Q: “How Do Doctors Decide Which ADHD Medication to Prescribe First?”
Doctors typically start newly diagnosed individuals with ADHD on a low dose of a long-acting methylphenidate before adjusting the dose or switching to a different medication based on the individual’s response. Learn more about what goes into selecting the best medication and dosage for adults and children with ADHD.
Q: “With so many ADHD medications on the market, how do doctors decide which medication to try first on someone who is newly diagnosed? Is there a tried-and-true process doctors use to get to the right medication and dosage for a patient?”
Each clinician has their own way of determining the right ADHD medication and dosage for a patient. A common approach (and the one I use) is the following:
- Start patients on a low dose of a long-acting methylphenidate.
- If the patient is a young child or has difficulty swallowing a capsule, consider a liquid formulation, a chewable tablet, or a skin patch.
- If symptoms persist on the lower dose, consider increasing the dose.
- If methylphenidate is ineffective even at the higher dose and/or produces significant side effects, switch to a long-acting amphetamine.
- If either methylphenidate or amphetamine are effective but produce significant and intractable side effects, consider adding a non-stimulant.
- If either stimulant is ineffective, switch to a non-stimulant entirely.
[Get This Free Download: Comparison Chart of Stimulants & Non-Stimulants]
Why This Approach Works
Decades of research indicate that methylphenidate is as effective as amphetamine, but more easily tolerated as it comes with fewer side effects, which is why methylphenidate is commonly prescribed first.1 Long-acting methylphenidate provides most patients with the all-day coverage they need, though I may prescribe a short-acting preparation during key points of the patient’s day, like in the morning to jump-start the beneficial effects of medication as the child gets ready for school, or as the medication is wearing off to extend the duration of the initial long-acting medication.
We start a patient with a low dose and adjust dose upward from there to ensure that there is optimum benefit with minimal or no side effects. We gradually increase the dose until the patient sees positive results (or even greater benefit).
Even if a patient, whether a child or an adult, sees benefits with the low dose of medication I started them on, I still encourage them to experiment with a higher dose of the medication. Parents of children who are newly diagnosed with ADHD are often resistant to the idea, but I explain to them that the benefits, even with a minimal dose increase, may be even greater than what they are currently seeing. If side effects do occur at a higher dose, then the dose can be lowered to the previous one. To further fine-tune a patient’s dose, I would consider a liquid preparation or a skin patch.
It is important to understand that while decades of scientific research establish the effectiveness of ADHD medications, a trial-and-error approach is often necessary when starting an ADHD medication, as each patient may respond differently to a given medication. Thankfully, the many different ADHD medication options available allow us to tailor treatment to the needs of each child or adult for maximum benefit with the least amount of side effects.
How to Treat ADHD in Children: Next Questions
- What ADHD medications are used to treat children?
- Are ADHD meds safe for my child?
- What are common side effects associated with ADHD medication?
- What natural treatments help kids with ADHD?
- How can I find an ADHD specialist near me?
The content for this article was derived, in part, from the ADDitude ADHD Experts webinar titled, “ADHD Medication Options and Benefits for Children” [Video Replay & Podcast #438] with Walt Karniski, M.D., which was broadcast on January 19, 2023.
Dr. Karniski is the author of ADHD Medication: Does It Work and Is It Safe?
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1 Cortese, S., Adamo, N., Del Giovane, C., Mohr-Jensen, C., Hayes, A. J., Carucci, S., Atkinson, L. Z., Tessari, L., Banaschewski, T., Coghill, D., Hollis, C., Simonoff, E., Zuddas, A., Barbui, C., Purgato, M., Steinhausen, H. C., Shokraneh, F., Xia, J., & Cipriani, A. (2018). Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis. The lancet. Psychiatry, 5(9), 727–738. https://doi.org/10.1016/S2215-0366(18)30269-4