Indications for Hospitalization or Discharge

ADHD is a condition that affects behavior, cognition, academic, emotional, and social functioning. When a patient is experiencing extreme behaviors that interfere with normal activities of daily living, this constitutes a medical emergency and requires hospitalization. ADHD can make a patient have suicidal tendencies.

Patients who feel they want to hurt themselves or someone else are in a medical emergency and require immediate hospitalization. Upon discharge, it is important for the patient to understand and adhere to all provider discharge instructions.

Patients on stimulants and antidepressants need to take their medications as directed and under the supervision of a family member or caregiver. Family, friends, and caregivers need to understand that these medications can lead to suicidal tendencies. At any signs or red flags, the patient must seek care immediately.

For any reasons, if the medicine that was prescribed is not helping, having side effects, or most importantly, if the patient is having an allergic reaction, they must visit the provider right away.

It is important for patients and families to maintain a medical health record and a list of patient medications at all times. Regular follow-ups with a healthcare provider are key.

According to UpToDate, “Medications combined with behavioral/psychological interventions are recommended for most school-aged children (6 years) and adolescents who meet diagnostic criteria for ADHD, as an adjunct to behavioral interventions for preschool children who meet diagnostic criteria for ADHD and fail to respond to behavioral interventions alone. However, the values and preferences of the patient and family are critical factors in deciding whether or not to initiate medication. The decision of families who choose to decline medication must be respected.” It is important to take into account the patient and family’s wishes and the patient’s comorbid conditions. Stimulants are the first-line agents preferred over other medications because they have a rapid onset of action and a long record of safety and efficacy.

Amphetamines are used to treat ADHD. Atomoxetine is an alternative to stimulants and may be more appropriate for patients with a history of illicit substance use or family members with the same, concern about abuse or diversion, or a strong family preference against stimulant medication. Alpha-2-adrenergic agonists (guanfacine, clonidine) usually are used when children respond poorly to a trial of stimulants or atomoxetine, or have unacceptable side effects. As a class, they are less effective than stimulants.

Patients and families need to understand that stress can make ADHD worse. Learning how to calm both the mind and body, through techniques such as deep breathing, muscle relaxation, listening to music, and biofeedback is beneficial. Talking to a friend, spouse or family member is encouraged. Patients are encouraged to learn more about ADHD. Drinking alcohol is prohibited, while eating a healthy diet and maintaining a regular sleep schedule are vital to optimum health with ADHD.

Pharmacotherapy for ADHD has three stages: titration, maintenance, and termination. During the titration stage, the optimal dose and frequency of the medication is determined over one to three months. This time period requires close monitoring (usually weekly) by the clinician, some of which can be done by phone.

The dose-response relationship for stimulant medication varies by child. When children and adolescents who are being treated with stimulant medications develop side effects, it’s important to determine the timing of the medication’s effect and whether the effect is related to a coexisting disorder or environmental stressor.
Clinicians must take into account the client’s decreased appetite, poor growth, dizziness, insomnia/nightmares, mood lability, rebound, tics, psychosis, diversion, and misuse. Patient teaching is crucial when it comes to taking the medication exactly as prescribed for dose and frequency, or when evaluating whether it’s working. Alcohol must be avoided, along with other illegal substances. Patients must know where to administer the medication safely and avoid being coerced or tempted to sell the medication.

There must be a plan for the transition of responsibility from child to adolescent. The adolescent must be fully responsible for managing his or her medication regimen before leaving home, and while at school or at work.

Treatment failure is part of the process, so the patient and family’s wishes must be taken into consideration.

Maintenance therapy begins once the optimal dose and frequency of the medication has been determined. During the maintenance stage, regular monitoring is necessary to review the process and adjust doses if necessary. A review of the child’s and adolescent’s understanding and compliance with the medication is also necessary.

The termination stage is individualized. After several years of medication, it is reasonable to offer children and adolescents, who have stable improvements in ADHD symptoms and target behaviors, a trial period off of the medication in order to determine whether it is still necessary.

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