ADHD & Sleep Disorders in Children
The Relationship Between Sleep & ADHD
More is becoming known regarding the relationship between sleep and behavior in children, especially over the last two decades; however, some of the most interesting information uncovered has concerned the role sleep plays in children with ADHD. Director of the Office of Psychiatric/Medical Services at the Behavioral Health and Developmental Disabilities Administration in Michigan, James Dillon, M.D. and Adjunct Clinical Assistant Professor in the Department of Psychiatry at the University of Michigan, Ronald Chervin discuss the relationship in their article “ADHD and Sleep Disorders in Children.”1
Sleep problems can occur when there is either too much or too little sleep.1 Sadeh and colleagues report that even minor changes in sleep can significantly affect the neurobehavioral function of children. He and his colleagues monitored 77 fourth and sixth grade students for five nights. For the first two nights, all of the children were able to sleep as they normally would; however, for the last three nights, some were asked to restrict their sleep by one hour and others were asked to extend their sleep by one hour.2 Results of a performance test revealed that the performance of the restricted group deteriorated while that of the extended group improved.2 Therefore, it is important to understand that a child’s sleep may be effected by busy family schedules, sleep-related breathing disorders (SRBD), behavioral insomnia, restless leg syndrome, and periodic leg movements. Many of these experiences interfere with REM sleep, leaving the child tired and groggy the next day. Sleep problems also lead to inattention, hyperactivity, neuropsychological deficits, and behavior disorders.1 However, overall, the magnitude of the relationship between ADHD and sleep remains a mystery.1
Sleep Disorders that Occur Often in Children with ADHD
Dillon and Chervin focus on restless leg syndrome, periodic limb movements, sleep-related breathing disorders (SRBD), and the effects of medicines in their article regarding ADHD and sleep problems.1 They state that Sadeh and colleagues found that the comorbidity of restless leg syndrome symptoms in children with ADHD is approximately 24 percent and the frequency of periodic limb movements was significantly heightened in children with ADHD. Sadeh and colleagues believe these to be functional dopamine deficits, successfully treated with dopamine agonists. In fact, most patients who have restless leg syndrome also have periodic limb movements, and while restless leg syndrome is characterized by voluntary movements, periodic limb movements are involuntary and last from 0.5 to 5 seconds, recurring in cycles of 5 to 90 seconds during non-REM sleep.1 Both restless leg syndrome and periodic limb movements reduce the amount of sleep obtained, as well as the quality.1 Restless leg syndrome can prevent children from falling to sleep or returning to sleep once awakened, and periodic limb movements cause children to awaken from sleep often.1
Regarding sleep-related breathing disorders (SRBD), obstructive sleep apnea is the most common disorder occurring in children.1 While most psychiatrists are familiar with obstructive sleep apnea in adults, the disorder differs amongst children and so does the treatment.1 Oftentimes, children with obstructive sleep apnea suffer from enlarged adenoids and palatine tonsils.1 Children who have obstructive sleep apnea may snore, be sleepy during the daytime, have difficulty getting up in the morning, have unsatisfying sleep, have a nasal speech, breathe through their mouths, and drool while sleeping.1 The treatment for the disorder is adenotonsillectomy. While numerous studies have examined the impact of the disorder on children with ADHD, findings have remained quite inconsistent.1 Some studies state that postsurgical improvements were not significant, while others state that it is; however, it is reasonable to believe that there is an association between SRBD and neurobehavioral problems.1
For Sleep & ADHD: Medicines & Their Side Effects
Side-effects of medicines are also attributed to sleep problems, and insomnia is a common adverse effect of ADHD stimulant medicines.1 As most children take two or three doses of short-acting medicines each day, they can return to experiencing ADHD symptoms at the day’s end—which unfortunately usually coincides with bedtime.1 Galland and colleagues conducted a study of children taking methylphenidate and found that those taking the drug had an increased sleep latency period of 29 minutes and reduced sleep by 1.2 hours, while the results of children with ADHD who did not receive the medicine were identical to controls (children without ADHD). Therefore, when trials of methylphenidate and amphetamine fail to control ADHD symptoms or interrupt sleep, atomoxetine is used, which produces somnolence and allows children to fall asleep faster, sleep better, and rise easier. Also, various sedating drugs are used in conjunction with stimulant treatment for sleep problems. Clonidine or guanfacine are usually prescribed, targeting insomnia, hyperactivity, and aggression; however, neither drug is FDA-approved for sleep or ADHD.1 Melatonin can be used to promote sleep, as well.1
While researchers are uncovering more information regarding the relationship between sleep and behavior in children with ADHD, its magnitude remains a mystery.1 Dillon and Chervin focused on the common disorders of restless leg syndrome, periodic limb movements, sleep-related breathing disorders (SRBD), and the effects of medicines in their article regarding ADHD and sleep problems.1 They state that in order to screen for sleep disorders, there are several useful questionnaires, including the Pediatric Sleep Questionnaire. Also, clinicians should remember the acronym BEARS to guide their own screening: bedtime problems, excessive daytime sleepiness, awakenings during the night, regular bedtime and awakening time, and snoring or difficulty breathing during sleep.
 Dillon, J.E. and Chervin, R.D. (2012, June 13). ADHD and Sleep Disorders in Children: A Quick Primer for Clinicians. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/display/article/10168/2082687
 Sadeh A, Gruber R, Raviv A. Effects of sleep restriction and extension on school-age children: what a difference an hour makes. Child Dev. 2003;74: 444-455.
 Cortese S, Konofal E, Yateman N, et al. Sleep and alertness in children with attention-deficit/hyperactivity disorder: a systematic review of the literature. Sleep. 2006;29:504-511.
 Gruber R, Xi T, Frenette S, et al. Sleep disturbances in prepubertal children with attention deficit hyperactivity disorder: a home polysomnography study. Sleep. 2009;32:343-350.
 Sadeh A, Pergamin L, Bar-Haim Y. Sleep in children with attention-deficit hyperactivity disorder: a meta-analysis of polysomnographic studies. Sleep Med Rev. 2006;10:381-398.
 Chervin RD, Archbold KH, Dillon JE, et al. Associations between symptoms of inattention, hyperactivity, restless legs, and periodic leg movements. Sleep. 2002;25:213-218.
 Galland BC, Tripp EG, Taylor BJ. The sleep of children with attention deficit hyperactivity disorder on and off methylphenidate: a matched case-control study. J Sleep Res. 2010;19:366-373.
 Sangal RB, Owens J, Allen AJ, et al. Effects of atomoxetine and methylphenidate on sleep in children with ADHD. Sleep. 2006;29:1573-1585.
 Prince JB, Wilens TE, Biederman J, et al. Conidine for sleep disturbances associated with attention-deficit hyperactivity disorder: a systematic chart review of 62 cases. J Am Acad Child Adolesc Psychiatry. 1996;35:599-605.
 Chervin RD, Weatherly RA, Garetz SL, et al. Pediatric sleep questionnaire: prediction of sleep apnea and outcomes. Arch Otolaryngol Head Neck Surg. 2007;133:216-222.
 Mindell JA, Owens JA. A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems. Philadelphia: Lippincott Williams & Wilkins; 2003. ADHD.