My child won't sit still! Is it ADHD, or an underlying sleep disorder?

“Sleep disorders may not be at the front of your mind when evaluating a child for the first time, with inattention, hyperactivity, or behavioral disturbances,” began Grace Wang, MD, FAAP, assistant professor of pediatrics, Penn State Health in Lancaster, Pennsylvania, at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition. “I hope to convince you, by the end of this talk, that children and adolescents with attention-deficit/hyperactivity disorder (ADHD) have a consistently higher prevalence of sleep disorders as compared to the general pediatric population. There is evidence that shows that resolving the underlying sleep disorders can improve and in some cases, resolve, a patient’s ADHD diagnosis.”

“Sleep disorders are not listed in the differential diagnosis of ADHD in the DSM-5,” Wang continued. This, Wang believes, is why practitioners evaluating children for ADHD might not have it on their radar to screen for sleep disorders.

Wang went on to describe several case studies, the first being a 6-year-old female with seasonal allergies and dysfunctional voiding patterns in the context of constipation; hyperactive and emotionally labile; threw frequent tantrums; has difficulty sustaining attention; and is starting to fall behind her peers at school. She had no past surgical history, no family history of ADHD, and family would rather not start her on a stimulant, asking if anything else can be done. She presented as an alert girl with normal vital signs, normal intellect, good eye contact and cooperative with interview. Vanderbilt parent/teacher rating scales are implemented and the child screens for ADHD, combined type. Psychometric testing reveals normal intellect with no learning disabilities. In recalling that sleep disorders can be seen in children with ADHD, the physician asks about snoring, and discovers the child does indeed snore, is a mouth breather, is restless throughout sleeping and occasionally sleepwalks. Furthermore, she is exhausted after school, falling asleep in the car on the drive home. This prompts a polysomnography, which shows she has sleep-related hyperventilation, and a mild/ borderline degree of obstructed sleep apnea syndrome (OSAS).

At this point, Wang interjects, “Studies have shown that 25% of children with ADHD have OSAS, and 33% have snoring. Additionally, 25% to 64% of patients with ADHD have some sort of sleep-disordered breathing.” The million-dollar question then becomes, Wang, admits, “can you expect improvement of ADHD symptoms after addressing sleep disorders? Literature shows that adenotonsillectomy in treating sleep disorders does improve ADHD symptoms and may even resolve the diagnosis,” proven in studies such as the Childhood Adenotonsillectomy Trial, which showed improved quality of life and behavior ratings by parents and teachers, says Wang. She points to a remarkable study of 5 to 13 year old children, where 28% were diagnosed with ADHD before an adenotonsillectomy. One year after the surgery, half of those children no longer met DSM criteria for ADHD. Similarly, ADHD scores were normalized in 69% of 40 children who had undergone the surgery 6 months prior.

Returning to the case study of the 6-year-old-child with a diagnosed sleep disorder, it was ultimately recommended that she get an adenotonsillectomy. Not only did her sleep improve after the surgery, but so did her attention span and behavioral issues.

Another patient discussed in this session was a 15-year-old male with Delayed Sleep-Wake Phase Disorder, a condition where children do not feel as sleepy as their peers at bedtime because of the delayed release of melatonin. Treatments for this condition include consistent weekday and weekend sleep schedules; avoiding blue light in the evening; and exposing the child to bright, natural light upon waking. If these do not resolve the disorder, sleep medicine and behavioral therapy are often suggested.

Wang also went into a discussion of restless leg syndrome (RLS) in patients with ADHD, which can be treated with iron supplements, leg massages, compression devices, and lower body exercises.

In concluding, Wang summarized, “keep that high index of suspicion for both sleep disorders and RLS in children with ADHD; as RLS runs in families, ask about RLS in the biological parents and siblings; and as iron deficiency is a risk with RLS, be sure to check on that as well. Also, she stated, since sleep deprivation and RLS can mimic symptoms of ADHD, have a high index of suspicion when examining and screening a patient for these conditions.

Reference

1. Wang G. My child won’t sit still! Is it ADHD, or an underlying sleep disorder? American Academy of Pediatrics 2021 National Conference & Exhibition; virtual. Accessed October 9, 2021.