The relationship between Attention Deficit Hyperactivity Disorder (ADHD) and sleep disorders/problems is complex. The effects of sleep disorders (without ADHD) can lead to a clinical picture similar to ADHD and can even increase the symptoms in children who have been diagnosed with this disorder.
Accumulating evidence shows that behavioral treatments are effective in reducing some of these sleep disorders, and points to the need to perform a comprehensive sleep assessment as part of the clinical assessment of children suffering from attention deficit disorder.
ADHD affects many children and their families. These children are at increased risk of developing difficulties in social, academic and family functioning. Studies show that 59%-87% of children with ADHD suffer from at least one other psychiatric disorder and 20% suffer from three or more other disorders, including sleep disorders. It is important to note that most of the clinical and research work on this topic is devoted to the symptoms that appear during the day and not to the nocturnal symptoms.
Up to 70% of parents of children suffering from attention deficit hyperactivity disorder (ADHD) report disturbances and problems with their children’s sleep, such as difficulty falling asleep and difficulty maintaining the sleep sequence, even without the side effects of the stimulant treatment. A study conducted by Sung and associates from 2008 revealed that in school-aged children suffering from attention deficit hyperactivity disorder there is a relationship between the severity of the disorder and sleep problems and impairment of their quality of life and daily functioning. It was also found that compared to children without sleep disorders, children with moderate to severe sleep problems are more likely to be late for school or absent from it, and their parents are more likely to be late for their work.
However, as mentioned at the beginning, the relationship between ADHD and sleep disorders/problems is complex and influenced by a variety of factors. First, there is evidence that the treatment with stimulants, along with its benefits, may affect the quality of sleep. Second, the symptoms of the additional psychiatric disorders that these children may suffer from, such as anxiety and mood disorders, are related to sleep disorders themselves, and can negatively effect sleep by increasing struggles or resistance to going to sleep, disrupting sleep-promoting activities, resulting in lack of sleep hours or impairment in sleep quality.
Some of the sleep disorders and problems are related to ADHD even without the influence of the accompanying disorders mentioned. In a meta-analysis that was done, which did not include children with ADHD who are treated with medication or those who suffer from other disorders of anxiety or depression, it was found that parents of these children reported a higher frequency of problematic behaviors while going to sleep, while waking up, and during the night.
Another factor that contributes to the complex clinical picture is the effect that the drugs used have on the accompanying psychiatric disorders mentioned.
Finally, previous studies have also shown that children with ADHD may suffer more from additional sleep disorders, such as sleep-disordered breathing and night nightmares. Even without the existence of ADHD, any of these sleep problems can lead to symptoms similar to ADHD during the day, or alternatively, accompany this disorder and even increase the severity of the symptoms during the day.
In fact, there is a lot of overlap between the consequences of sleep disorders and problems and those of ADHD. The symptoms associated with both sleep problems and ADHD are difficulty concentrating and focusing, hyperactivity, irritability, lack of control over behavior, and more.
There are claims that many children diagnosed with ADHD suffer from a primary sleep disorder that can explain the clinical picture. In this context, it is important to note that according to many testimonies, even among children and adults who do not suffer from ADHD, when the quality of sleep is temporarily or permanently impaired, there is a significant effect on behavior, mood and cognitive function.
Assessment of sleep problems
Since sleep problems are common in children suffering from ADHD and due to their potential negative impact, it is highly recommended e to evaluate the sleep characteristics and sleep problems in these children. A subjective evaluation of sleep can include questionnaires for parents or interviews, or even filling in a weekly sleep diary that also includes the level of daily fatigue. Many behavioral questionnaires also have scales that assess sleep problems in general and can turn on a “red light” in case of a problem in this area and lead to a more comprehensive assessment of this subject. In these cases, it is even recommended to perform a comprehensive sleep assessment objectively or subjectively. Objective tools for sleep evaluation include, among others, testing in a sleep laboratory and home use of an actigraph.
Treatments for Sleep Problems for Children with ADHD
The most common treatment today in the treatment of ADHD is treatment with stimulants. However, as mentioned, several claims and concerns have been raised regarding the side effects of these drugs, thus it is important to develop interventions that will reduce the need for drug treatment.
Identifying sleep problems in children suffering from ADHD and treating these problems are important directions in this context. Many of the sleep problems of children with ADHD occur during bedtime, and are behavioral in nature. The effectiveness of behavioral interventions in the treatment of sleep disorders have been proven to be extremely effective among normal populations, and also in other populations of children suffering from more complex problems. However, the scope of research examining the effectiveness of behavioral approaches in the treatment of sleep disorders in children suffering from ADHD is small.
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