What is the initial dose and titration schedule for stimulant therapy, such as Ritalin (methylphenidate) or Adderall (amphetamine), in a patient with Attention Deficit Hyperactivity Disorder (ADHD)?

Initial Stimulant Dosing for ADHD

Start methylphenidate (Ritalin) at 5 mg twice daily or amphetamine/dextroamphetamine (Adderall) at 2.5 mg once daily in children, or 10 mg once daily in adults, then increase weekly by 5-10 mg increments based on standardized rating scales until symptoms resolve or side effects emerge. 1

Starting Doses by Medication Class

Methylphenidate (Ritalin, Concerta)

• Children (6+ years): Begin with 5 mg twice daily (after breakfast and lunch), with optional third dose after school for homework coverage 1
• Adults: Start with 10-20 mg daily in divided doses, given 30-45 minutes before meals 2
• Maximum FDA-approved dose: 60 mg/day 2

Amphetamine/Dextroamphetamine (Adderall)

• Children (3-5 years): Start with 2.5 mg once daily 3
• Children (6+ years): Start with 2.5-5 mg once or twice daily 1, 3
• Adults: Start with 10 mg once daily in the morning 4
• Maximum FDA-approved dose: 40 mg/day 3

Lisdexamfetamine (Vyvanse)

• Standard starting dose: 30 mg once daily in the morning 5, 6
• Alternative conservative start: 20 mg once daily 6
• Maximum FDA-approved dose: 70 mg/day 5

Titration Protocol

Weekly Dose Escalation Strategy

• Increase methylphenidate by 5-10 mg increments weekly until optimal response or side effects occur 1
• Increase amphetamine by 5 mg increments weekly for children, 10 mg for adults 1, 3
• Increase lisdexamfetamine by 10-20 mg increments weekly 6
• Continue titration through the full dose range (methylphenidate 10-60 mg/day, amphetamine up to 40 mg/day) until symptoms resolve 1

Alternative "Forced Titration" Approach

• Administer all four dose levels (e.g., methylphenidate 5,10,15,20 mg or amphetamine 2.5,7.5,10 mg) for one week each 1
• Collect standardized rating scales at each dose level 1
• Select the dose that provides optimal symptom control with minimal side effects 1
• This method provides systematic data across the dose range but may expose patients to suboptimal or excessive doses temporarily 1

Monitoring Requirements During Titration

Assessment at Each Dose Adjustment

• Obtain standardized ADHD rating scales from teachers and parents for children, or from patient and significant others for adults before each increase 1, 4
• Measure vital signs: blood pressure, pulse, height, and weight at each in-person visit 1, 4
• Systematically query specific side effects: decreased appetite, insomnia, headaches, irritability, social withdrawal 4
• Contact frequency: Weekly visits or phone contact during initial titration, then monthly after stabilization 4, 5

Critical Pitfall to Avoid

Do not use weight-adjusted dosing (mg/kg) in clinical practice because standard tablets are unscored, requiring pill-cutting that produces fragments of unknown strength, and research shows little correlation between weight-adjusted doses and symptom reduction 1. The fixed-dose escalation method using whole pills reflects standard U.S. practice and allows for individualized response assessment 1.

Evidence-Based Dosing Principles

Flexible Titration Produces Superior Outcomes

• Meta-analysis of 65 RCTs involving 7,877 children/adolescents demonstrates that flexible-dose trials show increased efficacy and reduced discontinuations with higher doses, whereas fixed-dose trials show plateauing benefits beyond moderate doses 7
• This occurs because flexible titration allows dose adjustment based on symptom control and tolerability, maximizing benefit while minimizing dose-limiting adverse events 7
• More than 70% of patients respond to methylphenidate when the full dose range is systematically trialed 1
• More than 90% respond to at least one stimulant class when both methylphenidate and amphetamine formulations are tried 1

Dose-Response Characteristics

• For methylphenidate in fixed-dose trials, incremental benefits decrease beyond 30 mg/day 7
• For amphetamine in fixed-dose trials, incremental benefits decrease beyond 20 mg/day 7
• However, in flexible-dose trials that mirror clinical practice, incremental benefits remain constant across the full FDA-licensed dose range because practitioners can reduce doses when side effects emerge 7

When Maximum Dose Fails to Control Symptoms

Sequential Medication Trials

• If maximum dose of first stimulant (methylphenidate 60 mg/day or amphetamine 40 mg/day) does not adequately control symptoms, switch to the alternative stimulant class 4
• Methylphenidate and amphetamine have different mechanisms of action and individual response varies significantly 1, 8
• Do not add non-stimulants before maximizing stimulant dose, as stimulants have the largest effect sizes for ADHD core symptoms 4

Adjunctive Non-Stimulant Therapy

• If stimulant optimization produces partial response, consider adding atomoxetine or guanfacine extended-release 4, 9
• Atomoxetine provides continuous norepinephrine reuptake inhibition that may complement stimulant effects on executive function 4
• Guanfacine enhances prefrontal cortex function through alpha-2A adrenergic agonism and may improve working memory and impulse control 4

Timing and Duration Considerations

Optimal Administration Times

• Methylphenidate immediate-release: After breakfast and lunch, with optional third dose after school 1
• Amphetamine: Early morning, with noon dose added if duration insufficient 1
• Lisdexamfetamine: Single morning dose provides all-day coverage 5, 6
• Adjust timing to minimize side effects such as reduced appetite at dinner and delayed sleep onset 1

Comparative Duration of Action

• Adderall produces longer duration of effect than Ritalin, with sustained efficacy at midday and late afternoon when Ritalin effects wear off 8
• Lower doses of Adderall (7.5 mg) produce effects comparable to higher doses of Ritalin (17.5 mg), suggesting greater functional potency 8

Special Population Considerations

Older Adults

• Use more conservative titration: increase by 5 mg every 2 weeks instead of weekly 4
• Older adults demonstrate increased sensitivity to both therapeutic and adverse effects due to age-related pharmacokinetic changes 4

Preschool Children (Under 6 Years)

• Methylphenidate lacks robust evidence for safety and efficacy in preschoolers, despite FDA approval for children as young as 6 years 1
• Amphetamine/dextroamphetamine has FDA approval for children as young as 3 years, though published controlled data are lacking 1
• Exercise particular caution with slow titration and small dose increments in young children 1

Common Reasons for Inadequate Response

Factors Contributing to Treatment Failure

• Poor adherence due to adverse effects, lack of perceived effectiveness, concerns about addiction, difficulty swallowing, or cost 9
• Inadequate dosing: Many patients in community practice receive lower doses and less frequent monitoring than optimal 1
• Dose-limiting adverse effects that prevent titration to therapeutic range 9
• Severity and complexity of ADHD, including comorbid conditions 9

Addressing Inadequate Response

• First, verify adherence and address barriers 9
• Second, optimize current stimulant dose to maximum FDA-approved range using standardized rating scales 4, 9
• Third, if dose-limiting side effects occur, switch to alternative stimulant class 9
• Fourth, if partial response persists despite optimization, add non-stimulant adjunct 4, 9