Sleep Disorders and ADHD-Joseph J. House, Ed.D.

Sleep Disorders and ADHD
CHADD International Conference Chicago 2000
© Joseph J. House, Ed.D. Licensed Psychologist
Minneapolis, Minnesota

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Mike was a 51-year-old man who was seen for a follow up visit after I had assessed him for ADHD a year earlier. He was doing fairly well with his dose of Adderall and an antidepressant. In our conversation he mentioned that his wife was still bothered by his snoring. I had recently attended a sleep disorder workshop and his chance comment caught my attention. A subsequent evaluation at a local sleep disorder clinic revealed that Mike had severe obstructive sleep apnea, and a CPAP machine was prescribed. His sleep doctor told Mike that because of his significant family history of heart disease, he
was at risk for early death, if his sleep disorder had not been treated. This case experience increased my own interest in sleep disorders and made this a routine area of clinical inquiry in all my evaluations of children and adults. Over the past two years, I have made dozens of referrals to sleep disorder specialists who have diagnosed sleep apneas, narcolepsy, and disrupted sleep cycles in patients initially referred for ADHD assessment.


Sleep problems probably occur at some point in each persons lifetime; oftentimes it is a brief episode that does not become a chronic or clinical disorder. However, the National Sleep Foundation (1999) estimates that 30 to 40 million Americans suffer from sleep disorders that effect their health and daily functioning. Sleep problems are common in school-aged children (Aronen, 2000). Significantly higher rates of parental reports of sleep problems are found in children with attentional and learning disorders (Efron, 1997, Gruber, 2000, Marcotte, 1998). Disrupted sleep patterns are commonly found with many
psychiatric disorders and are diagnostic criteria items in many DSM-IV listings (American Psychiatric Association, 1994). Sleep disturbance can be a symptom (e.g. depression), a side effect to medication (e.g. Prednisone), lifestyle induced (e.g. obesity, smoking, caffeine) or a clinical disorder (e.g. obstructive sleep apnea).

Many of the popular behavioral checklists or rating forms used in ADHD assessments inquire into sleep patterns or wakefulness. The Conners Parent Rating Scale - Revised, long version (Multi-Health Systems, 1997) questions if the child seems tired or slowed down all the time. The Child Behavior Checklist (Achenbach, 1991) includes sleeps less than most kids, trouble sleeping, nightmares, overtired, and sleeps more than most kids during the day and/or night. For adults the Attention Deficit Scales for Adults (1996, Bruner/Mazel) includes I have trouble sleeping. The Brown ADD Scales (Psychological Corporation, 1996) inquires if the patient feels sleepy or tired dunng the day, even after a decent sleep the night before, and has a hard time waking up in the morning; finds it difficult to get out of bed and to get going.


Published guidelines for assessment of ADHD encourage a comprehensive evaluation, including questions about sleep. In his book on adult ADHD evaluation, Triolo (1999) recommends questions concerning possible sleep disorders. Barkleys clinical workbook (1990) includes questions about the patients sleep patterns. Because of the high comorbidity of other clinical conditions in ADHD populations (Pliszka, 1999,Biederman, 1995, Barkley, 1999), it is important to do an extensive rule-out and this list needs to include sleep disorders.

TYPES OF SLEEP DISORDERS

In reviewing the sleep disorder literature, it appears that there are a number of slightly different organizational outlines available. The DSM-IV organizes sleep disorders into three categories: Primary Sleep Disorders, Sleep Disorders Related To Another Mental Disorder, and Other Sleep Disorders. The focus of this paper is on Primary Sleep Disorders.

The Primary Sleep Disorders category is comprised of Dyssomnias and Parasomnias. Dyssomnias include primary insomnia, primary hypersomnia, narcolepsy, breathing- related sleep disorder, circadian rhythm sleep disorder, and dyssomnia nos. The Parasomnias include: nightmare disorder, sleep terror disorder, sleepwalking disorder, and parasomnia nos. In the following outline, the types of sleep disorders most commonly encountered will be listed pragmatically with clinical labels. These include insomnia, sleep apnea, periodic limb movements, sleepwalking, narcolepsy, and other sleep-related problems.

Insomnia

The DSM-IV describes primary insomnia as a complaint of difficulty initiating or maintaining sleep or of nonrestorative sleep that lasts for at least 1 month and causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

Difficulty in falling asleep or maintaining sleep can be caused by anxiety, depression, or poor sleep hygiene, and is common in children with ADHD (Corkum, 1999). In my own clinical practice I find that many adults with ADHD have a problem with both sleep onset and sleep arousal in the morning. Chronic insomnia and disrupted sleep can cause inattention and academic problems in school-aged children (Aronen, 2000). In adults disruptive sleep patterns have similar cognitive effects, and can lead to dramatic outcomes, such as serious car accidents (Mayo Health Oasis, 1999).

Sleep Apnea
Snoring can be a symptom of obstructive sleep apnea. During sleep the muscles relax,causing reduced airflow through the throat that produces the distinct snoring sound. In obstructed sleep apnea, there is a cessation of breathing between snoring. The individual experiences sleepiness throughout the day. An obstructed sleep apnea condition is not harmless or simply a problem with snoring. The reduced oxygen intake constantly disrupts sleep cycles and can cause heart problems. A sleep study or polysomnographic recording is conducted in a sleep lab, where the intermittent cessation in breathing can be closely monitored and analyzed, and a definitive diagnosis can be established. In central
sleep apnea, there is also cessation of ventilation during sleep but without airway obstruction. These individuals usually complain of insomnia. This type of sleep apnea is more common in elderly people (American Psychiatric Association, 1994)Periodic Limb Movements

In their article on periodic limb movement disorder in ADHD children, Picchietti, et al.(1998) describe brief, repetitive jerking of the legs or feet that usually occurs in stage one or two of non-rapid eye movement sleep. Restless legs syndrome is an associated condition that occurs while the person is awake. The individual feels unpleasant leg sensations, which usually begin while resting and is relieved by moving the muscles,such as shaking the legs or walking.

Sleepwalking

It is estimated that about 15% of children have at least one episode of sleepwalking. It is rare in adolescence (Anders, 2000) and only about 1% to 5% of children or adults have repeated episodes which could be labeled as a disorder (American Psychiatric Association, 1994).

Narcolepsy

Individuals with this disorder experience repeated, irresistible urges for sleep, which provide a brief period of relief from sleepiness, only to be followed by another sleep attack. For some, emotional arousal can trigger a loss of muscle control (cataplexy) that can last for seconds or several minutes. The sleep attack can cause dangerous outcomes,such as falling asleep while driving. Studies have suggested a genetic cause of narcolepsy (American Psychiatric Association, 1994). The rate of occurrence in adolescents is less than 1% (Anders, 2000) and it is rare in adults.

Other Sleep-Related Problems

Nightmares and intense dreaming are common in children and adults. In sleep terror the child or adult awakens, usually after crying out, and seems to be unable to leave their semiconscious state, making it difficult to comfort them. Problems with bedtime settling can be particularly common in ADHD children (Day, 1998.) In my clinical practice I have seen many adults with ADHD who frequently complain of difficulty with getting to bed. At the other end of the sleep cycle is awakening. It has been common
in my clinical practice to encounter ADHD adolescents and adults for whom this has been a chronic problem. In the case of the adolescent, the morning routine can be most stressful for the parent who is responsible for getting the youngster off to school, while the adult struggles with chronic work tardiness. Additional sleep-related problems include enuresis and bruxism, or teeth grinding. Enuresis is diagnosed after age five, is not due to a medical condition or medication side effect and continues into adulthood in
only 1% of the individuals (American Psychiatric Association, 1994). There is an association of enuresis with sleep apnea in children (Sakai, 2000).

TREATMENTS AND RESOURCES


The various medical procedures used for the treatment of a diagnosed sleep disorder,including medications and surgeries (e.g. obstructive sleep apnea) are outside the scope of this paper. Sleep disorder clinics are available at most regional health centers and can be located through the American Sleep Disorders Association (www.adsa.org) and additional information can be obtained from the National Sleep Foundation (www.sleepfoundation.org). The Mayo Foundation offers a health information website
with helpful information on sleep disorders (www.mayohealth.org).

Information on the effect of medications on childrens sleep, including questions of side-effects, can be found in Straight Talk about Psychiatric Medications for Kids (1999, Guilford Press) by Timothy Wilens. He also discusses medications used to help with sleeping problems.

Most publications emphasize the need for good sleep habits and a healthy lifestyle. Regular exercise, weight control, avoidance of smoking, moderation of alcohol intake, and stress management are all important. Good sleep habits include regular bedtimes, a comfortable sleep environment and limiting sleep to the nighttime. Avoiding caffeine and spicy, hard to digest food late in the evening is also recommended. Children need a consistent bedtime routine or ritual than transitions them from high arousal to low arousal. In my clinical practice the use of a fan or other white noise source in the bedroom can help both children and adults to acquire a drowsy state prior to initiation of sleep. Morning sleep arousal can be helped by a programmed light source that can come on before the auditory alarm (Ingersoll, 1998).

Poor sleep can be quite disruptive for most people if it becomes a chronic pattern and can cause inattention, irritability, and increase stress on the body. For individuals with ADHD, a sleep disorder further compromises their cognitive functioning and needs to be part of all assessment and treatment protocols.



REFERENCES
American Psychiatric Association. (1994). Diagnostic and StatLctical Manual of Mental
Disorders, 4th edition (DSM-IV). Washington, DC: American Psychiatric
Association.
Anders, T.F. & Eiben, L.A. (1997). Pediatric sleep disorders: a review of the past 10
years. Journal of the American Academy of Child and Adolescent Psychiatry,
36(1), 9-20.
Aronen, E.T., Paavonen, E.J., Fjallberg, M., Soininen, M., & Torronen, J.B. (2000).
Sleep and psychiatric symptoms in school-age children. Journal of the American
Academy of Child and Adolescent Psychiatry, 39(4), 502-508.
Barkley, R.A. (1990). Attention Deficit Hyperactivity Disorder: A Handbook for
Diagnosis and Treatment. New York: Guilford Press.


Biederman, J., Newcorn, J. & Sprich, S. (1991). Comorbidity of attention deficit
hyperactivity disorder with conduct, depressive, anxiety, and other disorders.
American Journal of Psychiatry, 148, 564-577.
Chervin, R.D., Dillon, J.E., Bassetti, C., Ganoczy, D.A. and Pituch, K.J. (1997).
Symptoms of sleep disorders, inattention and hyperactivity in children. Sleep,
20(12), 1185-i 192.
Corkum, P., Moldofsky, H., Hogg-Johnson, S., Humphries, T., & Tannock R (1999).
Sleep problems in children with attention-deficitlhyperactivity disorder: impact of
subtype, comorbidity, and stimulant medication. Journal of the American
Academy of Child and Ado/secent Psychiatry, 38(10), 1285-1293.
Corkum,P., Tannock, R., & Moldofsky, H. (1998). Sleep disturbances in children with
attention-deficitlhyperactivity disorder. Journal of the American Academy of
Child and Adolescent Psychiatry, 37(6), 637-646.
Day, H..D., and Abmayr, S.B. (1998). Parent reports of sleep disturbance is stimulant-
medicated children with attention-deficit hyperactivity disorder. Journal of
Clinical Psychology, 54(5), 701-716.
Gruber, R., Sadeh, A.D., & Raviv, A. (2000). Instability of sleep patterns in children
with attention-deficit/hyperactivity disorder. Journal of the American Academy
of Child and Adolescent Psychiatry, 39(4), 495-501.
Ingersoll, B.D. (1998). Daredevils and daydreamers. Main Street Books: New York.

Marcotte, A.C., Thacher, P.V., Butters, M., Bortz, J., Acebo, C. and Carskadon, M.A.
(1998). Parental report of sleep problems in children with attentional and learning
disorders. Journal of Developmental and Behavioral Pediatrics, 19(3), 178-186.
Mayo Health Oasis, (1999), Sleep well, www.mayohealth.org.
National Sleep Foundation, (1999), The nature of sleep, www.sleepfoundation.org.
Picchietti, D.L., England, S.J., Walters, A.S., Willis, K. & Verrico, T. (1998). Periodic
limb movement disorder and restless legs syndrome in children with attention-
deficit hyperactivity disorder. Journal of Child Neurology, 13(12), 588-594.
Pliszka, SR., Carlson, C.L. and Swanson, J.M. (1999). ADHD with Coniorbid
Disorders. Guilford Press: New York.
Sakai, J. and Hebert, F. (2000). Secondary enuresis associated with obstructive sleep
apnea. Journal of the American Academy of C7hilcl and Adolescent Psvchtatiy,
39(2), 140-141.
Triolo, S.J. (1999). Attention deficit hyperactivity disorder in adulthood.
Brunner/Mazel: Philadelphia.




Joseph J. House, Ed.D.
Licensed Psychologist
1405 Lilac Drive Suite 150
Minneapolis, MN 55422
www.housejj @msn.com