How do you conduct an assessment and prescribe Attention Deficit Hyperactivity Disorder (ADHD) medications, such as Ritalin (methylphenidate) or Strattera (atomoxetine), virtually or online?

Virtual/Online ADHD Assessment and Prescribing

Conduct a thorough diagnostic evaluation using DSM-5 criteria via telehealth, obtain collateral information from multiple settings, complete cardiac screening, and prescribe FDA-approved ADHD medications following the same clinical standards as in-person visits. 1

Diagnostic Assessment via Telehealth

Initial Psychiatric Evaluation

• Verify DSM-5 diagnostic criteria through structured interview: symptoms must be present before age 12, persist for at least 6 months, occur in 2+ settings (home, work/school), and cause clinically significant impairment 1, 2
• For inattentive presentation: document at least 6 symptoms including lack of attention to details, difficulty sustaining attention, poor listening, failure to follow through on tasks, poor organization, avoidance of sustained mental effort, losing things, easy distractibility, and forgetfulness 2
• For hyperactive-impulsive presentation: document at least 6 symptoms including fidgeting, leaving seat inappropriately, excessive running/climbing, difficulty with quiet activities, being "on the go," excessive talking, blurting answers, difficulty waiting turn, and intrusiveness 2
• Obtain collateral information from parents, teachers, or workplace supervisors using standardized rating scales to confirm symptoms across multiple settings 1

Screen for Differential Diagnoses and Comorbidities

• Rule out bipolar disorder, mania, or hypomania through personal and family psychiatric history before initiating any ADHD medication 2
• Assess for substance use disorders, particularly in adolescents and adults, as this requires specialized management before ADHD treatment 1
• Evaluate for anxiety disorders, depression, oppositional defiant disorder, and conduct disorder which commonly co-occur with ADHD 1, 3
• Consider personality disorders in adults as ADHD is frequently misdiagnosed as borderline personality disorder, cyclothymia, or atypical depression 3

Cardiac and Medical Screening

• Obtain detailed cardiac history including Wolf-Parkinson-White syndrome, sudden death in family, hypertrophic cardiomyopathy, long QT syndrome, and specific cardiac symptoms 1
• Perform baseline vital signs including blood pressure and heart rate, which can be obtained at local pharmacy or with home monitoring devices 1
• Order ECG if cardiac risk factors present before starting nonstimulant medications (atomoxetine, guanfacine, clonidine), and consider cardiology referral if ECG abnormal 1
• Screen for narrow-angle glaucoma and pheochromocytoma as these are contraindications to atomoxetine 2

Neuropsychological and Functional Assessment

• Assess severity and functional impairment using validated scales such as the Weiss Functional Inventory Rating Scale (WIFRS) 4
• Consider formal neuropsychological testing (WAIS-IV, Conner's CPT-3) when diagnosis is unclear or comorbidities complicate the presentation 4
• Document impairment in social, academic, or occupational functioning to justify pharmacological intervention 2

Age-Specific Prescribing Guidelines

Preschool-Aged Children (4-5 Years)

• Prescribe evidence-based parent/teacher behavior therapy as first-line treatment before considering medication 1
• Consider methylphenidate only if behavior therapy fails AND there is moderate-to-severe dysfunction AND symptoms persist for at least 9 months 1
• Start at lower doses (2.5 mg methylphenidate) with smaller increments due to slower metabolism in this age group 1
• Note that methylphenidate use remains off-label in this age group despite moderate evidence for safety and efficacy 1

Elementary School-Aged Children (6-11 Years)

• Prescribe FDA-approved stimulant medications as first-line (methylphenidate or amphetamine preparations) with effect size of 1.0 1
• Start methylphenidate at 5 mg or dextroamphetamine at 2.5 mg, given after breakfast and lunch for immediate-release formulations 1
• Titrate weekly in increments of 5-10 mg for methylphenidate or 2.5-5 mg for amphetamines until optimal response achieved 1
• Maximum doses: 60 mg/day total for methylphenidate, 40 mg/day for amphetamines per PDR (though clinical practice may occasionally exceed these) 1
• Consider nonstimulants (atomoxetine, extended-release guanfacine, extended-release clonidine) as second-line with effect size of 0.7 1
• Combine with parent/teacher behavior therapy for optimal outcomes 1

Adolescents (12-18 Years)

• Prescribe FDA-approved medications with adolescent's assent as primary treatment 1
• Screen for substance abuse before initiating treatment and monitor for medication diversion 1
• Consider medications with lower abuse potential such as atomoxetine, extended-release guanfacine, lisdexamfetamine, dermal methylphenidate, or OROS methylphenidate if diversion risk is high 1
• Ensure medication coverage extends to driving hours using longer-acting or late-afternoon short-acting formulations 1

Adults

• Initiate atomoxetine at 40 mg/day and increase after minimum 3 days to target dose of 80 mg/day, with maximum of 100 mg/day 2
• For patients >70 kg: follow adult dosing; for patients <70 kg: use 0.5 mg/kg initially, target 1.2 mg/kg/day 2
• Methylphenidate initiation in adults requires off-label use in many jurisdictions, though it remains highly effective 3, 4
• Screen carefully for bipolar disorder, substance use, and personality disorders which are commonly comorbid 3, 4

Medication Selection Algorithm

First-Line: Stimulants

• Methylphenidate or amphetamine preparations are equally effective with approximately 40% responding to both, 40% to only one, making individual response idiosyncratic 1
• Choose long-acting formulations for once-daily dosing and improved adherence (OROS methylphenidate, lisdexamfetamine, extended-release mixed amphetamine salts) 1
• Immediate-release formulations require 2-3 times daily dosing due to short duration of action 1

Second-Line: Nonstimulants

• Atomoxetine: selective norepinephrine reuptake inhibitor, no abuse potential, useful for patients with substance abuse risk, anxiety, or tics 1, 5, 6
• Extended-release guanfacine or clonidine: α2-adrenergic agonists, useful for patients with tics or as adjunctive therapy 1, 6
• Note: nonstimulants are less effective than stimulants (effect size 0.7 vs 1.0) but have different side effect profiles 1

Adjunctive Therapy

• Only extended-release guanfacine and extended-release clonidine have FDA approval for adjunctive use with stimulants 1
• Consider adjunctive therapy when stimulant monotherapy provides partial response or is limited by side effects 1

Titration and Monitoring Protocol

Initial Titration Phase (2-4 Weeks)

• Conduct weekly telehealth or phone check-ins during dose adjustments 1
• Obtain parent and teacher rating scales at each contact to assess response 1
• Use fixed-dose titration trial (similar to MTA study) where different doses are tried weekly, then select the most effective dose 1
• Systematically assess side effects by asking specific questions about insomnia, anorexia, headaches, social withdrawal, tics, weight loss 1

Maintenance Phase

• Schedule monthly telehealth visits until symptoms stabilized 1
• Obtain teacher reports before or at each visit when possible 1
• Monitor weight at each visit as objective measure of appetite suppression 1
• Check blood pressure and heart rate regularly throughout treatment 2
• Reassess long-term need periodically with consideration of medication holidays 2

Common Pitfalls and Safety Considerations

Stimulant-Specific Concerns

• Growth suppression: expect 1-2 cm decrease in height, most pronounced in first 2 years, with diminishing effect by year 3 1
• Cardiovascular effects: monitor for chest pain, shortness of breath, fainting; stimulants cause statistically but not clinically significant increases in heart rate and blood pressure 1, 2
• Psychotic symptoms: rare occurrence of hallucinations; discontinue if these develop 1
• Sudden cardiac death: extremely rare and evidence is conflicting whether stimulants increase risk 1

Atomoxetine-Specific Concerns

• Black box warning for suicidal ideation: monitor closely, especially in first weeks of treatment 1, 2, 5
• Hepatotoxicity: extremely rare but serious; educate patients about signs of liver injury 1, 2
• Slower onset of action: may take 2-4 weeks for full effect compared to immediate stimulant response 2, 5
• CYP2D6 metabolism: poor metabolizers have greater exposure and slower elimination; consider lower doses 5

α2-Agonist-Specific Concerns

• Somnolence and sedation: most common side effects, may limit tolerability 1
• Rebound hypertension: must taper off rather than abruptly discontinue 1
• Bradycardia and hypotension: monitor vital signs regularly 1

Diversion and Misuse Prevention

• Use prescription drug monitoring programs to identify potential diversion 1
• Consider nonstimulants or abuse-deterrent formulations for high-risk patients 1
• Monitor prescription refill requests for signs of misuse 1
• Educate patients about proper storage and not sharing medications 2

Documentation Requirements

• Document comprehensive diagnostic evaluation including DSM-5 criteria, collateral information, and functional impairment 1, 2
• Record informed consent discussion including risks, benefits, alternatives, and off-label use when applicable 4
• Maintain detailed medication logs with doses, titration schedule, response, and side effects 1
• Document cardiac screening and any contraindications identified 1
• Note that atomoxetine is indicated as part of total treatment program that may include counseling or other therapies 2