2. Journal of the American Psychiatric Nurses Association, Vol. 12, No. 4 217
Sleep Disorders and Attention-Deficit Hyperactivity Disorder
difficulties, and impulsivity. The American Academy of
Pediatrics (AAP) has published recommendations for
systematic diagnosis of ADHD in children (American
Academy of Pediatrics, 2000). To ensure an accurate
diagnosis of ADHD, the guidelines recommend that
children meet the Diagnostic and Statistical Manual
of Mental Health Disorders (4th ed., text revision;
DSM-IV-TR; American Psychiatric Association, 2000)
criteria for ADHD. For DSM-IV-TR criteria for diagno-
sis of ADHD to be met, a child must have displayed
inattentive, impulsive, and problematic behavioral pat-
terns before the age of 7, and the behaviors must have
a negative impact on the child’s function in two or more
settings (American Psychiatric Association, 2000).
The AAP further recommends that clinicians use
additional tests to differentiate the presence of
another condition that may be contributing to the dis-
ruptive behavioral symptoms before concluding a
diagnosis of ADHD. Blood tests are commonly per-
formed to rule out the presence of iron deficiency, lead
poisoning, thyrotoxicosis (i.e., Graves’ disease), and
hypothyroidism in children presenting with behav-
ioral and cognitive symptoms associated with ADHD.
Iron deficiency was recently reported to be present in
6% to 17% of children in the United States (Brotanek,
Halterman, Auinger, Flores, & Weitzman, 2005). Lead
poisoning has been described as the most common
environmental illness of children, and elevated blood
lead levels have been reported in up to 16.4% of
children living in older homes within large urban areas
(Lanphear et al., 2002). Thyrotoxicosis is most com-
monly reported as Graves’ disease in children and has
a very low incidence ranging from 0.1/100,000 in
infants to 0.96/100,000 in adolescent females
(Forssberg et al., 2004). Similarly, hypothyroidism has
an infrequent occurrence pattern of 0.5% in the general
population over age 12 (Hollowell et al., 2002). Iron
deficiency, lead poisoning, thyrotoxicosis, and hypothy-
roidism have all been individually associated with
behavioral and school performance difficulties in
children (Lozoff, Jimenez, Hagen, Mollen, & Wolf, 2000;
Stiles & Bellinger, 1993; Wu, Flowers, Tudiver, Wilson,
& Punyasavatsut, 2006) and are differential diagnoses
commonly ruled out before the diagnosis of ADHD.
In a recent survey of more than 1,000 pediatricians,
most considered differential diagnoses such as ane-
mia, high serum lead level, and hyperthyroidism or
hypothyroidism as a basis for the presenting behav-
ioral problems, but no mention was made of diagnostic
sleep tests to rule out the presence of a sleep disorder
as a differential diagnosis (Chan et al., 2005). However,
sleep disorders have a higher prevalence rate in
children than thyroid disorders and are also associated
with problematic cognitive and behavioral symptoms.
A confound to the ability of the clinician to detect or
diagnose sleep disorders in children is the current lack
of a standardized, specific, and sensitive tool that can
easily be used in the office to assess sleep habits
and patterns during a brief clinic visit. When children
present with problematic behavioral symptoms, a dif-
ferential diagnostic algorithm is initiated in the
search for a likely source of the symptoms. This differ-
ential often begins with documentation of subjective
parental and teacher reporting of symptom patterns.
Currently, the most widely accepted standard for diag-
nosis of several major sleep disorders in children is
not a questionnaire but a complete, overnight, sleep-
laboratory-based polysomnographic (PSG) sleep study
(Ghegan, Angelos, Stonebraker, & Gillespie, 2006).
SYMPTOMS OF ADHD
ADHD is associated with subjective reporting of
physical symptoms such as fidgeting with hands and
feet, inability to sit still, and seeming to be “on the go”
or as if “driven by a motor” (American Psychiatric
Association, 2000). Symptoms of ADHD also include
the child’s tendency to “butt into” conversations and
be unable to wait his or her turn in situations where
such behavior is expected (American Psychiatric
Association, 2000). Subjective symptoms of ADHD
also include parental and teacher reports of a child
who is forgetful in daily activities, blurts out answers
before it is his or her turn, and fails to give close
attention to details, making what seem to be “care-
less” mistakes in daily work and play (American
Psychiatric Association, 2000). This constellation of
subjective behavioral symptoms, among others, is
reported to the clinician and considered a critical
component of diagnostic criteria for ADHD.
In addition to subjectively reported symptoms,
research has shown that children who have been diag-
nosed with ADHD demonstrate deficiencies in several
objective cognitive processes such as sustained atten-
tion, problem solving, and visual information process-
ing (Lawrence et al., 2004). Specifically, researchers
have reported that children with ADHD showed
decreased speed of processing information when
attempting the color-naming portion of the Stroop
task and showed more perseverative errors on the
Wisconsin Card Sort Task, an indication of impaired
mental flexibility (Lawrence et al., 2004; Pennington
& Osonoff, 1992) when compared with nonaffected
control children.
3. 218 Journal of the American Psychiatric Nurses Association, Vol. 12, No. 4
Archbold
Although there is no gold standard, diagnostic, neu-
ropsychological test for ADHD, research has demon-
strated that children with ADHD perform differently
than their nonaffected counterparts on objective tests
of cognitive functions such as higher perseverative
tendencies on the Wisconsin Card Sort Task and
decreased speed of information processing on the
Stroop Color Naming tasks (Lawrence et al., 2004;
Pennington & Osonoff, 1992). ADHD is a diagnosis
that is primarily associated with subjectively reported
symptoms of behavioral and cognitive problems.
Although the disruptive behavior and cognition pat-
terns are commonly assessed in ADHD, sleep patterns
are less often assessed and may also be disrupted.
A child with ADHD is more likely to fall asleep
more quickly during a daytime multiple sleep latency
test (MSLT) nap opportunity than a child without
ADHD (Golan, Shahar, Ravid, & Pillar, 2004;
Lecendreux, Konofal, Bouvard, Falissard, & Mouren-
Siméoni, 2000). The MSLT provides four or five
20-min opportunities during the day at regular 2-hr
intervals for the child to take a nap or to “try to fall
asleep.”A montage of several electroencephalographic
leads is used to record brain activity and sleep stag-
ing patterns throughout each MSLT nap attempt.
The objective pattern of shorter latency to sleep onset
reported in children with ADHD during MSLT
may explain why current pharmacotherapy for
children with ADHD often includes amphetamines;
more recently, nonamphetamine therapies such as
modafinil have been used in treatment of ADHD
(Biederman et al., 2005; Swanson et al., 2006).
It is currently not known why sleep patterns in
children with ADHD are often disturbed (Cortese,
Konofal, Yateman, Mouren, & Lecendreux, 2006).
The etiology of ADHD remains elusive, but evidence
suggests that cortical hypoarousal may result from a
deficiency of dopamine and inhibition of noradrener-
gic systems within prefrontal, striatal, and limbic
brain regions (Russell, Allie, & Wiggins, 2000).
This cortical hypoarousal may in turn result in inat-
tentive and impulsive behavior patterns seen in
children with ADHD (Filipek et al., 1997; Swanson
et al., 1998; Zametkin et al., 1990; Zametkin et al.,
1993). Dysfunctional dopaminergic activity has also
been implicated as a possible etiology for RLS and
PLMD (Clemens, Rye, & Hochman, 2006; Stiasny,
Oertel, & Trenkwalder, 2002).
Researchers have reported that children diag-
nosed with ADHD may also have a comorbid sleep
disorder, including RLS, PLMD, or OSA (Chervin,
Dillon, Bassetti, Ganoczy, & Pituch, 1997; Chervin
et al., 2002; Huang et al., 2004; Picchietti & Walters,
1996; Sangal, Owens, & Sangal, 2005).
RLS AND PLMD
RLS is a disorder that is associated with uncom-
fortable sensations in the limbs, but mainly the legs
(American Academy of Sleep Medicine, 2005). RLS is
associated with an urge to move the legs because of
“creepy,” “crawly,” pulling, and/or pins-and-needles
type sensations. Moving the legs or walking will
temporarily alleviate this discomfort. These sensa-
tions and urges to move the legs occur mainly in the
evening, when the patient is resting or has gone to
bed for the night (Aldrich, 1999; Allen et al., 2005).
However, specific to the RLS diagnosis are the
symptoms of waking dyskinesias that RLS patients
report to occur at any point during the day (Aldrich,
1999). They can be seen to fidget or shift frequently
at rest, and the movements may worsen as the
person tries to stop them (Aldrich, 1999; Lesage &
Hening, 2004). Children with RLS have specifically
described their RLS symptoms as sensations of
“freezing” of the legs or “a tickle” in their legs that is
worse at night and can be relieved with movement
(Picchietti & Walters, 1996).
RLS has been estimated to affect 5% to 10% of the
general population of people 18 years of age or older
(Allen et al., 2005). The disorder can occur at any age
but most frequently is reported to develop within the
second decade of life (Walters et al., 1996). Little is cur-
rently known about the exact prevalence and severity
of RLS in children; however, some estimates suggest
that 1% to 3% of children may have clinically signifi-
cant RLS symptoms (Chervin & Hedger, 2001), and ret-
rospective reports in adults of childhood onset of RLS
symptoms are common (Picchietti & Walters, 1996).
RLS is most commonly diagnosed within the
clinical setting and does not require PSG for confir-
mation. Diagnosis is based largely on subjective
responses to questions about parasthesias, dysthe-
sesias of the limbs, motor restlessness, and worsen-
ing of these symptoms as the day progresses or at
night (Aldrich, 1999; Lesage & Hening, 2004).
When adult RLS patients do undergo PSG, they
have been shown to have less efficient sleep, spend
more time in lighter stages of sleep, and spend less
time in deeper, more restorative stages of sleep
(Garcia-Borreguero et al., 2002). A landmark study
found that 80.2% of adult RLS patients demonstrate
periodic limb movements during sleep, evidence that
limb movements continue during sleep for many RLS
4. Journal of the American Psychiatric Nurses Association, Vol. 12, No. 4 219
Sleep Disorders and Attention-Deficit Hyperactivity Disorder
patients (Montplaisir et al., 1997). Unfortunately, there
are no reports of similar studies in children with RLS.
Studies have also shown that adults with RLS
have deficits in attention, mental flexibility, and plan-
ning (Pearson et al., 2006; Wagner, Walters, & Fisher,
2004). A recent study found that nonmedicated RLS
patients were significantly deficient in performance
of a Verbal Fluency and Trail-Making test of pre-
frontal lobe cognitive functions (Pearson et al., 2006).
Similar studies have not yet been reported in
children, so it is not known what sorts of cognitive
sequelae, if any, children with RLS may experience.
RLS may affect up to 12% of children diagnosed
with ADHD (Cortese et al., 2005; O’Brien, Ivanenko,
et al., 2003; Picchietti & Walters, 1996). Although
the mechanisms to connect the two disorders have
yet to be elucidated, research shows that dopamine
antagonists such as metoclopramide worsen RLS
symptoms (Earley, Yaffee, & Allen, 1999). This sug-
gests that dysfunctional dopaminergic pathways
within the brain may be involved in RLS as they are
hypothesized to be in ADHD.
Patients with RLS were found to have reduced
binding of dopamine 2 receptors in the striatum
(Turjanski, Lees, & Brooks, 1999). In the adult,
RLS symptoms are alleviated with pharmacologic
dopamine agonist treatments such as pergolide and
ropinirole (Allen et al., 2005), yet no data exist on
the effectiveness or use of these agents for treatment
of RLS in children.
Low serum ferritin levels can negatively affect
the ability of dopamine to bind to receptor sites
within the brain (Borisenko, Kagan, Hsia, & Schor,
2000) and this mechanism of action has been impli-
cated in the production of RLS pathology in children
(Kryger, Otake, & Foerster, 2002). Treatment with
supplemental iron has been anecdotally reported
to alleviate RLS symptoms in children (Hoban &
Chervin, 2005).
Supplemental iron therapy may also be helpful in
the treatment of ADHD, particularly for children who
do not respond to amphetamine agents (Konofal,
Cortese, Lecendreux, Arnulf, & Mouren, 2005; Konofal,
Lecendreux,Arnulf, & Mouren, 2004). However, results
from full double-blind, placebo-controlled clinical trials
of supplemental iron therapy for the treatment of RLS
and/or ADHD for children have yet to be reported in
the literature.
PLMD
Whereas RLS is associated with motor restlessness
symptoms that occur during waking hours and during
sleep, PLMD occurs exclusively during sleep. PLMD is
characterized by periodic and sustained contractions of
one or both leg muscles (anterior tibialis) during sleep
(American Academy of Sleep Medicine, 2005).
In more severe cases, contractions of four limbs and
trunk musculature can occur (Mahowald & Thorpy,
1995). These contractions may not always be associ-
ated with arousals from sleep, and the consequences of
PLMD on general health and cognition are currently
not well known. PLMD is diagnosed during an
overnight PSG study.
When limb movements occur at a rate of five or
more on average per hour of sleep, the situation is con-
sidered to be clinically problematic and diagnostic of
PLMD for children (Picchietti & Walters, 1996). Exact
data about PLMD prevalence and age of onset in
children are unavailable, but the disorder is estimated
to occur in 4% of the general population between the
ages of 15 and 100, with peak initial reporting of
symptoms in the 20s (Ohayon & Roth, 2002).
Children with PLMD have been shown to spend
less time in deep stages of sleep (Stages 3 and 4)
and more time in lighter, more fragmented sleep
(Stages 1 and 2; Crabtree, Ivanenko, O’Brien, & Gozal,
2003). Rapid eye movement (REM) sleep amounts are
also reduced in the presence of PLMD (Crabtree et al.,
2003). In children, these sleep perturbations have been
linked to decreased academic performance, hyperkine-
sis, and impaired cognition (Fallone, Acebo, Seifer, &
Carskadon, 2005; Gruber & Sadeh, 2004; Huang et al.,
2004; Lecendreux et al., 2000; Sadeh, Raviv, & Gruber,
2000). Again, these are the behavioral symptoms that
are most commonly attributed to ADHD.
A paucity of clinical data exists on the mechanistic
causes of PLMD and potential treatment of this disor-
der in children. However, treatment with dopamine
agonists has been reported, albeit anecdotally, to be
effective in elimination of RLS and PLMD-associated
sleep perturbations (Hening, Allen, Earley, Picchietti,
& Silber, 2004; Hoban & Chervin, 2005).
RLS and PLMD are both sleep disorders that
occur in childhood, disrupt sleep, impair daytime
cognitive and behavioral functions, and may have a
similar dysfunction of dopamine-related brain path-
ways among their possible mechanisms of action.
ADHD is a disorder that has these same properties.
OSA is another sleep disorder that also occurs
in childhood and is associated with disturbed sleep
and impaired daytime cognitive and behavioral
functions (Archbold, Giordani, Ruzicka, & Chervin,
2004; Chervin et al., 2002; Mulvaney et al., 2005;
Guilleminault, Korobkin, & Winkle, 1981; O’Brien,
Mervis, Holbrook, Bruner, Smith, et al., 2004).
5. 220 Journal of the American Psychiatric Nurses Association, Vol. 12, No. 4
OBSTRUCTIVE SLEEP APNEA
OSA is a form of sleep-disordered breathing that
is estimated to affect approximately 1% to 3% of
children (Ward & Marcus, 1996). OSA occurs when
the airway repeatedly closes completely or partially
during sleep (American Academy of Sleep Medicine,
2005). The main causes of OSA in children are
enlarged tonsillar and adenoid tissue (Marcus, 2000)
and childhood obesity (O’Brien, Sitha, Baur, &
Waters, in press). OSA has a peak age of onset in the
child around the age of 5 years, when the size of
the tonsils is largest in relation to the size of the
oropharynx, facilitating airway occlusion during
sleep (Ward & Marcus, 1996). Obesity contributes to
OSA whereby pressure from subcutaneous adipose
tissue adjacent to the pharynx and surrounding the
neck causes the airway to collapse during sleep
(Shelton, Woodson, Gay, & Suratt, 1993).
For accurate diagnosis of OSA, a full PSG sleep
study in a laboratory is required, and treatment
often consists of adenotonsillectomy followed by con-
tinuous positive airway pressure therapy if OSA
remains present after surgery. In addition, nutri-
tional counseling, weight loss, and interventions to
help increase the child’s level of physical activity
may be needed if the child is obese (Marcus, 2000).
OSA is associated with frequent, intermittent
hypoxic episodes and highly, fragmented sleep.
Children with OSA have an increased number of
arousals from sleep (Stepanski, Zayyad, Nigro,
Lopata, & Basner, 1999) and severe levels of inter-
mittent oxygen desaturation. Oxygen saturation lev-
els can drop well below 65% in more severe cases of
OSA, and respiration can partially stop for periods
of 3 s to 3 min at one time (Anders & Eigen, 1997).
Cognitive problems have been described in children
diagnosed with OSA. Reported problems include
impaired mental flexibility, inability to problem solve,
impaired attention span, and decreased memory
capacity in children as young as age 5 (Archbold et al.,
2004; Gottlieb et al., 2004; Lewin, Rosen, England, &
Dahl, 2002; O’Brien, Holbrook, et al., 2003; O’Brien,
Mervis, Holbrook, Bruner, Smith, et al., 2004).
Cognitive problems have also been reported
in also children whose parents report that their
child snores most of the time while asleep, a major
symptom of OSA (Blunden, Lushington, Lorenzen,
Martin, & Kennedy, 2005; LeBourgeois, Avis, Mixon,
Olmi, & Harsh, 2004; O’Brien, Mervis, Holbrook,
Bruner, Klaus, et al., 2004).
Academic behavior and performance may also be
related to OSA in children. A landmark study showed
that when adenotonsillectomy was performed on
children with OSA, their behavior and academic per-
formance were significantly improved (Gozal, 1998).
Children treated for OSA increased in one full evalua-
tive grade over the course of the academic year follow-
ing treatment for OSA when data were compared with
a similar demographically matched, nontreated control
group (Gozal, 1998). For these reasons, poor academic
performance may be yet another nonspecific symptom
for which a sleep disorder could be suspected.
For reasons that have yet to be clarified, it is
unclear how and whether OSA and ADHD are linked
in the childhood population. Studies have found that
25% of children with a diagnosis of ADHD have symp-
toms suggestive of OSA (Chervin et al., 1997), and
19% to 50% of children with ADHD were diagnosed
with OSA following PSG (Golan et al., 2004; Huang
et al., 2004).
Still other data have shown that children with
ADHD have no higher rate of OSA than children
without ADHD (Cooper, Tyler, Wallace, & Burgess,
2004; O’Brien, Ivanenko, et al., 2003; Sangal et al.,
2005). Such discrepancies in findings may exist
because of the lack of universal, industry-accepted
definitions of obstructive sleep apnea in children,
sampling biases, and relatively small sample sizes.
The issues of comorbidity, behavioral and cognitive
effects, and prevalence of OSA, RLS, PLMD, and
ADHD in children are important ones that all war-
rant further, scientifically rigorous investigation. In
the interim, psychiatric nurse clinicians can use the
following suggestions to screen children for sleep
disorders in the clinical setting.
CLINICAL ASSESSMENT OF
OSA, PLMD, AND RLS
The Pediatric Sleep Questionnaire (PSQ) was devel-
oped to assess disordered sleep symptoms quickly dur-
ing outpatient clinic visits (Chervin, Hedger, Dillon, &
Pituch, 2000). The PSQ assesses a full range of sleep
and daytime behaviors and has been validated with
polysomnography to accurately identify risk for OSA,
PLMD, and RLS (Chervin et al., 2000; Chervin &
Hedger, 2001).
The PSQ is a 73-item yes/no/don’t know format
questionnaire that screens for symptoms of such
sleep disturbances as insomnia, excessive daytime
sleepiness (EDS), nocturnal bruxism, night terrors,
and habitual snoring. It also assesses contextual and
environmental sleep patterns such as time to bed, bed-
time resistance, and sleep hygiene. The PSQ contains
a 22-item Sleep Related Breathing Disorder (SRBD)
Archbold
7. 222 Journal of the American Psychiatric Nurses Association, Vol. 12, No. 4
comes to the practice setting for evaluation, interven-
tion, and nursing care, we must be careful to differen-
tiate whether an occult sleep disorder could be at the
center of the difficult behavioral symptoms. If a sleep
disorder is present, specific therapies can be initiated
that may obviate the need for the amphetamine or
other psychostimulant medications commonly used as
frontline therapies in ADHD.
Psychiatric nurse practitioners have the tools nec-
essary to assess and manage disordered sleep pat-
terns in the child with difficult behavioral symptoms.
When a sleep disorder is suspected as a potential
source for the behaviors, a referral should be made to
an accredited pediatric sleep disorders center for a
full PSG. Psychiatric nurses can then work in collab-
oration with sleep specialists to ensure that appropri-
ate therapeutic interventions are planned and
completed leading to good mental health of the
children and families with which we work.
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