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This presentation explores the relationship between sleep disorders and ADHD, discussing the clinical implications and management strategies. It covers various sleep problems commonly seen in ADHD, assessment methods, and the impact of sleep on behavior and learning.
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Sleep disorders and ADHD Neel Kamal MD, FRCPCH, MFFLM,MCNS, MAACAP Consultant Community Paediatrician Senior Tutor HYMS Convener; George Still Forum
Outline of the presentation • Introduction • Outline of sleep physiology status • Evidences of relationship • Clinical implications • Applications
Sleep disorders and ADHD • Treatment response may vary depending on co-morbid or co-existing conditions • Learning objective - how to manage
Purpose of Sleep • Good for us!! • Commonly prescribed for many ailments? • Restoration Theory • Evolutionary theory • Energy Conservation • Learning – Registration, consolidation->Retention of information
Falling asleep • The process incorporates a number of behavioral and physiological adjustments • Modulation of responsiveness to auditory and visual stimuli , alteration in memory etc etc.
Prevalence • 25-50%---80% ADHD children with sleep problem
Sleep analysis and learning • Relationship between REM latency , and hyper kinesia , learning (Bushby et al) • Minor cerebellar–vestibular disturbance ( Levinson et al)
Sleep problem • Defining sleep problem • Falling asleep • Returning to sleep • Bedtime anxiety/resistance • Snoring/OSA • Restless leg (syndrome)/Periodic Limb Movement • Enuresis • Nightmares/night-terrors • Shortened sleep
Behavioral Insomnia in ADHD • Intrinsic abn of neuro/ circadian factors • Coexisting medical problem eg GOR, asthma/eczema • Comorbid psychiatric conditions eg anxiety , depression, • Medication effects eg AED, Psychostimulants • Comorbid sleep disorders eg parasomnias and sleep related movement disorders
Osler on OSA • At night the child’s sleep is greatly disturbed ; the respirations are loud and snoring, and there are sometimes prolonged pauses, followed by deep, noisy inspirations. The child may wake up in a paroxysm of shortness of breath.. In longstanding cases the child is very stupid-looking, responds slowly to questions , and may be sullen and cross… • The influence upon the mental development is striking. Mouth- breathers are usually dull, stupid, and backward. It is impossible for them to fix the attention for long …Headaches, forgetfulness, inability to study without discomfort , are frequent symptom of this condition in students . Among other symptoms.. General listlessness , and indisposition for physical or mental exertion.
Assessment • Subjective • Objective
Assessment : Parental beliefs /knowledge of sleep • Ascertain their knowledge and practices • Re-emphasize the importance of sleep • Identify if appropriate strategy is being applied • Mindfulness
Melanopsin • Another retinal photoreceptor • Transmits to suprachiasmatic nucleus Important = ‘blue light’
Melatonin • Dim- light -> melatonin onset • DLMO – phase advancing, earlier sleep onset and earlier waking time • Phase shifting ( chronobiotic/hypnotic effect) • (administer 4-6 hrs before)
Paediatric Sleep Problems: • Pr. Sleep problems: sleep disordered breathing/narcolepsy • Behavioral sleep problems : eg resistance to bedtime
Objective sleep assessments(poly somnography/ actigraphy) • Reduced sleep efficiency • Sleep fragmentation • Increased apnea-hypoapnea index
Parent Ratings of Behaviour • Subjective measure = correlates with behavior • ‘Halo effect’ parent and teacher high ratings on one trait is accompanied by high ratings on other features which might not be true.
Cause and effect phenomenon • ADHD commonly presents with co morbid psychiatric conditions , hence it is unclear how and if sleep problem is related to ADHD. • Accardo et al study: • ADHD +Anxiety or Depression • Anxious children scored high on sleep Habits Questionnaires • Sleep onset delay in both groups; • depressed children slept for longer • No relation with sleep related Breathing problem
Cortese et al • Met analysis inclusive of PSG, actigraphy ,MSLT and subjective measures
ADHD type and Sleep Problems • ADHD types: • ADHD COMBINED –>CIRCADIAN rhythm problem • ADHD INATTENTIVE -> hypersomnia • ADHD HYPERACTIVE- IMPULSIVE-> delayed sleep phase
Restless leg Syndrome • Diagnostic Criteria ( 2-12 years) • urge to move/unpleasant sensation • Sensation begins/worsens during rest • Sensation relieved by movement eg walking/stretching • Worse in the evening • Sleep disturbance , worsening with age • A biological parent with definite RLS
RESTLESS LEG /PLM • Dopamine deficit theory • Anatomical and functional difference eg caudate , globus pallidus , reduced D2/D3 Recepter density in nucleus accumbens and midbrain • Low ferritin level : Iron supplements improve both
What is behaviour ? • Behaviour is largely the product and manifestation of high –level cognitive functions , that influences self- control • Collectively referred to as Executive function. • (Role of Disturbed restorative sleep and cellular homeostasis due to sleep problem)
Beebe and Gozal hypothesis • Impaired executive function can result from disordered sleep or daytime sleepiness • Intermittent Hypoxia and hypercarbia resulting from obstructive sleep apnea impair restorative sleep and cellular homeostasis. • Prefrontal cortical dysfunction
Prefrontal cortical dysfunction features: • Difficulty manipulating information • Poor judgment • Rigid thinking • Poorly maintained attention • Motivation • Emotional lability • Over activity /impulsivity
Role of inflammation • Gozal et al:- • Executive function model of Sleep and ADHD • Oxidative stress and inflammation due to OSA • -> cellular changes underlying Neurocognitive deficit in Children with OSA
Inflammation indices OSA • C- Reactive protein ( high sensitivity testing) • Soluble CD40 ligand ( endothelial inflammation) • IGF-I ( Neuroprotective hormone) in children with neurocognitive dysfunction • Oxidative stress and cellular immunity has also been suggested in ADHD even without sleep problem
Role of inflammation • Atopy /itch and sleep disturbance (atopic dermatitis) • Food sensitivity • Practicability problem has prevented its application in the main stream practice . More research is required.
Question now.. • Less pronounced sleep–associated disturbances in breathing also cause significant neuro behavioural pathology ?
Sleep disordered breathing • Huang et al : ADHD + Mild OSA • Treatment options: • Adenotonsillectomy • Psychostimulant • No treatment • Surgery -> best outcome on ADHD rating, Continuous performance test
Long term outcomes of SDB • Ali et at: 2 year follow-up 4-5 year olds persistent habitual snorers--- hyperactivity ,sleepiness and restless sleep increased during the period. • Chervin et al: SDB base line indicators strong predictors of hyperactivity index • SDB = trajectory hyperactivity • Conduct problems • Peer difficulty
Melatonin • A hormone secreted by pineal gland • Receptors in suprachiasmtic nucleus ( Hypothalamus) • Supplements endogenous hormone • chronobiotic effect • Hypnotic effect • Special indications in neurodevelopmental disorders blindness/ Rett /autism) • Hypothalamic – gonadal axis suppression rebound precocious puberty • Exogenous melatonin peak < I hour. • ( delayed sleep phase disorders suggests small dose 5-6 hrs prior to sleep time)
ADHD and sleep management • Child in a Family : life style (stable, harmony) Sleep hygiene ( irregular execution of sleep hygiene) Bed time rituals/ambience distractions Stimulant medications
ADHD /stimulants and Sleep Stimulant medication: reduction of sleepiness Rebound hyperactivity
Non-stimulants • Atomoxetine • Clonidine /guafenacine • Stimulants leading to sleep problem, needs medication review( Behaviour intervention is futile) • Longer acting stimulants preferable.
Non Stimulants • CLONIDINE • Alpha 2 adrenergic agonist • 62 children and adolescents • 85% improvement at CGI • 31% adverse effects • Also used in daytime treatment of ADHD
Take home message • The association between two correlated disorders may be causal in either direction or it may arise from a third condition. • The cause may not be the sole cause but may be contributing. • Organizing a relationship between sleep problems and ADHD is worthwhile if it helps understand what ADHD is . • Do not forget OSA and RLS
Bibliography • Picchiety et al ,Advances in pediatric restless leg syndrome. Sleep Med 2010;11 • Konofal et al; Effects of Iron supplementation on attention deficit hyperactivity disorder in children.Ped Neurology 2008 • Gozal et al, Obstructive Sleep apnea and endothelial function in school –aged non-obese children; Circulation 2007 ; • Owens et al, Neurocognitive and behavioral impact of sleep disordered breathing in children. Ped. Pulmonol.2009 • Sadeh et al.Sleep in Children with ADHD. Sleep Med Rev 2006 • Cortese et al Sleep and Alertness in children withADHD .Sleep 2006