ADHD Follow-Up Appointment Framework
Follow-up appointments should occur at least monthly until symptoms are stabilized, with weekly contact during initial medication titration (2-4 weeks), then transition to maintenance monitoring every 3-6 months once optimal response is achieved. 1
Initial Titration Phase (First 2-4 Weeks)
Contact Schedule
- Weekly contact (can be by telephone) during dose adjustment period 1
- Stimulant medications can be titrated on a 3-7 day basis due to immediate effects 1
- Increase methylphenidate by 5-10 mg per dose or dextroamphetamine by 2.5-5 mg weekly if symptom control not achieved 1
- For atomoxetine, increase after minimum of 3 days from 0.5 mg/kg/day to target of 1.2 mg/kg/day 2
Assessment at Each Contact
- Target ADHD symptoms from both parent AND teacher reports 1
- Use standardized rating scales (not just clinical impression) 1
- Obtain self-ratings from adolescents and adults 1
- Systematically assess specific side effects by direct questioning: insomnia, anorexia, headaches, social withdrawal, tics 1
- Weigh the patient at every visit for objective appetite monitoring 1
Stabilization Phase (Until Symptoms Controlled)
Appointment Frequency
- At least monthly until symptoms stabilized 1
- More frequent if: side effects present, significant comorbid psychiatric disorders, poor medication adherence, or need for psychoeducation 1
Key Questions at Each Visit
- Symptom control: Are core ADHD symptoms (inattention, hyperactivity, impulsivity) reduced to near-normal levels in ALL settings (home, school, work)? 1
- Functional improvement: Academic performance, peer relationships, family functioning, occupational performance 1
- Side effects: Specific inquiry about appetite, sleep, mood changes, tics, cardiovascular symptoms 1
- Adherence: Is medication taken as prescribed? Any missed doses? 1
- Comorbidities: Screen for emerging anxiety, depression, substance use, oppositional behavior 1
Maintenance Phase (After Stabilization)
Long-Term Monitoring Schedule
- Continue same dose that achieved response in titration phase 2
- Follow-up every 3-6 months for stable patients 1
- More frequent visits if concerns about adherence, side effects, or comorbid conditions 1
Periodic Reassessment
- Reevaluate long-term medication need periodically 2
- Consider medication holidays or dose reductions to assess ongoing need 1
- Monitor growth parameters (height, weight) at each visit, particularly in first 2 years of treatment 1
- Reassess for emerging comorbidities: learning disabilities, mood disorders, substance use 1
Treatment Adjustment Algorithm
If Inadequate Response at Target Dose
- Verify adherence first 1
- Increase dose to maximum recommended (methylphenidate 60 mg/day total, amphetamine 40 mg/day total) 1
- If top dose ineffective, switch medication class rather than exceeding limits 1
- Consider environmental or psychosocial interventions 1
If Side Effects Emerge
- Adjust dose or timing first (most side effects are dose-related and short-lived) 1
- Consider switching to different stimulant formulation or non-stimulant 1
- Address specific side effects: appetite (give with meals, caloric supplementation), insomnia (earlier dosing, avoid evening doses), tics (may resolve spontaneously, consider non-stimulant) 1
Critical Pitfalls to Avoid
- Suboptimal dosing: Community-treated patients often receive lower doses with less monitoring and have worse outcomes than those with systematic titration 1
- Inadequate monitoring frequency: Monthly follow-up is minimum during stabilization—less frequent contact leads to poor outcomes 1
- Relying only on parent report: Must obtain teacher input and adolescent/adult self-report 1
- Missing comorbidities: Screen systematically for anxiety, depression, learning disabilities, substance use at every visit 1
- Ignoring functional impairment: Symptom reduction alone is insufficient—assess real-world functioning in multiple domains 1
- Premature discontinuation: ADHD is chronic; long-term treatment often needed, but requires periodic reassessment 2