ebook_ADHD2019

The World Federation of ADHD Guide 107 gradually raised after several days to b.i.d. dosing and then further adjusted ba- sed on clinical effects and adverse effects. The patient should receive a complete physical examination with ECG recording before starting treatment. Treatment should be considered only if the following limits are not exceeded on the ECG: 200 msec for the PR, 120 msec for the QRS, and 450 msec for the QTc, and the heart rate should be regular and not higher than 100 bpm. If there is personal history of arrhythmias, dizziness, fainting, palpitation, or heart abnormalities, a more tho- rough evaluation by a cardiologist is appropriate. Family history of sudden unex- pected death or life-threatening arrhythmias should be reason for avoiding use of tricyclic medication. Clinical effects may become evident after a few days, but full response may take weeks and the dose usually needs multiple adjustments. The usual therapeutic dose is between 0.7 and 3.5 mg/kg/day. The ECG, pulse, and blood pressure should be monitored when a steady state is reached (usually after 4-5 days of treatment) and each time the dose is increased above 3 mg/kg/day. Abrupt discontinuation can trigger withdrawal symptoms, such as nausea, vomi- ting, headache, lethargy, flu-like symptoms. To prevent withdrawal symptoms, the medication should be tapered off gradually, decreasing the dose by 10-25 mg every 2-3 days until complete discontinuation. Atypical antipsychotics Whilst there is limited evidence to support an effect of atypical antipsychotics on aggressive behaviours, especially in the context of autism spectrum disorder, there is no evidence to suggest that these are effective medications for treating ADHD. In addition, the evidence that children and adolescents treated with atypicals are at increased risk of serious adverse effects including dystonias, dyskinesias and metabolic syndrome is convincing. Conflicts of interest Prof. Coghill reports grants from The European Union FP7 Programme and Shire; honoraria from Shire, Eli-Lilly, Novartis, and Janssen-Cilag; acted as an advisor to Shire and Lundbeck; and received royalties from Oxford University Press. He was a member of British Association for Psychopharma- cology ADHD, Depression and Bipolar Disorder Guideline groups. Professors Silva and Chen report no conflict of interest. REFERENCES 1. Hinshaw SP, Scheffler RM, Fulton BD, Aase H, Banaschewski T, Cheng W, et al. International variation in treatment procedures for ADHD: social context and recent trends. Psychiatr Serv. 2011;62(5):459-64.