Sleep and ADHD. Outline of talk 9/13/2018

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ADHD and Executive Function Canonsburg, PA

1 Sleep and ADHD Brant P. Hasler, PhD, CBSM University of Pittsburgh School of Medicine Center for Sleep and Circadian Science 7th Annual Conference on ADHD and Executive Function Canonsburg, PA September 14, 2018 Outline of talk Intro to sleep and circadian rhythms ADHD-like consequences of sleep/circadian disturbance Sleep/circadian differences in ADHD 1

Sleep is critical for health and well-being Learning and memory

Cardiovascular disease Obesity and diabetes Accidents Etc, etc, etc.

optimal health Sleeping >9 hours per night may be appropriate for

2 Sleep is critical for health and well-being Learning and memory Interpersonal relationships Immune function Depression Cardiovascular disease Obesity and diabetes Accidents Etc, etc, etc. Adults should sleep 7+ hours per night on a regular basis to promote optimal health Sleeping >9 hours per night may be appropriate for young adults, individuals recovering from sleep debt, and individuals with illnesses 2

Questionnaires Measuring sleep Diaries/Logs Actigraphy Polysomnography http://www.howsleepworks.com/types_cycles.

Sleep-related movement disorders Description Difficulty with falling or staying asleep Sleep apnea Conditions that cause severe

g., sleep terrors, sleepwalking, nightmares) Restless Leg Syndrome, Periodic leg movements, body rocking Childhood insomnia

sleep after awakening. Limit-Setting Type Children refuse or stall bedtime.

3 Questionnaires Measuring sleep Diaries/Logs Actigraphy Polysomnography Sleep disorders Insomnia Category Sleep-related breathing disorders Hypersomnias Circadian rhythm sleep disorders Parasomnias Sleep-related movement disorders Description Difficulty with falling or staying asleep Sleep apnea Conditions that cause severe daytime sleepiness (e.g., narcolepsy) Sleep disturbances resulting from problems with the biological clock (e.g., shift work problems) Unusual behaviors or experiences during sleep (e.g., sleep terrors, sleepwalking, nightmares) Restless Leg Syndrome, Periodic leg movements, body rocking Childhood insomnia Sleep-Onset Association Type Children won t sleep because they need to be with a specific item or person to fall asleep or get back to sleep after awakening. Limit-Setting Type Children refuse or stall bedtime. They may scream and cry or ask for hugs kisses or even drinks of water to avoid sleeping. Parents who struggle enforcing limits such as a scheduled bedtime may encourage this behavior. 3

behavioral processes for optimal interaction with the environment Temporal order is essential for

4 Insomnia vs Sleep Deprivation Insomnia Sleep Deprivation Sleep Opportunity Adequate Reduced Sleep Ability Reduced Adequate Circadian rhythms, broadly 24-hour rhythms that organize physiological and behavioral processes for optimal interaction with the environment Temporal order is essential for health - Anna Wirz-Justice (2003) An orchestra of clocks Light is the most important cue for our clocks 4

5 Chronotype: from larks to owls Two-process model of sleep regulation Two-process model of sleep regulation 5

6 Two-process model of sleep regulation Outline of talk Intro to sleep and circadian rhythms ADHD-like consequences of sleep/circadian disturbance Sleep/circadian differences in ADHD Does sleep disturbance and/or sleep loss lead to ADHD-like symptoms? Sleep disturbance and/or loss Inattentiveness, distractibility, and executive dysfunction Mood disturbance Substance abuse Other behavioral problems 6

Neurobehavioral consequences of insomnia Cognitive complaints are typical (poor concentration, memory, not sharp ), but mixed evidence of demonstrable effects 2012 Meta-analysis: Small-to-moderate

function (Fortier-Brochu et al, 2012 SMR) Worse performance only in insomniacs with short sleep?

7 Neurobehavioral consequences of insomnia Cognitive complaints are typical (poor concentration, memory, not sharp ), but mixed evidence of demonstrable effects 2012 Meta-analysis: Small-to-moderate impairment in episodic memory, problem solving, and aspects of working memory, but no differences in general cognitive function, various dimensions of attention, and other aspects of executive function (Fortier-Brochu et al, 2012 SMR) Worse performance only in insomniacs with short sleep? (Fernandez- Mendoza et al, 2010) Risk factor for development of anxiety, depression, and alcohol and substance use disorders Early sleep disturbance predicts attentional and behavioral problems later in childhood and adolescence Childhood sleep problems predict adolescent neurobehavioral problems Anxiety/Depression Attention problems Aggression Gregory and O Connor, 2002 Neurobehavioral consequences of sleep loss Disrupts executive function Particularly tasks dependent on sustained attention and intact working memory Learning and memory decrements Specific to prefrontal cortex (PFC)? Mixed evidence of effects on hyperactivity (e.g., Fallone et al, 2001 Percep and Motor Skills) Increases in impulsivity (some mixed evidence) Also mood and motivational disturbance Decreased positive mood; increased anxiety, irritability Mood instability/reactivity More sensitive to rewards; less sensitive to losses? 7

Attention deficits due to sleep loss Sleep loss in children Behavorial manifestations range those that are classically sleepy, such as yawning, rubbing eyes, and/or

-Owens, 2005, citing Fallone, Owens, and Deane 2002 Sleep Med Rev Sleep effects on neurobehavioral function in children Sleep extension vs restriction 73 4 th and 6

8 Attention deficits due to sleep loss Sleep loss in children Behavorial manifestations range those that are classically sleepy, such as yawning, rubbing eyes, and/or resting the head on a desk, to externalizing behaviors, such as increased impulsivity, hyperactivity, and aggressiveness, to mood lability and inattentiveness. -Owens, 2005, citing Fallone, Owens, and Deane 2002 Sleep Med Rev Sleep effects on neurobehavioral function in children Sleep extension vs restriction 73 4 th and 6 th graders Three groups (post-hoc) SRG = restricted 30+ min NCG = failed to restrict/extend SEG = extended 30+ min Continuous Performance Task Sadeh etal 2003 Child Development 8

9 Neurobehavioral consequences of sleep-disordered breathing Overall, SDB linked to executive function deficits in children and adults Up to 95% of OSA pts have attentional deficits (Youssef et al, 2011) Sleep disruption and/or oxygen desaturation Snoring and other SDB symptoms associated with inattention and hyperactivity in children (Chervin 2002 Pediatrics) Childhood snoring and overall SDB score predicted increased hyperactivity symptoms 4 years later (Chervin 2007 Sleep) Outline of talk Intro to sleep and circadian rhythms ADHD-like consequences of sleep/circadian disturbance Sleep/circadian differences in ADHD Does ADHD lead to sleep problems? ADHD meds Sleep disturbance and/or loss Inattentiveness, distractibility, and executive dysfunction ADHD Mood disturbance Substance abuse Other behavioral problems 9

10 Sleep problems in ADHD Children with ADHD have difficulties falling asleep, night awakenings, and restless sleep ~2-3X that of children in control groups, based on parental report Sleep-association and limit-setting disorders (Sung et al, 2008) Fewer self-report studies in adolescents and adults Objective (actigraphy and PSG) evidence mixed Longer sleep onset latency, lower sleep efficiency (Cortese et al, 2009) Increased daytime sleepiness (Cortese et al, 2006, SLEEP) Greater instability (night-to-night variability) Actigraphy-based sleep and ADHD (24 studies of 2179 children) Longer Sleep Latency No difference in Sleep Duration Lower Sleep Efficiency 0.51 [0.10, 0.92] 0.10 [-0.26, 0.06] 0.69 [1.32, 0.05] De Crescenzo et al 2015 Adolescent sleep and ADHD Sleep duration Sleep deficiency Time to fall asleep % with diagnosis Insomnia No ADHD ADHD Delayed Sleep Phase Disorder Hysing et al

Adult sleep duration and ADHD Bogdan & Reeves 2016 Medication effects/confounds Sleep problems a side effect of psychostimulants, not ADHD per se? (e.g., Barkley et al, 1990) Late-day dose of psychostimulants to prevent rebound arousal and hyperactivity?

11 Adult sleep duration and ADHD Bogdan & Reeves 2016 Medication effects/confounds Sleep problems a side effect of psychostimulants, not ADHD per se? (e.g., Barkley et al, 1990) Late-day dose of psychostimulants to prevent rebound arousal and hyperactivity? Longer sleep latency in at least 2 studies (Konofal etal, 2010) Other studies suggest that stimulants can improve sleep in some individuals with ADHD (e.g., Kim et al,2010; Surman and Roth, 2011) Youth more sensitive to sleep-disturbance effects? (Santisteban et al, 2014) Other sleep disorders and and ADHD Sleep-Disordered Breathing Apnea-hypopnea index (AHI) higher in ADHD children (Cortese et al, 2009) 50% of ADHD children with SDB symptoms vs 20% of control group (Golan et al, 2004) 20 to 30% incidence of OSA in ADHD (Youssef et al, 2011) Restless Leg Syndrome/Periodic Limb Movement Disorder Up to 44% with ADHD have RLS symptoms; up to 26% with RLS have ADHD symptoms (Cortese et al 2005) ADHD symptoms more severe in children with both ADHD and RLS or PLMD than ADHD alone (Konofal et al, 2007 ; Frye et al, 2018) Also rhythmic movement disorders (e.g., body rocking and head banging), parasomnias (e.g., sleepwalking, sleep terrors), narcolepsy, and circadian rhythm disorders (Walters et al, 2008 JCSM) 11

Circadian rhythms and ADHD (the problem with being a night owl) Greater eveningness associated with ADHD symptoms and neuropsychological deficits (Caci, 2009; Rybak et al, 2007; Voinescu et al 2012)

delayed melatonin and cortisol rhythms (Baird et al, 2012; Van der Heijden, 2005; Van Veen, 2010) Disrupted molecular clock (e.g.

Fargason et al 2017) Melatonin advanced rhythms and improved sleep, but did not alter problem behavior, cognitive performance, or QOL (Van der Heijden et al, 2007) Adolescents and social jet lag

12 Circadian rhythms and ADHD (the problem with being a night owl) Greater eveningness associated with ADHD symptoms and neuropsychological deficits (Caci, 2009; Rybak et al, 2007; Voinescu et al 2012) Delayed sleep timing; delayed melatonin and cortisol rhythms (Baird et al, 2012; Van der Heijden, 2005; Van Veen, 2010) Disrupted molecular clock (e.g., Baird et al, 2012) In two trials of adults with ADHD, light therapy reduced subjective and objective ADHD symptoms, which correlated in turn with shifts in circadian timing (Rybak et al, 2006; Fargason et al 2017) Melatonin advanced rhythms and improved sleep, but did not alter problem behavior, cognitive performance, or QOL (Van der Heijden et al, 2007) Adolescents and social jet lag Circadian and preferred sleep timing shift later (delay) during adolescence Mismatch with early school start times Preferred s/w timing Monday Tuesday Wednesday Thursday Friday Saturday Sunday Circadian misalignment; insomnia; sleep loss Better alignment; make up sleep Clock Time Sunday Social jet lag Monday Like traveling from SF to NYC every week Social jet lag associated with more ADHD symptoms and impulsivity (McGowan et al 2016) 12

13 A sleep and ADHD vicious cycle? ADHD meds Sleep disturbance and/or loss Inattentiveness, distractibility, and executive dysfunction ADHD Mood disturbance Substance abuse Other behavioral problems Treating sleep can improve ADHD symptoms Behavioral sleep treatment in children with ADHD improved ADHD symptoms at 3- and 6- months (Hiscock et al 15) In children with comorbid obstructive sleep apnea and ADHD, several studies have shown that adenotonsillectomy surgery results in significant improvements in attention and reduced hyperactivity. Whether sleep problems mimicking ADHD, or sleep problems comorbid with bonafide ADHD, treatment of sleep problems is indicated! Recommendations Sleep should be assessed in all children and adults with ADHD or ADHD-like symptoms Sleep questionnaires and diaries Polysomnography if sleep-disordered breathing, etc is suspected Sleep onset problems can indicate circadian rhythm disorder Prioritize sufficient sleep opportunity Treat sleep disorders Appropriately time ADHD medications (see Konofal et al, 2010 Sleep Med) 13

impacting you Practices that help sleep Exercise Daily routines Treating medical problems Comfortable sleep environment Keeping your bed

14 Keep sleep debt down Every night that you get too little sleep contributes to a sleep debt Your sleep debt keeps growing until you pay it off, which typically requires more than one good night s sleep As your sleep debt grows, your brain loses the ability to notice how it s impacting you Practices that help sleep Exercise Daily routines Treating medical problems Comfortable sleep environment Keeping your bed for sleep (& sex) Practices that hurt sleep Alcohol Caffeine Worries Poor sleep environment Using your bed for things other than sleep (& sex) 14

15 Treatments for insomnia Behavioral approaches e.g., CBT-I, BBTI Work relatively quickly, benefits persist in the long-term Few adverse effects Medications Benzodiazepines, Non-BZ like zolpidem (Ambien), sedating antidepressants, clonidine, melatonin, etc. Work quickly, but benefits only persist while on the medication Some adverse side effects, some risk of dependence Melatonin may be safe and effective in kids (Bendz & Scates, 2014) Different strokes for different folks Behavioral strategies based on two-process model 4 Steps to Sleeping Better (adapted from BBTI) 1) Reduce your time in bed if awake > 30 min. 2) Get up at the same time every day of the week, no matter how much you ve slept before 3) Don t go to bed unless you re sleepy, thus teaching your brain that bed = sleep 4) Don t stay in bed unless you re asleep, and pursue distracting, relaxing activities in low light if you do get up in the night Troxel, Germain, & Buysse (2012) Behavioral Sleep Medicine 15

Intro to Circadian Rhythm Treatments Goal to shift internal timing (usually earlier) Bright light ~30 minutes 2500-10000 lux Spontaneous awakening in morning Melatonin Dark signal ~0.

16 Intro to Circadian Rhythm Treatments Goal to shift internal timing (usually earlier) Bright light ~30 minutes lux Spontaneous awakening in morning Melatonin Dark signal ~0.5 ~6 hours before bedtime Advance by ~1 hr/week until reach desired schedule What about school start times? Organizations that recommend starting middle/high school at 8:30am or later: American Academy of Pediatrics (AAP) American Medical Association (AMA) Centers for Disease Control (CDC) The Sleep Research Society (SRS) The National Association of School Nurses 2017: Society for Behavioral Sleep Medicine (SBSM) The National Education Association (NEA) National Parent Teacher Association (PTS) And others. Summary Sleep is vitally important for everyone Sleep problems can cause neurobehavioral problems akin to ADHD Sleep problems tend to co-occur with ADHD Preventing and/or treating sleep problems can resolve ADHD-type and other symptoms 16

17 Some recommended readings/resources Owens, J. A. (2005). The ADHD and sleep conundrum: a review. Journal of Developmental & Behavioral Pediatrics, 26(4), Imeraj, L., Sonuga-Barke, E., Antrop, I., Roeyers, H., Wiersema, R., Bal, S., & Deboutte, D. (2012). Altered circadian profiles in attention-deficit/hyperactivity disorder: an integrative review and theoretical framework for future studies. Neuroscience & Biobehavioral Reviews, 36(8), Konofal, E., Lecendreux, M., & Cortese, S. (2010). Sleep and ADHD. Sleep Medicine, 11(7), Mindell, J. A. (2010). Sleeping Through the Night: How Infants, Toddlers, and Parents Can Get a Good Night's Sleep. Zondervan. Troxel, W. M., Germain, A., & Buysse, D. J. (2012). Clinical management of insomnia with brief behavioral treatment (BBTI). Behavioral sleep medicine,10(4), And, finally, feel free to contact me at: haslerbp@upmc.edu 17

ADHD and Sleep. Dr. Jessica Agnew-Blais MRC Postdoctoral Fellow SDGP Centre Institute of Psychiatry, Psychology & Neuroscience

ADHD and Sleep. Dr. Jessica Agnew-Blais MRC Postdoctoral Fellow SDGP Centre Institute of Psychiatry, Psychology & Neuroscience ADHD and Sleep Dr. Jessica Agnew-Blais MRC Postdoctoral Fellow SDGP Centre Institute of Psychiatry, Psychology & Neuroscience Who am I? Who I am: ADHD researcher Parent Who I am not: Clinician Sleep expert