A 7-year-old girl with attention-deficit/hyperactivity disorder (ADHD), combined subtype, and oppositional defiant disorder presents with a complaint of marked insomnia. Her parents describe 60 to 90 minutes of nightly initial insomnia that began with the initiation of 36 mg OROS methylphenidate (Concerta) 2 months ago. Behavioral interventions and limiting caffeine intake have been ineffective in addressing the insomnia, but the parents are reluctant to change medications due to the robust response of the ADHD symptoms. A previous trial of 27 mg OROS methylphenidate was ineffective in adequately addressing the target ADHD symptoms, and methylphenidate given twice daily had an inadequate duration of action. When asked how they would pharmacologically address the patient's case in the previous vignette, each of the three practitioners shares their experience, and thought processes, as they examine the symptoms this patient exhibits clinically, explore the pros and cons of each pharmacological alternative, and expand the education of the parents regarding the strengths and weaknesses of stimulant treatment and the inevitable trade-offs that are sometimes required when treating children with ADHD, so that parents can aid and assist the physician in developing and implementing effective medication strategies.