Insomnia in Children With ADHD

Question

How do I differentiate psychostimulant-related insomnia from ADHD-related insomnia? How can I address this issue in my patients?

Response from Adelaide S. Robb, MD

One of the easiest ways to address this issue is to take a careful history in your patients. For any new patient with ADHD, it is important to ask about bedtime routine and sleep habits. Other important factors to consider include whether the patient shares a room, snores, or has a television, radio, or computer/computer games in the bedroom. For many patients with unmedicated ADHD, sleep issues center around going to bed and the bedtime routine. These children may pop in and out of the bedroom asking for a snack, drink of water, one more hug, etc. Once the child has gone to bed, he/she tends to sleep through the night. For these children, the time between going to the bedroom to sleep and actual onset of sleep time typically is somewhere between 30 and 90 minutes. Another important factor in delay of sleep onset is the consumption of caffeine-containing beverages and the use of other medications that may cause sleep changes, including steroids and other asthma medications as well as selective serotonin reuptake inhibitors.

Patients with sleep disruption related to ADHD medications will complain about a new-onset sleep disruption or change in sleep difficulties. Atomoxetine can be associated with insomnia, but also frequently hypersomnia. Some people, most often adolescents, will complain that they sleep longer and need to nap when switching to atomoxetine from a stimulant. This hypersomnia can be managed with a cross titration from stimulants to atomoxetine rather than just stopping the stimulants and starting atomoxetine. Adolescents can take the majority of their dose in the evening to minimize daytime sedation and titrate the dose more slowly, at 0.5 mg/kg daily for longer than 4 days (as recommended on the package insert).

Patients receiving stimulants may also complain about insomnia and have difficulty falling asleep. This sleep-initiation insomnia should increase with increasing stimulant dosage. Once asleep, children and adolescents with stimulant-related insomnia usually experience a good quality of sleep for the rest of the night. Some patients may have difficulty sleeping if they take an afternoon dose of a short-acting stimulant in addition to a morning dose of a long-acting stimulant.

Several different approaches may be used to treat the insomnia associated with stimulants. For younger children with little or no homework demands, switching from a stimulant with a 12-hour duration of action to one with an 8- to 10-hour duration of action may eliminate the insomnia. For kindergartners, using a short-acting stimulant for the schoolday may also eliminate insomnia. Middle and high school students who need an afternoon dose of a short-acting stimulant and have insomnia may need their dose reduced to the minimum amount possible.

In addition, attention to good sleep hygiene is important, including removing television, computers, and cell phones from the bedroom to eliminate the temptation to watch TV or instant-message with friends. Again, caffeine and other medications may contribute to problems with sleep.

If dose and timing adjustments do not help eliminate the insomnia, several other options exist. Many physicians use a low dose of clonidine for stimulant-associated insomnia. A recent NINDS [National Institute of Neurological Disorders and Stroke] study of ADHD treatment with methylphenidate plus clonidine found that this combination is safe for the treatment of ADHD. Another option is melatonin 5 mg approximately 30-60 minutes before sleep. A good review of ADHD-associated sleep problems can be found in the April 2005 issue of Clinical Pediatrics.^[1]