ADHD and Sleep in Kids: Unraveling the Connections

Whenever I see a patient with snoring and school difficulties, I get excited. Why? Because I know that if I can diagnosis obstructive sleep apnea or another sleep disorder and treat it, I can make that child’s life better by improving their school performance, mood, and energy level. Many of these children have actually been diagnosed with attention deficit hyperactivity disorder (ADHD), or the disorder is suspected. So what are the connections between ADHD and sleep problems? NB: Many of the links below link to specific research which may be too technical so feel free to skip the links.

Sleep Disorders can Mimic Attention Deficit Hyperactivity Disorder

Earlier this week there was a great article on recent research documenting a relationship between obstructive breathing at night and behavioral problems in later childhood. (Thanks to Wendy Sue Swanson, aka Seattle Mama Doc, for bringing it to my attention). The author of the Times article, Kate Murphy,  makes a critical point:

Many children are given a diagnosis of A.D.H.D., researchers say, when in fact they have another problem: a sleep disorder, like sleep apnea. The confusion may account for a significant number of A.D.H.D. cases in children, and the drugs used to treat them may only be exacerbating the problem.

ADHD is characterized by impulsivity, hyperactivity, and inattention. This disorder has

A child not paying attention in class.

A child not paying attention in class. (Photo credit: Wikipedia)

become more and more common in the last ten years, with 9.5% of children having the diagnosis at some point in their childhood. Sleep disorders, such as obstructive sleep apnea, has become more common as children have become more obese. Moreover, snoring and sleep disordered breathing is more common in children with ADHD.

Sleep disorders associated with fragmented sleep or short sleep can mimic ADHD by causing inattention and behavioral difficulties. If children with these symptoms are prescribed stimulant medications such as Adderall or Ritalin, they can develop insomnia which will worsen the problem. Treatment of the underlying sleep disorder may “cure” the ADHD, or make it much easier to manage.

ADHD is Associated With Sleep Abnormalities.

This gets more complicated when you examine the body of research suggesting that children with ADHD have inherent abnormalities in their sleep. Snoring is more common in children with ADHD. They have been shown to be sleepier  compared with children without ADHD. Their sleep architecture is different as well: they have less total sleep, less total rapid eye movement (REM) sleep, and a lower proportion of REM sleep. Problems such as bedwetting are more common. One study showed that children with ADHD were more vulnerable to the effects of inadequate sleep compared with other children, even when sleep was reduced by one hour. Indeed, parts of the brain (the frontal and prefrontal cortext) associated with attention are implicated in both the mechanisms of ADHD and sleep deprivation. Restless leg syndrome (RLS), a disorder characterized by leg discomfort which is worse in the evenings, relieved with motion, and difficulty falling asleep, is significantly more common in children with ADHD, as are rhythmic leg twitches associated with RLS called periodic leg movements of sleep. This hardly seems surprising, considering that fidgeting is a characteristic of ADHD.

So what are you supposed to do?

Obviously, not every child with school difficulties or ADHD requires an overnight sleep test, or evaluation by a sleep medicine specialist.  However, sleep quality and quantity should be discussed with your child’s pediatrician. Here are some recommendations.

All children will benefit from:

  • A cool, dark, quiet sleep room.
  • Avoidance of caffeine in the afternoon or evening.
  • Avoidance of television or computer in the child’s bedroom.
  • Provision of an age appropriate sleep opportunity for children: School age: 10-11 hours of sleep; Teenage years: 8.5-10 hours of sleep

For children presenting with symptoms of inattention, hyperactivity, and/or daytime sleepiness:

  • Snoring, gasping or choking should prompt evaluation by the child’s doctor for obstructive sleep apnea.
  • Difficulty falling asleep or waking up at night may be associated with restless leg syndrome. The child should be asked about leg discomfort at night, frequently described as a “creepy crawly sensation” or feeling like there is “too much energy in my legs.”
  • Ensuring these children get enough sleep is especially important. 
  • Evaluation by a sleep specialist may be helpful

To me, I think that aggressively improving a child’s sleep clearly pays dividends in school performance, behavior, and self esteem. Some children may no longer have ADHD after their sleep disorder is addressed. Other will still have ADHD but will have much less difficult managing their symptoms.

I’m curious to know: do any parents out there have experience with sleep problems in a child with ADHD? Any physicians who have struggled to address these issues in their patients?

Here are some other links:

For MDs and interested parents, there is a good scientific review here.

http://www.webmd.com/add-adhd/guide/adhd-sleep-disorders

http://www.sleepfoundation.org/article/sleep-topics/adhd-and-sleep

http://sleepdisorders.about.com/od/causesofsleepdisorder1/a/ADHD_Sleep.htm

http://psychcentral.com/news/2009/03/02/sleep-problems-linked-to-adhd-in-children/4478.html

10 Comments

  1. Yikes, lost my earlier post!
    As your friend and colleague in I know we’ve discussed this one… I love when a sleep study means not giving a kid meds for ADHD, but in my world that scenario is the exception more than the rule. Maybe that’s because I’m a neurologist (albeit one who really hates meds unless absolutely necessary), and I wouldn’t say it’s not valid to pursue a sleep study– just that, from my vantage point, behavioral treatments really need to be solidly implemented first, when there’s not a structural issue present.

    Reply

    1. Sarah– so great to get your feedback here. Some of this may be a function of our different referral populations. I have definitely seen kids with resolution of their attentional issues– they have had pretty severe sleep disorders. I would say that it is especially important that meticulous attention is paid to sleep quality and quantity for children with any learning or behavioral difficulties, as these children may be more vulnerable to the effects of limited or disrupted sleep. Also, it’s worth looking for problems like RLS.

      Reply

      1. When parents come in with the ‘teacher suggested I have him tested for ADHD’ line, I know we have a lot of ground to cover. We almost always find something significant in terms of stressors in the home environment, daily routine, poor sleep or use of TV and media into the night. I know it’s a wastebasket term but I really think the cause is ‘multifactorial.’
        I think Family Therapy is often important for dealing with issues outside the child’s control.
        I personally think sleep, media overusage, stress, and lack of outdoor play are big contributors. I find it really encouraging to read your article, the comments, and to know that we are trying to explore all the avenues of treatment, not just pharmacotherapy.

      2. Thanks, Matthew. I think that the best issues are the hardest to optimize– getting enough sleep, avoiding excessive screen time, diet and exercise. Many kids will benefit so much from these interventions.

  2. i skimmed through that article last week and found it great to hear a professional’s thoughts on it. i work with a fair number of kiddos with ADHD and a lot of them, upon diagnosis, get prescribed ritalin almost immediately. i was also reminded of this article a few months back “children’s ADD drugs don’t work long term” (http://www.nytimes.com/2012/01/29/opinion/sunday/childrens-add-drugs-dont-work-long-term.html). it’s hopeful to know that *some* kids with ADHD actually have sleep disorders and possibly not ADHD, and therefore respond to sleep training. hopefully in future, more time will be spent correctly diagnosing these kids, resulting in a decrease in using ritalin as the first line of treatment.

    Reply

    1. Thanks. I saw the NYT article as well and thought it was really interesting. In terms of the sleep piece, if you drew a Venn diagram of the kids with sleep disorders, ADHD, there would be a significant amount of overlap. The more I practice clinical medicine, the more I see the importance of diet, exercise, and sleep in treating a whole host of disorders.

      Reply

  3. Thank you for sharing this article. Gotta show this to good friend. Her son has ADHD and is always up at night, well not all the time but most of the time. Even when the bedroom is suitable for sleeping (dark, quiet) the child is still having a hard time sleeping. If everyone else is asleep, he will just talk and talk to himself.

    Reply

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