Methylphenidate dosage for children with ADHD over time under controlled conditions: Lessons from the MTA

To examine the trajectory of methylphenidate (MPH) dosage over time. follow ing a controlled titration, and to ascertain how accurately the titration w as able to predict effective long-term treatment in children with attention -deficit/hyperactivity disorder (ADHD). Method: Using the 14-month-treatmen t database of the NIMH Collaborative Multisite Multimodal Treatment Study o f Children With Attention-Deficit/Hyperactivity Disorder (MTA), the outcome of the initial placebo-controlled, double-blind, randomized daily switch t itration of MPH was compared with the subsequent maintenance pharmacotherap y. Children received monthly monitoring visits and, when needed, medication adjustments. Results: Of the 198 children for whom MPH was the optimal tre atment at titration (mean +/- SD dose: 30.5 +/- 14.2 mg/day), 88% were stil l taking MPH at the end of maintenance (mean dose 34.4 +/- 13.3 mg/day). Ti tration-determined dose and end-of-maintenance dose were significantly corr elated (r = 0.52-0.68). Children receiving combined pharmacotherapy and beh avioral treatment ended maintenance on a lower dose (31.1 +/- 11.7 mg/day) than did children receiving pharmacotherapy only (38.1 +/- 14.2 mg/day). Of the 230 children for whom titration identified an optimal treatment. 17% c ontinued both the assigned medication and dosage throughout maintenance. Th e mean number of pharmacological changes per child was 2.8 +/- 1.8 (SD), an d time to first change was 4.7 months +/- 0.3 (SE). Conclusions: Far most c hildren, initial titration found a dose of MPH in the general range of the effective maintenance dose, but did not prevent the need for subsequent mai ntenance adjustments. For optimal pharmacological treatment of ADHD, both c areful initial titration and ongoing medication management are needed.