What is the recommended dose of Adderall (amphetamine and dextroamphetamine) for a patient with Attention Deficit Hyperactivity Disorder (ADHD)?

Adderall Dosing for ADHD

Start Adderall at 5 mg once or twice daily for children aged 6 years and older, or 10 mg once daily for adults, then increase by 5 mg weekly increments until optimal symptom control is achieved, typically reaching 20-40 mg/day total, with a maximum of 40 mg/day for children and 50 mg/day for adults. 1, 2

Starting Doses by Age Group

Children Ages 3-5 Years

• Begin with 2.5 mg daily 1
• Increase by 2.5 mg increments weekly until optimal response 1

Children Ages 6 Years and Older

• Start with 5 mg once or twice daily 1
• Give first dose upon awakening, with additional doses (1-2) at 4-6 hour intervals 1
• Increase by 5 mg weekly increments based on standardized ADHD rating scales from parents and teachers 3, 4

Adults

• Initiate at 10 mg once daily in the morning 2
• Titrate by 5 mg weekly increments based on response and tolerability 2
• Maximum recommended dose is 50 mg/day 2

Titration Protocol

Use fixed-dose titration with whole pills rather than weight-based calculations, as current evidence shows little correlation between weight-adjusted doses and symptom reduction 5, 4. Weight-adjusted dosing may inappropriately restrict titration for smaller children who need higher doses or expose them to excessive amounts 5.

Weekly Titration Schedule

• Increase dose every 7 days based on systematic assessment 4, 3
• In urgent situations, titration can occur as rapidly as every 3 days 4
• Obtain standardized ADHD rating scales from both home and school settings before each dose increase 3, 4
• Continue titration until optimal symptom control without significant adverse effects 3

Target Dose Range

• Most children require 20-40 mg/day for optimal control 5
• Rarely necessary to exceed 40 mg/day in children 1
• Adults may require up to 50 mg/day 2
• More than 70% of patients respond when a full range of doses is properly titrated 4

Critical Monitoring Requirements

At Each Visit

• Assess blood pressure and pulse to monitor cardiovascular effects 5, 2
• Monitor height and weight to detect growth suppression 5
• Systematically query specific side effects: insomnia, decreased appetite, headaches, irritability, social withdrawal 3
• Use standardized ADHD rating scales with age- and gender-specific norms 5

Follow-Up Schedule

• Schedule appointments at least monthly after dose stabilization 2, 3
• Weekly contact during active titration phase 3

Administration Timing

Give first dose upon awakening 1. Avoid late evening doses due to resulting insomnia 1, 2. For immediate-release formulations, additional doses can be given at 4-6 hour intervals 1.

When Maximum Dose Fails

If adequate response is not achieved after reaching 40 mg/day (children) or 50 mg/day (adults):

• Switch to methylphenidate, as more than 90% of patients respond to one of the psychostimulant classes when both are tried 4, 3
• Consider adding atomoxetine or guanfacine as adjunctive therapy for persistent executive function deficits 3
• Re-evaluate the diagnosis and assess for comorbid conditions affecting treatment response 2

Common Pitfalls to Avoid

• Do not stop titration prematurely at low doses before assessing response at higher doses, as many children require 20-40 mg/day 5
• Do not calculate doses based solely on mg/kg, as individual response is highly variable and unpredictable 4, 5
• Do not start at excessively high doses, which leads to unnecessary side effects and decreased adherence 2
• Do not fail to systematically assess both benefits and side effects during each titration step 2
• Do not increase doses more frequently than weekly without allowing sufficient time to evaluate response 2

Special Population: Older Adults

For older adults, use a more conservative approach 2:

• Increase by 5 mg every 2 weeks instead of weekly 2
• Monitor vital signs particularly carefully due to age-related pharmacokinetic changes 2
• Older adults are more sensitive to both therapeutic and adverse effects 2

Expected Response Rates

Research demonstrates that 89% of patients show positive response by either parent or teacher criteria when properly titrated 6. Response rates range from 59% when requiring concurrence between observers to 82% based on parent criteria alone 6. In adults, approximately 54% respond positively, with mean effective doses around 10.77 mg/day (0.14 mg/kg/day) 7.

Anxiety Considerations

Exercise caution in patients with comorbid anxiety disorders, as Adderall may precipitate acute anxiety symptoms in vulnerable individuals 7. If anxiety emerges during titration, consider dose reduction or switching to an alternative medication class 7.