Book Review: 1000 Best Tips for ADHD

1000 Best Tips for ADHD, by Susan Ashley, PhD, a psychologist specializing in behavioral disorders in children, is a practical book that has helpful tips for improving various aspects of life for parents of kids with ADHD.

The book has an introduction on how to use the book, followed by a list of tips categorized by the issue at hand.  The introduction is crucial to using the book, otherwise, the book is a reference style manual meant to help parents with specific common problems faced by children with ADHD.  The book avoids being trite and it acknowledges the hard work that sometimes comes with implementing behavioral strategies, so in a sense, while this is a book of tips, it is not a book of hacks.  Some of the suggestions given are easier to implement than others, and some of them will not work for a given child's situation.

The book has many strengths.  It is very practical and is not a long treatise on a certain approach or philosophy.  The main philosophy in this book seems to be, "Do what works."  Many parents with ADHD willl appreciate that fact that this book is reference style, so you don't have to read the whole book to understand or get to the part that you want, which is a fix for your child's problems.   The book offers a wide variety of tips in a wide variety of areas such as medication, behavioral issues, school, diet, and social issues.

There are several downsides to this book.   I was looking for a book about managing behavioral issues specific to older children and teens with ADHD, things like hygiene, organizational skills, and driving.   Those issues are not specifically addressed in this book.   I  would love to see the author write a similar book about teens with ADHD.  Another omission was that the book only talked about children having difficulty in brick and mortar school situations and did not address how to alter home schooling to help a child with ADHD.  It does refer the reader to a website and there are some tips on homework and specific subjects which could be helpful, however. 

Overall, though, the book offers many useful behavioral strategies you can try to help your child with ADHD.  While it is not the only book you will ever need, and not really a "complete reference for parenting a child with ADHD" as it is advertised to be, it certainly is a solid starter book for parents new to dealing with ADHD in a younger child.

What is Using a Bedwetting Alarm Actually Like? Practical Tips and Pointers

 Enuresis is very common and can be especially difficult to conquer in a child who has ADHD.   Bedwetting alarms are a behavioral way of treating enuresis that has relatively high success rates and few side effects compared to medications and surgery.   We've recently started using a bedwetting alarm with one of our children so we thought we'd share some tips with you.

 When should you start?  Like many other things potty related, you should only start using a bedwetting alarm when your child is ready.  Bedwetting can be very tiring for a parent, but you need to have your child's buy-in or this technique will not work.  Getting up in the middle of the night is not fun for you or the child.  You need to have everyone be motivated for this or someone will quit before they are done.

Generally speaking, I would recommend waiting until your child is at least 6 or 7 before trying a bedwetting alarm, and I would also wait until your child talks to you about wanting to get out of diapers at night.  Prior to 5, most children do not need to go through this involved of a procedure to get dry at night.

The beginning stages of alarm use will be easiest if they take place at home and when your bedtime schedule and routine can be fairly normal.  However, once your child is fairly secure with alarm use,  it should be fine to go on vacation or stay up a little later than normal, provided the bed is protected in case of an accident.

 What type of alarm should you get?  There are many different types of moisture sensor alarms.   Some are pads that go under the child, and some clip to the underwear.  Pads are difficult because you have to make sure your child stays on the pad, which many ADHD kids will not, due to lots of in bed movements.  Pads also require a lot more liquid to come out which means bigger cleanups for the adult.  You should look for a secure clip, a fairly loud alarm (because the adult has to hear it, get up and get the child out of bed), and a wire that is long enough to extend from the underwear to the child's shoulder area, with a secure clip for the alarm to go on the pajamas.  If the alarm is not loud enough to wake you, you may need to use a baby type monitor in your child's room.
Some alarms have a variable feature, which could be handy if you or your child do not wake up to alarms after the first few nights of hearing them.  I can't say how likely this is, however.  I tend to wake up to an alarm more readily if it is the same one over and over again because it is a conditioned response.

 What else do you need to have to get started?
The alarm works best with tighter fitting underwear (i.e. briefs, not boxers).  Your child will have accidents, so a waterproof mattress cover is a must.  You can also try a waterproof pad, however, if it does not secure to the mattress it may slip off during the night.  Leftover waterproof pads from the crib could also be used if you still have them.

If your child sleeps with a sibling, the alarm probably will be loud enough to wake up everyone in the room.  If the sibling isn't good at getting back to sleep on their own, you may want to move one child to a different room.  It's not possible to predict how long the alarm will actually go off at night.  Some children only need it to go off for less than a week, but some will have alarms over several weeks time.

 How much parental involvement does it take?
At least one adult must get up when the alarm goes off to make sure the child does what he is supposed to do.  You should not count on your child doing this for herself.  Many children either do not wake up when the alarm goes off (until they are trained by force of habit to do so) or turn off the alarm and go back to sleep.  Even if your child does wake up fully, he may still have difficulty with taking the alarm off, going to the bathroom, and then reattaching it, or she may be unable to change her bed linens.  You should pick a time in your family's life where it will be ok if you miss a little sleep.

The first week or so, you may find it is better to sleep in the room with your child to make sure you learn to hear the alarm and can get to your child quickly.  After the first week, you can try sleeping in your own bed with the doors open or using a baby monitor to magnify the sound of the alarm in your room.

How do you know it isn't going to work?
If no adult is able to get up with the child despite using a loud alarm and a monitor, then this probably won't work.

Otherwise, it's a good idea to give it several months (up to 6) for your child to learn to hear the alarm and respond.  Most children will not have alarms every night for 6 months, so try not to envision the procedure that way! A more accurate way to think of it is this: typically if your child is making progress, having generally fewer and fewer alarms, it may take 6 months to be sure they are completely dry at night.

When should you stop?

A new habit takes at least 4 weeks to form, so you should continue use of the alarm for at least 4 weeks after the last accident, minor or major.  If there is an accident, you should restart your 4 week count.

Are There Dangers to Using Melatonin for Sleep in ADHD?

Melatonin is a hormone produced by the body which tells it, among other things, when it is time to sleep.  Patients with ADHD often have sleep problems and are typically advised to take melatonin, which is currently sold over the counter as a dietary supplement.  Recently the media has featured multiple doctors discouraging the public from using melatonin, citing dangers such as possibly worsening sleep, cardiovascular and reproductive side effects long term.  So, how unsafe is melatonin?

Melatonin has been demonstrated in 4 clinical studies (some small, some not randomized) to help with sleep initiation in people with ADHD.  This isn’t entirely  impressive but when you consider that many people with ADHD also have difficulty with sleep phase regulation (a disorder of circadian rhythm, which is regulated by melatonin) and abnormal melatonin levels, it makes sense.  Melatonin has also been recommended by experts in ADHD for sleep for more than 10 years, which likely reflects some effectiveness, though exactly how much remains to be seen.

There are some known short term risks to taking melatonin.  For example, it’s possible it could cause tumors in a developing fetus (it does in some doses in rats), so pregnant women should avoid it.  It may lower the seizure threshold in epileptics.  It also has some drug interactions and short term side effects, like headaches and nightmares.  For this reason, a doctor should always supervise the use of melatonin and all of your doctors should know you take melatonin before prescribing other medications.

The long term risks to taking melatonin are a lot less well defined.  The main question comes up when you talk about how long melatonin is safe to use, and at what doses.  The reason melatonin is not regulated as a drug is because it can be found in many foods, such as meat, eggs, and nuts.  In other words, in low enough doses, taking it is as safe as eating (barring any harmful additives).  One to 3 mg of melatonin would be found in  approximately 100-300g (3.5 to 10.5 ounces) of tart cherries, which is probably more than most people could eat in a day but not a lot more.  The lowest doses of melatonin currently available are 0.3mg and 0.5mg.

Speaking of additives, not all melatonin is the same.  Since melatonin is regulated as a supplement and not a drug, the FDA does not tightly police how much melatonin is in any give preparation.  In one study from 2017, the amount of melatonin in a pill varied from the labeling by as much as 400% and that more than 70% of pills contained a dose more than 10% different from their label .  It is possible that consumers could get around this by purchasing only “pharmaceutical grade” melatonin verified by the United States Pharmacopeia (USP).  Furthermore, melatonin often comes with other “inactive” ingredients like gluten, artificial coloring, or other supplements like chamomile.  Many supplements marketed for children often contain flavoring and coloring, so checking for these ingredients is important if the patient shows sensitivity to them.

The main theoretical concerns about long term usage are based on the fact that we know melatonin is a hormone and many body processes depend on correct hormonal balances.  In animals, melatonin is involved in regulating reproduction in species that breed seasonally.   In rats, melatonin has been investigated as an anti-breast cancer agent, and it has been suggested that it could function as an anti-estrogenic hormone based on the fact that rats predisposed to cancer that are given melatonin have been observed to live longer and to develop fewer tumors.  Melatonin has also been demonstrated in human breast cell cultures to inhibit the enzyme aromatase, which is necessary for the production of estrogen from testosterone.

In human studies, however, chronic use of melatonin over 1-3 years has not seemed to change the rate children experience puberty.  Available studies are admittedly small, including one of adolescents with sleep phase delay syndrome (not receiving melatonin for ADHD related sleep onset insomnia) and one of children with ADHD.  The results of these studies were also not segregated by sex, which could be important if the issue is sex hormones.

Another concern is that many hormones are regulated by a feedback mechanism which shuts down hormone production if there are high enough levels of the hormone in the bloodstream.  This is certainly the case for many hormones in the body.  However, scientists have known for many years that melatonin is mostly regulated by the amount and time pattern of light reaching the eyes.  It is not at all clear that taking melatonin will cause the pineal gland to malfunction or atrophy, and pineal atrophy due to exogenous melatonin has never been documented in any study of any species. 

In many studies of patients with ADHD who take melatonin, however, the need for melatonin on a chronic basis is high.  In clinical studies usually only about 10% of patients are able to stop using melatonin after using it chronically, and about 70-85% continue to take it daily into long term follow up.    This does not mean that taking melatonin will cause a person to be unable to produce melatonin, however.  It could reflect an underlying deficiency in melatonin to begin with. 

People with ADHD who have sleep onset insomnia have a few alternatives outside of standard behavioral measures.  However, these all have their own side effects.

Clonidine, for example, works as a sedative, but cannot be taken as needed due to the fact that it can cause severe rebound hypertension (high blood pressure) which can (rarely) lead to stroke, heart attack, or kidney damage.  It also can cause hallucinations and nightmares, as well as headaches. 

Standard sleep medications often do not work well in patients with ADHD related insomnia, and almost all of them are potentially addictive and can interfere with sleep architecture during long term use.

The Bottom Line

You should only use melatonin under the supervision of a physician, and for an appropriate reason.   While it is unlikely to cause significant problems with judicious use, the issue of which doses of melatonin are safe to use long term needs more clinical study, especially in children.  Unfortunately, no such study is being done at this time, so it is likely that we will be living with uncertainty on this issue for a long time.  Lower doses are likely to be safer so it’s smart to start with 0.3-0.5 mg and only as needed after behavioral measures have failed.

References:

"MELATONIN: Uses, Side Effects, Interactions and Warnings." WebMD. WebMD, n.d. Web. 24 Apr. 2017.

Technical Resources International, Inc. "NTP Nomination History and Review: Melatonin." 4th ser. 73.31 (n.d.): n. pag. Mar. 1996. Web. 24 Apr. 2017.

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ADHD Symptoms Worsen in the Winter

ADHD can definitely worsen in some patients during the winter months.   You might feel like you are succumbing to old wives tales and folk wisdom when you start to feel that January (or February or December) is getting to you.  However, many clinical studies point to the mental health of people with ADHD being worsened by winter.  Adults with ADHD are known to have a higher prevalence of Seasonal Affective Disorder (or SAD) than the general population (27% vs. 5%).  They also report more ADHD symptoms in the winter.   Although most of the research in this area has focused on adults, we do know that children with ADHD tend to seek fewer prescriptions during the summer and may see the doctor less for ADHD during the summer as well.  While these behaviors may reflect seasonal school attendance, the studies do not rule out other seasonal influences on ADHD.

The main causes for greater winter symptoms in ADHD adults seem to be SAD and delayed circadian phase sleep disorder.  SAD is mainly characterized by depressed mood and irritability, which is usually worse in the winter.  The person might even wake up earlier and be unable to get back to sleep, although some people with SAD sleep too much.   Other symptoms include worsened concentration, carb craving, fatigue, and feeling inappropriately guilty.

The main symptoms of delayed circadian phase sleep disorder are having a hard time waking up in the morning and having a tough time falling asleep at night because you don’t feel sleepy yet.  A person with a delayed circadian phase will usually not get enough sleep if they have to wake up in the morning for a job or school.  They are typical night owls, but as their sleep debt accumulates, they might start to be grouchy and feel down on themselves for being unable to get up in the morning and being late all day. 

In children, seasonal worsening may also have a social component to it.  The winter season typically brings a rise in holiday celebrations with accompanying over-stimulation, dietary disruptions, and schedule changes, as well as midterm examinations which can lead to a perfect storm for children, in addition to issues of SAD and circadian phase disruption.

Treatment for seasonal worsening of ADHD depends on the cause.  People with SAD are known to respond to bright morning light from full spectrum lighting.  Some health insurances will pay for special therapeutic lamps.  Antidepressants also are a possibility.  Circadian phase delay is treated with strict sleep hygiene, bright morning lights and possibly evening melatonin.

References:

Moses, MD Scott. "Delayed Sleep Phase." Family Practice Notebook. Family Practice Notebook, LLC, 05 Feb. 2017. Web. 05 Feb. 2017.

Moses, MD Scott. "Seasonal Depression." Family Practice Notebook. Family Practice Notebook, LLC, 05 Feb. 2017. Web. 05 Feb. 2017

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ADHD-Related Insomnia

Many people who have ADHD have difficulty with sleep, on or off medication.  The problem is, if you can’t sleep, it can make your ADHD symptoms worse.  This article is about basic steps anyone with ADHD can take to address a sleep problem. 

Sleep hygiene

Sleep hygiene sounds terrible, almost like someone is accusing you of not showering enough.  However, it really has nothing to do with that.  You can think of sleep hygiene as healthy sleep habits.  Having ADHD can make it difficult to naturally have sleep habits that are healthy, but they are important to getting a good night’s sleep, so it is worth the extra effort to establish and maintain these habits.

Keep a regular schedule.  Going to sleep and waking up at the same time every day trains your body’s pineal gland (a part of your brain that governs sleep-wake cycles) to make sleep hormones like melatonin at predictable concentrations every day.  It helps to set alarms, but if you find you ignore them, enlist the help of a loved one.

Have a regular bedtime routine.  A consistent ritual before bed will train your brain to be ready for sleep.  For example, a bath, put on pajamas, brush teeth, a short bedtime story and a kiss goodnight would be a simple child’s routine.  With children a regular routine also helps them to know when to expect bedtime, and keeps them from fighting you when the time comes. 

Avoid screens close to bedtime.  The blue light from computers, video games, phones, tablets, and the like can trick the pineal gland into thinking it is day time.  Also, if the activity is engaging enough, you can become hyperfocused and not realize how much you need to go to sleep.

Get plenty of exercise during the day.  Exercise doesn’t have to be boring, either.  If you don’t like to go to the gym, consider martial arts, gardening, hiking, walking a dog, or even shoveling snow for a neighbor.   Exercise in the morning also can help you stay focused during the day.

ADHD Medication Management

If your insomnia started, or clearly worsened within a month of starting or increasing your ADHD medication, you may want to consider the following steps with your doctor:

1)      Move your long acting medication dose to earlier in the day.

2)      If you need more coverage in the evening, consider a booster dose of a short acting medication.  People who struggle with a lot of busy thoughts or need to move during the evening may need their medication to last until after they get to sleep.

3)      Consider adding guanfacine or clonidine at the end of the day.

4)      Consider switching to a nonstimulant.

A Word About Other Sleep Aids

Some research suggests that traditional sleep medicines (like Valium or Unisom) do not work for ADHD related insomnia.  Since many of these medications can have addictive properties, or can result in long term harm to your sleep patterns, it’s best to stay away from them.

Medicines that have been used to help with ADHD related insomnia include guanfacine and clonidine.  Some herbal/natural preparations are also showing promise.  Melatonin has been widely used in ADHD related insomnia for a number of years.  It can be tricky to dose, but is generally thought to be relatively safe in most patients, with a few exceptions.  L-theanine is a product that is generally recognized as safe by the FDA.  It has shown possible effectiveness for mid-night awakenings and restless sleep in patients with ADHD.

Some patients with ADHD may also have a sensory processing issue.   This is especially common with autism spectrum disorder.  However, it can occur with ADHD without ASD.   In these cases, a weighted blanket can sometimes offer needed proprioceptive input.  

Have you already taken all of these steps and you are still having problems?  It is possible that you have a sleep disorder, other than garden variety insomnia.  The next article in this series will examine sleep disorders that commonly occur with ADHD.

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Behavioral treatments for insomnia work for some children with ADHD

In a recent randomized, controlled trial done by researchers in Australia, children with ADHD were treated with behavioral steps to reduce insomnia, or given usual treatment by a pediatrician.  At 3 and 6 months, children in the treatment arm showed fewer symptoms of ADHD, better working memory, behavior and quality of life compared to children in the control arm of the study.  The treatments did not cure the ADHD, but they did reduce the symptoms and impact of ADHD on the child's life.

What kind of treatments were they?  Well, to start with, parents were given information about how sleep works in children and about techniques that help neurotypical children fall asleep easily.  These techniques include:
having a set wake and sleep time
having a soothing bedtime routine (such as snack, brush teeth, pajamas, read a story, go to bed)
keeping the bedroom media free
no caffeine after 3 pm

The families were also given specialized instructions depending on what kind of sleep problem the child had.

Limit setting sleep disorder.  This occurs when the parents are unable to get the child to comply with a set bedtime.  The child may employ stalling techniques, including tantrums, asking questions, saying they have to go to the bathroom, and many other creative alternatives.  Behavioral treatment involves not giving in, and basically ignoring any protests and sending the child gently back to bed.   Also, it is important to note that giving in (for weekends, special events, etc) when still in the learning phase will make things more difficult for everyone.

Delayed sleep phase.    This occurs when a child's biological clock is set for a longer than 24 hour day, so that their body does not produce the hormones needed for sleep until later and later every night.  Behavioral treatment for this disorder includes keeping the child awake until later than they normally would fall asleep at first, to accustom them to falling asleep quickly, while waking them at a set time in the morning, then gradually moving their bedtime earlier.  Delayed sleep phase can also be successfully treated with bright light therapy and melatonin.

Anxiety related sleep disorder.  Children with this problem have trouble sleeping because of excessive worry at bedtime.  Behavioral treatment for this problem involves learning relaxation techniques and visualization (i.e. imagining a relaxing place).

Better sleep helps people with ADHD.  This study shows that sometimes treatments that do not involve medication can be effective in helping improve sleep in individuals with ADHD.  However, some people with ADHD do have other, more serious or more difficult to treat sleep disorders.  If the above steps are not working for your child, it is important to consult with a medical professional to determine if one of these sleep disorders is present.  Some of the disorders are described in my article ADHD and Sleep Disorders.

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L-Theanine for ADHD related insomnia

L-theanine is a compound found in green tea, which has been found to help some patients with ADHD related insomnia with their sleep.  But how good is it, really?  And is it safe?

Effectiveness:  There has really only been one study of patients with ADHD and L-theanine.  In this study, 93 boys with ADHD were given L-theanine or placebo.  Their sleep was then compared using actigraphy (electronic monitors of different physiological functions) and parental reports.  

L-theanine did not affect patient's ability to fall asleep, nor did it increase the amount of time spent in sleep.  However, it did improve the percentage of the night spent in sleep and restless middle of the night behaviors.  It did not improve symptoms of ADHD.

Safety:  

In the above study, there were no severe side effects noted.  One child had to be pulled from the study due to recurrence of tics, but it isn't clear whether the tics were exacerbated by the L-theanine or not.

Although L-theanine has not been extensively studied as a treatment for ADHD, it has been studied for the treatment of other disorders, such as schizophrenia and cancer, so some of its side effects are known and include:

• lower blood pressure
• possible interactions with stimulant medications--may cause the stimulant medication to not work as well in enhancing alertness
• daytime sedation

L-theanine is currently classified by the FDA as GRAS (Generally Recognized as Safe).

Bottom line:

As yet, L-theanine is not definitely helpful with sleep and but probably relatively safe, especially in adults who are taking lower doses of less than 20mg daily on an intermittent basis.  It may be a helpful aid to those who struggle with insomnia and have failed or been unable to tolerate other methods of treatment, such as sleep hygiene, clonidine, and melatonin.    However, patients should be aware that L-theanine is not guaranteed to work, nor guaranteed to be safe--the research is still not very clear on all the risks, especially in children and in those taking L-theanine at higher doses on a daily basis.

References:
Lyon, M. R., M. P. Kapoor, and L. R. Juneja. "The Effects of L-theanine (Suntheanine®) on Objective Sleep Quality in Boys with Attention Deficit Hyperactivity Disorder (ADHD): A Randomized, Double-blind, Placebo-controlled Clinical Trial." Alternative Medicine Revie 16.4 (2011): 348-54. Web.

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Melatonin: How to Use it for ADHD Related Sleep Disorders

Physicians have recommended melatonin for years to help with sleep problems related to ADHD.  However, because melatonin is available over the counter, it isn't always clear how, or when to use melatonin.  A recent article published in the European Journal of Paediatric Neurology  clarifies some of these questions.  Here is a summary.

Is it ok for children to use melatonin for sleep?

Yes.  Although early reports cautioned that melatonin might cause seizures in children with certain medical problems, newer data suggest that melatonin may actually decrease the probability of seizures.  If your child has neurological problems such as autism or seizures, it is a good idea to consult your neurologist before giving melatonin.   

It should be noted that while there have been no reports of significant side effects from melatonin, long term studies have not been done.

Does melatonin work for all sleep disorders related to ADHD?

No.  Melatonin works only for those with difficulty falling asleep--either those who never get to sleep, or those who will only get to sleep much later than they should.  It does not help those who cannot stay asleep.  It works best if given 3 to 5 hours before the time when melatonin is normally released (midnight to 8AM).  That is, the best time to give it is about 7PM-9PM.

Is extended release melatonin better?

So far, research has not shown that extended release melatonin is more helpful.   Extended release melatonin is primarily useful for elderly patients who have melatonin deficiency due to diseases such as diabetes or Alzheimer's disease.  Patients with ADHD generally have a higher level of melatonin than average, so extended release melatonin is not expected to be more helpful.

Will a higher dose of melatonin help a person who cannot sleep on a standard dose of melatonin?

Not always.  Because the body senses melatonin by a change in concentration in the blood, and not by the amount, some people who metabolize melatonin slowly actually need to take LESS melatonin for the body to sense a change and become sleepy.

Does melatonin interact with any other substances or medications?

Some people metabolize melatonin slowly due to medication.  Medications that may have this effect include verapamil (used to control blood pressure and heart rhythm) ciprofloxacin (an antibiotic), and fluvoxamine (used mainly for obsessive compulsive disorder).  Lowering the dose of melatonin can help it retain its effectiveness for sleep.

Reference:

Bruni, O., D. Alonso-Alconada, F. Besag, V. Biran, W. Braam, S. Cortese, R. Moavero, P. Parisi, M. Smits, K. Van Der Heijden, and P. Curatolo. "Current Role of Melatonin in Pediatric Neurology: Clinical Recommendations." European Journal of Paediatric Neurology (2014): n. pag. Web. 9 Jan. 2015.

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Usual Sleep Medications May Not Work for ADHD Related Insomnia

In an article recently published in Pediatrics, researchers studied the effect of  eszopliclone(Lunesta) on ADHD related insomnia and found it to be ineffective in helping children ages 6-12 get to sleep any faster than placebo.

Eszoplicone (Lunesta) is one of the most widely prescribed agents for insomnia.  However, like many of these agents, it has several drawbacks including next day impairment (think driving accidents) and potential for addiction.  Now, this research suggests that typical sleep medications may not help patients with ADHD.

What can a person with ADHD and insomnia do?
1)  Keep a regular schedule.
2)  Avoid being overstimulated at bedtime.  This includes bright screens, intense exercise, and being overfed.
3)  Take your stimulant earlier in the day, if possible.  This includes caffeine.
4)  Learn specific relaxation techniques to promote sleepiness.

For details, see my article on ADHD and Insomnia.

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ADHD and Sleep Disorders

Adults and children with ADHD often have trouble sleeping.  The connection between ADHD and sleeping is complex.  Researchers believe that sleep difficulties can worsen ADHD symptoms, but also that ADHD makes sleep more difficult.  People with sleep problems and ADHD often are told to try medication modifications, sleep hygiene methods (such as a strict sleep schedule) and melatonin, but sometimes these strategies don't work.  What can be done then? 

The first step is to get a better idea of what could be happening, so that you can better know what symptoms to look for.  This is a summary of some very common sleep disorders that are often found in people with ADHD, and what types of treatment to expect.

Primary ADHD sleep disorder

Symptoms:   This isn't an official diagnosis, but this is how the core symptoms of ADHD look when a person is trying to fall asleep.  They may have difficulty settling, racing thoughts (but not related to worries or fears), and physical restlessness not related to discomfort.  Some people have difficulty putting down that "one last thing" for fear they'll forget it in the morning.

Treatment:  To slow down brain activity prior to sleep try relaxation techniques such as mindfulness techniques, imagery (helpful audios can be found at Excel at Life) , and avoiding stimulating activities (like TV, video games, sports, work) for 1-2 hours before bedtime.  Strict sleep hygiene (regular schedule even on weekends, set an alarm if necessary) will help your body secrete hormones related to sleep at the same time every night.  If all of this fails, nonstimulant medication can be helpful.  Often doctors will recommend something like clonidine or guanfacine, both of which can be sedating.  Melatonin has also been shown to be helpful with primary ADHD sleep disorder.

Sleep apnea

Symptoms:  This disorder is characterized by loud snoring and breath holding.  It may be caused by enlarged tonsils, overweight, or strange neck positions while sleeping.  Patients are often sleepy during the day, although children may have the opposite reaction in an attempt to stay awake.

Treatment:  In children, the main treatment is surgery to remove the tonsils, which often is curative.  In adults, weight loss and/or a type of breathing machine worn over the nose (CPAP) usually helps with daytime sleepiness.

Periodic leg movement disorder/restless legs

Symptoms:  It is said that up to 40% of patients with ADHD also have restless legs, a disorder characterized by an uncomfortable sensation in lower extremities, temporarily relieved with movement, worse at rest, and worse at night.  Usually the person just cannot stay still while trying to fall asleep.  In children it is often heriditary.   Children often cannot describe symptoms and may resist bedtime or have difficulty falling asleep.

Treatment:  This disorder can be easily treated in some people because the condition can be much worse if the person is deficient in iron.   Taking an iron supplement may be all that is needed to find relief.  However, excessive iron can cause stomach problems or diabetes in the long term, so its important to get regular blood tests to know when to start and stop taking the supplement.  There are many other treatments for restless legs (none FDA approved in children), but so far, its not certain that treating with anything other than iron helps symptoms of ADHD.

Delayed sleep onset latency

Symptoms:  This is a fancy way of saying that a person's biological clock has a longer than 24 hour day.  The patient is not sleepy at bedtime and wakes up late (if allowed), with a normal or increased sleep duration.

Treatment:   To train the patient's biological clock back to normal, a strict schedule is necessary.  Aids to the process include melatonin at bedtime, bright light in the morning,  and avoidance of night time bright lights or screen time (including smart phones).

There are many other disorders that disrupt sleep, such as sleepwalking and seizures.   If you suspect these problems, you should discuss them with your physician.

References:

Carter, Kevin A., Nathanael E. Hathaway, and Catherine F. Lettieri. "Common Sleep Disorders in Children." American Family Physician 89.5 (2014): 368-77.

Miano, S., R. Donfrancesco, P. Parisi, J. Rabasco, A. R. Mazzotta, A. Tabarrini, O. Vitelli, and M. P. Villa. "Case Reports of Sleep Phenotypes of ADHD: From Hypothesis to Clinical Practice." Journal of Attention Disorders 17.7 (2013): 565-73. Web.

Summer Sleep Tips for ADHD

People with ADHD often complain of insomnia.  There are a number of sleep disorders that can make it difficult for people with ADHD to get to sleep, including restless legs.  However, even if there is no sleep disorder in the mix, folks with ADHD often complain of difficulty settling down and calming their minds so they can drift off.

Summer time can be especially difficult.  Being overheated can contribute, as can the extra daylight.  Some children get overexcited from being outside later at night, or can fall victim to summer couch potato-itis.  If you or your child have difficulty sleeping these days, try these tips.

1)  Make sure your child gets plenty of exercise during the day.  At least an hour of physical activity is needed by most children for optimum health benefits.
2)  Cool things down.  Splurge on a little extra air conditioning, if possible.
3)  Darken the bedroom.  Shades work the best, but black out curtains are also very effective.  If neither are an option, try hanging a blanket or towel over the window.
4)  Avoid excitement after dinner, if possible.
5)  Try listening to a relaxation CD.  If that does not help, try an audio like these from Excel at Life.  Go to the menu and look under "PsychAudios".  They have Relaxation Audios for adults and children.  While these were designed to help people with depression to relax, they work well for anyone to calm their mind.    The audios are also available on Excel at Life's Android App, available on Google Play.
6)  Practice good sleep hygiene--follow a strict sleep schedule to train your body to release sleeping hormones at bedtime.


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