ebook_ADHD2019

92 Rohde, Buitelaar, Gerlach & Faraone -course of action and understanding of not only the short term but also long-term effects. Every clinician who is prescribing or monitoring ADHDmedications needs to have these facts at their fingertips with a script ready to share with patients and their families at a pace that allows them to listen and in a language that they can understand. Whilst it can seem dull and repetitive to give the same story several times a day, week after week, it is important to remember that whilst you have he- ard the story many times it is new to the patient and they typically only get to hear it once. Time spent explaining things carefully at this stage can pay big dividends later on in terms of acceptance and adherence with treatment recommendations. Starting treatment with medication When should we start a medication treatment for ADHD? This used to be a ques- tion that was guaranteed to spark a heated debate between clinicians in the USA and Europe. Europe was more conservative and generally medication was reser- ved for those with severe ADHD and behavioural parent training was preferred for those with mild to moderate symptom and impairment. Whilst there is still a stronger preference for parent training approaches in Europe and many other parts of the world than the US, the differences are now less stark. For example, the most recent NICE guidelines acknowledge the difficulty assessing severity of ADHD and suggest that medication can be considered as a first line treatment for ADHD as long as there is also some effort to provide environmental modifications and provide advice and support about appropriate parent management techni- ques. 10 When a decision is made to start a medication treatment for ADHD, it is important to think about which medication to use first. This will obviously depend on availability. It is of course very important to take into account any relative contra-indications to ADHD medications. These include: high risk for psychosis, glaucoma, hypertension, and known cardiac risk such as a familial history of con- genital arrhythmia. 4 Choosing the first medication As noted above there are several medications and several formulations licensed for the treatment of ADHD. It is therefore important to think about the effect size of medication, order in which these should be usually prescribed and under what circumstances these general rules should be broken. Taken together the evidence from clinical trials suggests that there are few differences in overall efficacy, sa- fety and tolerability between methylphenidate and the amphetamine medications (including lisdexamfetamine) but that these psychostimulants are, – at least at the group level, – more effective than the non-stimulants licensed for use in ADHD (atomoxetine, guanfacine and clonidine). 11,14,15 Most guidelines conclude that,