ADHD is one of the most commonly diagnosed disorders in pediatrics and adults. It affects around 3% – 5% of youths and 2.9 % of adults worldwide. ADHD, affecting 2-3% of children, is characterized by problems with attention, hyperactivity and impulsivity. Sleep disturbance mainly occurs in approximately around 70% of children diagnosed with ADHD.1 In an individual one suffering through ADHD, sleep disturbances that results in sleep fragmentation or sleep restriction can lead to daytime sleepiness, breathing problems during sleep, interference with mood, attention, physical health and behavior. However, although sleep problems are very common in individuals with ADHD, Co-morbid psychiatric problems are very frequent and are left untreated. In addition children suffering from ADHD are more likely to have increased risk of restless leg syndrome (RLR), obstructive sleep apnea (OSP), and disrupted sleep.3
There may be a number of reasons why children suffering from ADHD have problems with sleep: use of stimulant medications, lack of sleep routine, circadian rhythm disturbance and poor sleeping habits. Often it becomes difficult to resolve the real problem, i.e. the sleep problem exacerbating the ADHD behaviors or the ADHD causing the sleep problem? 4
Therefore, an evaluation of a child suffering from ADHD and sleep disturbance should be assessed when the child goes to bed has difficulty staying asleep, seems restless during sleep, or has increased daytime sleepiness or irritability and whether the child snores. The use of sleep diary, BEARS((B=Bedtime Issues, E=Excessive Daytime Sleepiness, A=Night Awakenings, R=Regularity and Duration of Sleep, S=Snoring) tool or Children Sleep Habits Questionnaire (CSHQ), this may be a useful tool for screening for environmental or behavioral influences as well as primary sleep disorders.2 The caregiver should assess for evaluation for comorbid disorders that might be contributing such as oppositional defiant disorder, substance abuse or depression as these children tend to exacerbate sleep disturbances, appropriate discipline measures used in the home and evaluate the child’s sleep schedule. In the end the physician should also monitor the use of ADHD stimulant medications, the dose and the dosage. Individuals suffering from ADHD should be educated on healthy sleep habits and treat comorbid conditions and routines and behavior with appropriate therapies. Only after these issues are addressed accordingly the medication for ADHD should be adjusted. Additionally for improving routines and sleep habits, for children with circadian rhythm delay or sleep-onset insomnia, melatonin may be added at 3-6 mg around 30 minutes before bedtime and 2-10 mg/day maximum.5
Children suffering from ADHD and sleep disturbances may be benefited from an adjustment in their medication regimens. Each regimen should be adjusted to the timing of administration, individualized, typically, a decrease in the total daily dose of the medication or changes in the formulation may be sufficient to improve sleep, also a non-stimulant medication or shorter-acting stimulants may be an alternative choice to treat ADHD.
References:
- Gruber R. Sleep characteristics of children and adolescents with attention deficit-hyperactivity disorder. Child and Adolescent Psychiatric Clinics. 2009 Oct 1;18(4):863-76.
- Kieling R, Rohde LA. ADHD in children and adults: diagnosis and prognosis. Behavioral neuroscience of attention deficit hyperactivity disorder and its treatment. 2010:1-6.
- Feldman HM, Reiff MI. Attention deficit–hyperactivity disorder in children and adolescents. New England Journal of Medicine. 2014 Feb 27;370(9):838-46.
- Felt BT, Biermann B, Christner JG, Kochhar P, Van Harrison R. Diagnosis and management of ADHD in children. American Family Physician. 2014 Oct 1;90(7):456-64.
- Tsai MH, Hsu JF, Huang YS. Sleep problems in children with attention deficit/hyperactivity disorder: current status of knowledge and appropriate management. Current psychiatry reports. 2016 Aug;18(8):1-9.
