Monitoring during drug treatment of attention deficit hyperactivity disorder in children

Review a child regularly during treatment for attention deficit hyperactivity disorder (ADHD) (eg monthly during the early stages of treatment, then at least a few times a year when stable). Monitor:

• symptoms of ADHD—this will help determine if drug titration is needed (symptoms can worsen during times of growth, which may indicate the need for a change in dose). Social withdrawal and tearfulness may be indicators of an excessive dose
• height and weight—stimulants and atomoxetine can affect growth in children, but the effect is relatively minor. If there is concern about a child’s growth, drug-free intervals may be appropriate at times when some increase in symptoms is acceptable (eg weekends, school holidays)
• blood pressure and heart rate—all drugs for ADHD can cause cardiovascular adverse effects. Stimulants can cause hypertension. Clonidine and guanfacine can cause hypotension and, when withdrawn, rebound hypertension. If a change in blood pressure or heart rate is clinically significant, further investigation of cardiovascular effects is needed (eg electrocardiogram [ECG])
• adverse effects—many children become tolerant to adverse effects without the need to reduce doses. If adverse effects continue, increase the frequency of monitoring. Dosage adjustment or a change of drug may be required if the patient cannot tolerate the adverse effect
• comorbid conditions, including substance abuse
• adherence—if nonadherence is identified, address contributing factors and consider a change in formulation or use of a combination of formulations.

Ensure family or carers of children with ADHD have contact with teachers before review appointments to obtain information about performance at school. Questionnaires may be used to help gather information from different sources and may help with monitoring of benefits and adverse effects.