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
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
Pilcher JJ, Huffcutt AI. Effects of sleep deprivation on performance: a meta-analysis. Sleep.
Sadeh A, Gruber R, Raviv A. Effects of sleep restriction and extension on school-age children: what a difference an hour makes. Child Dev.
Gruber R, Wiebe S, Montecalvo L, et al. Impact of sleep restriction on neurobehavioral functioning of children with attention deficit hyperactivity disorder. Sleep.
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.
Gruber R, Xi T, Frenette S, et al. Sleep disturbances in prepubertal children with attention deficit hyperactivity disorder: a home polysomnography study. Sleep.
Corkum P, Tannock R, Moldofsky H. Sleep disturbances in children with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry.
Spruyt K, Gozal D. Sleep disturbances in children with attention-deficit/hyperactivity disorder. Expert Rev Neurother.
Silvestri R, Gagliano A, Aricò I, et al. Sleep disorders in children with Attention-Deficit/Hyperactivity Disorder (ADHD) recorded overnight by videopolysomnography. Sleep Med.
Sung V, Hiscock H, Sciberras E, Efron D. Sleep problems in children with attention-deficit/hyperactivity disorder: prevalence and the effect on the child and family. Arch Pediatr Adolesc Med.
Cortese S, Faraone SV, Konofal E, Lecendreux M. Sleep in children with attention-deficit/hyperactivity disorder: meta-analysis of subjective and objective studies. J Am Acad Child Adolesc Psychiatry.
Sadeh A, Pergamin L, Bar-Haim Y. Sleep in children with attention-deficit hyperactivity disorder: a meta-analysis of polysomnographic studies. Sleep Med Rev.
Chervin RD, Archbold KH, Dillon JE, et al. Associations between symptoms of inattention, hyperactivity, restless legs, and periodic leg movements. Sleep.
Cortese S, Konofal E, Lecendreux M, et al. Restless legs syndrome and attention-deficit/hyperactivity disorder: a review of the literature. Sleep.
Vendrame M, Zarowski M, Loddenkemper T, et al. Selective serotonin reuptake inhibitors and periodic limb movements of sleep. Pediatr Neurol.
Konofal E, Lecendreux M, Arnulf I, Mouren MC. Iron deficiency in children with attention-deficit/hyperactivity disorder. Arch Pediatr Adolesc Med.
Osler W. The Principles and Practice of Medicine.
Edinburgh: Young J. Pentland; 1892.
Dillon JE, Blunden S, Ruzicka DL, et al. DSM-IV diagnoses and obstructive sleep apnea in children before and 1 year after adenotonsillectomy. J Am Acad Child Adolesc Psychiatry.
Chervin RD, Ruzicka DL, Giordani BJ, et al. Sleep-disordered breathing, behavior, and cognition in children before and after adenotonsillectomy. Pediatrics.
Li HY, Huang YS, Chen NH, et al. Impact of adenotonsillectomy on behavior in children with sleep-disordered breathing. Laryngoscope.
Galland BC, Dawes PJ, Tripp EG, Taylor BJ. Changes in behavior and attentional capacity after adenotonsillectomy. Pediatr Res.
Mitchell RB, Kelly J. Child behavior after adenotonsillectomy for obstructive sleep apnea syndrome. Laryngoscope.
Calhoun SL, Mayes SD, Vgontzas AN, et al. No relationship between neurocognitive functioning and mild sleep disordered breathing in a community sample of children. J Clin Sleep Med.
Bourke RS, Anderson V, Yang JS, et al. Neurobehavioral function is impaired in children with all severities of sleep disordered breathing. Sleep Med.
O’Brien LM, Ivanenko A, Crabtree VM, et al. The effect of stimulants on sleep characteristics in children with attention deficit/hyperactivity disorder. Sleep Med.
Galland BC, Tripp EG, Taylor BJ. The sleep of children with attention deficit hyperactivity disorder on and off methylphenidate: a matched case-control study. J Sleep Res.
Sangal RB, Owens J, Allen AJ, et al. Effects of atomoxetine and methylphenidate on sleep in children with ADHD. Sleep.
Huang YS, Tsai MH, Guilleminault C. Pharmacological treatment of ADHD and the short and long term effects on sleep. Curr Pharm Des.
Prince JB, Wilens TE, Biederman J, et al. Conidine for sleep disturbances associated with attention-deficit hyperactivity disorder: a systematic chart review of 62 cases. J Am Acad Child Adolesc Psychiatry.
Sciberras E, Efron D, Gerner B, et al. Study protocol: the sleeping sound with attention-deficit/hyperactivity disorder project. BMC Pediatr.
Chervin RD, Weatherly RA, Garetz SL, et al. Pediatric sleep questionnaire: prediction of sleep apnea and outcomes. Arch Otolaryngol Head Neck Surg.
Mindell JA, Owens JA. A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems.
Philadelphia: Lippincott Williams & Wilkins; 2003.
Gozal D, Bandla H. Comer Children’s Hospital, University of Chicago. Section of Pediatric Sleep Medicine. http://www.uchicagokidshospital.org/pdf/uch1001270.pdf
. Accessed May 14, 2012.