How do you approach stimulant-related insomnia for pediatric patients who are otherwise good responses to low-dose stimulant treatment for ADHD?

Clonidine 0.1 mg qhs is my first choice if I have to use something. However, first consider decreasing the stimulant dose or changing to a shorter-acting stimulant. Or go with Strattera so you can use a lower dose of stimulant. Or go with guanfacine so you can also use a lower dose of stimulant. Sti...

Ask 3-5 times about electronics in the bedroom and sleep hygiene. I suggest parents look at the free app CBT-i coach. Look at dose reduction and/or timing then melatonin low dose. Or clonidine, mirtazapine, trazodone, etc. (as has been shared). Also, look at changing medication to another stimulant ...

Education and habit forming is the most important thing. ADHD children fight against sleep, as a norm. Take away all stimulation (TV, iPad, cellphone) one hour before sleep time. Make going to bed and rising from bedtimes always the same, school or non-school days, to create a stable habit. Give tim...

Consider guanfacine at bedtime.

In my outpatient clinical population (children, teens, and adults) over the past 35 years or so, the most reliable medication to improve stimulant-induced insomnia is mirtazapine 4.75-7.5 mg at bedtime off-label. The mirtazapine will also increase appetite. The trick with mirtazapine is to use a low...

I use low-dose melatonin 1-3 mg typically. If needed further, then clonidine is likely next.

Sleep hygiene, habits review, and education are needed multiple times in my experience. Included in this will nearly universally be a recommendation and a plan for “all electronics out of the bedtime at some...

I often start with melatonin. Most patients use a dosage that is too high, ranging from 5-15 mg. Going to very low doses is generally better, and my sleep specialist colleagues often have people compound it to 0.25 mg. I usually have patients use sublingual 1.5 mg tablets. These bypass the first-pas...

I like to use melatonin and magnesium glycinate. If those fail, I’ll consider adding on clonidine or guanfacine.

Timing. Administer the last dose of the stimulant 4-6 hours before the patient’s bedtime. It has worked very well with my adult patients.

I usually recommend non-prescription approaches before introducing another prescription medication for my ADHD patients:

1. Warm (not boiled) milk. Does not have to be hot or warm when consumed. Warming hydrolyzes milk protein, which is rich in tryptophan, a precursor to serotonin.
2. Sleepytime EXTRA Te...