Sleep Disorders

If you look at children with ADHD and ODD, almost half of them have trouble sleeping. In most cases, this is because of a combination of their ADHD, ODD, and the environment. However, there are other cases when a sleep disorder is actually causing ADHD or ODD.

• Not enough sleep (62)

Many children with ADHD or ODD do not get enough sleep. Overall, a child needs 9-11 hours of sleep a day. There are a number of things to check out to make sure common causes of insomnia aren’t missed.

Things the child is doing or taking that make him aroused

• Medications- especially meds for ADHD, but also some asthma medications
• Caffeine- no children with sleep problems should take the following after about 4:00 pm: coffee, tea, pop, chocolate
• Video- Video arouses people, no matter how dull it may seem at the time. Kids should not be playing video games, using computers, or watching TV less than an hour before bedtime

Environment

• The bedroom should be for sleeping and other dull activities. There should not be TVs, computers, or video games in the child’s room. The child should not be using the bed for a place to study, relax, talk with friends, play games, or anything else.
• The bedroom should be the right temperature and quiet.
• Bedtimes should be regular and relatively inflexible. Even on the weekends, it shouldn’t vary by more than 90 minutes. The same applies to wake-up time.
• parents need to follow the same approach to sleep hygiene.

Sleep Apnea (61, 63)

When a person goes to sleep, he or she is supposed to breathe deeply and with little effort. If there is an obstruction so that the person can not breathe well, then they will not get enough sleep and awaken. In sleep apnea, a variety of factors are leading to obstructed airways during sleep so that everytime a person falls deeply asleep, their breathing is worse, and they awaken. Since they do not get deep unbroken sleep, they get psychiatric problems. They have trouble learning, are inattentive, irritable, and more difficult overall. In adults, they are usually tired out, but in children, it results in hyperactivity. About 2% of children have sleep apnea. Those at greatest risk are children who have the following features:

• Obesity
• Family History of sleep apnea
• Premature birth
• Gasping, labored breathing during sleep, lound snoring
• Wheezing in the day
• Sinus problems and mouth breathers
• People who are African-american in race
• Certain genetic syndromes
• Enlarged tonsils and adenoids

The reason this is important, is that the usual treatment for obstructive sleep apnea in Children is having your tonsils and/or adenoids removed. This results in 80-90% of the children improving.

Diagnosing Sleep Apnea

If the clinical picture looks right, the best test is to do a full sleep study. This involves going to a sleep centre and having an all night recording of sleep while you have many things attached to you. This includes electrodes to monitor your brain waves, tubes to monitor your breathing, a finger mitten to monitory the oxygen in your blood, and another few wires to monitor your movement. Unfortunately, many children with psychiatric problems can not actually sleep with all this on. Secondly, there are very few centres for this and the backlog is quite long, as you can only do the test at night.

The second choice is a home sleep study. This includes quite a few less items. You have a finger mitten to monitor oxygen in the blood, movement monitors, and a tube to measure airflow in and out of the mouth. Most kids can sleep with this on. If this is consistent with sleep apnea, it is not necessary to do a full sleep study. The next step is to do go to a ENT surgeon to see if surgery is reasonable.

The third choice is oximetry. That is a finger mitten only. In difficult kids who are non-compliant, it is better than nothing. It if is very abnormal, it would make me want to pursue a home sleep study, if possible.

And what if the surgery doesn’t work?

Sometimes people have sleep apnea and ADHD. Other times the diagnosis wasn’t carefully checked out before surgery.

Restless Leg Syndrome and ADHD (58)

This is a disorder where people have a hard time keeping their legs still. If they don’t keep moving their legs, they get unusual sensations in their legs. Sometimes it is pain, sometimes, aches, and other times it is some sort of vague discomfort. This goes away if they start moving. It is usually worse in the night. Often it is accompanied by Periodic Leg Movement Disorder, in which people’s legs make sudden movements in the night to such a degree that they wake themselves up.

So what does this have to do with ADHD?

If a person can not keep still because of Restless Leg Syndrome, it can look just like the hyperactivity of ADHD. Likewise, people who have both ADHD and Restless Leg Syndrome have a hard time getting to sleep. Many of them are sleep deprived because they can not get to sleep because of the restless legs and then they are awakened by periodic leg movements. This can result in bad tempered children who can not pay attention, common signs of ADHD.

What causes Restless Leg Syndrome and Periodic Leg Movement Disorder?

There are two common causes: low iron and genetics. It is very strongly inherited, especially if it appears in children. Almost always a child with these disorders will have a parent with them. Overall, they become worse, not better, with age. However, often times they will come and go in intensity over time.

ADHD and Restless Leg Syndrome run together

About 44% of children with ADHD also have signs of Restless Leg Syndrome. On the other hand, 26% of children with Restless Leg Syndrome have signs of ADHD.

Signs that this may be Restless Leg Syndrome and Periodic Leg Movement Disorder and not just ADHD

Children can not sit still because it hurts to sit still.

Worse restlessness in the evening

The restlessness primarily involves the legs, not the arms and the rest of the body

Watching the child in the hours of 3am until 5am shows sudden movements

Parents with the same problem

How is it diagnosed? According to International Restless Legs Syndrome

Study Group, the first thing is to make sure the person has the four main signs:

• An urge to move the legs, usually accompanied or caused by uncomfortable or unpleasant sensations in the legs (Sometimes the urge to move is present without the uncomfortable sensations and sometimes the arms or other body parts are involved in addition to the legs.)
• The urge to move or unpleasant sensations begin or worsen during periods of rest or inactivity such as lying or sitting.
• The urge to move or unpleasant sensations are partially or totally relieved by movement, such as walking or stretching, at least as long as the activity continues.
• The urge to move or unpleasant sensations are worse in the evening or night than during the day or only occur in the evening or night.(When the symptoms are very severe, the worsening at night may not be noticeable, but must have been previously present.)
• In children, there also should be a parent with the same problem, major problems with sleep and Periodic Leg Movements

How common is this?

It depends on your age. In those over age 65, it has been estimated that almost 25% of people may have it. In young adults, the prevalence is 5-15% Everyone who is suspected of having this disorder also should have their Ferritin level in their blood checked, too.

What can be done?

Like most things in medicine, there are medical and non-medical treatments.

Non-Medical Treatments

• Eliminate caffiene after 3pm
• Moderate exercise every day
• Stretching excercises before bed
• Stop smoking, do not drink alchohol

Medical treatments

Eliminate drugs which might be causing the problem.

Commonly used psychiatric drugs to try and avoid:

(fluoxetine), Paxil (Paroxetine), Zoloft (Sertraline), Celexa (Citalopram), Luvox (Fluvoxamine), Risperdal (Risperidone),

Non-psychiatric drugs to avoid:

cold medications, nausea medications

• None of the ADHD medications which are stimulants or antidepressants such as Ritalin, Dexedrine, Concerta, Adderall, Strattera, Desipramine consistently make RESTLESS LEG SYNDROME worse or better.

Quite safe psychiatric medications which may even help:

Welbutrin

Medications for Restless Leg Syndrome

Permax (Pergolide)

This is a medication used for Parkinsons and Restless Leg Syndrome. It has also been used in children who have Tourette’s. It is quite well tolerated. It comes in a .05 mg size pill and the dose would be given an hour or so before sleep. There are no trials of its use in children

Mirapex (Pramipexole)

This is also used for Parkinsons and Restless Leg Syndrome in adults. The usual dose is one one half of a .25 mg tablet before bed. There are some case reports of this successfully being used in children. (59)

Requip (Ropinirole)

This is the first approved drug for Restless Leg Syndrome. It has mostly been used for Parkinsons. The dose is usually started at one-half of a .25 mg pill. There is one case report of the use of this drug in a child with ADHD and RESTLESS LEG SYNDROME. Both sets of symptoms improved.(60)

Side effects-

Nausea –

this is usually mild if the dose is slowly increased

Augumentation-

What this means is that rather than having the symptoms primarily in the evening, they start happening in the day. As a result you sometimes have to give more earlier in the evening.

Long term side effects –

so far in children, there do not seem to be any. The longest any child has taken these medications in the medical literature is 3 years.

If my child has ADHD and RESTLESS LEG SYNDROME, will RESTLESS LEG SYNDROME medication make his ADHD go away?

There are only a few articles written on this. There are cases where adding medications for RESTLESS LEG SYNDROME has made a huge difference in a child’s ADHD symptoms and ODD symptoms. Other times it has led to a lower dose of ADHD medication. Often times people ending up taking medications for RESTLESS LEG SYNDROME and ADHD at the same time.

More information about Restless Leg Syndrome link here to this information