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AUTHOR PROOF
Sleep Problems in the Child with
Attention-Deficit Hyperactivity Disorder
Defining Aetiology and Appropriate Treatments
Margaret D. Weiss
1
and Jay Salpekar
2
1 Children’s and Women’s Health Centre of British Columbia, Vancouver, British Columbia, Canada
2 Children’s National Medical Center, George Washington University School of Medicine,
Washington, DC, USA
Contents
Abstract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2. Identifying Sleep Disturbances in Children with Attention-Deficit Hyperactivity Disorder (ADHD). . . . . . 4
2.1 Parent-Child Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2.1.1 Pediatric Sleep Questionnaire (PSQ). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.1.2 Children’s Sleep Habit Questionnaire (CSHQ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.2 Sleep Diaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.3 Clinical Interviews: BEARS Sleep Screening Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.4 Overnight Sleep Studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.4.1 Polysomnography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.4.2 Actigraphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3. Possible Aetiology of Sleep Disturbances in Children with ADHD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
3.1 Delayed Sleep Onset . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
3.2 Medication-Related Sleep Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
3.3 Excessive Daytime Sleepiness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
4. Treatment of Sleep Disturbances in Children with ADHD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
4.1 Behavioural Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
4.1.1 Sleep Hygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
4.1.2 Cognitive Behaviour Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
4.2 Dietary Factors Associated with Sleep Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
4.3 Pharmacological Management of Treatment-Induced Insomnia in ADHD. . . . . . . . . . . . . . . . . . . 13
4.4 Melatonin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Abstract An estimated 25–50% of children and adolescents with attention-deficit
hyperactivity disorder (ADHD) experience problems with sleep. The most
common sleep problems reported in children with ADHD include delayed
sleep onset, sleep or bedtime resistance, prolonged tiredness upon waking and
daytime sleepiness. Higher incidences of sleep disorders such as restless legs
syndrome, periodic limb movement disorder and sleep-disordered breathing
have been reported in paediatric ADHD populations compared with con-
trol populations. In some cases, medications for ADHD and/or co-morbid
Approval for publication Signed Date Number of amended pages returned
THERAPY IN PRACTICE
CNS Drugs 2010; 24 (10): 1-18
1172-7047/10/0010-0001/$49.95/0
ª 2010 Adis Data Information BV. All rights reserved.
AUTHOR PROOF
disorders may also contribute to sleep disturbances. Assessment tools, such
as parent-child questionnaires and sleep diaries, can help clinicians evaluate
sleep disturbances. Sleep problems may potentially exacerbate ADHD
symptoms, and interventions targeted at ensuring adequate sleep (including
behavioural, dietary, specific pharmacological agents for treatment-induced
insomnia, and melatonin) could in turn potentially attenuate symptoms
associated with ADHD, such as irritability. Whether metabolic or neuro-
logical pathways common to both sleep and ADHD may be disrupted, and
whether targeting treatments to these pathways may simultaneously improve
both ADHD and sleep symptoms, needs further elucidation.
1. Introduction
Attention-deficit hyperactivity disorder (ADHD)
is estimated to affect between 4% and 8% of
school-age children worldwide, although pre-
valence rates may vary depending on whether
samples are obtained from clinical or community
settings.
[1]
ADHD is characterized by persistent
core symptoms (inattention, hyperactivity and
impulsivity) that can impair academic, social and
occupational functioning and health-related qual-
ity of life.
[2-4]
Along with the core symptoms of the
disorder, parent-reported sleep problems occur in
an estimated 25–50% of children and adolescents
with ADHD.
[5]
A recent survey of the families of
239 children with ADHD reported that mild to
severe sleep problems affected as many as 73.3%
of all children participating.
[6]
The most common
sleep problems reported by children or their parents
include difficulties initiating sleep (i.e. delayed
sleep onset or bedtime resistance), maintaining sleep
(i.e. frequent nocturnal awakenings or restlessness),
tiredness on waking and daytime sleepiness.
[6-9]
Part of these reported sleep problems have been
confirmed by overnight polysomnography and acti -
graphy studies, which have also documented a range
of other sleep disturbances, includi ng increased
sleep latency, decreased rapid eye movement stage
sleep, decreased overall sleep time and increased
nocturnal activity in children with ADHD.
[8,10-13]
Several studies have also reported higher incidences
of sleep disorders such as restless legs syndrome
(RLS), periodic limb movement disorder (PLMD)
and sleep-disordered breathing (SDB) in children
with ADHD.
[7,14-17]
A recent meta-analysis of both subjective and
objective studies of sleep in children with ADHD
compared 722 children with ADHD with 638
controls.
[18]
This study demonstrated an in-
creased risk of both subjective and objective sleep
disorders in children with ADHD compared with
controls. On subjective measures, children with
ADHD had higher bedtime resistance, more
trouble falling asleep, waking during the night,
problems waking in the morning and excessive
daytime sleepiness. On objective measures, the
authors confirmed that children with ADHD
were at greater risk for an increase in the time it
took to fall asleep (sleep-onset latency) when
measured by actigraphy, the frequency of sleep
stage shifts and SDB as measured by the apnoea-
hypopnea index. They also had lower sleep effi-
ciency on polysomnography and decreased sleep
time on actigraphy. The best measure of excessive
daytime sleepiness is the Multiple Sleep Latency
Test,
[19]
which for years has been used as a mea-
sure of sleepiness associated with narcolepsy. On
this test, the children with ADHD were falling
asleep faster at nap opportunities than controls,
indicating increased excessive daytime sleepiness.
Taken together, these results suggest that there is
an association between ADHD and a wide range
of sleep impairments. Whether ADHD causes sleep
problems, or vice versa, is unclear. Regardless of
the aetiology, the evidence suggests that evalua-
tion of patients with ADHD should also include
evaluation of sleep difficulties.
Sleep problems can impose a substantial impact
on the quality of life and emotional well-being
both of children with ADHD and their parents.
2 Weiss & Salpekar
ª 2010 Adis Data Information BV. All rights reserved. CNS Drugs 2010; 24 (10)
AUTHOR PROOF
Sung and colleagues
[6]
found that children with
ADHD who had moderate to severe sleep prob-
lems (n = 107), such as difficulty falling asleep,
bedtime resistance, difficulty breathing and fre-
quent waking had lower Pediatric Quality of Life
Inventory total and psychosocial scores than
those without sleep problems (n = 64; p < 0.001).
The impact of childhood sleep problems can be
intensified by their effect on parents’ sleep, result-
ing in parental daytime fatigue, mood disturbances
and a decreased level of effective parenting.
[20]
Parents typically need their children to sleep 10 hours
in order to have time for themselves, and 8 hours
in order to master the patience necessary for rais-
ing an ADHD child. When a child is sleeping con-
siderably less than that but the parent must be
awake while the child is awake to assure their
safety, the impact on parental well-being is pro-
found. Primary caregivers of children with ADHD
with moderate or severe sleep problems are more
likely to be clinically depressed or anxious than
caregivers of children with ADHD but without
sleep problems (odds ratio = 2.72 ; 95% CI 1.33,
5.54).
[6]
Conversely, it is also true that parents
with sleep disorders and aberrant sleep schedules
have difficulty establishing both sleep hygiene
and zeitgebers (external sleep cues) in their off-
spring. Consequently, effectively managing sleep
problems can significantly improve the quality of
life not only of children with ADHD but also of
their families.
Evidence that the treatment of some primary
sleep disorders can ameliorate ADHD-like symp-
toms suggests an association between sleep prob-
lems and ADHD that may have important
clinical implications. Specifically, observations
from several case reports indicate that treating
RLS with dopamine receptor agonists may ame-
liorate ADHD symptoms in children with co-
morbid RLS and ADHD, particularly in those
who have previously responded poorly to stimu-
lant medications for ADHD symptoms.
[16]
As an
example, one study reported that three of seven
children diagnosed with ADHD and co-morbid
RLS no longer met DSM-IV-TR criteria for
ADHD after being treated for RLS with levodopa/
carbidopa or pergolide.
[16,21]
Importantly, five
of seven children in this study had previously
been treated with stimulants that were either in-
effective (n = 4) or caused intolerable side effects
(n = 3).
[21]
Unfortunately, there are no well con-
trolled clinical trials on treatment of RLS in
children, and very little is known about the extent
to which RLS may be related to ADH D versus
treatment effects. Because both ADHD and RLS
may involve underlying dopamine system dys-
function,
[16]
it is unclear whether dopaminergic
drugs may improve ADHD symptoms by directly
improving RLS or by moderating a primary
ADHD-related dopamine dysfunction.
Another growing body of evidence suggests
that adenotonsillectomy treatment of SDB can
improve symptoms of inattention and hyper-
activity in children.
[22-24]
Chervin et al.
[22]
found
that children scheduled for an adenotonsillectomy
(n = 78, aged 5–12.9 years) were significantly more
hyperactive on well validated parent rating scales,
inattentive on cognitive tests, sleepy on the Multi-
ple Sleep Latency Test
[19]
and likely to have DSM-
IV-defined ADHD compared with age-matched
controls (n = 27) who underwent surgery for an
unrelated condition. Differences between the two
groups in the same measures were no longer
significant 1 year after surgery, as children who
underwent an adenotonsillectomy improved sub-
stantially in all measures, whereas control subjects
improved in none.
[22]
However, polysomnographic
assessments of baseline SDB and its subsequent
amelioration were not predictive of either base-
line ADHD morbidity or improvement in any
area other than sleepiness, suggesting the need
for improved understanding of underlying causal
mechanisms.
[22]
More recently, a study of 66 chil-
dren with DSM-IV-defined ADHD and co-morbid
SDB
[23]
reported that adenotonsillectomy-treated
patients (n = 25, aged 6–12 years) scored significant-
ly lower on the ADHD rating scale
[25]
6 months
after surgery (21.16 – 7.13) than before surgery
(31.52 – 7.01; p = 0.0001); both inattention and
hyperactivity subscales were significantly lower
(p = 0.0001).
[22]
It should be noted, however, that
while there is evidence that some children with
ADHD may have problems with SDB, SDB is
not a common cause of ADHD.
[9]
Nevertheless,
SDB appears to be part of the differential of
ADHD-like symptoms, so care should be taken
Sleep Problems in the Child with ADHD 3
ª 2010 Adis Data Information BV. All rights reserved. CNS Drugs 2010; 24 (10)
AUTHOR PROOF
to rule out sleep disturbances in children who are
inattentive and hyperactive.
In addition to primary sleep disorders, co-
morbid psychiatric disorders that include symptoms
of insomnia are relatively common in patients
with ADHD. Co-morbi dities such as mood dis-
orders (15–20%), anxiety disorders (20–25%) and
tic disorders (~20%) have all been linked with sig-
nificant sleep disturbances.
[2,26,27]
For example, one
study assessing subjective reports of sleep-rel ated
symptoms in children (aged 7.3–14.9 years) di-
agnosed with major depressive disorder reported
that sleep disturbances were present in 72.7% of
the children, with 53.5% experiencing insomnia
alone, 9% hypersomnia alone and 10.1% experienc-
ing both insomnia and hypersomnia.
[28]
Although
it is unclear how the treatment of psychiatric co-
morbidities may affect sleep, or if treatment of
sleep difficulties might alleviate some of the im-
pairment associated with these co-morbid con-
ditions, a heightened clinical awareness of how
co-morbid disorders may contribute to sleep prob-
lems is essential to comprehensively manage sleep
problems in children with ADHD. It is beyond
the scope of this article to review the relationship
between sleep and disorders other than ADHD,
or the relationship between sleep and children
with ADHD and another major psychiatric ill-
ness associated with insomnia.
In contrast with primary sleep disorders, or
sleep problems caused by co-morbid psychiatric
problems, there are other sleep problems that
may develop in the context of ADHD. These in-
clude behaviourally based sleep problems (e.g.
insufficient limit setting and counterproductive
behavioural associations with sleep onset), physio-
logically based sleep problems (e.g. exce ssive
daytime sleepiness and chronic sleep-onset in-
somnia) and sleep problems caused by ADHD
medications (e.g. stimula nts). Give n the potential
association between ADHD and a wide range of
sleep problems, clinicians need to be vigilant and
assess an d treat both conditions, especially when
prescribing medications for ADHD that may
exacerbate the underlying sleep problems.
This article reviews the clinical tools to identify
sleep disorde rs, sleep hygiene and pharmacolo-
gical options for sleep problems in children with
ADHD, to better enable the clinician to evaluate
and manage the routine sleep difficulties they are
likely to encounter in their patients with ADHD.
The objective of this article is to bring the recent
and growing research literature on ADHD and sleep
into clinical practice. MEDLINE and PubMed
search engines were used to identify appropriate
data sources. Only studies of children with ADHD
were included; studies with adolescents were in-
cluded only if the demographics included chil-
dren. Studies with adults were included only for
comparative purposes where appropriate. Search
terms included attention deficiency/ hyperactivity
disorder and sleep, sleep problems, insomnia, as-
sessing sleep, sleep questio nnaires and/or aetiol-
ogy. Searches focused on the years 2000–10.
2. Identifying Sleep Disturbances in
Children with Attention-Deficit
Hyperactivity Disorder (ADHD)
Identifying relationships between sleep prob-
lems and ADHD is essential to a comprehensive
care plan for the management of patients with
ADHD. Practitioners should routinely screen
for clinical sleep problems in patients with ADHD
by taking a careful sleep history and baseline
measurements of sleep functioning. A number of
tools are available, including psychometrically
validated parent and child questionnaires,
[29-32]
clinical interviews and sleep diaries
[33-36]
that can
help identify sleep problems, particularly those
that may suggest major sleep disorders (e.g. RLS ,
PLMD and SDB) [table I] and the need for fur-
ther evaluation and definitive diagnosis by a sleep
specialist.
[37-39]
2.1 Parent-Child Questionnaires
A number of parent-child questionnaires for
the assessment of sleep problems in children have
been developed. These include, among others, the
Sleep Disturbance Index,
[29]
the Sleep Disorders
Questionnaire,
[30]
the Sleep Disturbance Scale for
Children,
[40]
the Pediatric Sleep Questionnaire
(PSQ)
[31]
and the Children’s Sleep Habit Ques-
tionnaire (CSHQ).
[32]
We discuss two of the more
recently validated questionnaires, the PSQ and
4 Weiss & Salpekar
ª 2010 Adis Data Information BV. All rights reserved. CNS Drugs 2010; 24 (10)
AUTHOR PROOF
the CSHQ, which are available in both full and
abbreviated formats that may be particularly
helpful for quickly screening patients for possible
sleep problems.
2.1.1 Pediatric Sleep Questionnaire (PSQ)
The PSQ was developed with the goal of
evaluating disordered sleep symptoms quickly
during outpatient clinic visits.
[31]
The full ques-
tionnaire consists of 73 ‘yes/no/don’t know’ items
that assess a full range of night-time and day-
time behaviours indicative of sleep disturbances
(e.g. insomnia, excessive daytime sleepiness, night
terrors, habitual snoring, bedtime resistance,
sleep hygiene and sleep-related breathi ng dis-
orders).
[31]
Polysomnography studies have con-
firmed the utility of the PSQ for identifying
obstructive sleep apnoea, PLMD and RLS.
[31,41]
As it takes about 25 minutes for a parent and child
to complete the entire PSQ, a subset of questions
from the PSQ (table II) has been selected that
may be helpful for quickly identifying major signs
suggestive of a primary sleep disorder (e.g. RLS,
SDB).
[42]
Positive answers to questions on this
subscale should prompt further evaluation and
possible referral to a paediatric sleep specialist.
[42]
2.1.2 Children’s Sleep Habit Questionnaire (CSHQ)
The CSHQ is a parent-reported sleep screening
instrument designed for school-age children (aged
4–12 years) and is available free online (http://
www.kidzzzsleep.org/researchinstruments.htm).
[32]
It focuses on sleep disorders common to this age
group in three domains: dyssomnias (difficulty
getting to sleep or staying asleep), parasomnias
(sleepwalking/talking, night terrors, bedwetting,
Table I. Primary sleep disorders that can occur in children with attention-deficit hyperactivity disorder (ADHD)
[37]
Sleep disorder Symptoms Diagnosis
Periodic limb movement disorder Repetitive flexions of the toes, feet, legs, thighs
and/or arms during sleep
Occur in series of four or more, with each
movement lasting 0.5-5 sec and separated by
intervals of 5-90 sec
Polysomnography: specific electromyograph
criteria that must occur only at night
Impact on either sleep or daytime functioning in
medical history
Restless legs syndrome Desire to move legs usually associated with
paraesthesias
Motor restlessness (both day and night)
Worsening of symptoms at night
Worsening of symptoms at rest relieved by activity
Sensations often lead to insomnia
Children may describe restless legs syndrome
symptoms differently than adults
[38]
Based on subjective responses to questions about
paraesthesias, dysesthesias of the limbs, motor
restlessness and worsening of these symptoms
as the day progresses or at night
Ferritin levels should be tested as low iron levels
have been associated with both restless legs
syndrome and ADHD
[39]
Sleep-disordered breathing:
upper airway resistance
syndrome and obstructive sleep
apnoea
Reduction (upper airway resistance syndrome) or
cessation (obstructive sleep apnoea) of airflow
lasting a minimum of 10 sec when the airway
completely or partially closes during sleep
Often results in sleep fragmentation and excessive
daytime sleepiness
Polysomnography (specific electromyograph
criteria that must occur only at night): should also
evaluate leg movements, because sleep-
disordered breathing can be misinterpreted as a
limb movement disorder
Primarily caused by enlarged tonsillar and
adenoid tissue as well as childhood obesity
Treatment often involves adenotonsillectomy
Table II. Abbreviated version of the Pediatric Sleep Questionnaire
(PSQ) that may be easily administered to parents during a clinical
appointment (reprinted from Archbold,
[42]
by permission of SAGE
Publications, Copyright ª 2006 American Psychiatric Nurses Asso-
ciation)
While sleeping does your child:
1. Snore more than half the time?
2. Snore loudly?
3. Have ‘heavy’ or ‘loud’ breathing?
4. Have trouble breathing or struggle to breathe?
5. Have you ever seen your child stop breathing during the night?
6. Does your child describe restlessness of the legs when in bed?
7. Does your child have ‘growing pains’ that are worse in bed?
8. At night, does your child usually get out of bed (for any reason)?
9. Does your child wake up more than twice a night on average?
Sleep Problems in the Child with ADHD 5
ª 2010 Adis Data Information BV. All rights reserved. CNS Drugs 2010; 24 (10)
AUTHOR PROOF
RLS, etc.) and SDB. This instrument yields both a
total score and eight subscale scores. The internal
consistency and validity of the CSHQ subscale and
total score were established in a study of the par-
ents of 469 school-age children, in which receiver
operator curve analysis indicated that a total score
‡41 (sensitivity: 0.80, specificity: 0.72) was an ap-
propriate cutoff for referral to a sleep specialist.
[32]
The CSHQ may be particularly useful for eval-
uating children with ADHD, as it is capable of
identifying a range of both medically and behav-
iourally based sleep problems that can often co-
occur in these patients.
2.2 Sleep Diaries
Sleep diaries involve having the parent or child
(or both) record a child’s sleeping and waking
times with related information, usually over a
period of several weeks. A sample structure for a
child’s sleep diary is presented in table III.
[33]
Others are available online at the National Sleep
Foundation and National Institutes of Health
websites.
[33,34]
Two weeks of baseline sleep diary
recordings are usually sufficient to delineate sleep
patterns.
[35]
Although answering one questionnaire
about a typical week’s sleep is often more con-
venient than asking individuals to complete daily
sleep diaries, sleep diaries are particularly useful for
diagnosing and treating sleep disorders and for
monitoring whether treatments are successful.
A specific form of a sleep diary is the somno-
gram, or sleep log. The sleep log is a form of sleep
diary in which the day is broken into a table in
which each row is divided into 15-minute inter-
vals for the 24 hours of the day and each column
represents 1-hour blocks of a 24-hour day. Since
the sleep log typically has seven rows for each day
of the week and blocks where the patient is
sleeping are shaded, the result is an immediate
visual image of the time the patient is put to bed
(indicated by a downwards arrow), time the pa-
tient falls asleep (sleep onset latency), wakings
during the night, time the patient is woken up (an
upwards arrow) and time the patient actually gets
out of bed (difficulty with morning waking).
Boxes that correspond with the time the patient is
awake are unshaded. Figure 1 illustrates a typical
somnogram. This tool provides a quick visual
representation of variance and difficulties in the
sleepcycleandisausefultool for patient education.
For example, in looking at the somnogram, it may
be obvious that when patients sleep late, they have
difficulty falling asleep early that evening. Most
importantly, it provides a visual image for the pa-
tient that illustrates not only the circadian rhythm,
but the impact of sleeping late on later delayed sleep
onset, and day-to-day variability of sleep success.
2.3 Clinical Interviews: BEARS Sleep
Screening Tool
A simple user-friendly screening tool is the
BEARS (B = Bedtime Issues , E = Excessive Day-
time Sleepiness, A = Awakenings, R = Regularity
and Duration of Sleep, S = Snoring). This easy-
to-remember acronym allows the clinician to
easily and routinely screen patients for the most
common sleep problems during the assessment
interview and to identify those difficulties that
may need further evaluation.
[43]
The BEARS
provides brief, easy-to-remember questions that
screen for the most common paediatric sleep
complaints across a range of ages in a diverse
patient populatio n. Clinicians are prompted to
ask parents initial screening ‘yes/no’ questions
about possible problems in each domain and, in
cases of a ‘yes’ response, ask parents to further
describe the problem. Examples of developmen-
Table III. Information logged in a sleep diary: sample structure
[33]
Time tried to fall asleep
Time thinks sleep onset actually occurred
The number, time and length of any night-time awakenings
Time person had wanted or intended to wake up
Time of morning wakening
Time the person got out of bed
Whether the person woke up spontaneously, by an alarm clock, or
because of other (specified) disturbance
A few words about how the person felt during the day (mood,
drowsiness, etc.), often on a scale from 1 to 5
Start and end times of any daytime naps
Name, dosage and time of any drugs used including caffeine and
alcohol
Time of evening meal, heavy or light
Stress level before bedtime
Activities during the last hour before bedtime
6 Weiss & Salpekar
ª 2010 Adis Data Information BV. All rights reserved. CNS Drugs 2010; 24 (10)
AUTHOR PROOF
tally appropriate BEARS trigger questions are
listed in table IV. In a study of 195 children aged
2–4 years, con ducted in a primary care setting,
the BEARS tool significantly increased the
amount of sleep information recorded, as well as
the likelihood of identifying sleep problems,
compared with standard well-child checklists.
[43]
Incorporating a short list of brief questions about
sleep, such as those outlined by BEARS, into the
routine screening of ADHD patients may allow
for su bstantial improvements in the rate of de-
tection of sleep problems in this population.
2.4 Overnight Sleep Studies
Further sleep evaluation conducted by sleep
specialists at an accredited sleep laboratory may
be useful when findings from interviews, question-
naires or diaries suggest a primary sleep disorder
that requires polysomnography for diagnosis,
such as sleep apnoea, periodic limb movement
syndrome, problems with sleep architecture, nar-
colepsy or sleep misperception (parental or child
complaints of lack of sleep in the face of normal
sleep durati on and efficiency).
2.4.1 Polysomnography
A polysomnogram combines a number of mea-
sures of body function during sleep. Brain ac-
tivity is monitored with an EEG, eye movements
with an electrooculogram, skeletal muscle acti-
vation with an electromyogram, heart rhythm
with an ECG and respiratory function with mea-
surements of nasal and oral airflow combined
with pulse oximetry.
[35]
Paediatric polysomno-
graphy may not be easily accessible to clinicians
who are working in areas that are remote from
a paediatric sleep centre. Recent advances in
polysomnography have made it less expensive
and more child friendly in that mobile poly-
somnograms can be done in the child’s home.
2.4.2 Actigraphy
Actigraphy involves the use of an actiwatch, a
small device that stores movement information,
to assess physical movement during sleep.
[44]
Actigraphy can be used to clinically evaluate in-
somnia, circadian rhythm sleep disorde rs, sleep
misperception and RLS. It is also used to assess
the effectiveness of pharmacological, behavioural,
Midnight
1 AM
2 AM
3 AM
4 AM
5 AM
6 AM
7 AM
8 AM
9 AM
10 AM
11 AM
Noon
1 PM
2 PM
3 PM
4 PM
5 PM
6 PM
7 PM
8 PM
9 PM
10 PM
11 PM
October 19
October 18
October 17
October 16
October 15
October 14
October 13
October 12
Date
Sleep hygiene
week 2
Fig. 1. Example of a somnogram illustrating sleep and wake patterns over 1 week. The downwards arrow indicates when the patient went to
bed. The patient shades in the 15-minute time slots for the period in which he or she is asleep. The shading stops slightly before the patient
actually gets out of bed, as indicated by the upwards arrow. The lighter shading represents sleep latency and the darker shading actual sleep.
Sleep Problems in the Child with ADHD 7
ª 2010 Adis Data Information BV. All rights reserved. CNS Drugs 2010; 24 (10)
AUTHOR PROOF
phototherapeutic or chronotherapeutic treat-
ments for such disorders. Actigraphy is not quite
as accurate as polysomnography for measuring
sleep reference times, such as the time of sleep
onset and awakening.
[9]
Nevertheless, because poly-
somnography can be uncomfortable for patients
and is relatively expensive, it is increasingly being
supplemented or replaced by actigraphy, partic-
ularly when longitudinal data are needed. Fur-
thermore, the use of an actigraph is a simple and
easy procedure that can become routine for clin-
icians who do not have access to a sleep labora-
tory. The advantages of actigraphy include the
ability to assess the child in his or her natural sleep
environment and over many nights to provide data
on night-to-night variability in sleep, whi ch has
been shown to be a critical outcome variable in chil-
dren with ADHD.
[45,46]
When patients observe
the printout of the actigraph that docu ments their
weekly sleep cycle, this becomes a method of teach-
ing and engagement for them to participate fur-
ther in understanding the importance and impact
of circadian rhythm.
3. Possible Aetiology of Sleep
Disturbances in Children with ADHD
Before selecting treatment for sleep disorders
in children with ADHD, it is necessary to identify
the aetiology of the disorders. This includes con-
tributions from primary sleep disorde rs, such as
RLS and SDB (table I), as well as contributions
from co-morbid psychiatric disorders. If a pri-
mary sleep disorder can be ruled out, the focus
Table IV. Examples of developmentally appropriate trigger questions for use in the BEARS (B = Bedtime Issues; E = Excessive Daytime
Sleepiness; A = Night Awakenings; R = Regularity and Duration of Sleep; S = Snoring) paediatric sleep screening tool (reprinted from Owens
and Dalzell,
[43]
Copyright ª 2004, with permission from Elsevier)
Preschool (2–5 y) School-age (6–12 y) Adolescent (13–18 y)
Bedtime issues To parent:
Does your child have any
problems going to bed?
To parent:
Does your child have any problems at bedtime?
To child:
Do you have any problems
falling asleep at bedtime?
Falling asleep?
To child:
Do you have any problems going to bed?
Excessive
daytime
sleepiness
To parent:
Does your child seem overtired or
sleepy a lot during the day?
Does he/she still take naps?
To parent:
Does your child have difficulty waking in the
morning, seem sleepy during the day or take naps?
To child:
Do you feel sleepy a lot
during the day?
In school?
While driving?
To child:
Do you feel tired a lot?
Awakenings
during the night
To parent:
Does your child wake up a lot at
night?
To parent:
Does your child seem to wake up a lot at night?
Any sleepwalking or nightmares?
To child:
Do you wake up a lot at
night?
Have trouble getting back to
sleep?
To child:
Do you wake up a lot at night?
Have trouble getting back to sleep?
Regularity and
duration of sleep
To parent:
Does your child have a regular
bedtime and wake time?
What are they?
To parent:
What time does your child go to bed and
get up on school days?
Weekends?
Do you think he/she is getting enough sleep?
To child:
What time do you usually go
to bed on school nights?
Weekends?
How much sleep do you
usually get?
Sleep-
disordered
breathing
To parent:
Does your child snore a lot or have
difficulty breathing at night?
To parent:
Does your child have loud or nightly snoring or any
breathing difficulties at night?
To parent:
Does your teenager snore
loudly or nightly?
8 Weiss & Salpekar
ª 2010 Adis Data Information BV. All rights reserved. CNS Drugs 2010; 24 (10)
AUTHOR PROOF
should be on sleep problems that may be related
to primary ADHD, such as initial insomnia or
medication-related sleep problems.
3.1 Delayed Sleep Onset
Parents of children with ADHD often report
that their children have difficulty initiating sleep
at bed time. In some cases, behavioural problems
such as poor limit setting, or co-morbid disorders
such as opposit ional defiant disorder, may con-
tribute to resistance to parental requests to get
ready for bed, bedtime resistance and delayed
sleep onset.
[7]
However, it is also true that chil-
dren who are forced to go to bed when they are
not tired, knowing that they will not be able to
fall asleep, may develop sleep resistance that
could be misinterpreted as oppositional. Objec-
tive data do not confirm the hypothesis that op-
positional disorder is a significant contributor to
sleep disorders in ADHD.
[47]
Rather than being
defiant, it may be that the child is being asked to
do something boring, frustrating and unsustain-
able. A child with ADHD will only experience
frustration and decreased sleepiness if forced to
lie in bed with nothing to do and no subjective
experience of being sleepy. This is the paediatric
equivalent of adults who toss and turn for hours,
watching the clock and unable to ‘shut down’ and
fall asleep. For these reasons, it is very useful to
assure that one has obtained the child’s point of
view of their own subjective sleep experience.
Many children complain that ‘‘they cannot
turn their thoughts off,’’ and the experience of
lying in bed in a hyper-alert state leads them to
seek other stimuli that might help pass the time
until they finally fall asleep. A parent who at-
tempts to compensate for perceived sleep diffi-
culty as manifested by cranky behaviour may
react by putting a child to bed even earlier. This
further widens the time frame between ‘going to
bed’ and ‘feeling tired’; as a result, the child is
likely to experience an increase rather than a de-
crease in sleep-onset latency. In fact, part of the
bargaining tool most often likely to be successful
in engaging children to ‘buy into’ a sleep hygiene
programme is a later bed time, which combined
with melatonin and modest sleep restrictions, al-
lows them to have the experience of feeling tired,
‘‘being able to turn their thoughts off’’ and falling
asleep quickly. Parents measure the success of
sleep by its duration, whether or not the child is
actually sleeping. In working with parents using
this method, clinicians generally explain that
sleep efficiency is as important as sleep duration,
and that a child who sleeps deeply for a somewhat
shorter period may be as or better rested than a
child who cannot fall asleep. Clinical experience
also shows that when ADHD childr en are put to
bed too early there are other negative con-
sequences. Lying in bed with nothing to do when
you are not tired is an attention-demanding task
that leads children to resent going to bed. Fur-
thermore, a child that goes to bed prior to the
onset of normal sleepiness and misses this critical
period often stays up much later than a child that
goes to bed when tired.
It has been suggested that the roughly 30%
of medication-free children with ADHD who
experience chronic sleep-onset insomnia
[46]
may
actually have a delayed endogenous circadian
pacemaker, as evidenced by measurements of
delayed sleep onset, dim light, melatonin onset
and time of awakening.
[37,48]
Delayed sleep-onset
latency has also been demo nstrated in a study
of adults with ADHD (n = 40).
[49]
Adults with
ADHD and sleep-onset insomnia showed a de-
layed start and end of their sleep period and a
delayed melatonin onset compared with adults
with ADHD who did not have sleep-onset in-
somnia (p = 0.006; p = 0.023; p = 0.02, respectively).
Regardless of its behavioural or physiological basis,
treatment of delayed-sleep onset can be approached
through the use of behavioural methods for im-
proving sleep, such as sleep hygiene training.
3.2 Medication-Related Sleep Problems
Initial insomnia may be further exacerbated by
medications given to treat ADHD or co-morbid
conditions.
[7,50,51]
Medications used to treat ADHD
include stimulants (methylphenidate, amfetamine),
atomoxetine, bupropion, tricyclic antidepressants
(TCAs), a-receptor agonists and modafinil.
[50]
In
one report, stimulant-treated children with ADHD
had nightly increases in sleep latency or insomnia
Sleep Problems in the Child with ADHD 9
ª 2010 Adis Data Information BV. All rights reserved. CNS Drugs 2010; 24 (10)
AUTHOR PROOF
at almost three times the rate of untreat ed chil-
dren with ADHD.
[52]
While the degree of sleep-
onset latency varies with drug, dose and time of
administration,
[7,51]
stimulant-induced increases
in sleep-onset latency >30 minutes have been com-
monly reported.
[53-57]
It has been unclear whether children receiving
stimulants have difficulty falling asleep because
of a direct effect of the medication or because of a
rebound effect associated with waning blood con-
centrations of medication. Pervasive clinical ob-
servations that adolescents and adults sometimes
need to take their stimulant in the evening in or-
der to fall asleep have lent support to the rebound
hypothesis.
[7,58]
However, studies using a third
evening stimulant dose to avoid a possible re-
bound effect have observed more significant delay
in sleep onset in children treated with stimulants
versus untreated children.
[59,60]
Clinical lore sug-
gests that for some children, it is easier to fall
asleep while on stimulants than off stimulants.
There are several possible interpretations. First,
for some children, going to bed is an attention-
demanding activity or routine that is easier to
accomplish while medicated. An alternative ex-
planation is that the pathway by which stimu-
lants interfere with sleep may relate not only to
the alerting properties of a medication but also to
interference with the onset of sleep when the drug
is waning and the child ‘rebounding’. Rebound is
described as a period in which children are more
irritable, reactive and agitated,
[61]
all of which
may be considered to be antithetical to the state
of restfulness and calm required to induce sleep.
Medications used to treat co-morbid condi-
tions are also associated with a number of sleep
disturbances. For example, some selective sero-
tonin reuptake inhibitors (SSRIs) may increase
sleep-onset latency, cause daytime sedation and
suppress rapid eye movement sleep, whereas TCAs
have been associated with decreased sleep-onset
latency and decreased arousals during sleep stage
transitions but may also increase daytime sleepi-
ness.
[7,35]
However, attributing sleep problem s to
these medications may be subject to significant
confounds, as patients are presumably taking these
medicines for co-morbid affective or anxiety dis-
orders, all of which are associated with high degrees
of sleep problems prior to treatment.
[27]
Recently,
there has been a significant increase in the prescrib-
ing of second-generation antipsychotics, such as
risperidone or quetiapine, to treat irritability,
anger and tantrums – all common phenomena in
ADHD. These medications also have the added
benefit of being sedative and increasing appetite,
thus mitigating stimulant side effects.
3.3 Excessive Daytime Sleepiness
Excessive daytime sleepiness in children with
ADHD has been noted in three studies.
[8,62,63]
Lecendreux et al.
[63]
reported shorte r nap sleep-
onset latency for children with ADHD (n = 30,
boys aged 5–10 years) compared with age- and
sex-matched controls (n = 22) using the Multiple
Sleep Latency Test. The number and duration of
sleep onsets was also significantly correlated with
hyperactivity-impulsivity and inattentive-passiv-
ity scores, and none of these differences could be
attributed to differences in nocturnal sleep.
[63]
A second study, of 34 children with ADHD
(mean age, 12.4 years), also used the Multiple
Sleep Latency Test and found that children with
ADHD were significantly more drowsy com-
pared with controls (p < 0.05).
[62]
Another recent
study of 107 non-medicated children with
ADHD and 46 healthy control children, all aged
6–14 years, reported that ch ildren with ADHD
experienced significantly more daytime sleepiness
than control children as reported in children’s
diaries.
[8]
Lastly, a study in adults with ADHD
observed that up to one-third of adults with
ADHD may have subjective sleepiness (a score of
>12 on the Epworth Sleepiness Scale ),
[64,65]
and
that inattention scores were correlated with the
excessive daytime sleepi ness values. These results
have led some researchers to propose that chil-
dren with ADHD may have a deficit in alertness
due to excessive daytime sleepiness, and that ex-
cessive motor activity might be a paediatric mani-
festation of sleepiness, similar to what is experi-
enced with the normal ‘overtired’ child.
[9,17,63]
These observations have led to the suggestion
that wake-promoting agents (e.g. modafinil) may
be an important alternative to stimula nts in those
children with ADHD who present with a sub-
10 Weiss & Salpekar
ª 2010 Adis Data Information BV. All rights reserved. CNS Drugs 2010; 24 (10)
AUTHOR PROOF
jective complaint of daytime somnolence con-
firmed by short, but not excessive, mean sleep
latencies.
[17,62,63,66,67]
It should be noted that recent
clinical trials confirmed the efficacy of modafinil
for the treatment of ADHD, but the drug did not
receive US FDA approval because of concern re-
garding Stevens Johnson syndrome.
[68,69]
4. Treatment of Sleep Disturbances in
Children with ADHD
4.1 Behavioural Treatments
4.1.1 Sleep Hygiene
Sleep hygiene has been defined as the range of
behavioural and environmental factors preceding
sleep that can influence sleep initiation and main-
tenance.
[70]
Improving sleep hygiene measures
has been shown to improve sleep quality
[71,72]
and
to effectively treat initial insomnia in children
with ADHD.
[37,48]
Sleep hygiene training involv-
es establishing consistent behaviour surrounding
bedtime to promote produ ctive and restful sleep.
In children, factors that may improve sleep include
a calm bedtime routine and a stable bedtime and
wake time (table V).
[70,73]
Of these interventions,
the most important is a regular wake time. It is
not possible to put a wakeful child to bed early,
but it is possible to wake a tired child early in the
morning so that they increase their sleep debt and
fall asleep earlier the next night. Parents are often
unaware that, for all practical purp oses, the sleep
clock is set in the morning.
Sleep hygiene always needs to be individ-
ualized. For example , some children request a
small, dim night light or to sleep with a pe t or
sibling before going to bed at night. If the child
has established this kind of sleep cue (often re-
ferred to in the literature as a ‘zeitgeber’), there is
no hard and fast rule to preclude these habits.
This is probably not true for computer games,
Internet, intense and stimulating exercise or caf-
feine intake. Exposure to bright light from a
computer screen close to the face is likel y not only
to suppress endogenous but also exogenous mela-
tonin. For the physician, sleep hygiene training
begins with a baseline assessment of sleep patterns
through the use of pa rent-completed somnol ogs
or an assessment tool such as the Children’s Sleep
Hygiene Scale (table VI)
[70]
or the sleep hygiene
index.
[74]
The Children’s Sleep Hygiene Scale in-
cludes six anchors on 24 items, with higher scores
representing better hygiene, and ca n be obtained
from the author. Jan et al.
[75]
recently reviewed
the myria d of considerations relevant to individual-
izing a sleep hygiene programme for children with
neurodevelopmental disorders. Many of these are
not specific to ADHD and apply to any child or
adult with a sleep problem. There are also sleep
hygiene considerations specific to children with
ADHD as discussed in the remainder of this section.
When parents are overtired because the child’s
insomnia is affecting their own sleep, several pos-
sible approaches can be considered. In two-parent
Table V. Behavioural practices for good sleep hygiene (adapted
from the American Academy of Sleep Medicine,
[73]
with permission.
Copyright ª 2008 American Academy of Sleep Medicine)
Set an appropriate and consistent bedtime
if too early, bedtime can contribute to bedtime resistance
follow set bedtime 7 days a week
minimize late nights on weekends
Relaxing bedtime routine
consistent routine that can be easily followed every night, such as
a warm bath or reading
Appropriate bedroom environment
dark, quiet and comfortable temperature
associate bed with sleep
do not use the bed to watch television, listen to the radio or read
Minimize pre-bedtime activity and electronic media use
too much activity close to bedtime can keep children awake
no television, computer or text messaging 1 hour before bed
avoid emotionally upsetting conversations and activities
Avoid large meals close to bedtime
No caffeine less than 6 hours before bedtime
Consistent wake-up time
wake at the same time every day, even on weekends and on
holidays
Avoid daytime naps
napping can disturb normal pattern of sleep and wakefulness
Exercise
vigorous exercise in the morning or late afternoon can promote
night-time sleep
relaxing exercises (e.g. yoga) before bed can help initiate a restful
night’s sleep
Daytime exposure to natural light
Avoid medications that may interfere with sleep (e.g. decongestants
and some asthma medicines)
Sleep Problems in the Child with ADHD 11
ª 2010 Adis Data Information BV. All rights reserved. CNS Drugs 2010; 24 (10)
AUTHOR PROOF
families, it is possible to have one parent take
the morning shift and another take the even-
ing shift. Parents can also implement a morning
routine that habituates the child to watch televi-
sion or do another ‘safe’ activity until the parents
are awake. When a child with ADHD is keeping
siblings awake because they share a room, it may
be important to separate them or put one child to
bed when the first child is already soundly a sleep.
Exhausted parents of a child with ADHD wi ll
sometimes use ‘going to bed’ as a baby sitter,
setting a bed time that is much earlier than ap-
propriate. A simple and often parent friendly way
of dealing with this problem is to find an activity
that the child can engage in independently while
the parent completes other tasks. Most ADHD
children have another activity they can do for
long periods on their own. In some circum-
stances, for example, with single parents who do
shift work, more intensive and individualized in-
tervention will be needed.
Children with ADHD find computer games,
television or handheld video games to be atten-
tion relieving and may spend many hours in front
of brightly lit screens in an addictive-like activity
late at night. For many ADHD children these
games can be described as ‘addictive’, in that
attempts to turn them off are met with great re-
sistance. This may also lead to a state of hyper-
arousal that affects the child’s capacity to settle to
sleep when the next level of the game is left un-
tried. Consistent clinical experience has demon-
strated that melatonin may ‘stop working’ when
used contiguously with bright light computer games,
and that discontinuation of these games in the
evening returns the exogenous melatonin efficacy.
Sleep hygiene involves severa l steps. First, it
is important to establish, with the parent, what
a reasonable durati on of sleep is for the child.
Many parents have unrealistic expectations re-
garding how long a child should sleep, partic-
ularly when they interpret ADHD behaviour as a
sign that the child is ‘overtired’. A child with de-
layed-phase sleep syndrome is often described by
parents as ‘‘impossible’’ to wake in the morning,
and education is required to teach parents that
every child can be woken at a reasonable hour,
and that waking a child requires a firm, no-
‘snooze button’ approach. Parents are told to
avoid going into the room, telling the child to
wake up and then leaving. Instead, they are in-
structed to wake the child, get him or her out of
bed and initiate an activity that precludes going
back to sleep, such as sitting the child down to
breakfast or having the child take a shower.
When the child and parent have both come to
accept that an earlier waki ng will be accompanied
by a later bedtime (or sleep restriction), and
that being woken up by the parent is a prescribed
and absolute requirement, many of the difficul-
ties with morni ng waking abate. When parents
are given methods of waking their child even
in the face of resistance, and the sleep schedule
begins with mild sleep restriction and other hygiene
measures, the result is often a child who falls asleep
easily, which both parents and even the child re-
port as rewarding, especially when documented as
a success on later sleep logs or actigraphs.
4.1.2 Cognitive Behaviour Therapy
In addition to improving sleep hygiene, other
behavioural methods of treating sleep deficits,
Table VI. Selected items included in the Children’s Sleep Hygiene
Scale (CSHQ)
a
Naps 4 hours before bedtime
Caffeine 4 hours before bedtime
Does relaxing things before bedtime
Drinks lots of liquids before bedtime
Plays rough before bedtime
Does things that are alerting
Goes to bed about the same time
Complains about being hungry at bedtime
Does things in bed that keep him/her awake
Goes to bed in the same place
Goes to bed feeling upset
Sleeps alone
Has a calming bedtime routine
Uses bed for things other than sleep
Put to bed after falling asleep
Stays up past usual bedtime
Gets out of bed at same time in morning
a Caretakers are asked to evaluate each item on a 6-point rating
scale: never; once in a while; sometimes; often; frequently/
always; always.
[70]
12 Weiss & Salpekar
ª 2010 Adis Data Information BV. All rights reserved. CNS Drugs 2010; 24 (10)
AUTHOR PROOF
such as cognitive behaviour therapy, may also
have valuable roles in improving sleep in children
with ADHD. Cognitive behaviour therapy for sleep
problems includes a combination of relaxati on
training, stimulus control therapy, sleep restric-
tion and cognitive therapies. Although there are
no reported studies evaluating its efficacy for
the treatment of sleep problems in children with
ADHD, a number of trials have shown that
cognitive behaviour therapy is effective for the
treatment of chronic insomnia associated with
conditions ranging from chronic pain to depres-
sion.
[76-78]
It may be worthwhile noting that cog-
nitive techniques are not going to change a short
sleeper into a long sleeper, nor will they address
major biological causes of insomnia. Several
other techniques used in adult sleep clinics, such
as chronotherapy for delayed sleep phase, have
not been tested or may not be practical in chil-
dren and therefore cannot be recommended at
this time.
4.2 Dietary Factors Associated with
Sleep Problems
Treatment with stimulants often leads to sig-
nificant appetite suppression during the day.
[79]
This suppression often wears off at the end of the
day as the medication levels fall, at which point a
child is likely to not only feel hungry, but may feel
excessively hungry from the lack of eating during
the day. This is common at bedtime when a child
may protest, ‘‘But I am starving.’’ This may be
interpreted as a stalling technique to go to bed,
but it also may be the first time the child has both
had an appetite and the attention to recognize it.
Clinical experience dictates that allowing the
child to go to bed well fed rather than hungry
makes it easier to fall asleep. Parents often have
myths that eating before bed will cause bad
dreams or poor sleep. In this case explaining the
facts regarding stimulants and appetite suppres-
sion is helpful.
4.3 Pharmacological Management of
Treatment-Induced Insomnia in ADHD
Re-evaluating the ADHD medication, along
with sleep hygiene assessment and training, should
be the first steps in managing medication-induced
insomnia.
[51,58]
Medication re-evaluation may in-
volve either changing the medication dose, the
dosing regimen or the treatment formulation so
that less medication is administered later in the
day.
[7,51,58]
Alternatively, the use of a medication
with a more appropriate pharmacokinetic profile
with a greater a.m. versus p.m. release may help
to eliminate sleep disturbances in some patients.
The clinician may want to ensure that the child is
on a stimulant that minimizes evening exposure
or that the child is not going to bed during the
period of peak rebound. Longer-acting stimu-
lants taken only once a day may have greater
effects on sleep, and switching to either a longer-
acting formulation that exhibits declining phar-
macokinetics in the evening or a shorter-acting
formulation that is taken again in the afternoon
may he lp to reduce sleep problems.
[50]
In other
cases, sleep problems may be improved by switch-
ing to a non-stimulant (e.g. atomoxetine).
One study comparing sleep problems with meth-
ylphenidate with the non-stimulant drug ato-
moxetine showed that atomoxetine was generally
associated with different sleep problems than
methylphenidate.
[56]
In this randomized, double-
blind, crossover trial of children aged 6–14 years
with ADHD (n = 85), delayed sleep onset was
significantly shorter following 7 weeks of treat-
ment with twice- daily atomox etine (42.17 min-
utes, standard deviation [SD] = 31.61) compared
with three times-daily short-acting methylpheni-
date (69.35 minutes, SD = 43.86).
[56]
Child and
parent diaries also indicated that it was easier to
fall asleep and get up in the morning, and that
there was a better quality of sleep, when taking
atomoxetine versus methy lphenidate.
[56]
How-
ever, methylphenidate was associated with a sig-
nificant decrease in the total number of sleep
interruptions or awakenings compared with ato-
moxetine, suggesting that the relatively longer
sleep latency experienced with stimulants may
result in a more consolidated (i.e. less disrupted)
sleep.
[56]
Therefore, the relative impacts of dif-
ferent medications on specific aspects of sleep (i.e.
insomnia vs sleep consolidation) must be care-
fully considered on a case-by-case basis. When
evaluating sleep, it is important to consider not
Sleep Problems in the Child with ADHD 13
ª 2010 Adis Data Information BV. All rights reserved. CNS Drugs 2010; 24 (10)
AUTHOR PROOF
only the duration of sleep and the time spent in
bed but also the sleep efficiency or the ratio be-
tween the two.
If all other attempts at finding a solution
through behavioural interventions and adjusting
primary ADHD medications have been unsuc-
cessful, the use of a sleep-promoting medication
may be appropriate as a final resort. There are no
FDA-approved sleep medications for children.
However, a-agonists (clonidine), antidepressants
(trazodone and mirtazapine), antihistamines and
hypnotics have been used in clinical practice.
[51]
The evidence for these treatments, their con-
tinued effectiveness over time and their effect on
sleep quality have not been studied empirically,
and there are limited safety and longitudinal data
for combination treatment.
[51]
Furthermore, when
administered over a long period of time, some sleep-
promoting medications can sometimes be coun-
terproductive; tolerance to the medication might
develop, making increased dosages necessary.
[17]
Recently, it has become more common to use
an atypical antipsychotic as a hypnotic, on the
assumption that the low doses needed are rela-
tively benign, both in adults and in children.
However, more recent work suggests that atypi-
cal antipsychotics, even in low doses, may be
associated with weight gain an d the potential for
metabolic syndrome;
[80-82]
therefore, it is our re-
commendation that antipsychotics should not be
used as hypnotics for children .
4.4 Melatonin
An alternative treatment may be treatment
with the naturally occurri ng sleep hormone, mel-
atonin (shown to have a relative phase delay in
release in children with ADHD
[83]
), which has a
relatively benign side-effect profile. Two well
controlled studies have shown that melatonin is
significantly better than placebo in reducing sleep-
onset latency and enhan cing total time asleep in
stimulant-treated
[48]
and medication-free
[84]
children
with ADHD and chronic sleep-onset insomnia. In
the first study, a double-blind, placebo-controlled,
30-day crossover trial (n = 27), stimulant-treated
children with ADHD who received melatonin
(5 mg/day taken 20 minutes before bedtime for
10 days) following a non-response to sleep hygiene
training (n = 19) experienced a significant decrease in
sleep-onset latency compared with placebo (mela-
tonin: 46.4 – 26.4 minutes vs placebo: 62.1 – 26.6
minutes; p < 0.01).
[85]
An even more substantial
overall decrease in sleep-onset latency of 60 min-
utes (final sleep-on set mean latency of 31 minutes
vs pre-trial mean latency of 91 minutes) was ob-
served following 90 days of post-trial open-label
melatonin treatment.
[48]
In a second randomized,
double-blind, placebo-controlled trial, medication-
free children with ADHD and chronic sleep-onset
insomnia (n = 105, aged 6–12 years) were given
melatonin 3 or 6 mg (depending on bodyweight)
or placebo for 4 weeks.
[84]
Compared with base-
line measures, sleep onset occurred 26.9 – 47.8
minutes earlier in patients treated with melatonin
(n = 53) and shifted to 10.5 – 37.4 minutes later in
children given placebo (n = 52; p < 0.0001).
[84]
In
addition, total time asleep increased with mela-
tonin (19.8 – 61.9 minutes) compared with placebo
(-13.6 – 50.6 minutes; p = 0.01).
[84]
Adverse events
experienced with melatonin treatment did not
significantly differ from placebo in either of these
two studies.
[48,84]
A follow-up study of 105 children
who participated in the second study
[84]
reported
no serious adverse events or treatment-related co-
morbidities associated with melatonin after a mean
follow-up time of 3.7 years.
[86]
Long-term melatonin
treatment was deemed effective against sleep-onset
problems in 88% of the cases, and improvement
of behaviour and mood was reported in 71% and
61%, respectively. Discontinuation of melatonin
treatment led to a relapse of sleep-onset insom nia
and in resuming melatonin treatment in about
90% of these children.
[86]
Therefore, melatonin,
along with re-evaluation of medication and sleep
hygiene, may be an appropriate treatment for
stimulant-induced sleep problems.
[51]
Augmentation of behavioral strategies with mela-
tonin is often quite helpful, administered in doses
of 3–6 mg 30 minutes before desired sleep onset.
Parents require appropriate education about
melatonin, since myths abound about this sub-
stance; information can be obtained on the Na-
tional Sleep Foundation website.
[87]
Melatonin is
made synthetically, is not a source of mad cow
disease and has both hypnotic and chronobiotic
14 Weiss & Salpekar
ª 2010 Adis Data Information BV. All rights reserved. CNS Drugs 2010; 24 (10)
AUTHOR PROOF
effects, and there is no proof that exogenous
melatonin suppresses the long-term release of
endogenous melatonin.
5. Conclusions
Properly assessing and treat ing sleep problems
will help improve the health, well-being and pos-
sibly the behavioural outcome of children with
ADHD (table VII). The treatment of sleep dis-
orders in children has a major impact on the fam-
ily’s quality of life and caregi ver strain. Care
should be taken to identify sleep disorders that
may have an increased prevalence in children with
ADHD, including circadian rhythm sleep dis-
orders, RLS, PLMD and SDB. Other sleep dis-
turbances, such as chronic sleep-onset insomnia
and excessive daytime sleepiness, may be related
to primary ADHD pathophysiology or medica-
tions used to treat ADHD (e.g. stimulants). The
first version of DSM-III actually included restless
sleep as one of the diagnostic criteria for ADHD.
Recent research suggests that the relationship
between ADHD and sleep is worth further inves-
tigation, as ADHD may be associated with ex-
cessive movement at night as well as excessive
sleepiness during the day. Additional research
may identify common metabolic or neurological
pathways to both the sleep and ADHD impair-
ments that occur in this co-morbid population.
Common metabolic pathways underlie the pro-
duction of melatonin, dopamine and noradren-
aline (norepinephrine).
A number of patient- and caregiver-based tools
are available that can help assess sleep problems
and identify patients who require referral to a sleep
specialist. A sleep specialist can help decide when
further assessment (e.g. polysomnography or the
Multiple Sleep Latency Test) and treatments for
identified sleep disorders (e.g. RLS, PLMD) may
be necessary. Thes e assessment procedures are
only available in sleep laboratories and cannot be
done easily in most general practice settings.
Behavioural methods, including education
and sleep hygiene, are the first line of therapy for
treating initial insomnia in children with ADHD.
For children experiencing stimulant-related in-
somnia, adjustments in the medication dosing
schedule and the use of a medication with a more
appropriate pharmacokinetic profile may help
sleep patterns. Atomoxetine and methylpheni-
date affect sleep patterns in different ways. There-
fore, decisions to switch medications should be
made on an individual basis. Further study may
help to ascertain whether ADHD in some chil-
dren may be conceptualized not only as a daytime
behavioural problem but also as a 24-hour dis-
order that affects sleep physiology, which may af-
fect treatment selection.
Acknowledgements
Editorial support was provided by Ann T. Yeung, PhD
(Phase Five Communications Inc., New York, NY, USA)
with funding from Novartis Pharmaceuticals. Ann Yeung re-
viewed each draft for consistency, references and errors; fa-
cilitated conference calls in which the outline of the paper was
drafted; and coordinated changes made at each stage. Dr
Weiss has received funds from Eli Lilly, Shire, Purdue and
Janssen for investigator initiated research, and honoraria for
talks and consultation.The authors have no conflicts of in-
terest that are directly relevant to the content of this review.
Table VII. Clinical pearls regarding proper assessment and treat-
ment of sleep problems for children with attention-deficit hyper-
activity disorder (ADHD)
All children presenting with ADHD should be assessed for their sleep
schedule and common sleep problems, either clinically or through
the use of a scale
In the event of identification of difficulties with circadian rhythm, the
initial step should be the use of a sleep log or diary to examine the
patient’s sleep patterns and to contract a sleep hygiene that
establishes a regular and reasonable amount of sleep
If the clinician identifies sleep disorders that require specialist care or
a polysomnographic technologist, referral to a paediatric sleep
laboratory is required. However, a significant fraction of children will
have sleep disorders such as initial insomnia that are highly
responsive to clinical and office-based treatment
Common treatments for sleep disorders in children with ADHD
include sleep hygiene, modification of stimulant treatment and use of
melatonin as benign but effective interventions
Where medication for ADHD is the major impediment to a delay in
sleep-onset latency, if the stimulant is working well, the clinician can
consider adding melatonin 3-6 mg 30 minutes before bedtime once a
sleep schedule is established
In the event that use of stimulants is associated with intractable sleep
problems, consideration should be given to switching to a medication
such as atomoxetine, which may cause less insomnia
Sleep is a physiological function that impacts on many aspects of
health, and addressing sleep issues may allow us to minimize the
negative effects of insomnia on ADHD, and the negative effects of
ADHD on insomnia
Sleep Problems in the Child with ADHD 15
ª 2010 Adis Data Information BV. All rights reserved. CNS Drugs 2010; 24 (10)
AUTHOR PROOF
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Correspondence: Dr Margaret D. Weiss, Children’s and
Women’s Health Centre of British Columbia, Box 178, 4500
Oak Street, Vancouver, BC, V6H 3N1, Canada.
E-mail: mweiss@cw.bc.ca
18 Weiss & Salpekar
ª 2010 Adis Data Information BV. All rights reserved. CNS Drugs 2010; 24 (10)
