Sleep and ADHD

An Evidence-Based Guide to Assessment and Treatment

Harriet Hiscock, Emma Sciberras

• Publisher: Academic Press
• Year: 2019
• Print ISBN:
  9780128141809
• eBook ISBN:
  9780128141816
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Sleep and ADHD begins with an overview of sleep (normal sleep, sleep cues, developmental phases, etc.) and continues with the epidemiology of ADHD and sleep problems, including medical issues (e.g. sleep apnea), parasomnias, behavioral insomnias (i.e. limit setting, sleep onset association disorders, circadian rhythm disorders and anxiety-related insomnia). It then covers the etiology of sleep problems, including the role of sleep hygiene and habits, the developing child, and the role of stimulants and medications used in the management of ADHD sleep problems. As the first book of its kind, users will find this reference an invaluable addition to the literature on ADHD. - Covers both the pharmacological and non-pharmacological management of sleep problems - Addresses sleep issues in younger children, but also addresses adolescents and adults - Discusses the impact of sleep problems on the family as well as the child with ADHD - Reviews the evidence around the neurobiology of sleep and systems regulating sleep in ADHD

Chapter 1

Attention Deficit Hyperactivity Disorder

An Overview

Daryl Efron^1,2,3, ¹Centre for Community Child Health, Murdoch Children’s Research Institute, Melbourne, VIC, Australia, ²Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia, ³General Medicine, The Royal Children’s Hospital, Melbourne, VIC, Australia

Abstract

Attention deficit hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder. It is a polygenic disorder with multifactorial etiology, including genetic and environmental factors. Onset occurs in childhood, but symptoms usually persist across developmental stages into adult life, at least to some extent. A range of cognitive deficits are seen in ADHD, underpinning the substantial functional difficulties experienced by individuals with the condition. Management includes both pharmacological and nonpharmacological interventions. Comorbidities such as sleep problems are common and contribute to the impairments. These need to be identified and addressed alongside ADHD symptoms. ADHD is associated with an increased risk of negative long-term outcomes however, with support many patients thrive and have successful lives.

Keywords

Attention deficit hyperactivity disorder; comorbidities; genetics; psychostimulant medication

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by developmentally inappropriate levels of hyperactivity, impulsivity, and/or inattention. Onset occurs in childhood, but persistence into adolescence and adult life is common. Heterogeneity in symptom profile, comorbidity mix, genetic and environmental risk factors, neurocognitive deficits, and response to treatment is a notable feature of ADHD. Furthermore, the presentation and functional difficulties associated with ADHD evolve across developmental stages as demands change (Cherkasova, Sulla, Dalena, Pondé, & Hechtman, 2013). ADHD is associated with impairments in social, academic, and family functioning and poorer outcomes in childhood (Efron, Sciberras, & Anderson, 2014), adolescence and adulthood (Shaw et al., 2012).

ADHD is classified as a Neurodevelopmental Disorder in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5) (American Psychiatric Association, 2013), alongside autism spectrum disorder (ASD), intellectual disability, learning disorders, and communication disorders. This represents an important conceptual shift from the DSM-IV (1994) where it was classified as a disruptive behavior disorder and is appropriate recognition of its strong neurobiological basis.

DSM-5 Diagnostic Criteria for ADHD (American Psychiatric Association, 2013)

1. A. A persistent pattern of inattention and/or hyperactivity–impulsivity that interferes with functioning or development, as characterized by (1) and/or (2):
   1. 1. Inattention: Six* (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
      1. a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).
      2. b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).
      3. c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
      4. d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
      5. e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).
      6. f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
      7. g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
      8. h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
      9. i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).
   2. 2. Hyperactivity and impulsivity: Six* (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
      1. a. Often fidgets with or taps hands or feet or squirms in seat.
      2. b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).
      3. c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)
      4. d. Often unable to play or engage in leisure activities quietly.
      5. e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).
      6. f. Often talks excessively.
      7. g. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).
      8. h. Often has difficulty waiting his or her turn (e.g., while waiting in line).
      9. i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).
2. B. Several inattentive or hyperactive–impulsive symptoms were present prior to age 12 years.
3. C. Several inattentive or hyperactive–impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities).
4. D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.
5. E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

Specify whether:

• Combined presentation: If both Criterion A1 (inattention) and Criterion A2 (hyperactivity–impulsivity) are met for the past 6 months.
• Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity–impulsivity) is not met for the past 6 months.
• Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivity–impulsivity) is met but Criterion A1 (inattention) is not met over the past 6 months.

Specify if:

• In partial remission: When full criteria were previously met, fewer than the full criteria have been met for the past 6 months, and the symptoms still result in impairment in social, academic, or occupational functioning.
  Specify current severity:
• Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in only minor functional impairments.
• Moderate: Symptoms or functional impairment between “mild” and “severe” are present.
• Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning.

*For older adolescents and adults (age 17 and older), at least five symptoms are required.

In the descriptive text, DSM-5 emphasizes the importance of gathering independent information “confirming substantial symptoms across settings” from informants “who have seen the individual in those settings,” that is, parents and teachers. DSM-5 also explicitly recognizes the fact that comorbidities are the rule rather than the exception in ADHD and need to be identified and addressed.

1.1 Historical Perspective

The disorder we currently call ADHD was first described in the medical literature over 200 years ago (Lange, Reichl, Lange, Tucha, & Tucha, 2010). In 1798, Scottish physician Sir Alexander Crighton published a work entitled “An inquiry into the nature and origin of mental derangement: comprehending a concise system of the physiology and pathology of the human mind and a history of the passions and their effects” in which he described individuals with either congenital or acquired mental restlessness, who were easily distracted by extraneous stimuli and had “an incapacity of attending with a necessary degree of constancy to any one object.” In the mid-19th century, German psychiatrist and author of popular illustrated children’s books Dr Heinrich Hoffman created two characters: Fidgety Phil, who drives his parents crazy with his inability to sit still at the dinner table, and Johnny Look-in-the-Air, who watches swallows and clouds as he walks and so falls into a river. These boys would be recognizable today as having the Combined and Inattentive presentations of ADHD, respectively. At the turn of the 20th century, the father of British pediatrics Sir George Still, in his Goulstonian Lectures to the Royal College of Physicians in London, described a series of 43 teenagers with “defective moral control.” They displayed symptoms such as “passionateness” (impulsivity), and “a quite abnormal capacity for sustained attention,” core symptoms of ADHD. Some of these children also demonstrated “spitefulness,” “lawlessness,” and “wanton mischievousness,” symptoms which today would suggest diagnoses of oppositional defiant disorder (ODD) or conduct disorder, which often co-occur with ADHD. The language used by Still betrays the Victorian period’s prevailing interpretation of aberrant behavior as symptomatic of character flaws and moral we...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• List of Contributors
• Chapter 1. Attention Deficit Hyperactivity Disorder: An Overview
• Chapter 2. Overview of Sleep in Children
• Chapter 3. Epidemiology and Etiology of Behavioral Insomnias, Circadian Rhythm Disorders, and Parasomnias in ADHD
• Chapter 4. Epidemiology and Etiology of Medical Sleep Problems in ADHD
• Chapter 5. Healthy Sleep Practices (Sleep Hygiene) in Children With ADHD
• Chapter 6. ADHD Medications and Sleep
• Chapter 7. Child and Family Impacts of Sleep Problems in Children and Adolescents With ADHD
• Chapter 8. Assessing Sleep Problems in ADHD
• Chapter 9. Pharmacological and Nonpharmacological Treatment of Insomnias, Parasomnias, and Circadian Rhythm Disorders Associated With ADHD
• Chapter 10. Treatment of Medical (Sleep Breathing Disorders, Restless Legs Syndrome, Periodic Limb Movement Disorder, and Narcolepsy) Sleep Problems in ADHD
• Chapter 11. The Triple Threat of Sleep, Adolescence, and ADHD
• Chapter 12. Sleep in Adults With ADHD—Etiology, Impact, and Treatments
• Chapter 13. New Frontiers: Neurobiology of Sleep in ADHD
• Chapter 14. Future Research Directions in Attention Deficit Hyperactivity Disorder and Sleep
• Index