section epub:type=”chapter”> Margaret D. Weiss1, Anna Ivanenko2 and Nicole M. McBride3, 1Cambridge Health Alliance, Cambridge, MA, United States, 2Division of Child and Adolescent Psychiatry, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, United States, 3UAMS Child Study Center, Little Rock, AR, United States In this chapter, we discuss how to assess and screen for sleep problems in attention deficit hyperactivity disorder (ADHD), including who to screen, when, and the range of subjective and objective assessment tools available. We discuss the role of clinical assessment, sleep rating scales, somnologs, sleep diaries, and objective measures such as actigraphy, polysomnography and the multiple sleep latency test. A comprehensive clinical interview for sleep includes the details of bedtime, daytime sleepiness, awakenings, sleep schedule, and sleep duration. In patients receiving medication for ADHD or sleep, the clinical interview also needs to address the effects of medication. We provide examples of the kinds of questions that clinicians need to include in their interview to get a good sleep history. The use of somnologs, sleep diaries, and actigraphs also contribute to the clinician’s awareness of whether the patient has established an entrained circadian rhythm, problems with being phase advanced or phase delayed and night-to-night variability. Sleep studies are necessary to understand specific sleep disorders common in patients with ADHD such as periodic limb movement syndrome or restless legs syndrome. The combination of all these assessment tools provides a robust picture of the patient’s sleep health and/or sleep concerns. For the majority of patients with ADHD, conducting a full assessment of sleep is an essential part of patient care. Sleep; screening; assessment; somnolog; rating scales; actigraphy; polysomnography Sleep disorders are one of the most common comorbidities reported in individuals with attention deficit hyperactivity disorder (ADHD), affecting approximately 73% of children and adolescents with the condition (Sung, Hiscock, Sciberras, & Efron, 2008), and up to 80% of adults with ADHD (Wynchank, Bijlenga, Beekman, Kooij, & Penninx, 2017). The high prevalence of sleep disorders in those with ADHD is a consistent finding, despite differences between studies with regard to population demographics and sleep assessment methodology (e.g., subjective or objective measurement). There have been numerous reports detailing the multidirectional impact that sleep and ADHD have on each other, noting that both sleep and ADHD-related impairments may originate from common neurobiological pathways (Stein, Weiss, & Hlavaty, 2012; Weiss & Salpekar, 2010). This chapter will review the clinical assessment of the unique attributes of sleep in ADHD patients, including subjective tools such as the clinical interview, rating scales, somnologs, and objective tools such as a polysomnogram (PSG), actigraphs, and the multiple sleep latency test (MSLT) to assess narcolepsy. Even patients with ADHD who do not have a sleep disorder, may experience subjective sleep anxiety, or other sleep symptoms which cause distress and impairment for either the patient or for their families. Patients who are hyperactive and stimulus seeking may resist going to bed. They may complain of boredom while they “wait to fall asleep,” and patients with ADHD experience boredom as intolerable. Alternatively, they may complain of finding it impossible to “turn their thoughts off,” or complain that they cannot lie still while they try to settle for the night. Patients with ADHD have difficulties with self-regulation which make it difficult to keep to any regular schedule, including a sleep schedule. Additionally, individuals with ADHD have problems transitioning to attention demanding activities which includes waking up to get ready for school or work. Many patients with ADHD complain that while they are hyper at night, they are tired during the day. Many parents complain that they cannot easily get their child to go to bed or to fall asleep, but then note that it is equally difficult to wake their child up in the morning because they sleep so deeply. Assessment of sleep disorders in patients with ADHD requires the clinician to disentangle the relationship between sleep and ADHD. For example, a patient with ADHD may have a circadian rhythm sleep disorder (CRSD) that is being driven by difficulty going to bed or as a side effect of stimulants. Conversely, problems with attention and disinhibition can be a consequence of poor sleep, such as attention problems secondary to sleep-disordered breathing (SDB). The relationship between ADHD and sleep can be conceptualized as a bilateral comorbidity in which there is an increase in risk for the comorbid condition when either is present. Further, we know that ADHD and sleep disorders both contribute to the patient’s functional impairment, even though it is the ADHD that is most often the target of clinical attention (Craig, Weiss, Hudec, & Gibbons, 2017). It is standard care that an ADHD assessment also includes screening for difficulties with sleep, both initially and during the course of treatment for ADHD. The acronym BEARS describes the key elements to be covered in a clinical interview to screen for sleep problems: Bedtime and time to fall asleep, Excessive daytime sleepiness, Awakenings, Regularity and duration of sleep, and Snoring (Owens, 2005). We will describe the clinical questions appropriate for an evaluation using BEARS. Each of the bulleted questions below can be addressed to a parent about their child, or directly in an interview with the child, adolescent or adult. In the management of children, it is important to review bedtime routines, as well as the parent’s and child’s subjective experience of what happens at night (e.g., is bedtime a comforting time or a source of conflict?). Some parents have unrealistic ideas of how much sleep a child needs, or may simply want their child to go to sleep because they are exhausted themselves and are in fact using “going to bed” as a babysitter so that they themselves can have some downtime. Parents assume that if they put a child to bed earlier, the child will fall asleep earlier or sleep longer. In fact, however, the opposite may be true. A child put to sleep before they are tired may actually fail to fall asleep when they otherwise would have if they had gone to bed when they were actually tired. It is helpful to explain to parents that the restorative value of sleep may be driven as much by sleep efficiency as by sleep duration. The clinical interview should include questions about bedtime such as: Lastly, when asking about bedtime, the clinician should also get a sense of the sleep setting. These same questions can easily be rephrased where appropriate to be used in self-report with adults. Age specific considerations in evaluation of sleep in adults include: Excessive daytime sleepiness (EDS) includes subjective feelings of somnolence, objective observation of sleepiness by others, and manifestations of behavior that are “masked” sleepiness. The classic example of masked sleepiness is the child who is perceived by the parent as “overtired”: silly, hyper-, or disinhibited. In fact, Michel Lecendreux has postulated that ADHD children may have EDS even when they appear hyperactive, and found that when compared to controls they appear to be borderline narcoleptic (see Chapter 4) (Lecendreux, Konofal, Bouvard, Falissard, & Mouren-Simeoni, 2000). Although parents seem to be aware of when a tired child gets their “second wind,” the same phenomena occurs in adults. A child or an adult who is actually sleepy, but does not look sleepy, may be described as having “masked sleepiness.” In adults, masked sleepiness may present as making careless mistakes, problems spacing out, or excessive caffeine use. It is important to ask about daytime sleepiness, and specifically whether or not the patient is actually nodding off for brief periods. This is especially true for adults driving or children falling asleep in class. It is also important to ensure that the patient understands the difference between being tired (i.e., low in energy) and being sleepy. Questions to assess EDS may include: It has been postulated that the high level of hyperarousal in ADHD manifests at night by a vulnerability to wakefulness. In fact, the DSM-III included restless sleep as one of the symptoms of ADHD. Asking children about whether they have restless sleep or wake up in the night is challenging since they may not be able to report their own behavior while presumably asleep. A memorable example in my own practice was a 14-year-old boy who was going out to his rabbit patch in the middle of night, unbeknownst to anyone until we put an actigraph on him. When I asked another child how he knew he was a restless sleeper, he responded “because I have never woken up in my bed!” Questions to assess awakenings during sleep may include: Entrainment of circadian rhythm is a learned behavior and a developmental skill. This further implies that the clinical interview needs to review the history of the successes and failures this patient has experienced in acquiring this skill. ADHD is a disorder of self-regulation and is associated with marked impairment in life skills and it also runs in families, meaning that it is not uncommon to see marked impairment in entrainment of circadian rhythm in multiple family members. This means that sleep problems are familial in both the genetic sense, and because parents who do not have an entrained circadian rhythm are not going to be able to establish one for their children. By the same token, an ADHD child who has an irregular schedule is going to impair their parents’ sleep routine. One of the hallmarks of sleep in individuals with ADHD is night-to-night variability (Cohen-Zion & Ancoli-Israel, 2004). Thus, for patients who do not have a regular schedule, the clinician needs to find out whether or not this is causing functional impairment, and the extent of the mismatch between their internal clock and their ability to be awake when they need to be. For children with any CRSD, it is also critical to consider the impact on the parent’s well-being of having a child who goes to sleep very late or wakes very early in terms of whether or not the parent is getting enough sleep. The clinical interview to assess regularity and duration can include questions such as: The reality of clinical practice is that although sleep problems in ADHD patients are common, impairing, and the source of considerable subjective distress, the reality of obtaining adherence to good sleep habits in patients with ADHD is difficult. Sleep hygiene training is much more than providing a patient with a handout. The difficulties patients with ADHD have with sleep hygiene and establishing a circadian rhythm are deeply embedded in the biology of the disorder. This means that in obtaining a history of the patient’s sleep routines the clinician needs to inquire about what the patient knows about sleep hygiene, and if they have made attempts to change their sleep habits in the past. Clinicians looking for a web-based source to provide patient education can find good materials at the American Academy of Sleep Medicine (sleepeducation.org) or the National Sleep Foundation (sleepfoundation.org) (see Chapter 5). Typical sleep hygiene recommendations include maintaining a regular sleep/wake schedule, and avoiding caffeine, alcohol, naps, and screens late at night. For children, Better Nights/Better Days (Corkum et al., 2016) may provide access to expert intervention. For adults, apps such as CBTi COACH (Cognitive Behavior Therapy for Insomnia) or SHUTi (Sleep Health Using the Internet) provide access to sleep education as well as a way to systematically measure response. Although snoring is clearly a risk factor for daytime sleepiness and obstructive sleep apnea (OSA; Gottlieb, Yao, Redline, Ali, & Mahowald, 2000), there are patients that snore and are not apneic and patients may have apneic episodes they are unaware of (Lai et al., 2018). When asking about sleep apnea, it is useful to demonstrate an apneic episode and the pause in breathing to see whether this has been observed independent of snoring. The clinical exam is also critical for assessment of obesity, adenoids, mouth breathing, and other physical risk factors for sleep apnea.
Assessing Sleep Problems in ADHD
Abstract
Keywords
8.1 Assessment of Sleep in ADHD Patients
8.2 The Clinical Sleep Interview
8.2.1 BEARS
8.2.1.1 Bedtime
8.2.1.2 Excessive Daytime Sleepiness
8.2.1.3 Awakenings
8.2.1.4 Regularity and Duration
8.2.1.5 Snoring
Related posts:
Epidemiology and Etiology of Behavioral Insomnias, Circadian Rhythm Disorders, and Parasomnias in ADHD
Child and Family Impacts of Sleep Problems in Children and Adolescents With ADHD
Future Research Directions in Attention Deficit Hyperactivity Disorder and Sleep
Epidemiology and Etiology of Medical Sleep Problems in ADHD
New Frontiers: Neurobiology of Sleep in ADHD
Healthy Sleep Practices (Sleep Hygiene) in Children With ADHD
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Assessing Sleep Problems in ADHD
