GROWING TREND OF STIMULANT USE IN YOUNG PATIENTS MISDIAGNOSED WITH ADHD: A CASE-BASED SYSTEMATIC REVIEW

Objective

The rise in pediatric ADHD diagnoses and stimulant prescribing has raised concerns about misdiagnosis, inappropriate treatment, and psychiatric harm. This systematic review examines pediatric and adolescent case reports of stimulant-associated psychiatric and behavioral adverse effects, with attention to prolonged exposure or potential ADHD misdiagnosis, and presents a novel case of an adolescent female with long-term stimulant treatment and comorbid depression who presented with intentional overdose and psychotic features.

Methods

Data Sources: A database search of PubMed, PsycINFO, and Embase was conducted for pediatric and adolescent case reports published through October 1, 2025, using keywords related to attention-deficit/hyperactivity disorder, stimulant medications, and psychiatric adverse effects. Study Selection: Of 312 records identified, 42 articles were screened, and 10 were selected for full-text review. Publications not available in English, review articles, and reports lacking accessible full text were excluded. Data Extraction: Relevant data were extracted and summarized in a clinically oriented manner, including sex, age, primary diagnosis, medication exposure, and associated psychiatric or behavioral adverse effects; no quantitative analyses were conducted. Case Presentation: An 18-year-old female was brought to the emergency department (ED) on a mental health crisis hold following an intentional overdose of bupropion, amphetaminedextroamphetamine, fluoxetine, and alcohol. In the interview, the patient appeared guarded and was reluctant to provide details. She reported initiation of amphetamine-dextroamphetamine at 5 years of age, with intermittent discontinuation periods throughout childhood and adolescence. The patient herself recalled developing depressive symptoms around 6 years of age, approximately one year after starting stimulant therapy. Despite this history, she was resistant to considering the possibility that long-term amphetamine-dextroamphetamine use may have contributed to her mood symptoms. During the encounter, the patient exhibited psychotic features, including suspicion and paranoia. She refused trainee presence, consenting only to the attending, and repeatedly asked, “Are they talking about me?” suggesting persecutory ideation. The patient was counseled on the potential psychotic effects of stimulant medications, particularly in individuals without a definitive ADHD diagnosis, and was ultimately receptive. The patient was admitted for medical monitoring, with plans to resume fluoxetine and discontinue amphetamine-dextroamphetamine. Referral to child and adolescent psychiatry was recommended for further evaluation and management.

Results

A total of 10 pediatric and adolescent case reports were identified and 1 novel case presented, describing stimulant-associated psychiatric and behavioral adverse effects, including psychosis, mania, depression, aggression, trichotillomania, paradoxical sedation, and suicidality, often occurring in the context of early stimulant initiation, prolonged exposure, dose escalation, comorbid neurodevelopmental or psychiatric conditions, or suspected ADHD misdiagnosis.

Conclusions

This case and prior pediatric reports highlight the need for developmentally informed ADHD diagnosis, cautious stimulant prescribing, and close psychiatric monitoring to balance therapeutic benefit against potential long-term neurobehavioral risk in children and adolescents.