What are the recommended medications and dosages for treating Attention Deficit Hyperactivity Disorder (ADHD)?

ADHD Medications: First-Line Treatment and Dosing

Stimulant medications—specifically methylphenidate or amphetamine formulations—should be your first-line pharmacological treatment for ADHD in both children (age 6+) and adults, as they demonstrate the largest effect sizes for reducing core ADHD symptoms with rapid onset of action. 1

First-Line Stimulant Selection

Stimulants are recommended as first-line therapy over non-stimulants due to superior efficacy, with approximately 70-90% response rates when both methylphenidate and amphetamine classes are tried. 1

Methylphenidate Dosing Protocol

For children (ages 6-11):

• Start with 5 mg twice daily (after breakfast and lunch) 1, 2
• Increase by 5-10 mg weekly based on response 1, 2
• Maximum daily dose: 60 mg for immediate-release formulations 1
• Maximum daily dose: 72 mg for OROS (extended-release) formulations 1

For adolescents and adults:

• Start with 5-10 mg in the morning 3
• Titrate by 5-10 mg increments weekly 3
• Average adult dose: 20-30 mg daily in divided doses 2
• Maximum recommended: 60-72 mg daily depending on formulation 1, 3

Amphetamine/Dextroamphetamine Dosing

For children:

• Start with 2.5 mg once or twice daily 1
• Increase by 2.5-5 mg weekly 1
• Maximum: 40 mg daily 1

For adults:

• Start with 10 mg once daily in the morning 3
• Increase by 5 mg weekly 3
• Maximum: 50 mg daily 3

Critical Pre-Treatment Requirements

Before initiating any stimulant, you must:

• Assess cardiovascular risk: baseline blood pressure, pulse, and screen for symptomatic heart disease (stimulants are contraindicated in symptomatic cardiac disease) 1, 3, 2
• Screen for substance use history: active substance use disorders represent a relative contraindication requiring close supervision or consideration of non-stimulants 1, 3
• Evaluate for psychiatric comorbidities: screen for risk factors for mania, as stimulants can precipitate manic episodes 2

Monitoring Parameters During Treatment

Monitor at each visit:

• Height and weight (especially in children—growth suppression is a concern) 1
• Blood pressure and pulse 1, 2
• ADHD symptom rating scales from teachers/parents (children) or patient/significant other (adults) 1, 3
• Adverse effects: decreased appetite, sleep disturbances, headaches 1

Second-Line Treatment Algorithm

If the first stimulant fails after adequate trial (appropriate dose and duration):

1. Switch to alternative stimulant class (if methylphenidate failed, try amphetamine or vice versa) before moving to non-stimulants 1, 4
2. If methylphenidate fails, lisdexamfetamine should be preferred as next option over non-stimulants 1

Non-Stimulant Alternatives (Second-Line)

Atomoxetine:

• Start: 40 mg daily 3, 5
• Target: 1.2 mg/kg/day or 80-100 mg daily 1
• Maximum: 100-120 mg daily (or 1.4-1.8 mg/kg) 1, 5
• Key advantage: "around-the-clock" effects, no abuse potential 1
• Key disadvantage: 6-12 weeks until full effects observed, smaller effect size than stimulants 1
• Monitor for: suicidality, especially in first weeks of treatment 1

Alpha-2 Agonists (Guanfacine, Clonidine):

• Guanfacine extended-release: Maximum 6 mg daily 1
• Clonidine: 0.1 mg tablets, maximum 0.2-0.4 mg daily (weight-based) 1
• Key advantage: useful for comorbid tics, sleep disorders, or disruptive behavior 1
• Key disadvantage: sedation is frequent; smaller effect size than stimulants 1
• Critical safety: obtain cardiac history before starting—rule out sudden death, fainting, or arrhythmias in patient or first-degree relatives 3

Special Populations and Formulation Selection

Long-acting formulations are superior for:

• Improving adherence 3
• Providing 8-12 hours of symptom control 3
• Reducing stigma (no school dosing required) 1

Consider non-stimulants as first-line when:

• Active substance use disorder present 1
• Comorbid tic disorder or Tourette's syndrome 1
• Significant anxiety requiring concurrent treatment 1

Common Pitfalls to Avoid

Do not:

• Start at excessively high doses—this increases adverse effects and reduces adherence 3
• Increase doses more frequently than weekly—allow adequate time to assess response 1, 3
• Discontinue stimulants abruptly for "drug holidays" during important events—symptoms return rapidly 3
• Combine bupropion with stimulants until further safety data available 3
• Prescribe to patients with symptomatic cardiovascular disease, uncontrolled hypertension, or within 14 days of MAOI use 2

Important nuance: Afternoon doses of methylphenidate may need to be higher than morning doses to prevent symptom attenuation later in the day. 3

Age-Specific Recommendations

Preschool children (ages 4-5):

• Behavior therapy is first-line 1
• Methylphenidate may be prescribed only if behavioral interventions fail and moderate-to-severe impairment persists 1
• Use with more restraint—higher rates of adverse events in this age group 1

Elementary school-age (6-11):

• FDA-approved medications (preferably stimulants) AND/OR evidence-based behavioral therapy, preferably both 1

Adolescents (12-18):

• FDA-approved medications with adolescent assent, preferably combined with behavioral therapy 1