Sleep disorders in ADHD


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Dr Yasir Hameed (MRCPsych)
Specialist Registrar
Norfolk and Suffolk NHS Trust
28 March 2014

This presentation was presented at ADHD Training Day at Dunston Hall in Norwich on 28 March 2014.

The day is free for all staff and is kindly sponsored by Eli Lilly Neuroscience plus is supported by the Trust NDD Steering Group and the Postgraduate Department.

Published in: Health & Medicine
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Sleep disorders in ADHD

  1. 1. Dr Yasir Hameed (MRCPsych) Specialist Registrar Norfolk and Suffolk NHS Trust 28 March 2014 Yasir Hameed (MRCPsych) Digitally signed by Yasir Hameed (MRCPsych) DN: cn=Yasir Hameed (MRCPsych) gn=Yasir Hameed (MRCPsych) c=United Kingdom l=GB o=Norfolk and Suffolk NHS Trust ou=Norfolk and Suffolk NHS Trust Reason: I am the author of this document Location: Date: 2014-03-29 11:44Z
  2. 2. » Sleep and its importance » Sleep disorders in adults with ADHD (focus on Delayed Sleep Phase Disorder DSPD) » Assessment » Treatment 2
  3. 3. Upon completion of this educational activity, participants should be able to: » Recognise the delayed sleep phase in adults with ADHD. » Explain the consequences for health in general of late and short sleep on the long term and how to treat the delayed sleep phase. 3
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  6. 6. Sleep
  7. 7. » Restorative/homeostatic » Thermoregulation/energy conservation » Consolidation of learning and memory
  8. 8. » Cyclic nature of sleep is reliable » REM periods every 90 – 120 minutes » First REM period is shortest » Most deep sleep (Stage 3 & 4) occurs early » Most REM occurs late
  9. 9. » All variety of sleep disorders are more common amongst children and adults with ADHD than healthy controls, controls with other psychiatric illness, and health siblings » The DSM-III considered excessive movements during sleep to be a criterion for hyperactivity in children » Sleeping disorder (predominantly delayed sleep phase disorder) prevalence in clinical studies of adults is 80 % and in clinical studies in children – 73 % » Kooij, JJS. Adult ADHD Diagnostic Assessment and Treatment. Third edition. 2013. Pearson publication.
  10. 10. » - (Very) late Chronotype » - A chronic pattern of (very) late sleep and preference for late rise » - May result in daytime sleepiness and/or insomnia » - May be compensated for by an irregular sleep pattern » - Leads to dysfunctioning due to increased inattentiveness and/or social problems » - Main complaint is sleep onset insomnia 11
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  13. 13. » Partners having different bedtimes is another common problem for having sex » High rates of divorce and separation (Biederman J, Faraone SV, Keenan K, et al. 1992) » 4 times more likely to have complaints of poor quality relationships (Biederman J, Faraone SV, et al 2006)
  14. 14. » Clinical history ˃ Sleep initiation, maintenance, duration; refreshed and alert in AM; bedtime routine; anxiety/depression; unusual night-time behaviours » Sleep log ˃ 2-3 weeks to document sleep-wake patterns ˃ Munich Chronotype Questionnaire (MCTQ) » Smartphone apps ˃ Sleep Cycle Calculator » Actigraphy and Polysomnography ˃ Needed for OSAS, RLS, or nocturnal seizures
  15. 15. » Management is “diagnostically driven”, and depends on thorough assessment and a formulation to include the likely underlying cause or causes.
  16. 16. » Interventions: ˃– Sleep diary ˃– Sleep hygiene ˃– Switch of medication ˃– Dose reduction ˃– Other medication ˃– Drug holiday
  17. 17. » In a randomized, crossover study in children with ADHD, results indicated that, relative to baseline, immediate-release MPH increased sleep-onset latency statistically significantly more than did atomoxetine (p<.001), consistent with the time to onset of persistent sleep and mean time to onset of first sleep epoch (p<.001 for both) » No difference in ADHD rating scale IV-Parent Version » Sangal et al. Effects of atomoxetine and methylphenidate on sleep in children with ADHD. Sleep. 2006;29(12):1573-1585 19
  18. 18. » Medication is rarely the first and only choice » Behavioural strategies aiming to sustain improvement and minimise adverse effects
  19. 19. » Melatonin has both immediate and extended- release forms (Circadin®) » Evidence? » In practice, adverse effects are relatively uncommon and self-limiting. There is increasingly reassuring evidence that this is a safe medication in hypnotic doses of up to 10mg . Bendz L.M.,and Scates A.C. Melatonin treatment for insomnia in pediatric patients with attention deficit hyperactivity disorder. Ann Pharmacother 2010 44(1) 185-191 Weiss M.D., Wasdell M.B., et al Sleep hygiene and melatonin treatment for children and adolescents with ADHD and initial insomnia. J Am Acad Child Adolesc Psychiatry 2006 45(5) 512-519 Rossignol D.A., and Frye R.E. Melatonin in autism spectrum disorders : a systematic review and meta-analysis. Dev Med Child Neurol 2011. 9.(783-792)
  20. 20. » Promethazine » Clonidine » Benzodiazepines » Z hypnotics » Antidepressants
  21. 21. » Whatever medication is tried, periodic breaks from treatment are prudent to assess whether ongoing treatment is necessary. » Most hypnotics will remain ineffective in the presence of poor sleep routines, overstimulation at bedtime or the challenges of nocturnal multimedia. » Always give advice on sleep hygiene 23
  22. 22. • Sleep difficulties are highly prevalent in ADHD, are often multifactorial in origin, and significantly impair quality of life • Sleep difficulties exacerbate daytime ADHD symptoms • Shared biological dysregulation in ADHD may contribute to disordered sleep • Assessment of ADHD is incomplete without a sleep history (pre- and post-treatment) • Sleep diaries are particularly useful in assessment
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