Vinculan fármacos estimulantes para el TDAH con problemas de sueño en niños

Stimulant Medications and Sleep for Youth With ADHD: A Meta-analysis

Abstract

CONTEXT: Mixed findings exist on whether stimulant medications alter youth sleep.

OBJECTIVE: To determine the effect of stimulant medications on sleep.

DATA STUDIES: Studies published through March 2015 were collected via CINAHL, PsycINFO, and PubMed. References of retrieved articles were reviewed.

STUDY SELECTION: Eligibility criteria included studies with children/adolescents who had attention-deficit/hyperactivity disorder (ADHD), random assignment to stimulants, and objective sleep measurement. Studies that did not include information about key variables were excluded.

DATA EXTRACTION: Study-level, child-level, and sleep data were extracted by 2 independent coders. Effect sizes were calculated by using random effects models. Potential moderators were examined by using mixed effect models.

RESULTS: A total of 9 articles (N = 246) were included. For sleep latency, the adjusted effect size (0.54) was significant, indicating that stimulants produce longer sleep latencies. Frequency of dose per day was a significant moderator. For sleep efficiency, the adjusted effect size (−0.32) was significant. Significant moderators included length of time on medication, number of nights of sleep assessed, polysomnography/actigraphy, and gender. Specifically, the effect of medication was less evident when youth were taking medication longer. For total sleep time, the effect size (−0.59) was significant, such that stimulants led to shorter sleep duration.

LIMITATIONS: Limitations include few studies, limited methodologic variability, and lack of unpublished studies.

CONCLUSIONS: Stimulant medication led to longer sleep latency, worse sleep efficiency, and shorter sleep duration. Overall, youth had worse sleep on stimulant medications. It is recommended that pediatricians carefully monitor sleep problems and adjust treatment to promote optimal sleep.

Abbreviations:

ADHD —

attention-deficit/hyperactivity disorder

CI —

confidence interval

PSG —

polysomnography

RCT —

randomized controlled trial

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent neurobehavioral disorder that occurs in ∼7% of children and adolescents.¹ Stimulant medication is the most common treatment of ADHD, with recent estimates indicating that ∼3.5 million children in the United States are prescribed ADHD medications.² Given the high occurrence of stimulant use, it is imperative to carefully examine potential adverse effects, including the influence stimulant medications may have on youth sleep.

Experts disagree about the effects of stimulant medications on the sleep of youth with ADHD. Some researchers have suggested that stimulants impair child sleep, citing evidence of objectively measured deficits in sleep quantity and quality, as well as parent reports of child insomnia, as common adverse effects of stimulant medications.^3,4 Stimulants increase and maintain alertness, which could increase the time it takes to fall asleep (sleep latency) and reduce both total sleep time and sleep efficiency. These sleep-interfering effects may be particularly problematic when doses are taken later in the day (ie, closer to bedtime) or with extended-release versions that may remain active in the child’s body while preparing for bed.³

Conversely, some researchers have argued that stimulants may actually improve a child’s sleep, noting that these medications are generally well tolerated and are effective in reducing the core symptoms of ADHD, and these positive effects may generalize to sleep problems as well.^5,6 Sleep problems are common for youth with ADHD even when they are not taking medications,⁷ and some clinicians claim that children with ADHD sleep better when taking medications.⁸ Stein et al⁹ explained that difficulties falling asleep commonly observed in children with ADHD may be due to a “rebound effect” in which the child experiences withdrawal symptoms as the medication wears off near bedtime, suggesting that there may be benefits to maintaining active stimulants in the child’s body even in the hours approaching bedtime. Furthermore, stimulant medications may positively influence sleep indirectly by improving compliance and reducing bedtime resistance (a common problem for children with ADHD), thereby allowing children to fall asleep faster.⁸

The effects of poor sleep on the emotional, cognitive, and physical functioning of youth are well documented,^10–12 making the issue of how stimulants affect child sleep a critical one. Pediatricians need to know the potential effects of stimulant medications on sleep, either positive or negative. This information can then be considered along with potential effects on core ADHD symptoms to make informed decisions about prescribing these medications to children with ADHD. However, because the results of previous studies have been mixed,^13–16 a simple review of the literature may not be sufficient to yield clear conclusions on this critical issue. This situation is ideal for a meta-analysis, which pools results across studies by using rigorous empirical methods to summarize the findings emerging from the literature. Furthermore, meta-analysis allows for examination of moderators, including methodologic variations that may explain some of the differences in findings across studies.

The purpose of the present study was to conduct a meta-analysis synthesizing the results from randomized controlled trials (RCTs) by using the objective measurement of sleep to determine the effects of stimulant medications on sleep in youth with ADHD. The effect sizes of objectively measured sleep outcomes were estimated, and key study-level, child-level, and procedural moderators were examined.