Associations of sleep disturbance with ADHD: implications for treatment.

In August 2014 Hvolby published an article about the association between ADHD and sleep which raises many interesting questions about the assessment and treatment of ADHD.

Attention-deficit/hyperactivity disorder (ADHD) is commonly associated with disordered or disturbed sleep. The relationships of ADHD with sleep problems, psychiatric comorbidities and medications are complex and multidirectional.

Evidence from published studies comparing sleep in individuals with ADHD with typically developing controls show an association with: hypopnea/apnea; increased sleep onset latency and shorter sleep time; and bedtime resistance, difficulty with morning awakenings, sleep onset difficulties, sleep-disordered breathing, night awakenings and daytime sleepiness.

ADHD is also frequently common with sleep disorders (obstructive sleep apnea, peripheral limb movement disorder, restless legs syndrome and circadian-rhythm sleep disorders). Psychostimulant medications are associated with disrupted or disturbed sleep, but also 'paradoxically' calm some patients with ADHD for sleep by alleviating their symptoms.

Long-acting formulations may have insufficient duration of action, leading to symptom rebound at bedtime. Current guidelines recommend assessment of sleep disturbance during evaluation of ADHD, and before initiation of pharmacotherapy, with healthy sleep practices the first-line option for addressing sleep problems.

This review aims to provide a comprehensive overview of the relationships between ADHD and sleep, and presents a conceptual model of the modes of interaction: ADHD may cause sleep problems as an intrinsic feature of the disorder; sleep problems may cause or mimic ADHD; ADHD and sleep problems may interact, with reciprocal causation and possible involvement of comorbidity; and ADHD and sleep problems may share a common underlying neurological etiology.

Te research shows that accurate diagnosis is essential to correct treatment, and incorrect diagnosis through a lack of understanding of the effect of sleep on atention skills, can result in the inappropirate prescription of medication, and potential worsening of symptoms.