Sleep in children and adolescents with attention deficit hyperactivity disorder

INTRODUCTION — Attention deficit hyperactivity disorder (ADHD) is a disorder that manifests in childhood with symptoms of inattention, hyperactivity, and impulsiveness [1,2]. These symptoms can affect cognitive, academic, behavioral, emotional, and social functioning. It is a common disorder, diagnosed in approximately 5 percent of children and adolescents [3]. (See "Attention deficit hyperactivity disorder in children and adolescents: Clinical features and diagnosis", section on 'Diagnostic criteria'.)

Sleep disturbances are common among children with ADHD. The association is complex and most likely bidirectional; ADHD and its treatment appear to promote sleep disturbances, while disrupted or inadequate sleep can contribute to ADHD symptoms. The evaluation and management of children with ADHD and sleep complaints will be discussed in this topic review. Other topic reviews with related material include:

●(See "Behavioral sleep problems in children".)

●(See "Attention deficit hyperactivity disorder in children and adolescents: Clinical features and diagnosis".)

●(See "Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis".)

●(See "Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications".)

SLEEP PROBLEMS IN CHILDREN WITH ADHD

Common sleep complaints — Sleep disturbances have been reported in as many as 70 percent of children with ADHD, although this rate varies widely depending upon the method and definitions used to measure the sleep problems [4-6]. Most studies that document subjective sleep complaints utilize sleep diaries, brief screening questionnaires like the BEARS survey (table 1) [7], or validated survey instruments such as the Children's Sleep Habits Questionnaire (CSHQ) [8], Children's Sleep Behavior Scale (CSBS) [9], or Pediatric Sleep Questionnaire Sleep-Related Breathing Disorders (PSQ-SRBD) Scale [10].

In these studies, common sleep complaints include [11]:

●Bedtime resistance

●Sleep-onset difficulties

●Night awakenings

●Difficulty with morning awakenings

●Sleep-related breathing problems

●Daytime sleepiness

Other sleep problems reportedly associated with ADHD in children and adolescents include difficulties with sleep maintenance, increased nocturnal motor activity, snoring, restless sleep, parasomnias, nightmares, delayed sleep-wake phase, short sleep time, and nocturnal anxiety [12-15]. Home confinement associated with the COVID-19 pandemic has exacerbated many of these complaints [16], and children with evening chronotypes may be particularly vulnerable [17].

Objective sleep measures — Other studies use objective measures to assess physiologic characteristics of sleep in children with ADHD, including polysomnography (PSG), actigraphy, and the multiple sleep latency test (MSLT). Compared with a healthy population, sleep in children and adolescents with ADHD is more likely to have the following abnormalities:

●Limb movements – Increased prevalence of restless legs syndrome (RLS), and the associated phenomenon of periodic limb movements of sleep, sometimes sufficient in the absence of RLS to diagnose periodic limb movement disorder (PLMD) [18-20].

●Obstructive sleep apnea (OSA) – Increased prevalence of sleep-disordered breathing (increased apnea-hypopnea index) [11,19]. One systematic review reported OSA in 20 to 30 percent of children with ADHD, compared with approximately 3 percent in the general population [21].

●Reduced or disrupted sleep time – Increased sleep onset latency, lower total sleep time, lower sleep efficiency, more stage shifts per hour of sleep, and more time in stage N1 (light) sleep [11,22]. These associations are partly but not fully explained by other factors, such as age, sex, comorbidities, and adjustments to conditions in the sleep laboratory (sometimes known as the first-night effect).

Studies of daytime sleepiness (measured by sleep latency on the MSLT) have had mixed results. Two studies reported significantly reduced mean sleep latency compared with controls, indicating increased sleep propensity during the day [19,23]. However, other studies found no significant differences in MSLT measures, with some inter-test variability among children with ADHD [24,25]. These variable results are consistent with the observation that children with ADHD have variable physiologic phenotypes, in that some children tend to have lower levels of alertness compared with children without ADHD, and others do not.

Pathophysiology of associations — The association between ADHD and sleep is complex. In some cases, the sleep problem may be caused or exacerbated by environmental factors (eg, poor sleep habits), stimulant medications used to manage the ADHD, or psychiatric or medical comorbidities. Conversely, disrupted or inadequate sleep may result in tiredness and daytime behavioral difficulties with focused attention, learning, and impulse regulation, which may mimic or exacerbate ADHD symptoms [20,26-30].

In some cases, inadequate sleep may be the primary problem, leading a child to qualify for a diagnosis of ADHD even though the condition may be reversible by proper diagnosis and treatment of the underlying sleep issue. As a result, children undergoing evaluation for ADHD should have a focused clinical assessment for sleep-disordered breathing, as recommended by the American Academy of Pediatrics [31]. (See "Cognitive and behavioral consequences of sleep disorders in children".)

Effects of ADHD medications on sleep — ADHD medications are known to influence sleep characteristics in children and adolescents and may delay sleep onset (sleep-onset insomnia) or disrupt sleep continuity (sleep-maintenance insomnia). Effects of stimulants on sleep vary considerably between individual patients and between different medications, depending on individual vulnerability, pharmacokinetic properties of the drug, and duration of treatment.

●Stimulant medications – Stimulant medications such as methylphenidate tend to delay sleep onset and/or to decrease total sleep time in patients with ADHD [32-34]. However, there is a wide individual variability in the impact of stimulants on sleep characteristics, with sleep quality being either unaffected [33], decreased, or improved [32,35], depending on the dose schedule, type of formulation, and the patient's age. As an example, a meta-analysis of controlled trials concluded that treatment with methylphenidate compared with placebo was associated with longer sleep onset latency, lower total sleep time, and lower sleep efficiency (time spent sleeping/time in bed) [36]. Similar findings are reported for other stimulant medications such as dextroamphetamine and dextroamphetamine-amphetamine [37-39]. In another study, an extended-release formulation of methylphenidate showed a small negative effect on sleep during the initial treatment phase, but this effect gradually resolved during the first two weeks of treatment [40]. This finding suggests that the effects of stimulant medications on sleep may be transient and tend to resolve with longer duration of treatment.

Paradoxically, in some children, sleep-onset insomnia could be related to insufficient stimulant medication effect in the evening, leading to inadequately controlled ADHD symptoms at bedtime. In this case, the sleep problems emerge as the result of rebound effect (ie, waning effect of the afternoon dose of medication) rather than a direct effect of the psychostimulant itself. This mechanism is suggested by case reports in which some children with sleep-onset insomnia improve after adding a low evening dose of stimulant.

●Nonstimulant medications – Atomoxetine is a nonstimulant medication that is used as a first-line treatment for ADHD in selected patients. Atomoxetine in comparison with stimulants generally has fewer adverse effects on sleep. In one study, parental reports indicated better sleep quality in children treated with atomoxetine compared with methylphenidate [34,41]; an increase in somnolence was reported in 9.9 percent of participants [41]. (See "Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications", section on 'Stimulants versus other medications'.)

Extended-release formulations of guanfacine and clonidine are selective alpha-2 adrenergic receptor agonists that are treatment options for ADHD and can be used as an adjunct to stimulant treatment or as monotherapy [42,43]. These drugs have sedating effects and may be helpful for patients with insomnia [44].

Circadian rhythm disorders — ADHD may be associated with disruption of the circadian cycle, manifested as "evening" tendencies, often with sleep-onset insomnia. When persistent and extreme, this is known as delayed sleep-wake phase disorder. In one study, children with ADHD-related insomnia in comparison with controls had delayed dim-light melatonin onset, indicating circadian phase delay [45,46]. Similarly, delayed circadian phase (evening) tendencies were reported among children with ADHD using the morning-evening preference scale, a parent-rated questionnaire [47,48]. Scores on this scale were correlated with both parental and polysomnographic measures of sleep-onset delay.

EVALUATION — Evaluation of a child with ADHD and sleep complaints involves the following steps:

●Characterize the sleep problem(s) and assess for behavioral contributors, circadian phase shift, and potential effects of medications

●Assess for primary sleep disorders, which may contribute to the sleep symptoms or ADHD symptoms

●Assess for comorbid psychiatric disorders, which may contribute to the symptoms and also inform medication management

Referral to the sleep specialist may be indicated when sleep-disordered breathing, sleep-related movement disorders, or abnormal daytime sleepiness are suspected. A full evaluation may require additional instrumental assessment of sleep, including overnight polysomnography (PSG), multiple sleep latency test (MSLT), or actigraphy.

General evaluation — A structured sleep history assesses the sleep-wake schedule, difficulties initiating or maintaining sleep, presence of snoring, abnormal movements or behavior during sleep, and daytime symptoms (eg, sleepiness, inattentiveness, or irritability). This information helps to identify behavioral and environmental contributors to the problem and screens for possible primary sleep disorders. Useful tools include sleep logs, screening instruments like BEARS (table 1), or validated questionnaire instruments such as Children's Sleep Habits Questionnaire (CSHQ). The evaluation is similar to that for children without ADHD; a stepwise approach is outlined in a separate topic review. (See "Assessment of sleep disorders in children".)

In children with ADHD symptoms, particularly important components of the history include:

●Sleep habits – Evaluate for healthy sleep practices, including whether the child gets an age-appropriate amount of sleep (table 2), variability in the sleep schedule, sleeping environment, and bedtime routines (table 3A-B). (See "Assessment of sleep disorders in children", section on 'Insufficient sleep'.)

●Behavioral contributors – Evaluate for environmental and behavioral factors that may contribute to the sleep problem, including problematic sleep-onset associations, inadequate limit-setting by parents/caregivers, or anxiety. Common manifestations of behavioral sleep problems include bedtime resistance, prolonged night awakenings, and delayed sleep onset, although these symptoms also may have other causes. A thorough clinical history and sleep diaries help to define these contributors and design an intervention. (See "Behavioral sleep problems in children", section on 'Evaluation'.)

●Circadian rhythm disturbances – Circadian rhythm disturbances are common among children with ADHD. To assess this factor, determine the child's sleep and wake schedule, whether it is regular, and whether it causes difficulties for the child and family (eg, problems with sleep onset or difficulty waking for school). For children with a significantly delayed sleep onset or inconsistent sleep schedule, a two-week sleep log with or without actigraphy can be helpful in defining circadian rhythm disturbances and designing an intervention. Circadian rhythm disturbances take several forms:

•Sleep and wake times that are consistently later than the desired or required sleep schedule. When severe, this is known as delayed sleep-wake phase disorder. (See "Behavioral sleep problems in children", section on 'Delayed sleep-wake phase disorder'.)

•Irregular sleep and wake times, including very different sleep patterns on weekends compared with weekdays or daytime napping after the age of five years. When severe, this pattern constitutes irregular sleep-wake rhythm disorder, in which the circadian system fails to consolidate periods of wakefulness and periods of sleep. As a result, multiple short sleep episodes are spread across the 24-hour day, interspersed with multiple periods of wakefulness.

These circadian rhythm disturbances may be triggered or exacerbated by behavioral or environmental factors (eg, poor sleep hygiene, use of electronic media at night) or by medications.

●Medications – Assess for medications that may affect sleep, including stimulants used to treat the ADHD and any psychoactive drugs. Careful documentation of each medication, dose, and timing is important to determine potential effects on sleep and inform decisions about medication management. (See 'Adjustment of ADHD medications' below.)

Assess for primary sleep disorders — Screening for primary sleep disorders is recommended for all children undergoing evaluation for ADHD because they are at increased risk for several types, as described above (see 'Objective sleep measures' above). Moreover, identification and treatment for a primary sleep disorder may reduce or even eliminate the ADHD symptoms because sleep disturbances can mimic or exacerbate ADHD symptoms. (See "Cognitive and behavioral consequences of sleep disorders in children".)

●Sleep-disordered breathing – Symptoms suggesting obstructive sleep apnea (OSA) include habitual snoring, often with mouth breathing and sometimes gasping for air during sleep, and witnessed apneas (table 4). Children with these symptoms should be evaluated in the sleep laboratory with overnight PSG. (See "Evaluation of suspected obstructive sleep apnea in children".)

Referral to a specialist (ear, nose, and throat [ENT], sleep medicine, or allergy/immunology) may be indicated for additional evaluation and treatment. In children with OSA, surgical treatment with adenotonsillectomy is associated with improvements in neurobehavioral symptoms and academic performance [21,27,49-53].

●Restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) – RLS may resemble symptoms of hyperactivity in children with ADHD. Useful questions to elicit RLS symptoms include "do your legs bother you at night?" and "do your legs ever hurt?" Children may describe RLS symptoms as a "need to kick," "like bugs crawling," or "weird/funny feelings" [54]. The symptoms begin or worsen during rest or inactivity (eg, lying down or sitting), are relieved by movement, and occur exclusively or predominantly in the evening or night (table 5).

Children with symptoms that suggest RLS should be evaluated for iron deficiency by serum ferritin. Nonpharmacologic interventions for RLS include establishment of healthy sleep habits; regular exercise; and avoidance of caffeine, alcohol, nicotine, and certain medications. Children with serum ferritin <50 ng/mL may benefit from treatment with iron supplements. PLMD is diagnosed in a symptomatic child based on the finding of frequent periodic leg movements during PSG but no RLS or other sleep disorder to explain the symptoms; the disorder can be treated in a manner similar to RLS. (See "Restless legs syndrome and periodic limb movement disorder in children".)

Assess for comorbid psychiatric disorders — Children and adolescents with ADHD exhibit a high rate of coexisting psychiatric disorders, which may manifest as or contribute to sleep problems [13]. Important considerations include (see "Attention deficit hyperactivity disorder in children and adolescents: Clinical features and diagnosis", section on 'Evaluation for coexisting disorders'):

●Oppositional defiant disorder (ODD) – Children with the hyperactive subtype of ADHD are at increased risk for developing ODD, which may manifest with reluctance to follow rules at bedtime. ODD is thought to be a consequence of the child's hyperactivity and impulsive response style, which is perpetuated by responses from adults.

●Anxiety disorders – Separation anxiety may present with bedtime resistance/bed refusal or nocturnal anxiety with fear of being left alone and being attacked or kidnapped during sleep. Children with generalized anxiety disorder are also prone to the psychophysiologic subtype of chronic insomnia (also known as "conditioned" insomnia), which is characterized by anxiety specifically about falling or staying asleep. (See "Behavioral sleep problems in children", section on 'Psychophysiologic (conditioned) insomnia'.)

●Depression – Children with ADHD are at increased risk for depressed mood, characterized by negative ruminating thoughts, which may lead to sleep-onset delay, nocturnal awakenings, and difficulty getting up in the morning. The incidence of depression increases with age and especially adolescence.

●Substance use – Adolescents with newly diagnosed ADHD should be assessed for substance use/abuse [31]. Substance use may complicate the clinical presentation of insomnia. Any substance use disorder can disrupt sleep patterns due to disruption of daily routines. Some substances such as alcohol and stimulants also have direct effects on insomnia.

In addition, bipolar disorder often presents during adolescence, and sometimes in younger children, and may be initially misdiagnosed as ADHD. Symptoms may include an increased level of energy in the evening with reduced need for sleep. A distinguishing feature is that individuals with bipolar disorder are not distressed by their insomnia, whereas this is not the case for children with ADHD. Other features that help to distinguish bipolar disorder from ADHD are summarized in the table (table 6). (See "Pediatric bipolar disorder: Assessment and diagnosis".)

MANAGEMENT OF SLEEP PROBLEMS IN ADHD — Treatment of sleep disturbances associated with ADHD should be individualized, recognizing the child's developmental needs for sleep, behavioral issues, parent/caregiver-child interactions, family culture, and the sleeping environment.

Management typically starts with nonpharmacologic intervention, followed by adjustment of ADHD medications if appropriate, then consideration of specific pharmacotherapy for insomnia in refractory cases.

In addition, any primary sleep problem (eg, obstructive sleep apnea [OSA] or restless legs syndrome [RLS]) should be carefully investigated and treated since these disorders may cause or contribute to ADHD symptoms. Referral to a specialist may be needed for evaluation and management. (See 'Assess for primary sleep disorders' above.)

Similarly, any coexisting psychiatric disorders should be addressed as they may contribute to the sleep or behavioral symptoms and also inform medication management. Coordination of care with a mental health professional is important, particularly for decisions about pharmacotherapy because of complex effects of psychotropic drugs on sleep. (See 'Assess for comorbid psychiatric disorders' above.)

Initial steps

Establish and maintain healthy sleep habits — In children and adolescents with ADHD, an appropriate amount of sleep is critical, within a sleep-wake schedule that remains consistent throughout the week, including weekends (table 3A-B). (See "Behavioral sleep problems in children", section on 'General guidance to parents'.)

Treat behavioral contributors — Behavioral contributors to sleep problems are common among children with ADHD and may include problematic sleep-onset associations, inadequate limit-setting by parents/caregivers, or anxiety. If these contributors are identified, they should be addressed as they would be for typically developing children. Some behavioral adaptations may be required for children with ADHD, such as additional warnings and more structured bedtime routines. (See "Behavioral sleep problems in children".)

Establish healthy circadian patterns — For children with irregular sleep patterns or delayed sleep-wake phase, the first step is to establish a regular sleep schedule. If sleep onset is significantly delayed, make gradual changes toward the desired bedtime (eg, by advancing bedtime by 15 minutes daily).

If the sleep-wake phase remains significantly delayed despite these measures, bright light therapy or melatonin may be useful. These therapies are optimally implemented in consultation with a sleep specialist. Bright light therapy, typically consisting of exposure to 30 minutes of bright light therapy upon awakening, is a recommended treatment for children and adults with delayed sleep-wake phase disorder [55], and there is some evidence that it can be effective in advancing sleep phase in children with ADHD [56]. Although only limited evidence of efficacy exists in this population, bright-light therapy is a low-risk intervention. In our experience, evening administration of melatonin may be helpful for sleep-onset insomnia. The combination of bright light in the morning and melatonin in the late afternoon, a few hours before bedtime, is a common regimen in the treatment of delayed sleep-wake phase disorder. (See 'Pharmacologic treatment of insomnia' below and "Delayed sleep-wake phase disorder".)

Subsequent management

Adjustment of ADHD medications — Once healthy sleep habits have been implemented, consider revision of the psychostimulant regimen, such as a reduction in the total daily dose of stimulant, a new formulation, or use of a different psychostimulant or nonstimulant medication for ADHD. As the effects of these medications on sleep vary considerably between individual patients and between different medications and formulations, an individualized trial approach is warranted. (See 'Effects of ADHD medications on sleep' above.)

Decisions about medication changes depend on the child's regimen, primary sleep problem (ie, sleep-onset insomnia or bedtime resistance, sleep-maintenance insomnia, or daytime sleepiness), as well as efficacy for managing the ADHD. Examples of useful strategies include:

●Adjustment of stimulant medications

•For children with sleep-onset insomnia who are on a long-acting stimulant (eg, Concerta, Daytrana, Mydayis, or other methylphenidate extended-release formulation), change to a stimulant with a shorter half-life (eg, Metadate-ER, Ritalin-SR, or amphetamine sulfate [Evekeo]) (table 7). This will reduce the amount of medication available in the afternoon and should improve sleep onset. For children who are very sensitive to alerting effects of stimulant medication, an immediate-release formulation (eg, methylphenidate, dexmethylphenidate, dextroamphetamine (table 8)) may be a better option as it further decreases the medication effect later in the day.

•Occasionally, sleep-onset insomnia may be due to rebound hyperactivity after the morning dose of stimulant medication wears off. In such cases, addition of immediate-release stimulant in the early- to midafternoon may improve control of ADHD symptoms in the evening and thus improve sleep-onset insomnia. This possibility might be suggested by the history and is established by a treatment trial.

Other considerations about adjusting ADHD stimulants are discussed in detail in a separate topic review. (See "Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications".)

●Use of nonstimulant medications – If careful adjustments of stimulant options fail to resolve insomnia, a switch to a nonstimulant medication should be considered.

•Atomoxetine (Strattera) is moderately effective for ADHD symptoms and is used as a first-line treatment in selected patients, instead of stimulants. Because it does not tend to have adverse effects on sleep, it is a reasonable choice for children with ADHD and insomnia. (See 'Effects of ADHD medications on sleep' above.)

•Alpha-2 adrenergic agonists such as clonidine or guanfacine are moderately effective for ADHD symptoms in children and adolescents and usually have a favorable effect on sleep onset and maintenance, although this is based on anecdotal clinical experience and a few descriptive or retrospective studies [57-59]. These drugs can be used as monotherapy for the ADHD or in combination with stimulants to both optimize control of ADHD symptoms and regulate sleep. Some clinicians use clonidine or guanfacine in the evening after dinner time or closer to bedtime to achieve the most beneficial results for sleep. Adverse effects may include sedation, lethargy, anticholinergic effects, irritability, and dysphoria. (See "Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications", section on 'Treatment failure' and "Pharmacotherapy for insomnia in children and adolescents: A rational approach", section on 'Alpha-adrenergic agonists'.)

Pharmacologic treatment of insomnia — If chronic insomnia persists despite careful implementation of each of the above steps, pharmacologic treatment with an hypnotic agent may be an appropriate consideration [60]. The majority of sleep-promoting medications have not been systematically studied in children and adolescents, and the safety and efficacy of these drugs has not been established. No medications are approved in the United States for treatment of insomnia in pediatric patients. Therefore, pharmacotherapy for chronic, persistent insomnia usually should be managed by a clinician with special expertise in managing sleep disorders in children.

If pharmacologic intervention is planned for chronic insomnia in a child with ADHD, the main considerations are:

●Melatonin – For patients with sleep-onset insomnia or circadian phase delay, melatonin can be used in conjunction with ongoing efforts to optimize sleep habits and treat behavioral contributors. Several small randomized trials and observational studies suggest that melatonin is effective for improving sleep-onset insomnia in children with ADHD, although the quality of the evidence is low [46,59,61,62]. The optimal dose may depend on the type of insomnia:

•For sleep-onset insomnia, typical doses for school-aged children are 3 to 6 mg given 30 minutes before bedtime [46,61,63].

•For circadian phase delay, lower doses (eg, starting at 0.2 to 0.5 mg) can be given three to four hours before bedtime.

•For sleep-maintenance insomnia (night wakings), melatonin is not effective, due to its short half-life. Anecdotal reports describe use of a long-acting formulation of melatonin or administration of another dose of melatonin in the middle of the night upon awakening. However, there is no clinical evidence that this practice increases total sleep time in children with ADHD.

Melatonin is not regulated by the US Food and Drug Administration. Over-the-counter formulations may vary in strength and purity and should be used at a minimally effective dose. (See "Pharmacotherapy for insomnia in children and adolescents: A rational approach", section on 'Melatonin'.)

●Alpha-2 adrenergic agonists – Clonidine or guanfacine are sometimes used as part of a regimen for ADHD, in part because of their beneficial effects on sleep, as discussed above. (See 'Adjustment of ADHD medications' above.)

●Nonbenzodiazepine receptor agonists – Nonbenzodiazepine receptor agonists such as zolpidem and eszopiclone generally improve insomnia in adults. However, two large controlled trials in children with ADHD-related insomnia raise concerns about lack of efficacy and side effects [64,65]. These concerns limit the utility of these drugs in pediatric populations. (See "Pharmacotherapy for insomnia in children and adolescents: A rational approach", section on 'Nonbenzodiazepine receptor agonists'.)

Further details about pharmacotherapy for insomnia in children are provided separately. (See "Pharmacotherapy for insomnia in children and adolescents: A rational approach".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Insomnia in children" and "Society guideline links: Attention deficit hyperactivity disorder".)

SUMMARY AND RECOMMENDATIONS

●Clinical spectrum – Sleep disturbances are common among children with attention deficit hyperactivity disorder (ADHD). Common complaints are bedtime resistance, sleep-onset difficulties, night awakenings, difficulty with morning awakenings, and daytime sleepiness. ADHD is also associated with primary sleep disorders such as obstructive sleep apnea (OSA) and restless legs syndrome (RLS). (See 'Sleep problems in children with ADHD' above.)

●Contributing factors – In some cases, the sleep problem may be caused or exacerbated by environmental factors (eg, poor sleep habits), stimulant medications used to manage the ADHD, or psychiatric or medical comorbidities. (See 'Pathophysiology of associations' above.)

●Evaluation – Evaluation of a child with ADHD and sleep complaints involves:

•Characterization of the sleep problem and assessment for behavioral contributors, circadian phase shift, and potential effects of medications (table 1) (see 'Evaluation' above)

•Assessment for primary sleep disorders (table 4 and table 5), which may contribute to the sleep symptoms or ADHD symptoms (see 'Assess for primary sleep disorders' above)

•Assessment for comorbid psychiatric disorders, which may contribute to the symptoms and also inform medication management (see 'Assess for comorbid psychiatric disorders' above)

●Initial management – Management typically starts with nonpharmacologic intervention, including:

•Establishment and maintenance of healthy sleep habits (table 3A-B) (see 'Establish and maintain healthy sleep habits' above)

•Treatment of behavioral contributors (see 'Treat behavioral contributors' above)

•Establishment of a regular sleep schedule to entrain circadian patterns (see 'Establish healthy circadian patterns' above)

●Next steps – For some children, adjustment of the timing and formulations of ADHD medications may help to manage insomnia, using an individualized trial approach tailored to the patient's type of sleep problem, current regimen, and response.

•ADHD medication adjustments – Options include use of shorter-acting formulations of stimulants or a nonstimulant medication (table 7). Occasionally, sleep-onset insomnia may be due to rebound hyperactivity after the morning dose of stimulant medication wears off. (See 'Adjustment of ADHD medications' above.)

•Pharmacotherapy for insomnia – If chronic insomnia persists despite careful implementation of each of the above steps, specific pharmacotherapy for insomnia may be appropriate. For patients with sleep-onset insomnia or circadian phase delay, a trial of melatonin can be considered, in conjunction with ongoing efforts to optimize sleep habits and treat behavioral contributors. For other medications for insomnia, limited data exist on efficacy and safety in children and adolescents. Pharmacotherapy with these drugs usually should be managed by a sleep medicine specialist. (See 'Pharmacologic treatment of insomnia' above.)