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Sleep Disturbances and Attention Deficit Hyperactive Disorder

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Sleep Disturbances and Attention Deficit Hyperactive Disorder

Trina S. Willison

Attention Deficit Hyperactivity Disorder (ADHD) is the most common problem presented to children’s mental health services (Corkum, P., Moldofsky, H., Hogg-Johnson, S., Humphries, T. and Tannok, R., 1999, Corkum, P., Tannock, R. and Moldofsky, H., 1998, O’Brien, L. M., Holbrook, C. R., Mervis, C. B., and Klaus, C. J., 2003).  It is estimated that 5% of school-age children meet the DSM-IV criteria for attention deficit hyperactivity disorder. The cause of is not completely understood, however many studies have looked at the link between sleep disturbances and inattentive and hyperactive behavior.  

 ADHD is characterized by a combination of disruptive behaviors, academic underachievement and poor social relations (Corkum, P., Tannock, R. and Moldofsky, H., 1998).  The core symptoms include varying degrees of inattention, impulsiveness, and restlessness.  These characteristics have also been long known to be symptoms of sleep deprivation.  Previous versions of the DSM included excessive movement during sleep as criteria for the diagnosis of ADHD (Corkum, P., Moldofsky, H., Hogg-Johnson, S., Humphries, T. and Tannok, R., 1999, Gruber, R., Sadeh, A., Raviv, A., 2000).   Chervin, Archbold, Dillon, Panahi, Pituch, Dahl and Guilleminault (2002) suggest that in many instances unrecognized medical conditions underlie the problematic behavior.  

 Many studies have found a link between ADHD and sleep disturbances (Crabtree, V. M., Ivanenko, A., and Gozal, D., 2003, Aronen, E. T., Paavonen, E. J., Fjallberg, M., Soininen, M., and Torrenen, J., 2000, O’Brien, L. M., Holbrook, C. R., Mervis, C. B., and Klaus, C. J., 2003).  Sleep problems in the average school-aged population are at about 7%.  It is estimated that for children with ADHD the numbers range from 25 to 43%.  The association has been found in clinical populations.  However, the studies differ on how sleep influences ADHD behavior and what types of sleep disturbances are related to inattentive and hyperactive behavior.
 Corkum, Moldofsky, Hogg-Johnson, Humphries, and Tannok, (1999) state that sleep disorders are commonly classified into four groups.  The first group is dyssomnias.  These include insomnia and circadian rhythm sleep disorders.  The second group is sleep-related involuntary movements, which includes bruxism, periodic limb movement disorder and sleep talking.  The next group includes obstructive sleep apnea and  is sleep-related breathing disorders.  The final group is non-rapid eye movement parasomnias, including sleepwalking and sleep terrors.   The link between these sleep disturbances and ADHD differs from group to group and various studies show different results.

 According to one study sleep disturbances were found in 61.5% of the ADHD population. The most frequent were initial and middle insomnia, nocturnal enuresis and parasomnias (Ring, A., Stein, D., Barak, Y., Teicher, A., Hadjez, J., Elizure, A., and Weizman, A., 1998).  Dyssomnias are one of the most commonly linked disturbances to hyperactivity and inattention (Corkum, P., Moldofsky, H.,  Hogg-Johnson, S., Humphries, T., and Tannock, R., 1999).  In one study, teachers linked a decreased amount of sleep to externalizing behaviors including hyperactivity (Iranian, E. T., Paavonen, E. J., Fjallberg, M., Soininen, M., and Torrenen, J., 2000).  There was a clear association between the teacher reported symptoms and an objective measure of true sleep time.  One complication is that dyssomnias are also linked with oppositional defiant disorder and stimulant medications in children with ADHD.  Another complication is in some studies the ADHD group did not differ from the normal control group in total sleep time (Corkum, P., Tannock, R. and Moldofsky, H., 1998).  They did however show more restless sleep.

 This leads to the second group of sleep disorders, sleep-related involuntary movements.  This group of disorders is also linked closely to ADHD (Aronen, E. T., Paavonen, E. J., Fjallberg, M., Soininen, M., and Torrenen, J., 2000,  Corkum, P., Moldofsky, H.,  Hogg-Johnson, S., Humphries, T., and Tannock, R., 1999, Corkum, P., Tannock, R. and Moldofsky, H., 1998).  One study found that 34% of patients being evaluated for ADHD had sufficient symptoms of periodic leg movement disorder to warrant further study (Corkum, P., Tannock, R. and Moldofsky, H., 1998).  Sixty-seven percent of the studies found that children with ADHD displayed more movements during sleep.  However, at least one study found that hyperactive children did not display more periodic limb movements than controls with the exception of those displaying severe symptoms of ADHD (O’Brien, L. M., Holbrook, C. R., Mervis, C. B., and Klaus, C. J., 2003).  The researchers suggest that this may represent a separate category of ADHD.

 Obstructive sleep apnea (OSA) and sleep related breathing disorders (SBD) comprise the third type of sleep disturbance.  Obstructive sleep apnea usually results from adenotonsillar hypertrophy (Chan, J., Edman, J. C., and Koltai, P. J., 2004).  It can also result from neuromuscular disease and craniofacial abnormalities.  Inattentive and hyperactive behavior are often common among children with OSA  (Chervin, R. D., Archbold, K. H., Dillon, J. E., Panahi, P., Pituch, K. J., Dahl, R. E., and Guilleminault, C., 2002, O’Brien, L. M., Holbrook, C. R., Mervis, C. B., and Klaus, C. J., 2003, Ring, A., Stein, D., Barak, Y., Teicher, A., Hadjez, J., Elizure, A., and Weizman, A., 1998).   Although OSA appears to be linked to inattention and hyperactivity, it is seen mostly in children with mild behavioral hyperactivity.  It may induce a mile form of hyperactivity.  

 Like OSA, sleep related breathing disorders (SBD) have been linked to inattention and hyperactivity (Aronen, E. T., Paavonen, E. J., Fjallberg, M., Soininen, M., and Torrenen, J., 2000, Chan, J., Edman, J. C., and Koltai, P. J., 2004, Chervin, R. D., Archbold, K. H., Dillon, J. E., Panahi, P., Pituch, K. J., Dahl, R. E., and Guilleminault, C., 2002,  O’Brien, L. M., Holbrook, C. R., Mervis, C. B., and Klaus, C. J., 2003)  One study found that 25% of all children with ADHD showed SBD.  One third of those SBD symptoms such as snoring are associated with severe daytime sleepiness, and inattention and hyperactivity.   However, one study shows that excessive daytime sleepiness is not usually associated with SBD, but rather sleep insufficiency (Chervin, R. D., Archbold, K. H., Dillon, J. E., Panahi, P., Pituch, K. J., Dahl, R. E., and Guilleminault, C., 2002).

 Finally non-rapid eye movement parasomnias, including sleepwalking and sleep terrors disturb sleep.  There has been some study of the link between REM sleep and attention and hyperactivity, but there has been little research in the area of non-rapid eye movement parasomnias.  Overall, compared to control groups and their own healthy siblings, children with ADHD show greater prevalence of single or multiple sleep disturbances, as well as higher rates of specific sleep disorders (Ring, A., Stein, D., Barak, Y., Teicher, A., Hadjez, J., Elizure, A., and Weizman, A., 1998).  The data may appear inconclusive as to how these sleep disorders are related to ADHD, but one consistent factor seems to be the link between the body, sleep, and the mind, attention and hyperactivity; disturbances of the sleep-wake cycle or arousal (Aronen, E. T., Paavonen, E. J., Fjallberg, M., Soininen, M., and Torrenen, J., 2000, Corkum, P., Moldofsky, H.,  Hogg-Johnson, S., Humphries, T., and Tannock, R., 1999, Gruber, R., Sadeh, A., and Raviv, A., 2000, O’Brien, L. M., Holbrook, C. R., Mervis, C. B., and Klaus, C. J., 2003, Ring, A., Stein, D., Barak, Y., Teicher, A., Hadjez, J., Elizure, A., and Weizman, A., 1998).

 The role of the sleep-wake cycle and arousal in ADHD deserves close scrutiny (Aronen, E. T., Paavonen, E. J., Fjallberg, M., Soininen, M., and Torrenen, J., 2000, Corkum, P., Moldofsky, H.,  Hogg-Johnson, S., Humphries, T., and Tannock, R., 1999, Gruber, R., Sadeh, A., and Raviv, A., 2000, O’Brien, L. M., Holbrook, C. R., Mervis, C. B., and Klaus, C. J., 2003, Ring, A., Stein, D., Barak, Y., Teicher, A., Hadjez, J., Elizure, A., and Weizman, A., 1998).  ADHD appears to be an impairment in arousal regulation.  Irregularities in the quality and quantity of sleep may play an integral role in the problems of children with ADHD.  These irregularities lead to excessive daytime sleepiness which is linked to inattention and hyperactivity.  

 The mechanism of action linking the sleep-wake cycle and ADHD has been limitedly researched (Anonymous, 2005, Gruber, R., Sadeh, A., and Raviv, A., 2000, O’Brien, L. M., Holbrook, C. R., Mervis, C. B., and Klaus, C. J., 2003, Ring, A., Stein, D., Barak, Y., Teicher, A., Hadjez, J., Elizure, A., and Weizman, A., 1998).  Diffusion tensorimaging has shown that children with ADHD show decreased fractional anisotropy in the frontal and cerebellar white matter bundle that is involved in the process that regulates attention, impulsive behavior, motor activity and inhibition (Anonymous, 2005).  

 The prefrontal cortex appears to modulate higher cognitive functions and regulation of sleep and affect (Gruber, R., Sadeh, A., and Raviv, A., 2000).  Having an unstable sleep-wake system is expected to be related to the inability of systems such as the attentional, behavioral and emotional systems as seen in ADHD.  ADHD and some types of insomnias are associated with hyperarousal conditions (Ring, A., Stein, D., Barak, Y., Teicher, A., Hadjez, J., Elizure, A., and Weizman, A., 1998).  One thought as to the cause of this is resulting from a dysregulation of excitatory and inhibitory activity in the ascending reticular activating system and from frontal lobe dysfunction.  PET scans have shown lowered glucose metabolism in a specific area of the left anterior frontal lobe in children with severe ADHD symptoms.  

Frontal lobe dysfunction may also be related to difficulties initiating and maintaining sleep (Ring, A., Stein, D., Barak, Y., Teicher, A., Hadjez, J., Elizure, A., and Weizman, A., 1998).  This dysfunction leads to reduced slow-wave N-REM sleep resulting in a deleterious effect on prefrontal cortex functioning.  This includes executive functioning such as control of attention and emotions.

Studies have shown multiple contributing factors that disrupt the sleep-wake cycle (O’Brien, L. M., Holbrook, C. R., Mervis, C. B., and Klaus, C. J., 2003).  O’Brien et. al. lists the some of the multiple factors which include: polygenic influences and dopaminergic, adrenergic, and glutamatergic alterations in specific brain regions.  These result in interference to executive functioning such as working memory, self-regulation of affect/arousal, internalization of speech, and reconstitution.  

When OSA is the cause of the inattentive or hyperactive behavior, the causes are more clear as discussed above (O’Brien, L. M., Holbrook, C. R., Mervis, C. B., and Klaus, C. J., 2003).  However, the mechanism is not completely understood.  It is possible that sleep fragmentation and episodic hypoxia lead to alterations in neurochemic substrate of the prefrontal cortex resulting in executive dysfunction.  

When looking at diagnosis of ADHD it may prove helpful to examine the child’s sleep patterns.  Most of the studies have used subjective measures such as sleep diaries and this has resulted in inconclusive data.  However, there are objective measures that can look at sleep and determine if it is disordered.  Studies of sleep should be conducted over a four to five day period, excluding weekends and holidays (O’Brien, L. M., Holbrook, C. R., Mervis, C. B., and Klaus, C. J., 2003).  This eliminates factors such as unfamiliarity with setting, and other environmental factors that may affect sleep.  Actigraphy is one measure that can be used to determine movement in sleep.  It is a device worn like a wrist watch and measures movement.  A second type of assessment that can be conducted is a multiple sleep latency test (MSLT).  This measures the onset of sleep and how long it takes the child to enter REM sleep.  A maintenance of sleep wakefulness test can also help to determine daytime sleepiness.  Undergoing these types of assessment will better establish if a problem with the body is interfering with the function of the mind.  

ADHD is often treated with stimulant medications.  However, these can interfere with the person’s sleep pattern and exacerbate the symptoms.  Stimulant medications have been shown to prolong sleep latency and the onset of the first REM cycle (Corkum, P., Tannock, R. and Moldofsky, H., 1998).  However, treatment of the sleep disorders may help to reduce if not eliminate symptoms of inattention and hyperactivity (Aronen, E. T., Paavonen, E. J., Fjallberg, M., Soininen, M., and Torrenen, J., 2000).  Behavioral modifications and chronotheray (successively delay sleep times around the clock until sleep onset realigns with an early clock time) are some types of therapy that can be used  (Corkum, P., Tannock, R. and Moldofsky, H., 1998).  Common treatment for periodic limb movement disorder is pharmacological, using drugs such as clonidine or leodopa/carlidopa.  This has been shown to be successful in treatment of both nighttime and daytime behavioral difficulties.  Children with OSA difficulties show marked improvement after adenotonsillectomy.  Overall treatment for specific sleep problems improves attention and hyperactivity.  

References 

Anonymous, (2005).  SessionB: Early development: ADHD and sleep.  Developmental Medicine and Child Neurology, 47, 7-10. 

Aronen, E. T., Paavonen, E. J., Fjallberg, M., Soininen, M., and Torronen, J., (2000).  Sleep and psychiatric symptoms in school-age children.  Journal of the American Academy of Child and Adolescent Psychiatry, 39 (4), 502-508.

Chan, J., Edman,  J. C., and Koltai, P. J., (2004).  Obstructive sleep apnea in children.  American Family Physician, 69(5), 1147-1154.

Chervin, R. D., Archbold, K. H., Dillon, J. E., Panahi, P., Pituch, K. J., Dahl, R. E., and Guilleminault, C., (2002).  Inattention, hyperacivity, and symptoms of sleep-disordered breathing.  Pediatrics, 109(3), 449-456.

Corkum, P., Moldofsky, H., Hogg-Johnson, S., Humphries, T., and Tannock, R., (1999).  Sleep problems in children with attention deficit/hyperacivity disorder: Impact of subtype, comorbidity and stimulant medication.  Journal of American Academy of Child and Adolescent Psychiatry, 38(10), 1285-1293.

Corkum, P., Tannock, R., and Moldofsky, H., (1998).  Sleep disturbances in children with attention deficit/hyperacivity disorder.  Journal of American Academy of Child and Adolescent Psychiatry, 37(6), 637-646.

Crabtree, V. M., Ivanenko, A., and Gozal, D., (2003).  Clinical and parental assessment of sleep in children with attention deficit/hyperactivity disorder referred to a pediatric sleep medicine.  Clincal Pediatrics, 42(9), 807-?. 

Gruber, R., Sadeh, A., and Raviv, A., (2000).  Inability of sleep patterns in children with attention-deficit/hyperactivity disorder.  Journal of Americal Academy of Child and Adolescent Psychiatry,  39(4), 495-501.

O’Brien, L. M., Holbrook, C. R., Mervis, C. B., Klaus, C. J., et al., (2003).  Sleep and neurobehavioral characteristics of 5- to 7-year-old children with parentally reported symptoms of attention-deficit/hyeractivity disorder.  Pediatric, 111(3), 554-564.

Ring, A., Stein, D., Barak, Y., Teicher, A., Hadjez, J., Elizure, A., and Weizman, A., (1998).  Sleep disturbances in children with attention-deficit/hyperactivity disorder: A comparative study with healthy siblings.  Journal of Learning Disabilities, 31(6), 572-578.