adhd FOLLOW UP VISITS

Follow up visits for ADHD:

If your child is taking ADHD medication, regular follow-up is needed for effective treatment. According to Arkansas State Medical Board regulations, ADHD medications require follow-up visits at least every 6 months. Regular follow-up visits are not just regulatory requirements; they’re essential for ensuring that your child receives the best possible care.

Initial Follow-Up: One Month After Starting Medication

After starting a new DEA class II stimulant medication, it is necessary to conduct a follow-up visit within one month, as mandated by the Arkansas State Medical Board. This visit serves several purposes:

Evaluation of Medication Effectiveness: During this initial follow-up, we will discuss with the child and their parents or caregivers any changes in symptoms. Improvements in focus, reduced hyperactivity, and enhanced impulse control can indicate that the medication is effective.

Monitoring Potential Side Effects: Stimulant medications can sometimes cause side effects such as appetite suppression, sleep disturbances, or mood swings. This visit allows for discussing any adverse effects and making necessary dosage adjustments.

Gathering Family and Teacher Feedback: Insights from family members and teachers provide a comprehensive view of the child's response to medication across settings, including academic performance and social interactions. Parent and Teacher Vanderbilt rating scales are best.

During this follow-up, a second prescription—and possibly the third or fourth—can be issued. Additional prescriptions cannot be provided without completing this crucial step.

Continued Care: Follow-Ups Every Three to Six Months

Once a stable medication and dosage are established, follow-up visits are scheduled every three to six months to ensure continued effectiveness and minimal side effects:

1. Evaluating Long-Term Outcomes: These visits are opportunities to reassess how well the medication manages symptoms over time and to make any necessary adjustments.
2. Prescription Management: Typically, during these visits, three prescriptions are provided, with another set prepared three months later upon request. It’s essential to request these prescriptions two to three days in advance to avoid any lapse in medication.
3. Regulatory Compliance: Follow-up visits must not exceed a six month interval to maintain compliance with DEA and Arkansas State Medical Board regulations and requirements. These rules protect both the patient's well-being and the medical provider's license. We will not prescribe any DEA Schedule II medications without an ADHD visit within the past 6 months.
   

Importance of Regular Monitoring

Regular follow-up ensures that ADHD treatment remains effective and side effects are controlled. While mild side effects from ADHD medications are common, they are generally manageable and do not necessitate discontinuing the medication. Regular appointments are key to keeping the treatment on track and optimizing outcomes.

Adhering to these follow-up schedules ensures that your child’s treatment is consistent and effective, helping them thrive academically and socially. Always make sure to schedule appointments ahead of time to avoid disruptions in your child’s treatment plan.

Side Effects:

The most common side effect of stimulant medications for ADHD is appetite suppression, so monitoring your child’s weight is crucial. Since these medications typically last 8 to 12 hours, schedule meals during times when your child is likely to be hungry. Ensure they have a good breakfast before taking their morning medication.

In addition to a hearty dinner, encourage an extra evening meal, known as a “fourth meal,” making sure food is available later in the evening. This helps counteract reduced lunch intake from the medication. While your child may have less appetite at lunchtime, it's still important to encourage them to eat something.

Taking stimulant medications for ADHD can sometimes lead to a phenomenon known as the “rebound effect.”  This occurs when the effects of the stimulant wear off, causing symptoms like irritability, hyperactivity, impulsivity, or mood swings. The rebound effect can be particularly challenging because it may result in temporarily worsened behavior, often towards the end of the day as the medication’s effects diminish. The rebound effect may also contribute to insomnia or difficulty sleeping because the child’s brain becomes activated by the return of impulsivity and hyperactivity. Clonidine and guanfacine are two effective medications for managing insomnia related to the rebound effect. Consult us in an office visit if this phenomenon happens in your child.

Insomnia associated with ADHD can also occur for a different reason, such as when stimulants are taken too late in the day. Long acting stimulants enhance alertness and can disrupt natural sleep cycles, so they should be taken early in the morning hours before 10:00 am to ensure they wear off before bedtime.

Other potential less common side effects of stimulant medications include: headache, stomachache, socially withdrawn state, sadness, crying, dullness, tired, listless behavior, tremors/feeling shaky, tics, twitching, eye blinking, picking at skin or fingers, nail biting, lip or cheek chewing, and seeing or hearing things that aren’t there. If any of these happen, stop the medication and make an office visit appointment with one of our physicians to discuss the situation. 

Dose Titration:

An important aspect of ADHD treatment with stimulant medication is dose titration. It’s crucial to find the right dose for your child, as stimulant medications are not dosed based on weight like many other medications. Instead, they are dosed based on how your child responds to them. The initial dose of most ADHD stimulant medications may not be sufficient to control ADHD symptoms for most children. Therefore, the dose must be gradually increased until it effectively manages the symptoms without causing troubling side effects. Regular follow up visits help ensure the medication is dosed correctly ensuring safety and effectiveness. There are three possible scenarios in dosing a stimulant medication in a child with ADHD:

1. The child is on too low of a dose.  This means that the child will likely have few side effects of the medication, but the ADHD symptoms will be poorly controlled. ADHD symptoms were listed earlier in this section. Controlling ADHD symptoms requires that the dose of the medication be high enough. The dose needs to be increased.
2. The child is on just the right dose. This means that the ADHD symptoms will be well controlled and side effects should be minimal. Parents should see improvement in their child’s behavior and academic performance. However, appetite suppression is common on doses that are effective.
3. The child is on too much stimulant medication. This means that the ADHD symptoms will be well controlled, but side effects will be greater. The two most common side effects of too much medication are: a socially withdrawn state (a zombie like stare) and emotional lability. The dose should be diminished to correct this situation. Contact us regarding the proper course of action.

ADHD stimulant medications typically begin working within a few minutes of ingestion and reach peak effectiveness 30 to 60 minutes later. Once a day’s dose of medication wears off, its effects diminish and do not carry over to the next day.

Legal Warnings on the use of stimulant medications

Stimulant medications for ADHD are classified as Schedule II controlled substances by the DEA. Misuse of these drugs is a felony and can result in imprisonment. Prescribing them carries legal risks for physicians, who could face imprisonment and loss of their medical license if they violate regulations. Therefore, it is crucial for both prescribers and patients to follow legal guidelines to ensure safety and compliance.

To adhere to DEA and Arkansas State Medical Board requirements, we follow these rules when prescribing stimulants:

1. Prescription Method: Prescriptions must be issued electronically with token verification or written on authorized prescription paper by a licensed physician. They cannot be phoned into the pharmacy. Therefore, they can only be issued during regular office hours. Please do not request prescriptions after office hours. We will not do it.
2. No Refills: Stimulant prescriptions cannot be refilled. We can issue three new prescriptions at a time, each with sequential effective dates, typically during follow-up visits.
3. Medication Storage: Always keep ADHD medications in their original labeled pharmacy containers. Carrying them loose may result in arrest, as they are only legal in their containers issued by the pharmacy.
4. Legal Use: Do not sell ADHD medications or take someone else’s, as both actions are illegal.
5. Lost Prescriptions: If you lose your prescription, note that we are reluctant to reissue it due to the potential for illegal diversion.

By strictly following these guidelines, we strive to ensure the safe and appropriate use of ADHD medications. Parents or caregivers who do not follow the rules and regulations above will not have prescriptions renewed for their children.