Adjusting ADHD Drug Dosing May Improve Children's Sleep

Diana Swift

November 24, 2015

Children and adolescents receiving stimulant medications suffer sleep impairment and should be monitored for sleep issues, and perhaps switched to different dosing schedules, according to a small meta-analysis published online November 23 and in the December issue of Pediatrics.

Objective measurements of sleep in randomized controlled trials published up to March 2015 found that these medications, used in an estimated 7% of US children and youth for attention-deficit hyperactivity disorder (ADHD), resulted in poor sleep patterns. These included longer latency, worse efficiency, and shorter duration, report researchers led by Katherine M. Kidwell, MA, a pediatric psychologist at the University of Nebraska in Lincoln.

The authors recommend that "pediatricians carefully assess for sleep problems in children with ADHD and monitor medication type and dosage schedules to promote optimal sleep and minimize medication-induced sleep impairments."

The nine eligible studies showed a fair degree of interstudy heterogeneity, the authors note. The patients, more than 70% of whom were male, ranged in age from 8.5 to 11.6 years.

In terms of latency, the effect of stimulants was significant: the adjusted effect size (difference between baseline and medicated sleep efficiency) was 0.54 (95% confidence interval [CI], 0.28 - 0.81; P < .001).

Frequency of dose was a key moderator in determining how long it took to fall asleep: For every dose taken each day, the effect increased by 0.42. "Thus, these results suggest that the recommendation of taking a third dose after school to prevent the rebound effect may not be helpful," Kidwell and associates write.

They also note that extended-release formulations, taken once a day and wearing off in 8 to 12 hours, have less effect on sleep latency than immediate-release agents taken two or three times day, including a dose close to bedtime.

Stimulants also had a significant adverse effect on sleep efficiency (adjusted size effect, −0.32; 95% CI, −0.63 to −0.01; P < .001), regardless of the duration of therapy. Gender and duration of treatment both modified effect of treatment on sleep efficiency. Boys had worse sleep efficiency than girls. "However, as youth took stimulants for longer durations, sleep efficiency became 'less bad'; that is, children seemed to adjust to the medication the more days they took stimulants during the study," the researchers write. They note that with each 1-day increase in treatment duration, the effect size became "less negative" by 0.05.

Stimulant ADHD medications were also significantly associated with shorter total sleep time (effect size, −0.59; 95% CI, −0.84 to −0.35; P < .001), although the authors point to the high degree of interstudy heterogeneity, at 82.67%. No significant moderators of sleep time emerged.

"In the meta-analysis, we weren't able to examine the effects of dosage or taking drug holidays on weekends because of the way the individual studies were designed," Kidwell commented to Medscape Medical News. But the study provides information about a potential cost that physicians should consider when prescribing stimulants for children with ADHD. "Physicians could use their clinical judgment to reduce dosage or try other types of stimulant medications until the individual child had the best response and fewest adverse effects," she said.

She added that physicians can encourage parents to help their children sleep better by inculcating good sleep habits and consistent bedtime routines. They can also provide referrals to psychologists or behavioral health specialists.

Acknowledging the small number of studies eligible for this analysis, Kidwell and colleagues stress the importance of new high-quality research. "As the relevant literature grows, additional meta-analyses may be warranted to update the conclusions that can be drawn from the extant literature," they write.

This study received no external funding. The authors have disclosed no relevant financial relationships.

Pediatrics. 2015;136:1144-1153. Abstract

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