What needs to be covered during a medication management follow-up visit with a patient on Adderall (amphetamine/dextroamphetamine) for Attention Deficit Hyperactivity Disorder (ADHD)?

Medication Management Follow-Up Visit for a 12-Year-Old on Adderall for ADHD

At each follow-up visit, systematically assess ADHD symptom control through parent and teacher reports, monitor for specific side effects (sleep onset delay, appetite suppression, weight loss, tics, stomachache, headache, jitteriness), measure vital signs and weight, evaluate medication adherence, and screen for emerging comorbidities or substance use concerns. 1

Core Assessment Components

ADHD Symptom Evaluation

• Obtain structured feedback from multiple informants: Collect parent reports of symptom control at home and teacher reports of school functioning at each visit 1
• Use standardized rating scales: Supplement clinical assessment with validated ADHD rating scales from both parents and teachers to objectively track symptom severity 1
• Include adolescent self-report: At age 12, the patient's own perspective on symptom control and medication effects is essential 1
• Assess functional domains: Evaluate academic performance, peer relationships, family interactions, and ability to complete age-appropriate tasks 1

Systematic Side Effect Monitoring

Ask specific questions about known amphetamine side effects rather than general inquiries 1:

• Sleep disturbances: Inquire about difficulty falling asleep, time to sleep onset, total sleep duration, and daytime fatigue 1
• Appetite and weight: Ask about decreased appetite, meal skipping, and food intake patterns 1
• Gastrointestinal symptoms: Screen for stomachache, nausea, or abdominal discomfort 1
• Neurological effects: Assess for headaches, jitteriness, tremor, or any new or worsening tics 1
• Mood and behavior changes: Evaluate for social withdrawal, irritability, anxiety, or emotional lability 1

Objective Physical Measurements

• Weight measurement at every visit: This provides objective evidence of appetite suppression and is essential for monitoring growth 1
• Vital signs: Measure blood pressure and heart rate at each visit, as stimulants can cause cardiovascular effects 2
• Height tracking: Monitor linear growth over time, particularly important during adolescence 1

Medication-Specific Considerations

Adherence Assessment

• Evaluate dosing consistency: Determine if the patient takes medication daily as prescribed or skips doses 1
• Identify barriers to adherence: Assess for stigma concerns, forgetfulness, side effects prompting discontinuation, or difficulty with school administration 1
• Review timing of doses: Confirm medication is taken after breakfast and at appropriate intervals for the formulation prescribed 1

Dose Optimization

• Assess adequacy of current dose: If symptom control is inadequate, consider dose adjustment in increments of 2.5 to 5 mg for amphetamine formulations 1
• Evaluate duration of coverage: Determine if symptoms return before the next dose, suggesting need for longer-acting formulation or additional afternoon dose 1
• Recognize dose ceiling: If maximum recommended doses (40 mg total daily for amphetamines) don't provide benefit, consider switching medications rather than exceeding limits 1

Critical Adolescent-Specific Concerns

Substance Use Screening

Before and during treatment of adolescents, screen for symptoms of substance use 1:

• Ask directly about alcohol, marijuana, and other drug experimentation
• If active substance use is identified, refer to a subspecialist for guidance 1

Medication Diversion Risk

• Monitor for signs of misuse or diversion: Watch for early refill requests, lost prescriptions, or inconsistent symptom reports 1
• Educate about diversion risks: Discuss with both patient and parents the importance of secure medication storage and not sharing with peers 1
• Consider abuse-deterrent options: If diversion concerns arise, consider switching to non-stimulant medications like atomoxetine or extended-release guanfacine 1

Driving Safety

• Ensure medication coverage during driving hours: For adolescents who drive or will soon drive, provide symptom control during afternoon/evening hours with longer-acting formulations or late-afternoon short-acting doses 1
• Adolescents with ADHD have significantly elevated crash and violation risks that medication can mitigate 1

Visit Frequency and Follow-Up Schedule

During Dose Adjustment

• Maintain weekly contact during titration: Use telephone follow-up between visits during the 2-4 week dose adjustment phase 1
• Schedule in-person visits for significant changes: See the patient in person when making dose adjustments or addressing side effects 1

Maintenance Phase Monitoring

• Monthly visits until stabilization: Once on a stable dose, continue monthly appointments until symptoms are consistently well-controlled 1
• Extend to every 3-4 months for stable patients: After achieving stable symptom control without significant side effects or comorbidities, visits can be spaced to quarterly 1
• Increase frequency for complications: More frequent visits are warranted if side effects emerge, adherence problems develop, or comorbid conditions require attention 1

Common Pitfalls to Avoid

Side Effect Management Errors

• Don't dismiss mild side effects without intervention: Adjust dose timing or amount rather than accepting problematic side effects 1
• Recognize preexisting symptoms: Staring, daydreaming, irritability, and anxiety may actually improve with higher doses, representing ADHD symptoms rather than medication side effects 1
• Address sleep and appetite issues proactively: When these side effects occur but the medication is highly beneficial, use adjunctive strategies rather than discontinuing effective treatment 1

Cardiovascular Monitoring Gaps

• Take a thorough cardiac history: Before continuing treatment, obtain history of patient and first-degree family members for sudden death, syncope, or arrhythmias 1
• Don't ignore new cardiovascular symptoms: If the patient reports palpitations, chest pain, syncope, or exercise-induced symptoms, hold medication immediately and obtain ECG and cardiology consultation 2

Assessment Limitations

• Don't rely solely on parent report: Teacher input is essential for assessing school functioning, and adolescent self-report provides critical perspective 1
• Avoid subjective-only assessment: Use standardized rating scales to complement clinical judgment and track changes objectively 1