What alternatives can I offer a patient requesting Attention Deficit Hyperactivity Disorder (ADHD) medication if I don't want to prescribe it?

When a Patient Requests ADHD Medication You're Reluctant to Prescribe

If you are hesitant to prescribe ADHD medication, offer evidence-based behavioral therapy as the primary alternative, particularly parent training and behavioral interventions for children or cognitive-behavioral therapy for adults, which have demonstrated efficacy as standalone treatments. 1

Confirm the Diagnosis First

Before declining medication, ensure the patient truly meets diagnostic criteria:

• Verify DSM criteria are met: Symptoms must be present in at least two settings (home, school/work), cause moderate-to-severe impairment, have been present before age 12, and persist for at least 6 months 1, 2
• Obtain collateral information: Gather reports from at least two sources in different settings (parents, teachers, partners, employers) using validated rating scales 1
• Rule out alternative explanations: Ensure symptoms aren't better explained by environmental factors, other psychiatric disorders, or psychosis 2

Critical pitfall: Medication is explicitly not appropriate for patients whose symptoms don't meet full DSM criteria for ADHD, even if they have some attentional difficulties 1

Evidence-Based Non-Pharmacological Alternatives

For Children and Adolescents

Behavioral therapy represents the strongest non-medication option and should be your first recommendation:

• Parent training in behavior management: This teaches parents specific techniques to modify behavior through positive reinforcement, planned ignoring, and appropriate consequences 1
• Classroom behavioral interventions: School-based programs that help teachers implement structured reward systems and environmental modifications 1
• Organizational skills training: Helps children develop systems for managing tasks, time, and materials 1

For preschool-aged children (4-5 years), behavioral therapy is actually the recommended first-line treatment before any medication consideration 1

For Adults

• Cognitive-behavioral therapy (CBT): Specifically adapted for ADHD, focusing on organizational skills, time management, and cognitive restructuring 3, 4
• Psychoeducation: Teaching patients about ADHD, its impact, and compensation strategies 3, 4
• "Third wave" therapies: Including mindfulness-based approaches targeting emotional regulation 3

Important caveat: The evidence for non-pharmacological treatments in adults is more limited than for children, and these interventions are generally less effective than medication for core ADHD symptoms 4

When Behavioral Interventions Are Insufficient

If you've tried behavioral approaches and the patient continues to have moderate-to-severe impairment:

Consider Non-Stimulant Medications First

If your reluctance is specifically about stimulants (due to abuse potential, diversion concerns, or patient substance use history), non-stimulant medications are legitimate alternatives:

• Atomoxetine: Start at 40 mg daily, increase to 80 mg after 3 days, with maximum of 100 mg daily; has no abuse potential and may be particularly appropriate for patients with comorbid anxiety 5, 2
• Extended-release guanfacine or clonidine: Alpha-2 agonists with no abuse potential, though less effective than stimulants 1

These medications are explicitly recommended for adolescents at high risk for diversion or those with substance use concerns 1

Address Specific Concerns About Stimulants

If your hesitation involves specific safety concerns:

• Cardiovascular screening is mandatory: Check blood pressure, pulse, and screen for symptomatic cardiovascular disease before any stimulant; stimulants are contraindicated in symptomatic heart disease 1, 6
• Substance abuse assessment: Screen thoroughly for current or past substance use; active substance use disorder is a relative contraindication requiring subspecialist consultation 1, 6
• Diversion risk in adolescents/young adults: Consider formulations with lower abuse potential like lisdexamfetamine, dermal methylphenidate, or OROS methylphenidate if stimulants are eventually needed 1

Referral Options

If you remain uncomfortable prescribing after appropriate evaluation:

• Refer to psychiatry or developmental-behavioral pediatrics: Specialists with expertise in ADHD can provide comprehensive assessment and management 1
• Refer to psychology for behavioral interventions: Licensed psychologists can deliver evidence-based behavioral therapies while you continue medical management 1

What NOT to Do

• Don't dismiss the patient without offering alternatives: Simply refusing medication without providing evidence-based behavioral options or appropriate referral is inadequate care 1
• Don't prescribe medication for subthreshold symptoms: Medication is explicitly not indicated for patients who don't meet full diagnostic criteria, even if they request it 1, 2
• Don't use "drug holidays" as a compromise: Abruptly discontinuing effective stimulants during important events causes rapid symptom return and is not recommended 6

Documentation Strategy

When declining to prescribe, document:

• The specific diagnostic criteria that were or weren't met 1
• The behavioral interventions recommended and why they should be tried first 1
• Any contraindications identified (cardiovascular concerns, active substance use, lack of moderate-to-severe impairment) 1
• Referrals offered for subspecialty evaluation or behavioral therapy 1

This protects both you and the patient by demonstrating thoughtful clinical reasoning rather than arbitrary refusal.