Choosing the Best Dose of Medication for Treating Attention Deficit Hyperactivity Disorder


Unlike most other medications, the medication doses for ADHD/ADD are not based on weight.

We begin with a low dose of medication and gradually increase the dose because the response to a particular dose can vary from one patient to another.

The first dose that a child’s symptoms respond to may not be the best dose to improve function. The AAP recommends continuing to use higher doses to achieve better responses.3 This strategy may require reducing the dose when a higher dose produces side effects orno further improvement.

The best dose of medication for a given child is the one that leads to optimal effects with minimal side effects.

For example, if there is a need for relief of symptomsonly during school, a 5-day schedule may be sufficient. Some children need relief of symptoms at home as well as at school and do best with medication 7-days a week..

Stimulants are generally considered safe medications, with few contraindications to their use. Side effects occur early intreatment and tend to be mild and do not last long.

The most common side effects are decreased appetite, stomach ache or  headache, delayed sleep onset, jitteriness, or social withdrawal.

 Most of these symptoms can be successfully managed through adjustments in the dosage or schedule of medication.

Approximately 15% to30% of children experience motor tics while on stimulant medications. Most tics are short term. In addition, approximately half of children with Tourette syndrome have ADHD. The effects of medicationon tics are unpredictable. The presence of tics before or during medical management of ADHD is not an absolute contraindication to the use of stimulant medications.41,42 A review of 7 studies comparing stimulants with placebo or withother medications indicated no increase in tics in children treated with stimulants.2

According to the Physicians’ Desk Reference43 and medication package insert, methylphenidate is contraindicatedin children with seizure disorders, a history of seizure disorder,or abnormal electroencephalograms. Studies of the use of methylphenidate have not, however, demonstrated an increase in seizure frequencyor severity when it is added to appropriate anticonvulsant medications.44-46

Children who receive too high a dose or who are overly sensitive may become overfocused on the medication or appear dull or overly restricted. Many times this side effect can be addressed by lowering the dose. Rarely, with high doses, some children experience psychotic reactions, mood disturbances, or hallucinations.

No consistent reports of behavioral rebound, motor tics, or dose-related growth delays have been found in controlled studies.

Appetite suppression and weight loss are common side effects of stimulant medication,with no apparent difference between methylphenidate and dextroamphetamine.

Concern for growth delay has been raised. Studies of stimulant use have found little or no decrease in expected height, with any decrease in growthearly in treatment compensated for later on.

Many clinicians recommend drug holidays during summers, although no controlled trials exist to indicate whether holidays have gains or risks, especially related to weight gain.

At least 80% of children will respond to one of the stimulants if they are tried in a systematic way. Children who fail to show positive effects or who experience intolerable sideeffects on one stimulant medication should be tried on another of the recommended stimulant medications. The reasons for thisrecommendation include the following:

  • The finding that most children who fail to respond to one medication will have a positive response to an alternative stimulant
  • The safety and efficacy of stimulants in the treatment of ADHD compared with nonstimulant medications
  • The numerous crossover trials that indicate the efficacy of different stimulants in the same child

Source: American Academy of Pediatrics: Guideline on Treatment of Attention Deficit Disorder