1. Dr Yasir Hameed (MRCPsych)
Specialist Registrar
Norfolk and Suffolk NHS Trust
28 March 2014
Yasir Hameed (MRCPsych)
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Date: 2014-03-29 11:44Z
2. » Sleep and its importance
» Sleep disorders in adults with ADHD (focus on Delayed
Sleep Phase Disorder DSPD)
» Assessment
» Treatment
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3. Upon completion of this educational activity,
participants should be able to:
» Recognise the delayed sleep phase in adults
with ADHD.
» Explain the consequences for health in
general of late and short sleep on the long
term and how to treat the delayed sleep
phase.
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8. » 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
9. » All variety of sleep disorders are more common amongst
children and adults with ADHD than healthy controls,
controls with other psychiatric illness, and health siblings
» The DSM-III considered excessive movements during sleep
to be a criterion for hyperactivity in children
» Sleeping disorder (predominantly delayed sleep phase
disorder) prevalence in clinical studies of adults is 80 % and
in clinical studies in children – 73 %
» Kooij, JJS. Adult ADHD Diagnostic Assessment and Treatment. Third edition. 2013. Pearson
publication.
10.
11. » - (Very) late Chronotype
» - A chronic pattern of (very) late sleep and preference for
late rise
» - May result in daytime sleepiness and/or insomnia
» - May be compensated for by an irregular sleep pattern
» - Leads to dysfunctioning due to increased
inattentiveness and/or social problems
» - Main complaint is sleep onset insomnia
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14. » Partners having different bedtimes is another
common 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 poor
quality relationships (Biederman J, Faraone SV,
et al 2006)
15. » Clinical history
˃ Sleep initiation, maintenance, duration; refreshed and
alert in AM; bedtime routine; anxiety/depression; unusual
night-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
16.
17. » Management is “diagnostically driven”, and
depends on thorough assessment and a
formulation to include the likely underlying
cause or causes.
18. » Interventions:
˃– Sleep diary
˃– Sleep hygiene
˃– Switch of medication
˃– Dose reduction
˃– Other medication
˃– Drug holiday
19. » In a randomized, crossover study in children with
ADHD, results indicated that, relative to baseline,
immediate-release MPH increased sleep-onset
latency statistically significantly more than did
atomoxetine (p<.001), consistent with the time to
onset of persistent sleep and mean time to onset of
first 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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20. » Medication is rarely the first and only choice
» Behavioural strategies aiming to sustain
improvement and minimise adverse effects
21. » Melatonin has both immediate and extended-
release forms (Circadin®)
» Evidence?
» In practice, adverse effects are relatively
uncommon and self-limiting. There is
increasingly reassuring evidence that this is a
safe medication in hypnotic doses of up to
10mg .
Bendz L.M.,and Scates A.C. Melatonin treatment for insomnia in pediatric patients with attention deficit hyperactivity
disorder. Ann Pharmacother 2010 44(1) 185-191
Weiss M.D., Wasdell M.B., et al Sleep hygiene and melatonin treatment for children and adolescents with ADHD and
initial insomnia. J Am Acad Child Adolesc Psychiatry 2006 45(5) 512-519
Rossignol D.A., and Frye R.E. Melatonin in autism spectrum disorders : a systematic review and meta-analysis. Dev
Med Child Neurol 2011. 9.(783-792)
23. » Whatever medication is tried, periodic breaks
from treatment are prudent to assess whether
ongoing treatment is necessary.
» Most hypnotics will remain ineffective in the
presence of poor sleep routines,
overstimulation at bedtime or the challenges of
nocturnal multimedia.
» Always give advice on sleep hygiene
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24. • Sleep difficulties are highly prevalent in ADHD, are often
multifactorial in origin, and significantly impair quality of life
• Sleep difficulties exacerbate daytime ADHD symptoms
• Shared biological dysregulation in ADHD may contribute to
disordered sleep
• Assessment of ADHD is incomplete without a sleep history (pre-
and post-treatment)
• Sleep diaries are particularly useful in assessment