ADHD AND SLEEP
Attention-Deficit/Hyperactivity Disorder is a neurobiological disorder characterized by developmentally inappropriate problems with sustaining attention to tasks, persistence of effort, vigilance, inhibiting behavior, impulsiveness, poor self-regulation, and increased activity and restlessness. Hyperactivity symptoms have been shown to decline significantly across the elementary school years, while problems with attention tend to remain stable across time. Although excessive activity levels decrease over time, problems with inhibition are typically exhibited in symptoms of poor self-regulation across development. About 70% of males and females that meet criteria for ADHD in childhood continue to experience significant ADHD impairments through adulthood. The prevalence of ADHD in school-age children is 2% - 7%. There are three primary subtypes of ADHD including: predominately inattentive type, predominately hyperactive-impulsive type, and combined type.
Many parents of children and adolescents with ADHD complain of sleep problems including bedtime struggles, delayed sleep onset, increased nightwakings, restless sleep, and shortened sleep duration. The relationship between sleep and ADHD is complicated by the fact that most of the common behavioral symptoms of ADHD can also result from inadequate and disrupted sleep including mood, attention and behavioral symptoms. Research suggests that some children with ADHD are misdiagnosed and actually have a primary sleep disorder including obstructive sleep apnea, restless leg syndrome, and periodic leg movement. In addition, sleep disorders can worsen symptoms of ADHD when they coexist.
Sleep problems in children with ADHD can have multiple causes:
A primary sleep disorder that “mimics” ADHD symptoms. These symptoms may improve or be eliminated with treatment of the sleep disorder.
Inadequate sleep related to the environment or lifestyle factors (e.g., inconsistent schedules, noisy environment etc.).
Coexisting sleep disorder that may make the cognitive, mood, and behavioral disturbances associated with ADHD worse.
Coexisting psychiatric disorders such as oppositional defiant disorder, anxiety and mood disorders, Tourette syndrome, and sensory integration disorder and associated impairments in self-soothing skills may contribute to sleep disturbances.
Pharmacologic agents used to treat ADHD and/or comorbid psychiatric conditions may be associated with sleep onset and maintenance problems and restless sleep. Sleep problems may be a result of dosage or dosing schedule of medication.
Poor Central Nervous System regulation of arousal/activity associated with ADHD may result in sleep disturbances. Parents may report that their child has difficulty “winding down” at bedtime and may be a result of problems with delayed sleep onset.
The accurate identification of children with ADHD requires careful screening followed by a comprehensive evaluation and diagnosis. Screening for sleep disorders should be part of the evaluation for every child with suspected ADHD in order to rule out or appropriately treat a primary sleep disorder prior to the diagnosis of ADHD. In addition, periodic rescreenings for sleep disorders should be a part of the ongoing management of every child with ADHD.
What to expect when you arrive at the sleep clinic
When you arrive for your initial consultation with the sleep team, the team will spend time evaluating your child’s medical history, developmental history, family history (including medical history, psychological history, parenting skills, and limit-setting abilities), and your child’s behavioral history. A detailed history of your child’s sleep behaviors will also be discussed. Your child will have a brief physical examination. If any medical causes are suspected of contributing to your child’s sleep problems (e.g., gastroesophageal reflux, periodic limb movement, restless sleep, sleep apnea etc), further medical evaluation may be recommended including an overnight sleep study. Our sleep psychologist may also request that you and your child’s teachers complete brief questionnaires to better understand what behavioral and neurocognitive symptoms your child is exhibiting in the home and school setting.
If your child has been diagnosed with ADHD, his or her treatment plan likely already includes a behavior management plan, classroom accommodations, individual and family counseling, and medication. Treatment for children who have comorbid ADHD and sleep problems should include the treatment of the primary sleep disorder. Our sleep psychologist will work with your family one-on-one to develop a personally tailored sleep behavior medicine program to fit your family’s needs. Interventions may include the completion of a sleep log to gather further information, extended bedtime routine to help your child learn to decrease his arousal level, the development of good sleep hygiene, a consistent sleep/wake schedule, bedtime fading, and the development of a reward system for appropriate bedtime skills. Our sleep psychologist and medical providers along with your primary care doctor or psychiatrist will review your child’s current medication regimen and consider if any of the sleep symptoms your child is exhibiting are related to ADHD medication effects or rebound effects as the medication is wearing off. Changing the dose, timing, or type of medication can decrease ADHD behaviors and make bedtime easier. On some occasions a child may present with other behavioral and mental health problems that are negatively impacting both daytime and nighttime functioning. When this is the case, it is recommended that your child participate in a comprehensive psychological evaluation to ensure the appropriate identification and treatment of your child. The frequency and duration of follow-up depends on each families needs, but you can expect to return in approximately 2 - 4 weeks following your initial visit.