Pharmacology
Attention Deficit Hyperactive Disorder (ADHD)
Case Study
Patient Profile
Name: Max
Age: 10 years old
Gender: male
History of Present Illness
The parents of a 10-year-old boy, Max, bring him to the office because they have become increasingly concerned about his behavior in school and at home. Historically, since starting school, he has complained about being bored. He has been disruptive, has fought with classmates, and has been rude to his teacher. At home, despite attempting to engage him in meal planning and preparation, he cannot sit still at mealtime and meals have been very unpleasant for everyone involved. The parents have two older daughters who say their brother is a “pain” and spoiled. There were no pregnancy or birth problems including no in utero substance exposures. Max has been playing, eating, drinking, and urinating as usual. There has been no diarrhea or constipation. He has had all his scheduled immunizations. His weight in the office today was 72 pounds (32.7 kg).
You have gathered information from observations of the child both at home and in school. You have also talked with his teacher and obtained results of psychological testing. The patient has been able to be interviewed and there is no evidence that the child is under undue stress or is the victim of any abusive situations. While the mental health expert is assisting with behavioral interventions, the parents and mental health professionals are in support of medication therapy. Max does not seem to be concerned about taking medication at school and is happy that there might be something to help him stop getting into trouble daily.
Current Medications
None
Relevant Assessment
Max has undergone comprehensive medical, developmental, educational, and psychosocial evaluation, and the diagnosis of ADHD is established.
No other expanded review of system (subjective data) or examination (objective data) has an impact on the diagnosis reviewed in this case.
Differentials
ADHD, mood disorders, anxiety disorders, substance use disorders, learning disabilities, and intellectual disabilities, as well as medical conditions like epilepsy and sleep disorders
Diagnosis
ADHD
Diagnostic Testing
None at this time
Referrals
See above; additionally, none at this time. Patient is working with school psychologist and counselor.
Patient/Provider Collaborative Goals
Max will experience less school and home relationship distress by the next follow-up visit.
Therapeutic Interventions
- Describe a first-line pharmacologic treatment: Include drug name, dose and formulation, frequency, and length of treatment at this dose.
Answer:
Methylphenidate IR (Ritalin) 5 mg by mouth once on day one then two times per day for two weeks, then evaluate response to the medication/dose at the follow-up office visit.
- Drug Mechanism of Action:
Answer:
Methylphenidate has a mild central nervous system stimulant effect. It works by blocking the reuptake of norepinephrine and dopamine into presynaptic neurons.
- Contraindications if applicable:
Answer:
Hypersensitivity to methylphenidate or any of its components. Concurrent use or use 14 days after cessation of monoamine oxidase inhibitors. Keep in mind there is a boxed warning about abuse potential. It is important to screen patients of any age related for stimulant drug use. Ask about a history of illicit use and prescribed stimulant agent misuse prior to prescribing methylphenidate for ADHD.
- Drug Mechanism of Action:
- Therapeutic advisement and monitoring: (include any specific instructions that apply, such as when to take the medication, if there are foods to avoid, storage issues, etc; include what laboratory/other (i.e., EKG) test monitoring to expect and how often and monitoring for adverse effects both common and serious)
Answer:
Specific Instructions: Instruct the patient and caregivers to monitor the patient’s appetite, sleep, and behavior/concerns they have at this visit including disruptive, rude, aggressive, and inattentive behaviors. Instruct the patient and caregivers to avoid the use of beverages or food products with caffeine as these may lead to feeling jittery. Advise the patient and caregivers to check with you before taking over-the-counter medications like non-steroidal anti-inflammatory medications or cough, cold, and flu medications as combining these products with methylphenidate may elevate blood pressure.
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- Therapeutic Monitoring: During the first year, follow up is recommended at least every 3 months. The following should be monitored at baseline with therapy initiation at each follow-up: blood pressure, heart rate, signs of digital vasculopathy, sleep, height/weight, behavioral, and psychiatric changes. After one year, if very stable, monitoring may be every six months for the duration of treatment and more often with dosage adjustments. Patients should also be advised to report any serious adverse effects listed below.
- Monitor Side/Adverse Effects: The NP should ask about and examine the patient checking for common side effects including decreased appetite, nausea, xerostomia, headache, insomnia, and irritability.
- Serious Adverse Effects:
- Cardiovascular: Myocardial infarction, tachycardia, and hypertension are all possible; even sudden cardiac death is a risk particularly if a patient has a structural heart defect or if the patient takes other medications that may prolong the QT interval. Patients should have a baseline EKG at the initiation of therapy if there is personal medical cardiac history or family history of ventricular dysrhythmia or sudden cardiac death. If the patient develops exertional chest pain, unexplained syncope, or other symptoms of cardiac disease during therapy, the patient should be evaluated in the emergency department.
- Growth retardation.
- Sexual dysfunction: Can include the inability to attain or sustain an erection, decreased sex drive, priapism. If the patient experiences priapism, they should be instructed to go to the emergency department immediately for evaluation and treatment to avoid permanent damage to penile tissue.
- Psychiatric: There is potential for aggressive behavior. Additionally, there is potential for new onset mania; there is increased risk of new onset mania for those with a family history of bipolar disorder, patient history of depression with psychotic episodes, female gender, and younger age at onset of depression.
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- Planned follow-up should consider adverse effect monitoring, dose adjustment considerations, and decisions about continuing versus discontinuing. In this case, planned follow-up would be:
Answer:
Office visit follow-up in two weeks. The patient/caregivers should be instructed sooner if there are any concerns.
Review Questions
Click the arrow to expand the section and view the correct answers.
- Classes of medications that may be helpful in treating children, adolescents, and adults with attention deficit hyperactivity disorder include (Select all that apply):
-
- Selective serotonin reuptake inhibitor
- Selective norepinephrine reuptake inhibitor
- Central nervous system stimulants
- Central nervous system depressant
- Centrally acting alpha2A-adrenergic receptor agonists
Answer(s):
B. Selective norepinephrine reuptake inhibitor; C) Central nervous system stimulants; E) Centrally acting alpha2A-adrenergic receptor agonists
- Molly is an 18-year-old college student who you see in your office today. She is concerned that she may need to re-start medication for ADHD. However, there is a documented history of stimulant illicit substance use in her record. Which of the following would be the safest option to start her on?
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- Methylphenidate
- Dexmethylphenidate
- Atomoxetine
- Dextroamphetamine
Answer(s):
C. Atomoxetine
- Max is a 10-year-old boy who started on a central nervous system stimulant three months ago. At a follow-up visit Max and his parents express concern for the adverse effect of insomnia. Which of the following is a potential way to mitigate this adverse effect?
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- Switch to a non-stimulant medication to avoid adverse effects on Max’s school work
- Increase the afternoon dose and administer the last dose before 4 p.m.
- Add 4 mg melatonin at bedtime to Max’s bedtime routine
- Reduce the afternoon dose and administer the last dose no later than 4 p.m.
Answer(s):
D. Reduce the afternoon dose and administer the last dose no later than 4 p.m.
- True or False: When using central nervous system stimulants for ADHD, administering the medication before meals helps to prevent appetite suppression, thus growth suppression.
-
- True
- False
Answer(s):
B. False
- When prescribing atomoxetine, a second line choice for ADHD, patient education should include which of the following?
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- Appetite might increase, so be mindful of making healthy food choices.
- Monitor suicidal thinking, especially during the first few months of therapy.
- Renal failure may result from the use of this agent.
- Suicidal thinking will not occur with the use of this agent because it is a selective norepinephrine reuptake inhibitor.
Answer(s):
B. Monitor suicidal thinking, especially during the first few months of therapy.
- Medication therapy for ADHD is effective when the adolescent student exhibits which behaviors? (Select all that apply)
-
- Decreased fidgeting
- Increased fidgeting
- Increased inability to wait for their turn when playing games
- Increased ability to wait for their turn when playing games
- Brings home more incomplete work from school
- Brings home more complete work from school
Answer(s):
A. Decreased fidgeting; D) Increased ability to wait for their turn when playing games; F) Brings home more complete work from school.
- You see a patient who is on methylphenidate who had a dose increase two days ago. The patient calls the office with concern for exertional chest pain. Your next action should be which of the following:
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- Send the patient to the emergency department for an immediate evaluation
- Have the patient continue the increased dose and follow-up with you in the office tomorrow
- Refer the patient to outpatient cardiology
- Have the patient come to the office today and if the EKG is normal sinus rhythm continue with the dose increase; the exertional chest pain is temporary
Answer(s):
A. Send the patient to the emergency department for an immediate evaluation.
- Central nervous system stimulants are a schedule ___ controlled substance.
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- I
- II
- III
- IV
Answer(s):
B. Schedule II-controlled substance
References
Chan, E. (2025). Pharmacology of drugs used to treat attention deficit hyperactivity disorder in children and adolescents. Up To Date®. Retrieved June 10, 2025 from https://www.uptodate.com/contents/pharmacology-of-drugs-used-to-treat-attention-deficit-hyperactivity-disorder-in-children-and-adolescents
Rosenthal, L. D., & Burchum, J. R. (2026). Central nervous system stimulants and attention-deficit/hyperactivity disorder. In Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (3rd ed., pp. 246–252). Elsevier.
Rosenthal, L. D., & Burchum, J. R. (2026). Substance use disorders I: Basic considerations. In Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (3rd ed., pp. 253–257). Elsevier.
Up To Date® (2025). Methylphenidate: Drug information. Lexidrug™. Retrieved June 9, 2025 from https://www.uptodate.com/contents/methylphenidate-drug-information
Zhang, L., Yao, H., Li, L., Du Rietz, E., Andell, P., Garcia-Argibay, M., D’Onofrio, B. M., Cortese, S., Larsson, H., & Chang, Z. (2022). Risk of cardiovascular diseases associated with medications used in attention-deficit/hyperactivity disorder. JAMA Network Open, 5(11). https://doi.org/10.1001/jamanetworkopen.2022.43597
