Don't Lose Sleep Over It!
By: Carolyn E. Hart
AD/HD and sleep problems
Sleep problems are very common among children and adults with AD/HD. In fact, about 80 percent of them struggle with sleep in some way and are among the 70 million Americans who are chronically sleep-deprived. Although we still do not know exactly why the brain needs to sleep, all species need certain regular amounts of sleep. Human babies need 18-20 hours of sleep each day, children need 9 - 11, teens need 8 - 10, and adults need 7 - 9. Surveys have shown that our grandparents generally got enough sleep whereas in our fast-paced lives today, most of us are sleep-deprived. Teens especially tend to run a "sleep-deficit," naturally falling asleep later and awaking later than at other ages. This circadian pattern does not fit well with classes starting at 7:00 or 7:30 a.m. in many schools. Consequently, many teens' schoolwork and relationships suffer due to fatigue. At any age, sleep deprivation causes many problems, including headaches, irritability; AD/HD-like symptoms, hypertension and even heart problems. Inadequate sleep is a major public health issues that is very common and often overlooked.
Sleep difficulties among people with AD/HD can be divided into two categories: trouble falling asleep and trouble staying asleep.
Difficulty failing asleep, or sleep-onset insomnia, is the most common sleep problem associated with AD/HD. Many young patients of mine describe not being able to settle down and "stop thinking" at bedtime. Distracted thinking after stimulants have worn off may make them unable to focus enough to relax and fall asleep. For these youngsters, moderate afternoon exercise, maintenance of consistent bedtime routine and relaxation strategies in bed may be sufficient. However, when that doesn't work, a mild sleep aid like clonidine or melatonin (a hormone/antioxidant) could be helpful. Ironically, a small dose of stimulant medication in the late evening can sometimes help when distracted thinking is the problem.
- Try to go to bed (or put your children to bed) at the same time every day.
- Avoid resorting to naps or sleeping in on weekends to "catch up" on sleep.
- Eat right and exercise regularly.
- Lose or gain weight if needed.
- Seek treatment for allergies, pains, snoring or other problems that disrupt sleep.
- Avoid caffeine and nicotine.
- Don't use alcohol to go to sleep.
- Avoid heavy exercise and arguments in the evening.
- Listen to your parents or spouse when they say it is time for bed.
- Relax your mind and body, and once in bed, ZZZZZzzzzzz.
There are also a variety of other barriers at bedtime including uncompleted homework (the midnight scholar), gripping television shows and video games (the "just a few more minutes" sleeper), bedtime fears or loneliness (the "please stay with me sleeper"), and oppositionality (the bedtime warrior). Each of these presents unique challenges, but each can be successfully managed with consistent maintenance of schedule, rules and good parental example. Brief professional counseling may be needed if the problem is entrenched. For more tips, see the Sleep Tips table.
Adults with AD/HD often contend with similar barriers at bedtime, including worry, loneliness, uncompleted tasks, caffeine or nicotine effects, and overfocusing on the Internet or other engrossing activities. A spouse or partner's reminders to come to bed often go unheeded. Self-awareness, regular exercise and improved bedtime habits are the best solutions, but again, sleep-promoting medication may be needed. There may be side effects to consider when medication is selected as an option, so it should be used rarely, usually in cases where other interventions have proven ineffective. Options include clonidine, melatonin, zolpidem, zaleplon, and trazodone. I usually avoid prescribing benzodiazepines like alprazolam due to the likely development of tolerance and possibility of addiction.
Difficulty staying asleep is another common problem for people with AD/HD. Many are restless sleepers who tear up the bed in the night, and others are "fragile sleepers" who waken at the slightest noise.
About one-third of children with AD/HD have bedwetting or nocturnal enuresis, and although many outgrow this by age ten, some persist into the teenage years. Management strategies such as limiting fluids after supper and voiding at bedtime can be helpful, but often medications are necessary, at least for camp and sleepovers. Old-fashioned imipramine is still useful for enuresis, but the newer DDAVP, a hormone that decreases urine production, is now more often used.
Nocturnal enuresis is due to immaturity of certain control circuits and is not willful. Many children are deeply ashamed of this problem, and it is important to explain enuresis to them openly and to include them in clean-up tasks, but not in a punitive way. One enuretic boy recently wept quietly behind his mother, while pleading in her ear not to tell me "his secret." Thankfully, adults with AD/HD do not have this problem, since everyone eventually outgrows enuresis of this type.
Other common sleep-associated problems or parasomnias include sleep-talking (somniloquy), sleep-walking (somnambulism), sleep anxiety and unusually vivid dreams. If these cause sleep disruption or dangerous roaming about in the night, clonazepam or other agents which alter the ratio of REM sleep time to non-REM sleep time may be helpful.
Obstructive Sleep Apnea (OSA) and Periodic Limb Movement Disorder (PLMD) are also common, but under- recognized sleep foes. OSA can affect anyone at any age, not just overweight adults. Snoring and lapses in breathing are helpful clues, but are not always present. PLM's are jerking movements of the legs, arms or the whole body, and if frequent and violent enough, they can awaken a person multiple times each night. PLM's are sometimes associated with daytime feelings of uncomfortable restlessness in the legs or Restless Legs Syndrome (RLS). OSA and PLMD are usually diagnosed by a sleep study (polysomnogram or PSG). PSG should not be done routinely for children or adults with AD/HD, but should be considered if daytime fatigue and lack of concentration persist despite intervention, or if snoring or PLM's are observed to cause arousals from sleep. OSA is usually treated with CPAP (continuous positive airway pressure) which entails wearing a mask through which air blows all night. Although this takes some "getting used to," it really works. PLMD is treated with various medications including clonazepam and dopamine (brain released chemical) agents such as ropinirole and pramipexole.
Narcolepsy can also coexist with or imitate AD/HD This is a disorder in which sleep and wakefulness are not cleanly distinct, but intrude on each other. This too should be diagnosed with PSG. It is treated with a combination of medication at night to improve sleep quality and daytime stimulants to improve alertness.
Nocturnal seizures and allergy symptoms are two medical causes of sleep disruption. Both usually give daytime clues too, but often allergy symptoms worsen at night and seizures might only occur during deep sleep so parents may not be aware of these problems. Electroencephalogram (EEG) monitoring, PSG, and allergy testing should be considered if fatigue and inattention seem resistant to treatment efforts. One young teen was brought to me for an evaluation regarding suspected AD/HD; she fell asleep sitting in my tenth floor window seat, drooling down the window, while her parents told me her life story. She turned out to have nocturnal allergy symptoms and not AD/HD.
Some people with AD/HD simply have trouble staying asleep and awaken often in the night or too early in the morning. When this causes daytime fatigue or family sleep loss, medication treatment should be considered. Medications that can help include zolpidem, trazodone, amitriptyline, and guanfacine.
Depression at any age can cause premature awakening or other sleep problems, along with daytime symptoms of sadness, irritability, inattention, and either sluggishness or hyperactivity. Counseling, close attention to good general health habits, and other support strategies should be provided as soon as depression is recognized. Antidepressants may be warranted, and when sleep is disturbed, mirtazapine, nefazodone, or other sleep-promoting antidepressants may be appropriate, either alone or with other sleep aiding medication.
AD/HD at all ages includes or co-exists with many types of sleep problems, and conversely, various sleep disorders can cause symptoms that imitate AD/HD, but really should be treated differently. Although sleep remains mysterious in many ways, it is difficult to over-emphasize the importance of sleep in our daily lives. Our new understanding and array of medication for brain-related problems greatly help many people struggling to sleep, but the best medications will not replace the need for good sleep habits (see sleep tips). Our grandparents knew that, so remember what they said and, "brush your teeth and go to bed."
Carolyn Hart, M.D., is a pediatric neurologist who specializes in neurocognitive disorders. She is the president of her county medical society and her practice, Mecklenburg Neurological Associates, an adult and pediatric clinic in Charlotte, NC.
Carolyn E. Hart, M.D. Attention! @ Chadd.org, December 2001, pp. 24-27