What are the recommended starting doses, titration increments, maximum daily dose, dosing schedule, contraindications, and common side effects for Adderall immediate‑release (mixed amphetamine salts) in children aged 6‑12 years, adolescents aged 13‑17 years, and adults?

Adderall Immediate-Release Dosing

Starting Doses

For children aged 6–12 years, start Adderall IR at 5 mg once or twice daily; for adolescents aged 13–17 years and adults, start at 5 mg twice daily (after breakfast and lunch). 1, 2

• Children aged 3–5 years (rarely indicated): Begin with 2.5 mg daily, though ADHD treatment in this age group is uncommon 2
• The FDA label specifies giving the first dose on awakening, with additional doses (1 or 2) at intervals of 4–6 hours 2
• Ideally, administer after breakfast and lunch, with a potential third dose after school to help with homework and social activities 1

Titration Schedule

Increase the dose by 5 mg weekly increments until symptoms resolve or side effects emerge. 1, 2

• Base dose adjustments on standardized ADHD rating scales obtained from teachers and parents (for children) or from the patient and significant other (for adults) 1
• Weekly contact during titration is recommended, with rating scales collected before each dose increase—this can be done via phone 1
• Continue escalating the dose through the therapeutic range until clinical improvement is achieved or troublesome side effects occur 1

Maximum Daily Doses

The maximum daily dose is 40 mg for children aged 6–12 years and 40–60 mg for adolescents and adults. 1, 2, 3

• For children, it is rare to exceed 40 mg total daily dose 2
• Adults may require 10–50 mg daily for optimal symptom control, with some patients needing up to 60 mg 1, 4
• One study found that adult responders achieved symptom control at a mean dose of only 10.77 mg/day (0.14 mg/kg/day), suggesting that relatively low doses may be effective for some individuals 4

Dosing Schedule

Administer Adderall IR in divided doses throughout the day, typically 2–3 times daily, with the first dose on awakening and subsequent doses every 4–6 hours. 1, 2

• A standard regimen is three times daily, though the exact timing must be adjusted to cover school and afternoon homework periods 1
• Avoid late evening doses to prevent insomnia 2
• The timing and strength of the end-of-day dose should be adjusted to minimize side effects such as reduced appetite at dinner and delayed sleep onset 1
• Some patients may benefit from increasing the morning dose to extend duration of action 1

Contraindications

Absolute contraindications include concurrent MAOI use (or within 14 days of MAOI discontinuation), active psychosis, symptomatic cardiovascular disease, uncontrolled hypertension, hyperthyroidism, glaucoma, and known hypersensitivity to amphetamines. 5

• Exercise caution in patients with comorbid substance abuse disorders; consider long-acting formulations with lower abuse potential in this population 5
• Ensure patients with seizure disorders are stable on anticonvulsant therapy before initiating stimulants 5
• Stabilize mood disorders before starting stimulants, though secondary depression may improve once ADHD symptoms are treated 5

Common Side Effects

The most frequently reported side effects are decreased appetite (anorexia), insomnia, headache, and irritability. 1, 6

• Appetite suppression and weight loss are common and dose-related; monitor weight regularly 6, 7
• Insomnia can be managed by adjusting the timing of doses, particularly avoiding late-day administration 1
• Headache and irritability are generally mild 6
• Acute anxiety symptoms may occur, particularly in patients with comorbid anxiety disorders 4
• Cardiovascular effects include modest increases in blood pressure and pulse, but these are typically not clinically significant in healthy children 7

Baseline Assessment and Monitoring

Before starting Adderall IR, measure blood pressure, pulse, height, and weight; repeat vital signs at each dose adjustment and monitor weight regularly throughout treatment. 1, 5, 7

• Obtain a detailed cardiac history (syncope, chest pain, palpitations) and family history of premature cardiovascular death or arrhythmias 5
• During titration, collect weekly symptom ratings and vital signs 1
• In the maintenance phase, adults should have quarterly blood pressure and pulse checks; children require annual vital-sign assessment and height/weight measurement at every visit 5
• Screen adolescents and adults for substance-use risk before initiating treatment 5

Clinical Pearls

• Do not rely solely on weight-based (mg/kg) dosing; systematic titration to the lowest effective dose is preferred. 5
• Approximately 70–80% of patients respond to stimulants when properly titrated 5
• If one stimulant class fails, trial the other class (methylphenidate vs. amphetamine) before considering non-stimulants, as approximately 40% of patients respond to only one class 5
• Small children require careful titration with lower starting doses to avoid unnecessary side effects that may decrease willingness to continue treatment 1
• Dextroamphetamine has a shorter plasma half-life in children (7 hours) compared to adults (10–12 hours), which may influence dosing frequency 3