Dr Yasir Hameed (MRCPsych)Specialist RegistrarNorfolk and Suffolk NHS Trust28 March 2014

» Sleep and its importance

» Sleep disorders in adults with ADHD (focus on DelayedSleep Phase Disorder DSPD)

» Assessment

» Treatment

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Upon completion of this educational activity,participants should be able to:

» Recognise the delayed sleep phase in adultswith ADHD.

» Explain the consequences for health ingeneral of late and short sleep on the longterm and how to treat the delayed sleepphase.

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Sleep

» Restorative/homeostatic» Thermoregulation/energy conservation» Consolidation of learning and memory

» Cyclic nature of sleep is reliable» REM periods every 90 – 120 minutes» First REM period is shortest» Most deep sleep (Stage 3 & 4) occurs early» Most REM occurs late

» All variety of sleep disorders are more common amongstchildren and adults with ADHD than healthy controls,controls with other psychiatric illness, and health siblings

» The DSM-III considered excessive movements during sleepto be a criterion for hyperactivity in children

» Sleeping disorder (predominantly delayed sleep phasedisorder) prevalence in clinical studies of adults is 80 % andin clinical studies in children – 73 %

» Kooij, JJS. Adult ADHD Diagnostic Assessment and Treatment. Third edition. 2013. Pearsonpublication.

» - (Very) late Chronotype

» - A chronic pattern of (very) late sleep and preference forlate rise

» - May result in daytime sleepiness and/or insomnia

» - May be compensated for by an irregular sleep pattern

» - Leads to dysfunctioning due to increasedinattentiveness and/or social problems

» - Main complaint is sleep onset insomnia11

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» Partners having different bedtimes is anothercommon problem for having sex

» High rates of divorce and separation(Biederman J, Faraone SV, Keenan K, et al. 1992)

» 4 times more likely to have complaints of poorquality relationships (Biederman J, Faraone SV,et al 2006)

» Clinical history˃ Sleep initiation, maintenance, duration; refreshed and

alert in AM; bedtime routine; anxiety/depression; unusualnight-time behaviours

» Sleep log˃ 2-3 weeks to document sleep-wake patterns˃ Munich Chronotype Questionnaire (MCTQ)

» Smartphone apps˃ Sleep Cycle Calculator

» Actigraphy and Polysomnography˃ Needed for OSAS, RLS, or nocturnal seizures

» Management is “diagnostically driven”, anddepends on thorough assessment and aformulation to include the likely underlyingcause or causes.

» Interventions:

˃– Sleep diary˃– Sleep hygiene˃– Switch of medication˃– Dose reduction˃– Other medication˃– Drug holiday

» In a randomized, crossover study in children withADHD, results indicated that, relative to baseline,immediate-release MPH increased sleep-onsetlatency statistically significantly more than didatomoxetine (p<.001), consistent with the time toonset of persistent sleep and mean time to onset offirst sleep epoch (p<.001 for both)

» No difference in ADHD rating scale IV-Parent Version

» Sangal et al. Effects of atomoxetine and methylphenidate on sleep in children with ADHD.Sleep. 2006;29(12):1573-1585

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» Medication is rarely the first and only choice

» Behavioural strategies aiming to sustainimprovement and minimise adverse effects

» Melatonin has both immediate and extended-release forms (Circadin®)

» Evidence?

» In practice, adverse effects are relativelyuncommon and self-limiting. There isincreasingly reassuring evidence that this is asafe medication in hypnotic doses of up to10mg .

Bendz L.M.,and Scates A.C. Melatonin treatment for insomnia in pediatric patients with attention deficit hyperactivitydisorder. Ann Pharmacother 2010 44(1) 185-191Weiss M.D., Wasdell M.B., et al Sleep hygiene and melatonin treatment for children and adolescents with ADHD andinitial insomnia. J Am Acad Child Adolesc Psychiatry 2006 45(5) 512-519Rossignol D.A., and Frye R.E. Melatonin in autism spectrum disorders : a systematic review and meta-analysis. DevMed Child Neurol 2011. 9.(783-792)

» Promethazine» Clonidine» Benzodiazepines» Z hypnotics» Antidepressants

» Whatever medication is tried, periodic breaksfrom treatment are prudent to assess whetherongoing treatment is necessary.

» Most hypnotics will remain ineffective in thepresence of poor sleep routines,overstimulation at bedtime or the challenges ofnocturnal multimedia.

» Always give advice on sleep hygiene23

• Sleep difficulties are highly prevalent in ADHD, are oftenmultifactorial in origin, and significantly impair quality of life

• Sleep difficulties exacerbate daytime ADHD symptoms

• Shared biological dysregulation in ADHD may contribute todisordered sleep

• Assessment of ADHD is incomplete without a sleep history (pre-and post-treatment)

• Sleep diaries are particularly useful in assessment

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