ADHD Treatment—A Look at Non-Stimulant Options

Okay, so let’s say it’s been determined that your child has ADHD, and you’ve already tried a stimulant—and the trial went sideways.  After taking a stimulant, your child became extremely irritable or anxious.  You might be scared, tired, or frustrated and ready to throw in the towel with this whole medication business.  And I don’t blame you.  There is the option to ditch medication altogether and just see what happens.  In very mild cases of ADHD, this could possibly work for a while—with the right behavioral interventions.  However, for most children with ADHD, taking medication to treat symptoms is clearly beneficial, but it’s a matter of finding the right fit medication. 

So, I’m Dr. K with Mental Health | Plain Speak.  I’m a general and child and adolescent psychiatrist based in the Southeast, and I’m creating brief videos to provide education about mental health and illness.  And today, the focus is on nonstimulant treatments for ADHD. 

Now, as I mentioned in previous talks, finding the right fit medication for psychiatric or behavioral disorders can be a bit like trying on shoes.  It’s a matter of being patient with the process.  Stimulant medications are considered first line treatments because of their effectiveness and safety profile when dosed appropriately.  However, if your child has tried different formulations of stimulant treatments and the trials all went sideways, or if stimulants are not an option because of other medical conditions, then there are a few nonstimulant options. 

Among these options are guanfacine and clonidine, which are considered second-line treatments for ADHD.  Now, these medications were originally devised for the treatment of high blood pressure, but it was later found that they can also help treat symptoms of ADHD.  If your child has ADHD, but also has a tic disorder, an anxiety disorder, a genetic or developmental disorder like Autism Spectrum Disorder, bipolar disorder, or a history of hallucinations, then guanfacine or clonidine can be solid options for treatment and possibly a better choice than stimulant medications—because stimulant medications may worsen symptoms of those disorders.  Both of these medications work in the front part of the brain to increase norepinephrine signaling.  Remember from the previous talks that ADHD seems to result in part from a lack of availability of two important chemical messengers called norepinephrine and dopamine.  We also discussed that ADHD affects the frontal lobes of the brain.  More specifically, ADHD can be attributed to problems in a region of the brain called the prefrontal cortex which is responsible for controlling attention, impulse control, planning, and the ability to remember information while making decisions.  Guanfacine and clonidine work by increasing the availability of norepinephrine in the prefrontal cortex—thus helping treat those core symptoms of ADHD.  These medications are especially helpful for treating hyperactive and impulsive behavior, but guanfacine—more so than clonidine--can help with increasing the ability to pay attention.  Do know that these medications do not at all work as quickly as stimulants—to see clear and sustained efficacy it may take anywhere from a week to a month at the target dose.  Guanfacine and clonidine both come in short-acting formulations taken two to three times daily or long-acting formulations taken once or twice daily.  The extended-release version of guanfacine is called Intuniv, and the extended-release version of clonidine is called Kapvay.  Your provider can help you to determine which of these formulations would be best for your child.  For example, in my experience with patients with mood disorders and ADHD, the shorter-acting or immediate-release version of guanfacine may be preferable for treating ADHD symptoms over the extended-release version. The extended-release version warns about irritability and hallucinations as potential side effects.  Now, the most common side effect that I’ve seen with both of these medications is sleepiness or sedation.  In my experience in using these medications in clinic, the younger the child and the lower the weight of the child, the more likely they are to experience drowsiness and lethargy.  For many kids, this effect wears off in one to two weeks.  However, for some it persists.  In my experience, kids are much more likely to experience drowsiness or sedation with Kapvay or clonidine.  However, oftentimes, this side effect can actually be beneficial.  The medication can be dosed at night to help kids who struggle with sleep, especially if the problems with sleep arise from taking a stimulant medication during the day.  I do want you to be aware that these medications can be prescribed in addition to stimulants because they can really work well together or synergistically to treat ADHD and lower doses of both the stimulant and the nonstimulant can be used when they are combined for treatment. 

Now, to shift gears, third line agents for the treatment of ADHD in children include two different medications.  One is called atomoxetine or Strattera and the other is called viloxazine or Qelbree.  These are considered third-line agents because they have not been found to be as effective as stimulant medications or guanfacine and clonidine.  However, they can still be a solid treatment option for those kids with ADHD who do not tolerate the first or second-line medications.  In my clinical experience, I found atomoxetine or Strattera useful in younger kids with developmental disorders like Autism who also had ADHD but who would more likely be prone to experiencing side effects with first- or second-line agents.  These medications also work to increase the availability of norepinephrine and possibly dopamine in the prefrontal cortex.  Sometimes benefits of these medications can be observed with the first doses, but to see maximum benefit it may take four to six weeks.  The most common side effect I’ve observed is nausea and decreased appetite, but this usually resolves within a week or two, and the nausea can be decreased when the medication is taken with food. 

Alright.  That ends our talk for today.  I hope that this content has been helpful.  Remember to talk to your provider before implementing any suggestions I make in these talks.  This has been Dr. K with Mental Health | Plain Speak.  And remember, “Be kind.  For everyone you meet is fighting a hard battle.”