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
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.