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90 Rohde, Buitelaar, Gerlach & Faraone that they are dosed such that the patient is given an equivalent immediate release dose. For example to switch from 10mg IR methylphenidate three times a day you would need to prescribe 45mg of Concerta. Similar conversions are available for other formulations. 13 Figure 5.2 illustrates the pharmacokinetic profiles of some common ADHD medications. Evidently, the twice daily use of IR methylphenidate leads to larger peaks and troughs throughout the day. This may induce a marked ‘on-and-off ef- fect’: with side-effects at the peaks; but break-through and rebound symptoms in the troughs. Extended release preparations tend to yield a smoother profile, with larger ‘area under the curve’ (AUC), thus greater action effects. When you review treatment response, it is therefore critical to ask the patient and carer about symptom control throughout the day, and not just a global impres- sion for the whole day. We recommend asking about medication response within 3 or 4 hour-windows thorough the day, in order to titrate the dosage probably across these windows throughout the day. We therefore also recommend that you study the pharmacological profiles of each medication you prescribe. The next section will focus on the specific ADHD medications and how to use them. DECIDING ON THE INITIAL TARGETS FOR TREATMENT Although medications are not the only treatment for ADHD, they are often very effective in reducing the core symptoms of ADHD (inattention, distraction and/ or hyperactivity). They may also improve self-esteem, school performance, family functioning, interactions with friends, memory, performance, mood and sleep. Most children with ADHD presents with multiple additional problems beside their core ADHD symptoms and impairments. This means that it is usually neces- sary to decide which problem or problems should be tackled first. Sometimes the decision is simple (e.g. child protection concerns or significant suicidality clearly outweigh most other problems), but in many circumstances the choice depends on a combination of severity (actual and perceived), relative importance (to the child, their parents, the school, and the clinician), the availability of an evidence-based treatment, and a combination of rational and pragmatic clinical decision-making. For example poor peer relationships and academic functioning with low self-este- em are often judged to be secondary to ADHD symptoms, in which case it would seem sensible to treat the ADHD symptoms first and observe the impact of this on the other difficulties). It is very important to be clear and explicit about the overall goals of treatment, what order they will be tackled and also to identify expectations that may not be realistic. In this way patient and parental expectations are more easily met and managed and compliance with treatment is likely to be higher.