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Child Development – Consideration for Assessing and Improving Sleep in Children with ADHD

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By Katie Alonso, Nursing Trainee
Riley Child Development Center LEND Program

Sleep disturbance occurs in approximately 70% of children diagnosed with ADHD. Examples of sleep concerns include, but are not limited to resistance to bedtime, difficulty with sleep onset, daytime sleepiness, waking up at night, breathing problems during sleep, and trouble waking in the morning. Additionally, children with ADHD are more likely to have an increased risk for restless leg syndrome (RLR), obstructive sleep apnea (OSP), and disrupted sleep. There may be numerous reasons as to why children with ADHD have issues with sleep including: poor sleeping habits, lack of sleep routine, circadian rhythm disturbance, use of stimulant medications as well as psychiatric/medical comorbidities.  Often it is difficult to parse out the real problem, i.e. is it the ADHD causing the sleep problem, or is it the sleep problem exacerbating the ADHD behaviors?

Therefore, a thorough evaluation of a child with ADHD and sleep disturbance should involve assessing when the child goes to bed and when they fall asleep, and whether the child snores, has difficulty staying asleep, seems restless during sleep, or has increased daytime sleepiness or irritability. Using a sleep diary, or Children’s Sleep Habits Questionnaire (CSHQ), or the BEARS tool, may be useful for screening for behavioral or environmental influences as well as primary sleep disorders. The care provider should assess for limit-setting and appropriate discipline measures used in the home, evaluate the child’s sleep schedule, and evaluate for comorbid disorders that might be contributing such as anxiety disorders, oppositional defiant disorder, depression or substance abuse as children with these comorbidities tend to exacerbate sleep disturbances.  Lastly, the clinician should evaluate the use of ADHD stimulant medications, the dose, and when they are taken. Provide education on healthy sleep habits and routines and treat comorbid conditions and behavior with appropriate therapies. Only after these issues have been addressed should ADHD medication be adjusted. In addition to improving sleep habits and routines, for children with sleep-onset insomnia or circadian rhythm delay, melatonin may be added at 3-6mg 30 minutes before bedtime.

Children with ADHD and sleep disturbances may benefit from an adjustment in their medication regimens. Although each regimen should be individualized, typically, adjustment of the timing of administration, a decrease in the total daily dose of the medication, or changes in the formulation may be sufficient to improve sleep; however, shorter-acting stimulants or a non-stimulant medication may also be an alternative choice.

References:
Ivanenko, A. (2019). Sleep in children and adolescents with attention deficit hyperactivity disorder. Chervin, R.D. (Ed.) In UpToDate. Retrieved on February 25, 2020 from https://www.uptodate.com/contents/sleep-in-children-and-adolescents-with-attention-deficit-hyperactivity-disorder

Katie Alonso, BSN, RN is a Pediatric Nurse Practitioner student at IU School of Nursing and is a member of a year-long cohort of trainees in the Leadership Education in Neurodevelopmental and Related Disabilities (LEND) training program in the Department of Pediatrics, Division of Child Development.

The views expressed in this content represent the perspective and opinions of the author and may or may not represent the position of Indiana University School of Medicine.
Author

Cristy James

Resource and Data Coordinator

Data coordinator in Pediatrics division of Child Development.