When it comes to addressing Attention Deficit Hyperactivity Disorder (ADHD) in children, the primary course of action often involves the prescription of stimulant medication. This choice is grounded in solid reasoning, as stimulant-based drugs such as Ritalin, Concerta, Adderall, and Vyvanse have been extensively researched for over half a century.
The evidence is compelling, affirming their exceptional effectiveness in aiding children with ADHD in concentrating and managing impulsivity.
However, stimulant drugs aren’t always the best option. A non-stimulant medicine may be prescribed by doctors or requested by parents in place of (or in addition to) more conventional treatments for a variety of conditions.
Here, we examine the definition of nonstimulant drugs, their potential applications, and the advantages and disadvantages of each.
The Nature of Nonstimulant Medications
They are not stimulants, to start. ADHD stimulant drugs operate by improving nerve-to-nerve transmission in the brain. They achieve this by increasing the availability of neurotransmitters, specifically dopamine and norepinephrine.
They activate the prefrontal cortex, which controls thought, conduct, and emotion, and improve the connections between it and other brain regions. This facilitates concentration in kids and lessens impulsivity and hyperactivity.
Either methylphenidate or amphetamine is present in all stimulant medicines. Stimulant drugs are prohibited substances because they have the potential for abuse.
To prevent them from being used as recreational drugs, the USDA closely controls their dose, distribution, and consumption.
Methylphenidate and amphetamine are not included in nonstimulant drugs. Despite not being as effective as stimulants, they employ various active substances that have similar effects on ADHD symptoms. Non-stimulant drugs are not controlled substances because there is no potential for addiction and they cannot be used as a recreational drug.
The Right Time for Nonstimulant Medications in ADHD Treatment
Several scenarios warrant the consideration of nonstimulant medications in the treatment of ADHD.
- Ineffectiveness of Stimulants
Stimulant medications do not offer a universal solution. When given stimulant drugs, some ADHD youngsters don’t experience a decrease in symptoms. 70 percent of children respond to methylphenidate drugs, and that number rises to 85 percent for amphetamine medications, according to Sarper Taskiran, MD, a child and adolescent psychiatrist at the Child Mind Institute.
2. Intolerable Side Effects
By modifying the dose, timing, or formulation of the medication, the negative effects of stimulant medications can often be reduced in children. However, some people experience severe or enduring issues with their eating, sleep, tics, or mood, necessitating the search for other treatments. Dr. Taskiran points out that young adults in particular may experience more severe side effects from stimulants and may be candidates for nonstimulant options.
3. Coexisting Disorders
ADHD frequently coexists with other disorders such as anxiety or Tourette’s syndrome. A nonstimulant medicine may be the best option if stimulant medications have a detrimental impact on those symptoms.
4. Supplementary Treatment
Combining nonstimulant drugs with traditional stimulants may be beneficial for some children. For instance, Dr. Taskiran notes, that a nonstimulant given the night before can help enhance focus and reduce irritation if a child is having problems getting ready for school in the morning before their stimulant medication comes in.
Another option is a lesser dose mixed with a nonstimulant if a youngster can’t endure the side effects of a high enough dose of a stimulant drug to be successful.
5. Substance Use Concerns
Teenagers with a history of substance use or substance use problems may face risks with stimulant medications. Nonstimulant medications, devoid of abuse potential, may be a safer choice in such cases.
Categories of Nonstimulant Medications for ADHD
Based on their effects on the brain, nonstimulant drugs can be divided into two groups: alpha agonists and norepinephrine modulators. Both have received FDA approval for the treatment of ADHD in children.
A new drug named Viloxazine (Qelbree) and Atomoxetine (Strattera), the most widely prescribed nonstimulant drug, are both norepinephrine modulators. The other two often used nonstimulant drugs for ADHD are alpha agonists: clonidine (Catapres, Kapvay) and guanfacine (Tenex, Intuniv).
Dr. Taskiran points out that children using either of these types of medication need to have their blood pressure checked regularly. Blood pressure and heart rate are raised with Viloxazine and Atomoxetine. Guanfacine and clonidine also reduce blood pressure.
The first nonstimulant medicine for children with ADHD to receive FDA approval was atomoxetine (Strattera), which is also the most frequently given. Atomoxetine works by increasing the brain’s supply of the neurotransmitter norepinephrine.
Better signaling between nerves and brain regions is made possible by this. It accomplishes this by impeding a process that eliminates norepinephrine. Selective Norepinephrine Reuptake Inhibitors, or SNRIs, are the name given to medications that function in this manner.
Atomoxetine has been shown in a large number of carefully conducted studies to lessen the symptoms of ADHD in kids who did not respond to stimulant medication or whose side effects were intolerable.
It has been demonstrated to be beneficial in all forms of ADHD. In comparison to the 70–85 percent of children who respond to stimulant medicine, depending on the type, it is thought to be effective in around half of the children who try it.
Atomoxetine takes up to six weeks to achieve its peak effectiveness in contrast to stimulant medications, which take effect right away. Additionally, Atomoxetine operates continuously, in contrast to stimulants, which often only last up to 12 hours per day.
Atomoxetine has been demonstrated to lessen the anxiety or tics in children with ADHD who also have these conditions, in addition to the ADHD symptoms.
The majority of the known short-term side effects of atomoxetine include:
- Appetite control/weight reduction
To prevent initial fatigue, experts advise starting youngsters at a modest dose and gradually increasing their dosage. Reduced nausea and stomach pains can be achieved by taking it with meals.
In rare circumstances, the initial few weeks of treatment with atomoxetine may see a rise in suicidal thoughts, according to the medication’s label. Atomoxetine is regarded as a safe medicine because this adverse effect is so uncommon.
In April 2021, the FDA authorized the new drug viloxazine (Qelbree) for the treatment of ADHD in children aged 6 to 17 years old. It is a norepinephrine reuptake inhibitor, similar to Atomoxetine, which modifies the level of norepinephrine in the brain by preventing its clearance.
It’s too early to compare viloxazine’s efficacy to that of stimulants or atomoxetine because those two drugs haven’t been directly compared, says Dr. Taskiran. According to preliminary evidence, it may start working between two and four weeks sooner than Atomoxetine, which could be beneficial. But more investigation is still needed to determine that as well.
Guanfacine (Tenex, Intuniv) and clonidine (Catapres, Kapvay)
The other two nonstimulant drugs for ADHD that are frequently used are clonidine (Catapres, Kapvay) and guanfacine (Tenex, Intuniv). Their name is “alpha agonists.” These pharmaceuticals, which belong to the hypertensives drug class, were initially created to treat adult patients with excessive blood pressure.
However, because they stimulate particular receptors in the brain to produce the release of the neurotransmitter norepinephrine, they were classed as alpha agonists.
These drugs have been found to lessen impulsivity and hyperactivity while increasing focus. Between 55 and 60 percent of children who try an alpha agonist medicine report benefiting from it, according to estimates. To experience the full benefits of these meds, it takes two to four weeks.
Children with tics, aggressiveness, and sleep issues can also benefit from the usage of clonidine and guanfacine.
Both come in forms that are short-acting and long-acting.
Tenex is the short-acting version of Guanfacine, while Intuniv is the long-acting version.
The immediate-release version of clonidine is Catapres, whereas the extended-release version is Kapvay.
The following are the most typical adverse effects of clonidine and guanfacine:
- Drowsiness, exhaustion, and sedation
- Dry Mouth
- Reduced appetite
- Abdominal pain
The most frequent side effect of these drugs is sleepiness, especially in young patients. Many people find that their fatigue lessens as they go on. Dr. Taskiran points out that clonidine is more sedating than guanfacine, hence it is less well tolerated by kids. Another delivery method for clonidine is a patch.