Jessica is a handful by daylight, and most observers outside her home heave a sigh for her parents that the day will eventually be done with, and night and sleep will be on the way. Ahhh! Sleep and quiet. But in reality, many parents of children with ADHD say that the night is filled with agitation, restlessness and sleeplessness, and the calm after the storm isn’t as tranquil as outsiders would like to believe.
In other words, the biology that helps define a child with ADHD doesn’t shut down at the stroke of 9 p.m. In fact, psychiatrists and sleep researchers are trying to understand whether the common ADHD sleep issues among children are cut from the biology of the behavioral disorder or a result of the mix of medicines these children have to take to calm their symptoms. In fact, there are researchers who are studying the possibility that the irritability, hyperactivity and inattentiveness of ADHD may, for some, be due to a lack of sleep.
Unfortunately, the jury is still out.
“Children with ADHD are so wound up that it takes them a long time to turn their motor off,” said Dr. Gabrielle Carlson, director of child and adolescent psychiatry at the State University of New York at Stony Brook. “It might seem that their energy level is there all the time.”
But what Carlson and others who work ’round-the-clock with severe ADHD, see is that children on Stony Brook’s inpatient unit sleep, well, like babies. They have no problems falling asleep — or staying asleep. “With structure, a lot of the sleep problems disappear.”
Canadian psychologist Rosemary Tannock and her research colleague, Penny Corkum, recently documented this in Tannock’s laboratory at the Hospital for Sick Children in Toronto. “We couldn’t find evidence that sleep was an integral part of the ADHD picture,” she said. The real culprits: the separation anxiety that many kids with ADHD share; stimulants; and a lack of a consistent bedtime routine.
Corkum added that the children with ADHD didn’t look different from those children with anxiety and other symptoms of mental illness. But Corkum, who is now at Mount St. Vincent University in Halifax, Nova Scotia, also said that shorter sleep times are generally related to more attention problems. “If your mind is racing, it is difficult to go to sleep.”
She believes that medicines could play an important role in keeping some children up and helping others to settle down. “If a child is suffering at night, you might want to look at an alternate dosing schedule.”
In the study, the scientists recruited 30 children with ADHD, and this was a special group of children whose parents said had severe sleep problems. An equal number of kids without ADHD were brought in to compare sleep patterns during a 7-day study. The children slept in their own beds and wore a wrist device, much like a watch, that records virtually every body move the child makes. The children and parents also kept sleep diaries throughout the week. Children with ADHD had no more movements than the kids without.
The researchers also looked for evidence of restless leg syndrome, the symptom de jour these days, and it was not a problem in the kids with ADHD who were studied. People who have restless leg syndrome describe it as an uncomfortable sensation — crawling, tingling, pulling or twitching feeling — that begins right before they fall asleep and forces them to move their leg. Some investigators believe there is a link between RLS and ADHD and one theory is that both share a lack of the brain chemical dopamine. Dopamine regulates movement as well as behavior and mood.
But these children clearly took longer getting to sleep, and had greater difficulty getting up in the morning. In fact, the kids with ADHD slept longer than the other children, suggesting that they need more sleep to integrate and store a brain system that Tannock says is “overloaded” during the day.
She has seen parents pull their hair out (figuratively, of course) trying to get their child to sleep. They use more requests, and there is far more follow-through. Over and over again. “Kids with ADHD are difficult to organize and the symptoms make it difficult to do things in a timely matter,” she explains.
Tannock and her colleagues can’t rule out the possibility that different medicine regimens in the United States may color another sleep picture for American children. Ritalin and other ADHD medicines are often used three times a day whereas in Canada it is given twice a day. What she is hoping to study is whether the high anxiety in these children — one third of them constantly worry about being alone — can be treated to overcome nighttime problems. Addressing the anxiety should be separate from treating the ADHD attention and hyperactivity problems, experts agree. Many now teach coping strategies so children can recognize “worry” symptoms — the racing heart, the agitation — and use mental exercises to help them go away.
Anyone who has ever lost a lot of sleep knows that concentration falls, memory slips and a bit of crankiness is justified. Isn’t that why we don’t want our kids staying up until all hours at a sleepover?
Researchers in Sydney, Australia are taking a different research road to understand ADHD and sleep problems. Dr. Arthur Teng and his colleague, Grant Betts, are studying 50 children in the sleep medicine unit at Sydney Children’s Hospital. Their theory is that these children are overly restless, cranky and uncontrollable simply because an underlying sleep problem is depriving them of a healthy sleep.
The researchers are testing children diagnosed with mild ADHD before and after they receive treatment for sleep disorders to see whether behavioral symptoms improve. The common sleep problems among these children: snoring and apnea, which is disrupted breathing. They believe enlarged tonsils and adenoids may cause sleep apnea, the periodic missed breaths during the night.
The Australian researchers have already completed the first part of testing on a few dozen children, and that includes memory and attention tests prior to treatment for their sleep disorders. They also obtain extensive parent and teacher ratings on behavioral and attention issues. Four months after the treatment, the children will be retested to see whether their ADHD problems have lessened.
This is just one theory — and needs proper testing before anyone makes the great leap to sleep treatment to rule out ADHD. In fact, John Harsh at the University of Southern Massachusetts is also testing whether children with ADHD are sleepier in the daytime than children without ADHD. During a recent meeting of the Associated Professional Sleep Societies, held in Chicago, Dr. William Orr, an Oklahoma City sleep specialist, said that he also believes that treating sleep disorders improves daytime behavior in children.
“ADHD seems to be a 24-hour condition, disrupting daytime and sleep,” says Lynne Lamberg, co-author of The Body Clock Guide to Better Health. Most people, she adds, “think about behavioral treatments but not the basic physiology and how that contributes to the symptoms.” During the recent sleep meeting, she listened to French researchers describe how giving Ritalin and similar medicines in the evening paradoxically decreases activity during sleep.
Dr. Ronald Chervin is acting director of the University of Michigan’s Sleep Disorders Center and a leading expert in ADHD and sleep. Chervin says that scientists are testing the idea that a child with ADHD has a biological clock, the body’s internal ticker that tells us when to fall asleep, that may be slightly off. A recent study by Reut Gruber of the federal National Institute of Mental Health in Bethesda reported that children with ADHD have a more varied sleep schedule than children without the behavioral disorder. Gruber found that children without ADHD fell asleep at roughly the same time during a five-day study period, within 40 minutes of lights out. But the children with ADHD had a very erratic ‘falling to sleep’ schedule, two to three times longer than the children without. The study was published in the April issue of the American Academy of Child and Adolescent Psychiatry.
The bottom line in all of these studies is this: Parents should tell their child’s doctor about sleep patterns, and ask if there is anything they can do to better help their child fall asleep at night.
Children need anywhere from 9 to 11 hours of sleep nightly, and it doesn’t take a scientist to tell you that the nation’s sleep debt is great. Last February, the federal government embarked on an educational campaign to promote healthy sleeping habits in children. (See the American Academy of Child and Adolescent Psychiatry‘s signs of sleep deprivation, below.)
No one knows why humans require sleep for at least a third of their day. There is strong evidence that sleep is restorative, the body needs quiet time each day to process the activities of the day. Scientists have discovered that dreams, which take place during a period of sleep called Rapid Eye Movement or REM, are important for learning and memory.
Rosemary Tannock advises parents that the best way to avoid sleep problems is to secure a set bedtime and make it pleasurable. “The child should know that at a specific time every night they can expect to be alone,” she says. “Give a 10-minute warning and then share a pleasant activity with your child. And make sure they have water before they can ask for it. Make it a relaxing routine.”