An 8-year-old female patient with Attention Deficit Hyperactivity Disorder (ADHD) treated with Vyvanse (lisdexamfetamine) 20 mg daily for 2 years, with recent increased ADHD symptoms, poor appetite, and minimal weight gain, what are the recommendations for adjusting her treatment plan?

Management of Worsening ADHD Symptoms with Growth Concerns in a Child on Vyvanse

Increase the Vyvanse dose to 30 mg daily and implement strategic timing of medication with high-calorie supplementation in the evening to address both inadequate symptom control and appetite suppression. 1, 2

Addressing the Dual Problem: Symptom Control and Growth

Your patient presents with two interconnected issues that require simultaneous management:

Primary Issue: Inadequate Dose for Current Developmental Stage

• The current 20 mg dose is likely subtherapeutic after 2 years of treatment. Children grow and their therapeutic needs change—this is not tolerance development, but rather inadequate dosing for her current weight and developmental stage 3
• Lisdexamfetamine dosing for children ranges from 20-70 mg daily, with systematic titration in 10-20 mg weekly increments until optimal response 4, 5
• Increase to 30 mg daily immediately, then reassess after one week. If symptoms persist, continue titrating by 10 mg weekly up to 50-70 mg as needed for full symptom control 2, 4
• The worsening ADHD symptoms over 6 weeks strongly suggest the dose is no longer adequate, not that the medication has stopped working 3

Managing Appetite Suppression and Growth

Implement these specific tactics simultaneously with dose optimization: 1

• Give Vyvanse with breakfast to minimize meal-time appetite suppression 1
• Provide a high-calorie drink or substantial snack late in the evening (8-9 PM) when medication effects have worn off—this is when appetite returns 1
• Schedule regular high-calorie meals: substantial breakfast before medication, protein-rich lunch even if appetite is reduced, and calorie-dense evening meal/snack 1
• Monitor height and weight monthly during titration, then every 3 months during maintenance 2

Critical Monitoring During Dose Adjustment

Track these parameters weekly during titration: 2

• Core ADHD symptoms using standardized parent and teacher rating scales (not just subjective reports)
• Appetite patterns throughout the day—document when she eats and caloric intake
• Sleep onset and quality—ensure the increased dose doesn't worsen sleep
• Blood pressure and pulse at each visit
• Weight gain trajectory—expect some catch-up growth once appetite strategies are implemented

What NOT to Do

Do not switch medications prematurely. 2 The issue is inadequate dosing, not medication failure. Lisdexamfetamine has 70-80% response rates when properly titrated 3, 2

Do not accept underdosing due to growth concerns. 2 Untreated ADHD symptoms cause significant functional impairment that outweighs manageable appetite effects. The growth delays from stimulants are typically small and do not result in clinically significant height impairment in adulthood 1

Do not use weight-based dosing calculations. 1 Current evidence does not support this approach—titrate to clinical effect within safe dose ranges 1, 2

Expected Timeline

• Symptom improvement: within 1-3 days of reaching optimal dose 3
• Appetite pattern adjustment: 2-4 weeks as family implements evening supplementation strategy 1
• Weight gain: should resume within 4-8 weeks if caloric intake is adequate 1

When to Reassess the Plan

If after reaching 50-70 mg daily with proper titration there is still inadequate response, then consider: 2

• Switching to methylphenidate-based stimulant (different mechanism may work better) 2
• Evaluating for comorbid conditions affecting treatment response 3
• Ensuring medication adherence and proper administration timing 2

The combination of dose optimization with strategic appetite management addresses both problems without compromising either ADHD control or growth. 1, 2