ADHD Medication Dosing in Children and Adolescents
Stimulant Medications
Methylphenidate
For elementary school-aged children (6-11 years), start methylphenidate at a low dose and titrate weekly in 5-10 mg increments until optimal symptom control is achieved, typically reaching 0.3-1.0 mg/kg/day or a maximum of 60 mg/day. 1
Initial Dosing and Titration
- Begin with 5-10 mg once or twice daily in the early morning 2
- Increase by 5-10 mg increments at weekly intervals based on parent and teacher rating scales 1
- Target dose range: 0.3-1.0 mg/kg/day, with maximum of 60 mg/day regardless of formulation 2, 3
- Dose calculation based on weight is not particularly helpful due to individual variability in response 1
Extended-Release Formulations
- Provide 8-12 hours of symptom coverage, eliminating need for school-day dosing 2
- Concerta (12-hour): Uses osmotic pump technology 2
- Metadate CD and Ritalin LA (8-hour): Use microbead technology 2
Monitoring Requirements
- Obtain standardized ADHD rating scales from both parents and teachers before each dose increase 4
- Assess blood pressure, pulse, height, and weight at each visit 4, 5
- Systematically evaluate for side effects including insomnia, appetite suppression, headaches, and mood changes 5
Amphetamine/Dextroamphetamine (Adderall)
Start immediate-release amphetamine at 5 mg once or twice daily and titrate in 5-10 mg weekly increments to a target of 40-60 mg total daily dose, with a maximum of 40 mg/day. 6
Dosing Protocol
- Initial dose: 5 mg once daily in early morning, with noon dose added if needed 6
- Extended-release: Start at 10 mg once daily in the morning 6
- Titrate in 5-10 mg increments weekly based on symptom control and tolerability 6
- Maximum dose: 40 mg/day for immediate-release formulations 5, 6
Lisdexamfetamine (Vyvanse)
Begin lisdexamfetamine at 20-30 mg once daily in the early morning and increase by 10-20 mg increments at weekly intervals until optimal symptom control is achieved. 4
Titration Strategy
- Administer in early morning to provide full-day coverage 4
- Increase by 10 mg increments at approximately weekly intervals 4
- Some clinicians use "forced titration" where the child receives all dose levels (30 mg, 50 mg, 70 mg) for one week each with rating scales collected at each dose 4
Non-Stimulant Medications
Atomoxetine
Atomoxetine is a second-line option when stimulants are ineffective or contraindicated, though specific pediatric dosing guidelines were not detailed in the provided evidence. 1, 5
- Consider for patients with concerns about substance abuse or medication diversion 5
- Monitor closely for suicidality, clinical worsening, and unusual behavioral changes 5
Extended-Release Guanfacine
For children aged 6 years and older, start guanfacine extended-release at 1 mg daily and titrate by 1 mg increments weekly to a target range of 0.05-0.12 mg/kg/day or 1-4 mg/day, with a maximum of 4 mg daily. 5
Dosing and Monitoring
- Initial dose: 1 mg daily 5
- Titrate by 1 mg increments weekly based on clinical response and tolerability 5
- Target range: 0.05-0.12 mg/kg/day or 1-4 mg/day 5
- Maximum dose: 4 mg daily 5
- Most common adverse effects: somnolence/sedation, fatigue, drowsiness, and dry mouth 5
Extended-Release Clonidine
Extended-release clonidine is an alternative non-stimulant option, particularly useful in adolescents with substance abuse concerns, though specific dosing was not detailed in the provided evidence. 5
Age-Specific Considerations
Preschool Children (4-5 Years)
Behavior therapy should be first-line treatment for preschool-aged children, with methylphenidate reserved only for those with moderate-to-severe dysfunction who have not responded to at least 9 months of behavioral interventions. 1, 5
- When medication is necessary, use lower starting doses with smaller incremental increases due to slower metabolism 1, 5
- Only consider medication for children with dysfunction in both home and school/childcare settings 5
- May prescribe methylphenidate if behavioral interventions do not provide significant improvement 1
Elementary School-Aged Children (6-11 Years)
For elementary school-aged children, prescribe FDA-approved ADHD medications (preferably stimulants) and/or evidence-based behavioral therapy, ideally both. 1
- Stimulant medications are first-line pharmacological treatment 1
- Evidence is particularly strong for stimulants and sufficient but less strong for atomoxetine, extended-release guanfacine, and extended-release clonidine (in that order) 1
Adolescents (12-18 Years)
For adolescents, prescribe FDA-approved ADHD medications with the assent of the adolescent and may prescribe behavioral therapy, preferably both. 1
Special Adolescent Considerations
- Screen for substance use symptoms before initiating medication 5
- Monitor for medication diversion (use by parents, classmates, or acquaintances) 5
- Consider non-stimulant medications to minimize abuse potential 5
- Provide medication coverage for driving hours using longer-acting or late-afternoon short-acting medications 5
Critical Monitoring and Titration Principles
Systematic Titration Approach
Titrate from a low dose to one that achieves maximum optimal effect in controlling symptoms without adverse effects, as individual response to stimulants is variable and unpredictable. 1
- Stimulant medications can be effectively titrated on a 7-day basis, but in urgent situations may be titrated in as few as 3 days 1
- More than 70% of children respond to methylphenidate when a full range of doses is administered 1
- More than 90% of patients will respond to one of the psychostimulants if medications from both methylphenidate and amphetamine classes are tried 1
Monitoring Requirements
Use standardized ADHD rating scales with age- and gender-specific norms to assess symptoms before treatment and after each major dose adjustment. 5
- Assess blood pressure, pulse, height, and weight at each visit 4, 5
- Systematically assess for side effects including insomnia, anorexia, headaches, weight loss, and mood changes 5
- Rating scales should be obtained from both parents and teachers 4
- Phone contact between visits may be needed to guide titration decisions 4
Common Pitfalls to Avoid
The MTA study demonstrated that community treatment resulted in less beneficial outcomes compared to optimal medication management, primarily because community-treated children received lower medication doses and less frequent monitoring. 1
- Avoid calculating dose based solely on milligrams per kilogram, as variations in dose have not been found to be related to height or weight 1
- Do not assume higher doses are always better—if the top recommended dose doesn't help, consider changing medication or adding psychosocial interventions 6
- Alert parents that changing medication dose and occasionally changing medications may be necessary for optimal management and may require a few months to achieve optimal success 1
- Remember that parents themselves may be significantly challenged by ADHD, affecting their ability to cooperate with treatment 1
Medications for Other Psychiatric Conditions
Risperidone for Psychotic Disorders and Irritability in Autism
For adolescents with schizophrenia, start risperidone at 0.5 mg once daily and titrate in 0.5-1 mg increments at 24-hour intervals to a target of 3 mg/day, with an effective range of 1-6 mg/day. 7
Schizophrenia Dosing (Adolescents)
- Initial dose: 0.5 mg once daily 7
- Titration: Increase in 0.5-1 mg increments at intervals of 24 hours or greater 7
- Target dose: 3 mg/day 7
- Effective range: 1-6 mg/day 7
- Doses higher than 6 mg/day have not been studied 7
Irritability in Autistic Disorder
- For children weighing less than 20 kg: Start 0.25 mg daily, may increase to 0.5 mg by Day 4, then increase by 0.25 mg increments at intervals greater than 2 weeks to target of 0.5 mg/day (range 0.5-3 mg) 7
- For children weighing 20 kg or more: Start 0.5 mg daily, may increase to 1 mg by Day 4, then increase by 0.5 mg increments at intervals greater than 2 weeks to target of 1 mg/day (range 0.5-3 mg) 7
Fluoxetine for Depressive and Anxiety Disorders
For pediatric major depressive disorder and OCD, start fluoxetine at 10-20 mg daily in the morning and titrate based on response, with maximum doses of 60-80 mg/day depending on indication. 8
Major Depressive Disorder
- Initial dose: 20 mg/day administered in the morning 8
- Dose increase may be considered after several weeks if insufficient clinical improvement is observed 8
- Doses above 20 mg/day may be administered once daily or twice daily (morning and noon) 8
- Full therapeutic effect may be delayed until 5 weeks of treatment or longer 8
Obsessive Compulsive Disorder (Pediatric)
- Adolescents and higher weight children: Start 10 mg/day, increase to 20 mg/day after 2 weeks, with target range of 20-60 mg/day 8
- Lower weight children: Start 10 mg/day, with target range of 20-30 mg/day 8
- Experience with daily doses greater than 20 mg is very minimal, and there is no experience with doses greater than 60 mg 8
- Maximum dose should not exceed 80 mg/day 8