eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Attention Deficit Hyperactivity Disorder: Follow-up

Author: Susan Louisa Montauk, MD, Medical Director, The Affinity Center, Cincinnati; Professor, Departments of Family Medicine and Public Health Science, University of Cincinnati College of Medicine
Coauthor(s): Christine A Mayhall, PhD, Clinical Psychologist, The Affinity Center
Contributor Information and Disclosures

Updated: Feb 27, 2009

Follow-up

Further Outpatient Care

  • Follow-up for attention deficit hyperactivity disorder (ADHD), previously termed attention deficit disorder (ADD), varies and depends on the patient's profile, the clinician's experience, and the access to healthcare providers.
  • After the patient's condition is stabilized, a follow-up frequency of every 6-12 weeks is often appropriate for the first year.
  • After that, patients whose conditions are stable may do best with visits every 4 months to assess their medications.
  • Psychotherapy may need to be continued for months to years.

Inpatient & Outpatient Medications

Complications

  • Coexisting neuropsychiatric disorders and learning disorders can complicate the diagnosis and treatment of ADHD (ADD). See History.

Prognosis

  • The prognosis for patients with ADHD (ADD) is excellent if the following conditions are present:
    • The patient has no major comorbidity.
    • Medication management takes into account minor comorbidities and the great range of individual responses.
    • Patients and caregivers receive appropriate education about ADHD (ADD) and ADHD (ADD) management.
    • Adherence to therapy continues.
    • Any and all coexisting learning disabilities are diagnosed, and remediation is scheduled and undertaken.
    • Any and all coexisting emotional problems are investigated and treated appropriately by a primary care provider or the patient is referred to a mental health professional.

Patient Education

  • Provide information about the pathophysiology in lay terms.
  • Provide information about complementary therapeutic approaches to medication (eg, involvement of education specialists, counseling or coaching, school accommodations, parent training).
  • Provide clinical medication information.
  • Include appropriate follow-up parameters.
  • Attend to administrative issues related to medication (eg, prescription writing and safety, compliance with state laws).
  • Provide emergency information.
  • Seek school accommodations.
  • Provide contact information for local and national support organizations.
  • Provide literature or written resources (eg, books, periodicals).
  • For excellent patient education resources, visit eMedicine's Mental Health and Behavior Center. Also, see eMedicine's patient education article Attention-Deficit/Hyperactivity Disorder.

Miscellaneous

Medicolegal Pitfalls

Used in the treatment of attention deficit hyperactivity disorder, previously termed attention deficit disorder (ADD), methylphenidate and the amphetamines are all schedule II controlled substances (C-II); therefore, prescriptions for these drugs must follow strict federal and state guidelines.

  • Any psychostimulants that legal authorities find (eg, while writing a speeding ticket to a patient) can cause suspicion. Therefore, if patients must carry their medication away from home, the drugs should be kept in the original container from the pharmacy. In some states, having the medication in any container is acceptable as long as the pills are accompanied by the prescriber's order on a prescription form or letterhead that states that the patient is under the clinician's care and takes the medication as directed.
  • Many clinicians ask all patients receiving C-II drugs to sign an agreement stating that they will use only one pharmacy, that they will never share the medication, and that they will never use more than the prescribed amount.
  • Although the rate of stimulant abuse in ADHD (ADD) specialty centers is low, it is not zero, and stimulant misuse on college campuses is a growing concern.
    • Warn adolescent patients about the potentially fatal outcomes of intravenous psychostimulant abuse.
    • Snorting crushed psychostimulants (observed in many adolescent environments) is potentially addictive and fatal; therefore, warn patients about the dangers of snorting drugs.
    • Consider reminding adolescent patients with ADHD (ADD) that if any of their medication knowingly leaves their hands and is used as an intravenous psychostimulant or snorted as a crushed psychostimulant, the fate of the abuser is partially his or her responsibility.
  • Federal and state laws grant special educational accommodations for patients with ADHD (ADD) and learning disabilities who have documented negative impact on their ability to learn. Become familiar with these laws.

Special Concerns

  • In the International Classification of Disease, Ninth Revision (ICD-9), ADHD (ADD) is coded as follows:
    • 314.00 - All ADHD (ADD) without hyperactivity (eg, inattentive type)
    • 314.01 - All ADHD (ADD) with hyperactivity (eg, predominantly inattentive type with hyperactivity and hyperactive type)
    • 314.9 - Nonspecific (ie, other prominent symptoms of ADHD [ADD] that do not meet the above criteria)
  • ADHD (ADD) is a controversial diagnosis for several reasons. Many well-meaning individuals have spoken out against making children behave according to a norm or take medications for the sake of improving their grades. These individuals have expressed concern about addiction or medication of children. This concern is valid; however, the following issues must also be considered:
    • Improved school performance is often linked to improved social skills and heightened self-esteem.
    • Stimulants used to treat ADHD (ADD) do not cause addiction. Although tolerance usually develops for the stimulant-associated effects of anorexia, insomnia, or mild euphoria, tolerance does not develop to the neurotransmission augmentation of ADHD (ADD)-related neurochemistry.
    • The use of psychostimulants in children should be scrutinized carefully. Fortunately, methylphenidate (historically the major medication for ADHD [ADD]) has been available for more than 40 years. Although no placebo-controlled prospective studies have been performed, experience has shown it to be one of the safest pharmaceuticals used in children.
    • Data from a recent analysis of all available studies of the possible effect of stimulant treatment for ADHD (ADD) on future substance abuse support the safety of stimulant treatment. Conducting a meta-analysis, researchers from the Massachusetts General Hospital found that medication treatment for children with ADHD (ADD) reduced the risk of future substance abuse by almost 2-fold.
 


More on Attention Deficit Hyperactivity Disorder

Overview: Attention Deficit Hyperactivity Disorder
Differential Diagnoses & Workup: Attention Deficit Hyperactivity Disorder
Treatment & Medication: Attention Deficit Hyperactivity Disorder
Follow-up: Attention Deficit Hyperactivity Disorder
References
Further Reading
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References

  1. APA. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association Press; 1994:78-85.

  2. Brown TE. Brown ADD Scales. San Antonio, TX: Psychological Corp; 1996:5-6.

  3. Elia J, Ambrosini PJ, Rapoport JL. Treatment of attention-deficit-hyperactivity disorder. N Engl J Med. Mar 11 1999;340(10):780-8. [Medline].

  4. Hunt RD, Paguin A, Payton K. An update on assessment and treatment of complex attention-deficit hyperactivity disorder. Pediatr Ann. Mar 2001;30(3):162-72. [Medline].

  5. Johnson TM. Evaluating the hyperactive child in your office: is it ADHD?. Am Fam Physician. Jul 1997;56(1):155-60, 168-70. [Medline].

  6. Millichap JG. Etiologic classification of attention-deficit/hyperactivity disorder. Pediatrics. Feb 2008;121(2):e358-65. [Medline].

  7. Nadeau KG, Littman E, Quinn P. Understanding Girls With AD/HD. Springfield, MD: Advantage Books; 2000.

  8. Ramchandani P, Joughin C, Zwi M. Attention deficit hyperactivity disorder in children. Clin Evid. Jun 2002;262-71. [Medline].

  9. Rappley MD. Clinical practice. Attention deficit-hyperactivity disorder. N Engl J Med. Jan 13 2005;352(2):165-73. [Medline].

  10. Reeves G, Schweitzer J. Pharmacological management of attention-deficit hyperactivity disorder. Expert Opin Pharmacother. Jun 2004;5(6):1313-20. [Medline].

  11. Spencer TJ, Biederman J, Wilen T. Pharmacotherapy of ADHD with antidepressants. In: Barkley RS, ed. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 2nd ed. New York, NY: Guilford Press; 1998:552-63.

  12. Wolraich ML, ed. The Classification of Child and Adolescent Mental Diagnoses in Primary Care: Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child. Elk Grove, IL: American Academy of Pediatrics; 1996.

  13. Wilens TE. Straight Talk about Psychiatric Medications for Kids. New York, NY: Guilford Press; 2002.

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Further Reading

Additional resources on attention-deficit/hyperactivity disorder (ADHD) are available at Medscape's Attention Deficit/Hyperactivity Disorder (ADHD) Resource Center.

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Keywords

attention deficit hyperactivity disorder, AD/HD, ADD, ADD/ADHD, ADHD, attention deficit disorder, attention deficit disorder with and without hyperactivity, attention–deficit/hyperactivity disorder, attention-deficit hyperactivity disorder, hyperkinetic impulse disorder, hyperactive syndrome, hyperkinetic reaction of childhood, minimal brain damage, minimal brain dysfunction, undifferentiated attention deficit disorder, learning disorders, restless-legs syndrome, ophthalmic convergence insufficiency, depression, anxiety disorders, antisocial personality disorder

substance abuse disorder, conduct disorder, inattentive ADHD, inattentive ADD, pervasive developmental disorder, premenstrual dysphoric disorder, schizophrenia, psychotic disorder, mood disorder, anxiety dissociative disorder, personality disorder, major arterial disease, narrow-angle glaucoma, heart disease, heart palpitations, hepatic disease, hypertension, orthostasis, renal disease, seizure disorder, generalized anxiety disorder, GAD, obsessive-compulsive disorder, OCD, panic disorder, social phobia, oppositional defiant disorder, dissociative disorders, eating disorder, enuresis, encopresis, Asperger syndrome, posttraumatic stress disorder, PTSD, sleep disorder, Tourette syndrome, physical abuse, sexual abuse

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Contributor Information and Disclosures

Author

Susan Louisa Montauk, MD, Medical Director, The Affinity Center, Cincinnati; Professor, Departments of Family Medicine and Public Health Science, University of Cincinnati College of Medicine
Susan Louisa Montauk, MD is a member of the following medical societies: American Academy of Family Physicians and Society of Teachers of Family Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Christine A Mayhall, PhD, Clinical Psychologist, The Affinity Center
Christine A Mayhall, PhD is a member of the following medical societies: American Psychological Association
Disclosure: Nothing to disclose.

Medical Editor

Chet Johnson, MD, Medical Director, Child Development Unit, Department of Pediatrics, Professor, University of Kansas Medical Center
Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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