Introduction
Attention Deficit Hyperactivity Disorder is a psychiatric disorder in which patients exhibit impulsive behaviour and an inability to fix attention for any significant length of time. Behaviour patterns of such persons are not age-appropriate. This disorder is detected predominantly in children and presents between ages 6 to 12. Diagnosis can be definite only after the condition has existed for a minimum period of six months to a year. The major presenting symptom is lack of attention at school and home study which reflects on academic performance. Clinical diagnosis is based on certain standardized tests – questionnaires for parents as well as children. These include the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) criteria and the ICD-10(International Statistical Classification of Diseases and Related Health Problems) criteria. ADHD presents in three main ways – inattentiveness, impulsivity and hyperactivity (or restlessness).
Inattentiveness – Inattentiveness is characterized by distraction, difficulty in focusing, inability to focus, organize, or complete tasks, difficulty with comprehension and learning new things, day dreaming, and disobedience.
Hyperactivity – Hyperactive children are unable to sit still for any given length of time. They are always on the move and find it difficult to complete any one task. School work is often left incomplete. Complaints from school are in the nature of being talkative, and distracting others.
Impulsivity – Children with ADHD are impulsive by nature. They act with a complete disregard for the consequences of their actions. This may seem common to all children but such impulsivity continues into teenage in the case of children with ADHD. Such children are also impatient and find it difficult to wait for things to happen. They often butt into conversations without consideration for other participants.
While many people have sleep disorders, it is believed that children with ADHD are more likely to suffer from the condition. This has been shown in a number of studies. Sleep disorders, also called somnipathy, is the medical term for disordered sleep of humans and animals. This may be apparent in the form of snoring, difficulty in falling asleep, restlessness and thrashing during sleep and not feeling refreshed after sleep. Polysomnography (PSG) is a test which is used to study sleep patterns. PSG in combination with the Multiple Sleep Latency Test (MSLT) which is used to measure the time from the start of sleep (when a person goes to bed) and the onset of sleep, help determine whether a subject has sleep disorder and the severity of the disorder.
For the purpose of this paper we have identified seven articles which present evidence to show that children (and often adults) with ADHD also have sleep disorders. Although these authors recommend further research on the connection between ADHD and somnipathy, it is our opinion that the articles prove that children diagnosed with ADHD and receiving no medical treatment for the condition do exhibit disturbed sleep patterns. Many of the studies included in this paper use both PSG and MSLT to study sleep patterns. These studies have been summarized below.
Annotated Bibliography of the 7 articles.
- Sleep disorders and daytime sleepiness in children with attention-deficit/hyperactivity disorder: A two-night polysomnographic study with a multiple sleep latency test
Authors: Iva Prihodova a,⇑, Ivo Paclt b, David Kemlink a, Jelena Skibova c, Radek Ptacek b, Sona Nevsimalova a
Retrieved from: Sleep Medicine journal homepage: www.elsevier.com/locate/sleep
This is a research conducted by Pridhova et al. to study the incidence of sleep disorders and daytime inattentiveness in children between the ages of 6 and 12. The study included both boys and girls - with a predominance of boys – that were specifically diagnosed with ADHD but had not been pharmacologically treated for the same. The sample tested on two separate nights for sleep patterns using the polysomnography (PSG) and multiple sleep latency test (MSLT) tests. The tests revealed that there were no differences in the basic sleep pattern of the two groups. However, sleep disordered breathing and periodic limb movements were observed in children with ADHD. After adaptation night and excluding psychiatric comorbidities, the basic sleeping parameters remained largely unchanged. No evidence of increase in daytime sleepiness was found although dysregulated arousal was observed in children with ADHD. The research concluded that children with ADHD do not present different sleeping patterns or sleep disturbances different from normal children.
- Sleep in Children With Attention-Deficit/Hyperactivity Disorder: Meta-Analysis of Subjective and Objective Studies
Authors: SAMUELE CORTESE, M.D., PH.D., STEPHEN V. FARAONE, PH.D., ERIC KONOFAL, M.D., PH.D., AND MICHEL LECENDREUX, M.D.
Adolesc. Psychiatry, 2009;48(9):894Y908.
This research identified 16 studies that provided both subjective and objective parameters for children with ADHD. The criteria for inclusion were children below the age of 18, with ADHD but excluding children with co-morbid disorders like anxiety or depression or children who had been pharmacologically treated for the condition. The studies provided 9 subjective and 15 objective parameters. The pooled sample totalled 722 children with ADHD and 638 in the control group. The research concluded that children with ADHD showed significant sleep impairments as compared to the control group. The paper recommends further evidence based research on sleep disorders in children with ADHD.
- Sleep Problems in the Child with Attention-Deficit Hyperactivity Disorder Defining Aetiology and Appropriate Treatments
Margaret D. Weiss^ and Jay Salpekar
- Children's and Women's Health Centre of British Columbia, Vancouver, British Columbia, Canada
- Children's National Medical Center, George Washington University School of Medicine, Washington, DC, USA
Retrieved From: CNS Drugs2010. 24 (10):811-828 I nCHinr I IIN rHMV^IIV,C • l 172-7O47/1O/OO1CH)81 1;S/I9.95/O © 2010 Adb Data Information BV. All tights reserved.
This article deals with the therapy for Sleep Problems in children with ADHD. The general age-group referred to in the article is school going children (approximately age 6-12). The authors state that a significant number of children with ADHD experience sleep disorders. They further elaborate that the most significant among the disorders are a delayed onset of sleep, tiredness, and sleepiness during the day. Restless legs syndrome and periodic limb movements are also exhibited as also sleep disordered breathing. Medications for ADHD and some co-morbid conditions also contribute to disturbed sleep. Evaluation of sleep disorders are based on parent and child questionnaires. Therapeutic and pharmacological intervention for sleep disorders could exacerbate the symptoms of ADHD. The article recommends further research on whether or not addressing metabolic and neurological areas of children with ADHD can help improve the symptoms of both ADHD and sleep disorders.
- Sleep Disorders and Daytime Sleepiness in Children with Attention-Deficit/
Hyperactive Disorder
Authors: Natali Golan BSc1; Eli Shahar MD2; Sarit Ravid MD2,3; Giora Pillar MD, DSc1,3
The objective of this study was to understand whether children with ADHD should be treated with stimulant medications. The hypothesis of the study was that children with ADHD are sleepy during the day. The research was a single blind study that compared the observations in thirty four children with an average age of 12 years, who had been previously diagnosed with ADHD against those of a control group with similar age group. The children were observed at the University medical centre by the Department of Paediatric Neurology Unit, and Department of Paediatrics at the A, Rambam Medical Center and Technion-Israel Institute of Technology, Haifa, Israel. All children were tested with PSG followed by MSLT. The study concluded that the children with ADHD exhibited increased sombulance during the day which could be improved by using stimulant medication. The report recommends that sleep disorders should be looked into during clinical evaluation of children with ADHD.
- The ADHD and Sleep Conundrum: A Review
Judith Owens, in her review entitled “The ADHD and Sleep Conundrum” explores the relationship between ADHD and sleep. Owens opines that the relationship is complex and challenging. Referring to studies, the author states that ADHD is most prevalent in school going children between the ages 0f 6-12. She states that children exhibiting sleep disturbances also exhibit behavioural and academic disturbances. This fact points to the fact that sleep disorders play a role in the clinical diagnosis of inattention and other behavioural problems. A closer look at the sleep patterns of children with known ADHD has furthered the knowledge on the subject. The article further explores the relationship based on literature and research and goes on to indicate areas where further study may be required as well as suggest how clinicians may approach the diagnosis of ADHD along with sleep disorders.
- Review Article Sleep and ADHD
Authors: Eric Konofal a,b,*, Michel Lecendreux a, Samuele Cortese c
- Paediatric Sleep Disorders Center, Robert Debré Hospital, Paris, France
- Child and Adolescent Psychiatry Unit, Robert Debré Hospital, Paris, France
- Child and Adolescent Psychiatric Unit, University Hospital ‘‘Clocheville”, Tours, France
Sleep Medicine 11 (2010) 652–658 Contents lists available at ScienceDirect Sleep Medicine journal homepage: www.elsevier.com/locate/sleep
Konofal et. al. explore the relationship between sleep disorders and ADHD from the perspective of clinical management of the condition. They present studies conducted on the subject and treatment strategies based on these studies. These studies indicate that ADHD is most prevalent in children, and is diagnosed around the age of 7. The most significant symptoms are delay in onset of sleep, restless leg syndrome, differences in breathing pattern, periodic limb movements, and lack of alertness and attention during the day. These symptoms may be accounted for by medications for ADHD, however they are also seen in children who do not receive any medication. The authors further explore the possibility and need for further research.
- Subjective and objective measures of sleep in children with attention-deficit/hyperactivity disorder
Judith Owens a,*, R. Bart Sangal b, Virginia K. Sutton c,1, Rosalie Bakken d,
Albert J. Allen d, Douglas Kelsey d
a Brown Medical School, Ambulatory Pediatrics, Potter 200, 593 Eddy Street, Providence, RI 02903, United States
b Clinical Neurophysiology Services PC, Troy, MI, United States
c i3 Research, Cary, NC, United States
d Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, United States
Received 30 October 2007; received in revised form 11 March 2008; accepted 15 March 2008
Available online 6 August 2008
This study conducted by Judith Ovens from Brown Medical School, Providence, USA et. al. aims to compare the measures of sleep in children with ADHD. The study addressed a sample of 107 children who were diagnosed with ADHD and had not received any medication for the condition. The observations of this sample group were compared with those in a control group of 46 healthy children. All children in the sample group as well as the control group were aged between 6 to 14 years. The children were monitored for 5 days and the subjects as well as their parents, maintained diaries recording the behaviour of the subjects. The study showed that children with ADHD had shorter sleep time as compared to healthy children. The diaries showed that children with ADHD were significantly more sleepy during the day than the control group. Owens et. al. concluded that children with ADHD have reduced sleep both quantitatively as well as qualitatively as evidenced by restlessness and disturbed sleep. Parent reports showed more problematic behaviours. They recommended management strategies and medical treatment for ADHD.
Conclusion
ADHD affects the life of children both at home and at school. Children with ADHD are restless, impulsive and find it difficult to fix their attention for any length of time. They find it impossible to complete their tasks and are frequently losing their things like pencils and pens without which they cannot complete their tasks.
At school, when assignments are not submitted on time or school work is not completed, such children are reprimanded without a complete understanding of their problem. At home, they are not able to participate in activities with their peers and some are even unable to complete routine tasks independently. All this affects the lives of children with ADHD.
New research has proved that children with ADHD also have sleep disorders. The restlessness and hyperactivity percolates into their sleep and they are unable to get a restful sleep for any length of time. This makes them sleepy and tired during the day which further distracts them from their tasks.
Although there has been considerable research on the relation between ADHD and sleep disorders, the relationship needs to be further researched. Clinical psychologists and psychiatrists need to address the subject of sleep patterns of their patients during clinical assessment and follow-up. Medications should be used where indicated by the severity of the sleep disorder. Treatment for sleep disorders may also be called for which may have a positive effect on the ADHD. However all this needs to be well researched and proven.
