ADHD stimulants and sleep
- Sara L
- Apr 7, 2024
- 5 min read
Updated: May 19, 2024
Children with ADHD are genetically predisposed to sleep problems¹. Because of this they display higher levels of bedtime resistance, difficulty getting to sleep (taking more than 30 minutes), wake up during the night, have difficulty getting out of bed in the morning and have daytime sleepiness more than their neurotypical friends².
Therefore ADHD doesn't just impact children during the day, but at night too. In addition ADHD can give people restless legs, periodic limb movement disorders and excessive daytime sleepiness, further interfering with their sleep–wake cycles².
All in all they're getting lower quality sleep overall which can worsen both their mood and their ADHD symptoms. It is a vicious cycle. If a child has any other mental health conditions such as autism, anxiety or ODD in addition to the ADHD, it can of course make those symptoms worse.
10–20% children with ADHD will have sleep problems at baseline³, even without stimulants.
The worst hit are children with both a diagnosis of ADHD plus anxiety, who have worse sleep disturbance scores compared to those with just ADHD alone². The ADHD subsets (such as inattentive, hyperactive, or combined-type) all differ in terms of how much they impact sleep at baseline. Children with combined type inattentive ADHD sleep worse than children with inattentive ADHD for example².
Adding a stimulant to the situation is a double whammy and can make any pre-existing sleep issues worse. Insomnia is a frequent side effect of all stimulant medications affecting every one in three children taking stimulant medications².
However on the flip side of this, this means that the remaining 2 out of 3 children (the majority) do not experience difficulty sleeping whilst on a stimulant (or at least do not meet full criteria for what would be considered difficulty sleeping). This suggests that for 66% of kids on a stimulant medication, it does not greatly impact sleep, and they sleep ok, or better with the stimulant than without it².
Stimulants can also impact sleep indirectly, through something called "behavioral rebound". When stimulants start to wear off, it causes increased overactivity, impulsivity, inattention and irritability into the later afternoon and evening⁴. This causes difficulty falling asleep. So, for some people, they need a stimulant in their system to counter their ADHD symptoms to get to sleep²,⁴. The stimulant calms down their busy brains and allows them to relax and switch off enough to sleep.
Overall the sleep situation is complex and is specific to each patient. In the situation where behavioral rebound is contributing to the insomnia, children can be given a very low dose of a short acting stimulant in the evening to help them get to sleep (which seems counter intuitive). Another option is switching from a short-acting to a long-acting stimulant to cover the rebound effect⁴.
Therefore stimulants can disrupt sleep in 2 ways: either by directly interfering with sleep by increasing alertness, as they do for 33% of children, or by wearing off too early and causing "behavioral rebound" later in the day, contributing to difficulties in falling asleep.
For those who have issues sleeping while using a stimulant, the good thing to know is that there are options⁴:
Switching the long-acting stimulant for a short-acting stimulant. For children who are taking a long-acting medication, you can ask their healthcare provider about changing it to an intermediate- or shorter-acting version⁴, provided that it still gives enough coverage to help them with their school day and doesn't wear off too quickly.
If your child is already taking a short-acting stimulant, have a conversation with their health care provider regarding reducing the dosing or stopping the medication in the afternoon so that your child’s body has ample time to process and break it down, so that they are able to get to sleep in the evening.
Switching from short- to long-acting stimulant. Wait, why short to long? Because, as we noted above, some kids need a little stimulant in their system to get to sleep by calming their busy brains, and/or to combat the behavioral rebound of the short-acting wearing off. The long acting stimulant will naturally gradual taper down on its own as the day progresses reducing the risk of behavioral rebound (though behavioral rebound may still occur especially if the child is a fast metabolizer). A good way to test this is to see if your child could benefit from the switch to a long-acting from a shorter acting is to see if they can nap during the day whilst on the long acting formulation. If they can nap while on the long-acting stimulant, then getting to sleep at night should not keep them awake⁵.
Adjusting the time that the stimulant is given. For example, talk to your child’s healthcare provider about taking the medication earlier in the day.
Some studies have suggested adding melatonin to help children get to sleep faster and to sleep for longer.
Adding a non-stimulant to the stimulant, or switching to a non-stimulant. Clonidine and guanfacine have been used off label to treat sleep problems in children with ADHD as well as stimulant-induced insomnia in children. Studies have shown that low dose clonidine has a beneficial effect on sleep in children with ADHD who are taking stimulants. These medications can be used either on their own or together with the stimulant medication. They cause sedation and fatigue in between 20 to 40% of children when used on their own, but work less well when a child is on a stimulant causing sedation and sleepiness in only 15 to 20% of children².
A healthy bedtime routine can also help. This can include warm baths, bed time cuddling and reading. These activities should relax your child. It is also a good idea to restrict access to distracting and stimulating electronics as well as limit blue light, as it is suggested that blue light can decrease the amount of melatonin in the brain making it harder for them to get to sleep naturally⁴.
To help keep track of how your child is sleeping, ask their healthcare provider to provide you with a children's sleep habits questionnaire or a sleep log that you can keep to monitor how they are doing with certain medications.
If changes have been made and your child is still not sleeping well consider asking their healthcare provider about a referral to a sleep specialist who can perform a sleep study to give us more information regarding where the sleep issues are coming from.
In conclusion:
ADHD by itself predisposes children to difficulties with sleep.
Stimulant medication can both directly and indirectly worsen sleep.
Stimulants increase alertness by impacting the central nervous system and increasing the level of chemical messages in the brain, which can make people feel more alert and energized.
Indirectly, stimulants can impact sleep when they begin wearing off leading to rebound ADHD symptoms such as hyperactivity, impulsivity and irritability, which can make it difficult to wind down and get to sleep.
Some people actually need a little stimulant in their bodies at bedtime to calm their busy brains, which allows them to sleep.
Depending on what the cause of the difficulty getting to sleep is, children may need to change the formulation of their stimulants (long- to short-acting or short- to long-acting), reduce the dosing of the stimulant, give the stimulant earlier in the day, micro-dose with instant release stimulant just before bed, add melatonin, add a non-stimulant to promote sleepiness, and adopt a healthy bedtime routine.
This site is for general informational purposes only and does not constitute the giving of medical advice. The contents do not constitute the practice of medicine, nursing, or other professional health care services. No provider–patient relationship is formed. Please consult with your child's healthcare provider when considering supplementation for children.
⁴://www.aacap.org/App_Themes/AACAP/Docs/resource_centers/adhd/adhd_parents_medication_guide_201305.pdf)
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