What is the recommended starting dose of Adderall (amphetamine and dextroamphetamine) for adults and children with Attention Deficit Hyperactivity Disorder (ADHD)?

Recommended Starting Dose of Adderall for ADHD

For adults with ADHD, the recommended starting dose of Adderall (amphetamine and dextroamphetamine) is 5 mg twice daily, with gradual titration by 5-10 mg weekly until optimal symptom control is achieved, while for children the starting dose is 2.5 mg twice daily with careful titration based on response and side effects. 1

Starting Doses by Age Group

Children

• Initial dose: 2.5 mg twice daily 1
• Titration schedule:
  • Week 1: 2.5 mg twice daily
  • Week 2: 5 mg twice daily
  • Week 4: 7.5 mg twice daily (omit this step for children weighing less than 45 lb/20 kg)
  • Week 4/5: 10 mg twice daily

Adults

• Initial dose: 5 mg twice daily 1
• Titration: Increase by 5-10 mg weekly until symptoms are controlled
• Maximum daily dose: Generally up to 40 mg for amphetamine salts, though some adults may require up to 50 mg 1

Dosing Algorithm

1. Start low: Begin with the lowest effective dose (2.5 mg twice daily for children, 5 mg twice daily for adults)
2. Titrate gradually: Increase dose weekly based on response and side effects
3. Monitor closely: Assess vital signs, weight, height (in children), and side effects at each visit
4. Evaluate effectiveness: Use standardized rating scales to assess symptom improvement
5. Adjust as needed: Select the dose that produces the most benefit with the fewest side effects

Important Considerations

Timing of Doses

• Immediate-release formulations typically require twice daily dosing 1
• First dose: After breakfast
• Second dose: After lunch (to avoid interference with appetite)
• A third afternoon dose may be added if needed for homework or evening activities 1

Monitoring During Titration

At each visit during titration, monitor:

• Blood pressure and pulse
• Height and weight (especially in children)
• Side effects (particularly appetite, sleep, and mood)
• ADHD symptom response using standardized rating scales 1

Common Side Effects to Monitor

• Decreased appetite
• Insomnia
• Headache
• Dry mouth
• Nervousness/anxiety 2

Special Populations

Small Children

• For children weighing less than 45 lb (20 kg), omit the 15 mg/7.5 mg step in the titration schedule 1
• Exercise extra caution with dose increases
• Monitor weight closely due to potential appetite suppression

Adults with Comorbidities

• Use caution in patients with anxiety disorders, as stimulants may exacerbate anxiety symptoms 3
• In a study of adults with ADHD, 4 of 7 patients with comorbid anxiety experienced acute anxiety symptoms when taking Adderall 3

Evidence on Effectiveness

Low-dose amphetamine salts have shown effectiveness in adults with ADHD. In one study, the mean effective dose for responders was only 10.77 mg/day (0.14 mg/kg/day) 3. Another study found that mixed amphetamine salts at an average dose of 54 mg daily (in two divided doses) produced a 42% decrease in ADHD symptoms 4.

Pitfalls to Avoid

1. Starting with too high a dose: This increases risk of side effects and may reduce medication adherence
2. Titrating too quickly: Gradual titration allows better assessment of both therapeutic effects and side effects
3. Ignoring vital signs: Always monitor blood pressure and pulse, as stimulants can affect cardiovascular function
4. Overlooking comorbidities: Anxiety disorders in particular may be exacerbated by stimulants
5. Continuing ineffective doses: If no improvement is seen after reaching maximum recommended doses, consider switching to an alternative stimulant 1

Remember that the goal is to find the lowest effective dose that adequately controls symptoms while minimizing side effects. Regular monitoring and adjustment are essential parts of effective ADHD management.