ADHD By Night: Sleep Problems and ADHD Medications

Abstract

It is now well established that impairments associated with ADHD often extend beyond the school day. As a result, new treatments have been developed to improve attention and reduce overactivity and impulsivity for increasingly longer periods of time. These longer-acting methylphenidate and amphetamine-based stimulants have become the most common ADHD medications. However, in addition to their salutary effects, ADHD medications can lead to less desirable effects in other functional domains, such as sleep. This review will describe the relationship between ADHD, stimulant medication, and sleep while highlighting clinical implications. A wide variety of sleep problems often co-occur with ADHD and often may ante-date treatment. In fact, treatment of some sleep disorders (e.g., Sleep Disordered Breathing Disorder, Delayed Sleep Phase Disorder) may, in and of themselves, lead to improved attention or behavior. As a result, a sleep history and baseline measure of sleep functioning are an essential component of a proper evaluation of individuals presenting with symptoms of ADHD. If a primary sleep disorder is suspected, further sleep evaluation should be conducted by appropriately trained professionals. More commonly, however, sleep problems coexist with ADHD and psychiatric comorbidity, or may result from, or are exacerbated by, stimulant medication. Insomnia and Stimulant Medication The most common sleep problem associated with stimulant medications is initial insomnia. This should be distinguished from bedtime resistance, which is associated with ADHD and frequent comorbid disorders such as Oppositional Defiant Disorder or anxiety and delayed sleep phase syndrome. Initial Insomnia = taking more than 30 minutes to fall asleep. Bedtime Resistance = child does not want to go to sleep or comply with other parental directives. Delayed Sleep Phase Syndrome = child is not tired at bedtime but has difficulty waking in the morning. This delay has been shown by Van der Heijden and colleagues to be correlated with a biological marker in which there is also a 90 minute delay in the onset of dim light melatonin. Subjectively, the child describes "not being able to turn my thoughts off" and may feel considerable frustration by the requirement to go