What are the recommended doses and administration times for Attention Deficit Hyperactivity Disorder (ADHD) medications, such as methylphenidate and amphetamine-based stimulants, like Vyvanse (lisdexamfetamine), in adolescents aged 13 and older?

ADHD Medication Dosing Guidelines for Adolescents

First-Line Treatment: Stimulant Medications

For adolescents aged 13 and older with ADHD, methylphenidate or amphetamine-based stimulants are the first-line pharmacological treatment, with both classes demonstrating robust efficacy and approximately 90% of patients responding when both are tried sequentially. 1

Methylphenidate Dosing

Starting Dose and Titration

• Start at 5 mg twice daily (after breakfast and lunch) 1
• Increase weekly by 5-10 mg increments per dose based on symptom response 1
• Continue titration until maximum symptom reduction is achieved without dose-limiting adverse effects 1
• Maximum total daily dose: 65 mg for adolescents and adults 1

Administration Timing

• Initial dosing: twice daily (morning and noon) 1
• Add a third afternoon dose at clinician's discretion for extended coverage, particularly important for driving safety in adolescents 1
• Long-acting formulations can provide 8-12 hours of symptom control with once-daily morning dosing 1, 2

Amphetamine/Dextroamphetamine (Adderall) Dosing

Starting Dose and Titration

• Start at 2.5 mg twice daily (after breakfast and lunch) 1, 3
• This is the minimum starting dose for children and adolescents 3
• Increase weekly by 2.5-5 mg per dose if symptom control is inadequate 3
• Maximum total daily dose: 40 mg 1, 3

Administration Timing

• Begin with twice-daily dosing (morning and noon) 1, 3
• Some patients may require only once-daily dosing depending on formulation 1
• Assess response using parent, teacher, and adolescent self-ratings at each dose level 3

Lisdexamfetamine (Vyvanse) Dosing

Starting Dose and Titration

• Start at 30 mg once daily in the morning 4
• After 1 week, increase to 50 mg/day as tolerated 4
• Further increase to 70 mg/day based on clinical response and tolerability 4
• Maximum dose: 70 mg/day 4

Key Advantages for Adolescents

• Prodrug formulation reduces abuse and diversion potential—critical consideration for adolescents 1, 5
• Single morning dose provides up to 13 hours of symptom control 5
• Smooth onset of action with potentially fewer rebound symptoms 5
• Particularly useful when medication diversion is a concern 1

Systematic Titration Strategy

The "Forced Titration" Approach

• Trial all dose levels systematically (e.g., 5,10,15,20 mg of methylphenidate OR 2.5,7.5,10 mg of amphetamine) 1
• Each dose condition lasts 1 week 1
• Collect parent, teacher, and adolescent ratings at each dose level 1, 3
• Select the dose producing maximum benefit with fewest side effects 1

Goal of Titration

• Aim for maximum symptom reduction approaching levels of adolescents without ADHD, not just "some improvement" 3
• This is a critical distinction—underdosing is a major problem in community practice 3

Monitoring Requirements During Titration

Baseline Assessment

• Blood pressure and pulse 3
• Height and weight 3
• Personal and family cardiac history 3
• Screen for substance abuse before initiating treatment in adolescents 1

Weekly During Titration

• Parent, teacher, and adolescent self-rating scales 1, 3
• Systematic assessment for side effects: insomnia, anorexia, headaches, social withdrawal, mood changes 3
• Blood pressure and pulse at each visit 3
• Weight monitoring to objectively track appetite suppression 3

Common Adverse Effects

• Decreased appetite, sleep disturbances, increased blood pressure and pulse, headaches, irritability, stomach pain 1
• These are generally mild and/or temporary 1
• Mean increases in vital signs: systolic/diastolic BP 1-3 mmHg, pulse 5-8 bpm 6

Sequential Treatment Algorithm

If First Stimulant Fails

• Approximately 70% respond to methylphenidate alone, but nearly 90% respond when both stimulant classes are tried 1, 7
• If methylphenidate fails after adequate trial, switch to amphetamine-based stimulant (or vice versa) 1, 7
• Individual patients may respond preferentially to either class despite similar overall efficacy 7, 8

Second-Line: Non-Stimulants

• Consider atomoxetine, extended-release guanfacine, or extended-release clonidine if both stimulant classes fail, are contraindicated, or cause intolerable side effects 1, 3
• Non-stimulants have smaller effect sizes compared to stimulants 7

Critical Considerations for Adolescents

Substance Abuse and Diversion

• Screen all adolescents for substance abuse symptoms before prescribing stimulants 1
• Monitor for signs of medication misuse or diversion 1
• Consider lower-abuse-potential formulations: lisdexamfetamine, dermal methylphenidate (Daytrana), or OROS methylphenidate (Concerta) 1
• Lisdexamfetamine is only activated after ingestion when metabolized by erythrocytes, making extraction difficult 1

Driving Safety

• Provide medication coverage for symptom control while driving 1
• Use longer-acting formulations or add late-afternoon short-acting dose 1
• This is particularly important given inherent risks of driving by adolescents with ADHD 1

Common Pitfalls to Avoid

Underdosing

• Community-treated children receive lower medication doses and less frequent monitoring than optimal medication management protocols, resulting in inferior outcomes 3
• Do not stop titration prematurely—continue until maximum symptom reduction is achieved 3

Inadequate Trial Duration

• Each dose level should be trialed for at least 1 week 1, 3
• Collect systematic ratings from multiple informants (parent, teacher, adolescent) 1, 3

Ignoring Long-Acting Formulations

• Long-acting formulations provide better medication adherence and lower risk of rebound effects 1
• Eliminate need for in-school administration, reducing embarrassment and improving compliance 2
• Different long-acting formulations have distinct pharmacokinetic profiles—select based on symptom pattern and individual needs 1