Stimulants

1. Introduction

Version followed: current US FDA prescribing information (Vyvanse label revised 09/2025; Concerta label revised 02/2026; Strattera label revised 06/2026, for the non-stimulant comparison), the FDA class-wide stimulant labelling update of May 2023, NICE guideline NG87 (published March 2018, last updated September 2019), the AAP 2019 ADHD clinical practice guideline, and the EMA 2009 methylphenidate referral. Doses, titration and scheduling are deliberately left out: they belong to the prescriber.

Stimulant medicines (methylphenidate and amphetamine-family products such as lisdexamfetamine and dexamfetamine) are prescription medicines used mainly for ADHD; lisdexamfetamine is also licensed in the US for moderate to severe binge eating disorder in adults only, and is "not indicated or recommended for weight loss" [source: Vyvanse label 2025]. They are Schedule II controlled substances in the US [source: Vyvanse and Concerta labels]. This is a prescriber-delivered treatment, so this guide is written for the psychotherapist working alongside the prescriber. Guidelines frame the medicine as one part of a comprehensive plan: the EMA describes methylphenidate as belonging within psychological, educational and social interventions [source: EMA methylphenidate referral 2009]; NICE puts information, environmental modifications and (for young children) parent training first, and medication within a written shared treatment plan [source: NICE NG87]. The psychotherapist's contribution to change is everything around the tablet: understanding the diagnosis, building routines and skills, family and school work, treating coexisting problems, supporting informed choice and honest adherence conversations, and noticing warning signs early and passing them to the prescriber [synthesis, grounded in NG87 and AAP 2019].

Who prescribes and regulatory status (as sources state):

• UK: NICE says ADHD medication should only be started by a healthcare professional with training and expertise in diagnosing and managing ADHD; once stable, prescribing and monitoring can move to shared care with primary care [source: NICE NG87 1.7.2, 1.7.29].
• EU: methylphenidate is authorised for children aged 6 and over and adolescents, prescribed under a specialist in childhood behavioural disorders [source: EMA referral 2009].
• US: Concerta is approved for ADHD in people aged 6 to 65 and not recommended under 6; Vyvanse is approved for ADHD in adults and children 6 and older and not recommended under 6 [source: Concerta label 2026; Vyvanse label 2025]. The AAP guideline allows methylphenidate to be considered for children aged 4 to under 6 only if behavioural treatment has not helped enough and moderate to severe impairment continues [source: AAP 2019 KAS 5a]. NICE says children under 5 should not be offered medication without a second specialist opinion [source: NICE NG87 1.5.9].
• Non-stimulants used when stimulants are unsuitable, as NICE names them: atomoxetine and guanfacine (children); atomoxetine (adults) [source: NICE NG87]. Viloxazine (Qelbree) was FDA-approved in 2021 [source: Contemporary Pediatrics report of the FDA/DEA 2023 letter]. Atomoxetine carries its own boxed warning about suicidal thinking in children (see 4.2).
• Psychedelic-assisted and ketamine-assisted psychotherapy are covered in Domain VII, not here.

2. Framework

This is not a phased psychotherapy; the frame below is the treatment pathway as guidelines describe it, with the psychotherapist's tasks at each stage [source: NICE NG87; AAP 2019; synthesis for the therapist tasks].

Stage A. Assessment and diagnosis (prescriber or specialist team). Goal: confirm the diagnosis and impairment in more than one setting, screen for coexisting emotional, behavioural, developmental and physical conditions (anxiety, depression, substance use, learning disorders, autism, tics, sleep apnoea) [source: AAP 2019 KAS 2–3]. Therapist tasks: share observations with consent, help gather information from parents and teachers, flag substance use, trauma, mood or psychosis history that the assessor needs.

Stage B. Non-drug first steps. NICE: information and support for everyone; environmental modifications before medication; for children under 5 an ADHD-focused group parent-training programme first; for children 5 and over, ADHD-focused information and support for parents and carers (can be as brief as 1–2 sessions), plus parent training if there are oppositional or conduct symptoms [source: NICE NG87 1.4, 1.5.7–1.5.13]. AAP: for ages 4–6, parent training in behaviour management and/or classroom behavioural interventions first [source: AAP 2019 KAS 5a]. Therapist tasks: deliver or refer to these; this is often the psychotherapist's main contribution. Moving on: NICE offers medication to children 5 and over and adults only if symptoms still cause persistent significant impairment in at least one domain after environmental modifications have been implemented and reviewed [source: NICE NG87 1.5.13, 1.5.15].

Stage C. Decision and baseline (prescriber). The prescriber discusses benefits and risks and completes a baseline: mental health and neurodevelopmental review, substance misuse and diversion risk, physical health including height, weight, pulse, blood pressure and cardiovascular history [source: NICE NG87 1.7.4–1.7.6]. US labelling requires the prescriber to assess each patient's risk of abuse, misuse and addiction before prescribing [source: Vyvanse and Concerta labels]. Therapist tasks: support shared decision-making, help the client or family prepare questions, explore ambivalence without steering.

Stage D. Starting and adjusting (prescriber). The prescriber adjusts treatment against symptoms and side effects, with rating scales completed by parents and teachers [source: NICE NG87]. Therapist tasks: help clients and families observe and record effects and side effects in plain words to bring to reviews; liaise with school with consent.

Stage E. Maintenance and shared care. Monitoring continues: in children, height and weight; in all, heart rate and blood pressure, effectiveness, side effects, sleep, tics, behaviour; and diversion and misuse throughout care [source: NICE NG87 1.7, 1.8]. Therapist tasks: ongoing psychosocial work (skills, CBT where indicated, family and school), adherence conversations, early warning sign detection.

Stage F. Annual review. NICE: a healthcare professional with ADHD expertise reviews medication at least once a year with the person and family, covering benefit, side effects, ongoing need and impact on education, work and health; any trial periods off medication are a prescriber decision [source: NICE NG87]. EMA likewise recommends that methylphenidate taken for more than a year be reviewed at least annually [source: EMA referral 2009]. Therapist tasks: contribute observations (with consent), help the client articulate what they want from the review.

Format: the therapist's work alongside medication is typically ongoing individual, family or group sessions; NICE also mentions brief group support for parents and CBT for young people and adults [source: NICE NG87 1.5.14, 1.5.17]. Session counts for psychotherapy are not set by the medication sources [uncertain].

3. Guiding principles

• Medicine decisions belong to the prescriber. Never suggest starting, stopping, skipping, increasing or switching; route every medication question to the prescriber or pharmacist [source: NICE NG87 1.7.2; synthesis].
• Medication is one part of a plan. Keep psychological, educational and family work active whether or not medication is used [source: EMA 2009; NICE NG87 shared treatment plan].
• Shared decisions, revisited. NICE asks for a written shared treatment plan and for decisions to be revisited, not made once; help the client be an informed partner [source: NICE NG87].
• Consent before sharing. NICE requires consent before sharing information with schools or other professionals; agree in writing what you pass on to the prescriber [source: NICE NG87 1.4.12].
• Children: assent and parental oversight. The AAP calls for adolescent "assent" to medication; NICE encourages parents to oversee children's medication [source: AAP 2019 KAS 5c; NICE NG87]. Ask the child's view in their own words [synthesis].
• Age limits are the regulator's, not the therapist's. Know them (6+ for the US labels and EU methylphenidate; NICE second-opinion rule under 5) so you can recognise when something is off-label and suggest the family ask the prescriber [source: labels; EMA; NICE].
• Take abuse, misuse and diversion seriously without moralising. The FDA's boxed warning applies to the whole class; most people who misuse prescription stimulants obtain them from family members or peers [source: IHS summary of FDA 2023 communication].
• Watch for warning signs and report them. Psychiatric reactions (psychosis, mania), cardiovascular symptoms, tics, growth and appetite, Raynaud's-type digital changes, priapism and suicidality (atomoxetine) are listed by regulators; your job is noticing and passing on, not judging causation [source: labels].
• Correct misconceptions. NICE asks clinicians to correct misconceptions, for example that medication changes personality [source: NICE NG87].
• Supply problems are a safety issue. Shortages can interrupt treatment; changes during a shortage are made by the specialist or prescriber [source: NatPSA/2023/011/DHSC].
• Only legitimate supply. Pills bought outside a licensed pharmacy may be counterfeit and contain methamphetamine or fentanyl [source: DEA Public Safety Alert 2021 via ADPH].
• Scope of practice. Work within your training and licence; when in doubt, consult the prescriber [synthesis].

4. Intervention inventory

Part A describes how the treatment is delivered and what official labelling says, at a descriptive level only, so you can recognise risks and speak accurately. Part B is the psychotherapist's own work.

4.1 What the medicines are and how they are given (descriptive)

• Purpose: know what your client is taking well enough to talk about it accurately and to recognise when to involve the prescriber.
• Steps (what the sources describe): methylphenidate and amphetamine-family stimulants are given by mouth; formulations include extended-release tablets (Concerta), capsules and chewable tablets (Vyvanse) [source: Concerta label 2026; Vyvanse label 2025]. Lisdexamfetamine is a prodrug of amphetamine [source: Vyvanse label]. NICE asks prescribers to consider modified-release preparations partly for convenience, adherence, reduced stigma at school and lower diversion risk, and to avoid easily injected or snorted preparations where misuse risk exists [source: NICE NG87]. Concerta's tablet is nondeformable and must be swallowed whole [source: Concerta label 5.8]. Choice of medicine, dose and timing are the prescriber's, following NICE's ordering (for children 5+, methylphenidate first-line; for adults, lisdexamfetamine or methylphenidate) [source: NICE NG87].
• Example language (illustrative): "I'm not the person who decides about your medicine, but I can help you get clear on what you want to ask your prescriber."
• Watch for: clients cutting, crushing or altering tablets, or taking someone else's; refer questions to the prescriber or pharmacist [synthesis based on label 5.8 and boxed warning].

4.2 Official warnings: the boxed warning and the main precautions (descriptive)

• Purpose: recognise risks the regulator has named so you can pass on concerns promptly.
• Boxed warning (all prescription stimulants): in May 2023 the FDA required the boxed warning to describe the risks of misuse, abuse, addiction and overdose consistently across the whole class, and asked prescribers to monitor closely for signs of misuse, abuse and addiction [source: IHS summary of FDA Drug Safety Communication, May 2023]. Current labels state a high potential for abuse and misuse that can lead to substance use disorder including addiction; misuse can cause overdose and death; risk is higher with higher doses or unapproved routes such as snorting or injection; prescribers must assess risk before prescribing, educate patients and families, and reassess throughout treatment [source: Vyvanse label 2025; Concerta label 2026].
• Contraindications named on labels: hypersensitivity, and use with a monoamine oxidase inhibitor (MAOI) or within the labelled interval after one is stopped [source: Vyvanse and Concerta labels]. If a client mentions any new medicine from another doctor, suggest they tell both prescribers and the pharmacist [synthesis].
• Warnings and precautions on the labels (as labels word them, summarised): sudden death in patients with structural heart abnormalities or serious heart disease; expected increases in blood pressure and heart rate; psychiatric reactions (worsening of psychosis, mania in bipolar disorder, new psychotic or manic symptoms; screening for mania risk factors before starting); slowed growth and weight loss in children; peripheral vasculopathy including Raynaud's phenomenon (finger and toe colour and sensation changes); motor and verbal tics and worsening Tourette's [source: Vyvanse and Concerta labels]. Amphetamine products add serotonin syndrome risk with serotonergic drugs [source: Vyvanse label 5.7]. Methylphenidate labelling adds priapism (prolonged, painful erections needing immediate medical care), acute angle-closure glaucoma and raised eye pressure [source: Concerta label 5.5, 5.9–5.10]. Pregnancy: the Vyvanse label says it may cause fetal harm and breastfeeding is not recommended [source: Vyvanse label].
• EU view: the EMA stated methylphenidate could cause or worsen depression, suicidal thoughts, hostility, psychosis and mania, and asked for psychiatric screening before and regular monitoring during treatment [source: EMA referral 2009].
• Non-stimulant comparison (atomoxetine): boxed warning for suicidal thoughts and behaviours in children and adolescents; in pooled short-term trials suicidal ideation occurred in 0.4% on atomoxetine versus 0% on placebo, all in children aged 6–12 and in the first month; families should watch closely, especially in early months and around dose changes, and report agitation, irritability, unusual behaviour changes and suicidal thoughts promptly. Other precautions: severe liver injury (jaundice), cardiovascular events, psychotic or manic symptoms, aggression or hostility, urinary retention, priapism [source: Strattera label 2026].
• Example language (illustrative): "That colour change in your fingers is something the leaflet lists. Could you mention it to your prescriber this week? I can help you write it down."
• Watch for: do not interpret symptoms as caused or not caused by the medicine; describe and refer [synthesis].

4.3 What monitoring the prescriber does (descriptive)

• Purpose: know what reviews should be happening so you can prompt a client or family who has lost touch with them.
• Steps (as NICE describes): height in children every six months; weight regularly in children, young people and adults; heart rate and blood pressure before and after each dose change and every six months; routine blood tests and ECGs not needed unless clinically indicated; monitoring of effectiveness, side effects, sleep, tics, behaviour, seizures; and monitoring for diversion and misuse throughout care; review at least annually [source: NICE NG87]. US labels likewise require monitoring of blood pressure, heart rate, height and weight, tics, psychiatric symptoms and misuse [source: labels].
• Example language (illustrative): "When was your last check-up with the ADHD team? It's usually at least once a year; would it help to book it?"
• Watch for: missed reviews, especially after transfer to shared care with the GP [synthesis].

4.4 Recognising when to suggest a medical review or urgent help

• Purpose: route concerns quickly and to the right place.
• Steps:
  1. Routine (contact prescriber soon): reduced appetite or weight loss in a child, sleep problems, new or worse tics, rebound irritability, finger or toe colour changes, persistent low mood or anxiety, wanting to change or stop the medicine, missed reviews [source: labels and NICE monitoring list; synthesis for triage].
  2. Prompt same-day contact with prescriber or urgent care: new suspiciousness, hallucinations, grandiosity or reduced need for sleep suggesting mania; suicidal thoughts (particularly on atomoxetine in a child); yellowing of skin or eyes on atomoxetine; signs of misuse or heavy use [source: labels; synthesis for triage].
  3. Emergency services: chest pain, fainting, severe palpitations or breathlessness; a prolonged painful erection; suspected overdose; imminent suicide risk [source: Concerta and Vyvanse labels list sudden death, priapism, overdose; synthesis for triage].
  4. Document what you observed, what you advised (seek medical review) and who you informed, within your consent agreement [synthesis].
• Example language (illustrative): "What you're describing needs a doctor today, not next week. Can we call the clinic together now?"
• Watch for: your own urge to reassure; when uncertain, err towards contact with the prescriber [synthesis].

4.5 Psychoeducation about ADHD and stimulant treatment

• Purpose: an accurate shared understanding that supports informed choice and engagement. NICE asks clinicians to discuss how ADHD affects education, work, relationships, driving and risk of substance misuse, and to give information sources [source: NICE NG87 1.4.3–1.4.5].
• Steps:
  1. Ask what the client (or parent and child) already believes about ADHD and medication, including from social media and family [synthesis].
  2. Explain that guidelines treat medication as one part of a plan alongside information, environmental changes, skills and family or school support [source: EMA 2009; NICE NG87].
  3. Correct misconceptions, for example that medication changes personality [source: NICE NG87].
  4. Point to the Medication Guide that comes with every US stimulant prescription and encourage reading it [source: FDA 2023 via IHS].
  5. For parents: NICE asks that parent training be presented without implying poor parenting [source: NICE NG87 1.4.11].
• Example language (illustrative): "Medicine can make it easier to use the strategies we practise here. It doesn't do the practising for you, and it shouldn't change who you are. If it seems to, that's worth telling your prescriber."
• Watch for: understanding checked back in the client's own words; for children, age-appropriate explanations [synthesis].

4.6 Supporting informed consent and shared decision-making

• Purpose: help the client (and family) bring their values and questions to the prescriber; NICE asks for a written shared treatment plan and for decisions to be revisited [source: NICE NG87].
• Steps:
  1. Help list the client's goals in daily-life terms (homework, work tasks, driving, relationships) [synthesis].
  2. Help them prepare questions for the prescriber: expected benefits, listed risks, how monitoring works, what to do if side effects occur, what non-drug options exist [synthesis; content of questions from NICE and labels].
  3. Explore preferences, fears and cultural or family views without steering [synthesis].
  4. If the client declines medication, support the decision and keep psychosocial treatment going; NICE describes non-drug treatment for adults who decline, have adherence difficulties or find medication ineffective or intolerable [source: NICE NG87 1.5.16–1.5.18].
• Example language (illustrative): "Whatever you decide, I'll keep working with you. Shall we write down the three things you most want to ask Dr ___?"
• Watch for: pressure from family, school or employer; the client's own capacity to weigh information [synthesis].

4.7 Children: safeguarding, consent, assent and parent and school involvement

• Purpose: protect the child and respect their voice.
• Steps:
  1. Know the regulator age limits: US labels approve ADHD use from age 6 and do not recommend it under 6; EU methylphenidate is for 6 and over; NICE requires a second specialist opinion before medication in children under 5; the AAP allows methylphenidate to be considered for ages 4–6 only after behavioural treatment [source: Vyvanse and Concerta labels; EMA 2009; NICE NG87 1.5.9; AAP 2019 KAS 5a].
  2. Seek the child's or adolescent's assent; the AAP explicitly asks for adolescent assent [source: AAP 2019 KAS 5c]. Ask how the medicine feels to them, privately where appropriate [synthesis].
  3. Clarify who holds parental responsibility and whose consent is needed for sharing with school; NICE requires consent before sharing with schools [source: NICE NG87 1.4.12; synthesis on parental responsibility].
  4. Encourage parents to oversee children's medication and keep it stored securely; labels recommend locked storage and no sharing [source: NICE NG87; Vyvanse label].
  5. Safeguarding: follow local procedures if you suspect medicine is being withheld, sold or misused within the household, a child is being given medicine not prescribed for them, or there is neglect of medical review [synthesis].
• Example language (illustrative, to a 10-year-old): "Some kids say their medicine makes their tummy feel funny or makes them not hungry. What's it like for you?"
• Watch for: a child who seems flat, tearful or frightened, appetite and growth concerns, or a child pressured by peers to hand over tablets [source: labels for appetite and growth; synthesis].

4.8 Adherence and ambivalence conversations (never advising a change)

• Purpose: help the client talk honestly about how they actually take the medicine and bring that to the prescriber. NICE suggests discussing benefits and risks, correcting misconceptions, and practical supports such as visual reminders, linking doses to routines, clear written instructions, peer support, and parental oversight for children [source: NICE NG87].
• Steps:
  1. Ask neutrally how it is going, including missed or extra doses, without judgement [synthesis].
  2. Explore both sides of any ambivalence (benefits noticed versus side effects, stigma, identity) [synthesis].
  3. Help with practical memory supports of the kind NICE lists, applied to the prescriber's instructions as written [source: NICE NG87].
  4. If the client wants to change, stop or take more, do not agree or disagree; encourage them to discuss it with the prescriber before acting, and offer to help prepare [synthesis].
• Example language (illustrative): "It sounds as if part of you wants to stop and part of you worries about how school will go. That's a really good conversation to have with your prescriber before you change anything."
• Watch for: self-adjusting, saving tablets, or using extra before exams or deadlines (a misuse sign) [source: boxed warning; synthesis].

4.9 Diversion and misuse awareness

• Purpose: reduce harm to the client and others. Labels and the FDA emphasise risk assessment, monitoring and counselling about storage, disposal and not sharing [source: Vyvanse and Concerta labels; FDA 2023 via IHS].
• Steps:
  1. Ask routinely and non-judgementally whether anyone asks them for their medicine, whether they have ever shared, sold or lost it, or taken more than prescribed [synthesis; FDA notes most misusers get stimulants from family or peers].
  2. Reinforce label messages: store safely, preferably locked; never give to anyone else; dispose of unused medicine through a take-back programme where available [source: Vyvanse label].
  3. Warn that taking stimulants other than as prescribed, or with alcohol or other controlled substances, can increase overdose and death risk [source: FDA 2023 via IHS].
  4. Warn that pills bought online or from friends can be counterfeit and contain methamphetamine or fentanyl; only medicines prescribed by a clinician and dispensed by a licensed pharmacist are safe [source: DEA Public Safety Alert 2021 via ADPH].
  5. Watch for misuse signs (early refill requests are named by the FDA as a diversion signal) and, with consent or under your safeguarding or risk duties, inform the prescriber [source: FDA 2023 via IHS].
  6. Where a client has a substance use history, make sure the prescriber knows; NICE includes substance misuse and diversion risk in baseline assessment [source: NICE NG87 1.7.4].
• Example language (illustrative): "Students tell me friends often ask for their pills before exams. Has that happened to you? How do you handle it?"
• Watch for: losing prescriptions, running out early, secrecy, mood swings, sleeplessness, weight loss beyond what was discussed [synthesis].

4.10 Observing and passing on effects and side effects

• Purpose: give the prescriber useful, timely information; NICE asks prescribers to judge response using rating scales from parents and teachers and to monitor sleep, tics, behaviour, appetite and weight [source: NICE NG87].
• Steps:
  1. Agree with the client (and parent) at the start what you will share with the prescriber, how, and when you would share without delay for safety [synthesis; consent principle from NICE NG87].
  2. Help the client keep a simple log in their own words: times of day when focus is better or worse, sleep, appetite, mood, irritability as the medicine wears off, any physical symptoms [synthesis].
  3. Report factually, without causal claims: what was observed, since when, how often, effect on functioning [synthesis].
  4. Encourage clients to report adverse effects themselves too; in the US, adverse events can be reported to FDA MedWatch [source: FDA 2023 via IHS]. UK equivalents exist [uncertain: Yellow Card].
• Example language (illustrative, letter to prescriber): "With [client]'s consent: over the past three weeks they report sleeping about two hours less and say their fingers turn white in the cold. I have suggested they discuss this with you."
• Watch for: the client minimising side effects for fear the medicine will be stopped [synthesis].

4.11 School and workplace liaison

• Purpose: align supports across settings. NICE: with consent, share the diagnosis, treatment plan and reasonable adjustments with school, college or university [source: NICE NG87 1.4.12]. AAP: school supports are a necessary part of the plan, often through an IEP or 504 plan [source: AAP 2019 KAS 5b–5c].
• Steps:
  1. Get written consent (parent and, as appropriate, the young person) specifying what may be shared [source: NICE NG87; synthesis].
  2. Help the family request adjustments and classroom behavioural supports [source: AAP 2019].
  3. Help teachers contribute observations through the prescriber's rating scales rather than ad hoc judgements about medication [source: NICE NG87 on teacher rating scales; synthesis].
  4. Discuss secure handling of any medicine taken during school hours as the school's policy states [synthesis].
• Example language (illustrative): "Would you be comfortable with me telling the teacher about the diagnosis and the plan, but not the medication details?"
• Watch for: teachers or employers pressing for medication or for dose changes; redirect them to the prescriber and family [synthesis].

4.12 Integrating psychosocial ADHD treatment

• Purpose: deliver the non-drug components guidelines call for, which work alongside or instead of medication.
• Steps (as guidelines name them; you deliver those within your competence):
  1. Environmental modifications: changes to the physical environment, routines, seating, lighting, noise, and structure at home, school or work, implemented and reviewed before medication [source: NICE NG87].
  2. Parent support: ADHD-focused information and support (group, brief); parent-training programmes for children under 5, and for older children with oppositional or conduct symptoms; advice on structure, consistent rules and positive parent-child contact [source: NICE NG87 1.4.9–1.4.11, 1.5.7–1.5.12]. AAP: parent training in behaviour management and classroom behavioural interventions [source: AAP 2019].
  3. CBT: NICE suggests considering a course of CBT for young people who have benefited from medication but still have significant impairment, and CBT for adults alone or alongside medication [source: NICE NG87 1.5.14, 1.5.17].
  4. Adults not taking medication: a structured, ADHD-focused supportive intervention with regular follow-up, at minimum [source: NICE NG87 1.5.18].
  5. Diet: NICE advises a balanced diet and exercise and does not recommend eliminating food additives or fatty acid supplements as general treatment [source: NICE NG87 1.6]. Lisdexamfetamine is not for weight loss [source: Vyvanse label].
  6. Treat coexisting anxiety, depression, trauma or substance use within your competence, coordinating with the prescriber [synthesis; AAP KAS 3 for screening].
• Example language (illustrative): "Let's use the hours when you notice you focus best to practise the planning routine, and see what still gets in the way."
• Watch for: skills generalising to settings and times when medication is not active; whether the written shared treatment plan still reflects the work [synthesis; NICE].

4.13 Crisis and safety planning

• Purpose: prepare for psychiatric warning signs listed by regulators (psychosis, mania, suicidal thoughts, particularly for atomoxetine in children) [source: labels; EMA 2009].
• Steps:
  1. Carry out standard risk assessment at intake and when mood changes, including after medication changes the client reports [synthesis].
  2. Build a written safety plan with warning signs, coping steps, contacts (including the prescriber's number and out-of-hours route) and lethal-means counselling (safe storage, including of medicines) [synthesis; safe storage from labels].
  3. For children on atomoxetine, make sure parents know the labelled warning signs (agitation, irritability, unusual behaviour change, suicidal thoughts) and the instruction to report promptly [source: Strattera label].
  4. If psychosis or mania appears, arrange urgent contact with the prescriber; NICE addresses medication during acute psychosis or mania as a prescriber decision [source: NICE NG87 1.7.19].
• Example language (illustrative): "If those thoughts come back, who would you tell first, and how would we get your doctor involved the same day?"
• Watch for: stimulant misuse with sleep loss, which can mimic or trigger psychiatric crisis [synthesis; psychiatric warnings from labels].

4.14 Supporting clients through medicine shortages

• Purpose: reduce harm from interrupted supply. In September 2023 a UK National Patient Safety Alert (NatPSA/2023/011/DHSC) covered shortages of several prolonged-release methylphenidate, lisdexamfetamine and guanfacine products, asking prescribers not to start new patients on affected products, primary care to contact patients early about remaining supply, and specialist teams to make individual plans [source: CPE summary of NatPSA]. In August 2023 the FDA and DEA issued a joint public letter on stimulant shortages, noting manufacturing delays and record prescription rates [source: Contemporary Pediatrics].
• Steps:
  1. Ask whether the client can get their prescription filled [synthesis].
  2. Encourage early contact with pharmacy and prescriber, and never obtaining tablets from friends or online sellers (counterfeit risk) [source: NatPSA; DEA alert].
  3. Help with coping strategies and environmental supports while supply is disrupted [synthesis].
• Example language (illustrative): "Before you run out, let's ring the pharmacy and your prescriber's team so they can plan with you."
• Watch for: distress, functional decline, risky sourcing [synthesis]. Shortage status changes; check current notices [uncertain: status as of October 2026 not checked].

4.15 Annual review, ending medication, and support afterwards

• Purpose: help the client make good use of the annual review and stay supported through any change decided by the prescriber.
• Steps:
  1. Before the review, help the client summarise benefits, side effects, ongoing need and impact on study, work and health, the topics NICE lists [source: NICE NG87].
  2. If the prescriber plans a trial off medication or other change, help the client and family agree how they will notice and report changes [source: NICE NG87 for trial periods; synthesis for the therapist role].
  3. After medication ends, keep up skills, environmental and family work, and watch for return of impairment, then prompt re-referral if needed [synthesis].
  4. At transition to adult services, help the young person understand the handover [synthesis; NICE NG87 covers transition; details uncertain].
• Example language (illustrative): "Your review is next month. What would you most like your prescriber to know about this year?"
• Watch for: loss to follow-up at transitions [synthesis].

5. Handling problems

The medication sources address prescriber actions; almost all therapist responses below are [synthesis] unless a source is named.

• Client asks you whether to take more, skip, stop or switch. Do not answer the medication question. Reflect the reason behind it, help them prepare to ask the prescriber, and offer to contact the prescriber with consent. Illustrative: "That's exactly the kind of decision your prescriber needs to make with you. What's making you want to change it?" [synthesis; NICE NG87 1.7.2 on who manages medication].
• Stuck: medication helps attention but life is still chaotic. NICE names CBT for young people with residual impairment after medication and for adults [source: NICE NG87 1.5.14, 1.5.17]. Shift to concrete skills, environment and routines; review the shared treatment plan [synthesis].
• Resistance or stigma ("I don't want to be a drugged kid"). Explore the meaning without persuading; correct misconceptions such as personality change [source: NICE NG87]; ensure the young person's assent is respected [source: AAP 2019 KAS 5c]. Keep non-drug work going.
• Family disagreement about medication. Separate the facts (what the leaflet and prescriber say) from values; suggest a joint appointment with the prescriber; document whose consent applies [synthesis].
• Non-adherence. Ask neutrally, problem-solve with the practical supports NICE lists (reminders, routine links, written instructions, parental oversight) [source: NICE NG87], and tell the prescriber with consent. Never treat it as defiance [synthesis].
• Overwhelm or rebound distress late in the day. Note timing and severity, add coping and routine supports, and pass the pattern to the prescriber; do not suggest timing changes [synthesis].
• Suspected misuse, selling or sharing. Raise it directly and non-judgementally, restate label advice (secure storage, never sharing), consider substance use assessment, and inform the prescriber within your consent and safety framework; if a child or other vulnerable person is at risk, follow safeguarding procedures [source: labels; FDA 2023 via IHS; synthesis for procedure].
• Student wanting stimulants "for exams" without a diagnosis. Explain the boxed-warning risks of misuse, addiction and overdose, and the counterfeit-pill danger; offer study and anxiety support, and refer for proper assessment if ADHD is genuinely suspected [source: labels; DEA alert; synthesis].
• New psychotic, manic or suicidal symptoms. Treat as urgent; same-day contact with the prescriber or crisis service; activate the safety plan [source: label warnings; synthesis].
• Physical warning signs reported in session (chest pain, fainting, prolonged erection, finger ulcers, yellow eyes on atomoxetine). Direct to urgent medical care; do not wait for the next appointment [source: labels; synthesis].
• Child's appetite and growth worries. Pass to prescriber, who monitors height and weight; avoid weight or diet advice [source: NICE NG87; labels].
• Rupture: client feels you are "policing" their medication. Acknowledge, explain why you ask (safety, not suspicion), re-agree what you share, and return to their goals [synthesis].
• Shortage leaves client without medication. Support contact with pharmacy and specialist team; no informal sourcing [source: NatPSA/2023/011; DEA alert].
• Prescriber hard to reach or a disagreement with the prescribing team. Use written, factual communication; escalate through the service route (GP, specialist team, clinical lead); never bypass by giving medication advice [synthesis].
• Off-label or under-age prescribing you are unsure about. Encourage the family to ask the prescriber about the age guidance on the label and in NICE/AAP; do not challenge the prescription to the family yourself [source: labels; NICE; AAP; synthesis].
• Your own competence limits. Seek supervision for complex comorbidity, substance use disorder and safeguarding situations [synthesis].

Sources

• FDA updating warnings to improve safe use of prescription stimulants (Indian Health Service summary, May 2023) — the FDA Drug Safety Communication itself (fda.gov) is not drawn on [uncertain: details taken from this summary].
• Vyvanse (lisdexamfetamine) prescribing information, revised 09/2025
• Concerta (methylphenidate ER) prescribing information, revised 02/2026
• Strattera (atomoxetine) prescribing information, revised 06/2026
• NICE NG87: Attention deficit hyperactivity disorder: diagnosis and management (2018, updated 2019)
• AAP 2019 ADHD guideline key action statements (AAP EQIPP)
• EMA: Methylphenidate referral (2009)
• Community Pharmacy England: National Patient Safety Alert on ADHD medicine shortages (September 2023)
• Contemporary Pediatrics: FDA, DEA address public on prescription stimulant medication shortages (August 2023)
• Alabama Department of Public Health: ADPH joins DEA in warning about lethal counterfeit pills (October 2021)