ebook_ADHD2019_engl.

84 Rohde, Buitelaar, Gerlach & Faraone a mixed private/public approach (e.g. Germany, Australia), there are wide variations across countries with respect to the balance between these two systems. There are also considerable differences in the way that doctors are trained. While in some countries child and adolescent mental health services see most of the children with ADHD, in others it is mainly through paediatrics. In countries where ADHD is still under recognized, under diagnosed and under treated, it seems likely that most of those referred for treatment will be at the more severe end of the ADHD spectrum, present with high levels of comorbidity and have a wide range of impairments that impact significantly on all aspects of their lives. Whilst we strongly endorse the use of evidence based clinical practice guidelines in determining what care and treatment should be delivered, we also recognise that even the best guidelines struggle to clearly describe how to deliver this care within routine clinical practice. Therefore, the purpose of this chapter is to unpack the evi- dence about using medications to treat ADHD and translate this into a more usable format that will help the clinician develop and implement clinical pathways in their everyday practice. Much of this work stems from the work conducted with the Eu- ropean ADHD Guidelines Group (EAGG) 4-8 translating their guidelines and those from others into our own day to day clinical practice. 9 We will attempt here to describe clearly an implementable version of the evidence-based guidance and strategies for initiation, monitoring, and maintenance of medications for ADHD. The National Institute for Health and Care Excellence (NICE) 10 and other authori- ties have supported the development of structured stepped care pathways for the management of ADHD. The most typical shared care will be for the specialist team to monitor care and adjust treatment depending on response, adverse effects and any comorbid problems and for the primary care team to prescribe medication and, sometimes, monitor growth and blood pressure as required in between the spe- cialist appointments. Whilst this is a sensible approach, it is clearly not suited to all healthcare systems. However, rather than dismiss the concept, it may be more hel- pful to try and see whether any of the concept could helpfully transferred into your own healthcare system. In this vein, and as it is not possible to draw up one set of recommendations that will fit all systems, we suggest that the most effective way of reading this chapter is in a problem-solving rather than problem-finding mode. We recognise that not everything we suggest will be possible in every setting, however if you think something may be helpful spend some time thinking about how you can make it, or something similar, work within your clinical environment. MANAGING ADHD The purpose of this chapter is to provide a framework for organizing ADHD care with the hope that this can help reduce variability in the care described above. The rest of the chapter is divided into eight main sections, which will focus on: