When initiating stimulant therapy for attention‑deficit/hyperactivity disorder (ADHD), how often should follow‑up visits be scheduled and what assessments (symptom control, blood pressure, heart rate, weight, height, growth velocity, appetite, sleep, mood, anxiety, tics, psychotic symptoms, misuse) are required?

Follow-Up Schedule and Monitoring When Starting Stimulant Therapy for ADHD

During the initial titration phase (first 2–4 weeks), maintain weekly contact—either by phone or in-person visit—to assess symptom response and side effects; once a stable maintenance dose is achieved, schedule at least monthly follow-up appointments until symptoms are fully stabilized, then transition to quarterly visits. 1

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Initial Titration Phase (Weeks 1–4)

Contact Frequency

• Weekly contact (by telephone or office visit) is recommended during dose adjustments 1
• The titration phase typically requires 2 to 4 weeks to establish an optimal dose 1
• In urgent clinical situations, dose adjustments may be made every 3 days, though weekly intervals are standard 1

Required Assessments at Each Contact

Symptom Control:

• Obtain ADHD rating scales from parents and teachers (or self-ratings for adolescents/adults) to track target symptoms 1
• Evaluate specific ADHD symptoms: inattention, hyperactivity, impulsivity, and functional impairment across multiple settings (home, school/work, social) 1

Cardiovascular Monitoring:

• Measure blood pressure and pulse at each dose adjustment 1
• These parameters should be checked at baseline before starting medication 1

Growth Parameters:

• Weigh the patient at each visit to objectively monitor appetite suppression 1
• Track height and weight regularly, particularly in children and adolescents 1

Side Effect Assessment:

• Systematically ask about specific known side effects: insomnia, anorexia, headaches, social withdrawal, tics, weight loss, stomachache, jitteriness 1
• Inquire about sleep onset delay and appetite changes 1
• Screen for mood changes, anxiety, irritability, and any psychotic symptoms (very rare but serious) 1

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Maintenance Phase (After Dose Stabilization)

Follow-Up Frequency

• Monthly appointments until symptoms are stabilized on a consistent dose 1
• After stabilization, the frequency can be adjusted based on:
  • Robustness of drug response 1
  • Family/patient adherence to the medication regimen 1
  • Presence and severity of side effects 1
  • Need for psychoeducation or psychosocial intervention 1
  • Severity of comorbid psychiatric disorders 1

When to Schedule More Frequent Visits

• Significant side effects requiring management 1
• Comorbid psychiatric disorders causing substantial impairment 1
• Problems with medication adherence 1
• Suboptimal response requiring further dose adjustment 1

Ongoing Monitoring Parameters

At Every Maintenance Visit:

• Blood pressure and pulse 1
• Height and weight (to track growth velocity in children/adolescents) 1
• ADHD symptom ratings from multiple informants (parent, teacher, patient) 1
• Side effect review: sleep quality, appetite, mood, anxiety, tics, any psychotic symptoms 1
• Functional assessment: performance at school/work, home behavior, social relationships 1

Specific Safety Concerns:

• Monitor for misuse or diversion of medication, especially in adolescents and adults 1
• Screen for substance abuse, particularly in patients with comorbid conditions 1
• Watch for tolerance development (rare but possible) 1

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Practical Implementation Algorithm

Week 1:

• Start low dose (e.g., 5 mg methylphenidate or 2.5 mg amphetamine twice daily) 1
• Obtain baseline: BP, pulse, height, weight, ADHD rating scales 1
• Educate family about expected effects and side effects 1

Weeks 2–4 (Titration):

• Weekly contact (phone or visit) 1
• At each contact: rating scales, BP/pulse, weight, side effect checklist 1
• Increase dose by 5–10 mg/dose for methylphenidate or 2.5–5 mg for amphetamine if symptom control inadequate 1
• Stop titration when optimal symptom control achieved or dose-limiting side effects occur 1

Months 2–6 (Early Maintenance):

• Monthly visits 1
• Full assessment: rating scales, vitals, growth parameters, side effects, functional outcomes 1
• Adjust frequency upward if problems emerge 1

Beyond 6 Months (Stable Maintenance):

• Quarterly visits if response is robust and adherence good 1
• Continue monitoring all parameters but less frequently 1
• Collect teacher reports before or at each visit (optional but helpful) 1

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Common Pitfalls to Avoid

• Under-monitoring during titration: Weekly contact is essential; skipping this leads to suboptimal dosing and missed side effects 1
• Stopping titration prematurely: Approximately 70% of patients achieve optimal response when systematic titration protocols are followed; don't settle for partial improvement 1
• Ignoring teacher input: School performance is a critical outcome; obtain teacher rating scales regularly 1
• Missing cardiovascular monitoring: Even though serious cardiac events are rare, BP and pulse must be checked consistently 1
• Failing to track growth: Stimulants can cause modest growth suppression (1–2 cm from predicted adult height); regular height/weight monitoring is mandatory 1
• Not assessing for misuse: Especially in adolescents and adults, screen for diversion or non-prescribed use 1

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Special Considerations

• Children < 25 kg: Use more cautious titration with smaller increments; single doses should generally not exceed 15 mg methylphenidate or 10 mg amphetamine 1
• Comorbid conditions: More frequent monitoring is needed when anxiety, depression, tics, or substance abuse coexist 1
• Long-acting formulations: May require different timing of assessments to capture full-day symptom coverage 1
• Adolescents/adults: Self-ratings become important; collateral information from significant others is valuable 1

The key principle is intensive monitoring during titration (weekly for 2–4 weeks), followed by monthly visits until stability, then quarterly maintenance visits—with flexibility to increase frequency based on clinical need. 1