Dr Yasir Hameed (MRCPsych) Specialist Registrar Norfolk and Suffolk NHS Trust 28 March 2014 This presentation was presented at ADHD Training Day at Dunston Hall in Norwich on 28 March 2014. The day is free for all staff and is kindly sponsored by Eli Lilly Neuroscience plus is supported by the Trust NDD Steering Group and the Postgraduate Department.

1. Dr Yasir Hameed (MRCPsych)
Specialist Registrar
Norfolk and Suffolk NHS Trust
28 March 2014
Yasir Hameed (MRCPsych)
Digitally signed by Yasir Hameed (MRCPsych)
DN: cn=Yasir Hameed (MRCPsych) gn=Yasir Hameed (MRCPsych) c=United Kingdom l=GB o=Norfolk and Suffolk NHS Trust
ou=Norfolk and Suffolk NHS Trust e=yasirmhm@yahoo.com
Reason: I am the author of this document
Location:
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
2

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.
3

4. 4

5. 5

6. Sleep

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

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.

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
11

12. 12

13. 13

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

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
19

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)

22. » Promethazine
» Clonidine
» Benzodiazepines
» Z hypnotics
» Antidepressants

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
23

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

25. 25