ebook_ADHD2019

The World Federation of ADHD Guide 101 recommend that both treatment response and adverse effects are routinely moni- tored for the duration of treatment and that their assessment is allocated adequate time and consideration. We also recommend getting feedback from teachers and young people, as well as parents. We have demonstrated that is not necessary, from a clinical perspective, for senior medical staff to conduct all follow up visits. Indeed, it is possible for junior medical staff and nurses to provide high-quality care with an adequate protocol through a well organised clinical pathway. 9 The same protocol, assessment sche- dule, and measurement tools used when initiating and titrating on to medication can be used for continuing care clinics. It is good practice to routinely and regularly make sure that an individual continues to require their medication. This is most often conducted by a trial off medication. As noted above, when stopping guanfacine and clonidine, it is good practice to taper the dose down gradually over a period of several days to avoid possible rebound hypertension. For the stimulants and atomoxetine, it is accep- table to stop them abruptly without dose tapering. It is generally recommended that an individual has a planned withdrawal from medication at least once a year while on stimulants to assess whether symptoms and impairment return. This is usually carried out in the long school holidays, as it does not interfere with their school work. A continued need for medication is more difficult to demonstrate with atomoxetine in view of its different mechanism of action and in particular because it has a more long-term pharmacodynamic effect. If a short withdrawal of atomoxetine results in a recurrence of symptoms, then one can conclude it should be restarted. If, however, symptoms do not immediately return after a short-term withdrawal, it is still possible that they will return after a longer break. The pro- blem for many families is that if symptoms do return after a moderate to long withdrawal, even when atomoxetine is restarted it may take several weeks for the symptoms to resolve again. This might be a problem for families considering that it might take some time to get another appointment at the clinic. There is no simple solution other than to ensure that withdrawal is monitored closely, and that the patient has quick and easy access to the clinic as required. Evidence from discontinuation studies suggest that for guanfacine there is often also a somewhat extended period before full symptoms return although the timescale is somewhat shorter than seen for atomoxetine. Adverse effects of medication Although there are several adverse effects associated with ADHD medication, some of them, such as sleep difficulties and irritability may already be present be- fore starting on medication. Stimulants are tolerated well in the short term when used optimally. As long-term randomized, placebo controlled studies are not fe- asible and long-term naturalistic studies are limited by absence of controls, there