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How to Incorporate Non-Stimulants Into ADHD Treatment Plans
When it comes to treating pediatric and adult attention-deficit/hyperactivity disorder (ADHD), many patients and providers automatically think of stimulant treatment options. As Greg Mattingly, MD, founding partner, St Charles Psychiatric Associates, and Elizabeth Judd, NP, MHS, CEO of her private practice, explain though, there are lots of non-stimulant options for pharmacological treatment.
Psych Congress Network sat down with Dr Mattingly and Nurse Judd at the 2023 Psych Congress NP Institute In-Person meeting to discuss key takeaways from their session “Exploring Stimulants and Non-Stimulants in the Treatment of ADHD.”
In this video, Dr Mattingly and Nurse Judd explain how they incorporate non-stimulants into patient treatment plans and offer advice to clinicians seeking to do the same.
For more news and insights on pediatric ADHD, visit our ADHD Resource Center.
Save the date for NP Institute In-Person, March 20-23, 2024 in San Diego, California! For more information, visit the meeting website.
Greg Mattingly, MD: Hello, this is Greg Mattingly. I'm an associate clinical professor at Washington University School of Medicine in St. Louis, Missouri, and the president-elect for the American Professional Society for ADHD and Related Disorders.
Elizabeth Judd, NP, MHS: Hi, I'm Elizabeth Judd, nurse practitioner. I've been an NP for 22 years and I just opened my own private practice last year.
Dr Mattingly: So Elizabeth, a lot of people forget about the non-stimulants. I know today during our talk, we pitched out the audience. What's the longest acting ADHD medicine?
Nurse Judd: Ooh, that was a good one.
Dr Mattingly: People kept listing various stimulants. How many people thought about a non-stimulant?
Nurse Judd: I think maybe one. It was kind of a trick question.
Dr Mattingly: It was a little bit of a trick question, but if you really want full day coverage, you start thinking about non-stimulants. Non-stimulants can be your base of coverage—it may not be your only coverage. So I know you and I talked about, we showed some slides about using a non-stimulant when a stimulant by itself wasn't getting the job done. I'll sometimes use a non-stimulant for 24-hour coverage. I'll sometimes use a non-stimulant to decrease the dose of stimulant, and I'll use them in combination with each other.
Nurse Judd: And we've got four, right?
Dr Mattingly: We've got four. The biggest benefit of a non-stimulant is we don't have to worry about abuse potential. If you've got a college kid who's gotten in trouble, you've got somebody who's had a history of substance abuse, the non-stimulants have very, very limited substance use potential. Beyond that though, where else would you think about using a non-stimulant?
Nurse Judd: So I'll definitely use them in conjunction with, like you just said, if I'm needing longer coverage. But I also use them quite a bit when I have kiddos or even adults who don't tolerate stimulants. Either, they make them too irritable or emotional.
Dr Mattingly: Some of the places I'll think about using non stimulants. As you said, those people that they have anxiety, mood disorders, couldn't tolerate a stimulant. Some of my autism spectrum kids and adults.
Nurse Judd: Yeah, that's right.
Dr Mattingly: A stimulant can make them ticky-twitchy. And I know you and I have both used non-stimulants for those kinds of patients. Some of my patients that have sleep issues, sometimes they use a non-stimulant in the evening, short-acting guanfacine, clonidine to help somebody be able to fall asleep. Maybe atomoxetine or viloxazine in the morning helping to calm anxiety along with ADHD.
Nurse Judd: I'll also use guanfacine or clonidine with somebody who's got some oppositional stuff as well.
Dr Mattingly: Yeah. One of the studies I was a part of looked at layering in a non-stimulant on top of the stimulant, and we focus specifically on improving oppositional behavior: making you a little less impulsive, being able to pause and think about a reaction before you react. Another slide that was popular with our audience, another comment, was thinking about pause before you react. So one of our comments was, thoughts become emotions, become actions. Our kids with ADHD or adults with ADHD, that thought slips right into an emotion, right into an action. I get frustrated, I blow up, I don't mean to, I'm not manic, I'm not depressed—but boom, this frustration pops right out. I say things, I do things I shouldn't. So teaching our patients to pause and hold a thought before it becomes an emotion, before it becomes an action. Thoughts become emotions, become actions.
Nurse Judd: Yeah, that’s great.
Greg Mattingly, MD, is a physician and principal investigator in clinical trials for Midwest Research Group. He is also a founding partner of St. Charles Psychiatric Associates where he treats children, adolescents and adults. He is an Associate Clinical Professor at Washington University where he teaches psychopharmacology courses for the 3rd year medical students. Dr. Mattingly has been a principal investigator in over 200 clinical trials focusing on ADHD, anxiety disorders, major depression, bipolar disorder and schizophrenia. Having served on numerous national and international advisory panels, Dr. Mattingly has received awards and distinctions for clinical leadership and neuroscience research. Dr. Mattingly currently serves as the President Elect for APSARD-The American Professional Society of ADHD and Related Disorders and is a certified evaluator for the NFL regarding ADHD and head concussions.
Elizabeth Judd, NP, MHS, specializes in ADHD, anxiety, depression, mood disorders, and autism spectrum disorders. She received her undergraduate degree from Washington University and her graduate degree from St. Louis University. Elizabeth was awarded a 1 million dollar grant for an innovative Autism Center at The Knights of Columbus Developmental and Behavioral Center at St. Louis University; she co-directed the autism program at Washington University’s Department of Child and Adolescent Psychiatry and directed the psychiatric care for two long-term residential facilities. Elizabeth collaborated in ground-breaking research in Early Detection of Autism Spectrum Disorders and developed a curriculum to teach residents effective listening and communication skills. She is trained in the evidenced-based PEERS social skills intervention for youth and adults with social challenges related to autism, ADHD, and anxiety. Elizabeth serves as an ADHD advisory board member and is very active in the ADHD community. Elizabeth currently has her own private practice in St. Louis.
