ebook_ADHD2019

94 Rohde, Buitelaar, Gerlach & Faraone this to happen, it is essential that the patient be treated with the right medication at optimal doses. Not every patient will respond to every medication and, for the stimulants, it is not possible to predict what the optimal dose will be before starting treatment. It is therefore necessary to individually titrate patients onto each new medication whilst carefully measuring both their response and any adverse effects. Key to a successful titration is the routine use of standardized instruments to measure treatment response and to also routinely assess for adverse effects. There are a wide range of measures available for assessing treatment response. We su- ggest the SNAP-IV 16 rating scale as the main measure of ADHD symptoms and response to treatment. It is freely available for clinical use 17 and is most effective when used as a clinician-rated semi-structured interview with parents and patient as the informants. We have found this to be more reliable than the parent rated questionnaire as it allows the clinician to enquire about particular symptoms when it is not clear how persistent, pervasive they are in day to day life. We have also found that when parents are going through a more difficult period with oppositio- nal behaviours they sometimes over score severity of ADHD symptoms as a way of indicating their distress and need for support. For this reason we started to use the oppositional defiant disorders section of the SNAP-IV at every clinic appointment in addition to the standard ADHD questions. This gives parents an opportunity to first discuss their child’s oppositional behaviours allowing them to then give a clearer and less prejudicial account of the ADHD symptoms. We also suggest that teacher ratings, using the ten-item SKAMP questionnaire (Murray et al. 18 ), 19 are also collected at each appointment. We have found that asking parents to both deliver and pick up the SKAMP from school maximises response rates. Whilst there is no need for patients starting on ADHD medications to have an ECG (except for the tricyclic antidepressants – see section “ Other medica- tions used off license to treat ADHD”), all patients or carers should be questio- ned about potential cardiac risk factors (past cardiac disease, familial history of arrhythmias, unexpected sudden death of a first degree relative before the age of 40 years, frequent syncope on exercise, excessive breathlessness on exercise) and have a cardiac examination (auscultation, blood pressure and cardiac frequency). For adverse effects, it is helpful to use a standardized set of questions that docu- ment presence or absence of common adverse effects and to note, where an effect is present, whether or not it is impairing. A list of general side effects expected with ADHD medications are listed in Box 5.1. Pulse, blood pressure, height, and weight should be measured and charted against age- and gender-matched norms. The Dundee ADHD Care Pathway contains a sample pro forma for collecting and recording this type of information in Coghill et al. 20 It is essential that these measures are first taken at baseline, prior to the first dose of medication, in order that change can be assessed accurately. This is espe- cially important for potential adverse effects as many children with ADHD will have issues with sleep, mood dysregulation, irritability.