Attention deficit hyperactivity disorder (ADHD) is one of the most common neuropsychiatric disorders, with a worldwide prevalence of 8% 1 . Symptoms may include inattention; impulsivity, and hyperactivity. Moreover, children with ADHD may have trouble sitting still, following directions and completing tasks at home or school. The prevalence of sleep disturbances in individuals with ADHD is reported to be in the range of 35-70% and differs as a function of gender, age, ADHD subtype, psychiatric comorbidities and medication use 1 .
The sleep- ADHD connection
The interrelations between sleep problems and ADHD are complex and probably multidirectional with significant impact on a child’s functioning. The ADHD symptoms and possible comorbidities, may disrupt sleep by increasing the probability of bedtime struggle or resistance, limit-setting sleep problems, inadequate sleep hygiene, insufficient sleep or poor sleep quality. Alternatively, each of these sleep problems may result in ADHD-like day-time behaviors. A sleepy or sleep-deprived child may display hyperactive, impulsive, inattentive and disruptive behaviors.
Sleep problems in ADHD children:
Difficulties such as settling down in the evening, getting to sleep, staying up too late and difficulty waking up in the morning are common among ADHD patient 1 . Moreover, children with ADHD showed decreased alertness and greater daytime sleepiness 2 . Sleep problems in children with ADHD are associated with increased ADHD symptom severity and poorer child and family functioning and quality of life 3 .
Restless Legs Syndrome (RLS) and Periodic limb movement syndrome (PLMS)
RLS is a neurological disorder characterized by an irresistible urge to move the legs to relieve uncomfortable sensations while the child is at rest. PLMS is a characterized by periodic limb movement during the sleep. Pediatric RLS occurs in only 1.9 % of the general population between 8 and 18 years of age, but a reported prevalence of 33-52% is noted in children and adolescents with ADHD 4 . Daytime symptoms of RLS can mimic ADHD symptoms and can cause daytime neurobehavioral problems 5 such as restlessness and inattention 6 .
Sleep Disordered Breathing (SDB)
The term sleep-disordered breathing (SDB) describes a spectrum of conditions ranging from obstructive sleep apnea (OSA) to primary snoring. SDB has been consistently associated with neurobehavioral and neurocognitive deficits, including inattentive or ADHD-like symptoms. Habitual snoring was found to be more frequent among children diagnosed with ADHD associated with higher levels of inattention and hyperactivity 7 . The frequency of SDB in children with ADHD is around 25-30% compared with 3% in the general population. Snoring and other symptoms of SDB are not only strong risk factors for future emergence of behavior problems, but might aggravate hyperactive behaviors 8
In addition to primary sleep disorders, sleep problems in children with ADHD can also be the result of common co-existing conditions. Comorbidities including anxiety and behavioral disorders that are often found in ADHD patients, are known to disturb sleep. Moreover, drug and alcohol abuse problems also have a negative impact on a person’s ability to sleep properly 8
The most common approved drugs for ADHD (stimulant medication), are likely to affect sleep-onset latency by increasing it by at least 30 minutes 9 . The anticipated effects of these drugs would be: reduced total sleep time, increased sleep-onset latency and reduced sleep efficiency 9 .
Management of sleep problems in children with ADHD
Sleep problems management includes sleep hygiene, behavioral interventions and medication treatment 10 . Some medications are prescribed solely to assist with sleep whereas others may help with a range of emotional and behavioral symptoms. The medications most commonly prescribed to treat sleep problems in children with ADHD are clonidine and antihistamines. Currently there are no medications approved by the Food and Drug Administration (FDA) for the treatment of pediatric insomnia. As a result many parents use over-the-counter treatments or food supplements and others use prescribed drugs including antihistamines, hypnotics, sedatives, antidepressants and benzodiazepines that are largely based on experience in adults with no proven record of safety and efficacy in children or determination of pediatric dosing 11 . These medications may cause side effects or have interactions with other medications, and also introduce a risk of overdose. Additional treatment option that is widely used to treat sleep problems among ADHD children is Melatonin. Melatonin was shown to be well-tolerated, safe and efficacious treatment option for pediatric patients with chronic sleep problems and ADHD for short and long term 9 12 .
Tips to help manage sleep problems in ADHD children:
Practice good sleep hygiene
Set up a realistic time for bed, and stick to that schedule. Use the bed for sleeping only and avoid having children watch television or videos before bedtime.
Keep the bedroom dark, quiet, cool and comfortable for the best sleep. Minimize potential interruptions, such as outside noise. Keep televisions, computers, video games and other electronic equipment out of the bedroom.
Exercise during the day
Exercise may help with hyperactivity and feelings of restlessness in patients with ADHD however exercise should be completed at least 3-4 hours before bedtime.
Monitor what and when you eat
Eating heavily too close to bedtime can inhibit a good night’s sleep. Avoid caffeine, alcohol, Spicy Food and Unhealthy Fatty Foods close to bedtime. Food that might help to get good nigh sleep includes dairy products, walnuts& almonds, chamomile tea/ passionfruit tea, banana and jasmine rice