Non-Stimulant Medications
Atomoxetine, guanfacine, and clonidine - alternative and additional options for ADHD treatment when stimulants aren't right.
Important to know:
- Non-stimulants are not "worse" than stimulants - they're different tools
- They work better for some individuals than stimulants
- Take longer to show full effect - patience required
- Often used in combination with stimulants
- Have their own side effect profile - different, not necessarily fewer
- Some (guanfacine, clonidine) must be tapered off slowly
When non-stimulants are used
Stimulants tried but not tolerated
Side effects too problematic despite trying different stimulants and doses.
Stimulants ineffective
Adequate trial of stimulants without sufficient improvement.
Co-occurring conditions
Anxiety (atomoxetine may help both), tics (guanfacine/clonidine may be better).
Substance misuse concerns
Non-stimulants have no abuse potential.
Need for 24-hour coverage
Some non-stimulants provide smoother, continuous coverage.
Add-on to stimulants
Guanfacine often added to boost effect or manage specific symptoms.
Non-stimulant medications
How it works:
Helps noradrenaline (a brain chemical for focus and alertness) stay active longer in the brain's planning and control centre.
Onset:
Gradual onset - may take 4-8 weeks to see full effect.
Duration:
24-hour coverage with once or twice daily dosing.
Common uses:
- •When stimulants cause problematic side effects
- •When stimulants are ineffective
- •When substance misuse is a concern
- •Co-occurring anxiety (may help with both)
- •Tic disorders where stimulants worsen tics
Side effects:
Takes longer to work than stimulants but provides continuous coverage. No abuse potential.
Rare risk of mood changes/suicidal ideation - monitor carefully, especially early in treatment.
How it works:
Strengthens the brain's planning centre to improve attention, behaviour, and impulse control.
Onset:
Gradual onset over 2-4 weeks.
Duration:
Extended-release provides 24-hour coverage.
Common uses:
- •When stimulants cause significant side effects
- •Add-on to stimulants for additional benefit
- •Prominent hyperactivity/impulsivity
- •Aggression or difficulty managing emotions
- •Tic disorders
Side effects:
Often used alongside stimulants. Must not be stopped suddenly - needs gradual reduction.
Monitor blood pressure and heart rate. Must taper off slowly.
How it works:
Similar to guanfacine, helps calm the nervous system.
Onset:
Effects may be noticed within days for hyperactivity; full effect over weeks.
Duration:
Shorter-acting than guanfacine.
Common uses:
- •Sleep difficulties in ADHD
- •Tics or Tourette syndrome
- •Aggressive behaviour
- •Sometimes with stimulants
Side effects:
Often used specifically for sleep or tics rather than core ADHD symptoms.
Must not be stopped suddenly. Monitor blood pressure.
Stimulants vs non-stimulants
| Aspect | Stimulants | Non-stimulants |
|---|---|---|
| Onset of action | Rapid - hours to days | Gradual - weeks to months |
| Coverage duration | Depends on formulation (4-14 hours) | 24-hour (atomoxetine, guanfacine XR) |
| Effect size | Generally larger effect on core symptoms | Smaller but significant effect |
| Abuse potential | Low risk but controlled substances | None - not controlled substances |
| Appetite effects | Common appetite suppression | Less appetite suppression (still possible) |
| Sleep effects | May disrupt sleep | Variable - may help sleep (clonidine) |
Non-stimulants are legitimate first-line or second-line options, not just a last resort. For some children, they work better than stimulants or are a better fit for their profile.
The key is finding what works best for your child - this might be a stimulant, a non-stimulant, a combination, or deciding that medication isn't needed at all.