What is the recommended assessment and medication adjustment plan at a follow‑up visit for an ADHD patient on stimulant treatment?

ADHD Follow-Up Visit: Assessment and Medication Adjustment Protocol

At every follow-up visit for an ADHD patient on stimulant therapy, systematically assess symptom control using parent and teacher reports, monitor specific side effects (sleep, appetite, cardiovascular), measure vital signs and weight, evaluate medication adherence, and screen for emerging comorbidities or substance use. 1

Core Assessment Components

Multi-Informant Symptom Evaluation

• Obtain structured feedback from both parents and teachers to assess ADHD symptom control across home and school settings, as symptoms may vary by environment 1
• Use standardized ADHD rating scales (not just subjective reports) to objectively track symptom severity and treatment response over time 1
• Include the patient's self-report of symptom control and medication effects, particularly for adolescents aged 12 and older 1
• Assess functional domains beyond core symptoms: academic performance, peer relationships, family interactions, and completion of age-appropriate tasks 1

Systematic Side Effect Monitoring

Ask specific questions about known stimulant side effects rather than vague inquiries like "any problems?" 1:

• Sleep disturbances: difficulty falling asleep, time to sleep onset, total sleep duration, daytime fatigue 1
• Appetite and weight: decreased appetite, meal skipping, food intake patterns 1
• Gastrointestinal symptoms: stomachache, nausea, abdominal discomfort 1
• Neurological effects: headaches, jitteriness, tremor, new or worsening tics 1
• Cardiovascular symptoms: palpitations, chest pain, syncope, exercise-induced symptoms 1, 2

Objective Physical Measurements

• Measure weight at every visit to provide objective evidence of appetite suppression and monitor growth 1
• Measure blood pressure and heart rate at each visit, as stimulants cause mean increases of 2-4 mmHg BP and 3-6 bpm HR 1, 2
• Monitor linear growth over time, particularly during adolescence, as chronic stimulant use can suppress growth by 1-2 cm from predicted adult height 3

Medication Adjustment Algorithm

When Symptoms Are Well-Controlled

• Continue current dose if ADHD symptoms are adequately managed across all settings with tolerable side effects 1
• Extend follow-up intervals to every 3-4 months for stable patients after initial monthly monitoring 1
• Maintain monthly visits until symptoms are consistently well-controlled before extending intervals 1

When Symptoms Persist Despite Treatment

• Assess medication adherence first: identify barriers such as stigma, forgetfulness, side effects, or cost 1
• Verify dosing timing: confirm medication is taken after breakfast and at appropriate intervals for the formulation prescribed 1
• Optimize current stimulant dose: increase in increments of 2.5-5 mg for amphetamines or 5-10 mg for methylphenidate weekly until symptoms resolve 3, 1
• Maximum doses: 40-50 mg daily for amphetamine salts (up to 60 mg with documentation), 60 mg daily for methylphenidate 3, 2
• If inadequate response after optimizing one stimulant class, switch to the other class (methylphenidate ↔ amphetamine), as approximately 40% of patients respond to only one class 3, 4

When Side Effects Are Dose-Limiting

• For insomnia: adjust dosing schedule, reduce dose, or add evening extended-release guanfacine 3
• For appetite suppression: administer medication after meals and provide supplemental caloric nutrition 3
• For cardiovascular concerns: consider switching to atomoxetine (60-100 mg daily) or alpha-2 agonists (guanfacine/clonidine), which have more favorable cardiovascular profiles 3, 4
• Switch to long-acting formulations if rebound effects or inconsistent coverage are problematic 3, 4

When Comorbidities Emerge

• If ADHD improves but mood/anxiety symptoms persist: add an SSRI (fluoxetine or sertraline) to the stimulant regimen rather than switching medications 3
• For residual symptoms despite optimized stimulant: add atomoxetine or extended-release guanfacine as adjunctive therapy 3, 5
• Screen for substance use before and during treatment, especially in adolescents 1

Visit Frequency Protocol

• During titration: maintain weekly contact (phone or in-person) and schedule in-person visits for dose adjustments 1
• Until stabilization: continue monthly appointments until symptoms are consistently well-controlled 1
• Maintenance phase: extend to every 3-4 months for stable patients 1

Critical Adolescent-Specific Concerns

• Screen for substance use symptoms at every visit using structured questions 1
• Monitor for diversion signs: early refill requests, lost prescriptions, inconsistent symptom reports 1
• Educate about diversion risks: emphasize secure medication storage and not sharing with peers 1
• Consider long-acting formulations to reduce abuse potential and improve adherence 3, 4

Common Pitfalls to Avoid

• Don't dismiss mild side effects without intervention—adjust dose timing or amount rather than accepting problematic effects 1
• Don't assume the first dose is adequate—70-80% of patients respond when properly titrated, but systematic dose optimization is required 3, 4
• Don't ignore new cardiovascular symptoms (palpitations, chest pain, syncope)—these require immediate evaluation 1, 2
• Don't delay ADHD treatment due to mild mood symptoms—stimulants can indirectly improve mood by reducing functional impairment 3
• Don't use "as-needed" dosing—ADHD requires consistent daily symptom control to prevent functional impairment 4