What are the recommended dosages for medications used to treat pediatric Attention Deficit Hyperactivity Disorder (ADHD)?

Recommended Dosages for Medications Used to Treat Pediatric ADHD

For pediatric ADHD, medication should be initiated at low doses and gradually titrated based on clinical response and side effects, with stimulants being the first-line treatment option and non-stimulants considered when stimulants are ineffective or contraindicated. 1

Stimulant Medications

Methylphenidate

• Initial dosing: Start with 5 mg twice daily (before breakfast and lunch) 2
• Titration: Increase dose by 5-10 mg weekly based on clinical response and side effects 2
• Maximum dose: Daily dosage above 60 mg is not recommended 2
• For children 4-5 years of age, use lower starting doses and smaller incremental increases due to slower metabolism of stimulant medications 1
• Extended-release formulations (8-12 hour duration) are available to avoid multiple daily dosing, particularly during school hours 3

Amphetamines (including Adderall)

• Initial dosing:
  • Ages 3-5 years: Start with 2.5 mg daily 4
  • Ages 6 years and older: Start with 5 mg once or twice daily 4
• Titration: Increase by 2.5 mg (ages 3-5) or 5 mg (ages 6+) at weekly intervals 4
• Maximum dose: 40 mg per day total daily dose 5, 4
• For children weighing less than 20 kg, use extra caution during titration and consider omitting the 15-20 mg dosage steps 5

Lisdexamfetamine (Vyvanse)

• Begin with low doses and assess clinical response and tolerability before each dose increase 6
• Weekly contact by telephone during initial titration is recommended, with 2-4 weeks typically required to reach optimal dosing 6
• After stabilization, follow-up appointments should be scheduled at least monthly 6
• Maximum recommended dose is 70 mg daily 1

Non-Stimulant Medications

Atomoxetine

• Children and adolescents up to 70 kg:
  • Initial dose: 0.5 mg/kg/day 7
  • Target dose: 1.2 mg/kg/day (after minimum of 3 days) 7
  • Maximum dose: 1.4 mg/kg/day or 100 mg, whichever is less 7
• Children and adolescents over 70 kg and adults:
  • Initial dose: 40 mg/day 7
  • Target dose: 80 mg/day (after minimum of 3 days) 7
  • Maximum dose: 100 mg/day 7
• Can be administered as a single daily dose in the morning or as evenly divided doses in the morning and late afternoon/early evening 7

Extended-Release Guanfacine and Clonidine

• These alpha-2 adrenergic agonists are alternative options for patients who cannot tolerate stimulants or when stimulants are contraindicated 1
• Particularly useful in adolescents with concerns about substance abuse or medication diversion 1

Special Considerations

Preschool Children (Ages 3-5)

• Behavior therapy should be the first-line treatment for preschool-aged children 1
• Medication should only be considered for those with moderate-to-severe dysfunction who have not responded adequately to behavior therapy 1
• Dextroamphetamine is the only medication FDA-approved for children younger than 6 years, though methylphenidate has more evidence for safety and efficacy in this age group 1

Adolescents

• Assess for symptoms of substance abuse before beginning medication treatment 1
• Monitor for potential diversion of stimulant medications 1
• Consider medications with lower abuse potential (atomoxetine, extended-release guanfacine, extended-release clonidine, lisdexamfetamine, dermal methylphenidate, or OROS methylphenidate) 1
• Ensure medication coverage for symptom control while driving 1

Monitoring Requirements

• Regularly assess blood pressure and pulse, especially at higher doses 5
• Monitor weight at each visit to assess for appetite suppression 6, 5
• Systematically assess for side effects including insomnia, anorexia, headaches, and mood changes 6, 5
• For children on atomoxetine, monitor closely for suicidality, clinical worsening, and unusual changes of behavior, especially during the first few months of treatment or at times of dose change 1

Common Pitfalls to Avoid

• Starting at too high a dose can lead to unnecessary side effects and decreased medication adherence 6
• Failure to systematically assess both benefits and side effects during titration 6
• Not considering alternative stimulant medication when first choice is ineffective (nearly 90% of children will respond if both methylphenidate and amphetamine stimulants are tried) 5
• Exceeding recommended maximum doses without careful documentation of necessity and monitoring for side effects 5, 8

Treatment Algorithm

1. Begin with behavior therapy, especially for preschool-aged children
2. If behavior therapy is insufficient, initiate stimulant medication at low dose
3. Titrate dose weekly based on clinical response and side effects
4. If inadequate response or intolerable side effects with first stimulant, try alternative stimulant class
5. If inadequate response to both stimulant classes, consider non-stimulant options
6. Periodically reassess need for continued medication treatment 1