QUESTION: I have been treating a 7 year old boy with ADHD using Concerta 54mg and afternoon methylphenidate. He developed trouble sleeping which initially responded to clonidine but that seemed to stop working. I discontinued the methylphenidate in the afternoon, and switched to guanfacine at bedtime but that was of no help. Last week I had him stop everything. His mother reports that he goes to bed at a regular time, but plays in his bedroom until after midnight. During yesterday’s interview, he giggles about this throughout the visit, as though as funny. She also reports that when he is not on stimulant medication he can be violent with himself and his brother. I have a sneaking suspicion that there may be something more going on and would welcome insight here.
ANSWER (Dr Rettew): This question brings up a number of important points to address.
1. Sleep problems are very common in ADHD, and can exacerbate daytime attention problems. Sleep medications such as alpha agents and over the counter remedies like melatonin can be effective but it is important also to consider other interventions such as improving sleep hygeine (such limiting caffeine intake, no TV in the bedroom) and making sure kids get enough physical activity during the day.
2. Stimulants, especially long acting ones, can make sleep problems worse. In some cases, it can be helpful to switch from long acting stimulants to medications with intermediate duration of action of around 8 hours. Nonstimulant preparations such as atomoxetine or the long acting versions of guanfacine and clonidine are less likely to cause sleep problems and have FDA indications in childhood ADHD.
3. The comment about “something more going on” is a good one. Kids can often be silly and often can have trouble sleeping, but violent behaior coupled with extreme silliness and decreased NEED for sleep (once offending medicatins are removed) may indicate something else, such as the manic phase of bipolar disorder. Consultation with a mental health specialist can be very appropriate in these situations.
Disclaimer: The reponses to questions in this section are meant to illustrate general guidelines and not as a substitute for specific treatment recommendations for specific patients. Each family and child is different and these differences can be very important in making clinical decisions on an individual bsais. Certain aspects of questions have been edited to protect patient confidentiality.