Sleep study abnormalities in children with attention deficit hyperactivity disorder

A failure of sleep-dependent consolidation of visuoperceptual procedural learning in young adults with ADHD

ADHD has been associated with cortico-striatal dysfunction that may lead to procedural memory abnormalities. Sleep plays a critical role in consolidating procedural memories, and sleep problems are an integral part of the psychopathology of ADHD. This raises the possibility that altered sleep processes characterizing those with ADHD could contribute to their skill-learning impairments. On this basis, the present study tested the hypothesis that young adults with ADHD have altered sleep-dependent procedural memory consolidation. Participants with ADHD and neurotypicals were trained on a visual discrimination task that has been shown to benefit from sleep. Half of the participants were tested after a 12-h break that included nocturnal sleep (sleep condition), whereas the other half were tested after a 12-h daytime break that did not include sleep (wakefulness condition) to assess the specific contribution of sleep to improvement in task performance. Despite having a similar degree of initial learning, participants with ADHD did not improve in the visual discrimination task following a sleep interval compared to neurotypicals, while they were on par with neurotypicals during the wakefulness condition. These findings represent the first demonstration of a failure in sleep-dependent consolidation of procedural learning in young adults with ADHD. Such a failure is likely to disrupt automatic control routines that are normally provided by the non-declarative memory system, thereby increasing the load on attentional resources of individuals with ADHD.

Psychopharmacotherapy of Attention Deficit-Hyperactivity Disorder in Children with Comorbid Conditions

One or more comorbidities occur in up to 80% of children with attention deficit-hyperactivity disorder. Attention deficit-hyperactivity disorder is also over-represented in several special populations. Pharmacotherapy can be challenging in these individuals with other conditions due to a suboptimal therapeutic response and an increased likelihood of adverse reactions. This article reviews the evidence supporting the psychopharmacologic management attention deficit-hyperactivity disorder when it occurs in individuals with common comorbidities.

The impact of comorbid mental health symptoms and sex on sleep functioning in children with ADHD

Children with attention-deficit/hyperactivity disorder (ADHD) display more sleep problems than their peers, but it remains unclear whether comorbid mental health symptoms [i.e., anxiety, depression, oppositional-defiant disorder (ODD)] are uniquely related to sleep functioning. It is also largely unknown whether boys and girls with ADHD differ in their sleep functioning. This study (1) examined whether boys or girls with ADHD differ in their sleep functioning, (2) evaluated comorbid symptoms as uniquely related to sleep functioning domains, and (3) explored whether sex moderated associations between comorbid symptoms and sleep. Participants were 181 children (ages 7-13; 69% male; 82% White) diagnosed with ADHD. Parents completed measures assessing their child's ADHD symptoms, comorbid symptoms, and sleep functioning. Girls had poorer sleep functioning than boys across most sleep functioning domains. Sixty percent of children met cutoff criteria for having sleep problems, though rates differed significantly between girls (75%) and boys (53%). No differences in rates of sleep problems were found between ADHD subtypes/presentations or between younger and older children. In path models including ADHD and comorbid symptom dimensions, anxiety symptoms were uniquely associated with increased bedtime resistance and sleep anxiety, ADHD hyperactive-impulsive symptoms were associated with more night wakings and more parasomnia behaviors, and ODD and depressive symptoms were associated with shorter sleep duration. Depression was also uniquely associated with increased daytime sleepiness and overall sleep problems. Sex did not moderate associations between comorbid symptoms and sleep problems. This study provides important preliminary evidence that girls with ADHD experience more sleep problems than boys with ADHD. Findings also demonstrate that the associations between comorbid symptoms and sleep functioning in children with ADHD vary based on both the specific symptoms and sleep domains examined.

Airway Dimensions in Children with Neurological Disabilities During Dexmedetomidine and Propofol Sedation for Magnetic Resonance Imaging Study

Objective

Children with neurological disabilities are at an increased risk of airway complications during anaesthesia for magnetic resonance imaging (MRI) with spontaneous respiration. The primary objective of this study was to evaluate airway dimensions during propofol and dexmedetomidine sedation for MRI in children with neurological disabilities. The secondary objective was to examine the adverse respiratory and sedation-related events.

Methods

Seventy-two children aged 1-6 years undergoing MRI were randomly selected to receive sedation with either 2 mg kg^-1 h^-1 of propofol or 2 μg kg^-1 h^-1 of dexmedetomidine. The airway dimensions were measured at soft palate, the base of tongue and mid-epiglottis. Adverse airway events were noted, and the quality of sedation was determined based on the need for dose modification, patient movement and repeat imaging requirements.

Results

There was no significant difference in airway dimensions observed between the dexmedetomidine and propofol groups, except for maximum and minimum transverse diameter (15.4±3.4 vs. 13.4±4.7, p=0.04 and 14.6±3.3 vs. 12.4±4.7, p=0.02 respectively) at soft palate and for cross sectional area difference at the base of tongue (14.5±13.9 vs. 20.1±19.3, p=0.03). Airway obstruction (2/36 vs. 3/36), apnoea (0/36 vs. 3/36) and desaturation (0/36 vs 2/36) occurred less frequently with dexmedetomidine. Additional requirement of sedation (6 vs. 3 patients; p=0.48), movement during imaging (9 vs. 5 patients; p=0.37) and poor image quality necessitating re-acquisition (4 vs. 0 patients; p=0.08) were more frequent with propofol.

Conclusion

Airway dimensions were similar during dexmedetomidine and propofol sedation, except for the transverse diameters at soft palate, and for cross-sectional area difference at the base of tongue in spontaneously breathing children with neurological disabilities. Airway complications were less frequent and the quality of sedation was better with dexmedetomidine.

Factors related to pediatric obstructive sleep apnea-hypopnea syndrome in children with attention deficit hyperactivity disorder in different age groups

This study aimed to retrospectively investigate the factors related to pediatric obstructive sleep apnea-hypopnea syndrome (OSAHS) with attention deficit hyperactivity disorder (ADHD) in children younger than 6 years and those older than 6 years.A total of 437 children who were hospitalized due to OSAHS between January 2014 and December 2014 were retrospectively reviewed. The children were further divided into OSAHS group and OSAHS + ADHD group. The general characteristics, OSA-18 quality of life, intention-hyperactivity score, and polysomnographic parameters (apnea-hypopnea index and the lowest oxygen saturation) were collected and compared between groups.There were 298 boys and 139 girls with the male to female ratio of 2.14:1. ADHD was found in 146 children including 105 boys and 41 girls with the male to female ratio of 2.56:1. Of these children, 31.62% and 35.46% had concomitant ADHD in children aged 4 to 5 years and those aged 6 to 11 years, respectively. In children aged 4 to 5 years, the incidence of allergic rhinitis was significantly higher (P = .016) and the adenoid hypertrophy was more severe (P = .001) in those with concomitant ADHD. In children aged 6 to 11 years, the tonsil hypertrophy was more severe in those with concomitant ADHD (P = .019). In children with concomitant ADHD, OSA-18 score was higher than in those with OSAHS alone (P < .001). Higher frequency of respiratory events (P < .001) and more severe hypoxia (P < .001) were found in children with concomitant ADHD than in those with OSAHS alone.As high as 30% of OSAHS children have concomitant ADHD, and the incidence of ADHD in OSAHS children is increasing over age. Boys are more likely to develop OSAHS and incidence of ADHD in OSAHS boys is higher than in OSAHS girls. In addition, risk factors of ADHD also vary between age groups. The ADHD is related to the severity of allergic rhinitis and adenoid hypertrophy in children aged 4 to 5 years, and to the severity of tonsil hypertrophy in children aged 6 to 11 years. Hypoxia may be an important factor causing ADHD. OSAHS should be treated as early as possible to reduce the incidence of ADHD in children.

Sleep and mental disorders: A meta-analysis of polysomnographic research

Investigating sleep in mental disorders has the potential to reveal both disorder-specific and transdiagnostic psychophysiological mechanisms. This meta-analysis aimed at determining the polysomnographic (PSG) characteristics of several mental disorders. Relevant studies were searched through standard strategies. Controlled PSG studies evaluating sleep in affective, anxiety, eating, pervasive developmental, borderline and antisocial personality disorders, attention-deficit-hyperactivity disorder (ADHD), and schizophrenia were included. PSG variables of sleep continuity, depth, and architecture, as well as rapid-eye movement (REM) sleep were considered. Calculations were performed with the "Comprehensive Meta-Analysis" and "R" software. Using random effects modeling, for each disorder and each variable, a separate meta-analysis was conducted if at least 3 studies were available for calculation of effect sizes as standardized means (Hedges' g). Sources of variability, that is, sex, age, and mental disorders comorbidity, were evaluated in subgroup analyses. Sleep alterations were evidenced in all disorders, with the exception of ADHD and seasonal affective disorders. Sleep continuity problems were observed in most mental disorders. Sleep depth and REM pressure alterations were associated with affective, anxiety, autism and schizophrenia disorders. Comorbidity was associated with enhanced REM sleep pressure and more inhibition of sleep depth. No sleep parameter was exclusively altered in 1 condition; however, no 2 conditions shared the same PSG profile. Sleep continuity disturbances imply a transdiagnostic imbalance in the arousal system likely representing a basic dimension of mental health. Sleep depth and REM variables might play a key role in psychiatric comorbidity processes. Constellations of sleep alterations may define distinct disorders better than alterations in 1 single variable. (PsycINFO Database Record

Influence of sleep-onset time on the development of 18-month-old infants: Japan Children's cohort study

OBJECTIVE

We report here the influence of sleep patterns on the development of infants in Japan. A total of 479 infants were registered in two different Japanese cities. Direct neurological observations were performed by licensed pediatric neurologists.

METHOD

We designed a prospective cohort study and identified the sleep factors of children showing atypical development. The Kinder Infant Developmental Scale (KIDS) was used to evaluate the infant developmental quotient (DQ); we also applied a neurobehavioral screening battery. Neurobehavioral observations in 18-month-old infants were designed to check all developmental categories within the three areas of motor function, language, and social function. Based on the observations, each infant was classified as having "atypical development" or "typical development".

RESULT

We found that later sleep onset time (>22:00 h), and longer naps during the day each had significant positive correlations with atypical development patterns in 18-month-old infants. For each hour the infant sleep-onset time extended past 22:00 h, the infants showed worse neurodevelopmental outcomes, at an odds ratio increase of 2.944.

CONCLUSION

Although our results may be confounded by sleep problems resulting from pre-existing developmental disabilities, we can safely conclude that appropriate sleeping habits are important for healthy development in 18-month-old infants.

The relationships between sensory modulation and sleep among adolescents with ADHD

OBJECTIVE

The purpose of this study was to investigate the effect of sensory modulation and sleeping among 30 adolescents diagnosed with ADHD, compared with 28 adolescents without ADHD.

METHOD

Two questionnaires were completed by parents to assess the participants' level of ADHD symptoms. Two other questionnaires were completed by the participants assessing difficulties in sensory modulation and sleep.

RESULTS

The ADHD group had more sensory difficulties in Activity Level, Hearing, and Low Registration, and more difficulties in the Sleep Behavior variables. Higher correlations between the sensory variables and the sleep measures were found in the ADHD group as compared with the non-ADHD group. Significant differences between correlations were found between three sleep measures and four sensory variables.

CONCLUSION

The discussion is devoted to an assessment of the relationships between the measures, with the conclusion that among adolescents with ADHD, it is important to assess and treat possible sensory and sleep difficulties.

Children diagnosed with attention deficit disorder and their hospitalisations: population data linkage study

Examine the hospital admission risk in young children who are subsequently diagnosed with attention deficit hyperactivity disorder (ADHD). We conducted a population-based, record linkage study. Records of all non-Aboriginal children under 18 years who met the DSMIV/ICD10 criteria for ADHD and prescribed stimulant medication in Western Australia between 2003 and 2007 (n = 11,902) were linked to two other health data systems-the hospital morbidity data system and the midwives notification system (MNS). The non-ADHD reference population (n = 27,304) was randomly selected from the MNS. Compared with controls, children under 4 years who subsequently were diagnosed and treated for ADHD were 70% [odds ratio (OR) 1.70; 95% confidence intervals (CI) 1.62-1.77] more likely to be admitted to hospital under 4 years of age. There was an increased risk for injury or poison (OR 1.73; 95% CI 1.59-1.88), respiratory disease (OR 1.49; 95% CI 1.40-1.59), ear disease (OR 2.03; 95% CI 1.86-2.21), infectious diseases (OR 1.68; 95% CI 1.53-1.85) and neurological conditions (OR 2.03; 95% CI 1.68-2.44). Admissions under 4 years of age for head injuries, burns, poisons, all other injuries, diseases of the tonsils and adenoids, asthma and early infections were all more common amongst children subsequently diagnosed with and treated for ADHD. There is significant early hospital morbidity for children subsequently diagnosed with ADHD. Multiple aetiologies and causal pathways need to be considered where some of these may include early infections, inflammatory conditions, epilepsy and injuries. Future studies should look at which of these conditions may be on the causal pathway or likely early markers for ADHD.

High incidence of sleep problems in children with developmental disorders: results of a questionnaire survey in a Japanese elementary school

OBJECTIVE

The aim of the present school-based questionnaire was to analyze the sleep problems of children with developmental disorders, such as pervasive developmental disorder and attention deficit hyperactivity disorder.

METHODS

The sleep problems of 43 children with developmental disorders were compared with those of 372 healthy children (control group). All children attended one public elementary school in Kurume, Japan; thus, the study avoided the potential bias associated with hospital-based surveys (i.e. a high prevalence of sleep disturbance) and provided a more complete picture of the children's academic performance and family situation compared with a control group under identical conditions. Children's sleep problems were measured with the Japanese version of the Children's Sleep Habits Questionnaire (CSHQ).

RESULTS

Children with developmental disorders had significantly higher total CSHQ scores, as well as mean scores on the parasomnias and sleep breathing subscales, than children in the control group. The total CSHQ score, bedtime resistance, sleep onset delay, and daytime sleepiness worsened with increasing age in children with developmental disorders; in contrast, these parameters were unchanged or became better with age in the control group. In children with developmental disorders, there was a significant association between a higher total CSHQ score and lower academic performance, but no such association was found in the control group. For both groups, children's sleep problems affected their parents' quality of sleep. There were no significant differences in physical, lifestyle, and sleep environmental factors, or in sleep/wake patterns, between the two groups.

CONCLUSIONS

Children with developmental disorders have poor sleep quality, which may affect academic performance. It is important for physicians to be aware of age-related differences in sleep problems in children with developmental disorders. Further studies are needed to identify the association between sleep quality and school behavioral performance.

Relationship between polysomnographic sleep architecture and behavior in medication-free children with TS, ADHD, TS and ADHD, and controls

OBJECTIVE

To describe the relationship between sleep architecture and behavioral measures in unmedicated children and adolescents with Tourette syndrome (TS), attention-deficit hyperactivity disorder (ADHD), TS and comorbid ADHD (TS + ADHD), and healthy controls. The study also set out to examine differences in sleep architecture with each diagnosis.

METHOD

A cross-sectional, 2-night consecutive polysomnographic sleep study was conducted in 90 children. All participants were matched for age, gender, and level of intelligence.

RESULTS

Scores on the Child Behavior Checklist delinquency measure were modestly but significantly correlated with the number of movements during REM sleep (r = .36, p = .003). Significant correlations were also noted among the number of total arousals and arousals from slow wave sleep (SWS), and scores on the measures of conduct disorder, hyperactivity/immaturity, and restless/disorganized behaviors. There were a few significant differences in sleep architecture among the diagnostic groups. The ADHD-only group exhibited a significantly higher number of total arousals (p < .01) and arousals from SWS (p < .01) compared with the other three study groups.

DISCUSSION

Our findings indicate that children with TS and/or ADHD and who have more arousals from sleep are significantly more likely to have issues with conduct disorder, hyperactivity/immaturity, and restless/disorganized behavior. It was also noted that having ADHD, alone or comorbid with TS, is associated with a significantly greater number of movements during both non-REM and REM sleep. This study underscores the compelling need for the diagnosis and treatment of any sleep disorders in children with TS and/or ADHD so as to facilitate better management of problem behaviors.

Sleep disturbances in children with attention-deficit/hyperactivity disorder

In this article, we advocate the need for better understanding and treatment of children exhibiting inattentive, hyperactive, impulsive behaviors, by in-depth questioning on sleepiness, sleep-disordered breathing or problematic behaviors at bedtime, during the night and upon awakening, as well as night-to-night sleep duration variability. The relationships between sleep and attention-deficit/hyperactivity disorder (ADHD) are complex and are routinely overlooked by practitioners. Motricity and somnolence, the most consistent complaints and objectively measured sleep problems in children with ADHD, may develop as a consequence of multidirectional and multifactorial pathways. Therefore, subjectively perceived or reported restless sleep should be evaluated with specific attention to restless legs syndrome or periodic limb movement disorder, and awakenings should be queried with regard to parasomnias, dyssomnias and sleep-disordered breathing. Sleep hygiene logs detailing sleep onset and offset quantitatively, as well as qualitatively, are required. More studies in children with ADHD are needed to reveal the 24-h phenotype, or its sleep comorbidities.

Sleep in attention-deficit/hyperactivity disorder in children and adults: past, present, and future

The understanding that sleep can give rise to, or exacerbate symptoms of attention-deficit/hyperactivity disorder (ADHD), and that good sleep hygiene improves attention and concentration tasks has sparked interest in the investigation of possible etiological relationships between sleep disorders and ADHD. Studies indicate that 30% of children and 60-80% of adults with ADHD have symptoms of sleep disorders such as daytime sleepiness, insomnia, delayed sleep phase syndrome, fractured sleep, restless legs syndrome, and sleep disordered breathing. The range and diversity of findings by different researchers have posed challenges in establishing whether sleep disturbances are intrinsic to ADHD or whether disturbances occur due to co-morbid sleep disorders. As a result, understanding of the nature of the relationship between sleep disturbances/disorders and ADHD remains unclear. In this review, we present a comprehensive and critical account of the research that has been carried out to investigate the association between sleep and ADHD, as well as discuss mechanisms that have been proposed to account for the elusive relationship between sleep disturbances, sleep disorders, and ADHD.

Attention-deficit/hyperactivity disorder and sleep disorders in children

Attention-deficit/hyperactivity disorder (ADHD) is a neurocognitive and behavior abnormality commonly seen in childhood and adolescence. Symptoms and consequences of ADHD and sleep problems frequently overlap, and their relationship is complex and bidirectional. To avoid inappropriate diagnosis and inadequate management, mental health professionals should assess sleep problems and disorders in children, adolescents, and adults with ADHD-related symptoms and in those with a diagnosis of ADHD. Screening for other psychiatric comorbidities and the side effects of medications, such as psychostimulants, is necessary when considering sleep complaints, because both have adverse effects on sleep.

The sleep of children with attention deficit hyperactivity disorder on and off methylphenidate: a matched case-control study

In the present study, we assessed the effects of regular use of methylphenidate medication in children diagnosed with attention deficit hyperactivity disorder (ADHD) on sleep timing, duration and sleep architecture. Twenty-seven children aged 6-12 years meeting diagnostic criteria for Diagnostic and Statistical Manual version IV ADHD and 27 control children matched for age (+/-3 months) and gender. Two nights of standard polysomnographic (PSG) recordings were conducted. ADHD children were allocated randomly to an on- or 48 h off-methylphenidate protocol for first or second recordings. Control children's recordings were matched for night, but no medication was used. Mixed modelling was employed in the analyses so that the full data set was used to determine the degree of medication effects. Methylphenidate in ADHD children prolonged sleep onset by an average of 29 min [confidence interval (CI) 11.6, 46.7], reduced sleep efficiency by 6.5% (CI 2.6, 10.3) and shortened sleep by 1.2 h (CI 0.65, 1.9). Arousal indices were preserved. Relative amounts of stages 1, 2 and slow wave sleep were unchanged by medication. Rapid eye movement sleep was reduced (-2.4%) on the medication night, an effect that became non-significant when control data were incorporated in the analyses. PSG data from ADHD children off-medication were similar to control data. Our findings suggest that methylphenidate reduces sleep quantity but does not alter sleep architecture in children diagnosed with ADHD. An adequate amount of sleep is integral to good daytime functioning, thus the sleep side effects of methylphenidate may affect adversely the daytime symptoms the drug is targeted to control.

Nocturia and snoring: predictive symptoms for obstructive sleep apnea

PURPOSE

Current screening for obstructive sleep apnea (OSA) emphasizes self-reported snoring and other breathing symptoms. Nocturia, a symptom with a precise pathophysiological link to sleep apnea, has not been assessed as a screening tool for this common disorder of sleep respiration. In a large sample of adults presenting to area sleep centers, we aimed to determine the predictive power of nocturia for OSA and compare findings with other markers of OSA commonly used to screen for this disease.

METHODS

This was a retrospective chart review. A consecutive sample of 1,007 adult patients seeking treatment at two sleep centers in New Mexico completed detailed medical and sleep history questionnaires and completed diagnostic polysomnography testing. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of nocturia, snoring, high body mass index, sex, and age for OSA were determined. Hierarchical linear regression determined unique variance contribution to the apnea-hypopnea index, the objective measure of sleep apnea severity.

RESULTS

The results are as follows: sensitivities--snoring, 82.6% and nocturia, 84.8%; specificities--snoring, 43.0% and nocturia, 22.4%; PPVs--snoring, 84.7% and nocturia, 80.6%; and NPVs--snoring, 39.6% and nocturia, 27.9%. With hierarchical linear regression, patient-reported nocturia frequency predicted apnea-hypopnea index (OSA severity) above and beyond body mass index, sex, age, and self-reported snoring (P<0.0001).

CONCLUSIONS

Nocturia appears comparable to snoring as a screening tool for OSA in patients presenting to a sleep medical center. Research in urology and primary care clinics is needed to definitively clarify the use of nocturia as a screening instrument for obstructive sleep apnea.