Sleep Disturbances & ADHD in Children

Three parts in Dr. Cortese Conference Session:

In the first one, he presented the results of the most recent systematic reviews and meta-analyses on the subjective (i.e., reported via questionnaires) and objective (i.e., assessed via actigraphy or polysomnography) sleep alterations in children and adolescents with ADHD.
In the second part, he discussed the bidirectional links between ADHD and sleep disorders and how sleep disturbances add to the burden of ADHD.
In the third part he presented the evidence-base for the treatment of sleep disturbances in ADHD.

Part 1: Meta- analysis

Sleep and ADHD in the clinical practice used to be overlooked by clinicians. This is changing with more recent guidelines including “sleep" issues specifically. The relevance of sleep issues relate to ¹ distress it causes for the child and the family, the fact that sleep disturbances may worsen ADHD symptoms and that sleep disturbances may mimic ADHD symptoms in children misdiagnosed with ADHD. The meta-analysis conducted by Cortese et al ² concluded that children with ADHD are significantly more impaired than the controls in most of the subjective and some of the objective sleep measures. These results laid the groundwork for future evidence-based guidelines on the management of sleep disturbances in children with ADHD.

A second study ³ , from 2016, found significant differences only in the meta-analysis with polysomnography as outcome. Children with ADHD were found to spend more time in stage 1 sleep than controls (pooled SMD = 0.32, 95% CI = 0.08-0.55, p value = 0.009). Although few differences in sleep between children with ADHD and controls have been found, further studies are required to examine the influence of assessment criteria and ADHD subtypes in the sleep characteristics of children with ADHD.

Part 2: Disorders

Several comorbidities may add to sleep issues in ADHD children.
Circadian rhythm disorder ⁴ADHD children with difficulties falling asleep may present with a circadian rhythm disorder determined by a delayed dim light melatonin onset.

Restless Leg Syndrome ⁵ (RLS)
RLS was found to be common in ADHD children and adolescents. RLS-mimic conditions were found in two-thirds of patients who previously met 4 essential RLS criteria. First-degree relative with RLS symptom was associated with RLS, and RLS was associated with functional impairment in the life skills and school (behavior) domains.

Sleep Disordered Breathing (SDB) – Differential Diagnosisor Co-Morbidity?

Primary disorder of alertness.

ADHD per se may account for difficulties falling asleep in some children with ADHD

Part 3: Evidence-base for the treatment of sleep disturbances in ADHD

Pharmacological Management ⁶ may have direct implications on sleep behavior. In a Metanalysis by Faraone et al. from 2019, significantly increased RRs for methylphenidate-associated sleep-related AEs were seen for: general insomnia (RR = 1.61, z = 9.2, P < .001), initial insomnia (RR = 2.78, z = 6.6, P < .001), middle insomnia (RR = 2.97, z = 183, P < .001), combined insomnia (RR = 2.97, z = 6.4, P < .001) and general sleep disorder (RR = 1.99, z = 4.2, P < .001)

The need for randomized control trials has been highlighted ⁷ as well as non -pharmacological treatments. The full study results by Corkum et al ⁸ for which only preliminary analyses were available when Cortese et al. reviewed the literature in 2012, have been published. This RCT aimed to assess the efficacy of a five-session manualized behavioral intervention for sleep problems in children with or without ADHD. The study showed that sleep of children randomized to the study intervention was rated as significantly improved by parents, compared to the control group, at postintervention (2 months) and 6-month follow-up.

Final recommendation for managing sleep disorders in ADHD⁹:

• Monitoring
• Implement sleep hygiene
• If behavioral measures are insufficient and it is not convenient to stop medication, review the possible causes of sleep problems:
• Treat RLS, mild sleep-disordered breathing (adenotonsillectomy) 
• Consider rebound effect with psychostimulants: add small doses of short-acting psychostimulants in the evening
• If psychostimulant is the current treatment: consider reducing dose, alternative classes or formulations of psychostimulants, or atomoxetine (ATX)
• Consider adding melatonin

Presenter:

Dr. Samuele Cortese, MD, PhD is currently Professor of Child and Adolescent Psychiatry at the University of Southampton and Honorary Consultant Child and Adolescent Psychiatry for Solent NHS Trust. He is a member of the European ADHD Guidelines Group, as well as of the child and adolescent psychiatry faculty of the European Collegium of Neuropsychopharmacology (and of the British Association of Psychopharmacology-child and adolescent psychiatry module).