A very challenging question, John. [I hope the snow in Arkansas yesterday didn't cause you any difficulty]. A broader question might be, "When should pediatricians be concerned over a child's sleep habits? How should a pediatrician or PCP screen children for sleep problems?" Because of the effects ADHD medications, both stimulants and nonstimulants, may have on sleep, either on insomnia or on daytime sleepiness or fatigue, it would seem appropriate to get a baseline concept of a child's sleep habits. A good screening instrument might then and there suggest the need for a sleep study, but certainly changes in sleep habits should be discusssed. Also, failure to adequately respond to medical treatment should also alert the physician to consider why response insufficient. A primary sleep disorder is only one of the issues to be considered at that juncture.

So a broader question--How do you educated physicians on the role of polysomnography or other evaluations by sleep specialists for the pediatric patient?

In our experience - and also based on the literature - it is very important to screen for sleep issues. If a sleep disorder is present, it is very worthwhile treating the sleep issue first (officially then the diagnosis ADHD might not even be used, since the sleep issues could be the cause and should be diagnosed as such).

Several studies for example have found that ADHD children with for example sleep breathing difficulties respond very well to adenotonsillectomy (if enlarged tonsils are causing their breathing issues), and the effect size for that intervention in this subgroup is larger than for stimulant medication, also see Huang et al. (2007). Also, recent work in NZ found that when dividing a large group of healthy children in those with and those without subtle signs of sleep breathing issues, explained 30-40% of the variance in IQ and school performance 3 years later (presented at last ESRS meeting in Paris, 2012). Similar findings have been obtained for restless legs syndrome and both these sleep disorders have an estimated prevalence of 20% in ADHD populations. Also see http://www.brainclinics.com/neurofeedback for a review article we just published on this topic with more references (2nd half of that manuscript).

The easiest - and most practical - approach is using a sleep diagnostic questionnaire (e.g. here we use the HSDQ, but there are also other validated measures) and the PSQI. In addition we have found actigraphy to be a very worthwhile addition. Often we find big discrepancies be sleep duration reported by parents and the duration as measured by actigraphy.

For a further interesting illustration about what the impact of sleep / circadian issues is, also see: http://www.brainclinics.com/association-adhd-intensity-sunlight-adhd-prevention

Thank you, Tom and Martijn. I agree that the lack of education on disordered sleep is a big problem for practitioners who serve as the primary care providers for children. I read an article recently that estimated the percentage of ALL children with sleep difficulties to range between 25-40%. I suspect, like you Tom, that a substantial number of these children suffer from poor sleep hygiene alone. Early administration of something as basic as a validated sleep questionnaire (HSDQ or PSQI) for screening patients suspected of having ADHD is an excellent suggestion, Martijn, if indeed this population exhibits such a high percentage of disordered sleep. Personally, I have not administered any type of sleep questionnaire when screening for ADHD, with the exception of clinical trials where a protocol specifically requires one. Children with clearly abnormal sleep questionnaires may be well served to have this issue resolved prior to making the diagnosis of ADHD. A targeted physical exam of the upper airway should not be overlooked in these kids. As Tom clearly stated, the education of the practitioner on sleep disorders is critical to avoid misdiagnosis and treatment of these children. I appreciate your input very much. John

Very interesting discussions. Agree that sleep history must be taken before considering ADHD as daytime concentration problems could be the result of sleep disturbance. Over the many years in practice I've kept my sleep specialist colleagues very busy assessing children where sleep apnoea was being considered. Low yield, but a very important consideration in children being assessed for ADHD.

If they are distractible in school or sleepy take a look in their oral cavity - if the tonsils are enlarged get a sleep study to look for OAS.

The relationship between sleep and ADHD is complex and most likely bi-directional. While some ADHD symptoms may be explained away by sleep deficit, there are sleep behaviors and sleep disruptions that may be related to the difficulty with self-regulation that are intrinsic to the diagnosis of ADHD. Sleep troubles must be addressed on several fronts, including parenting, sleep hygiene practices, and medications.