Is ADHD Actually a Sleep Problem?

Kids with ADHD sleep less well than other kids. Why is this?

Before we address this question, let’s back up and ask some preliminary questions:

A study published in the June issue of the Journal of Sleep Research presents some evidence that might help answer these questions.

These Danish investigators found that there is something funny about the way kids diagnosed with ADHD sleep. There are some notable and very important features of this study. The first has to do with the way researchers recruited families to participate.

The patients

Parents and pediatricians referred children to a clinic because of problems with attention. None of them had a diagnosis of ADHD. They filled out questionnaires and agreed to let their children have sleep studies. They did all of this before they had a diagnosis. In other words, the subjects were “blinded” to their placement in the study. This type of blinding helps remove any unconscious bias the parents may have had when answering the questions. By the end of the study, investigators had data from 76 children, average age nine. That’s not a huge study, but it is the largest study of ADHD sleep patterns to date.

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The study

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ADHD sleep and the brain

Parents kept a 1-week sleep diary, logging hours of sleep and various other data points. Then investigators fitted children with take-home sleep study (polysomnography) machines. Though not the most comfortable devices, most children tolerate them well. The machines measure brain wave activity, breathing and oxygen levels, among other things. Finally, researchers invited the children to a sleep lab to perform a Multiple Sleep Latency Test (MSLT). It’s a long name for a test that simply measures how long it takes you to fall asleep when you take naps during the day.

The results

The investigators also diagnostic tests for other disorders, such as autism, anxiety, and depression. They also performed intelligence tests and excluded children who scored an IQ less than 70. Investigators did not explain why they excluded mentally retarded children from the study. No part of the exams required any cognitive ability on the part of the child at all.

It turned out that 55 percent of the children with ADHD had some other diagnosis as well, called a “co-morbidity.” Before the study started, the investigators had guessed that children with multiple diagnoses would have more trouble sleeping.

This was not the case.ADHD sleep 3

To their surprise, investigators found that children with multiple diagnoses had the same sleeping patterns as children with only an ADHD diagnosis.

Shorter Sleep

Children with ADHD did not sleep as long as children in the control group. On average the 76 children with ADHD slept 501.9 minutes (about 8 hours and 20 minutes). Control children slept an average of 543.6 minutes (just over 9 hours).

Children in the ADHD had more sleep cycles (6.2) than the controls (4.4). In other words, the rise and fall of sleep, also called “sleep architecture” was significantly different.

It takes 10 minutes longer for children with ADHD to fall asleep at night, compared with control children.

By contrast, when taking the MSLT test, children with ADHD fell asleep faster, suggesting they are sleepier during the day despite being reported as more hyperactive and restless.

Taken together, these results suggest that the sleep of children with a diagnosis of ADHD may sleep differently than other children. What does this mean?

Is ADHD a problem with the part of the brain that controls attention and alertness? This has been the theory for decades. This theory is the basis of ADHD treatment with stimulants.

Sleep is more complex than this. Many parts of the brain are involved. Could it be that the symptoms of ADHD are caused by some other oddity in the way the brains of ADHD kids work?

ADHD Sleep TheoryADHD sleep 4

The results of this study are interesting, but raise more questions than they answer. At the end of the paper, investigators admitted that “it remains unclear whether sleep disturbances in ADHD are an aetiological (causal) factor, a co-morbid disorder or the result of an overlapping neurodevelopmental disorder of the brain.” In other words, the investigators cannot say whether kids with ADHD sleep poorly, or whether kids who sleep poorly have symptoms of ADHD.

What Imbalance?

This study provides another nail in the coffin of the “chemical imbalance theory“. This theory stated stated that ADHD was caused by too little stimulatory neurotransmitter in the brain.

Investigators also avoided making an obvious point: If symptoms of ADHD correlates with a sleep disorder, then giving amphetamine-based medications to children probably will not correct the underlying problem. The opposite is more likely. Indeed, insomnia is a well-known side effect of Ritalin and other ADHD drugs.

And lack of sleep never helped a distractible child.

Insomnia in Children

There’s something important about insomnia that I did not know before I studied it.

I confess I thought of insomniacs as people who stayed up all night because they did not get tired. I was wrong. People with insomnia are not merely tired. They are exhausted. They want to sleep desperately but cannot. The less they sleep the worse a person suffering with insomnia feels.

Worst of all, perhaps, children suffer from insomnia too. And it’s more common in children than I ever imagined. Some experts believe that as many as 30% of children suffer from insomnia or other significant sleep disturbance.

Insomnia in Children is Different from Adult Insomnia

…in some ways at any rate. It is often the parent, not the child, who first notices that there is a problem. And children have a type of insomnia that develops with the “help” of their parents. I’ll get to that a little later. But many of the causes are very similar to the things that keep adults awake. In fact, many adults report that they’ve had trouble sleeping since childhood.

The simple definition of insomnia is “habitual sleeplessness”. But embedded in that simple definition is the entire field of sleep problems in children. The problem is most often lack of sleep, or absence of enough sleep. The trick is to figure out what makes the absence of sleep “habitual”.

In children, we tend to define insomnia by its effects, not by its duration. If the sleeplessness has a negative effect on the child or her parents, it does not matter how recently it started or how long it lasts.

Long- and Short-term

Having said that, sometimes it’s useful to ask how long the child has had trouble sleeping. Short-term reasons for sleeplessness include illness, or a medication the child is taking. The sleep problem will often go away when the child recovers or stops the medication. But if the child is not sick or taking medication, and yet the sleep problem happens at least three times per week, and/or lasts more than a month, there might be another problem that deserves medical attention.

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I firmly believe that sleep is the natural condition. Children (and adults) sleep naturally unless there is something keeping them from sleeping. So it’s essential to figure out what is keeping the child awake.

Symptoms

In children, you are less likely to have her come up to you and say “Gee, mom, I’d really like to sleep but I can’t!” More likely, you’ll notice something is wrong before she does. Common symptoms in children include:insomnia 5

  • Early Waking: Typically, we’re talking about a child who awakens at 3:45 AM and appears to be up for the day. This may appear first as an annoyance to parents. It’s important to realize the child is not doing this on purpose!
  • Anxiety about going to bed and being able to fall asleep: The child knows they’ll have trouble falling asleep and they’re anxious about it. These anxieties can take the form of fear of the dark, or fear of monsters under the bed. The more anxious they become, the tougher it gets for them to fall asleep!
  • Daytime Sleepiness: Even if you believe the child is sleeping at night, they might not be getting enough restful sleep. They’ll tire out during the day.
  • School or behavior problems: Sometimes the first sign of a sleep problem will be notes coming home from school. Or you may notice the child misbehaving when she never did before. Or she’s misbehaving more often than before.
  • Irritability/mood swings: Irritability simply means sensitivity to changing moods quickly. This is different from simple grumpiness. The parent reports that the child is “easily set off”, or that she “flies into a rage” over seemingly small things. Lack of sleep will do this to a child (or an adult, for that matter!)
  • Depression: Sometimes the sleepless child will not be irritable or badly behaved. She’ll just have a flat, or depressed mood. It’s difficult sometimes to know which caused which, lack of sleep or the depression (more on this below)insomnia 1
  • Hyperactivity: It’s not unusual for children to misdiagnosed with ADHD. To some extent, this is understandable. Lots of things are mistaken for ADHD. Narcolepsy and Restless Legs Syndrome, for example. But neither is this an excuse. Whenever teachers or any other authority suggests to you that your child may have ADHD, it’s necessary to rule out other causes for the behaviors.
  • Decreased attention span: It’s difficult to concentrate when you haven’t slept. Most of the time the child herself will not realize she cannot stay on task. It will be pointed out to her by others.
  • Aggression: This is a product of the irritability mentioned above. A previously docile child may lash out unexpectedly. This is a red flag that should always raise concerns about a sleep disturbance.
  • Memory problems: There is a close association between sleeplessness and memory problems. It is suspected that a normal sleep pattern is necessary for solidifying memories. This is important to remember for students pulling “all-nighters”. Lack of sleep never helps memory.
  • Making errors or having accidents: This is a particularly serious, potentially deadly sign in young drivers. Attentiveness, distractibility, and reaction time are all affected by sleeplessness.

What Causes Insomnia in Children?

  • Stress: We like to think of childhood as carefree and blissful. Sadly this is a myth. It always has been a myth. Childhood is stressful, more or less for many, if not most children. Children have a limited number of ways to communicate that things are not okay in their world, and loss of sleep is one of them (the others are acting out and refusing to eat).
  • Caffeine or other stimulants: Many parents do not realize just how much stimulant their children are consuming in the form of soda and so-called “power drinks”. Leave aside the issue of sugar, and the damage it wreaks! You should always examine the diet of a child who cannot sleep.insomnia 3
  • Medications: The treatment for ADHD is notorious for causing insomnia. The medications are amphetamine-based stimulants. One thing for certain is that no inattentive child is made more attentive by losing sleep! These medications should be very closely monitored to say the least, if not eliminated entirely.
  • Medical causes: Difficulty breathing is a common, often unrecognized cause of sleeplessness. Sometimes sleep disturbance is the first sign of asthma in children. Children with obstructive sleep apnea often have a great deal of difficulty staying asleep. If a child is too itchy from her eczema, or too uncomfortable with her heartburn (reflux), she may have trouble falling asleep and staying asleep. Finally, thyroid problems may cause sleeplessness. All these potential causes should be addressed with a physician.
  • Psychiatric causes: Depressed children often do not sleep well. Their anxiety and irritability may be worse at night when they are not distracted by daytime activities. And then there is the cause no one wants to talk about, physical or sexual abuse. Nevertheless, abuse is a cause of sleeplessness and we should take it seriously.
  • Environment: Places that are too loud, too hot, too cold, or too light are difficult to sleep in. So are places where electronic devices are too close by!

The Special Cause of Childhood Insomnia

There is one cause of sleeplessness in which the parents are very much part of the cause. Many children cannot sleep because their parents did not allow them to learn to fall asleep on their own. These are the parents who, with the best of intentions, allow their children to develop bad sleep associations. The problem may be that the child needs contact with parents to fall asleep. Or perhaps the child needs to have a bottle or pacifier. These dependencies often lead to sleep problems that the parents end up wishing they never got into.insomnia 4

Another cause is parental lack of limits-setting at bedtime. Again, I’m sure this is done with the best of intentions, but the results can be devastating for sleep. For example, the child who asks for glasses of water repeatedly, or who is allowed to wander the house at bedtime.

Treating Insomnia in Children

The treatment is based on fixing the cause or causes. That’s why it is so important to understand all the possible ways that a child can lose sleep. Regardless of cause, there are some basic sleep techniques that are always helpful:

  • Set a consistent bedtime and routine: Everybody, child and adult, sleeps better when their day is regular and bedtime is is the same time every night. The bedtime routine should be the same as well. It should be as calm and as free of stimulation as possible. If the problem is truly that the child is not tired, try moving bedtime later, by 15 minutes at a time, until the child is good and ready for bed!
  • Comfortable sleep environment: Not too hot, not too cold, quiet and dark! It’s a good idea to keep clocks out of the room of a person who has trouble sleeping. This is especially true of clocks that glow in the dark. It goes without saying that devices with screens must be eliminated. They are the enemies of sleep!
  • Relaxation techniques: Most parents do not know how to teach relaxation. But there is an entire industry of relaxation products available that can help teach a child (or an adult for that matter) how to relax at bedtime. An easy way to start is to make the time between dinner and bedtime as boring and non-stimulating as possible.
  • No tossing and turning! If a child will toss and turn instead of sleeping, have her get out of bed and do something relaxing but boring, like reading in low light. Try this for 20 minutes at a time. If this does not work, have the child repeat at least twice.
  • Cognitive Behavioral Therapy: If medical causes have been ruled out, and you cannot help the child using these techniques, it may be useful to seek the help of a therapist. If nothing else, a therapist may help a child manage the anxiety that so often magnifies sleeplessness.insomnia 6
  • The Bell on the Door: For the child who insists on sleeping with you, I recommend calmly but firmly leading the child back to bed. No arguments, no explanations. You can even tie a bell to the child’s door and respond immediately when you hear it ring. If you do this correctly and do not give in, the child will give up trying to sleep with you.

What About Medications?

I and most sleep experts caution strongly against the use of medications to treat insomnia in children. The first and most important job of the physician and the sleep coach is to find the cause and to treat it. Only in the rarest circumstances, and only as a last resort, should you medicate a child for sleeplessness. The downsides outweigh the upsides. As with teaching a child to sleep on her own when she’s a baby, so it is with curing insomnia. If it is a medical problem, it should be identified so you can treat it. If it is a problem of environment or diet, these should be adjusted.

And if the problem is simply that you’ve developed bad sleep associations or poor limits-setting, these should be reversed. In some ways, these are the toughest causes of insomnia to fix. But fix them you must. The entire family’s sleep depends upon it.

Snoring: Why Your Toddler Does It

I can hear my kid snoring from down the hall!

She snores like an old man!

There are two kinds of snoring: the kind you don’t have to worry about and the other kind. How can you tell which is which?

Two Kinds of Snoring

There are two kinds of answers: the short answer and the long answer. The short answer is “see your pediatrician if you have any questions or concerns about your child’s snoring”. The longer answer is… well, read on!
Snoring is more than just loud breathing. When you sleep, the muscles in your upper airway (nose, mouth and upper throat) relax and become narrower. As you inhale, the upper airway wants to get even more narrow. This is because the air pressure goes down (you wouldn’t be able to inhale air into your lungs if the pressure didn’t go down in your airway – so this is a good thing).

Sometimes the airway becomes so narrow that the walls of the mouth and throat slap together audibly. This is the sound of snoring. If someone’s upper airway is narrower than normal, or floppier than normal, the more likely the “slapping together” is going to happen, giving rise to snoring.

Big Tonsils, Big Adenoids

One thing that can make an upper airway narrower than normal is big tonsils and adenoids.snoring

Before going on, we should talk a little about adenoids, because many people have heard of them but don’t really know what they are. As you can tell from the picture, one reason you may not know what adenoids are is that you can’t see them in most people’s mouths. They’re located high up at the place where the nose meets the throat.

Adenoids are part of your immune system. In people with allergies, adenoids can get large. They can get so large that they can partially or totally block off the nasal passages. People in this situation need to breathe through their mouths all the time. If they need to breathe through their mouths only during sleep, the person is more likely to snore. When adenoids are so large that they cause serious breathing problems, and trials of medical therapy do not work, patients and their doctors often choose to have them removed.

Snoring because of tonsils is easier to understand because you can see really big tonsils can get in the way of air flow. People with allergies can have big tonsils, as can people who have lots of throat infections. It used to be that frequent bouts of tonsillitis were the main reason tonsils were removed. This is no longer the case. Today, the most common reason for tonsillectomy is obstructive sleep apnea (OSA).

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What is OSA?

snoring 3
Uh-oh. Obstruction

The problem of OSA is defined by its name. The upper airway becomes obstructed during sleep, leading to pauses in breathing. Apnea literally means “cessation of breathing”.

It may be obvious why pauses in breathing can be a problem, but the consequences may not be well known. While snoring, people with OSA, including children, send signals to their brains that they are not inhaling enough oxygen. The signal causes the person in deeper sleep to arouse enough to shift, move, and sometimes fully awaken. Normal rhythm of sleep is disrupted. These people do not get enough restful sleep.

In children, this chronic lack of restful sleep can lead to behavior problems. In fact, many children who carry the diagnosis of ADHD are in fact suffering from chronic sleep deprivation due to OSA. I have seen a few children who had been diagnosed with ADHD cured by tonsillectomy/adenoidectomy.

For reasons that are not well understood, some children who wet the bed frequently do so because their breathing is disrupted during sleep. Again, many cases of bedwetting have been cured by treatment for OSA and other causes of “sleep disordered breathing“.

Young drivers with sleep disordered breathing tend to be less alert and are known to get into more frequent accidents.

Big Kids

Sadly, OSA is becoming more common in childhood because of the rapid rise of obesity. The thicker one’s neck is, the narrower the upper airway. Sometimes the only way to reverse airway obstruction is weight loss. And of course, the best, healthiest way to do this is healthy diet and exercise (see how diet, exercise and sleep all tie together?)

snoring
Not my fault I snore. I was bred this way

Does everybody who snores have OSA?

No. Sometimes it’s just plain “simple snoring”. This is loud breathing during sleep that does not lead to all the negative consequences I’ve detailed here. I lay out all this detail because it may not be immediately obvious that behavior problems or bedwetting may be related to sleep disordered breathing. The only way to tell sometimes would be to perform an overnight sleep study.

Non-surgical Therapies

Not everybody with OSA has to have surgery. For allergy sufferers who snore, even toddlers, the treatment may involve removing allergic triggers from the child’s environment, or simple over-the-counter allergy medications. Consult your child’s pediatrician about this if you suspect allergies.

Take Care of It Early

OSA can be annoying and lead to behavior consequences and bedwetting. But these symptoms tend only to occur in childhood. The reason to pay close attention to snoring in childhood is because over time, OSA can cause cardiovascular problems such as high blood pressure and heart disease. The sooner OSA is reversed, the easier it is to reverse these complications.

So if you have any question at all as two whether your child’s snoring is the normal, boring kind, or the kind that deserves attention, I recommend seeking medical attention. The impact on your child’s lifetime health and wellbeing may be substantial.