform a focused cardiac screening that includes personal and family cardiac history, physical examination with vital signs, and consideration of electrocardiogram for patients with risk factors. 1, 2, 3

Cardiac Screening Components

Medical History Assessment

• Obtain specific cardiac symptoms history 4:
  • Chest pain or discomfort, especially with exertion
  • Unexplained syncope or near-syncope
  • Palpitations
  • Excessive shortness of breath with exercise
  • Fatigue out of proportion to level of activity

Family History Assessment

• Screen for 4, 2:
  • Sudden death in family members (especially before age 50)
  • Hypertrophic cardiomyopathy
  • Long QT syndrome
  • Wolff-Parkinson-White syndrome
  • Other significant cardiac conditions

Physical Examination

• Measure baseline vital signs 1:
  • Blood pressure
  • Heart rate
  • Height and weight (for growth monitoring)
• Perform cardiac examination to detect:
  • Murmurs
  • Irregular rhythms
  • Other abnormal cardiac findings

Additional Evaluation

• Consider ECG if any risk factors are present 4, 5
• Consider referral to pediatric cardiologist if 2:
  • Abnormal ECG findings
  • Concerning cardiac symptoms
  • Significant family history of cardiac disease
  • Known structural cardiac abnormalities

Contraindications to Stimulant Therapy

Stimulants should generally not be used in patients with 2, 3:

• Known structural cardiac abnormalities
• Cardiomyopathy
• Serious heart rhythm abnormalities
• Coronary artery disease
• Other serious cardiac problems
• Concurrent treatment with MAOIs or use within preceding 14 days

Psychiatric Screening

• Screen for 2, 3:
  • Pre-existing psychosis (may be exacerbated by stimulants)
  • Bipolar disorder (risk of inducing manic episodes)
  • History of aggression or hostility
  • Family history of suicide, bipolar disorder, and depression

Substance Use Screening

• Consider urine drug screening, especially in adolescents and adults 4
• Assess risk for substance abuse, misuse, and addiction 3

Monitoring Plan

• Schedule follow-up within 2-4 weeks after starting medication 1
• Plan for weekly monitoring during initial titration 1
• Use standardized ADHD rating scales from parents and teachers to establish baseline symptoms and monitor treatment response 1
• Monitor vital signs, growth parameters, appetite, sleep patterns, and mood changes 4, 1

Documentation Considerations

• Document all screening components in the medical record
• Record baseline measurements for future comparison
• Note any risk factors identified and mitigation strategies

Special Considerations

Age-Specific Concerns

• Preschool children: Behavioral interventions are first-line; medication only if significant impairment persists 1
• School-age children: Monitor growth closely (risk of 1-2 cm height reduction) 4
• Adolescents: Assess for substance use risk 3
• Adults: More likely to have underlying cardiovascular disease 6

Common Pitfalls to Avoid

1. Failing to document baseline vital signs before starting treatment
2. Not screening for family history of sudden cardiac death
3. Missing comorbid psychiatric conditions that could be exacerbated by stimulants
4. Inadequate follow-up during initial titration period
5. Overlooking substance use risk, especially in adolescents and adults

By following this structured screening approach, clinicians can identify patients who may be at increased risk for adverse effects from stimulant medications and make appropriate decisions regarding treatment initiation, monitoring, or referral.