What is the recommended starting dose of Concerta (methylphenidate) for a 6-year-old child with Attention Deficit Hyperactivity Disorder (ADHD)?

Concerta Dosing for a 6-Year-Old with ADHD

For a 6-year-old child with ADHD who is stimulant-naïve, start Concerta at 18 mg once daily in the morning, which is equivalent to methylphenidate immediate-release 5 mg three times daily. 1

Initial Dosing Strategy

• The FDA-approved starting dose of Concerta for children 6 years and older who are new to stimulant treatment is 18 mg once daily, administered in the morning 1
• This 18 mg dose of Concerta provides equivalent therapeutic coverage to methylphenidate immediate-release 5 mg given three times daily throughout the school day 1
• Concerta's osmotic release oral system (OROS) delivers an ascending plasma drug level pattern that maintains symptom control for approximately 12 hours after a single morning dose 1

Titration Protocol

• Increase the dose gradually in weekly increments based on clinical response and tolerability 2
• For immediate-release methylphenidate formulations (which can guide Concerta titration), increase by 5-10 mg weekly 2
• The maximum recommended daily dose is 60 mg for pediatric patients, though this applies to total daily methylphenidate exposure 2

Key Pharmacokinetic Considerations

• Concerta has a delayed onset compared to immediate-release formulations, beginning to act approximately 90 minutes after ingestion versus 30 minutes for immediate-release preparations 1
• The peak behavioral and cognitive benefit occurs at 3 hours post-dose, one hour later than standard immediate-release preparations 1
• The ascending delivery pattern prevents the afternoon symptom deterioration commonly seen with immediate-release formulations 1

Critical Safety Screening Before Initiation

Prior to prescribing Concerta, you must assess for:

• Cardiac disease risk factors: Obtain careful personal and family history of sudden death, ventricular arrhythmia, structural cardiac abnormalities, cardiomyopathy, or serious arrhythmias, and perform a physical examination 2
• Tics and Tourette's syndrome: Evaluate family history and clinically assess the child for motor or verbal tics 2
• Risk factors for abuse and misuse: Assess personal and family history of substance use disorders, as methylphenidate has high abuse potential 2

Common Pitfalls to Avoid

• Do not start with higher doses in stimulant-naïve children, even if symptoms are severe—the 18 mg starting dose is appropriate and evidence-based 1
• Avoid administering doses late in the day as this can interfere with sleep; Concerta's 12-hour duration makes once-daily morning dosing optimal 1
• Do not assume plasma levels correlate with clinical response—titrate based on behavioral measures from teachers and parents, not blood levels 1
• Monitor for paradoxical aggravation of symptoms, which may require dose reduction or discontinuation 2

Monitoring Parameters

• Track growth parameters closely (height and weight) as stimulants can suppress growth in pediatric patients 2
• Monitor blood pressure and heart rate at baseline and during treatment 2
• Assess for emergence of psychiatric symptoms including new-onset psychosis, mania, or aggression 2
• Evaluate treatment response after one month—if no improvement is observed after appropriate dose adjustment, consider discontinuation 2

Expected Adverse Effects

The most common side effects include decreased appetite, insomnia, irritability, emotional lability, tachycardia, palpitations, and headache 1, 2