What is the appropriate assessment protocol for Attention Deficit Hyperactivity Disorder (ADHD) before prescribing stimulants, such as methylphenidate (Ritalin) or amphetamine, to a patient with potential cardiovascular history and risk of substance abuse?

Appropriate Assessment for ADHD Before Prescribing Stimulants

Before prescribing stimulants for ADHD, you must complete a comprehensive psychiatric evaluation with collateral information from multiple settings, obtain a detailed medical and cardiac history with specific screening for structural heart disease and sudden death risk factors, establish baseline vital signs and growth parameters, and assess for substance abuse risk—all while ruling out alternative diagnoses and identifying comorbidities that may complicate treatment. 1

Core Psychiatric Evaluation Components

The psychiatric evaluation must include interviews with both the patient and family members (or collateral informants for adults), balancing confidentiality needs against the requirement for a common information base for treatment decisions 1. This evaluation should:

• Gather information from multiple settings and informants to confirm that symptoms cause moderate to severe impairment in at least two different settings (home, school/work, social situations) 1
• Review previous treatment records to assess past successful and unsuccessful interventions, reducing the likelihood of repeating ineffective treatments 1
• Communicate with other professionals involved in the patient's care (teachers, pediatricians, school nurses) to obtain collateral history and establish monitoring systems 1
• Identify psychosocial factors that may impede medication trials or confound outcome assessment, ensuring psychosocial approaches are included in the treatment plan 1

The assessment must determine whether ADHD or another disorder is present, as ADHD has a broad differential diagnosis and high comorbidity rates 2, 3.

Critical Medical History and Cardiovascular Screening

Mandatory Cardiac History Elements

Before initiating stimulants, obtain a detailed personal and family cardiac history specifically screening for 4, 5:

• Personal cardiac symptoms: syncope, chest pain, palpitations, exercise intolerance, seizures
• Structural cardiac abnormalities: any known heart defects or cardiomyopathy
• Family history of sudden death before age 50, particularly unexplained sudden death
• Family history of specific conditions: Wolff-Parkinson-White syndrome, hypertrophic cardiomyopathy, Long QT syndrome, malignant arrhythmias 1, 4

Additional Medical Contraindications to Screen

Document and rule out 1, 4:

• Symptomatic cardiovascular disease, hypertension, or hyperthyroidism
• Glaucoma
• Active psychotic disorder (absolute contraindication) 1
• Seizure disorder (if present, must be controlled with anticonvulsants before starting methylphenidate) 1
• Current medication use: prescribed medications, over-the-counter drugs, complementary/alternative treatments, illicit substances 1
• Medication allergies and previous sensitivity to stimulants 1, 4

Baseline Physical Measurements

Required baseline measurements before any ADHD medication 4:

• Blood pressure and pulse (mandatory for all patients regardless of age)
• Height and weight to monitor growth effects during treatment 1, 4
• Physical examination to document that the patient is healthy and establish a normal baseline 1, 4

ECG Screening Controversy

Routine ECG screening is NOT required before stimulant initiation according to current guidelines 4. The American Academy of Pediatrics explicitly opposes routine ECG screening for all children, contradicting an earlier 2007 American Heart Association recommendation 4. However:

• ECG is mandatory if the cardiac history or physical examination reveals any concerning findings 6
• Cardiology referral is required if any cardiac risk factors are identified 4
• Large population-based studies show stimulants do not increase risk of myocardial infarction, sudden cardiac death, or stroke in the general population 4, 6, 7

Substance Abuse Risk Assessment

High-Risk Populations Requiring Special Precautions

Stimulants must be used with great care if there is a history of drug abuse and are contraindicated in patients with active stimulant abuse unless closely supervised 1, 4. Before prescribing:

• Assess each patient's risk for abuse, misuse, and addiction 5
• Consider urine drug screening in adults with high rates of comorbid substance abuse before starting stimulants 4
• Educate patients and families about abuse risks and proper medication storage 5
• If household members have stimulant abuse history, implement safeguards to prevent diversion 1

For patients with substance abuse history who require ADHD treatment, consider long-acting stimulant formulations (lower abuse potential) or non-stimulant alternatives like atomoxetine as first-line 4, 8.

Psychiatric Comorbidity Screening

Mandatory Screening Before Stimulant Initiation

Screen for risk factors for developing a manic episode before starting stimulants 5:

• Comorbid or history of depressive symptoms
• Family history of suicide, bipolar disorder, or depression
• Current psychotic symptoms (absolute contraindication to stimulants) 1

Common Comorbidities Requiring Assessment

Evaluate for 3:

• Anxiety disorders (present in significant proportion of ADHD patients)
• Mood disorders including depression and bipolar spectrum disorders
• Oppositional defiant disorder and conduct disorder
• Learning disabilities and developmental disorders
• Tic disorders and Tourette's syndrome (assess family history and clinically evaluate for motor or verbal tics) 5

Note: The presence of depression or anxiety is NOT a contraindication to stimulant therapy—both conditions can be treated concurrently 8. However, severe mood disorders may require addressing the mood disorder first 8.

Documentation Requirements

Before initiating stimulant treatment, document 1, 4:

• Adequate assessment confirming ADHD diagnosis
• Previous psychosocial treatments attempted and their outcomes
• Previous psychotropic medications: specific drugs, dosages, duration, response, side effects, and compliance
• Current medications including all prescribed, over-the-counter, and complementary treatments 1

Special Considerations for Patients with Cardiovascular History

For patients with hypertension or cardiovascular concerns 4:

• Confirm blood pressure is well-controlled (target <130/80 mmHg) before initiating stimulants
• Consider non-stimulant alternatives first: atomoxetine (minimal BP impact) or alpha-2 agonists like guanfacine/clonidine (may actually lower BP)
• If stimulants are necessary, use extended-release formulations for smoother cardiovascular effects and implement more frequent BP/pulse monitoring 4

Common Pitfalls to Avoid

• Do not skip cardiovascular screening even in young, apparently healthy patients—sudden death cases have been reported in patients with unrecognized structural cardiac abnormalities 5, 6
• Do not prescribe stimulants without confirming symptoms in multiple settings—single-setting impairment does not meet diagnostic criteria 1
• Do not assume a single informant provides adequate information—collateral information from teachers, family members, or workplace supervisors is essential 1
• Do not overlook substance abuse screening in adolescents and adults—stimulants have high abuse potential and require careful risk assessment 1, 4, 5
• Do not start stimulants in patients taking MAO inhibitors or within 14 days of MAOI discontinuation—risk of hypertensive crisis 1, 5