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SNRIs for Children’s ADHD: An Alternative to Stimulants

Medically Reviewed by Dan Brennan, MD on May 26, 2022

For children with ADHD (attention deficit hyperactivity disorder), stimulant drugs are usually the medical treatment doctors try first. But they don’t work for everyone, and some parents have serious concerns about using them.

If you’re thinking about nonstimulant options, your doctor might suggest a drug called a serotonin-norepinephrine reuptake inhibitor, or SNRI.

What Are SNRIs?

Serotonin-norepinephrine reuptake inhibitors are a kind of antidepressant. They raise your body’s levels of two brain chemicals called neurotransmitters: serotonin and norepinephrine.

Antidepressants aren’t approved by the FDA to treat ADHD. But doctors can prescribe them as an alternative to stimulants. It’s something a lot of doctors do called “off-label” use.

An older kind of drug called a tricyclic antidepressant (TCA) is one that’s sometimes used when stimulants don’t work or kids can’t take them. SNRIs work on the same neurotransmitters as TCAs. But they’re considered safer and have fewer side effects.

Two SNRIs have been tested for kids who have ADHD:

Duloxetine (Cymbalta). This is approved to treat depression and anxiety in adults. Beyond that, it’s approved for children over age 7 who have anxiety, and for adults and teens who have the pain disorder fibromyalgia and other types of long-term pain.

Venlafaxine (Effexor). It’s approved by the FDA to treat depression and anxiety in adults. It isn’t approved for use in children under 18 or for ADHD. But it’s sometimes prescribed that way, “off-label.”

How Might SNRIs Help With ADHD?

Doctors believe problems with how your body processes the neurotransmitters dopamine and norepinephrine cause ADHD symptoms. Some research has shown serotonin may also be involved.

Stimulants raise the level of dopamine in your brain. Serotonin-norepinephrine reuptake inhibitors raise the levels of serotonin and norepinephrine. Higher amounts of these chemicals help the nerve cells in your brain communicate better.

Better communication can mean better concentration and impulse control and less hyperactivity and aggressiveness. Kids on antidepressants may also be more likely to do what they’re asked and be less disruptive.

What Can We Expect With SNRIs?

If your child’s doctor prescribes an SNRI, they’ll probably start with a low dose and gradually increase it over several weeks. It may take 2-4 weeks for these drugs to take full effect. And it may take some time to find the dose that works best with the fewest side effects.

Venlafaxine comes as a pill or capsule your child may take two or three times a day. Duloxetine is a capsule your child may take once or twice a day. If they can’t swallow a pill, their doctor can give them either of these medicines in a form you can sprinkle into a spoonful of applesauce.

Side effects of SNRIs include:

  • Anxiety
  • Dry mouth
  • Headaches
  • Increase in hyperactivity
  • Insomnia
  • Irritability
  • Nausea
  • Nervousness
  • Reduced appetite
  • Sleepiness

It’s important for your child not to miss a dose of this medicine. If they suddenly stop taking an SNRI, they may have withdrawal symptoms like:

  • Dizziness
  • Headaches
  • Chills
  • Muscle aches
  • Upset stomach
  • Trouble sleeping, including nightmares

How Well Do SNRIs Work for ADHD?

Very little research has been done to show how well SNRIs work for kids with ADHD.

A few studies have tested venlafaxine in children aged 5-17. Between one-third and two-thirds of kids who participated had some improvement of their symptoms. Specifically, they showed less hyperactivity and better impulse control and concentration. But the studies had high dropout rates because of side effects.

One study on duloxetine in kids aged 11-18 showed some improvement in symptoms including not paying attention, hyperactivity, and not following rules.

By comparison, stimulants have been used and studied for decades. They improve symptoms in anywhere from 70%-90% of people who take them.

What Are the Risks of SNRIs?

SNRIs come with a “black box” or “boxed” warning. That is meant to point out serious risks. Like all antidepressants, these drugs may cause children and teenagers to have suicidal thoughts or actions, especially when they first start taking them.

That doesn’t mean your child shouldn’t take the drug. But you do need to be on the lookout for signs of depression or unusual behavior. If your child has suicidal thoughts, contact your doctor or 911 right away.

Show Sources

SOURCES:

Annals of Pharmacotherapy: “The Use of Serotonin Norepinephrine Reuptake Inhibitors in the Treatment of Attention-Deficit Hyperactivity Disorder in Pediatrics.”

Cleveland Clinic: “Attention Deficit Hyperactivity Disorder (ADHD): Nonstimulant Therapy (Strattera) & Other ADHD Drugs,” “What Does it Mean If My Medication Has a ‘Black Box Warning’?”

American Family Physician: “Diagnosis and Management of ADHD in Children.”

Expert Opinion on Emerging Drugs: “Emerging drugs for the treatment of attention-deficit hyperactivity disorder (ADHD).”

StatPearls: “Venlafaxine,” “Duloxetine.”

Mayo Clinic: “Serotonin and norepinephrine reuptake inhibitors (SNRIs),” “Venlafaxine (Oral Route),” “Duloxetine (Oral Route).”

Medline Plus: “Venlafaxine,” “Duloxetine.”

Psychiatry: “Non-Stimulant Treatment for Attention Deficit Hyperactivity Disorder.”

Therapeutic Innovation & Regulatory Science: “Attention-Deficit Hyperactivity Disorder and Pharmacotherapy—Past, Present, and Future: A Review of the Changing Landscape of Drug Therapy.”

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