Patient handout

Attention-Deficit/Hyperactivity Disorder (ADHD) — chronic stepwise (AAP 2019 PMID 31570648; APA 2024; NICE NG87 2024; MTA 16-yr Hechtman PMID 30019501)

PRODUCTION

1. Your condition

This handout is for attention-deficit/hyperactivity disorder (adhd) — chronic stepwise (aap 2019 pmid 31570648; apa 2024; nice ng87 2024; mta 16-yr hechtman pmid 30019501). Your care team identified this based on: inattention or hyperactivity-impulsivity symptoms with onset before age 12 yr in ≥ 2 settings (dsm-5-tr 2022 f90.x; aap 2019 pmid 31570648).

Other reasons your team may use this plan: academic decline (pediatric/adolescent) or occupational decline (adult) attributable to attention or hyperactivity-impulsivity symptoms (dsm-5-tr 2022; apa 2024); behavioral problems with oppositional or conduct features in pediatric — common adhd presentation with comorbid odd/cd ~ 30-50% (aap 2019; dsm-5-tr 2022); vanderbilt parent + teacher both ≥ 6/9 inattentive or hyperactive-impulsive symptoms with functional impairment in ≥ 2 settings (aap 2019 pmid 31570648).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
methylphenidate	IR: 5 mg PO BID-TID; ER (Concerta): 18 mg PO daily AM; ER (Ritalin LA / Focalin XR): 10-20 mg PO daily AM; titrate weekly	PO	IR BID-TID; ER daily AM	Methylphenidate-class first-line per AAP 2019 PMID 31570648 (pediatric) and APA 2024 (adult); multiple formulations (IR / ER / patch / liquid); baseline HR + BP + weight + height + cardiac history + FH SCD < 35; no routine EKG in healthy children; growth velocity + appetite + sleep monitoring Q3-6 mo
amphetamine-dextroamphetamine	IR (Adderall): 5 mg PO BID; ER (Adderall XR): 5-10 mg PO daily AM; titrate weekly	PO	IR BID; ER daily AM	Amphetamine-class first-line per AAP 2019 PMID 31570648 (pediatric) and APA 2024 (adult); Schedule II controlled substance; informed consent on abuse / dependence / diversion risks; same baseline screen + monitoring as methylphenidate-class
lisdexamfetamine	30 mg PO daily AM; titrate by 10-20 mg weekly	PO	once daily AM	Prodrug — lysine cleaved peripherally to active dexamfetamine; smoother PK; lower abuse liability than mixed amphetamine salts; same baseline screen + monitoring; also FDA-approved for moderate-severe BED (McElroy JAMA Psychiatry 2015 PMID 25587642 — dual indication if BED comorbid)

Plan: ADHD stepwise pharmacotherapy ladder — Step 1 stimulant first-line (methylphenidate-class OR amphetamine-class for ≥ 6 yr; behavioral first-line for 4-5 yr) → Step 2 within-class switch → Step 3 cross-class switch → Step 4 non-stimulant (atomoxetine, viloxazine) → Step 5 augmentation (alpha-2 agonist guanfacine ER or clonidine ER) (AAP 2019 PMID 31570648; APA 2024; NICE NG87 2024)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Doing well — symptoms controlled, functioning at school / work / home, no SI, no cardiovascular symptoms (AAP 2019; APA 2024)

If you have:

Attention + behavior at baseline (DSM-5-TR 2022)
Academic / occupational performance at baseline or improving (AAP 2019; APA 2024)
No suicidal thoughts (C-SSRS; Posner 2011)
No chest pain / palpitations / syncope (FDA black-box; AAP 2019)
Sleep + appetite + mood + tics at baseline (AAP 2019)
Engaging with usual activities and relationships (APA 2024)

Do this:

Take medications as prescribed every day — do not stop suddenly (alpha-2 agonists especially — rebound HTN risk) (FDA label; AAP 2019)
Continue therapy / coping practices — CBT for adult ADHD, parent training for pediatric, behavioral strategies (AAP 2019; APA 2024; Safren 2005)
Keep follow-up appointments — Q3-6 mo maintenance (AAP 2019)
Keep crisis line numbers (988 US) available even when feeling well (VA/DoD 2022)
Maintain consistent sleep-wake schedule; minimise alcohol and recreational drugs
Use school / workplace accommodations as appropriate (504 plan / IEP / ADA) (AAP 2019; APA 2024)
Drive safely — medication on driving days; defensive driving (APA 2024)

YELLOW — Caution — symptoms returning, school / work / home function declining, side effects emerging, passive SI without plan (AAP 2019; APA 2024)

If you have:

Attention / hyperactivity / impulsivity symptoms returning (DSM-5-TR 2022)
Academic / occupational performance declining (AAP 2019)
New side effect — severe appetite loss, sleep disturbance, irritability, rebound, tic emergence (AAP 2019)
Rising HR or BP (AAP 2019)
Passing thoughts that life is not worth living without intent or plan (C-SSRS; Posner 2011)
Increased alcohol or substance use (APA 2024)
Withdrawal from supports OR new conflict at home / school / work (APA 2024)

Do this:

Use coping strategies — call a support person, use distraction or grounding, take a break (APA 2024; Stanley-Brown 2012 NEEDS_SOURCE_REVIEW)
Contact your provider for an early appointment — within 1 week (AAP 2019; APA 2024)
Review medication adherence with provider — consider dose adjustment if appropriate (AAP 2019)
Avoid means of self-harm — lock or remove firearms; secure or limit medications to short supply (VA/DoD 2022)
Track HR + BP at home if able (AAP 2019)
Engage family / supports — let them know what is happening (APA 2024)
Do not increase stimulant dose without provider direction (FDA; APA 2024)

Call your provider if:

Symptoms not improving after 2 weeks of self-care (AAP 2019; APA 2024)
Side effects worsening (AAP 2019)
Any thoughts of suicide become more frequent (VA/DoD 2022)
Academic / occupational function declines significantly (AAP 2019)
HR or BP outside expected range (AAP 2019)

RED — Medical alert — chest pain / palpitations / syncope / hypertensive crisis on stimulant OR active SI with intent / plan / means OR severe agitation OR manic features (AAP 2019; APA 2024; FDA black-box)

If you have:

Chest pain or arrhythmia / palpitations or syncope on stimulant (FDA black-box; AAP 2019)
Severe HR or BP elevation — possible hypertensive crisis (FDA; AAP 2019)
Severe agitation / aggression / new psychotic symptoms (APA 2024)
Severe manic features — euphoria + decreased need for sleep + grandiosity + impulsivity new on stimulant (DSM-5-TR 2022; APA 2024)
Specific thoughts of how to end your life (C-SSRS; Posner 2011 PMID 22193671)
Access to means — firearms, large-quantity meds (APA 2024; VA/DoD 2022)
Recent self-harm or attempt (APA 2024)
Hearing voices or feeling unsafe with reality (APA 2024)
Inability to keep yourself safe (APA 2024)

Do this:

Call 988 (US) / your local crisis line / emergency services NOW for any SI or severe psychiatric symptom (APA 2024; VA/DoD 2022)
Go to the nearest emergency department for any cardiac symptom on stimulant — chest pain, palpitations, syncope, severe HR/BP elevation (FDA black-box; AAP 2019)
Do not be alone — call a trusted person to come with you (APA 2024)
Hand any means (firearms, pills) to a trusted person before going (VA/DoD 2022; Mann JAMA 2005 NEEDS_SOURCE_REVIEW)
Tell someone you trust what is happening (Stanley-Brown 2012 NEEDS_SOURCE_REVIEW)
Do not use alcohol or non-prescribed substances (APA 2024)
Bring medication list to ED including stimulant dose and time of last dose (AAP 2019)

Call your provider if:

Any red zone trigger — emergency department immediately, do not wait (AAP 2019; APA 2024; FDA)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Acute cardiovascular event in ADHD patient on stimulant — chest pain / palpitations / syncope / arrhythmia / hypertensive crisis (sustained SBP > 95th percentile pediatric or > 140/90 adult) / new exertional symptoms. Life-threatening if structural heart disease, serious arrhythmia, or ischemia underlying (FDA black-box).(life-threatening)
Stimulant diversion (giving / selling / sharing prescription) OR misuse (taking higher dose than prescribed, taking for non-prescribed indication like academic enhancement or weight loss, snorting / injecting) — common in adolescents and adults; high-risk for transition to SUD; legal + safety implications.
ADHD with active substance-use disorder — AUD (~15-20%), cannabis use disorder, opioid use disorder, stimulant use disorder, polydrug. Bidirectional risk: untreated ADHD elevates SUD risk; SUD complicates ADHD treatment + diversion / misuse risk.
C-SSRS positive for active SI with intent, plan, or recent preparatory behaviour in ADHD patient — comorbid MDD ~15-20% and active anxiety ~25% elevate SI risk; atomoxetine FDA black-box for pediatric SI especially first 4 wk.(life-threatening)

5. Follow-up

Continue treatment as long as functional benefit + no severe side effects; many continue lifelong; ADHD persists into adulthood ~50-65% per MTA 16-yr (Hechtman PMID 30019501); transition planning at age 17-18 with adult psychiatry handoff + written transition letter + medication-continuity plan + PCP handoff; relapse-prevention CBT for adult ADHD per Safren manual; ongoing comorbidity surveillance (MDD / anxiety / SUD / sleep / eating disorders)

6. Sources

Guideline: AAP Clinical Practice Guideline for ADHD in Children and Adolescents 2019 (Wolraich PMID 31570648) + APA Practice Guideline for Adult ADHD 2024 (verify publication — PMID NEEDS_SOURCE_REVIEW) + NICE NG87 Attention deficit hyperactivity disorder: diagnosis and management 2018 (last updated 2024) + MTA Cooperative Group 16-yr follow-up (Hechtman 2018 PMID 30019501)