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96 Rohde, Buitelaar, Gerlach & Faraone symptoms have improved, only to realise later that there was actually still quite a lot of room for improvement. For this reason, we have tended to increase the dose until there is clearly no improvement between doses and then revert to the lowest dose with the maximum benefit and least adverse effects. 9 When there is still some room for improvement, the dose is increased to the next level (e.g. from 5 to 10 mg immediate release) and the patient is again re- viewed after 1 to 2 weeks. It is usually best to start a new dose over a weekend, so that parents are the first to evaluate both the positive effects and new or worsening of adverse effects. Titration is continued until there is either no further room for improvement, there are significant adverse effects, or the maximum routine dose is reached (usu- ally 20 mg three times daily for immediate release methylphenidate). For younger and smaller children (< 25 kg), we pause the titration at 15 mg as tolerability problems are more common above this dose in this group of children. However, if there are no adverse effects at this point, we will, cautiously, increase the dose if clinically indicated. Whilst guidelines such as those from the European ADHD Guideline Group recommend a maximum daily dose of around 100mg methylphenidate, 4 we re- commend that doses higher than 60mg are normally only considered when there is already a clear, but not yet optimal, response to the 60 mg dose. How do you know when treatment is optimised? Whilst it is important to look at each case on its own merits, we are able to give some general guidance about the interpretation of scores on the SNAP-IV (and SKAMP) rating scales (Table 5.1). The easiest way to interpret these scores is to calculate the mean score per item. Then one is aiming to achieve a score of <1 for the total score and the hyperactive/ impulsive and inattentive subscales. By the end of the titration period the clinician will decide whether the patient: 1 has responded best to a particular dose; 2 has responded but cannot tolerate the optimal dose due to adverse effects, and either: – – shows an acceptable response, with no or tolerable adverse effects at a lower dose or, – – does not show an acceptable response at a lower dose 3 has not responded at any dose Whilst this approach to titration is acceptable to most families, there is a less intensive strategy which may be more practical in some situations. Here parents give an initial 5 mg dose of immediate release methylphenidate on a weekend/holi- day morning and introduce a cognitively demanding task about one hour later, and observe the general effect. If there are no adverse effects this can be followed by a 10 mg dose on another weekend/holiday morning (and 15 mg on another in te-