Why can't my child with ADHD sleep at night?
by Dr Berlinda Yeoh - Paediatrician, MBBS (Hons 1) USyd, FRACP, MPH
February 2019
by Dr Berlinda Yeoh - Paediatrician, MBBS (Hons 1) USyd, FRACP, MPH
February 2019
|
Does your child struggle to sleep each night? Do they pop in and out of bed multiple times for a drink of water, to ask yet another “burning” question that can’t wait until the morning, or want another goodnight hug? Do they wake often in the night and have trouble re-settling themselves? Are they difficult to wake in the morning? Certainly, for a significant number of the families I see, these are very common concerns, and ones that lead to substantial parental frustration.
|
|
Up to 70% of children with Attention Deficit Hyperactivity Disorder (ADHD) suffer from problems with their sleep. Almost half the parents of children with the diagnosis say that their child has moderate to serious sleep problems. Prior to puberty, 10 to 15 percent of children with ADHD have trouble getting to sleep. This is twice the rate found in children and adolescents without the disorder. This difficulty increases with age, with 70 percent of adults with ADHD reporting that they spend more than one hour trying to fall asleep at night. Sleep difficulties in children and adolescents with ADHD can be behaviourally-based and/or medically-based.
How much sleep do we need?
The above sleep duration recommendations are based on a report of an expert panel convened by the US based National Sleep Foundation and published in 2015 in their journal Sleep Health. http://www.sleephealthfoundation.org.au
Behaviourally based sleep difficulties in ADHD
Behavioural sleep problems in children with ADHD are similar to children with sleep difficulties without ADHD but occur more commonly. Children with ADHD and/or Oppositional Defiant Disorder (ODD) may struggle more to settle and follow bedtime routines. You may observe:
Behavioural sleep problems in children with ADHD are similar to children with sleep difficulties without ADHD but occur more commonly. Children with ADHD and/or Oppositional Defiant Disorder (ODD) may struggle more to settle and follow bedtime routines. You may observe:
|
|
Medically based sleep difficulties in ADHD
Sleep Disordered Breathing describes conditions ranging from obstructive sleep apnoea (OSA) to primary snoring. This has been consistently associated with neurobehavioral, including inattentive or ADHD-like symptoms. Sleep Disordered breathing in children with ADHD is approximately 25–30 percent compared with 3 percent in the general population.
Circadian-rhythm sleep disorders can occur when the normal physical, mental and behavioural changes throughout a 24-hour cycle, responding to light and darkness throughout the day are disrupted. One of the most common problems in this category is a delayed sleep-phase disorder, where sleeping and waking occur later than normal. This disorder may show up as difficulty getting to sleep, staying up too late and difficulty waking.
Anxiety symptoms in a child impact sleep as they may be worrying about being alone in bed, scared of the dark or worrying about things that have happened or will happen at school.
Stimulant medication can result in exacerbating or creating sleep difficulties with many children reporting difficulties falling asleep. This tends to be more of a problem in children who already had sleep initiation difficulties. Sometimes reducing the dose or changing timing of the dose can help.
Sleep Disordered Breathing describes conditions ranging from obstructive sleep apnoea (OSA) to primary snoring. This has been consistently associated with neurobehavioral, including inattentive or ADHD-like symptoms. Sleep Disordered breathing in children with ADHD is approximately 25–30 percent compared with 3 percent in the general population.
Circadian-rhythm sleep disorders can occur when the normal physical, mental and behavioural changes throughout a 24-hour cycle, responding to light and darkness throughout the day are disrupted. One of the most common problems in this category is a delayed sleep-phase disorder, where sleeping and waking occur later than normal. This disorder may show up as difficulty getting to sleep, staying up too late and difficulty waking.
Anxiety symptoms in a child impact sleep as they may be worrying about being alone in bed, scared of the dark or worrying about things that have happened or will happen at school.
Stimulant medication can result in exacerbating or creating sleep difficulties with many children reporting difficulties falling asleep. This tends to be more of a problem in children who already had sleep initiation difficulties. Sometimes reducing the dose or changing timing of the dose can help.
Consequences of poor sleep routine
Serious sleep problems in children can be very disruptive for daytime function for the household. The symptoms of sleep deprivation that children experience are not dissimilar to what we, as adults, would experience after a late night, and even more noticeable with chronic sleep deprivation. They may include:
Serious sleep problems in children can be very disruptive for daytime function for the household. The symptoms of sleep deprivation that children experience are not dissimilar to what we, as adults, would experience after a late night, and even more noticeable with chronic sleep deprivation. They may include:
- Tired and/or more irritable in the day
- Lethargic
- More prompting required for simple tasks
- Concentration and persistence with tasks is reduced
- Coordination can seem to be poorer
- More careless errors are made with everyday tasks and school work
- More emotionally reactive with crying or aggression with relatively smaller triggers
Poor sleep in children also has a significant negative impact on their parents, carers and siblings. Family members are likely to be sleep deprived themselves if kept up late or woken by their child during the night. They also bear the brunt of their child’s sleep-deprived frustrations. Poor sleep tends to result in more chaotic mornings which can increase family stress and conflict. Parents are also likely to have less quality evening time while being preoccupied with dealing with their child’s sleep routine, which can impact marital relationships, as well as create stress and mood concerns. Parents often report being late or even missing work due to their child's sleep difficulties.
Until we optimise a child’s sleep, treatment for ADHD and support for learning concerns are not going to be optimally effective.
How to improve sleep
Unfortunately, there is no easy solution and patience and persistence is required. Treatment of any underlying medical condition and referral to an ENT specialist or sleep physician is often required. This should be done first before any behavioural strategies are implemented to ensure the best chance of improvement.
Most children with sleep difficulties have sub-optimal sleep hygiene routines and dedicating a focus to improving this is important to improve sleep. Indeed, the biggest challenge for many of my patients is being able to put into place bedtime routines and to stick with the new routines and boundaries.
Until we optimise a child’s sleep, treatment for ADHD and support for learning concerns are not going to be optimally effective.
How to improve sleep
Unfortunately, there is no easy solution and patience and persistence is required. Treatment of any underlying medical condition and referral to an ENT specialist or sleep physician is often required. This should be done first before any behavioural strategies are implemented to ensure the best chance of improvement.
Most children with sleep difficulties have sub-optimal sleep hygiene routines and dedicating a focus to improving this is important to improve sleep. Indeed, the biggest challenge for many of my patients is being able to put into place bedtime routines and to stick with the new routines and boundaries.
|
Some important bedtime tips include:
|
|
Medication options
Melatonin: This naturally occurring peptide released by the brain in response to the sun and has some function in setting the body’s day/night cycle. It is available through your doctor. Melatonin may not be effective the first night, so several nights’ use may be necessary for assessing effectiveness.
Clonidine: Some practitioners recommend small doses one hour before bedtime. As this medication can reduce blood pressure, it is used less often now due to potential side effects. It exerts significant sedative effects for approximately four hours.
Melatonin: This naturally occurring peptide released by the brain in response to the sun and has some function in setting the body’s day/night cycle. It is available through your doctor. Melatonin may not be effective the first night, so several nights’ use may be necessary for assessing effectiveness.
Clonidine: Some practitioners recommend small doses one hour before bedtime. As this medication can reduce blood pressure, it is used less often now due to potential side effects. It exerts significant sedative effects for approximately four hours.
Sources
http://www.sleephealthfoundation.org.au
https://chadd.org/about-adhd/adhd-sleep-and-sleep-disorders/
Owens, Judith A, M.D., M.P.H. The ADHD and Sleep Conundrum: A Review, Journal of Developmental & Behavioral Pediatrics: August 2005 - Volume 26 - Issue 4 - p 312-322
Spender, T Biederman, J Willens T. Attention-deficit/hyperactivity disorder and comorbidity. Pediatr Clin North Am. 1999; 46915- 927
Sung V, Hiscock H, Sciberras E, Efron D. Sleep Problems in Children with Attention-Deficit/Hyperactivity Disorder: Prevalence and the Effect on the Child and Family. Arch Pediatr Adolesc Med. 2008;162(4):336–342. doi:10.1001/archpedi.162.4.336
http://www.sleephealthfoundation.org.au
https://chadd.org/about-adhd/adhd-sleep-and-sleep-disorders/
Owens, Judith A, M.D., M.P.H. The ADHD and Sleep Conundrum: A Review, Journal of Developmental & Behavioral Pediatrics: August 2005 - Volume 26 - Issue 4 - p 312-322
Spender, T Biederman, J Willens T. Attention-deficit/hyperactivity disorder and comorbidity. Pediatr Clin North Am. 1999; 46915- 927
Sung V, Hiscock H, Sciberras E, Efron D. Sleep Problems in Children with Attention-Deficit/Hyperactivity Disorder: Prevalence and the Effect on the Child and Family. Arch Pediatr Adolesc Med. 2008;162(4):336–342. doi:10.1001/archpedi.162.4.336