What are the guidelines for prescribing Adderall (amphetamine and dextroamphetamine) to adults and children with Attention Deficit Hyperactivity Disorder (ADHD)?

Adderall Prescribing Guidelines for ADHD

Age-Specific Treatment Algorithms

Preschool Children (Ages 4-5)

Begin with evidence-based parent and/or teacher-administered behavior therapy as first-line treatment before considering any medication. 1

• Only prescribe methylphenidate (not amphetamines like Adderall) if behavior therapy fails after at least 9 months AND the child has moderate-to-severe dysfunction in both home and other settings (such as preschool) 1
• Dextroamphetamine is FDA-approved for children as young as 3 years, but this approval was based on less stringent historical criteria rather than empirical evidence, and insufficient safety/efficacy data exists for this age group 1
• Start with 2.5 mg daily for ages 3-5 years if medication becomes necessary, increasing by 2.5 mg weekly until optimal response 2
• Preschool-aged children metabolize stimulants more slowly, requiring lower starting doses and smaller dose increments 1

Elementary School Children (Ages 6-11)

Prescribe FDA-approved stimulant medications AND evidence-based behavioral therapy together as the preferred approach. 1

• Stimulant medications have the strongest evidence (effect sizes 0.8-0.9), with amphetamines and methylphenidate equally effective as first-line options 1, 3
• Start with 5 mg once or twice daily for children 6 years and older, increasing by 5 mg weekly until optimal response 2
• Maximum dose rarely needs to exceed 40 mg per day total 1, 2
• Give first dose upon awakening, with additional doses (1-2) at 4-6 hour intervals 1, 2
• Atomoxetine, extended-release guanfacine, and extended-release clonidine are second-line options (in that order) with less robust evidence than stimulants 1

Adolescents (Ages 12-18)

Prescribe FDA-approved ADHD medications with the adolescent's assent, preferably combined with behavioral therapy. 1

• Start with 10 mg daily for patients 12 years and older, increasing by 10 mg weekly until optimal response 2
• Screen for substance abuse symptoms before initiating treatment, as diversion risk is highest in this age group 1
• Consider medications with lower abuse potential if substance use concerns exist: atomoxetine, extended-release guanfacine, extended-release clonidine, lisdexamfetamine, dermal methylphenidate, or OROS methylphenidate 1
• Provide medication coverage for evening hours to address driving safety concerns, using longer-acting formulations or late-afternoon short-acting doses 1

Adults

Stimulants remain first-line treatment with 70-80% response rates and the largest effect sizes from over 161 randomized controlled trials. 1, 4

• Typical adult dosing ranges from 10-50 mg daily of mixed amphetamine salts, with many patients requiring 20-40 mg daily 4
• Maximum doses can reach 40 mg for amphetamine salts, though some patients may require up to 60 mg total daily dose with clear documentation 1, 2
• Start with 5 mg daily, increasing by 5-10 mg weekly for immediate-release formulations 1
• Long-acting formulations provide better adherence and lower rebound risk compared to short-acting preparations 1

Titration and Monitoring Protocol

Initial Titration Phase (2-4 Weeks)

• Increase doses weekly by 5-10 mg per dose for immediate-release formulations until symptom control achieved or maximum dose reached 1
• Obtain weekly symptom ratings from parents AND teachers during dose adjustment 1
• Contact can be maintained weekly by telephone during titration 1
• Use standardized rating scales to supplement clinical assessment 1

Maintenance Phase Monitoring

• Schedule appointments at least monthly until symptoms stabilize 1
• Systematically assess specific side effects at each visit: insomnia, anorexia, headaches, social withdrawal, tics, weight loss 1
• Weigh patient at each visit as objective measure of appetite suppression 1
• Monitor blood pressure and pulse regularly 4
• Track height and weight, particularly in younger patients 4

Dose Optimization

Titrate to achieve maximum benefit with minimum adverse effects rather than using strict mg/kg calculations. 1

• If top recommended dose doesn't help, more is not necessarily better—consider changing medications or adding psychosocial interventions 1
• 70% of patients respond optimally when proper titration protocols are followed 4
• Consider adding afternoon/evening doses (5 mg) to address symptom coverage during homework, social activities, or driving 1, 4

Critical Safety Considerations

Cardiovascular Screening

• Expand history to include specific cardiac symptoms, Wolf-Parkinson-White syndrome, sudden death in family, hypertrophic cardiomyopathy, and long QT syndrome 1
• Avoid stimulants in patients with uncontrolled hypertension or symptomatic cardiovascular disease 4
• Sudden death in children on stimulant medication is extremely rare, and evidence is conflicting whether stimulants increase this risk 1

Common Adverse Effects

• Decreased appetite and weight loss (monitor weight at each visit) 1
• Insomnia (avoid late evening doses) 1, 2
• Growth velocity reduction of 1-2 cm with higher, consistently administered doses, though effects diminish by third year without compensatory rebound 1
• Rare occurrence of hallucinations and psychotic symptoms 1
• Preschool children may experience increased mood lability and dysphoria 1

Substance Abuse Considerations

• Assess adolescents for substance abuse symptoms before beginning treatment 1
• Monitor prescription-refill requests for signs of misuse or diversion 1
• Consider non-stimulant options (atomoxetine, extended-release guanfacine/clonidine) or stimulants with lower abuse potential (lisdexamfetamine) for high-risk patients 1, 4

Behavioral Therapy Integration

Evidence-Based Behavioral Interventions

• Behavioral parent training shows median effect size of 0.55 for improved compliance and parental understanding 1
• Behavioral classroom management shows median effect size of 0.61 for improved attention and decreased disruptive behavior 1
• Combination of medication and behavioral therapy produces optimal outcomes across all age groups 1

Implementation Requirements

• Parent training teaches specific techniques: positive reinforcement for desired behaviors, planned ignoring for unwanted behaviors, appropriate consequences when goals not met 1
• School environment and program placement must be part of treatment plan 1
• Consistent application of rewards and consequences with gradual increase in expectations as tasks mastered 1

Common Pitfalls to Avoid

• Do not assume 5 mg dose is adequate—54-70% of adults respond to stimulants when properly titrated, and systematic titration to optimal effect is essential 4
• Do not use medication as monotherapy when behavioral interventions are indicated, particularly in preschoolers and children with comorbid oppositional defiant disorder 3
• Do not skip behavioral interventions in preschoolers before considering medication 3
• Do not fail to involve both home and school environments in treatment planning and monitoring 3
• Do not prescribe amphetamines for preschool children when methylphenidate has stronger evidence in this age group 1
• Do not continue increasing dose indefinitely—if maximum recommended dose ineffective, change medication class rather than exceeding limits 1

Chronic Disease Management Approach

Recognize ADHD as a chronic condition requiring ongoing management following chronic care model and medical home principles. 1

• Establish bidirectional communication with teachers and school mental health clinicians 1
• Interrupt drug administration occasionally to determine if behavioral symptoms recur sufficiently to require continued therapy 2
• Provide extra support for parents who also have ADHD to ensure consistent medication administration and behavioral program implementation 1
• Longitudinal studies show greater risk of significant problems when treatment discontinued despite long-term need 1