What is the recommended initial dosage of medication for individuals starting treatment for Attention Deficit Hyperactivity Disorder (ADHD)?

Initial ADHD Medication Dosing

Recommended Starting Doses

For adults and children 6 years and older starting ADHD treatment, begin with methylphenidate 5 mg twice daily (after breakfast and lunch) or amphetamine/dextroamphetamine 2.5 mg once daily in the morning, then titrate upward weekly based on symptom response and tolerability. 1

Methylphenidate (MPH) Initiation

• Start with 5 mg given twice daily (after breakfast and lunch), with an optional third dose after school if needed for homework and social activities 1
• For adults, alternative starting dose is 5-10 mg in the morning after breakfast 2
• Increase by 5-10 mg increments weekly until symptoms improve or side effects emerge 1, 2
• Total daily doses typically range from 10-60 mg/day, though some adults may require up to 72 mg/day depending on formulation 1, 2
• Maximum benefit in fixed-dose trials occurs around 30 mg daily, though flexible titration allows for higher effective doses 3

Amphetamine/Dextroamphetamine (AMP/DEX) Initiation

• Start with 2.5 mg once daily in the early morning for children 1
• For adults, start with 10 mg once daily in the morning 2, 4
• Add a noon dose if symptom control doesn't last through the school/work day 1
• Increase by 5 mg weekly increments as needed 2, 4
• Maximum recommended dose is 40 mg/day for children and 50 mg/day for adults 1, 4

Lisdexamfetamine (Vyvanse) Initiation

• Start with 30 mg once daily in the morning for both adults and children 6 years and older 5
• Titrate in 10-20 mg increments at approximately weekly intervals 5
• Maximum recommended dose is 70 mg once daily 5

Weight-Based Dosing Considerations

Do not use weight-based dosing for initial titration - behavioral response is highly variable and not predicted by body weight 1, 6

• For children weighing less than 20 kg (45 lbs), omit the 15 mg dose step during methylphenidate titration 1
• Total daily MPH doses for children under 25 kg in clinical trials reached up to 35 mg 1

Titration Strategy: Fixed vs Flexible Dosing

Stepwise Titration (Preferred in Clinical Practice)

• Increase dose weekly based on symptom improvement and side effect profile 1
• Obtain standardized ADHD rating scales from teachers/parents for children, or from patient/significant other for adults before each increase 1
• Contact can be maintained by telephone during initial titration 7
• Stop titration when symptoms resolve and impairment diminishes, or when side effects become problematic 1

Forced Titration Trial (Alternative Method)

• Patient takes all four dose levels (5,10,15,20 mg of MPH or 2.5,7.5,10 mg of DEX/AMP) with each dose lasting 1 week 1
• At follow-up, review rating scales from all 4 weeks and select the dose with most benefit and fewest side effects 1
• This approach provides systematic comparison across dose levels 1

Pre-Treatment Assessment Requirements

Before initiating stimulants, perform the following mandatory assessments: 2, 4

• Cardiovascular screening: baseline blood pressure, pulse, and assessment for symptomatic cardiovascular disease 2, 4
• Family history: sudden death, ventricular arrhythmia, or cardiac disease 1
• Tic assessment: evaluate for motor/verbal tics or Tourette's syndrome 1
• Substance use screening: current or past substance abuse (relative contraindication requiring close supervision) 2

Monitoring During Titration

Schedule follow-up appointments at least monthly until symptoms stabilize 2, 7, 4

• Assess both therapeutic response and adverse effects at each dose adjustment using standardized rating scales 2, 7
• Monitor vital signs (blood pressure, pulse) with each dose increase 4
• Common adverse effects requiring monitoring: decreased appetite, gastrointestinal symptoms, sleep disturbances, increased blood pressure and heart rate 2
• Monitor weight regularly as weight loss is common with stimulants 7
• Systematically ask specific questions about known stimulant side effects such as insomnia, anorexia, and headaches 7

Timing of Administration

Administer stimulants in the morning to minimize sleep disturbances 4, 5

• Avoid afternoon doses of immediate-release formulations due to insomnia risk 5
• For immediate-release MPH, typical regimen is after breakfast and lunch, with optional third dose after school 1
• Afternoon doses may need to be higher than morning doses to prevent symptom attenuation later in the day 2
• Long-acting formulations provide 8-12 hours of coverage with once-daily dosing 2, 6

Critical Pitfalls to Avoid

Starting at excessively high doses increases adverse effects and reduces adherence - always begin conservatively 2, 4

• Do not increase doses too rapidly - allow minimum one week between adjustments to properly evaluate response 2, 4
• Failure to systematically assess both benefits and side effects during titration leads to suboptimal outcomes 7, 4
• Do not use plasma concentration monitoring - it is not clinically useful for methylphenidate 6
• Avoid abrupt discontinuation for "drug holidays" during important events as symptoms return rapidly 2
• Titrate slowly with small children and stop or reverse dose increases when side effects occur to maintain willingness to use stimulants 1

Special Populations

Older Adults

• More conservative titration recommended: increase by 5 mg every 2 weeks instead of weekly 4
• Older adults are more sensitive to both therapeutic and adverse effects due to age-related pharmacokinetic changes 4
• Careful monitoring of vital signs is particularly important in this population 4

Renal Impairment (for Lisdexamfetamine)

• Severe renal impairment (GFR 15-30 mL/min/1.73 m²): maximum 50 mg daily 5
• End-stage renal disease (GFR <15 mL/min/1.73 m²): maximum 30 mg daily 5

When to Consider Alternative Treatments

If adequate symptom control is not achieved at maximum dose, or intolerable side effects occur: 2, 4

• Switch to an alternative stimulant formulation (e.g., from methylphenidate to amphetamine or vice versa) before moving to non-stimulants 2
• Consider non-stimulant medications such as atomoxetine (starting at 40 mg/day, maximum 100 mg/day) or alpha-2 agonists as second-line options 2
• Reevaluate the diagnosis and consider comorbid conditions affecting treatment response 4

Evidence Quality Note

The dosing recommendations are based on high-quality guidelines from the American Academy of Child and Adolescent Psychiatry 1, 2 and FDA-approved labeling 5, with supporting evidence from meta-analyses demonstrating that flexible titration strategies allow for better efficacy and acceptability compared to fixed-dose approaches 3.