How to Start Adderall in Children and Adolescents with ADHD
Begin with low-dose Adderall at 2.5 mg once daily in the early morning, then titrate upward by 2.5-5 mg weekly based on standardized rating scales from parents and teachers until symptoms resolve or side effects emerge, with most children requiring 10-30 mg total daily dose divided into 2-3 doses. 1
Initial Dosing Strategy
Start with 2.5 mg of mixed amphetamine salts (Adderall) given once daily in the early morning for the first week 1. This conservative starting dose minimizes the risk of side effects that could decrease willingness to continue treatment 1.
- For children weighing less than 25 kg (55 lbs), maintain extra caution with slower titration 1
- Adderall may require only once-daily dosing initially, unlike methylphenidate which typically needs twice-daily administration from the start 1
- Evidence suggests that increasing the morning dose of amphetamines may extend duration of action, potentially eliminating the need for multiple daily doses 1
Systematic Titration Protocol
Use a stepwise dose escalation approach, increasing by 2.5-5 mg weekly based on objective feedback 1:
Week 1: 2.5 mg once daily in the morning 1
Week 2: 5 mg once daily (or split into 2.5 mg twice daily if duration is insufficient) 1
Week 3: 7.5 mg total daily dose 1
Week 4: 10 mg total daily dose 1
- Continue titration beyond 10 mg if symptoms persist and side effects remain tolerable 1
- Total daily doses in children typically range from 10-35 mg, though some may require up to 40 mg 1, 2
- The MTA study showed children weighing less than 25 kg reached total daily doses up to 35 mg when needed 1
Critical Monitoring Requirements
Base all dose adjustments on standardized, validated ADHD rating scales—not subjective impressions or continuous performance tests (CPTs) 1. CPTs have 20% false-positive and false-negative rates and have never been validated for medication titration 1.
Obtain ratings from both parents and teachers before each dose increase 1:
- Contact can be by phone between office visits 1
- Weekly symptom ratings during titration are essential 2
- Monitor for both efficacy (symptom reduction) and tolerability (side effects) 1
Monitor vital signs and growth parameters 2:
- Blood pressure and pulse at baseline and each visit 2
- Height and weight regularly 2
- Appetite and sleep disturbances are the most common side effects requiring monitoring 3, 4
Dosing Schedule Optimization
Add a second (noon) dose if the morning dose wears off before the school day ends 1. A third afternoon dose (around 4 PM) can be added to help with homework and social activities 1, 2.
- Adjust timing and strength of the end-of-day dose to minimize appetite suppression at dinner and delayed sleep onset 1
- 70% of children in clinical trials received Adderall once daily, compared to only 15% receiving methylphenidate once daily, suggesting longer duration of action 5
- Adderall's behavioral effects persist longer than methylphenidate after individual doses 5
Response Criteria and Treatment Goals
Stop titration when symptoms have resolved and functional impairment is diminished across multiple settings 1. Different target symptoms may require different doses, so prioritize which symptoms are most impairing 1.
Response rates for properly titrated amphetamine therapy:
- 70-80% overall response rate when adequately dosed 2, 6
- 89% showed positive response by either parent or teacher criteria in one large study 4
- 59% response rate when requiring strict concurrence between parent and teacher observers 4
Alternative Titration Approach: Forced Titration
Consider a "forced titration" trial where the patient takes all dose levels (2.5,7.5,10 mg) with each dose lasting one week, then select the optimal dose based on collected ratings 1. This systematic approach ensures you don't miss the optimal dose and provides comparative data across dose levels 1.
Common Pitfalls to Avoid
Do not stop at 5 mg assuming it's adequate—this is at the very low end of the therapeutic range and 54-70% of patients respond optimally only when proper titration protocols are followed 2. Systematic titration to optimal effect is more important than strict mg/kg calculations 2.
Do not increase doses when troublesome side effects occur—instead, stop or reverse the dose increase 1. Experiencing unnecessary side effects decreases willingness to use stimulants 1.
Do not rely solely on subjective impressions—always use standardized rating scales from multiple observers 1. Adults with ADHD are unreliable reporters of their own behaviors; obtain collateral information from family members when possible 6.
Do not assume tolerance will develop requiring dose escalation—there is little evidence of tolerance to stimulant effects on ADHD symptoms, and children most often continue to respond to the same dose even over prolonged treatment 2. If the top recommended dose doesn't help, more is not necessarily better; consider changing medications or adding psychosocial interventions 2.
Safety Considerations
The most common adverse events with Adderall include 4, 7:
- Decreased appetite/anorexia (35.6% vs 1.9% placebo) 7
- Insomnia (12.0% vs 3.7% placebo) 7
- Headache (16.3% vs 22.2% placebo) 7
- Abdominal pain (10.7% vs 1.9% placebo) 7
- Weight loss (9.4% vs 0% placebo) 7
Most adverse events are mild to moderate in intensity (97.5%), and Adderall is generally well-tolerated with a side effect profile similar to other psychostimulants 4, 8.
Contraindications and precautions 9:
- Avoid in patients with symptomatic cardiovascular disease 2
- Screen for family history of sudden cardiac death 9
- Clinical evaluation for tics and Tourette's syndrome should precede use, as amphetamines may exacerbate motor and phonic tics 9
- Amphetamines may exacerbate symptoms in psychotic patients 9
Long-Acting Formulation Consideration
Consider switching to Adderall XR (extended-release) after establishing optimal total daily dose 8, 7. Adderall XR provides 12-hour duration of action with once-daily dosing, improving adherence and reducing rebound effects 8, 7.