Pre-Stimulant Testing Requirements
No laboratory testing is absolutely required before starting stimulant medication in most patients, but a comprehensive cardiac history, physical examination with vital signs (blood pressure, pulse, height, and weight) are mandatory. 1
Required Pre-Treatment Assessment
Cardiac Evaluation (Mandatory)
The American Academy of Child and Adolescent Psychiatry and American Academy of Pediatrics guidelines establish clear requirements before initiating stimulants 1:
Obtain detailed cardiac history including:
- Personal history of cardiac symptoms (chest pain, syncope, palpitations, exertional symptoms)
- Family history of sudden death (especially before age 50)
- Family history of Wolff-Parkinson-White syndrome, hypertrophic cardiomyopathy, long QT syndrome, or ventricular arrhythmias 1
Physical examination with vital signs must include:
- Blood pressure measurement
- Heart rate/pulse
- Height and weight (to establish growth baseline) 1
Further cardiac evaluation (ECG, cardiology referral) is indicated only if positive findings on history or physical examination suggest cardiac disease 1
Important Distinction: ECG Not Routinely Required
Routine electrocardiography is NOT recommended for all patients before starting stimulants 1, 2. The 2019 Pediatrics guidelines explicitly state that stimulants have not been shown to increase risk of sudden death beyond baseline rates in children, and ECG screening should be reserved for those with concerning cardiac history or examination findings 1.
Additional Required Assessments
Psychiatric and Medical History
Before prescribing stimulants, document 1:
- History of psychotic disorders (absolute contraindication to stimulants) 1
- History of tics or Tourette's syndrome in patient and family 1, 3
- Current medications including over-the-counter drugs and supplements 1
- History of substance abuse (stimulants or other substances) 1
- Screening for bipolar disorder risk in patients with depressive symptoms 4
- Presence of glaucoma, hyperthyroidism, or symptomatic cardiovascular disease 1
- Current use of MAO inhibitors (absolute contraindication) 1
Documentation Requirements
Prior to initiating treatment, document 1:
- Previous psychosocial treatments attempted
- Previous medication trials (names, doses, duration, response, side effects)
- Assessment of treatment compliance history
Laboratory Testing: When Actually Needed
No routine laboratory tests are required for methylphenidate or amphetamine initiation 1. The guidelines explicitly state that "routine history, physical, and laboratory testing completed by a pediatric specialist is not necessary before starting most psychotropic medications" 1.
Exception: Pemoline Only
If pemoline were being considered (which is NOT recommended as first-line due to hepatotoxicity risk), baseline liver function tests would be mandatory 1. However, pemoline should only be used after failure of multiple other agents 1.
Common Pitfalls to Avoid
Over-testing: Ordering routine ECGs, complete blood counts, or metabolic panels delays treatment without evidence of benefit 1, 2
Under-assessment of cardiac risk factors: Missing family history of sudden death or patient's cardiac symptoms can lead to inappropriate stimulant use in high-risk individuals 1
Ignoring growth parameters: Failing to document baseline height and weight prevents monitoring of growth suppression, a known stimulant side effect 1
Inadequate substance abuse screening: Not assessing for personal or household history of stimulant abuse increases diversion risk 1
Monitoring After Initiation
While not "pre-treatment," establish a monitoring plan 1:
- Children: Vital signs checked annually during routine physical examination
- Adults: Blood pressure and pulse quarterly by treating or primary care physician
The cardiovascular effects of stimulants are generally modest (average increases of 1-2 beats per minute for heart rate and 1-4 mmHg for blood pressure), though 5-15% of individuals may experience larger increases requiring monitoring 1, 5.