Baseline Evaluations Before Starting ADHD Medication
Before initiating ADHD medication, you must obtain a comprehensive clinical history documenting symptom onset, duration, and cross-setting impairment; measure baseline blood pressure and pulse; screen for cardiovascular risk factors and family cardiac history; assess for comorbid psychiatric conditions and substance use (especially in adolescents); and use standardized rating scales to quantify symptom severity.
Essential Clinical History Components
ADHD Symptom Documentation
- Confirm that symptoms meet DSM-5 criteria for ADHD with evidence of inattention, hyperactivity, or impulsivity causing functional impairment in at least two settings (home, school, work) 1.
- Document symptom duration of at least 6 months in school-aged children and adolescents; for preschoolers (ages 4–5), symptoms must persist for at least 9 months before considering medication 1, 2.
- Verify that symptoms cause moderate-to-severe functional impairment across multiple domains (academic performance, social relationships, occupational functioning) 1.
Developmental and Treatment History
- Obtain detailed prior treatment history including all previous ADHD medications, doses, duration of trials, response, side effects, and reasons for discontinuation 3.
- For preschool-aged children, confirm that parent training and behavioral therapy have been attempted for at least 9 months and found inadequate before considering medication 1, 2.
Cardiovascular Assessment
Baseline Vital Signs
- Measure blood pressure and pulse in both seated and standing positions to establish baseline cardiovascular parameters and detect orthostatic changes 3, 4.
- Repeat blood pressure and pulse measurements at each dose adjustment during titration and quarterly during maintenance therapy in adults 3.
Cardiac History Screening
- Obtain a detailed personal cardiac history including syncope, chest pain, palpitations, exercise intolerance, or known structural heart disease 3.
- Document family history of premature cardiovascular death (before age 50), sudden cardiac death, arrhythmias, cardiomyopathy, or congenital heart disease 3.
- Identify absolute cardiovascular contraindications including symptomatic cardiovascular disease, uncontrolled hypertension, hyperthyroidism, and glaucoma 3, 4.
When to Obtain an ECG
- An electrocardiogram is not routinely required for all patients before starting stimulants, but should be obtained if the personal or family cardiac history reveals concerning features 3.
- Consider cardiology consultation if structural heart disease, arrhythmias, or significant family history is identified 3.
Psychiatric and Substance Use Screening
Comorbidity Assessment
- Screen for comorbid depression, anxiety, bipolar disorder, psychosis, tic disorders, and autism spectrum disorder using clinical interview and standardized rating scales 1, 5.
- Rates of comorbid psychiatric conditions range from 12–60% in children with ADHD, making systematic screening essential 6, 5.
- For adolescents and adults, assess for symptoms of substance use including alcohol, cannabis, and illicit stimulants before prescribing 1.
Substance Use Considerations
- If active substance use is identified in adolescents, refer to a subspecialist for consultative support and consider non-stimulant options (atomoxetine, guanfacine, clonidine) as first-line therapy 1.
- Monitor for diversion risk by assessing the patient's social environment, peer substance use, and prescription refill patterns 1.
Bipolar Disorder Screening
- Screen for personal or family history of bipolar disorder, mania, or hypomania because stimulants can precipitate manic episodes in vulnerable individuals 3.
- If bipolar disorder is confirmed, mood stabilizers must be optimized before initiating stimulant therapy 3.
Standardized Rating Scales
Symptom Quantification
- Use the Adult ADHD Self-Report Scale (ASRS) Part A as a structured screening tool for adults before initiating medication 7.
- Employ age-appropriate rating scales such as Conners' Rating Scales or Vanderbilt Assessment Scales to obtain parent and teacher reports for children and adolescents 1, 8.
- Gather collateral information from multiple informants (parents, teachers, partners) to confirm cross-setting impairment 7, 8.
Baseline Functional Assessment
- Document baseline functional impairment in academic performance, occupational productivity, social relationships, and daily living skills to track treatment response 1, 7.
Physical Examination and Growth Parameters
Baseline Measurements
- Record height and weight to establish baseline growth parameters, particularly in children and adolescents, as stimulants can affect growth velocity 3, 4.
- Perform a comprehensive physical examination including assessment for signs of hyperthyroidism, cardiovascular abnormalities, and neurologic conditions 3.
Ongoing Monitoring
- Track height and weight at every visit in children and adolescents to monitor for growth suppression 3, 4.
- Measure height and weight periodically in adults to detect appetite suppression and weight loss 3.
Laboratory Tests
Routine Laboratory Work
- No routine laboratory tests (CBC, metabolic panel, thyroid function) are required before starting ADHD medication unless clinically indicated by history or physical examination 3, 4.
- Neuropsychological testing is not necessary for diagnosis in most cases, although it may clarify learning strengths and weaknesses 1.
When to Order Labs
- Obtain thyroid function tests if hyperthyroidism is suspected based on clinical features (tachycardia, weight loss, tremor) 3.
- Consider metabolic screening if the patient has risk factors for diabetes or metabolic syndrome that may be exacerbated by stimulant-related appetite changes 4.
Special Population Considerations
Preschool-Aged Children (4–5 Years)
- Medication should only be considered after behavioral therapy has been attempted for at least 9 months and moderate-to-severe impairment persists across multiple settings 1, 2.
- Methylphenidate is the only stimulant with adequate evidence for this age group, although its use remains off-label 1, 2.
- Consultation with a mental health specialist experienced in preschool ADHD is recommended before initiating medication 1, 2.
Adolescents (12–18 Years)
- Systematically screen for substance use symptoms and assess risk of medication diversion to peers or family members 1.
- Obtain the adolescent's assent in addition to parental consent before prescribing medication 1.
- Consider long-acting formulations with lower abuse potential (lisdexamfetamine, OROS-methylphenidate) when diversion risk is elevated 1, 3.
Adults
- Confirm childhood onset of symptoms by obtaining developmental history and, when possible, collateral information from parents or school records 7, 4.
- Screen for comorbid mood and anxiety disorders which occur in approximately 10% of adults with recurrent depression 3.
Common Pitfalls to Avoid
- Do not initiate medication in preschoolers without first attempting behavioral therapy for at least 9 months 1, 2.
- Do not prescribe stimulants to patients with active psychosis, uncontrolled hypertension, symptomatic cardiovascular disease, or concurrent MAO inhibitor use 3, 4.
- Do not assume that irritability or mood lability automatically indicates bipolar disorder; these symptoms often improve with appropriate ADHD treatment 3.
- Do not rely solely on subjective rating scales; combine them with comprehensive clinical history and collateral information 6, 8.
- Do not start stimulants in adolescents with active substance use without subspecialist consultation; consider non-stimulant alternatives first 1.
Baseline Evaluation Checklist
Before prescribing ADHD medication, complete the following:
- Clinical history: DSM-5 symptom criteria, duration ≥6 months (≥9 months for preschoolers), cross-setting impairment 1, 2
- Cardiovascular assessment: Blood pressure, pulse, personal and family cardiac history 3, 4
- Psychiatric screening: Depression, anxiety, bipolar disorder, psychosis, substance use 1, 5
- Rating scales: ASRS (adults), Conners or Vanderbilt (children), collateral reports 1, 7, 8
- Physical exam: Height, weight, signs of hyperthyroidism or cardiac disease 3, 4
- Treatment history: Prior medications, behavioral interventions, response, side effects 3
- Special populations: Behavioral therapy trial for preschoolers, substance use screening for adolescents 1, 2