SLEEP PROBLEMS: OVERVIEW

SLEEP DISORDERS - OVERVIEW

Sleep dysfunction has been linked to both academic and social/behavioral problems. Since many adolescents don't get enough sleep because high schools start too early for an adolescent's sleep and melatonin cycles, we shouldn't be surprised that some students' functioning seems significantly impaired compared to their potential. Teenagers who don't get enough sleep are at risk for more car crashes, poorer performance in school, poorer performance in sports, and poorer performance at work. Students with the kinds of neurobehavioral disorders described on this web site are likely to have additional sleep-related problems as well, as many of these disorders are associated with significant sleep disorders.

Sleep disorders are also fairly common in children. One study found that 37% of school children they tested (from grades K - 4) suffered from at least one sleep-related problem.  

Restless Legs Syndrome, Periodic Limb Movements of Sleep, narcolepsy, insomnia, and sleep apnea are different types of sleep disorders that may all contribute to a poorer night's sleep, but they do not all have the same effect on daytime functioning, and not all neurobehavioral conditions have the same types of sleep problems associated with them.

Restless legs syndrome (RLS) is a neurological disorder characterized by sensations of discomfort in the legs during periods of inactivity. People with RLS report sensations of crawling, creeping, and/or pulling or tingling. The sensation causes an irresistible urge to move the legs, and the discomfort is generally relieved by moving or stimulating the legs. RLS symptoms usually occur before sleep onset and make it difficult for the individual to fall asleep.

Periodic limb movements of sleep (PLMS) involves episodes of repetitive, stereotyped limb movements during sleep; these movements are usually leg movements and associated with increased awakenings during the night. The individual may not be aware of these movements and/or of the awakenings.

In addition to sleep problems associated with the disorders, some children and adolescents also suffer from sleep-related side effects of medications that are used to treat the disorders. Stimulant medications used to treat Attention Deficit Hyperactivity Disorder, medications used to treat mood disorders, and some of the medications used to treat tics can all produce sleep problems that can affect the child in the classroom. Some medications do not affect sleep per se but may make the student very drowsy or sleepy shortly after they take their medication (e.g., Catapres that is used to treat ADHD and tics).

ATTENTION DEFICIT HYPERACTIVITY DISORDER AND SLEEP IMPAIRMENT

In 1999, Picchietti et al. reported that unmedicated children who were newly diagnosed with ADHD had significantly more periodic limb movements in sleep (PLMS), and that they had significantly more arousals (awakenings) and overall less sleep than their non-ADHD peers. Similarly, Owens et al. reported that children with ADHD had more difficulty falling asleep and staying asleep than their non-ADHD peers, and recommended that all children with ADHD be screened for sleep disturbances, particularly sleep-disordered breathing.

Could treating the PLMS impact the symptoms of ADHD or school functioning? In an intriguing pilot study, 7 children with ADHD and PLMS or ADHD and Restless Leg Syndrome (RLS) were given monotherapy with either levadopa or pergolide (both medications affect dopamine levels in the brain). The investigators reported that after treatment, three children no longer met the criteria for ADHD and three reverted to normal on the Test of Variable Attention. ADHD symptoms improved in all seven children (as measured by both the Connors and the Child Behavior Checklist). A significant improvement also occurred in the visual, but not verbal, memory scores on the Wide Range Assessment of Memory and Learning. Five of the seven children continued on dopaminergic therapy for at least 3 years after treatment initiation with good response. We do not know, at this time, what effect the stimulant medications usually used to treat children with ADHD might have on their sleep patterns.

MOOD DISORDERS AND SLEEP IMPAIRMENT

Depressed patients commonly complain of difficulties initiating sleep, maintaining sleep, and awakening early in the morning, and as any parent of a child or teenager with depression will tell you, getting depressed children up for school in the morning is a herculean task.

Hypomania and mania are features of Bipolar Disorder, and are also associated with sleep disturbance. Sometimes the first warning sign that a child or adolescent is going into a hypomanic or manic phase is that they go without sleep for one or two nights, but do not report feeling tired.

The treatment of unipolar or bipolar depression is complex, and if establishing good sleep hygiene via habits and lifestyle changes isn't sufficient, a referral to a sleep specialist may be indicated.

TOURETTE'S SYNDROME

Children and adolescents with Tourette's Syndrome (TS) report significantly more sleep problems than their non-TS peers. In boys with TS, sleep problems occur even more often when there is also comorbid Attention Deficit Hyperactivity Disorder. Children with TS are more likely to have disturbed sleep quality and efficiency. For children or teenagers with Tourette's, sleep onset may be delayed because they first have to "get their tics out."  They lie down to go to bed and may tic explosively or vigorously for an hour or more.

OBSESSIVE-COMPULSIVE DISORDER

Students with Obsessive-Compulsive Disorder also experience sleep problems, but of a different kind. Students with OCD may stay up late into the night working to get a paper "perfect," or may be so anxious about a school assignment that they can't get a good night's sleep. Other children and adolescents with OCD may have time-consuming rituals that they must engage in at night that prevent them from getting to sleep at a reasonable hour: toys must be lined up "just so," or the bedding must be in a particular way, or they may have extensive "good night" rituals involving a parent. Some children and teenagers with OCD may have time-consuming hygiene rituals and land up in the shower for hours instead of being able to take a quick shower and get ready for bed. These are just some examples -- the parents of the student can let you know the extent of the problem their child is experiencing.

AUTISM/ASPERGER'S

Sleep problems have long been noted in autistic children, but the impression of the extent and nature of difficulties depends, in part, on what methodology the investigators use to study the problem. Of particular note for educators is a study by Elia et al. (2000), who found that some of the sleep measures were significantly correlated with the child's functioning. Nonverbal communication showed significant correlation with sleep period time, wakefulness after sleep onset, and total sleep time. Relating to people and activity level items were found to be significantly correlated with rapid eye movement density.

WHAT TO DO

If the student or parents report sleep problems to you, scheduling a meeting with the student and parents to discuss what might be helpful is in order. But do not count on the parents remembering to mention sleep problems to you. They are often aware of them, but are so busy dealing with the symptoms of the primary diagnosis (or diagnoses) that they may neglect to tell you that the child is not sleeping well, is up all or night, or can't wake up in the morning. Because so many students do have sleep problems, I  recommend sending home the sleep survey during the second month of school as it may flag potential problems that need to be addressed. If students do need accommodations, use the Sleep Accommodation Tips file on this site to give you some ideas.