ADHD Review Appointment

Issues

Medical issues:

1. Attention Deficit Hyperactivity Disorder (ADHD) - combined presentation
2. Initial insomnia
3. Mild generalised anxiety

Medications

Current medications:

1. lisdexamfetamine (Vyvanse®) 30 mg PO mane
2. melatonin 2 mg PO nocte

Ceased Medications

Discontinued medicines:

• methylphenidate (Ritalin LA®) 20 mg PO mane - ceased due to significant afternoon rebound irritability and emotional lability.

Teams/Allied Health

Specialist and allied-health involvement:

• Ms Chloe Vance, Paediatric Occupational Therapist (fortnightly for emotional regulation and executive functioning)
• Mr David Chen, Psychologist (monthly for anxiety management)

I had the pleasure of reviewing Lucas Miller, aged 9 years and 4 months, who was accompanied by his mother, Sarah Miller, for his routine ADHD review on 14/05/2024.

Lucas attends Norwood Primary School and is currently in Year 4. Sarah reported that Lucas has made steady progress since transitioning to Vyvanse, with his classroom teacher noting improved focus during morning literacy blocks. However, Lucas mentioned that he still finds it hard to concentrate after lunch, when the medication effect seems to wear off. Sarah confirmed there have been no behavioural suspensions or aggressive outbursts this term, and his grades are currently meeting standard expectations. He receives small-group learning support twice a week for mathematics, though Lucas stated that his favourite subject is art.

Regarding side effects, Sarah observed that Lucas experiences mild appetite suppression during the middle of the day, often returning home with an uneaten lunchbox. Both Sarah and Lucas denied any headaches, abdominal pain, tics, or rebound irritability in the late afternoons.

Lucas previously trialled Ritalin LA 20 mg PO mane six months ago, which was discontinued due to marked afternoon emotional lability and tearfulness as the dose wore off.

Sarah reported that Lucas's eating habits are good outside of school hours, as he eats a substantial breakfast prior to his morning dose and has a large dinner, followed by an evening supper. Regarding sleep, Sarah noted that Lucas continues to struggle with settling at night, taking up to 45 minutes to fall asleep even with melatonin, though once asleep he does not wake overnight.

Lucas continues to engage well with fortnightly occupational therapy with Ms Chloe Vance, focusing on executive functioning and sensory regulation strategies. Sensory processing traits remain evident, particularly sensitivity to loud classroom noise, though clinical features do not suggest Autism Spectrum Disorder.

Outside of school, Lucas plays club soccer twice a week and participates in swimming lessons on Saturdays, which he thoroughly enjoys.

Sarah raised no new medical issues today, aside from ongoing concerns regarding the time it takes Lucas to fall asleep on school nights and whether his current stimulant dose covers his afternoon learning sufficiently.

Sarah noted that Lucas's baseline anxiety around school performance has settled considerably over the past three months. Lucas reported that his mood is generally happy and that he feels less frustrated with his schoolwork compared to last year.

Recent Vanderbilt ADHD Diagnostic Teacher Rating Scales returned from his classroom teacher indicated low symptom scores for hyperactivity and impulsivity, with mild residual inattentive symptoms noted specifically in the late afternoon sessions.

On physical examination today, Lucas appeared well and cooperative. His weight was 29.5 kg (50th centile) and his height was 135.0 cm (55th centile), tracking appropriately along his previous growth trajectories. His heart rate was 78 bpm and blood pressure was 98/62 mmHg, with normal dual heart sounds and a clear chest on auscultation.

No new laboratory or cardiac investigations were required today, given a normal baseline ECG prior to stimulant initiation and unremarkable cardiovascular findings.

Impression

Lucas Miller is a 9-year-and-4-month-old boy with combined-type ADHD who is responding well to lisdexamfetamine 30 mg mane, though there is scope to optimise his afternoon symptom control and evening sleep routine while maintaining his stable growth parameters.

Plan

1. Continue current occupational therapy and psychology supports, and monitor afternoon classroom focus over the remainder of Term 2.
2. Maintain lisdexamfetamine (Vyvanse®) 30 mg PO mane for now; a script was provided today, with a plan to consider titrating to 40 mg if afternoon inattention begins to impact academic progress.
3. Avoid screens during the hour before bedtime; consider trying Smiling Mind or Headspace meditation, or an audiobook. If sleep onset takes longer than an hour, melatonin may be continued. Every two months, trial stopping melatonin by using it on alternate nights for one week before discontinuing it. Restart it if sleep onset again exceeds one hour despite appropriate sleep hygiene.
4. Encourage a high-protein breakfast before morning medication administration and offer nutrient-dense afternoon snacks once the stimulant effect subsides.
5. Sarah to provide a copy of the Term 2 school report and an updated teacher Vanderbilt questionnaire prior to the next clinic visit.
6. Review in 6 months for growth, blood pressure, and medication check.