Reprinted from: Pediatric Development and Behavior Online ...



Reprinted from: Pediatric Development and Behavior Online 2007

The Impact of Sleep Disorders in ADHD

ADHD is a neuro-developmental disorder with a prevalence of 8-10% in the United States. The literature is replete with evidence that 60 to 75% of afflicted patients have other behavioral impairments, such as oppositional defiant disorder, mood disorders, and learning disabilities. However, there is another behavior that commonly plagues this population, which negatively impacts the core ADHD symptoms—abnormal sleep patterns. Sleep deprivation in children can result in inattentiveness, moodiness, and paradoxical hyperactivity. It has been postulated that the pathophysiologic pathway disturb sleep patterns is similar to that of ADHD. The severity can range from mild to debilitating, but one thing is for certain, evidence is building to support that sleep disorders have a major behavioral impact in this group of patients.

In the US, up to 25% of children will have a sleep disorder by 18 years of life.  In the ADHD population, this increases up to 50%. These patients tend to have more movement during sleep and sleep pattern variation from night to night. Children with any sleep disorder are at much higher risk (reports vary from 2 to 9 times) for ADHD like symptoms. Given this, regular screening is warranted for suspected and confirmed ADHD. A simple, structured assessment, such as using the acronym is B.E.A.R.D.S. (Figure 1) can be quickly used in conjunction with all ADHD office visits.

Figure 1 - B.E.A.R.D.S Sleep Assessment

|Bed time resistance / delayed onset |

|Excessive day time sleepiness or difficulty with morning awakening |

|Awakening during the night |

|Regularity, pattern and duration of sleep |

|Drugs – Any stimulant-like medications such as alternative medications, pseudo-ephedrine or caffeine |

|Snoring and other symptoms concerning for sleep disordered breathing |

Pediatric sleep disorders can be placed into 3 categories—dyssomnias, parasomnias, and medical-psychiatric disorders.  In general, pediatric sleep abnormalities are behavioral in nature and usually respond to consistently enforced sleep hygiene measures. However, there are 3 specific sleep disorders that deserve distinct attention because they will not respond to this usual treatment regimen and need to be approached differently.

Sleep Disordered Breathing (SDB) / Obstructive Sleep Apnea / Habitual Snoring

Undoubtedly, obstructive sleep apnea is the most familiar of all sleep disorders, but only accounts for only 2% of all sleep disorders in the general pediatric population. In ADHD, it affects 1-3% with up to 10% being habitual snorers with no airway obstruction. Habitual snoring is 3 times more common in ADHD than any other psychiatric disorders. The parental report of profound snoring and/or breath holding during sleep is the historical clue that can be confirmed by polysomnography. Treatments include tonsillectomy/adenoidectomy and positive airway pressure while sleeping, and both had been proven to be effective.  There have been several small studies that demonstrate patients with SDB who have undergone surgical intervention often have a substantial improvement in core ADHD symptoms.

Restless Leg Syndrome (RLS)

Restless Leg Syndrome is a common sensory motor disorder with a prevalence of 10-15% in the general population.  It is characterized by leg discomfort with a strong urge to move the legs resulting in temporary relief.  It is not uncommon that these movements become repetitive jerks. The diagnosis is made utilizing the International RLS Study Criteria for adults with modifications for children. There is no objective test to make this diagnosis. The pediatric population with RLS often experience inattention, hyperactivity, and mood labiality due to disruptive and inadequate sleep.  In several limited sample size studies, approximately 25% of patients with ADHD met RLS criteria. The postulated relationship between ADHD and RLS may be related to a common dopaminergic pathway. This may have relevant consequences for the treatment for these conditions when they occur simultaneously. Dopaminergic medications, such as Ropinirole (Requip) may be helpful, but the studies need to be completed first to provide supportive evidence based medicine.

Periodic Limb Movement Syndrome (PLMS)

PLMS is characteristic by repetitive flexion of lower extremities (most common) or upper extremities. In youths, this involuntary motion can last 0.5- to 5-seconds in duration and can occur 5-90 seconds apart. It is more prominent in stage 1 and 2 during the sleep cycle. Repetitive jerks are associated with frequent awakenings and daytime somnolence or insomnia. The pediatric population with PLMS often experiences inattention, over-activity, and mood labiality due to associated sleep disruption/fragmentation. PLMS can occur with and without RLS and it is strongly associated with ADHD and restless legs syndrome (RLS) in the pediatric population. The response to dopaminergic agents and the association with ADHD suggest that PLMS also may be a result of dopaminergic dysfunction.

Management

Once a sleep disorder is identified, the key is education to the family. An excellent handout on sleep hygiene can be found at . The parents must understand that consistency in enforcing these guidelines is critical to successfully transition a child into a normal sleep pattern. On rare occasions, medications are recommended to augment sleep management. Common categories include alpha-2 agonists (#1 class of medication prescribed for sleep disorders in the pediatric population), anti-depressants, antihistamines, hypnotics, and alternative medications. Melatonin is attaining increasing popularity in managing sleep disorders for several reasons. It is over-the-counter, comes in tablet and capsule form, relatively inexpensive, and has a rare side effect profile when used alone or in conjunction with other medications. Dosing is usually at 1-3 mg (but can be used up to 12 mg with little difficulty), 30-60 minutes before bedtime.

Conclusion

The area of research is fertile for advancing our understanding of sleep disorders and ADHD behaviors. Adequate sleep has a pivotal role in personal well being. When children are not receiving adequate rest, a multitude of behaviors may arise which can be easily confused with ADHD. Assessing for and maintaining a normal sleep pattern is a critical aspect of diagnosing and managing ADHD patients. When an abnormality is identified, appropriate sleep hygiene is usually effective, but beware of other types of sleep disorders, as identified above, that may require specialized treatment.

Recommended Resources:

1. Allen RP, Picchietti D, Hening WA et al. Restless Leg Syndrome diagnostic criteria, special considerations and epidemiology.  A report from the National Institutes of Health. Sleep Medicine. 2003;4:101-119

2. Chervin RD, Arcbold KH, Dillon JE, et al. Inattention, hyperactivity and symptoms of sleep disordered breathing. Pediatrics. 2002;109:449-456

3. Chervin RD, Dillon JE, Bassett C, et al. Symptoms of sleep disorders, inattention and hyperactivity in children. Sleep. 1997;20:1185-1192

4. Chervin, RD, Rusicka DL, Giordani BJ, et al. Sleep disordered breathing, behavior and cognition in children before and after adenotonsillectomy. Pediatrics. 2006;117:e769-e778

5. Cortese S, Konofal E, Lecendreux M, et al. Restless leg syndrome and attention deficit/hyperactivity disorder: a review of the literature. Sleep. 2005;28:1007-1013

6. Cortese S, Konofal E, Yateman N,et al. Sleep and alertness in children with attention deficit hyperactivity disorder: a systematic review of the literature. Sleep. 2006;29:504-511

7. Harnish MJ, Boyer S, Kukas L, Bowles AM, et al. The relationship between sleep disorders and attention deficit hyperactivity disorder (ADHD): objective findings. Sleep. 2001;24:A14.

8. Owens JA. The ADHD and sleep conundrum: a review. Journal of Developmental and Behavioral Pediatrics. 2005;26:312-322.

9. Picchietti DL, England SJ, Walters AS, et al. Periodic limb movement disorder and restless leg syndrome in children with ADHD. Journal of Child Neurology 1998;13:588-594

Author Bio

† - Dr Stuart graduated with a BS in Human Nutrition from the University of Maine and a MS in Clinical Nutrition from the Tufts University School of Nutrition.  He received his MD from the Tufts University School of Medicine while on a 4-year Navy Health Professions Scholarship.  He completed his residency at the National Capital Consortium (National Naval Medical Center and Walter Reed Army Medical Center).  He is currently a first year Developmental –Behavioral Pediatric fellow at the Medical University of South Carolina, Charleston, SC, completely funded by the US Navy Full Time Out Service Program.

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