Quiz: Stimulant Medications

Ren, Age 7

Ren is a 7-year-old boy newly diagnosed with ADHD-Combined Presentation after a comprehensive evaluation. His parents are ready to consider medication. A pediatrician colleague asks you which stimulant class should be tried first and what outcome numbers she can share with the family.

Q1. Which of the following most accurately describes the evidence-based first-line stimulant choice for a 7-year-old?

Q2. Ren's father, an engineer, asks for the specific numbers before agreeing to medication. You share that meta-analytic data show approximately 70% of children respond to stimulants versus approximately 30% on placebo, yielding a number needed to treat (NNT) of approximately 2-3. He notes the Cochrane Collaboration rated stimulant evidence certainty as 'very low' and asks how confident you are in these numbers. Which of the following is the most accurate way to present this evidence?

Q3. The pediatrician asks about dexmethylphenidate as an alternative to racemic methylphenidate. Which property is most clinically significant?

Q4. At a follow-up, Ren shows a partial response to methylphenidate ER at an adequate dose. His mother asks whether trying an amphetamine would be worthwhile or "just more of the same thing." Which of the following best explains why a class switch is a rational next step?

Ren, Age 7 (Three-Month Follow-Up)

Ren has been on OROS methylphenidate 27 mg for three months with good symptom control. At today's visit, his mother reports that after his last pharmacy refill one week ago, the medication "stops working by noon." His teacher confirms that afternoon symptoms have returned to near-baseline. His weight, diet, sleep, and adherence are unchanged.

Q5. Which of the following is the most appropriate first step?

Q6. After resolving the generic issue, Ren does well through the school day but struggles during homework (4:00-6:00 PM) and soccer practice. His parents want coverage extended. Which strategy is most appropriate?

Carmen, Age 10

Carmen is a 10-year-old girl who has been on methylphenidate ER for two years with good symptom control. At today's visit, she has dropped from the 50th to the 42nd height percentile and from the 60th to the 43rd weight percentile. Her mother asks two questions: "Is this medication damaging her bones?" and "Should we stop for the summer?"

Q7. Based on the growth evidence, which of the following most accurately explains the mechanism of stimulant growth effects?

Q8. Carmen's mother asks specifically about a summer medication break for height recovery. Based on the drug holiday evidence, which of the following is most accurate?

Q9. Carmen also reports difficulty falling asleep. Her parents describe 45-minute sleep onset delays since starting the medication. Based on the sleep evidence, which of the following is most accurate?

Andre, Age 12

Andre is a 12-year-old boy on methylphenidate ER 36 mg for one year. At today's visit, his mother raises three concerns: his grandmother read online that stimulants cause heart attacks, his pre-existing motor tics seem slightly worse this month, and he has been more irritable and "flat" for the past two weeks.

Q10. His grandmother asks whether Andre needs an EKG before continuing his medication. Based on current cardiovascular screening guidelines, which of the following is the most accurate response?

Q11. Andre has been on stimulants for one year. His mother asks how long blood pressure and heart rate monitoring needs to continue. Based on the long-term cardiovascular evidence, which of the following is the most accurate response?

Q12. Regarding Andre's pre-existing motor tics that seem slightly worse this month, which of the following is the most accurate clinical response?

Q13. Andre's mother reports the irritability and flattening are worst during mid-morning and early afternoon but improve by evening. Which of the following best explains this pattern?

Mira, Age 9

Mira is a 9-year-old girl on methylphenidate ER for 14 months. Her parents read online that "ADHD medications stop working after a few years" and cite the Multimodal Treatment of ADHD (MTA) study. They ask whether continuing medication is worth it if the benefit will not last. They also mention they have been giving medication only on school days for the past year without telling the clinician.

Q14. Which of the following most accurately explains why the initial medication advantage converged by 8 years in the longitudinal follow-up?

Q15. Mira's parents disclose the school-day-only pattern and ask whether they should switch to seven-day dosing. Mira functions well on unmedicated weekends with no safety concerns. Based on the evidence, which of the following is the most appropriate recommendation?

Q16. Mira's parents ask what the minimum standard monitoring should include at her maintenance visits. Her current clinician checks weight and asks "how's it going?" Which of the following represents the evidence-based monitoring protocol?

Isaac, Age 16

Isaac is a 16-year-old referred by his outpatient substance use counselor after completing a 60-day intensive outpatient program for cannabis use disorder. He was diagnosed with ADHD-Combined Presentation at age 9 and stopped taking methylphenidate at 14 when cannabis use escalated. He has been abstinent for 5 months. His counselor reports that untreated ADHD is derailing his recovery: he forgets appointments, cannot sustain attention in group therapy, and is falling behind in school.

Q17. Isaac's mother asks whether stimulant treatment will increase his risk of developing future substance use disorders (SUD). Based on the evidence, which of the following is most accurate?

Q18. Given Isaac's 5-month abstinence from cannabis, which medication formulation is most appropriate if a stimulant is indicated?

Q19. Isaac starts lisdexamfetamine with moderate improvement after 8 weeks. His mother wants to try methylphenidate instead because "it worked better when he was younger." If both classes are systematically trialed, what is the cumulative probability of a positive response?

Q20. Isaac's parents ask about taking weekend medication breaks to reduce side effects now that he is stable. Isaac recently obtained his driver's license and drives himself to his recovery group meetings. Which of the following is the most important consideration in this decision?

Margot, Age 11

Margot is an 11-year-old girl stable on methylphenidate ER who is transitioning care to a new prescriber. During the intake, the prescriber reviews the pharmacological basis of her treatment to ensure safe ongoing management.

Q21. The prescriber asks Margot's parents to explain why methylphenidate and amphetamine are not interchangeable. Which of the following mechanisms is unique to amphetamine and absent in methylphenidate?

Q22. The prescriber considers whether Margot might benefit from an amphetamine trial in the future. Her parents mention she drinks large amounts of orange juice daily. If she were switched to an amphetamine, which pharmacokinetic concern would be most relevant?

Q23. The prescriber notes that Margot's methylphenidate has no clinically significant interactions with her SSRI. Which enzyme primarily metabolizes methylphenidate?

Q24. During the review, the prescriber explains that lisdexamfetamine has the lowest abuse liability of any stimulant formulation. Which pharmacological property accounts for this?

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