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Does Late Afternoon Ritalin Cause Insomnia?
Parents and physicians are often reluctant to have children take a 3rd dose of stimulant medication after school because of concerns about the adverse effect this can have on the child's sleep. In many situations, a 3rd dose may seem necessary to help the child get through homework and to reduce behavioral difficulties as well. Nonetheless, this often not provided because of the concerns noted above. This concern is an important one, particularly because recent studies suggest that children with ADHD may be more prone to sleep difficulties, and, that sleep difficulties may exacerbate the symptoms for many such children (see Volumes 8 and 9 of ADHD RESEARCH UPDATE for reviews of recent studies on this topic.) A study published several years ago in the journal Pediatrics (August, 1995; pages 320-325) suggests that this concern - namely, that methylphenidate (i.e. the generic name for Ritalin) administered in the late afternoon will adversely affect a child's sleep - may be unfounded. In this study, 12 children with ADHD received a 4 PM dose of either 15 mg MPH, 10 mg MPH, or placebo in a randomized order for 12 consecutive days. Children in this study were inpatients at a child psychiatric hospital which allowed the researchers to monitor their sleep very carefully. Ratings of the children's behavior from the 4 PM dose through bedtime were also carefully recorded.
Results indicated that MPH, in either the 10 or 15 mg doses, yielded marked improvements in children's behavior compared to placebo. In regards to the effect on children's sleep, no change in sleep latencies (i.e. how long it took the children to fall asleep) were recorded. On the 10 mg dose of MPH, children were rated as less tired upon awakening compared to either the 15 mg dose or the placebo.
This study's findings show that children with ADHD derive substantial symptom reduction from medication administered in the late afternoon, without there necessarily being an adverse effect on their sleep. Although the sample size is small, and the study should be repeated, there does not seem to be any a priori reason for an afternoon dose to be ruled out because it will ruin a child's sleep.
I have had many parents tell me that their physician was unwilling to prescribe medication for after school hours because of this very concern. This can be unfortunate, because without medication, some children are just very difficult to manage at home and getting homework done in any reasonable way can seem almost impossible.
Please note that what can not be concluded from a study like this is that your child will also tolerate afternoon medication well and that it will not effect his or her sleep. As has been emphasized repeatedly in prior issues of ADHD RESEARCH UPDATE, children's response to medication - including how a late afternoon dose may affect their sleep - is highly individualistic. A study like this one only suggests that it is unlikely that your child would have their sleep disrupted, not that it can not possibly happen.
What guidelines, then, should be used to decide whether a child who is receiving medication should receive a dose in the later afternoon? First, I would want to know whether the problems with behavior and/or getting work done are severe enough to possibly warrant this. If a child is doing reasonably well in the afternoon without medication, then there may certainly be no clear reason to administer it. Second, I would want to know whether appropriate, behavioral strategies to deal with problems caused by a child's symptoms have been implemented without a sufficient level of success. Finally, it would be important to carefully monitor how a late afternoon dose affected this child's sleep - some children may really have their sleep affected in an adverse way even though this may be uncommon among children overall. If these questions are all addressed in a thoughtful and deliberate manner, than the odds that you are making the best choice for your own child will certainly be enhanced.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.