ADHD is a behavioural disorder that includes the symptoms:

1. Inattentiveness
2. Hyperactivity
3. Impulsiveness

Symptoms of ADHD are often noticed from an early age and may become more noticeable when children start school. It is not usually possible to diagnose a child with ADHD until they are at least 6 years old. 

The symptoms can improve to some degree with age, but many adults with ADHD, who were diagnosed as children, continue to have symptoms.

The exact cause of attention deficit hyperactivity disorder (ADHD) is not fully understood, although a combination of factors is thought to be responsible.

Genetics

ADHD tends to run in families and, in most cases, it's thought the genes you inherit from your parents are a significant factor in developing the condition. Research shows that parents and siblings of a child with ADHD are more likely to have ADHD themselves. However, the way ADHD is inherited is likely to be complex and is not thought to be related to a single genetic fault.

Brain function and structure

Research has identified a number of possible differences in the brains of people with ADHD from those without the condition, although the exact significance of these is not clear. For example, some studies have suggested that people with ADHD may have an imbalance in the level of neurotransmitters in the brain, or that these chemicals may not work properly. Other studies involving brain scans have suggested that certain areas of the brain may be smaller in people with ADHD, whereas other areas may be larger.

Groups at risk

Certain groups are also believed to be more at risk of ADHD, including people:

• who were born prematurely (before the 37th week of pregnancy) or with a low birthweight
• with epilepsy
• with brain injury – which happened either in the womb or after a severe head injury later in life

1. We will need to gather information from both you and your child’s teachers/ school. We usually start by sending questionnaires to both you and the school.
2. We will then usually ask for a face to face appointment with you and your child where we will ask for quite a lot more information including what your child was like at an early age, and finish with what their current difficulties, as well as strengths are. We will also ask about any other problems they have or have had, particular around the time of birth.
3. We will also examine your child including taking their weight & height measurements, pulse, listen to their heart and take their blood pressure.

We will then use all of this information to see if your child meets the ‘diagnostic threshold’ for ADHD.

• That means we will consider all the information we collect from you, your child and your child’s school to decide if the type of difficulties and the frequency of difficulties that your child has is enough to say their problems are caused by ADHD.
• We use fairly strict criteria to diagnosed ADHD. The specific criteria we use are international recognised and referred to as ‘DSM-5’ (or occasionally ‘ICD-10’) diagnostic criteria for ADHD (https://www.cdc.gov/ncbddd/adhd/diagnosis.html)
• We will also need to see that your child has the same type of problems in more than one area (for example at home and at school), and that they have been having problems from a relatively young age.

There are many different sources of information providing behavioural strategies for parents of children with ADHD. The following is intended as a starting point for parents. We encourage parents to read around this subject and attend a parenting course specifically designed for parents of children with ADHD if possible.

Many regular behavioural parenting methods require a child to listen, organise, plan ahead, remember, think before they act and be motivated by rewards.

Children with ADHD often have difficulties in some if not all of these areas. Therefore the following adaptations to regular parenting techniques may help in children with ADHD:

1. Clear communication
2. Simple instructions
3. Small number of important rules
4. Regular and repeated words

In addition, when parenting children with ADHD, it may be helpful to take into account the following:

• Routine, Structure & Consistency
  • Fixed routines and structure are really important in managing behaviour in children with ADHD.
  • Children with ADHD often struggle most during ‘in-between’ times, when they don’t have definite structure (such as in the classroom) and don’t have total freedom (such as in a playground). Anticipating these times can make them easier to deal with.

• Gaining attention
  • Eye contact- looking children in the eye, on their level. Making sure you approach them from the front, holding their hands out in front of them if appropriate.
  • Simple words- speak clearly, directly and address them by name
  • Show enthusiasm
  • Stepwise Instructions- clear, simple, step by step

     

• Ignoring the unimportant
  • This can often be hard to do but concentrating on the ‘bigger battles’ and ignoring smaller, less important irritations, can often make parenting interventions more successful (and often more enjoyable for all).

      

• Identifying triggers for unwanted behaviour
  • Identifying what triggers unwanted behaviour in your child (for example late nights, parties, visitors etc), even when you can’t avoid such situations, you can anticipate unwanted behaviour and therefore make managing these situations easier.

If your child continues to have behaviour that is difficult for you to manage, or your child is having oppositional or defiant behaviour, you may find the following useful.

1. Respond without anger:

   It’s important to respond to your OPOSITIONAL BEHAVIOURS child without anger—try to be as calm and matter-of-fact as possible. Just acknowledge the behaviour, state it as you see it, explain how it will need to change and then remove yourself from all arguments. You really have to pick your battles and decide what’s most important to you—and ultimately to your child.

2. Be clear and consistent:

   The nature of oppositional defiant behaviour is to wear parents down so that they eventually give in. You need to be strong, clear and consistent in your follow through.

3. Do not take things personally.

   Do not take your child’s behaviour personally. When your OPOSITIONAL BEHAVIOURS child acts out, as hard as it might be, stay as neutral and objective as possible. You need to be clear and concise and not get pulled into a power struggle—it’s really not about you, it’s about your child and what they need to learn. We as parents sometimes need to be great actors and actresses with our kids. The key is to keep practicing calm, consistent parenting and following through.

4. Don’t be your child’s friend—be the parent:

   Remember, being a parent is not a personality contest. There are times when your child won’t like you—they may even shout, “I hate you,” or call you foul names. But if you keep setting limits with your child and follow through by giving them consequences and holding them accountable, then ultimately you’re doing the best thing for your child.

5. What makes a child oppositional?

   There is probably a different answer for this question for every child identified as oppositional. However, some general explanations seem to apply to most oppositional children. First and foremost is that their oppositional behaviour pays off in some type of reward. Most often the children are not even aware of their own intentions. With this in mind, parents should not "blame" the child for his/her behaviour. Simply develop an understanding of the child's motivations and the underlying/unconscious processes that control the oppositional behaviour. Most parents express that they don't have a clue as to what is happening. To understand this more clearly we need to examine the focus of both the parents and child. When an argument occurs, the focus of the parent(s) is usually on resolution of the dispute. For the oppositional child the focus is not on the outcome of the argument, but on "winning" the argument. Winning does not necessarily mean the outcome of the argument leads to desired objects or activities. For the oppositional child winning means that he/she is able to demonstrate his/her power. Power can be demonstrated in a number of ways. For example, power can be demonstrated if the child is able to make the parent angry, cause an argument between mother and father, delay going to an appointment, or simply increase tension within the household. The point to remember is that the oppositional child is not interested in resolution or logical/rational solutions. The oppositional child's focus is on "winning" as defined above. Parents on the other hand, find themselves frustrated and confused because they can't understand "what is going on in his head”.

6. Jekyl and Hyde

   Some parents are surprised when told by others that their child is "so well mannered." "What," they say, "You couldn't have possibly been referring to my child." After recovering from the initial shock they come to realise that they are the primary target of their child's wrath. They are not the only targets, however. Their child will display oppositional/defiant behaviour toward most authority figures.

7. Principles of behaviour:

   In order to understand behaviour we must examine the consequences of the behaviour. In other words, what is the payoff of the oppositional behaviour? In order to understand the payoff we must first understand a concept referred by behavioural psychologists as avoidance conditioning. In essence, avoidance conditioning occurs when a person learns to avoid an aversive (bad) consequence. Psychologists tell us that avoidance conditioning influences much of human behaviour. That people learn that by doing something they can avoid an aversive circumstance. For example, people get up and go to work to avoid the consequence of losing their home and not being able to pay bills. We exercise and eat the right foods to avoid getting fat and having bad health. Wait!! Not everybody exercises and eats right! Even though most people understand that they should, they don't actually do what is best for them. Why? Because of competing reinforcers like cakes, and sitting on the couch watching the TV. So, while avoidance conditioning helps to explain some of our behaviour, it doesn't explain everything.

   Now that you have a basic understanding of avoidance conditioning, let's apply it to the oppositional child. The oppositional child not only responds to avoidance conditioning (as we all do), he/she also is a master at using it. By controlling the household through the regular application of aversives, the oppositional child gains power. Parents of oppositional children regularly report that they avoid anything confrontational (which is almost everything). Many parents make the statement, "We all walk on egg shells" to describe the reaction of the family to the oppositional child. This allows the oppositional child to win many silent victories. Parents become wary to confront the child. As a result, the child may be allowed to stretch limits and occasionally break rules.

   To complete our understanding of the dynamics of the oppositional child we must look to the concept of intermittent reinforcement. Intermittent reinforcement, as the name implies, is reinforcement (rewards) which occurs on an intermittent or irregular basis, not every time the behaviour occurs. Research clearly shows that the use of intermittent reinforcement is a powerful tool in establishing a behavioural response. Psychologists are not the only people who understand this principle, just look at the gambling industry. All games of chance use this principle to entice patrons to spend their hard earned dollars. With this in mind, we can now understand why the oppositional behaviour doesn't have to pay off every time, every once and awhile is enough.

   Having an understanding of Differential Reinforcements are a good basis for strategy planning for parents and teachers.

8. Changing the oppositional behaviour.

   The first step to changing the oppositional behaviour is to remove the payoff. The first payoff to deal with is the emotional response of the parent. Find out what your buttons are and protect them from assault. Be determined to keep your cool even in the heat of battle. The parent must assume control of the interaction and not allow the child to lead them to distraction. Most of our responses of anger are learned the same way the oppositional child learns his/her behaviour, by using the anger as an aversive consequence to get the results we want. Instead, we must learn to deal with the oppositional child from the perspective of a loving relationship. Don't mistake love with dependence. Some parents have developed a dependence on their child to fill their emotional needs. In cases like this the child often makes statements like "I hate you" or "you don't love me." These phrases are, once again, used due to their effectiveness in getting an emotional response from the parent. In other words, the child has identified a "button." Parents with dependency issues may need to seek the assistance of a counsellor or therapist to deal with this problem if they feel they cannot control their emotions.

   Next, refuse to discuss anything with the child when he/she is irrational or abusive. Be positive and supportive until the child attempts to "push a button" or use an irrational argument. Be firm and consistent with enforcing rules. Do not use physical punishment. Physical punishment will make matters worse when dealing with a child who is oppositional. Instead, make a list of rules and corresponding consequences. Everything should be spelled out as clearly as possible.

   Attempt to make consequences both natural and logical. The misbehaviour should result in an aversive that occurs naturally. An example of a natural consequence would be a situation where the child becomes angry and throws a toy on the floor, breaking it. The parent should calmly point out that the child no longer will have that toy. An example of a logical consequence would be a situation where the child tracks mud into the house. The parent then requires the child to clean up the tracks.

   Do not play "Let's Make a Deal" with the child, "If you'll clear up your room, you can go to the movies tonight." Too many parents use this approach to get the child to do something and bargaining becomes a way of life. The parent is constantly caught in a struggle to make the deal. Instead, enforce predetermined consequences and apply intermittent reinforcement for good behaviour. A reinforcer is anything that the child likes or desires. Examples of reinforcers can include praise, spending quality time together, or going to a movie to name a few. Part of parenting is identifying what those things your child finds rewarding. Instead of using the "Let's Make a Deal" method of behaviour management, the parent in the above scenario should have a rule listed stating that he/she will clean up his/her bedroom every afternoon (or whenever deemed appropriate). If the child fails to clean up his/her bedroom the parent should implement the predetermined consequence such as they have not earned time on their X-box. Do not debate the consequence, state it as a matter of fact.

   However these consequences should not come as a surprise to your child, it is best that you have a family meeting with all members of the household to explain the new rules and consequences. Again do not debate these consequences however do not be afraid to modify if there is truly a good reason as to why a particular consequence should not be implemented in the way you originally thought. Once discussion / family meeting has finished then implement consequences as agreed. 

9. "I don't care!"

   This is what almost every parent says their children will say to them when the need to use consequences for misbehaviour is explained to them.  The firm and consistent application of aversive consequences coupled with liberal doses of love and positive reinforcement will wear them down and they will care.

10. Be careful of what you ask

    Once you have issued a rule or instruction, you shouldn't back down. The primary rule is that the child must obey the parent - that means you! Asking children to do something means that if they don't, you are going to have to apply the consequences. Make certain your order makes sense, is necessary, and is something the child can accomplish. Try placing your orders in the form of a request and use the magic words, please and thank you. Always attempt to convey respect and concern for the child's feelings. Remember, much of the way children interact comes from modelling parent behaviour. Make certain the consequence is appropriate for the infraction. Be reasonable. Don't restrict the child to the house for three months because he/she made a phone call after hours.

11. Parental Cooperation

    In two parent households, BOTH parents must agree, be involved and committed to making the necessary changes involved in dealing with the oppositional child.

12. Remain calm and in control.

    Issue consequences for misbehaviour when you’re certain you feel calm and have control of your emotions. Many times it is best to wait and issue the consequence sometime after you have become aware of the behaviour. This allows for both the parents and the child to calm down and rationally deal with the problem. Tell the child that you are aware of the misbehaviour and will deal with it later. If, when issuing the punishment, the oppositional child attempts to distract you with an argument, apply a 5 or 10 minute time-out to give them a chance to calm down. Explain to them the reason for the consequence. Be firm, fair, and remain calm.

13. Warning:

    Increased negative interaction can interfere with a loving relationship. The oppositional child can cause a parent to be torn between feelings of intense love and hate. Remember that you love your child but hate the behaviour. Separate the two and deal with each.

    It is of utmost importance that parents put effort into nurturing the relationship they have with their child. The analogy of a gardener trying to raise a flower garden. Simply pulling the weeds is not enough. The gardener must water, feed, and provide a protected environment to achieve the desired result. Time, effort, and great patience must be put into the garden. Positive feedback and physical affection are needed to develop the oppositional child into a child who is responsive. Regularly tell the child what they are doing right. NEVER use the phrase, "You’re a bad boy/girl." This sets up an expectation that the child may feel obligated to meet. Instead make the child feel as if any misbehaviour on their part is inconsistent with whom they are. Say, "What you did was wrong and I can't understand why a smart/good/wonderful kid like you would do that."

14. Noncontingent Spontaneous Rewards:

    The word contingent means that something is given only if a certain act/behaviour is first carried out. So, Noncontingent Spontaneous Rewards means that rewards are given for no reason at all. The child doesn't have to do anything to get them, they just happen for no reason. Spontaneously take your child to a park, movie, zoo, or for a walk. Walk in the door after work with a small toy, comic book, or some sweets.

15. Tell them they're loved.

    At least four times a day! You don't even have to say "I love you" every single time. I overheard someone tell his little boy, "You light up my world." The boy's eyes brightened when he heard this and he ran and hugged my friend. What a great return for such a small investment. I heard another person tell her daughter, "I love you more than butterflies." The little girl giggled and said, "Me too." The key is to let your child know that he is loved and is important. Never allow the child to think that he/she is not loved because of their behaviour. Love must be constant and enduring.

16. Build their self-esteem

    Self-esteem and self-confidence are important factors in the development and prevention of oppositional behaviour. Children who are confident in themselves are less likely to feel threatened and become angry during a disagreement. I tell parents to try to avoid criticism and focus most on the things their child is doing right. This builds self-esteem in the child and makes her more willing to achieve goals. Support your child's interests and help her gain mastery in something.

17. Spend time with your child.

    Learn how to play Nintendo. Play with Barbie’s. Colour pictures. Play a game. Give a cooking lesson. Ride bikes. Take a walk. Go bird watching. Thumb wrestle. Do a puzzle. Make a model. Fly a kite. Play catch. Look at clouds/stars. Do something that they want to do.

18. Talk with your child, but mostly listen.

    Listen to your child and take what they have to say seriously. Spend time listening to them about their day and withhold any negative or critical comments.

19. Don't sweat the small stuff.

    Children are people too. Your child will make mistakes or behaviour in ways which you may not agree. You must ask yourself whether or not intervention is warranted. Some parents think children need to be like them and make the same decisions. This is far from the case and most often not the case at all. Allow the child to develop her own personality and way of dealing with the world. Many of the mistakes children make carry their own consequences (natural consequences) that are sufficient.

20. Don't expect miracles.
    Oppositional Behaviours are things will get worse before they get better. The oppositional child has well learned and established ways of interacting with you and change will not happen quickly or easily. The child will attempt to hang on to their previously successful behaviour. The child may become increasingly frustrated when parents change the effectiveness of his/her oppositional attempts. Have patience and be persistent, as well as consistent, in removing the oppositional payoff.
    
    Parents should learn and utilise stress management techniques. This will not only help them to cope with the pressures of raising a child with Oppositional Behaviours, but will also provide good examples for their children. Some parents of children with OPPOSITIONAL BEHAVIOURS offer other advice as well, which will not "cure" the condition but will help alleviate some of the symptoms. Limit the amount of television and computer time your child has, find out what interests they have and encourage them to develop them as much as possible, and enlist the help of others when you can.

ADHD can be treated using medication or non-medical therapy, but a combination of both is often best.

Non-medical therapies include

• Nutrition and diet
• Exercise
• Sleep
• Planning and organising
• Cognitive behavioural therapy and stress reduction strategies

There are two main types of medication licensed for the treatment of ADHD:

• Stimulants work by increasing the amount of a natural chemical in the brain, called dopamine. Increasing the amount of dopamine in the parts of the brain responsible for self-control and attention, stimulates them to work better. This then helps to focus your child's attention and improve concentration.
  • These are the most commonly used form of medication and come in short, and long acting formulations. Medications include methylphenidate, lisdexamphetamine and dexamphetamine.
  • Physical checks for patients on stimulants will need to be undertaken every 3 months. These will include height, weight and blood pressure.
• Non-stimulants work in a different way. These often take more time to work, but have a longer duration of effect. Medications include atomoxetine and guanfacine.

Although these medications are not a cure for ADHD, they may help people with ADHD to concentrate better, be less impulsive, feel calmer, and learn and practice new skills.

This information has been written specifically about the use of these medicines in children. The information may differ from that provided by the manufacturer. Please read this carefully. Keep it somewhere safe so that you can read it again

Starting dose

During the titration phase, doses are gradually increased until there is no further improvement in ADHD (that is, behaviour change, improvements in education and/or relationships) and side effects are tolerable.  The dose needs to remain the same for 3 months before we will share the prescribing with your GP.

We have a statement from our Community Paediatrics team regarding ADHD medication in schools which you can read here. 

Methylphenidate (sometimes known as methylphenidate hydrochloride)

This is the most prescribed stimulant medication for ADHD. Do not stop giving methylphenidate suddenly without first speaking to your doctor or nurse prescriber.

Brand names: Medikinet®, Ritalin®
Modified-release brands: Xaggatin XL, Concerta XL, Equasym XL, Matoride XL, Medikinet XL

Types of methylphenidate available: -

• Tablets: 5 mg, 10 mg, 20 mg; these contain small amounts of lactose. Ritalin® contains gelatin.
• Modified-release tablets: 18 mg, 27 mg, 36 mg, 54 mg; these may contain lactose.
• Modified-release capsules: 5mg, 10 mg, 20 mg, 30 mg, 40 mg; these contain gelatin and a small amount of sugar.

If you have any concerns or questions, speak with your child’s doctor or pharmacist.

When should I give methylphenidate?

Modified-release tablets/capsules (Xaggatin XL, Concerta XL, Equasym XL, Matoride XL, Medikinet XL) are usually given once each day, usually in the morning. These gradually release the medicine over the day.

• Xaggatin XL and Concerta XL can be given before or after breakfast and are not affected by food.
• Equasym XL is best given before breakfast.
• Medikinet XL is best given with or after breakfast.

Medikinet and Ritalin tablets are usually given two or three times each day. This should be in the morning, then around midday and, where necessary, late afternoon. Ideally, these times are about 4 hours apart. Do not give in the evening as your child will remain awake after their usual bedtime. Give the medicine at about the same time(s) each day so that this becomes part of your child’s daily routine, which will help you to remember.

How much should I give?
Your doctor will work out the amount of methylphenidate (the dose) that is right for your child. You will probably give your child a low dose to start with, then increase it gradually. Your doctor will explain what to do. It is important that you follow your doctor’s instructions about how much to give.

How should I give it?

• Slow release tablets (Xaggatin XL or Concerta XL) should be swallowed with a glass of water, milk or juice. Your child should not chew the tablet or they won’t release the medication slowly over the day.
• Medikinet® and Ritalin® tablets can be crushed and mixed with a small amount of soft food such as yogurt, honey or jam. Make sure your child swallows it all straight away, without chewing.
• Capsules should be swallowed with a glass of water, milk or juice. Your child should not chew the capsule. You can open the capsule and mix the contents with a small amount of soft food such as yogurt, honey or jam. Make sure your child swallows it all straight away, without chewing.

When should the medicine start working?
The medicine will start to work within 30–60 minutes, depending on which type of tablet or capsule your child has.

What if my child is sick (vomits)?

• If your child is sick less than 30 minutes after having a dose of methylphenidate, give them the same dose again.
• If your child is sick more than 30 minutes after having a dose of methylphenidate, you do not need to give them another dose. Wait until the next normal dose.

If your child is sick again, seek advice from your GP, pharmacist or hospital. They will decide what to do based on your child’s condition and the specific medicine involved.

What if I forget to give it?
Do not give the missed dose. Give the next dose as usual.  Never give a double dose of methylphenidate.

What if I give too much?

It may be dangerous to give too much methylphenidate.
If you think you may have given your child too much methylphenidate, contact your doctor or local NHS services (111 England and Scotland) or take your child to hospital. Take the medicine container or packaging with you, even if it is empty. This will be useful to the doctor. Have the medicine or packaging with you if you telephone for advice.

Are there any possible side-effects?
We use medicines to make our children better, but sometimes they have other effects that we don’t want (side-effects).

Side-effects you must do something about

• Your child may become irritable, aggressive, tearful or depressed. These effects are temporary and completely reversible on stopping treatment. You should contact your specialist or doctor as soon as possible. If you are worried, do not give any more doses of methylphenidate until you have talked to your doctor.
• If your child can feel their heart beating much faster than normal (they may say it is racing), contact your doctor straight away.
• If your child starts being sick every few hours or has stomach pains, take them to your doctor or hospital straight away.

Your child may have less of an appetite so they may not want to eat much. It may help to give each dose of methylphenidate with or after a meal.

• Your child may lose some weight during the first few months of treatment although they will probably put the weight back on. If you notice your child is losing a lot of weight contact your doctor.
• Your child may feel dizzy or light-headed when they stand up, or may faint. Encourage them to stand up slowly, and to sit or lie down if they feel dizzy or light-headed. If this happens often, contact your doctor who may need to check your child’s blood pressure.
• If your child is prone to tics (sudden muscle twitches of the face or body), methylphenidate may make these worse.

Other side-effects you need to know about

• Your child may get indigestion, stomach ache, feel sick (nausea) or be sick (vomit). Giving the medicine with some food or milk may help.
• Some children may get a dry mouth. Eating citrus fruits (such as oranges) and taking sips of water may help. This effect usually settles down quite quickly
• Your child may have a blocked nose more often whilst taking methylphenidate. Usually this does not need treatment and will get better on its own.
• Your child may have problems sleeping. This can be helped by taking the last dose at least 6 hours before bedtime.
• They may get a mild headache or pain in their muscles or joints.

If you are concerned about any side-effects contact your doctor.

Can other medicines be given at the same time as methylphenidate?
You can give your child medicines that contain paracetamol or ibuprofen, unless your doctor has told you not to. Check with your doctor or pharmacist before giving any other medicines to your child. This includes herbal or complementary medicines.

Is there anything else I need to know about this medicine?

• Methylphenidate may affect the growth of some children. Your doctor will monitor your child’s growth.
• Your doctor will check your child’s blood pressure regularly.

It is important that your child always has the same brand of methylphenidate if they have been prescribed a modified-release tablet or capsule (Xaggatin XL, Concerta XL, Equasym XL, Matoride XL, Medikinet XL) as there may be differences between brands. Keep a record of which medicines your child has.

General advice about medicines

• Try to give medicines at about the same times each day, to help you remember.

• Only give this medicine to your child. Never give it to anyone else, even if their condition appears to be the same, as this could do harm.
• If you are not sure a medicine is working, contact your doctor but continue to give the medicine as usual in the meantime. Do not give extra doses as you may do harm.
• If you think someone else may have taken the medicine by accident, contact your doctor straight away.

• Make sure that you always have enough medicine. Order a new prescription at least 2 weeks before you will run out.
• Make sure that the medicine you have at home has not reached the ‘best before’ or ‘use by’ date on the packaging. Give old medicines to your pharmacist to dispose of.

Where I should keep this medicine?

• Keep the medicine in a cupboard, away from heat and direct sunlight.
• Make sure that children cannot see or reach the medicine.
• Keep the medicine in the container it came in.

Getting the most from this treatment

• Keep the regular appointments with your doctor or specialist nurse. Your doctor/nurse will want to check to ensure that the treatment is helping. They will also monitor things like weight and height, and do some blood tests.
• There are treatment programmes that may be recommended for you and your child. These will provide you with strategies to improve their behaviour and reduce any long-term impact.
• From time to time your doctor or specialist nurse will assess the treatment to make sure it is still required. This may involve stopping methylphenidate for a short while.
• There is a small amount of evidence to show that a change in diet may help some children with ADHD. If you think that diet may be a factor for your child, discuss this with your doctor to see if speaking with a dietician might be of benefit.
• Before buying any medicines for your child, check with your pharmacist which medicines are safe for them to take alongside methylphenidate.
• Your child should not drink alcohol while on methylphenidate.
• If your child is due to have an operation, it is important that you tell the person carrying out the treatment that they are taking methylphenidate.
• Your child should not stop taking methylphenidate unless your doctor or specialist nurse tells them to do so. This is because stopping suddenly can cause problems and your doctor/ specialist nurse may recommend that the dose is reduced gradually.

Your doctor will have discussed with you the possibility that methylphenidate treatment may be associated with suicidal thoughts and thoughts about self-harm. Although this is very rare, if you think your child is having such thoughts, you must tell your doctor about it straightaway. If your child experiences any other symptoms which you think may be due to this medicine, speak with your doctor or pharmacist.

• Before starting this treatment, read the manufacturer's printed information leaflet. The leaflet will give you more information about lisdexamfetamine and a full list of side-effects which may be experienced from taking it.
• Make sure your child takes the capsules exactly as your doctor tells you. The starting dose is usually 20-30 mg daily, taken in the morning. This dose may then be increased over the following few weeks, which will mean taking a different strength of capsule. As there are several strengths of lisdexamfetamine capsule available, each time you collect a fresh supply, check to make sure it is the strength you are expecting.
• It is not important whether lisdexamfetamine is taken before or after food, but try to remember to take each dose at the same time every morning. If a dose is forgotten, do not take it later in the day, as this can cause sleeping problems. Skip the dose for that day, but remember to take a dose the next day as normal. Do not take two doses together to make up for a missed dose.
• The capsules can be swallowed whole, or you can open them up and stir the contents into a glass of water or orange juice or into soft food such as yoghurt. If you do this, the mixture must be stirred well until the medicine is dissolved and then swallowed straightaway.

Getting the most from your treatment

• Keep the regular appointments with your doctor. Your doctor will want to check to ensure that the treatment is helping. Your doctor will also monitor things like weight and height, and do some blood tests.
• There are treatment programmes that will be recommended for you and your child. These will provide you with strategies to improve behaviour and reduce any long-term impact.
• From time to time your doctor will assess the treatment to make sure it is still required. This may involve stopping lisdexamfetamine for a short while.
• There is a small amount of evidence to show that a change in diet may help some children with ADHD. If you think that diet may be a factor for you or your child, discuss this with your doctor to see if speaking with a dietician might be of benefit.
• Before buying any medicines, check with your pharmacist which medicines are safe to take alongside lisdexamfetamine.
• Your child should not drink alcohol while on lisdexamfetamine.
• If your child is due to have an operation, it is important that you tell the person carrying out the treatment that they are taking lisdexamfetamine.
• You should not stop taking this treatment without first talking to a doctor. This is because stopping suddenly may cause problems, and also the symptoms of ADHD may come back.

This is similar to lisdexamphetamine but comes in a much larger range of formulations particularly if your child has a problem with swallowing. These include:

• Tablets- 5mg, 10mg, 20mg
• Sugar-free Oral Solution (1mg per 1ml)
• Modified-release capsules- 5mg, 10mg, 15mg

Atomoxetine

Brand names: Strattera®

Why is it important to take this medicine?
Atomoxetine will help to reduce the symptoms of hyperactivity and impulsive behaviour and to increase attention and concentration span. It is used as part of a comprehensive treatment program.

How is Atomoxetine available?

• Capsules: 10 mg (white), 18 mg (gold/white), 25 mg (blue/white), 40 mg (blue), 60 mg (blue/gold), 80 mg (brown/white)

When should I give atomoxetine?
Atomoxetine is usually given once or twice each day. Your doctor will tell you how often to give it.

• Once a day: this should be in morning.
• Twice a day: this should be once in the morning and once in the late afternoon. It should not be given too close to bedtime.

Give the medicine at about the same time(s) each day so that this becomes part of your child’s daily routine, which will help you to remember.

How much should I give?
Your doctor will work out the amount of atomoxetine (the dose) that is right for your child. Your doctor will probably start with a low dose and then increase it gradually to find the lowest dose that works for your child. It is important that you follow your doctor’s instructions about how much to give.

How should I give it?
Capsules should be swallowed with a glass of water, milk or juice with or without food. Your child should not chew the capsule.

When should the medicine start working?
It will take a few weeks for atomoxetine to work properly so you may not see much difference in your child’s symptoms to start with. It is important that you continue to give the medicine as you have been told to by your doctor.

What if my child is sick (vomits)?

• If your child is sick less than 30 minutes after having a dose of atomoxetine, give them the same dose again. 
• If your child is sick more than 30 minutes after having a dose of atomoxetine you do not need to give them another dose. Wait until the next normal dose.

What if I forget to give it?

•  If you usually give it once a day: Give the missed dose when you remember during the day, as long as this is at least 12 hours before the next dose is due.
• If you normally give it twice a day: If you remember up to 4 hours after you should have given a dose, give your child the missed dose. For example, if you usually give a dose at about 7 am, you can give the missed dose at any time up to 11 am. If you remember after that time, do not give the missed dose. Just give the next dose as usual.

Never give a double dose of atomoxetine.

What if I give too much?
You are unlikely to do harm if you give an extra dose of atomexetine by mistake. If you concerned that you may have given too much, contact your doctor or NHS Direct (111). Have the medicine or packaging with you if you telephone for advice.

Are there any possible side-effects? 
We use medicines to make our children better, but sometimes they have other effects that we don’t want (side-effects). 

Side effects you must do something about

• If your child has dark urine, a yellowish tinge to their skin or the whites of the eyes, tenderness on the right side of the stomach just below the ribs, feelings of sickness (nausea), tiredness, itching, or flu-like symptoms, contact your doctor straight away as there may be a problem with your child’s liver.
• Occasionally some children who take atomoxetine have suicidal thoughts (thoughts of killing themselves) or become hostile (aggressive, arguing a lot, angry) or may seem emotionally unstable. If your child has any of these reactions, or you are at all worried, contact your doctor straight away.

Other side-effects you need to know about:

• When your child first starts taking atomoxetine, they may have headaches, lose their appetite, feel sick (nausea) or be sick (vomit), have stomach pain and feel sleepy. These effects should wear off after a week or two your child’s body gets used to the medicine.
• Your child may seem irritable and have mood swings.
• Your child may feel dizzy or light-headed, especially when standing up. Encourage them to stand up slowly, and to sit or lie down if they feel dizzy or light-headed.
• They may have problems sleeping or feel lethargic (weary).
• They may get constipation (difficulty doing a poo). Encourage them to drink plenty of fluid and to eat food that contains fibre (e.g. wholemeal foods, fruit and vegetables).
• They may get a rash, or swollen, reddened and itchy skin. Contact your doctor or pharmacist if this becomes troublesome.
• Your child may lose some weight during the first few months of treatment although they will probably put the weight back on. 
• Atomoxetine may affect the growth of some children. The specialist will monitor your child’s growth.

Can other medicines be given at the same time as atomoxetine?

• You can give your child medicines that contain paracetamol or ibuprofen, unless your doctor has told you not to.
• Atomoxetine should not be taken with some medicines that you get on prescription. Tell your doctor and pharmacist about any other medicines your child is taking before giving atomoxetine.

• Tell your doctor or pharmacist if your child has taken a medicine known as a monoamine oxidase inhibitor (MAOI), for example phenelzine, in the last 2 weeks (used to treat depression and other mental health problems).

• Check with your doctor or pharmacist before giving any other medicines to your child. This includes herbal or complementary medicines.

General advice about medicines

1. Try to give medicines at about the same times each day, to help you remember.
2. If you are not sure a medicine is working, contact your doctor but continue to give the medicine as usual in the meantime. Do not give extra doses, as you may do harm.
3. Only give this medicine to your child. Never give it to anyone else, even if their condition appears to be the same, as this could do harm. 
4. If you think someone else may have taken the medicine by accident, contact your doctor straight away.
   
   Make sure that you always have enough medicine. Order a new prescription at least 2 weeks before you will run out.
   
   Make sure that the medicine you have at home has not reached the ‘best before’ or ‘use by’ date on the packaging. Give old medicines to your pharmacist to dispose of.

Where I should keep this medicine? 
Keep the medicine in a cupboard, away from heat and direct sunlight. It does not need to be kept in the fridge.

• Make sure that children cannot see or reach the medicine.
• Keep the medicine in the container it came in.

Brand Name: Intuniv

Types of Guanfacine available:

Modified Release Tablets: 1mg, 2mg, 3mg, 4mg

If your child feels very dizzy, very drowsy or you notice they have a slow heartbeat, you must contact your doctor straight away.

If they feel very faint or lose consciousness you must contact your doctor immediately.

Very rarely, after stopping Guanfacine, a few children have been noted to have high blood pressure, particularly if it is stopped suddenly. This may present with headaches, feeling confused, nervousness, agitation, and tremors. If this were to happen, you should seek immediate medical help.

Guanfacine is a once-daily treatment for the management of ADHD in patients for whom stimulants are ineffective, unsuitable or not tolerated. It is indicated for use in children and adolescents aged 6 to 17 years.

When should I give Guanfacine?
The modified-release tablets should be given once daily in the morning or evening and should not be crushed, chewed or broken.

How much should I give?
The initial dose in all age groups is 1mg daily. If needed your doctor will consider if a higher dose is needed for your child, depending on their age, weight and symptoms.  It is important you follow your doctor’s instructions about how much to give.

How should I give it?
Although the tablets can be taken with or without food, administration with a high-fat meal is NOT recommended. (This may increase the amount of medication absorbed by your child).

What if I forget to give it?
Do not give the missed dose. Give the next dose as usual. Never give a double dose. If you miss more than one dose in a row, contact your doctor or specialist nurse for advice.

Are there any possible side effects?
We use medicines to make our children better, but sometimes they have other effects that we don’t want (side effects). Most of these side effects are more likely to occur at the start of treatment and may disappear as you continue with your treatment.

Side effects you must do something about

• If your child feels very dizzy, very drowsy or you notice they have a slow heartbeat, you must contact your doctor straight away.

• If they feel very faint or lose consciousness you must contact your doctor immediately.

• Very rarely, after stopping Guanfacine, a few children have been noted to have high blood pressure, particularly if it is stopped suddenly. This may present with headaches, feeling confused, nervousness, agitation, and tremors. If this were to happen, you should seek immediate medical help.

Other side effects you need to know about

• Your child may feel a bit sleepy.

Is there anything else I need to know about this medicine?
If you need to take Guanfacine for more than a year your doctor will monitor your response to treatment and your doctor may stop the medicine for a short time; this may happen during a school holiday. This will show if you still need to take the medicine.

The following are tips about diet and appetite in children with ADHD, particularly those on stimulant medication to help maintain their weight at an appropriate level:

1. Make breakfast the most important meal of the day, and serve it before the first stimulant dose takes effect. That may mean getting up half an hour earlier, and preparing a non-traditional breakfast. If you include your child's favourite dishes, even hyperactive youngsters often will consume everything on their plates. Parents also can offer sandwiches for breakfast, using whole wheat instead of white bread to pack in more nutrients. Cheese, peanut butter, chicken-all of these nutrient dense foods are great in sandwiches.
2. At mealtime, serve the most nutrient dense, high calorie foods first. Then move on to the vegetables if your child is still hungry. If dinner includes chicken, potatoes, green beans, and salad, serve your child a plate with only the chicken and potatoes, then offer green beans and salad when they're finished. Remember, these children may be able to eat only six bites and that's it. So make sure those six bites contain the most calories and nutrients. The priority here is to give them the most calories from any nutrient dense food. Don't overwhelm your child with food.
3. Serve small portions. Children with scant appetites get discouraged by the sight of a full plate, which makes them less likely to try and eat. Your child won't feel the task of finishing a small plate is insurmountable. If your child is still hungry, he or she will ask for more.  Other ways to make portions look less daunting:  Cut sandwiches into diagonal halves or quarters. And instead of serving one huge burger cut in half, divide it into two thinner parts.
4. Don't worry about sweets. Let the kid indulge a bit, particularly if sweets are delivered with nutrients. Hyperactive kids are hyperactive because they have a neurological disorder.  Carrot cake, or cookies with peanut butter, nuts and raisins are excellent choices. Ice cream also provides calories with nutrients. In this situation, don't worry about the fats so much. Sometimes more fat is necessary to provide sufficient calories if the child is unable to eat larger portions. Modify your recipes to increase or decrease calories dependent on your situation.
5. If you bake, substitute evaporated milk for whole milk. It serves the same purpose with double the nutrients. Add nuts and raisins to muffins and other baked goods. Use whole grain flour instead of white. Include a dollop of evaporated milk in milk shakes. Sprinkle in some powdered milk when making custards. If your child Likes Jelly try using milk instead of water.
6. Don't worry about school lunch. It's something over which you have very little to no control and if your child has had a packed breakfast, what they eat or don't eat at school matters a lot less. They may catch up later in the afternoon / evening especially if medication is effecting appetite at lunch.
7. Make vegetables count by increasing their calorie content. Smother a baked potato or broccoli with melted cheese.
8. If the rest of your family uses low-fat salad dressing, set aside a portion for your child that has dressing with a higher fat and calorie count.
9. Keep nutritious snacks ready for middle-of-the night refrigerator raids. Children who take medication can get hungry at unexpected times. Keep bowls of nuts and raisins around the house-even in your child's room.  Since parents often report finding their youngsters raiding the fridge after midnight, make sure it is filled with the right temptations, such as custard, yogurt, carrot cake, and raisin bread. You can even prepare a plate for your child filled with the foods he likes. Include meats, cheeses, pasta, whole grain bread, and dessert. If you put it in the refrigerator before bedtime, often you'll find it's gone the next morning.
10. Don't argue about food, and provide positive reinforcement when children do eat. Your child may develop a negative association with food, which only adds to the problem.  Instead, encourage him to eat right by purchasing and serving nutrient-rich foods, adjust to their idiosyncratic eating schedule, be flexible, and relax. Your child isn't refusing food just to drive you crazy!

Children with ADHD can sometimes find sleep difficult. Here are some general principles that might help:

1. Try and keep to the same bedtime each night
2. Older children should avoid daytime naps
3. Don’t send your child to bed hungry, instead offer a light snack, especially if they have done after sports activity
4. Physical exercise is a good way of burning off energy, but avoid exercise too close to bedtime
5. Avoid stimulating drinks at bedtime (e.g. tea, coffee, fizzy drinks, energy drinks)
6. Keep your child’s room at a warm temperature, not too hot, not too cold
7. Keep your child’s room as dark as possible at night. If your child doesn’t like the dark, consider buying a specific night light.
8. Avoid the use of screens for at least 1 to 2 hours before bedtime. The light they emit can interfere with the body’s ability to produce a natural hormonal that helps with sleep onset (Melatonin).
9. Reading before bed may help your child to relax. Try to avoid a bright bedside lamp.
10. A relaxing bath before bedtime can help

If you are doing all of these things consistently and your child continues to have difficulty with sleep, we encourage you to talk to your doctor about this. 

National Organisations:

1. http://www.addiss.co.uk/index.html
   ADDISS is a National Attention Deficit Disorder Information and Support Service. They provide people-friendly information and resources about Attention Deficit Hyperactivity Disorder to anyone who needs assistance - parents, sufferers, teachers or health professionals.
2. https://adhduk.co.uk/

   ADHD UK is a national charity providing information & support for people with ADHD by people with ADHD.

3. https://www.additudemag.com/
   Additude is a national website and magazine including many article looking at different aspects of ADHD.

4. https://www.123magic.com/
   The 123 Magic parenting program offers a simple and gentle-but-firm approach to managing the behaviour of 2 to 12-year-olds, whether they are average kids or special-needs children.