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Sleep Disorders

Sleep Studies for Children with ADHD

07/06/2009

Question:

My four-year-old son has not been able to sleep through the night since he was 18 months old. Around that time, he started waking up throughout the night and chewing the wood off the end of his crib. He litereally chewed half-way through the spindle on the top rail! I took pictures into our doctor of his crib, but he insisted that my son was bored and that was why he was chewing. As he progressed out of his crib, he would still wake-up throughout the night and play with toys or come into my husband`s and my bedroom.

Around age 3, he was displaying signs of autism, so we had him evaulated by a psychologist. The psychologist said his evaluation was inconclusive. My son showed signs of autism, but didn`t completely fit the symptoms. His sleeping problems persisted throughout.

This spring, as he is to begin kindergarten in the fall, we went back to the psychologist because he was having troubles focusing, he was very impulsive (blurt out inappropriate phrases and words), he would hit people and destroy things,and he was very hyper. He also didn`t respond to positive or negative reinforcement. He was diagnosed as having ADHD.

Currently, he is on Vyvance. This med appeared to be working, but his sleeping pattern has become more disturbed. He is up about 5 times a night for 15 minutes or so each time. He has also become increasingly violent towards his twin brother, myself, and friends at school. His impulsiveness, which we thought was under control, has spiraled to where it was when we started. Even when we take him off the med, he is still having these problems.

Our pediatrician said that we should try giving him Melatonin to help him sleep and to see if that calmed his hyperactivity so the medicine could work. The Melatonin only helped him fall asleep faster. He still woke up frequently.

Now our pediatrician is recommending a sleep study to see if his airways are blocked. He does not snore and he does not have sleep anpnea from our informal observations.

I am at a loss. I don`t know if he has a psychological problem worse than ADHD. And if he does, will that show up on a sleep study? How effective are sleep studies on young children? Why would a pediatrician recommend this route? I apologize for the length of this, but the background information is important to me.

Answer:

This is a common pediatric problem - a young child with daytime behavioral/developmental problems, that are not completely understood, who is also having difficulty with sleep onset (difficulty falling asleep) and sleep maintenance (difficulty staying asleep) insomnia.

While the diagnosis of autism and ADHD are being considered they may be difficult to make with certainty in a child at this age. Several history questions need to be answered in order to guide further investigation and treatment of the insomnia.

#1. Is there a family history of autism, ADHD, bipolar disorder or other psychiatric issues? If so, who is affected and at what age were they diagnosed?

#2. Is there a family history of insomnia? Who is affected, at what age and to what degree?

#3 An extensive history of the child’s usual bedtime routine including bedtimes and final wake up times, sleeping environment and parental response to the child’s awakening at night is important. For example, does the child sleep in his own room? Do you generally lie down in bed with him until he initially falls asleep? How do you respond to his awakenings at night? What seems to settle him? What seems to not settle him? Usual bedtime, usual times of awakening and usual wake up time are important to determine if the child is getting adequate sleep at night. How many naps does he take a day and for what duration?

#4 General questions regarding any other medical problems and pertinent review of systems (recent ear infections, previous surgeries, etc).

Children with either autism or ADHD can have insomnia that may require a comprehensive behavioral and pharmacological approach. Primary sleep disorders like obstructive sleep apnea (OSA) or restless leg syndrome (RLS) may cause increased night wakening. The fact that the child does not appear to snore at night makes OSA less likely but not impossible. OSA occurs overall in 2-3% of children at this age so that may be why your pediatrician is pursuing this concern.

Children with ADHD may have a higher incidence of RLS or excessive leg movements at night that may cause awakenings. Does the boy have a history of anemia, recurrent otitis media or other medical problems? It is important to note whether the child has a history of frequent leg movement at night or if there is a family history of restless legs syndrome. Does the child take a vitamin supplement? A sleep study may detect excessive leg movements responsible for awakening your child at night.

A variety of medications and behavioral techniques may be helpful in managing sleeplessness in children with behavioral/developmental issues. Medications that may help sleep maintenance in children with ADHD include Clonidine at bedtime. Structured bedtime and nap routines are also important. Behavioral strategies are almost always necessary to help these children return to sleep after awake. Several behavioral approaches may be combined. Interestingly, trying to get the children to bed earlier at night or spending more time in bed may paradoxically worsen the child’s sleep. Limit setting issues need to be addressed by the child’s psychologist for both bed time and day time behaviors.

Sleep studies generally can be performed successfully in children 4 yrs of age. However children with behavioral problems can be challenging for sleep labs that do not routinely caring for children. For that reason, I would recommend that your son, given his history of behavioral/developmental problems, be evaluated at a sleep center with expertise in dealing with children with developmental/behavioral problems such as autism or ADHD. These are commonly associated with tertiary level pediatric medical centers. These institutions often have developmental pediatricians, psychiatrists and sleep medicine physicians with experience in evaluating and treating causes of pediatric insomnia.

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Response by:

Mark   Splaingard, MD Mark Splaingard, MD
Clinical Professor of Pediatrics
College of Medicine
The Ohio State University