Clinical Commander

Back to dossier
psych.adhd.core.v1PRODUCTION
psych.adhd.core.v1

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

psychiatrychronicacuteadult
Hard-required inputs
0 / 14
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm DSM-5-TR 2022 ADHD criteria (≥ 6 inattentive OR ≥ 6 hyperactive-impulsive symptoms with onset < 12 yr + persistent ≥ 6 mo + ≥ 2 settings + functional impairment + not better explained by other condition); subtype assignment (F90.0 inattentive / F90.1 hyperactive-impulsive / F90.2 combined / F90.9 unspecified) (DSM-5-TR 2022; AAP 2019 PMID 31570648; APA 2024)

Inputs
0
Actions
0
Advance rule
Set
Advance when

DSM-5-TR criteria met + medical / psychiatric mimics ruled out + multi-informant agreement

Patient inputs (24)

Drug + therapy selection; preschool 4-5 (behavioral first-line per AAP 2019; methylphenidate only stimulant with FDA evidence); school-age 6-11 (stimulant + behavioral + school accommodations); adolescent 12-17 (stimulant + CBT + driving safety + transition planning); adult ≥ 18 (stimulant + CBT + workplace accommodations); older adult ≥ 65 (rare; cardiovascular risk; medical-mimic workup)

Behavioral first-line in pregnancy; risk-benefit for stimulant; immediate-release preferred over extended-release if continued (lower fetal exposure); APA reproductive psychiatry

Baseline + Q3-6 mo in pediatric stimulant patients; BMI trajectory; appetite suppression common (AAP 2019 PMID 31570648)

Baseline + Q3-6 mo in pediatric stimulant patients; growth velocity < 5th percentile triggers reassessment (AAP 2019 PMID 31570648)

PHQ-9 — comorbid MDD ~15-20% in ADHD; Q9 flags suicidality; informs SSRI choice for comorbid MDD (Kroenke 2001 PMID 11556941; APA 2024)

Pediatric ADHD diagnosis requires multi-informant report — parent + teacher Vanderbilt, with functional impairment in ≥ 2 settings (DSM-5-TR 2022; AAP 2019)

Comorbid SUD ~15-20% in adolescents and adults with ADHD; diversion + misuse risk drives non-stimulant preference or restricted-monitoring stimulant; addiction-medicine collaboration (APA 2024; AAP 2019)

MDQ pre-treatment bipolarity screen — mood instability + ADHD overlap; stimulant-induced or antidepressant-induced manic switch risk (Hirschfeld 2000 NEEDS_SOURCE_REVIEW; APA 2024)

MAOI washout 14 d before/after stimulant; CYP interactions for atomoxetine (CYP2D6); concurrent SSRI / SNRI serotonergic load; QTc-prolonging drugs (APA 2024; FDA)

Baseline + each visit on stimulant; tachycardia at high doses requires evaluation (AAP 2008 + 2019 + AHA 2008 NEEDS_SOURCE_REVIEW; FDA)

Baseline + each visit on stimulant; persistent SBP > 95th percentile pediatric or > 140/90 adult requires evaluation (AAP 2008 + 2019; FDA)

C-SSRS at intake + first 4 wk of atomoxetine or any new antidepressant — atomoxetine FDA black-box for SI in pediatric (Posner 2011 PMID 22193671; FDA 2005)

Personal cardiac history (structural / arrhythmia / HTN / palpitations / syncope) OR family history of sudden cardiac death < 35 — drives EKG + cardiology consult before stimulant (AAP 2008 + 2019 + AHA 2008 NEEDS_SOURCE_REVIEW; FDA black-box)

Vanderbilt parent + teacher both ≥ 6/9 inattentive OR hyperactive-impulsive symptoms with functional impairment in ≥ 2 settings — pediatric ADHD diagnosis anchor (AAP 2019 PMID 31570648)

GAD-7 — comorbid anxiety ~25% in ADHD (Spitzer 2006 PMID 16717171; APA 2024)

Tic or Tourette history — atomoxetine or alpha-2 agonist often preferred; tics are NOT absolute contraindication to stimulant per Tourette Syndrome Study Group 2002 (AAP 2019; APA 2024)

Sleep disorder + stimulant insomnia risk; OSA workup if obese; consider IR + short morning-only dosing if severe (AAP 2019; APA 2024)

LD co-occurs ~20-30% with ADHD; 504 plan / IEP coordination per IDEA + Section 504 (AAP 2019)

Baseline — rule out anemia mimicking inattention; not routinely required but reasonable in initial workup (AAP 2019)

Hyperthyroidism + hypothyroidism mimic ADHD symptoms; baseline screen reasonable in initial workup (APA 2024; AAP 2019)

Atomoxetine hepatotoxicity rare but reported — baseline + monitor if symptomatic (FDA atomoxetine label)

Stimulant + appetite effects; baseline metabolic screen if obese or family history (APA 2024)

NOT routinely required in healthy children per AAP / AHA 2008 joint statement; required if cardiac history OR family history of sudden cardiac death < 35 OR new cardiac symptom on stimulant (AAP 2019; AHA 2008 NEEDS_SOURCE_REVIEW)

ASRS v1.1 part-A ≥ 4/6 — adult ADHD screening anchor (Kessler 2005 PMID 15841682 NEEDS_SOURCE_REVIEW; APA 2024)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningacute_stimulant_cardiovascular_event (FDA black-box 2007 + 2008; AAP 2019 PMID 31570648)
    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).
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningadhd_with_acute_suicidal_ideation (Posner 2011 PMID 22193671; FDA 2005 atomoxetine black-box; APA 2024)
    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.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverestimulant_diversion_or_misuse (APA 2024; AAP 2019 PMID 31570648; FDA Schedule II)
    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.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereadhd_with_concurrent_substance_use (APA 2024; AAP 2019 PMID 31570648)
    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.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepediatric_growth_velocity_concern_on_stimulant (AAP 2019 PMID 31570648)
    Pediatric ADHD patient on stimulant with growth velocity < 5th percentile OR BMI dropping > 1 percentile band OR significant appetite suppression interfering with daily caloric intake — moderate severity; monitor and intervene.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepregnancy_adhd_medication_decision (APA reproductive psychiatry; APA 2024)
    Pregnancy with current ADHD pharmacotherapy OR planning pregnancy with active ADHD — moderate severity; risk-benefit decision per APA reproductive psychiatry; behavioral first-line; immediate-release preferred if continued.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatetic_emergence_on_stimulant (Tourette Syndrome Study Group 2002 NEEDS_SOURCE_REVIEW; AAP 2019 PMID 31570648)
    New motor or vocal tic emergence in ADHD patient on stimulant — moderate severity; not absolute contraindication per Tourette Syndrome Study Group 2002 pooled analysis but typically requires medication adjustment.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterebound_irritability_or_appetite_loss_severe (AAP 2019 PMID 31570648; APA 2024)
    Severe rebound irritability OR severe appetite loss OR severe sleep disturbance OR pre-dose anxiety in ADHD patient on stimulant — moderate severity; affects daily function and adherence.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateacademic_or_occupational_decline_despite_treatment (AAP 2019 PMID 31570648; APA 2024)
    Persistent academic decline (pediatric/adolescent) OR occupational decline (adult) despite "adequate" ADHD treatment — moderate severity; mandates re-evaluation of diagnosis + comorbidities + dose + class + adherence + non-drug supports.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildtransition_to_adult_care_at_18 (AAP 2019 PMID 31570648; APA 2024)
    Adolescent age 17-18 with current ADHD treatment + pending college / vocational / adult-life transition — high attrition window; bridge to adult psychiatry; medication continuity critical; functional supports change.
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

CONTEXTrequiredDrives screening
Loading…

Recommended regimen

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)
axis: adhd_stepwise_pharmacotherapystep 1 - Step 1 — Stimulant first-line for ≥ 6 yr (methylphenidate-class OR amphetamine-class; AAP 2019 PMID 31570648; APA 2024)
Selected step "Step 1 — Stimulant first-line for ≥ 6 yr (methylphenidate-class OR amphetamine-class; AAP 2019 PMID 31570648; APA 2024)" — ADHD diagnosis confirmed (DSM-5-TR + Vanderbilt / SNAP-IV / ADHD-RS + functional impairment ≥ 2 settings + multi-informant agreement) + age ≥ 6 yr + no contraindication (structural heart disease, serious arrhythmia, recent MI, active SUD without addiction-medicine collaboration, current MAOI within 14 d, pregnancy without reproductive-psychiatry risk-benefit) (AAP 2019; APA 2024; FDA)
  • methylphenidate
    first line
    stimulant_Schedule_II_methylphenidate_class
    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 (max: Concerta 72 mg/day (adolescents/adults); Ritalin LA 60 mg; Focalin XR 30 mg; IR 60 mg/day (per FDA label; AAP 2019))
    triggers: pediatric_school_age_first_line, adolescent_first_line, adult_first_line, preschool_methylphenidate_only_FDA_evidence_if_behavioral_inadequate
    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
    rxcui 6901
  • amphetamine-dextroamphetamine
    first line
    stimulant_Schedule_II_amphetamine_class
    IR (Adderall): 5 mg PO BID; ER (Adderall XR): 5-10 mg PO daily AM; titrate weekly • PO • IR BID; ER daily AM (max: Adderall XR 30 mg/day (children + adolescents) / 40-60 mg (adults per FDA label); Adderall IR 40 mg/day pediatric (per FDA label; AAP 2019))
    triggers: pediatric_school_age_first_line, adolescent_first_line, adult_first_line
    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
    rxcui 1100075
  • lisdexamfetamine
    first line
    stimulant_Schedule_II_amphetamine_prodrug
    30 mg PO daily AM; titrate by 10-20 mg weekly • PO • once daily AM (max: 70 mg/day (per FDA label; AAP 2019))
    triggers: adolescent_or_adult_with_diversion_concern_lower_abuse_liability_prodrug, comorbid_BED_dual_indication
    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)
    rxcui 700810

outpatient playbook — drug actions (7)

  1. 1. Stimulant first-line (methylphenidate-class OR amphetamine-class) for ≥ 6 yr
    Methylphenidate IR 5 mg BID-TID OR Concerta 18-72 mg daily AM OR Adderall XR 5-30 mg daily AM OR Lisdexamfetamine (Vyvanse) 30-70 mg daily AM; titrate weekly to functional response or max • PO (or transdermal Daytrana for methylphenidate) • IR BID-TID; ER daily AM
    trigger: DSM-5-TR ADHD diagnosis + age ≥ 6 yr + no contraindication (AAP 2019; APA 2024)
    Stimulant first-line per AAP 2019 PMID 31570648 (pediatric) and APA 2024 (adult); baseline screen + Q3-6 mo monitoring; lisdexamfetamine has lower abuse liability than mixed amphetamine salts due to prodrug design (FDA label)
  2. 2. Preschool 4-5 yr: behavioral parent training first-line; methylphenidate IR only if behavioral inadequate
    Behavioral parent training (Triple P / Incredible Years) × 8-12 wk; methylphenidate IR 2.5-5 mg BID-TID only if behavioral inadequate (AAP 2019) • behavioral + PO if needed • weekly behavioral + BID-TID stimulant if needed
    trigger: Preschool 4-5 yr ADHD diagnosis (AAP 2019)
    AAP 2019 PMID 31570648 — behavioral first-line for 4-5 yr; methylphenidate only stimulant with FDA evidence at this age; off-label otherwise
  3. 3. Within-class switch if Step 1 inadequate at adequate dose × 4-6 wk
    Methylphenidate-class: Concerta → Focalin XR; Adderall XR → Vyvanse • PO • daily AM
    trigger: Stimulant inadequate at adequate dose × 4-6 wk OR intolerance (AAP 2019)
    Different formulations have different PK + tolerability; within-class switch often successful (AAP 2019)
  4. 4. Cross-class switch if within-class switch inadequate
    Methylphenidate-class → amphetamine-class (or vice versa) • PO • daily AM
    trigger: Within-class switch inadequate at adequate dose × 4-6 wk (AAP 2019)
    ~30% of non-responders to one class respond to the other (AAP 2019)
  5. 5. Non-stimulant (atomoxetine first; viloxazine second) if both stimulant classes failed or contraindicated
    Atomoxetine 0.5 → 1.2-1.4 mg/kg/day pediatric (max 100 mg) OR 40-80-100 mg adult; viloxazine 100-400 mg pediatric / 200-600 mg adult • PO • once daily AM (atomoxetine; viloxazine)
    trigger: Stimulant failure / intolerance / contraindication / active SUD / diversion / tic exacerbation / patient-family preference (AAP 2019; APA 2024)
    Atomoxetine 4-week onset (counsel on delayed effect); FDA black-box for SI in pediatric — C-SSRS first 4 wk; CYP2D6 dose adjustment; viloxazine newer NRI (FDA 2021) fewer data
  6. 6. Alpha-2 agonist augmentation (guanfacine ER or clonidine ER)
    Guanfacine ER (Intuniv) 1-4 mg/day pediatric / 1-7 mg adult; clonidine ER (Kapvay) 0.1-0.4 mg/day pediatric • PO • daily HS (extended-release; bedtime sedation)
    trigger: Partial stimulant response OR comorbid tics OR sleep disturbance OR aggression / irritability (AAP 2019; APA 2024)
    FDA-approved pediatric ADHD monotherapy or stimulant adjunct; rebound HTN on abrupt discontinuation; HR + BP monitoring
  7. 7. SSRI for comorbid MDD (PHQ-9 ≥ 10) or anxiety (GAD-7 ≥ 10)
    Sertraline 25-200 OR escitalopram 5-10-20 (Cipriani 2018 PMID 29477251) • PO • daily
    trigger: PHQ-9 ≥ 10 or GAD-7 ≥ 10 — routes to psych.depression.core.v1 or psych.anxiety-disorders.core.v1
    Comorbid MDD ~15-20% and anxiety ~25% in ADHD; FDA 2004 black-box first 4 wk pediatric C-SSRS; treat ADHD first if mild MDD/anxiety; treat both if moderate-severe

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Inattention OR hyperactivity-impulsivity symptoms with onset before age 12 yr in ≥ 2 settings (DSM-5-TR 2022 F90.x; AAP 2019 PMID 31570648); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Attention-Deficit/Hyperactivity Disorder (ADHD) — chronic stepwise (AAP 2019 PMID 31570648; APA 2024; NICE NG87 2024; MTA 16-yr Hechtman PMID 30019501)** (psych.adhd.core.v1).
Phenotype framing: ADHD (F90.x) vs ODD (F91.3) vs CD (F91.x) vs anxiety (F40-F41) vs depression (F32-F33) vs bipolar (F31) vs learning disorder (F81.x) vs autism spectrum (F84.0) vs hearing / vision impairment vs hyperthyroidism vs sleep disorder / OSA vs substance use vs PTSD (F43.1) vs traumatic brain injury vs lead toxicity / heavy metals vs medication-induced (steroids, caffeine, bronchodilators) (DSM-5-TR 2022; AAP 2019; APA 2024)
Scope: Confirm DSM-5-TR 2022 ADHD criteria (≥ 6 inattentive OR ≥ 6 hyperactive-impulsive symptoms with onset < 12 yr + persistent ≥ 6 mo + ≥ 2 settings + functional impairment + not better explained by other condition); subtype assignment (F90.0 inattentive / F90.1 hyperactive-impulsive / F90.2 combined / F90.9 unspecified) (DSM-5-TR 2022; AAP 2019 PMID 31570648; APA 2024)

No severity triggers fired against current inputs.

Plan

Regimen axis: **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)** — step "Step 1 — Stimulant first-line for ≥ 6 yr (methylphenidate-class OR amphetamine-class; AAP 2019 PMID 31570648; APA 2024)".
1. 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 (stimulant_Schedule_II_methylphenidate_class, first line) — 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
2. 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 (stimulant_Schedule_II_amphetamine_class, first line) — 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
3. lisdexamfetamine 30 mg PO daily AM; titrate by 10-20 mg weekly PO once daily AM (stimulant_Schedule_II_amphetamine_prodrug, first line) — 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)

Setting playbook (outpatient) — Pediatric / adolescent / adult outpatient ADHD pathway — stimulant titration + behavioral therapy (parent training for pediatric; CBT for adult ADHD per Safren manual) + school / workplace accommodations + weekly-monthly visits during titration → Q3-6 mo maintenance with growth velocity + cardiovascular + comorbidity surveillance (AAP 2019 PMID 31570648; APA 2024; NICE NG87 2024)
4. Stimulant first-line (methylphenidate-class OR amphetamine-class) for ≥ 6 yr Methylphenidate IR 5 mg BID-TID OR Concerta 18-72 mg daily AM OR Adderall XR 5-30 mg daily AM OR Lisdexamfetamine (Vyvanse) 30-70 mg daily AM; titrate weekly to functional response or max PO (or transdermal Daytrana for methylphenidate) IR BID-TID; ER daily AM — DSM-5-TR ADHD diagnosis + age ≥ 6 yr + no contraindication (AAP 2019; APA 2024) (Stimulant first-line per AAP 2019 PMID 31570648 (pediatric) and APA 2024 (adult); baseline screen + Q3-6 mo monitoring; lisdexamfetamine has lower abuse liability than mixed amphetamine salts due to prodrug design (FDA label))
5. Preschool 4-5 yr: behavioral parent training first-line; methylphenidate IR only if behavioral inadequate Behavioral parent training (Triple P / Incredible Years) × 8-12 wk; methylphenidate IR 2.5-5 mg BID-TID only if behavioral inadequate (AAP 2019) behavioral + PO if needed weekly behavioral + BID-TID stimulant if needed — Preschool 4-5 yr ADHD diagnosis (AAP 2019) (AAP 2019 PMID 31570648 — behavioral first-line for 4-5 yr; methylphenidate only stimulant with FDA evidence at this age; off-label otherwise)
6. Within-class switch if Step 1 inadequate at adequate dose × 4-6 wk Methylphenidate-class: Concerta → Focalin XR; Adderall XR → Vyvanse PO daily AM — Stimulant inadequate at adequate dose × 4-6 wk OR intolerance (AAP 2019) (Different formulations have different PK + tolerability; within-class switch often successful (AAP 2019))
7. Cross-class switch if within-class switch inadequate Methylphenidate-class → amphetamine-class (or vice versa) PO daily AM — Within-class switch inadequate at adequate dose × 4-6 wk (AAP 2019) (~30% of non-responders to one class respond to the other (AAP 2019))
8. Non-stimulant (atomoxetine first; viloxazine second) if both stimulant classes failed or contraindicated Atomoxetine 0.5 → 1.2-1.4 mg/kg/day pediatric (max 100 mg) OR 40-80-100 mg adult; viloxazine 100-400 mg pediatric / 200-600 mg adult PO once daily AM (atomoxetine; viloxazine) — Stimulant failure / intolerance / contraindication / active SUD / diversion / tic exacerbation / patient-family preference (AAP 2019; APA 2024) (Atomoxetine 4-week onset (counsel on delayed effect); FDA black-box for SI in pediatric — C-SSRS first 4 wk; CYP2D6 dose adjustment; viloxazine newer NRI (FDA 2021) fewer data)
9. Alpha-2 agonist augmentation (guanfacine ER or clonidine ER) Guanfacine ER (Intuniv) 1-4 mg/day pediatric / 1-7 mg adult; clonidine ER (Kapvay) 0.1-0.4 mg/day pediatric PO daily HS (extended-release; bedtime sedation) — Partial stimulant response OR comorbid tics OR sleep disturbance OR aggression / irritability (AAP 2019; APA 2024) (FDA-approved pediatric ADHD monotherapy or stimulant adjunct; rebound HTN on abrupt discontinuation; HR + BP monitoring)
10. SSRI for comorbid MDD (PHQ-9 ≥ 10) or anxiety (GAD-7 ≥ 10) Sertraline 25-200 OR escitalopram 5-10-20 (Cipriani 2018 PMID 29477251) PO daily — PHQ-9 ≥ 10 or GAD-7 ≥ 10 — routes to psych.depression.core.v1 or psych.anxiety-disorders.core.v1 (Comorbid MDD ~15-20% and anxiety ~25% in ADHD; FDA 2004 black-box first 4 wk pediatric C-SSRS; treat ADHD first if mild MDD/anxiety; treat both if moderate-severe)

Non-pharmacologic actions:
- Behavioral parent training (Triple P / Incredible Years / Parent-Child Interaction Therapy PCIT) — first-line for preschool (4-5 yr) AAP 2019; adjunct for school-age + adolescent ADHD with comorbid ODD/CD
- CBT for adult ADHD per Safren manual — 12-15 sessions focusing on organization + planning + time management + emotion regulation (Safren 2005 + 2017 update; APA 2024)
- School accommodations — 504 plan (Section 504 of Rehabilitation Act 1973) OR Individualized Education Program (IEP under IDEA) — extended time, preferential seating, breaks, behavior intervention plan; pediatric academic decline (AAP 2019)
- Workplace accommodations — written instructions, regular breaks, quiet workspace, deadline support, ADA reasonable accommodations (APA 2024)
- Driving safety counseling for adolescent + adult ADHD — increased MVA risk especially untreated or undertreated; medication-on-driving days; defensive driving course (APA 2024)
- Educational + occupational coaching for adult ADHD — structured external supports; complementary to CBT (APA 2024)
- Family / caregiver involvement with consent — MANDATORY for pediatric behavioral parent training; helpful for adult ADHD (AAP 2019; APA 2024)
- Psychoeducation on ADHD as a chronic neurodevelopmental condition — persists into adulthood ~50-65% (MTA Hechtman PMID 30019501); treatment is long-term
- Psychoeducation on Schedule II controlled substance — abuse / dependence / diversion risks; safe storage; informed consent (FDA)
- Sleep hygiene — consistent schedule; screen restriction; CBT-I if persistent insomnia; OSA workup if obesity (AAP 2019)
- Exercise prescription — moderate-intensity aerobic 30 min × 5 days/week; demonstrable benefit for ADHD symptoms + executive function (APA 2024)
- Mindfulness-based training for adult ADHD — adjunct to CBT (APA 2024)
- Reduce alcohol; address substance use disorders concurrently — non-stimulant or restricted-monitoring stimulant; addiction-medicine collaboration (APA 2024; AAP 2019)
- MDQ administered before every stimulant initiation in patient with suggestive bipolar features (family history bipolar, early-onset MDE, atypical features, antidepressant-induced switch history) — avoids stimulant-induced manic-switch + ensures correct diagnosis (Hirschfeld 2000 NEEDS_SOURCE_REVIEW; APA 2024)
- Lethal-means counseling for any patient with current or historical SI — firearm + large-quantity-medication restriction (Mann JAMA 2005 NEEDS_SOURCE_REVIEW; Stanley-Brown 2012; VA/DoD 2022)
- Stanley-Brown 2012 safety-plan documented for any patient with current or historical SI — 6 steps
- Transition planning at age 17-18 — bridge to adult psychiatry BEFORE 18; medication-continuity plan; PCP handoff; written transition letter; college / vocational accommodations (AAP 2019; APA 2024)
- Annual ADHD re-evaluation — symptoms + functional impact + comorbidities + medication response + side effects + diversion / misuse screen (AAP 2019; APA 2024)
- Stimulant drug-holiday consideration — weekends + summer breaks may be reasonable for appetite-suppression + growth-velocity concerns; pediatric only; AAP 2019

AVOID / contraindication checks:
- Baseline_HR_BP_weight_height_cardiac_history_FH_SCD_lt_35_before_stimulant (AAP 2008 + 2019 + AHA 2008 NEEDS_SOURCE_REVIEW; FDA)
- Stimulant_CONTRAINDICATED_structural_heart_disease_serious_arrhythmia_recent_MI (FDA black box)
- Stimulant_caution_active_SUD_or_diversion_history_use_non_stimulant_or_restricted_monitoring (APA 2024; AAP 2019)
- MAOI_washout_14_days_before_after_stimulant_or_atomoxetine (FDA)
- Atomoxetine_pediatric_FDA_black_box_suicidal_ideation_C_SSRS_first_4_weeks (FDA 2005)
- Atomoxetine_LFT_monitoring_if_hepatic_symptoms (FDA label)
- Atomoxetine_CYP2D6_dose_adjustment_for_poor_metabolizers (FDA label)
- Growth_velocity_appetite_sleep_monitoring_pediatric_Q3_6mo (AAP 2019 PMID 31570648)
- Tic_emergence_on_stimulant_switch_atomoxetine_or_alpha2_agonist_not_absolute_contraindication (Tourette Syndrome Study Group 2002 NEEDS_SOURCE_REVIEW; AAP 2019)
- Discontinue_stimulant_for_chest_pain_palpitations_syncope_hypertensive_crisis_cardiology_consult (FDA black box; AAP 2019)
- Alpha2_agonist_rebound_hypertension_on_abrupt_discontinuation_taper (FDA label)
- Alpha2_agonist_HR_BP_monitoring_bedtime_sedation (FDA label)
- Schedule_II_informed_consent_abuse_dependence_diversion (FDA)
- No_routine_EKG_required_in_healthy_children_but_cardiac_history_and_FH_SCD_screen_mandatory (AAP 2008 + 2019 + AHA 2008 NEEDS_SOURCE_REVIEW)
- MDQ_screen_before_initiating_treatment_in_suggestive_bipolar_features (Hirschfeld 2000 NEEDS_SOURCE_REVIEW; APA 2024)
- C_SSRS_at_intake_and_first_4_weeks_of_atomoxetine_or_SSRI (FDA 2004 + 2005 black box)
- Driving_safety_counseling_adolescent_adult_ADHD (APA 2024; AAP 2019)
- Pregnancy_behavioral_first_line_immediate_release_preferred_if_continued (APA reproductive psychiatry; APA 2024)

Monitoring

Regimen monitoring:
- Weekly visits x 4 wk during initiation (AAP 2019; APA 2024)
- HR BP weight appetite sleep mood tics side effects each visit during titration (AAP 2019)
- Growth velocity BMI percentile Q3 6mo pediatric (AAP 2019 PMID 31570648)
- PHQ 9 GAD 7 Q4 wk during titration (Kroenke 2001; Spitzer 2006)
- C SSRS at intake and first 4 wk of atomoxetine or SSRI (FDA 2004 + 2005 black-box)
- Vanderbilt SNAP IV ADHD RS or Conners response assessment Q4 wk (AAP 2019)
- ASRS adult response assessment Q4 wk (Kessler 2005 NEEDS SOURCE REVIEW)
- Maintenance phase Q3 6mo visits (AAP 2019)
- Annual cardiac re screen personal FH SCD HR BP (AAP 2019; AHA 2008 NEEDS SOURCE REVIEW)
- Substance use sweep in adolescents and adults (APA 2024)
- Continue treatment as long as functional benefit (AAP 2019; MTA Hechtman PMID 30019501)

Setting (outpatient) monitoring:
- Weekly visits × 4 wk during initiation (AAP 2019; APA 2024)
- HR + BP + weight + appetite + sleep + mood + tics + side effects each visit during titration (AAP 2019)
- Growth velocity + BMI percentile Q3-6 mo (pediatric stimulant patients) (AAP 2019 PMID 31570648)
- PHQ-9 + GAD-7 Q 4 wk during titration (Kroenke 2001; Spitzer 2006)
- C-SSRS at intake + first 4 wk of atomoxetine or new SSRI (FDA 2004 + 2005 black-box)
- Vanderbilt / SNAP-IV / ADHD-RS / Conners response assessment Q4 wk during titration (AAP 2019)
- ASRS adult response assessment Q4 wk during titration (Kessler 2005 NEEDS_SOURCE_REVIEW; APA 2024)
- Maintenance phase Q3-6 mo visits with HR + BP + weight + functional-impact + comorbidity surveillance (AAP 2019)
- Annual cardiac re-screen — personal cardiac symptoms + FH SCD < 35 + HR + BP (AAP 2019; AHA 2008 NEEDS_SOURCE_REVIEW)
- Substance use sweep in adolescents and adults Q6-12 mo (APA 2024)
- EKG only if cardiac history OR FH SCD < 35 OR new cardiac symptom on stimulant (AAP 2019; AHA 2008 NEEDS_SOURCE_REVIEW)

Follow-up plan: 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)
- Close-out criterion: Maintenance plan in place

Monitoring phase: Initiation phase: weekly visits × 4 wk; HR + BP + weight + appetite + sleep + mood + tics + side effects; PHQ-9 + GAD-7 + C-SSRS during titration + first 4 wk of atomoxetine or new antidepressant (FDA 2004 + 2005 black-box); Vanderbilt / ASRS / Conners response assessment Q4 wk. Maintenance phase: Q3-6 mo visits; HR + BP + growth velocity + BMI percentile (pediatric); annual cardiac re-screen; ongoing functional-impact assessment; substance use sweep in adolescents and adults. Response = ≥ 30% symptom reduction on Vanderbilt / SNAP-IV; remission = symptom score < clinical threshold + sustained functional improvement (AAP 2019; APA 2024)

Disposition

Current setting: outpatient — Pediatric / adolescent / adult outpatient ADHD pathway — stimulant titration + behavioral therapy (parent training for pediatric; CBT for adult ADHD per Safren manual) + school / workplace accommodations + weekly-monthly visits during titration → Q3-6 mo maintenance with growth velocity + cardiovascular + comorbidity surveillance (AAP 2019 PMID 31570648; APA 2024; NICE NG87 2024)

Disposition criteria:
- Continue current step if responding — sustained ≥ 30% Vanderbilt / SNAP-IV / ADHD-RS reduction + functional improvement (AAP 2019; APA 2024)
- Step up if inadequate response at adequate dose × 4-6 wk (AAP 2019; APA 2024)
- Refer to psychiatry / specialty ADHD clinic if at Step 4 non-stimulant or beyond, complex comorbidity, pregnancy, or treatment-resistance (APA 2024; AAP 2019)
- ED for acute stimulant cardiovascular event OR acute SI with intent / plan / means OR severe agitation (FDA; APA 2024)
- Cardiology referral if cardiac concern OR FH SCD < 35 OR persistent HTN on stimulant (AAP 2019; AHA 2008 NEEDS_SOURCE_REVIEW)
- Addiction-medicine referral if active SUD or diversion / misuse (APA 2024)
- Transition to adult psychiatry at age 17-18 — before 18 ideal; medication continuity (AAP 2019; APA 2024)

Escalation triggers (move to higher acuity):
- Acute stimulant cardiovascular event (chest pain / palpitations / syncope / hypertensive crisis) → ED + cardiology + discontinue stimulant + alternative non-stimulant (FDA black-box; AAP 2019)
- Active SI with intent / plan / means → ED + cross-route to psych.suicidality.ed.core.v1 (Posner 2011; FDA 2005 atomoxetine black-box)
- Stimulant diversion or misuse → addiction-medicine + switch to non-stimulant or restricted-monitoring stimulant (APA 2024; AAP 2019)
- Active SUD with ADHD → non-stimulant first-line + concurrent SUD treatment; routes to psych.opioid_use_disorder.core.v1 or psych.alcohol_withdrawal.core.v1 (APA 2024)
- Pregnancy + current stimulant → reproductive psychiatry + behavioral first-line + immediate-release if continued (APA reproductive psychiatry; APA 2024)
- New tic emergence on stimulant → switch to atomoxetine or alpha-2 agonist (Tourette Syndrome Study Group 2002 NEEDS_SOURCE_REVIEW; AAP 2019)
- Growth velocity < 5th percentile on stimulant → growth + appetite monitoring + drug-holiday consideration (AAP 2019 PMID 31570648)
- Persistent severe HTN (sustained SBP > 95th percentile pediatric or > 140/90 adult) → discontinue stimulant + HTN workup + alternative non-stimulant (AAP 2019; FDA)
- Antidepressant-induced or stimulant-induced manic switch → cross-route to psych.bipolar-disorder.core.v1 (APA 2024)
- Academic / occupational decline despite "adequate" treatment → re-evaluate diagnosis + comorbidities + adherence + dose + class (AAP 2019; APA 2024)
- Adolescent age 17-18 → transition to adult psychiatry handoff (AAP 2019; APA 2024)
- Rebound irritability / appetite loss / sleep disturbance severe → adjust dose / formulation / class; alpha-2 agonist add-on for rebound (AAP 2019)

Patient Action Plan

**ADHD action plan + Stanley-Brown 2012 safety plan + stimulant cardiovascular warning (AAP 2019 PMID 31570648; APA 2024; FDA black-box)**
Personalised values: baseline_Vanderbilt_or_ASRS, current_medication_list, identified_supports, crisis_line_numbers, reasons_for_living, means_restriction_steps, school_or_workplace_accommodations, cardiac_history, identified_triggers.

**Doing well — symptoms controlled, functioning at school / work / home, no SI, no cardiovascular symptoms (AAP 2019; APA 2024)** (green):
Triggers:
- 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)
Actions:
- 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)

**Caution — symptoms returning, school / work / home function declining, side effects emerging, passive SI without plan (AAP 2019; APA 2024)** (yellow):
Triggers:
- 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)
Actions:
- 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)
Contact provider when:
- 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)

**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)** (red):
Triggers:
- 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)
Actions:
- 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)
Contact provider when:
- Any red zone trigger — emergency department immediately, do not wait (AAP 2019; APA 2024; FDA)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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] 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.
- [SEVERE] 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.

Citations

- 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) [PMID:31570648](https://pubmed.ncbi.nlm.nih.gov/31570648/)
- Cited evidence (PMID 30019501) [PMID:30019501](https://pubmed.ncbi.nlm.nih.gov/30019501/)
- Cited evidence (PMID 11556941) [PMID:11556941](https://pubmed.ncbi.nlm.nih.gov/11556941/)
- Cited evidence (PMID 16717171) [PMID:16717171](https://pubmed.ncbi.nlm.nih.gov/16717171/)
- Cited evidence (PMID 22193671) [PMID:22193671](https://pubmed.ncbi.nlm.nih.gov/22193671/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 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) — PMID:31570648
  • Cited evidence (PMID 30019501) — PMID:30019501
  • Cited evidence (PMID 11556941) — PMID:11556941
  • Cited evidence (PMID 16717171) — PMID:16717171
  • Cited evidence (PMID 22193671) — PMID:22193671