The Complex Interface between Sleep and ADHD Margaret Danielle Weiss MD PhD Cambridge Health Alliance CADDAC October 2020 Disclosures • Consultant fees and honoraria: Akili, Shire, Purdue Pharma, NLS Pharma, Multi-Health systems, Cingulate Therapeutics, Mundipharma, Global Medical Education, World Federation of ADHD, Israeli Federation of ADHD • Royalties: Johns Hopkins University Press, Multi-Health Systems Learning Objectives • Review of sleep disorders, and relative prominence of sleep problems in ADHD • Clarify how ADHD and sleep difficulty are mutually reinforcing • Assessment of sleep in ADHD • Review of behavioral treatments • Review of medication treatments • What we still don’t know! Sleep and ADHD • >78% of ADHD children have a sleep disorderSung,2008 • 96% medicated ADHD at least 1 sleep disturbance vs 55% “normal” sampleCorkum,1999 • SOL, sleep maintenance, sleep efficiency difficulty on PSGVirring,2016 Circadian Rhythm Sleep Wake Disorders (CRSWD) • Misalignment of sleep wake cycle • Delayed sleep wake phase type (DSWPT) • Motivated subtype in adolescents! • > 2 h delay in Dim light melatonin onset (DLMO) • Eveningness may be driven by a genetic component, caffeine, video games, screens, stimulants • Impact: sleep deprivation in parents, lack of supervision, special school placement, placement Sleep disorders • Behavioral insomnia of childhood • Anxiety related insomnia: anticipatory sleep anxiety • Excessive daytime sleepiness • Sleep onset latency (SOL), waking, total sleep time, sleep efficiency • Night to night variabilityCohenZion,2004 and intraindividual variability • Circadian rhythm sleep disorders (CRSD) • Obstructive Sleep Apnea (OSA), Restless Legs Syndrome (RLS), Periodic Limb Movement Disorder (PLMD), night terrors Sleep in Children • Active role in brain maturation, information processing, memory consolidation, learning, executive function, QoL, parental well being, family, healthZendarski,2019, Chapter 7 • 20% discussed sleep with PCPBlunden 2004 • 50% pediatricians confident with sleep problemsOwens 2001 • Almost half of normal childrenHiscock 2007 Sleep in Adolescents/Young Adults • Homeostatic sleep-wake component (sleep pressure) and circadian component or the “internal clock” (circadian pacemaker) is impaired • In adolescents biological, environmental, contextual changes disrupt both systems • Decrease Slow Wave Sleep (SWS, deep sleep), sleep pressure, > eveningness, w/e catch up, longer SOL, lower SE, EDS • Persistent and late onset ADHD associated with insomnia at age 18Gregory,2017 Behavioral Sleep Problems • Substance Use Disorders: alcohol, marijuana • Improper schedule • Arousing activities (games) close to bedtime • Uncomfortable sleep environments AASM, 2014 • Hunger, cold ELECTRONICS • later weekday bedtimes, fewer hours of sleep per week and more daytime sleepiness. • Adolescents with a bedroom television have later bedtimes, more difficulty initiating sleep and shorter total sleep times. • Texting and emailing after lights outs, even once per week, dramatically increases self- reported daytime sleepiness among teens. • Electronics for homework or other issues late at night is also not good for sleep COVID • No requirement to get up in the morning • Increased screen use to alleviate boredom • Parents working at home and supervising children with online school are stressed • Social isolation increases virtual socializing which is often at night • Increased gaming – often at night Source: Sleep On It! Resource: How to encourage good sleep habits for your children during the COVID-19 crisis URL: https://sleeponitcanada.ca/how-to-encourage-good- sleep-habit-for-your-children-during-the-covid-19-crisis/ Patient complaints • I can’t turn my thoughts off • I can’t wait to fall asleep • I can’t stop what I am doing to go to bed • I am a night owl: I get my best work done at night Family Myths • Sleep as a babysitter • Children “need” 9 hours sleep where the average ADHD child is sleeping 6.5 hours • Going to bed earlier increases sleep • My child can’t be tired because they are so hyper: an overtired child can become hyper • ADHD multiplex families have difficulty ‘teaching’ and setting up sleep hygiene which is a developmental skill Clinical Anecdotes • Clinician to child with ADHD: “how do you know you are a restless sleeper?” • Child to clinician: “I have never woken up in my bed” • Following effective sleep hygiene, “Yes, doctor, even the dog is sleeping.” Assessment BEARS; ABC SLEEPINGAllen,2016 B = Bedtime problems • Age E = Excessive daytime • Bedtimes sleepiness • Consistency A = Awakenings during the • Schedule night • Location R = Regularity and duration • of sleep Electronics • S = Snoring Exercise and diet • Positivity Owens, Mindell • Independence • Needs met • Great sleep Clinical Pearls • Sleep training can be challenging • Regulation of sleep co-occurs with regulation in ADHD and the family • You set the sleep clock in the morning and inability to wake a child is a rarely talked about sleep difficulty • Parents who don’t sleep may have difficulty teaching their children to sleep • Adolescents: Whose sleep is it anyway? • Co-sleeping; bed is only for sleep – some of these recommendations are culturally specific Sleep Outcome in ADHD • Sleep intervention needs to be family based, can be intensive and may need to be highly individualized • It may be possible to provide internet based sleep interventions with clinician support Corkum • Functional outcome of the child is directly related to treatment of BOTH sleep and ADHD Weiss, 2016,2018 • Variability in sleep in adolescents prospectively impacts brain development over and above sleep duration Telzer, 2015 ADHD Impairs Sleep • Dysregulated schedule, eating, exercise, mood • Sleep is an attention demanding activity: waiting to fall asleep is boring and “quiet thoughts”, or counting sheep is not an ADHD friendly activity • Requires executive function skills in family • Sleep is an entrained, developmental skill • A key to sleep is the zeitgeber Sleep Hygiene • Stick to a sleep schedule, even on weekends. • Practice a relaxing bedtime ritual. • Exercise daily. • Evaluate your bedroom to ensure ideal temperature, sound and light. • Sleep on a comfortable mattress and pillows. • Beware of hidden sleep stealers, like alcohol and caffeine. • Turn off electronics before bed. Behavioral Treatment • Behavioral first line Cortese 2013; Sciberras,2016 • Later start to the school dayOwens • Better Nights/Better DaysCorkum,2016 – 5 session manual and weekly telephone coach support Penny Corkum, Dalhousie • Better Nights/Better Corkum,2016 Web Based Treatment Days – 5 session manual and weekly telephone coach support • Sleepeducation.org • Sleepfoundation.org • CBTi COACH • SHUTi Websites American Academy of Sleep Medicine http://www.aasmnet.org Canadian Sleep and Circadian Network (CSCN) https://www.cscnweb.ca/ Canadian Sleep Society https://css- scs.ca KIDZZZSLEEP http://www.kidzzzsleep.org/index .htm National Sleep Foundation http://www.sleepfoundation.org Pediatric Sleep Council https://www.babysleep.com Sleep for Kids http://www.sleepforkids.org/ SleepNet http://www.sleepnet.com/ Sleep on it Canadian Sleep Campaign https://sleeponitcanada.ca/ Behavioral Treatment Source: Sleep On It! Resource: How to encourage good sleep habits for your children during the COVID- 19 crisis URL: https://sleeponitcanada.ca/how-to- encourage-good-sleep-habit-for-your- children-during-the-covid-19-crisis/ • CBT-INSOMNIAOkijima,2011: alter behavior patterns and thoughts • No approved medications, and a great deal of medication use • More likely to get drugs than sleep hygieneOwens,2003, Bruni,2017 Melatonin • Melatonin is a hormone that regulates sleep • It can be produced as a pill, liquid, chewable formulation • Dose is usually 1 – 10 mg 30 minutes before bedtime • Melatonin decreases the time it takes to sleep and the duration of sleep • The effects do not wear off with time: 50% children staying on MLT for yearsFurster,2015 • Side effects: drowsiness, dreams, headache, dizziness • Melatonin is not addictive. There are no withdrawal or discontinuation symptoms, nor does anyone abuse it. Other Medications • Sleeping pills such as zolpidem, zopiclone are not effective in children and less effective long term than behavioral treatmetn • Diphenhydramine/hydroxyzine: tolerance • Clonidine • TrazedoneJaffer,2017 • Mirtazepine • Prazosin Conclusion • Sleep and ADHD often co-exist and make each other worse causing impairmentWeiss,2006 • Treatment of ADHD and treatment of sleep will not necessarily improve the other problem • Improvement in either, leads to improvement in outcomeOwens,2016 • ADHD is a 24 hour disorder and assessment and treatment of sleep is essential to obtaining an optimal functional outcome Pleasant Dreams! 36.