Sleep and ADHD: Relationships and recommendations

There was a recent post on the CNN health blog written by Dr. Lisa Shives, a sleep expert.  Her post was discussing the association of ADHD and sleep disorders.  In this post, I am adding additional information regarding the connection between ADHD and sleep, including some action steps for parents concerned that their child may have a sleep disorder. Sleep is so vital for children of all ages.  It is a time for the body to rest and grow.  If children have disordered sleep patterns, or become chronically sleep deprived, it is well known that many areas of their life can suffer.  This may include behavior problems during the day, daytime sleepiness, and poor school performance.  Kids can also have physical complaints when sleep is inadequate, including headaches, chronic fatigue, and frequent infections.

Attention deficit/hyperactivity disorder (ADHD) is complex disorder resulting from many associated factors, including personal brain chemistry and genetic tendency.  An imbalance of neurotransmitters, or brain chemicals, changes the behavior and school performance of affected children.  It is estimated that approximately 6% of school-aged children suffer from some level of ADHD. Thankfully, there are many areas of treatment for children suffering from ADHD.  Common treatments include behavior modification techniques,  parent training, classroom adjustments, and medications.

Discussion about sleep is becoming more important when considering the diagnosis and treatment of children with ADHD.  It has been estimated that up to 70% of children with ADHD have disrupted sleep.  Abnormal sleep in these kids can be seen in numerous ways including bedtime resistance, sleep-initiation problems, frequent night-awakenings, and obstructive sleep apnea.  Sleep disorders themselves can effect a child’s quality of life, parental interaction, school performance, and parental mental health.  Research is continuing to examine the specific effects of sleep disorders in children with ADHD.

When discussing sleep problems and ADHD, it often becomes a “chicken or the egg” problem. Is a complication of the altered brain chemistry in children with ADHD leading to poor sleep, or is the chronic poor sleep of these children leading to the symptoms of ADHD?  Plus, a well- known side effect of the stimulant medications used to treat ADHD symptoms is sleep disruption.  Could the treatment be making an associated problem with ADHD kids worse? (Of note here: kids with untreated ADHD also have sleep disruption due to slow sleep-onset (fighting to go to bed/getting to sleep) and have increased restless sleep compared to kids without ADHD.)

Specifically, new information is suggesting that correcting sleep disruption should also be considered as a treatment for ADHD.  There is much focus on the connection between obstructive sleep apnea (OSA) and ADHD.  OSA is the most common pediatric sleep problem, up to 3% of children may have some apnea. This sleep problem is characterized by frequent episodes of abnormal breathing during sleep, often associated with snoring.  OSA may also be discovered by a child’s persisting bedwetting.  Kids with OSA have chronic sleep deprivation leading to symptoms similar to ADHD (poor school performance, behavior problems, poor focus.) Some researchers have suggested the natural conclusion is, therefore, correcting a sleep disorder may eliminate the symptoms of ADHD.

As with most areas of pediatric medicine, the study of sleep and its disorders is an evolving field.  The diagnosis and treatment of sleep disorders is not exact. In order to make the diagnosis of a sleep problem, some physicians require a history of sleep disruption that can be confirmed by a polysomnograph (PSG or “sleep study”.)  But the PSG is not a fool-proof test.  Researchers have suggested that some children with normal sleep studies still may have sleep disorders.  In fact, there have been interesting studies showing that some of the changes in ADHD sleep are not seen on a PSG test. In addition, the “classic” physical exam finding of enlarge tonsils is not always present in children with OSA.  And many of my patients with huge tonsils will deny snoring, restless sleep, or bedwetting.

There are some inconsistencies in the recommended treatments for sleep disorders like OSA. The treatments are varied, and may include removing a child’s tonsils.  Some research, however, does not support the association of tonsillectomy and improved OSA.  In this study of 84 children, for example, the OSA was improved but not eliminated.   OSA is often associated with obesity.  For these patients, weight loss alone can be seen as equally as effective as a tonsillectomy.  And, as with all surgeries, a tonsillectomy with associated anesthesia exposure is not without some risks.  At this time, therefore, there needs to be more definitive studies supporting the therapy before physicians should be routinely recommending surgery.

If your child has ADHD and you think they may have an associated sleeping disorder, here are some action steps:

  • Start a sleep journal for your child. Document the time a child gets into bed, and approximate time he is actually asleep.  Does your child have a cell phone or TV in their room?  Note your child’s ease of waking in the morning and complaints of daytime sleepiness.
  • Does your child snore? If so, video her while she is sleeping (in the non-creepy way.) Any further evaluation by a sleep specialist or an ENT will want to see your child sleeping.
  • Be sure that if your child suffers from allergies or asthma, these conditions are properly controlled.  Better control of these problems may eliminate the sleep disruption.
  • What about other healthy lifestyle issues?  Is your child getting regular exercise, so they are fatigued at the end of the day?  Too much TV or movies before bedtime?  Are they getting adequate nutrition and hydration?
  • Talk with your pediatrician about your concerns. Do all kids with ADHD need a referral to a sleep specialist or ENT?  No. Some healthy sleep habits alone may correct the problem.  If your child is taking medication for ADHD, maybe a change of medication or dosage may be more appropriate.  In addition, a referral to a family counselor to discuss sleep behaviors and possible associated sleep anxieties may be a better use of time.  If it seems that your child’s problem is more related to OSA, your pediatrician may refer you for additional evaluation.
  • Finally, if your child has been diagnosed with ADHD, don’t refrain from treating her appropriately through behavioral modification and/or medication while you considering additional evaluation.  It is always possible to step back on the treatment if another solution is found.  Until then, it is not fair for your child to unnecessarily struggle with her symptoms.

I hope this provides some reassurance and guidance.