What criteria determine discharge readiness for a patient with attention‑deficit/hyperactivity disorder on stimulant therapy?

ADHD Discharge Readiness on Stimulant Therapy

A patient with ADHD on stimulant therapy is ready for discharge when core symptoms are optimally controlled across multiple settings (home, school/work), adverse effects are tolerable or absent, cardiovascular parameters are stable, adherence is established, and functional improvement is documented through standardized rating scales from multiple observers.

Core Symptom Control Assessment

• Obtain parent and teacher ratings using validated instruments (e.g., ADHD Rating Scale) to measure reduction in the 18 core symptoms of inattention, hyperactivity, and impulsivity across both home and school settings. 1
• Stimulants demonstrate effect sizes around 1.0 for core symptom reduction, making them the most robust treatment option and setting the benchmark for adequate response. 1
• Approximately 70-80% of patients achieve optimal response when systematic titration protocols are applied, so failure to reach this threshold warrants further dose optimization before discharge. 2, 1

Medication Optimization Verification

• Confirm that the stimulant dose has been titrated to achieve maximum benefit with tolerable side effects rather than adhering strictly to mg/kg calculations. 3, 2
• Verify that dose adjustments occurred on appropriate intervals (3-7 days for stimulants given their rapid onset) and that the patient has been on the current optimized dose for at least 2-4 weeks. 2, 1
• If response is inadequate after proper titration of one stimulant class, document that the alternative class (methylphenidate vs. amphetamine) was trialed, as approximately 40% respond to only one class. 3, 2

Adverse Effect Monitoring and Management

• Document that common stimulant adverse effects—appetite loss, abdominal pain, headaches, and sleep disturbance—are either absent or managed to tolerable levels. 3
• Measure and record blood pressure and pulse at discharge, confirming that cardiovascular parameters remain within acceptable limits (average increases of 1-2 beats per minute for heart rate and 1-4 mm Hg for blood pressure are expected). 3
• For pediatric patients, verify that growth velocity is being tracked, as stimulants can reduce predicted adult height by 1-2 cm, with effects most pronounced in the first two years of treatment. 3, 2

Functional Improvement Documentation

• Assess functional outcomes beyond symptom reduction, including academic achievement, peer relationships, and family functioning, as these often require behavioral interventions even when core symptoms improve. 1
• Obtain teacher rating scales specifically evaluating classroom behavior, work completion, and attention to instruction to confirm school-based functional improvement. 2, 1
• For adolescents, ensure medication coverage extends to driving hours and document discussion of crash and violation risks. 1, 2

Adherence and Follow-Up Planning

• Establish a clear follow-up schedule: weekly during initial titration, then monthly until stability is achieved, followed by quarterly maintenance visits. 1, 2
• For long-acting formulations, confirm once-daily dosing adherence, as extended-release products improve compliance compared to multiple daily doses. 2, 4
• Document that the patient or responsible caregiver can reliably administer medication and that school personnel are available for in-school doses if needed. 3

Comorbidity Assessment

• Screen for and document management of coexisting conditions—anxiety, learning disorders, mood disorders, oppositional defiant disorder, and sleep problems—as these require separate assessment and may need additional treatment. 1, 3
• If ADHD symptoms improved but mood or anxiety symptoms persist, confirm that an SSRI has been added to the regimen, as no single medication treats both conditions effectively. 2, 1
• Verify that behavioral interventions (parent training in behavior management for children 6-12 years, evidence-based training interventions for adolescents) are in place, as combined treatment offers superior functional outcomes. 3, 1, 2

Age-Specific Discharge Criteria

Preschool Children (4-5 years)

• Confirm that behavioral interventions were trialed first and that methylphenidate was only initiated after ≥9 months of persistent symptoms with moderate-to-severe functional impairment. 2
• Document increased monitoring for mood lability and dysphoria, which occur more frequently in this age group. 3

School-Age Children (6-12 years)

• Verify that educational interventions and individualized instructional supports (IEP or 504 plan) are established as part of the treatment plan. 3
• Confirm that both parent training in behavior management (PTBM) and behavioral classroom interventions are in place alongside medication. 3, 2

Adolescents (12-18 years)

• Document that medication was prescribed with the adolescent's assent and that self-report measures are included in outcome assessment. 3, 1
• Verify medication coverage for driving hours and counsel on increased crash risk if ADHD is untreated during driving. 1, 2
• Screen for substance use risk and consider long-acting formulations with lower diversion potential. 2

Critical Pitfalls to Avoid

• Do not discharge patients on subtherapeutic doses; inadequate stimulant trials are a common cause of apparent treatment failure. 2
• Do not assume medication alone addresses all impairments—academic achievement and social functioning often require concurrent behavioral interventions. 1
• Do not overlook setting-specific effects; teachers may report different side effects than parents, and medication benefits may vary by environment. 1
• Do not discharge without confirming that the patient has been educated about the need for ongoing treatment, as ADHD benefits persist only while medication continues. 3, 1

Discharge Documentation Checklist

• Current stimulant dose, formulation, and timing
• Baseline and current cardiovascular parameters (BP, pulse)
• Height and weight (for pediatric patients)
• Standardized rating scale scores from multiple observers (parent, teacher, self-report if age-appropriate)
• Documentation of functional improvement in at least two settings
• Adverse effect profile and management strategies
• Comorbidity screening results and treatment plan
• Behavioral intervention components in place
• Follow-up schedule and monitoring plan
• Prescription Drug Monitoring Program (PDMP) check for adolescents and adults 2