By Barbara Howard, MD
The day wouldn’t be so bad if he would just go to sleep at night! How many times have you heard this plea from parents of your patients with ADHD? Sleep is important for everyone, but getting enough is both more important and more difficult for children with ADHD.
About three-quarters of children with ADHD have significant problems with sleep, most even before any medication treatment. And, inadequate sleep can exacerbate or even cause ADHD symptoms!
Solving sleep problems for children with ADHD is not always simple. The kinds of sleep issues that are more common in children (and adults) with ADHD, compared with typical children, include:
Behavioral bedtime resistance
Circadian Rhythm Sleep Disorder (CRSD)
Periodic Limb Movement Disorder (PLMD)
Restless Leg Syndrome (RLS)
Sleep Disordered Breathing (SDB)
Such a broad differential means a careful history and sometimes even lab studies may be needed.
Careful Histories, Assessments, and Studies
You will be helped at both initial and follow-up visits for ADHD by including:
A sleep history
A tool, e.g.
BEARS sleep screening tool
Children’s Sleep Habits Questionnaire
2-week sleep diary (http://www.sleepfoundation.org/) to collect signs of:
Apnea (for SDB)
Limb movements or limb pain (for RLS or PLMD)
You also need to ask about:
Mental health disorders or their treatments
Enuresis (alone or part of nocturnal seizures)
Electronics activating the child before bedtime – hidden under the covers, or signaling messages from friends in the middle of the night – and to encourage limits on these.
Some sleep disorders warrant polysomnography in a sleep lab or from MyZeo.com (for PLMD and some SDB), and checking on ferritin less than 50 mg/L (for RLS) for diagnosis and to guide treatment. Nasal steroids, antihistamines, or montelukast may help SDB when there are enlarged tonsils or adenoids, but adenotonsillectomy is usually curative.
Improve Sleep Hygiene
The first line and most effective treatment for sleep problems in children with or without ADHD is improving sleep hygiene. Improved sleep “hygiene” sounds easy, but for children with ADHD and their parents, who often have ADHD too, changing behaviors can be tough!
The key component is establishing habits for the entire sleep cycle – ideally 7 days per week:
A steady pattern of reduced stimulation in the hour before bedtime (no electronics)
A friendly rather than irritated bedtime routine
Bedtime stories read to the child can soothe at any age, not just toddlers!
Same bedtime and wake up time
Varying bedtime by up to 1 hour won’t mess up most biological clocks, but for some even this should be avoided
Sleeping alone in a cool, dark, quiet room, nightly in the same bed (not used for other activities), is considered the ideal
Earplugs, white noise generators, and eye masks may be helpful.
If sleeping with siblings is a necessity, bedtimes can be staggered to put the child to bed earlier or after others are asleep.
Struggles and Solutions
Struggles postponing bedtime may be part of a pattern of oppositionality common in ADHD, but the child may not be tired due to:
Being off schedule (from CRSD)
Napping on the bus or after school
Unrealistic parent expectations for sleep duration
Parents may want their hyperactive children to give them a break and go to bed at 8 p.m., but children aged 6-10 years need only 10-11 hours and those aged 10-17 years need 8.5-9.25 hours of sleep.
“Not tired” may instead be “wired” from lingering stimulant effects or even lack of such medication leaving the child overactive or rebounding from earlier medications.
Lower afternoon doses or shorter-acting medication may solve lingering medication issues
Sometimes an additional low dose of stimulants will actually help a child with ADHD settle at bedtime
All stimulant medications can prolong sleep onset, often by 30 minutes, but this varies by individual and tends to resolve on its own a few weeks after a new or changed medicine
Switching medication category may allow a child to fall asleep faster.
Atomoxetine and alpha agonists are less likely to delay sleep than methylphenidate (MPH)
If sleep issues are causing significant problems, medication for sleep is worth a try.
Controlled-release melatonin 1-2 hours before bedtime has data for effectiveness. There is no defined dose, so the lowest effective dose should be used, but 3-6 mg may be needed.
Sublingual melatonin that acts in 15-20 minutes is a good alternative or even first choice
Clonidine 0.05-0.2 mg 1 hour before bedtime speeds sleep onset, lasts 3 hours, and does not carry over to sedation the next day
Stronger psychopharmaceuticals can assist sleep onset, including low dose mirtazapine or trazodone, but among the side effects are daytime sleepiness
Management of waking in the middle of the night can be more difficult to treat as sleep drive has been dissipated. First, consider whether trips out of bed reflect a sleep association that has not been extinguished e.g. TV. Then consider:
A daytime atomoxetine or MPH may improve night waking
A low-dose evening, long-acting medication, such as osmotic release oral system (OROS)
Extended release methylphenidate HCL (OROS MPH)
Short-acting clonidine or melatonin in the middle of the night
Bedtime mirtazapine or trazodone are last resorts
Anxiety and other coexisting disorders
When dealing with sleep, keep in mind that 50% or more of children with ADHD have a coexisting mental health disorder including:
These often affect sleep onset, night waking, and sometimes early morning waking. The child or teen may need extra reassurance or company at bedtime (siblings or pets may suffice). Reading positive stories or playing soft music may be better at setting a positive mood and sense of safety for sleep, certainly more so than social media, which should be avoided.
Keep in mind that substance use is more common in ADHD as well as with those other mental health conditions and can interfere with restful sleep and make RLS worse.
Bipolar disorder can be mistaken for ADHD as it often presents with hyperactivity but also can be comorbid. Sleep problems are increased six-fold when both are present. Prolonged periods awake at night and diminished need for sleep are signs that help differentiate bipolar from ADHD. Medication management for the bipolar disorder with atypicals can reduce sleep latency and reduce REM sleep, but also causes morning fatigue and other major side effects.
Medications to treat other mental health problems can help sleep onset (for example, anticonvulsants, atypicals), or prolong it (SSRIs), change REM states (atypicals), and even exacerbate RLS (SSRIs). You can make changes or work with the child’s mental health specialist if medications are causing significant sleep problems.
There is Hope!
When we help improve sleep for children with ADHD, it can lessen not only ADHD symptoms but also some symptoms of other mental health disorders, improve learning and behavior, and greatly improve family quality of life!
Excerpts by Dr. Barbara Howard from Pediatric News. Dr. Howard is also the co-founder of CHADIS.
CHADIS is a unique screening, decision support and patient engagement system designed to streamline and optimize healthcare by providing clinicians with evidence-based data that improves diagnosis and management of health, emotional, developmental and behavioral concerns. www.chadis.com
CHADIS offers over 600 tools to help doctors, educators, and parents screen for and monitor a variety of developmental, behavioral health, and general health issues for children and adults. Tools Link
The CHADIS platform offers many ADHD related questionnaires as well as an ADHD module that gathers pre-visit ADHD information from parents AND teachers without any clinician effort and is FERPA compliant. The module offers graphics of questionnaire data, and suggests tailored, research-supported goals for clinicians to review with parents and generates 504 Plan and IEP letters. See more.