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J.D. Ball, Ph.D., ABPP, Professor Emeritus, Psychiatry and Behavioral Sciences, Eastern Virginia Medical School
Tuesday, October 24, 2017

Sleep and its relationship to neurodevelopmental disorders is an important field of study that naturally evolved from research on the relationship between Attention-Deficit Hyperactivity Disorder (ADHD) and sleep.  There is now a wider understanding that sleep difficulty is more prevalent among young people with a diverse array of neurodevelopmental problems than among youth in the general population.

I was among the earliest researchers of the relationship between sleep and ADHD, when, over 20 years ago, my students and I showed that parents of children with ADHD reported more sleep problems from their children than was the case for parents of typically developing children, independent of whether children with ADHD were or were not taking medication for ADHD.  This higher reported incidence of sleep problems among children with ADHD has since been found repeatedly, even while overnight sleep studies have not always found a basis for these reports.   Interestingly, an association between sleep and ADHD was once a diagnostic criterion for what was then termed “ADD” in a much earlier version of the American Psychiatric Association’s Diagnostic and Statistical Manual – Third Edition (DSM-III).  Thus, reported sleep difficulty had an association with ADHD was an association that was known, forgotten or neglected, and then rediscovered.  This ubiquitous association is made more complicated by the fact that the same brain regions seem to mediate the arousal dysfunction in ADHD and sleep difficulty.  Dr. Judith Owens, pediatrician/sleep researcher, has called this association the ADHD-Sleep Conundrum, explaining that sleep problems may make ADHD symptoms worse, ADHD symptoms may make sleep problems worse, and treatment for ADHD may also make sleep problems worse.  While stimulant treatment for ADHD is well recognized for adverse sleep related side effects, a close review of research involving ADHD-related stimulant medication reveals a more complex picture.  Sleep problem side effects from stimulant medication for children with ADHD may be temporary, perhaps dissipating after a few weeks.  There is less concern about these side effects when children take only short acting forms of stimulant medication at least four hours before bed, as can be necessary to contend with homework stress; and some research has suggested that there may be a subgroup of children with ADHD who settle down more quickly and then sleep better when given night time medication.  Of course, I strongly encourage all parents to make all medication decisions, including timing and dosing, in close collaboration with the prescribing physician.

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It is no surprise that interest in the Sleep-ADHD Conundrum has grown to include children with ASD who also experience both arousal dysfunction and significant attention problems.  Sleep problems associated with neurodevelopmental disorders may range from mild to severe.   Severe concerns receive sleep disorder diagnoses and can be grouped into insomnia, hypersomnia (excessive daytime sleepiness), and parasomnia (various unusual behaviors during sleep).  The prevalence of disturbed sleep in children ranges from 18-50% in the general population (highest among adolescents) to 24-86% among youth with various disabilities. The common idea that children will outgrow significant sleep problems has been challenged by data suggesting that these problems are rarely transient.  Sleep problems are among the most common complaints in pediatric care settings, and pediatric sleep medicine has become an established subspecialty in the healthcare field.

For parents seeking support for a child’s sleep problems I encourage discussions with pediatricians and therapists, pursuing a comprehensive psychological or neuropsychological assessment/consultation when questions remain, and, sometimes seeking a sleep specialist.  Beginning points of contact for these services or for related referrals include Chesapeake Bay Academy, Eastern Virginia Medical School’s Neuropsychology Program, and Children’s Hospital of the King’s Daughters.  At home, good sleep hygiene is the same for children with and without neurodevelopmental disorders.  Good sleep hygiene especially includes parental attention to a consistent structure with fixed (weekday and weekend) bedtimes and morning awakening times that permit least eight hours of sleep.   Adolescents are particularly prone to too little sleep.  While they would function best if allowed to shift their sleep cycle toward later bed and awakening times that still total 8-9 hours, it is best, even if particularly difficult for this age group, to maintain weekday sleep schedules even into the weekend.  Daytime napping is apt to be associated with night time sleep difficulty and with delayed sleep phase problems that continuously push sleep schedules later.  Ideally, the sleep environment should be a cool, dark, quiet, comfortable room that is brightly lit in the morning. There should be no electronic device use within thirty minutes of sleep and through the night, since laptops, tablets, and electronic phones emit a particularly disruptive blue light band that triggers the brain to suppress its normal bedtime release of sleep-inducing melatonin.  Like the rest of us, children and adolescents should avoid both going to bed hungry and eating heavily within two hours of bedtime.  Regular exercise is good, but it should not occur directly before bedtime.  All of us should refrain from night time intake of caffeine or chocolate.

Related News: Tuck.com a community advancing for better sleep, recently posted a worthwhile article that overviews Autism Spectrum Disorder (ASD) and its relationship to children’s sleep difficulties.


Relevant Scientific References
Alfano, C.A., & Gamble, A.L. (2009).  The role of sleep in childhood psychiatric disorders.  Child Youth Care Forum38, 327-340.  doi: 10.1007/s10566-0099081-y
Astill, R.G., Van der Heijden, KB., Van Zendoorn, M.H., Van Someren, & Eus, J.W. (2012).  Sleep,cognition, and behavioral problems in school-age children:  A century of research             meta-analyzed.  Psychological Bulletin138(6), 1109-1138.  doi: 10.1037/a0028204
Ball, J.D. & Koloian, B. (1995).  Sleep patterns among ADHD children.  Clinical Psychology Review15(7), 681-691.   doi:10.1016/0272-7358(95)00037-PBall, J.D., Tiernan, M., Furr, A., & Janusz, J. (1997).  Sleep patterns among ADHD children:  A re- examination of parent perceptions.  Journal of Pediatric Psychology22(3), 389-398.     doi: 10.1093/jpepsy/ee.3.389
Bartlett, L., Rooney, V. & Spedding, S. (1985).  Nocturnal difficulties in a population of mentally handicapped children.  British Journal of Mental Sub-Normality31, 54-59.Dahl, R.E., & Harvey, A.G. (2007).  Sleep in children and adolescents with behavioral andemotional disorders.  Sleep Medicine Clinics2(3), 501-511.  doi:10.1016/j.jsmc.2007.05.002
Didden, R., Korzilliu, H., van Aperlo, B., van Overloop., C., & de Vries, M. (2002).  Sleep problems and daytime behavior probems in children with intellectual disability.  Journal of Intellectual Disability46, 535-547.
Gruber, R., Cassoff, J., & Knauper, B. (2011).  Sleep health education in pediatric community settings:  Rationale and practical suggestions for incorporating healthy sleep into pediatric practice.  Pediatric Clinics of North America58, 735-754.
Katrari, S., Swanson, M.S., & Trevathan, G.E. (1987).  Persistence of sleep disturbances in preschool children.  Journal of Pediatrics110(4), 642-646.Meltzer, L.J. & Mindell, J.A. (2006).  Sleep and sleep disorders in children and adolescents. Psychiatric Clinics of North America29(4), 1059-1076.
Mindell, J.A. (1993).  Sleep disorders in children.  Health Psychology65, 305-318.
Owens, J.A. (2008).  Sleep disorders and attention-deficit/hyperactivity disorder.  Current Psychiatry Reports10(5), 439-444.
Owens, J.A. & Witmans, M. (2004).  Sleep problems.  Current Problems in Pediatric Adolescent Health Care34(4), 154-179.
Quine, L. (2001).  Sleep problems in primary school children:  Comparison between mainstreamand special school children.  Child Care Health Development27, 201-222.
Sadeh, A., Gruber, R., & Raviv, A. (2002).  Sleep, neurobehavioral functioning, and behavior problems in school-age children.  Child Development73(2), 405-417.  doi:10.1111/1467-8624.00414
Tietze, A.L., Blankenburg, M., Hechler, T., Michel, E., Koh, M., Schluter, B., & Zernikow, B.(2012).  Sleep disturbances in children with multiple disabilities.  Sleep Medicine   Reviews16(2), 112-127.
Zuckerman, B., Stevenson, J., & Bailey, V. (1987).  Sleep problems in early childhood:Continuities, predictive factors, and behavioural correlates.  Pediatrics80, 664-671.

J.D. Ball, Ph.D., ABPP, Professor Emeritus
Psychiatry and Behavioral Sciences
Eastern Virginia Medical School