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Hi! David Rosenberg here for the Psychopharmacology Institute. In this CAP—or Child and Adolescent Psychiatry—Smart Take, we will take a very close look at the long-term effects of methylphenidate on sleep in children and adolescents with ADHD. This is crucial because stimulants, such as methylphenidate, are still the most commonly prescribed treatment for ADHD worldwide, and methylphenidate has been widely reported to be associated with sleep problems. However, as we learn more about ADHD, some of our prior misconceptions are being overturned. Namely, sleep patterns in ADHD seem to be disrupted whether or not a person is on medication or psychostimulants. In other words, ADHD itself, with or without medication, is clearly associated with significant and severe sleep disturbances. Therefore, in our clinical program, we always obtain a detailed pretreatment baseline sleep inventory and assessment of all of our patients with ADHD who require treatment before initiating that treatment.
Although this is critical, our experience of receiving numerous referrals and second opinions tells us that this is one of the most often overlooked and missed areas of baseline assessment in many busy primary care and psychiatry practices. This means that sleep assessments are often not done at baseline, which can obviously hinder accurate and precise identification of whether or not the stimulant or methylphenidate is causing sleep disturbances if you do not know the child or adolescent’s baseline sleep functioning.
This has really challenged prior thinking that what we once presumed was a key side effect of methylphenidate. Is it really a side effect? How common is it? Could it be that it rather reflects the illness itself? However, to date, there have been strikingly few studies looking at the long-term impact of methylphenidate and other psychostimulants on sleep disturbances. This article, in particular, is a real advancement because it conducted a 2-year naturalistic, prospective, pharmacovigilance multicenter study of over 100 participants. They included 3 groups:
- Children and adolescents with ADHD who were intending to start methylphenidate
- Children and adolescents with ADHD who were not intending to be treated with methylphenidate
- A non-ADHD control group
So, what did they find? First of all, and perhaps not surprisingly, the only group that showed a significant increase in sleep from baseline was the control group. There were no significant differences in sleep between children and adolescents treated with methylphenidate and children not treated with methylphenidate. The results showed that sleep problems are very common in ADHD. Still, there were no significant negative long-term effects on sleep observed in children treated with methylphenidate compared with children and adolescents with ADHD not treated with methylphenidate.
Interestingly, and in contrast to what we might have expected, there actually appeared to be possible improvement of sleep in children with ADHD treated long-term with methylphenidate. This is significant because it indicates that ADHD can have a severe and substantial negative impact on sleep quality. Contrary to previous beliefs, treating ADHD with medication like methylphenidate may actually help improve the sleep patterns of children and adolescents diagnosed with ADHD. Of course, some children might experience negative long-term sleep impacts from methylphenidate, which might not have been detectable in this group assessment. So, we always need to monitor each child individually and carefully, as no 2 children are the same and different children can experience different effects when treated with the same medication. It is also really important to assess for medication interactions, as many children with ADHD will be treated with more than 1 medication. It is important to take into account comorbidity, as many patients with ADHD have depression and anxiety, both of which can definitely impair sleep.
The bottom line, though, is that this is a highly complex area. What should be reassuring is that long-term use of methylphenidate does not appear to make sleep worse and may actually improve sleep compared with children and adolescents with ADHD not treated with medication. This underscores again how vital it is to conduct pretreatment sleep inventories and assessments before initiating treatment in children and adolescents with ADHD.
Abstract
Methylphenidate and Sleep Difficulties in Children and Adolescents With ADHD: Results From the 2-Year Naturalistic Pharmacovigilance ADDUCE Study
Alexander Häge, Kenneth K C Man, Sarah K Inglis, Jan Buitelaar, Sara Carucci, Marina Danckaerts, Ralf W Dittmann, Bruno Falissard, Peter Garas, Chris Hollis, Kerstin Konrad, Hanna Kovshoff, Elizabeth Liddle, Suzanne McCarthy, Antje Neubert, Peter Nagy, Eric Rosenthal, Edmund J S Sonuga-Barke, Alessandro Zuddas, Ian C K Wong , David Coghill , Tobias Banaschewski
Objective: Short-term RCTs have demonstrated that MPH-treatment significantly reduces ADHD-symptoms, but is also associated with adverse events, including sleep problems. However, data on long-term effects of MPH on sleep remain limited.
Methods: We performed a 2-year naturalistic prospective pharmacovigilance multicentre study. Participants were recruited into three groups: ADHD patients intending to start MPH-treatment (MPH-group), those not intending to use ADHD-medication (no-MPH-group), and a non-ADHD control-group. Sleep problems were assessed with the Children’s-Sleep-Habits-Questionnaire (CSHQ).
Results: 1,410 participants were enrolled. Baseline mean CSHQ-total-sleep-scores could be considered clinically significant for the MPH-group and the no-MPH-group, but not for controls. The only group to show a significant increase in any aspect of sleep from baseline to 24-months was the control-group. Comparing the MPH- to the no-MPH-group no differences in total-sleep-score changes were found.
Conclusion: Our findings support that sleep-problems are common in ADHD, but don’t suggest significant negative long-term effects of MPH on sleep.
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Reference
Häge, A., Man, K. K., Inglis, S. K., Buitelaar, J., Carucci, S., Danckaerts, M., Dittmann, R. W., Falissard, B., Garas, P., Hollis, C., Konrad, K., Kovshoff, H., Liddle, E., McCarthy, S., Neubert, A., Nagy, P., Rosenthal, E., Sonuga-Barke, E. J., Zuddas, A., … Banaschewski, T. (2024). Methylphenidate and sleep difficulties in children and adolescents with ADHD: Results from the 2-Year naturalistic Pharmacovigilance ADDUCE study. Journal of Attention Disorders, 28(5), 699-707.
