Follow-up appointments for ADHD focus on medication effectiveness, education and compliance

Dr. Salvatore Ventimiglia and patient Myles Shroyer

An interview with Dr. Salvatore Ventimiglia, Shelby Pediatric Associates, Shelby Township

How do you assure that parents bring children in for a follow‑up within 30 days of an initial prescription for ADHD?

When I do an initial assessment, we discuss medication and the follow‑up and make an appointment. I usually say I’d like to see the patient within two to three weeks to be sure I follow‑up within the 30‑day timeframe.

I tell parents their child will be feeling different within the first week. I may have to tweak medication doses. The first few months may even require some medication adjustments so I set the expectation that we’ll be seeing a lot of each other.

What are you looking for in a follow‑up visit?

I first look first at behavior and how the patient and parent are coping. And I check for any untoward side effects, like irritability, excessive weight loss or mood change. I also do a depression screen if they’re old enough to see if I’ve unmasked a comorbid condition of depression or anxiety.

I also look to see if the teachers are satisfied or if there’s a need for written reassessments to gauge how they’re doing in school. Some kids who are not hyperactive will not see dramatic changes, but will see more subtle changes in grades and learning skills. We wait a few months to look for those changes.

Lastly, we look at physiological changes. I make sure the child has no stomach aches or headaches. I check their weight. Weight loss is one of the biggest concerns with some stimulants.

In my initial education session with parents, I tell them their children will likely be skipping lunch if they’re not hungry. We come up with alternative meals to meet nutritional needs. That might be a shake or smoothie instead of lunch.

How do you tailor your conversations with kids based on age?

For children ages 6 to 11, conversations are more parent‑driven because parents are controlling the medication and making sure their children take it appropriately. I’ll also turn to the child to show them pictures of pills, or syringes for liquid medications to try to give them an idea of the taste and texture so they’re not surprised by it.

For older children, 11 to 13 and up, I come up with a contract with them about what the medication is, what it’s supposed to be, what they should or shouldn’t feel when taking it. I make it clear they can call or text me with any questions they may have or, if they prefer, their parent can call. I also go over issues of confidentiality with adolescents to let them know what they can tell me. It’s a team effort. When adolescents are engaged, I get better compliance.

What are some of the challenges associated with treating patients on ADHD medication?

Sometimes, children take the medication only if they think they need it, or they don’t take it at all because they think they’re better. And, if they’re of the age that they can drive themselves to appointments, maintaining compliance can be harder. I get their phone and email address and put in our system so they get text reminders. I email parents as well. Everyone gets reminders. If they don’t come in, we hold their medications. We make it clear at every appointment that medications are important and I’ll explain that if the patient isn’t having side effects, it doesn’t mean in the next three months or six months, you may not.

We also get kids who talk about going off their medications. If they feel they don’t need it any longer, I say, ‘Let’s have a discussion if you want to be weaned off the medication.’ As kids get older, we talk about weaning and medication holidays.

Do you coordinate with behavioral health specialists when treating patients with ADHD?

We have a pediatric neuropsychologist at our office who does initial evaluations and recommendations. If a patient has some comorbid conditions, we may refer him or her to therapy. Or if a child is having a hard time with medications, we may refer to a psychiatrist.

Do you have any final thoughts?

There’s a myriad of medications that can be used for ADHD. I prefer longer acting medications that can be taken once a day so there’s no social stigma of taking medications in school and going to the nurse’s office.

Medications should be tailored to how long the child’s day is, including extracurricular activities.

I also educate patients about misuses and say bluntly, ‘If I hear you’re selling it, you’re out.’ I’ve had kids who’ve been caught selling their medications and then we have to have a tighter leash on them.