Sleep, Interrupted

The links between ADHD, anxiety, and insomnia in children.

Is your child ready for an overnight? With parent preparation - and a backup plan - she will be. ADDitude Magazine

Children with ADHD are so wound up that it takes them a long time to turn their motor off.

Signs of sleep deprivation

1. Frequent awakening during the night

2. Talking during sleep

3. Difficulty falling asleep

4. Waking up crying

5. Daytime sleepiness

6. Nightmares or bedwetting

7. Teeth grinding or clenching

Source: American Academy of Child and Adolescent Psychiatry

Jessica is a handful by daylight, and most observers outside her home heave a sigh for her parents that the day will eventually be done with, and night and sleep will be on the way. Ahhh! Sleep and quiet. But in reality, many parents of ADHD children say that the night is filled with agitation, restlessness and sleeplessness, and the calm after the storm isn't as tranquil as outsiders would like to believe.

In other words, the biology that helps define a child with ADHD doesn't shut down at the stroke of 9 p.m. In fact, psychiatrists and sleep researchers are trying to understand whether the sleep problems that are so common among ADHD children are cut from the biology of the behavioral disorder or a result of the mix of medicines these children have to take to calm their symptoms. In fact, there are researchers who are studying the possibility that the irritability, hyperactivity and inattentiveness of ADHD may, for some, be due to a lack of sleep.

Unfortunately, the jury is still out.

"Children with ADHD are so wound up that it takes them a long time to turn their motor off," said Dr. Gabrielle Carlson, director of child and adolescent psychiatry at the State University of New York at Stony Brook. "It might seem that their energy level is there all the time."

But what Carlson and others who work 'round-the-clock with severe ADHD, see is that children on Stony Brook's inpatient unit sleep, well, like babies. They have no problems falling asleep - or staying asleep. "With structure, a lot of the sleep problems disappear."

Canadian psychologist Rosemary Tannock and her research colleague, Penny Corkum, recently documented this in Tannock's laboratory at the Hospital for Sick Children in Toronto. "We couldn't find evidence that sleep was an integral part of the ADHD picture," she said. The real culprits: the separation anxiety that many kids with ADHD share; stimulants; and a lack of a consistent bedtime routine.

Corkum added that the ADHD children didn't look different from those children with anxiety and other symptoms of mental illness. But Corkum, who is now at Mount St. Vincent University in Halifax, Nova Scotia, also said that shorter sleep times are generally related to more attention problems. "If your mind is racing, it is difficult to go to sleep."

She believes that medicines could play an important role in keeping some children up and helping others to settle down. "If a child is suffering at night, you might want to look at an alternate dosing schedule."

In the study, the scientists recruited 30 children with ADHD, and this was a special group of children whose parents said had severe sleep problems. An equal number of non-ADHD kids were brought in to compare sleep patterns during a 7-day study. The children slept in their own beds and wore a wrist device, much like a watch, that records virtually every body move the child makes. The children and parents also kept sleep diaries throughout the week. Children with ADHD had no more movements than the kids without.

The researchers also looked for evidence of restless leg syndrome, the symptom de jour these days, and it was not a problem in the ADHD kids studied. People who have restless leg syndrome describe it as an uncomfortable sensation - crawling, tingling, pulling or twitching feeling - that begins right before they fall asleep and forces them to move their leg. Some investigators believe there is a link between RLS and ADHD and one theory is that both share a lack of the brain chemical dopamine. Dopamine regulates movement as well as behavior and mood.

But these children clearly took longer getting to sleep, and had greater difficulty getting up in the morning. In fact, the ADHD kids slept longer than the other children, suggesting that they need more sleep to integrate and store a brain system that Tannock says is "overloaded" during the day.

She has seen parents pull their hair out (figuratively, of course) trying to get their child to sleep. They use more requests, and there is far more follow-through. Over and over again. "ADHD kids are difficult to organize and the symptoms make it difficult to do things in a timely matter," she explains.

Tannock and her colleagues can't rule out the possibility that different medicine regimens in the United States may color another sleep picture for American children. Ritalin and other ADHD medicines are often used three times a day whereas in Canada it is given twice a day. What she is hoping to study is whether the high anxiety in these children - one third of them constantly worry about being alone - can be treated to overcome nighttime problems. Addressing the anxiety should be separate from treating the ADHD attention and hyperactivity problems, experts agree. Many now teach coping strategies so children can recognize "worry" symptoms - the racing heart, the agitation - and use mental exercises to help them go away.

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