ADHD/ADD AND SLEEP

It has recently become clear that there seems to be an association between sleep disturbances and Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD). It is not hard to comprehend that disturbed sleep can lead to symptoms of ADHD or ADD.

A normal child who is un-rested or is up past a typical bedtime frequently demonstrates poor behavior and lack of impulse control.

Attention Deficit Hyperactivity Disorder / Attention Deficit Disorder and its Relationship to Sleep

If a child suffers from a sleep disorder that causes brief disruption of their sleep throughout the night (called micro-arousals) this will lead to a chronic condition of an un-rested nervous system and behavioral changes occur similar to those seen in an un-rested or overly tired child. Two particular sleep disturbances have been reported to be associated with ADHD or ADD. One of these is a disorder known as Periodic Leg Movements of Sleep (PLMS), which can be seen in patients with restless leg sensations at night. Another sleep disorder causing ADHD is obstructive respiration during sleep such as Obstructive Sleep Apnea or the milder form known as the Upper Airway Resistance Syndrome. (See references below.)

Studies have described Obstructive Sleep Apnea in some children who presented with hyperactivity who after receiving treatment for their obstructive respirations demonstrate resolution of their daytime symptoms. Additionally, PLMS and the Restless Legs Syndrome have been found in patients with ADHD who also demonstrate improvement in ADHD symptoms after treatment for the RLS / PLMS disorder. Stimulant medications such as Ritalin and Adderall work by treating the ill effects of fragmented sleep and pharmacologically masking the symptoms of sleep deprivation in these patients.

Another way to achieve this effect would be to treat the underlying cause by resolving or preventing the fragmented sleep and therefore eliminating the need for stimulant medications. In children who have obstructive respirations as the cause for their fragmented sleep, the initial treatment is with continuous positive airway pressure (CPAP) therapy. This is the first step, and observations are made to determine if treating the child's airway provides improvement in their daytime symptoms of ADD or ADHD.

If improvement is recognized then the next step is to consider orthodontics. The child's airway can be modified to improve breathing through orthodontic means. Frequently this requires widening of the hard palate and/or bringing the mandible and maxilla forward. These orthodontic maneuvers frequently require the child to wear headgear at night. The challenge during that stage is to be sure that the child can wear the headgear while also wearing the CPAP mask. This is only a temporary requirement. Once the orthodontic changes have occurred then in many cases they no longer need to use CPAP and breath at night is restored to normal and the ADD / ADHD symptoms are no longer present.

This child had been on CPAP for over a year prior to the implementation of orthodontics. Using CPAP drastically improved his daytime performance. He slept better through the night, woke easily and did not have ADHD symptoms during the day. He did not need to take stimulant medications.

This picture shows how his head gear fits, working to bring his maxilla forwards and his mandible moves forwards as well.

Picture shows how a child wears a CPAP mask while also having their orthodontic head gear on during the period of orthodontic treatment where the maxilla and mandible are being brought forward.

Screening Questions for Parents to Ask Regarding Their Child's Sleep:

Does your child snore or make labored respiratory sounds while sleeping?
Does your child frequently breathe through his/her mouth while asleep (sometimes evidenced by drooling on the pillow)?
Does your child frequently wake in the morning with nasal congestion which was not present before going to bed?
Does your child make frequent kicking movements during sleep or frequently kick up the sheets while asleep?
Does your child appear sleepy during the day while sitting still?

If the responses to these questions are positive for a child with ADHD or ADD then consider having the child evaluated for a sleep disorder. Sleep disorders do not explain the cause of ADHD or ADD in all children but clearly, a significant percentage of cases can be attributed to a sleep problem. It is necessary to have a child evaluated properly first before concluding that there is an association and it needs to be determined on a case-by-case basis.

More work is needed in this area to further extract how to best identify and treat these individuals. What is clear is that for many children treatment does not have to consist of stimulant medications and treating a sleep disturbance (if present) is the best option.

References:

Guilleminault, C., Winkle, R., Korobkin, R., and Simmons, B., Children and nocturnal snoring: evaluation of the effects of sleep related respiratory resistive load and daytime functioning. European Journal of Pediatrics, 130, 1165-1171 (1982)
Ali, N J; Pitson, D; Stradling, J R. Natural history of snoring and related behavior problems between the ages of 4 and 7 years. Archives of Disease in Childhood, v.71, n.1, (1994): 74-76.
Carskadon, M A; Pueschel, S M; Millman, R P. Sleep-disordered breathing and behavior in three risk groups: Preliminary findings from parental reports. Child's Nervous System, v.9, n.8, (1993): 452-457.
Ali, N J; Pitson, D J; Stradling, J R. Snoring Sleep Disturbance and Behavior in 4-5 Year Olds. Archives of Disease in Childhood, v.68, n.3, (1993): 360-366.
Stradling, J R; Thomas, G; Warley, A R H; Williams, P; Freeland, A. Effect of adenotonsillectomy on nocturnal hypoxemia, sleep disturbance, and symptoms in snoring children. Lancet (North American Edition), v.335, n.8684, (1990): 249-253.
Kaplan, B J; Mcnicol, J; Conte, R A; Moghadam, H K. Sleep Disturbance in Preschool-Aged Hyperactive and Nonhyperactive Children. Pediatrics, v.80, n.6, (1987): 839-844.
Ali, N J; Pitson, D; Stradling, J R. Sleep disordered breathing: Effects of adenotonsillectomy on behavior and psychological functioning
Walters AS, Mandelbaum DE, Lewin DS, Kugler S, England SJ, Miller M. Dopaminergic therapy in children with restless legs/periodic limb movements in sleep and ADHD. Pediatr Neurol 2000;22:182-186
Picchietti DL, England SJ, Walters AS, Willis K, Verrico T. Periodic limb movement disorder and restless legs syndrome in children with attention-deficit hyperactivity disorder.
J Child Neurol 1998;13:588-594
Picchietti DL, Underwood DJ, Farris WA, Walters AS, Shah MM, Dahl RD, Trubnick LJ, Bertocci MA, Wagner M, Hening WA. Further studies on periodic limb movement disorder and restless legs syndrome in children with attention-deficit hyperactivity disorder. Move Dis 1999;14:1000-1007

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