Sleep and ADHD Medication Use: A Clinician’s Guide to Mitigating Side Effects in Children
Stimulant medications sometimes provoke and aggravate sleep problems in children with ADHD, who already struggle at bedtime. Here, learn how clinicians can devise a treatment plan for children that minimizes ADHD symptoms and side effects in lock step.
Sleep problems and ADHD are tightly interwoven. Research confirms the increased prevalence of sleep problems among children with attention deficit hyperactivity disorder (ADHD or ADD). And clinical experience shows us that ADHD symptoms and characteristics – difficulty “shutting down” the mind, for instance – plus comorbid psychiatric disorders like anxiety and oppositional defiant disorder (ODD) can cause or aggravate sleep problems as well.
Sleep problems, such as insomnia, are a common side effect associated with ADHD medications, especially stimulants. In other words, ADHD symptoms and the first-line interventions to treat those symptoms both elevate an individual’s risk for poor sleep.
In their work to achieve ADHD symptom reduction with minimal side effects, clinicians should titrate while evaluating a patient’s environmental and familial conditions, screen for primary sleep disorders, and, throughout treatment initiation and maintenance, encourage good sleep hygiene. Here is how.
ADHD and Sleep Problems: A Review of Medication Research
Individuals with ADHD are at an elevated risk for sleep problems and stimulant medications, no matter the formulation, further increase the risk for problems like difficulty falling and staying asleep, and shorter duration of sleep.1 About 30 percent of children with ADHD who take stimulants of any kind experience nightly insomnia (i.e. taking more than 30 minutes to fall asleep), compared to 10 percent of children with ADHD who do not take medication.2
When comparing patients with ADHD who use stimulants to those who use non-stimulants, it is clear that sleep is impacted in different ways. One study3 that analyzed the effects of methylphenidate (stimulant) and atomoxetine (non-stimulant) on sleep in children with ADHD found that the stimulant increased sleep-onset latency by a staggering 40 minutes. The non-stimulant had a beneficial effect on sleep onset of about 12 minutes.
Still, other non-stimulant formulations may be helpful in addressing sleep problems. Clonidine and guanfacine, alpha 2 agonists, are approved for ADHD treatment alone or in combination with stimulants, were previously used off-label to treat sleep disturbances linked to stimulant use. Indeed, stimulants and non-stimulants in combination can also effectively treat ADHD.
Research also suggests a strong correlation between stimulant medication dosage, ADHD symptom reduction, and the increased frequency of sleep problems. Reports of “severe” sleeping troubles increased as children with ADHD were given higher dosages of long-acting methylphenidate in one study (8.5 percent reported trouble sleeping at 18 mg.; 11 percent at 36 mg.; 25 percent at 54 mg).4 At the same time, clinically significant improvements in ADHD symptoms were also observed at the higher dosages. In all, up to 75 percent of children in the study saw a significant reduction in ADHD symptoms as their dosages increased.
ADHD and Sleep Problems: The Impact of Symptoms
ADHD alone is strongly associated with sleep-related problems like hypersomnia (tiredness during the day), night-time waking, and more that can complicate treatment.
ADHD symptoms during the day, like difficulty with time management and organization, can contribute to stress and restlessness, which may delay readiness to sleep as well. Comorbid psychiatric disorders — conditions like anxiety and mood disorder that co-occur with ADHD 70 percent of the time — also contribute to problems: A child with anxiety may not want to go to sleep, worrying that someone will break into the home. A child with ODD may disobey when a parent signals bed time.
Primary Sleep Disorders
Primary sleep disorders are also prevalent among individuals with ADHD. These disorders can both resemble ADHD symptoms and worsen them. Identifying these disorders as part of the ADHD diagnostic and treatment process is crucial. The most common disorders are:
- Sleep Disordered Breathing is characterized by interrupted breathing at night, causing less oxygen to circulate through the brain and affecting a patient’s overall functioning. The risk for other medical and psychiatric problems is high.
- Restless Leg Syndrome is characterized by unusual, uncomfortable sensations in the limbs that force movement and make sleep frustratingly difficult.
ADHD and Sleep Problems: Clinician Considerations for Stimulant Medications
Clinicians should follow several discrete steps when devising a stimulant medication plan that improves ADHD symptoms and keeps sleep problems at bay:
1. Screen for sleep problems. Prior to initiating any treatment, the clinician should ask the caregiver questions about the child’s sleep habits, including sleep environments, schedules, and any disturbances. The Sleep Habit Questionnaire5 is an effective assessment tool. Clinicians should note, however, that subjective reports on sleep behaviors may not always align with objective findings, as many studies on sleep problems and ADHD have shown. Screening for primary sleep disorders and other comorbidities also happens at this stage (patients should be referred out to sleep disorder specialists if signs are present). Depending on the results, clinicians may consider starting patients who exhibit substantial sleep problems at baseline on non-stimulant medications, or a stimulant/non-stimulant combination.
2. Observe during titration and maintenance. The clinician should monitor each patient on a variety of factors beyond ADHD symptom reduction in the weeks after medication is first administered. Sleep onset, duration, daytime alertness, treatment for other comorbidities, and other parameters measured before treatment should continue to be evaluated at this stage. It is helpful to think of ADHD as a “24-hour disorder,” not just a school disorder, in the process.
- Sleep hygiene: Clinicians should make sure patients are practicing good sleep hygiene, along other positive health behaviors like exercise (not too close to bed time), reduced caffeine intake, and minimized screen time. Clinicians should teach parents that sleep hygiene extends to the whole household.
- Medication adherence: Clinicians should see that patients are as consistent as possible in maintaining their medication schedule. They should also inform and remind parents that any adverse sleep effects from medication may attenuate over time and/or after adjusting dosages.
3. If sleep problems occur:
- If the stimulant is providing benefits, adjust the dose and/or timing as needed for optimal daytime and evening functioning, and evaluate if problems improve. Continue to monitor for proper sleep hygiene and medication adherence.
- Consider adding melatonin, which has been shown to reduce sleep problems. The recommended dose is 3 to 5 mg, taken 30 minutes before bed.
- If adjustments to stimulant dosing and timing worsen sleep problems, reassess the symptoms benefits of the stimulant, and consider switching to or adding a nonstimulant to the treatment plan. Continue to monitor for good sleep hygiene and optimal functioning at all hours.
- Worsening sleep problems, despite ADHD medication changes, proper hygiene, and melatonin, may warrant referral to a sleep specialist for further evaluation.
Sleep and ADHD Medication: Next Steps
- Read: How Parents Can Help Children with ADHD Fall Asleep
- Understand: The ADHD-Insomnia Link in Children
- Research: Melatonin for Kids: Is It Safe? Does It Work?
The content for this webinar was derived from the ADDitude Expert Webinar “Sleep Solutions for the ADHD Brain” by Mark Stein, Ph.D., which was broadcast live on June 2, 2020.
1 Stein, M. A., Weiss, M., & Hlavaty, L. (2012). ADHD treatments, sleep, and sleep problems: complex associations. Neurotherapeutics : the journal of the American Society for Experimental NeuroTherapeutics, 9(3), 509–517. https://doi.org/10.1007/s13311-012-0130-0
2 Stein, M. A. (1999). Unravelling sleep problems in treated and untreated children with ADHD. Journal of Child and Adolescent Psychopharmacology, 9(3), 157–168. https://doi.org/10.1089/cap.1999.9.157
3 Sangal, R. B., Owens, J., Allen, A. J., Sutton, V., Schuh, K., & Kelsey, D. (2006). Effects of atomoxetine and methylphenidate on sleep in children with ADHD. Sleep, 29(12), 1573–1585. https://doi.org/10.1093/sleep/29.12.1573
4 Stein, M. A., Sarampote, C. S., Waldman, I. D., Robb, A. S., Conlon, C., Pearl, P. L., Black, D. O., Seymour, K. E., & Newcorn, J. H. (2003). A dose-response study of OROS methylphenidate in children with attention-deficit/hyperactivity disorder. Pediatrics, 112(5), e404. https://doi.org/10.1542/peds.112.5.e404
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