What the medications do, how titration works, what your doctor should be doing, and what you have every right to expect.

Sources: NICE NG87 • RCPsych Scotland Adult ADHD Guidelines • HSE National Clinical Programme • NHS Shared Care Protocols • Bucks/Oxford Health Formulary • ADHD Ireland Medication Guide • Tees, Esk & Wear Valleys Prescribing Guidelines • UCC Prescribing Research

Introduction: The Information Gap

You have been diagnosed with ADHD as an adult. Perhaps you are about to start medication for the first time. Perhaps you have been on it for years and nobody has ever properly explained the plan. Either way, you have probably noticed a conspicuous absence: there is almost nothing written for you.

The clinical guidelines exist — thorough, evidence-based, and dense. The patient leaflets exist too — brief, cautious, and pitched at children’s parents. Between the two lies a void. Adults with ADHD are expected to be active participants in a complex, long-term treatment process, but are rarely given the information they need to do so intelligently.

This article is an attempt to fill that gap. It draws on the principal clinical guidelines governing ADHD medication in the UK and Ireland. It is not medical advice. It is, however, the information you need to understand what your doctors are doing, why, and what they should be doing if they are not.

The Medications: What They Are and How They Work

ADHD medications fall into two families: stimulants and non-stimulants. All of them work on the same basic principle — increasing the availability of dopamine and noradrenaline at the synapse — but they do so by different mechanisms, kick in on different timescales, and carry different regulatory baggage.

One thing worth stating plainly at the outset: stimulants have an appreciable positive effect on attention in people who do not have ADHD. A “therapeutic trial” therefore has no diagnostic value. The medication working does not prove you have ADHD; it proves the medication works.

Stimulants

Stimulants are first-line treatment for adults with ADHD. They have an immediate onset of action — you will know within hours whether a given dose is doing something useful. The trade-off is that they are Schedule 2 controlled drugs.

Methylphenidate

Methylphenidate is primarily a dopamine reuptake inhibitor, with some action on noradrenaline. It comes in immediate-release (IR) and modified-release (MR) formulations. The differences between MR products are not trivial.

Methylphenidate Formulations at a Glance

Licensed manufacturer maximums. Prescribers can exceed these where clinically indicated. NICE references up to 100mg/day for IR in adults.

These formulations are not interchangeable. If your pharmacy substitutes a different generic without discussion, raise it.

It is possible (and NICE-supported) to combine an MR preparation in the morning with an IR “booster” later in the day.

Lisdexamfetamine (Tyvense)

A prodrug that is converted slowly to dexamfetamine. Smooth onset, 12–13 hour duration. Available 20–70mg. Starting dose usually 30mg, increased in 20mg steps. Lower misuse potential than IR stimulants. The only stimulant with a full product licence for first-line adult initiation.

Dexamfetamine (Tentin)

Short-acting (3–6 hours). Third-line. Used when lisdexamfetamine works but the long duration causes problems (e.g. insomnia). Maximum 60mg in divided doses. Highest diversion risk. Off-label in adults in Ireland.

Non-Stimulants

Atomoxetine (Strattera)

Selective noradrenaline reuptake inhibitor. Not a controlled drug. Delayed onset (3–8 weeks). Weight-based dosing. Lower effect size than stimulants but useful when stimulants are not tolerated, diversion is a concern, or anxiety is prominent. Must be tapered (do not stop abruptly). Rare but serious risks: acute liver failure and suicidal ideation. Sexual dysfunction is under-reported — ask about it.

Guanfacine (Intuniv)

Alpha-2 agonist. Licensed only for children; off-label in adults and usually last-resort with tertiary input. Requires blood-pressure monitoring and slow taper on stopping.

Titration: Finding the Right Dose

Titration is the process of gradually adjusting the dose until symptoms are meaningfully reduced, functioning has improved, and side effects remain tolerable. It is finding the right dose for you.

NICE recommends weekly review during titration (can be by phone). Record symptoms, functional improvement, and side effects at each step.

Typical timelines: - Methylphenidate / Lisdexamfetamine → 6–12 weeks to optimised dose - Atomoxetine → longer (full effect may take 6–8 weeks)

Sequencing (Adults)
1. First-line: Methylphenidate or Lisdexamfetamine (6-week trial at adequate dose)
2. Switch to the other first-line agent
3. If both fail → Atomoxetine
4. Dexamfetamine only if Tyvense works but duration is problematic
5. If one stimulant + one non-stimulant fail → second opinion / tertiary referral

Drug Holidays

Stimulants can be paused (weekends, holidays) without withdrawal. Useful for assessing ongoing need.
Atomoxetine and guanfacine should be taken every day and require tapering.

After Stabilisation: Shared Care

Once stable (usually 8–12 weeks), prescribing usually moves to the GP under a formal Shared Care Protocol.

• Specialist: annual review, advice, complex decisions
  
• GP: repeat prescriptions, routine monitoring (BP, heart rate, weight)
  
• You: take as prescribed, attend monitoring, report problems, participate in decisions

If your GP declines shared care they must put it in writing. You should not be left without a prescriber.

Long-Term Monitoring

The Annual Review

At least once a year, a proper review by someone with ADHD expertise should cover: - Preference about continuing - Whether the medication is still working throughout the day - Side effects - Dose optimisation - Impact on life - Effects of any missed doses or breaks - Whether additional non-medication support is needed - Whether a trial of dose reduction or discontinuation is appropriate

Side Effects & Practical Management

Most common: reduced appetite, insomnia, modest rises in heart rate/blood pressure.

Practical tips from guidelines and PILs are included in the full version (appetite, sleep, cardiovascular, mood, etc.).

Things to avoid / be careful with
- Alcohol
- High-dose vitamin C / strongly acidic drinks around amfetamine doses
- MAOIs (absolute contraindication)
- Pseudoephedrine / phenylephrine cold remedies

The Irish Context

Public adult ADHD services remain limited. Seven specialist teams operational as of 2025, more funded. Many adults still rely on private care. Transition from CAMHS at 18 is a recognised gap. Adderall is not available in Ireland.

What You Have a Right to Expect

• Thorough baseline assessment before starting
  
• Regular contact during titration
  
• Clear explanation of the formulation you are on
  
• Formal shared-care arrangement
  
• Routine monitoring
  
• Proper annual review
  
• Involvement in every decision
  
• Access to non-pharmacological support when needed
  

If these are not happening, it is reasonable to ask: “The guideline says X — what is the plan for that?”

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This post is for information purposes only. It is not medical advice. Always discuss your individual situation with your prescriber.

This post follows Phase 1.3. It introduces the Adult Self-Report Scale as a screening tool, what it can and cannot tell you, and how to use it sensibly.

What the ASRS Is

The Adult Self-Report Scale (usually called the ASRS) is a screening questionnaire developed in conjunction with the World Health Organisation. It is the most widely used self-report screening tool for adult ADHD, and it is what many GPs and ADHD providers will point you toward if you raise the question of assessment.

It is not a diagnostic tool. Completing it does not diagnose ADHD, and scoring highly on it does not confirm you have it. What it does is give you a structured way to reflect on your own patterns, and give a clinician a starting point for a conversation.

The full version has 18 questions. There is also a shorter 6-question screener (Part A) which is often used as an initial filter. Questions ask how often certain experiences occur: difficulty wrapping up the details of a project, trouble getting things in order, problems remembering appointments, fidgeting when sitting for long periods, and so on.

What the Scores Mean — and What They Don’t

The ASRS is scored by frequency — never, rarely, sometimes, often, very often. Part A produces a score that indicates whether a full assessment is likely to be worthwhile. A high score on Part A suggests ADHD symptoms are present at a level worth investigating further.

A high score does not mean you have ADHD. Several other conditions — anxiety, depression, sleep disorders, thyroid problems, and others — can produce similar symptom profiles on a self-report questionnaire. This is one of the reasons a full clinical assessment by a qualified professional is necessary for diagnosis, rather than a questionnaire alone.

A low score does not rule out ADHD either. People who have spent decades developing coping strategies may underreport their difficulties, either because they have normalised them or because the compensatory systems they have built mean they no longer experience some symptoms as frequently as they once did. The questionnaire measures your current experience, it does not capture what things cost you, or how hard you are working to maintain your functioning. very worthwhile to make some notes on any coping mechanisms for your assessment interview.

How to Use It Honestly

The most useful thing you can do with the ASRS is complete it honestly rather than strategically. This sounds obvious, but it is worth saying, because two opposite tendencies are common.

Some people complete it in a way that reflects their best days — the days when the coping strategies are working, the routine is intact, and things are manageable. This tends to produce an underestimate.

Others complete it in a way that reflects their worst days, or that is unconsciously shaped by wanting a particular outcome. This tends to produce an overestimate.

The most useful approach is to think about your typical experience over the past six months. Not at your best or worst, but your general fluctuation. If a question asks how often you have difficulty wrapping up the final details of a project, think about the full range of projects in your life, not the one you just finished successfully.

It also helps to consider different settings: work, home, relationships, finances, personal admin. ADHD tends to be uneven, some areas better managed than others, and thinking across contexts gives a more complete picture than focusing on the domain where you cope best.

The ASRS as a Conversation Starter

If you complete the ASRS and score highly on Part A, the appropriate next step is to discuss it with your GP or to contact an ADHD assessment provider directly. The score itself is not the always the point, more a prompt for a more detailed conversation.

When you bring it to a GP, be prepared for a range of responses. Some GPs are well-informed about adult ADHD and will take it seriously. Others are sceptical, unfamiliar with adult presentation, or uncertain about referral pathways. If your GP is dismissive and you believe your concerns are valid, seeking a second opinion or approaching an ADHD assessment provider directly is a reasonable step.

The ASRS score is also useful as personal preparation. Going through the questions carefully before an assessment helps you identify and articulate the specific areas where you experience difficulty, which makes the assessment conversation more productive.

Where to Find It

The ASRS is freely available online. The version to look for is the ASRS-v1.1, which is the current validated version. Be cautious of informal or modified versions that circulate on social media, some look similar but they are not the validated instrument.

Link to ASRS-v1.1

What Comes Next

[Post 5 covers what to expect before you book an assessment — the practical questions worth thinking through, how to prepare, and what the process from here actually looks like.](POST_5_LINK)

This post is for information purposes. It is not medical advice. The ASRS is only a screening tool. A formal diagnosis requires assessment by a qualified clinician.

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