Sleep Soundly Every Night, Feel Fantastic Every Day (35 page)

ADHD children have difficulty staying awake during the day. Dr. Thomas Brown indicates that daytime drowsiness afflicts many with ADHD. Brown writes, “Many with ADD [ADHD] syndrome report that they are often tired during the day because they have chronic and severe difficulties in settling into sleep, even when they are very tired and want to fall asleep.”

If a child is excessively sleepy, the diagnosis may be narcolepsy. Unfortunately, the diagnosis of narcolepsy is frequently delayed by 10 or more years because the symptoms are frequently misattributed to some other disorder.

Restless legs syndrome (RLS) refers to uncomfortable, even painful sensations in the legs that can itch, tingle, or feel like ants crawling on you. Mostly occurring in the evening, the solution is movement. RLS can occur with periodic leg movement. This syndrome can often be alleviated with iron
supplements as it is related to low iron. Remember that 20% of adults recall having symptoms of restless legs as kids.

Children with RLS can present with symptoms that are hard to differentiate from ADHD. Many have a hard time relating what they are feeling, or are misdiagnosed as having “growing pains.” Their leg pain can deprive them of much needed sleep at night or make it impossible to sit still in class during the day.

These children not only move upper and lower limbs more frequently during the night, but also for longer periods. A cross-sectional survey of 866 children with ADHD symptoms, as well as RLS symptoms, showed the two symptoms were twice as likely to occur together than just by chance. Also, parents have reported during the years that their ADHD children displayed restless legs syndrome and periodic limb movement (PLM) during the day as well as at night.

Children with ADHD have an increased prevalence of PLMs and children with PLM disorders are more likely to have ADHD. PLMs are movements of the legs (and occasionally the upper limbs) that occur after falling asleep. Although very common in children with restless legs syndrome, they are not considered to be the same thing. RLS is a conscious discomfort. PLM occurs while sleeping and the individual is not aware. Treatment of PLM with dopamine agonists, a compound that activates dopamine receptors when dopamine is absent, improved sleep quality, sleep quantity, and also ADHD symptoms.

This group of disorders includes abnormalities of breathing patterns like pauses in breathing while sleeping. In children, the two primary sleep breathing issues are snoring and OSA. Three to twelve percent of children have incidents of habitual snoring. Of those who snore, 1% to 3% are most likely have sleep apnea. OSA, the most common type
of sleep apnea, is caused by obstruction of the upper airway and is characterized by repetitive pauses in breathing during sleep, typically last 10 to 40 seconds, and a reduction in blood oxygen saturation. Children with OSA often behave as if overtired: moody, aggressive, or hyperactive.

The good news is that OSA-diagnosed children's academic functioning improved with an adenotonsillectomy compared with children who were not treated. A recent NIH-sponsored study called the Childhood Adenotonsillectomy Trial (CHAT) addressed this issue. For seven months, researchers followed 464 children who were five to nine years old. All of the children had mild to moderate sleep apnea, and they were placed in one of two groups, for surgery or for “watchful waiting.” Those children who underwent the surgical procedure did better regarding impulsivity, restlessness, and emotional lability. They also slept better and were less sleepy and fatigued than the control group. Surprisingly, this study failed to demonstrate improvements in cognition although several studies have made this point.

This procedure helped my patient Sam, a pale-faced, thin nine-year-old child with a head of blonde curls. At our first meeting, he walked up to me, shook my hand, and in a West Texas drawl said, “Hiya, doctor. I'm Samuel James Buford thuh third. I'm here fer yer help!”

I noticed his mom. “Hello, Mrs. Buford, please have a seat. And Samuel James Buford, what name shall I call you?”

“Ya really wanna know?”

“Yes, of course.”

“Ya know all of us from West Texas have two names. Mom's is Carla Lou, and mine is Sammy Jim.” Saying “Sammy Jim” with the straightest face I bet he practiced all morning cracked the façade. The giddy boy was animated in laughing, high-fiving his knee several times, and bouncing into his chair next to his mother. The legs started swinging as if he were kicking air.

Sammy's medical file indicated he was recently referred to the school psychologist for an evaluation of possible ADHD. Records described him as hyperactive with a penchant for practical jokes, which apparently still gets him into trouble. He appears to be bright according to his school's test scores. His medical history also indicated he had the normal “going to school” childhood bouts with chicken pox, strep throat, and a cold or two. The family doctor wondered about a sleep issue for the snoring and hyperactivity.

“Mrs. Buford, how can I help you and Sammy Jim today?”

“Sammy Jim's teacher believes he needs to be checked for a sleep disorder after she read a news article. The possible confusion of symptoms between sleep and ADHD interested her. I wrote down what she referred to right here: ‘The symptoms of sleep deprivation in children resemble those of ADHD. While adults experience sleep deprivation as drowsiness and sluggishness, sleepless children often become wired, moody, and obstinate. They may have trouble focusing, sitting still and getting along with peers.' All of those symptoms except moody and obstinate describe Sammy Jim.”

I asked Mrs. Buford to complete my checklist of symptoms for children. Her responses are below:

 

Because of Sammy Jim's habitual snoring, I became suspicious that he might have sleep apnea. After all, the American Academy of Pediatrics recommends children be tested for sleep apnea if they snore chronically. We proceeded with a sleep study in the lab that confirmed Sam had sleep apnea. In fact, he stopped breathing about 16 times an hour. This would be considered moderate in an adult but indicates severity in a child. We also found that as a result of these episodes Sam's blood oxygen saturations dropped periodically with each event.

I had noticed during the physical exam that Sam had enlarged tonsils. I rated them a 3 to 4 on a scale of 4 that we use. As a result, I suggested Mrs. Buford consult with an ear, nose, and throat doctor as Sam seemed to be a good candidate for an adenotonsillectomy. Sam underwent the surgery and about eight weeks later, when he had healed, we retested him. He showed enough improvement that we did not need to proceed with continuous positive airway pressure therapy (CPAP) as a treatment.

For people diagnosed with ADHD in adulthood, misdiagnosis due to an unrecognized sleep disorder is a possibility. In one study, researchers compared narcolepsy (a neurological sleep disorder with disturbed nocturnal sleep and an abnormal daytime sleep pattern), idiopathic hypersomnia
(thought to be a neurological disorder, characterized primarily by severe excessive daytime sleepiness), and ADHD, and found a high percentage of overlapping symptoms, suggesting the possibility of adult ADHD misdiagnosis.

Adolescents and adults with ADHD are very restless sleepers with active movements like turning. They have a higher incidence of sleep-onset insomnia (going to sleep) and sleep-maintenance insomnia (staying asleep). The most common sleep problems reported are:

  
Insomnia. Adults with ADHD have a higher than normal incidence of insomnia.

  
Being restless—kicking, tossing, and turning. One study concluded that symptoms of ADHD are more common in RLS patients than in patients with insomnia. RLS and ADHD may be part of a single symptom complex, and dopamine deficiency may play a role in both disorders.

  
Difficulty waking up as a chronic problem, even if they felt they had a good night's sleep.

  
Sleep apnea.