Psychiatric Times.
No. 6
SLEEP DISORDERS: PART 1
ADHD and Sleep Disorders in Children
A Quick Primer for Clinicians
By James E. Dillon, MD and Ronald D. Chervin, MD, MS |
June 13, 2012
Dr Dillon is Director in the Office of Psychiatric/Medical Services, Behavioral Health and Developmental Disabilities Administration, Michigan Department of Community Health, and Adjunct Clinical Assistant Professor in the department of psychiatry, University of Michigan, Ann Arbor. Dr Chervin is Michael S. Aldrich Collegiate Professor of Sleep Medicine, Professor of Neurology, and Director of the Sleep Disorders Center, University of Michigan. Dr Dillon reports no conflicts of interest concerning the subject matter of this article. Dr Chervin reports that he has received grant support from the NIH; the University of Michigan has received support from Philips Respironics and Fisher & Paykel Healthcare; he is a board member of the American Academy of Sleep Medicine; and he is a consultant to Procter & Gamble.
Sangal and colleagues26 obtained mixed results, finding that sleep latency increased by 39 minutes in children who received methylphenidate(Drug information on methylphenidate) 3 times a day, while total sleep interval and the frequency and duration of interruptions decreased.
Longer-acting methylphenidate preparations reportedly have a minimal effect on sleep. Huang and colleagues27 recently reported that “randomized, double-blind, placebocontrolled trials have demonstrated that CNS stimulants do not cause a statistically significant increase in sleep problems, but showed that some beneficial effects were noted on the sleep of both children and adults with ADHD.” This would seem a very optimistic appraisal of the literature, which might be better characterized as showing mixed results: the most well-documented effect of stimulants is initial insomnia, the impact of which may be counterbalanced by fewer interruptions once sleep has been attained.
Atomoxetine, which for many clinicians is the preferred ADHD agent when trials of methylphenidate and amphetamine have failed, commonly produces somnolence, especially when used in higher doses or titrated rapidly. Compared with children who were being treated with methylphenidate, children treated with atomoxetine(Drug information on atomoxetine) fell asleep faster, arose more easily, and slept better.26
Various sedating drugs are popular adjuncts to stimulant treatment. Patients are likely to receive clonidine(Drug information on clonidine) or guanfacine(Drug information on guanfacine), both of which are available in long- or short-acting preparations, for target symptoms of insomnia, hyperactivity/impulsivity, and aggression.28 Clonidine reduces REM sleep and may be effective in treating bruxism, but the drug may be difficult to discontinue. Morning sedation is also a common effect of taking clonidine at bedtime.
Neither clonidine nor guanfacine is approved for sleep or for ADHD, although extended-release formulations of both, which presumably are less soporific than their shorter-life parent drugs, have FDA indications for ADHD. Melatonin(Drug information on melatonin) can be used to promote sleep and may be especially useful with a delayed sleep phase disorder.
Although treatment recommendations always include simple nostrums about sleep hygiene, these amount to mere tautologies absent a focused therapeutic effort to help parents establish a realistic bedtime routine. In adolescents, these disrupted routines may be aggravated by stimulating beverages, urgent social matters, daytime naps, and other lifestyle changes. An Australian project has developed a protocol designed to offer guidance to parents that is based on the nature of sleep problems in children who have ADHD. For example, in sleep-onset association disorder, parents are instructed to gradually fade their presence at bedtime. For limit-setting disorder, children are rewarded for adherence to bedtime routines and are ignored when protesting the bedtime rules. Delayed sleep phase disorder is managed by a combination of fixed morning awakening time, gradually earlier bedtime, and morning phototherapy.29
Practical considerations
There are several parent questionnaires for sleep disorder screening, including the Pediatric Sleep Questionnaire.30 Mindell and Owens31 offer a simple and popular acronym to guide screening: BEARS reminds us to inquire about bedtime problems, excessive daytime sleepiness, awakenings during the night, regular bedtime and awakening time, and snoring or difficulty in breath-ing during sleep. The University of Chicago’s detailed “Pediatric Sleep Medicine Questionnaire,” along with a 2-week pediatric sleep diary, can be downloaded from the University of Chicago, Comer Children’s Hospital.32
Sleep changes associated with psychotropic drugs are common enough to justify routinely obtaining a baseline sleep diary before beginning treatment, even when the initial screening for sleep disorders indicates that no further investigation is needed.
Also In This Special Report
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