What follow‑up questions should I ask a patient with ADHD who is taking methylphenidate, considering age, sex, and comorbidities such as anxiety, depression, tic disorder, hypertension, cardiac disease, or substance‑use history?

Follow-Up Questions for Patients on Methylphenidate for ADHD

At every follow-up visit, systematically assess treatment response, adverse effects, comorbid conditions, and medication adherence using structured rating scales from multiple informants—not subjective impressions alone.

Core Symptom Monitoring

ADHD Symptom Control

• Ask about symptom improvement across all settings (home, school/work, social situations) using standardized rating scales from parents, teachers, and the patient themselves, as objective measurement from multiple informants is essential for determining optimal dosing 1, 2.
• Inquire specifically about timing of symptom control: Does medication cover the entire day, or do symptoms return before the next dose? For adolescents who drive, ensure coverage extends to driving hours 2, 3.
• Assess functional impairment: Are academic performance, peer relationships, and family functioning improving? The goal is maximum symptom reduction approaching levels of children without ADHD, not merely "some improvement" 2.

Medication Adherence and Diversion Risk

• For adolescents, screen at every visit for substance use symptoms including alcohol, cannabis, and stimulant misuse, as adolescents with ADHD have elevated risk and may divert medication 1.
• Ask directly about medication-taking patterns: Is the patient taking medication as prescribed, or skipping doses? Are pills being shared, sold, or used in non-prescribed ways? 1, 4.
• In patients with substance use history or concerns, ask about route of administration: Any crushing, snorting, or injecting indicates serious misuse requiring immediate intervention 1, 4.

Cardiovascular and Growth Monitoring

Vital Signs (Mandatory at Every Visit)

• Measure and document blood pressure and heart rate at each visit, as methylphenidate increases both parameters 2, 5.
• Ask about cardiovascular symptoms: Any chest pain, shortness of breath, fainting, palpitations, or exercise intolerance? These require immediate evaluation and possible medication discontinuation 5.

Growth Parameters

• Weigh the patient at every visit to objectively monitor appetite suppression and growth velocity 2, 3.
• Measure height regularly (at least every 3–6 months), as stimulants can cause growth delays, though long-term data show minimal impact on final adult height 2, 3.

Common Non-Serious Adverse Effects

Sleep Disturbances

• Ask about sleep onset, sleep quality, and morning awakening: Difficulty falling asleep affects 17.9% of patients on methylphenidate 6.
• Determine timing of last dose: If sleep problems exist, ensure the last dose is not taken after 6 PM in adults or late afternoon in children 5.
• Distinguish medication-related insomnia from ADHD-related sleep problems, which may have existed before treatment 1.

Appetite and Gastrointestinal Effects

• Ask about appetite changes and meal patterns: Decreased appetite occurs in 31.1% of patients 6.
• Inquire about abdominal pain, nausea, or stomachaches: These affect 10.7% of patients and may require dose adjustment or taking medication with food 6.
• Monitor weight trends over time rather than relying on subjective reports, as objective measurement reveals true impact 2, 3.

Headaches and Other Somatic Complaints

• Ask about headache frequency and severity: Headaches occur in 14.4% of patients on methylphenidate 6.
• Assess whether headaches are new or worsened since starting medication, as pre-existing headaches may be unrelated 6.

Psychiatric and Behavioral Monitoring

Mood and Emotional Symptoms

• Screen for depressive symptoms at every visit: Ask about sadness, tearfulness, loss of interest, hopelessness, and suicidal thoughts, as ADHD patients have increased risk of depression and suicide 1.
• Assess for emotional lability and irritability: Does the patient become tearful, angry, or have tantrums, especially when medication wears off? This may indicate rebound effects or excessive dosing 1.
• In patients with comorbid depression on SSRIs, monitor for serotonin syndrome symptoms within 24–48 hours of any dose change: confusion, agitation, tremor, hyperreflexia, diaphoresis, tachycardia 2.

Anxiety Symptoms

• Ask about anxiety, nervousness, and worry: Comorbid anxiety is common and affects treatment response, though methylphenidate does not worsen anxiety in most patients 1.
• Distinguish anxiety from stimulant-induced activation or agitation, which may require dose reduction 1, 7.

Psychotic Symptoms and Mania

• Screen for new or worsening psychotic symptoms: Ask about hearing voices, seeing things that aren't there, paranoia, or unusual beliefs, as methylphenidate can precipitate psychosis (1.36 times increased risk) 1, 5, 6.
• Assess for manic symptoms: Elevated mood, decreased need for sleep, racing thoughts, grandiosity, or impulsive behavior, especially in patients with bipolar disorder or family history 5.

Tic Disorders

• Ask about new or worsening motor or vocal tics: While controlled studies show methylphenidate does not worsen tics in most patients with Tourette syndrome, individual variability exists 1, 8.
• If tics emerge or worsen, assess dose-response relationship: Does tic severity increase with higher doses? This may indicate medication-related exacerbation 1.

Social Withdrawal (Critical Red Flag)

• Ask parents and teachers if the child seems "zombie-like," overly quiet, or socially withdrawn: This indicates excessive dosing and requires immediate dose reduction 3.

Comorbidity-Specific Questions

For Patients with Oppositional Defiant Disorder or Conduct Problems

• Ask about defiant behavior, rule-breaking, and aggression: Methylphenidate improves oppositional behaviors, though the effect is smaller than for core ADHD symptoms 8.
• Obtain teacher reports, as teachers often report greater improvement in oppositional behaviors than parents 8.

For Patients with Learning Disabilities

• Ask about academic progress and school performance: Are grades improving? Is homework completion better? 1.
• Ensure the patient has appropriate educational supports (IEP or 504 plan), as medication alone is insufficient for learning disabilities 1.

For Patients with Substance Use History

• At every visit, ask about current substance use: Alcohol, cannabis, cocaine, opioids, and other stimulants 1, 4.
• Monitor for signs of stimulant misuse: Taking higher doses than prescribed, using non-oral routes, or running out of medication early 1, 4.
• Consider switching to lower-abuse-potential formulations (lisdexamfetamine, OROS methylphenidate, transdermal methylphenidate) if diversion risk is high 2, 3.

For Patients with Cardiac Disease or Hypertension

• Ask about exercise tolerance and any new cardiac symptoms at every visit, as methylphenidate increases cardiovascular risk 5, 6.
• Ensure baseline ECG was obtained if personal or family history of cardiac disease exists, and repeat if new symptoms develop 2.

Medication-Specific Inquiries

Dosing and Timing

• Ask what time the patient takes each dose: Is timing consistent? Is the last dose too late, causing sleep problems? 5.
• For long-acting formulations, ask if symptom control lasts the full expected duration (8–12 hours), or if breakthrough symptoms occur before the next dose 2.
• If symptom control is inadequate in late afternoon/evening, consider adding a short-acting booster dose (methylphenidate 5–10 mg at 3–4 PM) 2.

Adverse Effects Leading to Discontinuation

• Directly ask if the patient is considering stopping medication due to side effects: Withdrawal due to adverse events occurs in 6.2% for non-serious effects and 1.2% for serious effects 6.
• If side effects are problematic, explore dose reduction, formulation change, or switching to a different stimulant class before abandoning pharmacotherapy 2, 3.

Age-Specific Considerations

Preschool-Aged Children (4–5 Years)

• Methylphenidate is off-label in this age group: Ensure symptoms persisted ≥9 months, behavioral therapy failed, and moderate-to-severe impairment exists across multiple settings before continuing 9, 3.
• Use lower doses and smaller titration increments due to slower metabolism in preschoolers 9, 3.
• Monitor growth and development closely, as long-term safety data in this age group are limited 9.

Adolescents (12–18 Years)

• Screen for substance abuse at every visit, as adolescents have the highest risk of stimulant misuse and diversion 1, 2.
• Ask about driving: Does medication cover driving hours? Adolescents with ADHD have elevated crash risk, and medication reduces this risk 2, 3.
• Assess for suicidal ideation and self-harm, as risk increases during adolescence 1.
• Ask about academic performance and future planning: Are college or vocational goals on track? 1.

Adults

• Ask about occupational functioning: Is work performance improving? Are deadlines being met? 2.
• Screen for comorbid depression and anxiety, which are common in adults with ADHD 10.
• If the patient is on an SSRI plus methylphenidate, monitor for serotonin syndrome symptoms (confusion, agitation, tremor, autonomic instability) within 24–48 hours of dose changes 2.

Common Pitfalls to Avoid

• Do not rely solely on subjective impressions: Use standardized rating scales from multiple informants (parents, teachers, patient) at every visit to objectively measure response 1, 2.
• Do not underdose: Community-treated children often receive lower doses and less frequent monitoring than optimal, resulting in inferior outcomes. Titrate to maximum symptom control without adverse effects, not to a predetermined target dose 2, 3.
• Do not ignore cardiovascular screening: Obtain personal and family cardiac history before starting methylphenidate, and measure blood pressure and heart rate at every visit 2, 5.
• Do not miss substance abuse in adolescents: Screen at every visit, as adolescents may feign symptoms to obtain stimulants or divert medication 1.
• Do not dismiss social withdrawal as "good behavior": This indicates excessive dosing and requires immediate dose reduction 3.
• Do not forget to assess driving safety in adolescents: Ensure medication coverage extends to after-school driving hours 2, 3.