Elsevier

Sleep Medicine Reviews

Volume 10, Issue 6, December 2006, Pages 399-405
Sleep Medicine Reviews

CLINICAL REVIEW
Sleep and sleep disorders in adults with attention deficit/hyperactivity disorder

https://doi.org/10.1016/j.smrv.2006.05.002Get rights and content

Summary

Attention deficit/hyperactivity disorder (ADHD) is a frequent disorder that often persists in adulthood. Persistent ADHD is known to be a serious risk factor for other disorders in adulthood, and adults with ADHD often report on sleep disorders. Despite this, only few studies have investigated the subjective and objective quality of sleep in adults suffering from ADHD. Previous studies have revealed seriously impaired subjective sleep quality and increased nocturnal motor activity in spite of essentially normal standard polysomnographic parameters in this patient group. However, primary sleep disorders such as sleep apnea syndrome or restless legs syndrome (RLS) may be misdiagnosed as ADHD. Moreover, ADHD and primary sleep disorders may occur as comorbidities. In particular, RLS was suggested to be highly associated with ADHD, indicating a probable common central nervous dopaminergic dysfunction. To date, larger studies with adequate sample sizes that compare sleep in adult patients with ADHD, healthy control groups and patients with other primary sleep disorders are still lacking.

Introduction

In childhood and adolescence, attention deficit/hyperactivity disorder (ADHD) is a common psychiatric disorder characterized by a persistent pattern of impaired attention, impulsive behavior, and hyperactivity. The prevalence rate of ADHD in children ranges from 3–12%, depending on sample selection and diagnostic criteria utilized.1, 2, 3, 4 In 40–60% of the afflicted children, ADHD symptoms persist in adulthood. This includes cases with partial remission.5 The prevalence rate of adults that meet full criteria for ADHD (DSM-IV) is estimated to range from 1% to 2%.5 Formerly, sleep disturbances were included in the ADHD diagnostic criteria for children. However, due to lacking empirical evidence, sleep disturbances were removed from the Third Revised Edition of the Diagnostic and Statistical Manual of Mental Disorders.6 In college students, on the other hand, subjective sleep disorders were found to be predictive for inattention and hyperactivity.7

In clinical practice, adults with ADHD often complain about their sleep disorders. On the other hand, primary sleep disorders can mimic some symptoms of ADHD (attention deficits, concentration problems) and may sometimes be misdiagnosed as ADHD in adults. However, only few studies have investigated sleep quality and sleep disturbances in adults with ADHD. The aim of this review is (1) to summarize the evidence with respect to sleep (assessed either by questionnaires, actigraphy or polysomnography) in adult ADHD, (2) to examine the prevalence of other sleep disorders in adult ADHD and (3) to discuss relevant differential diagnoses that primarily affect the quality of sleep.

We performed a PubMed search for articles published between 1990 and February 2006, limited to adults, using the following key words: attention deficit disorder, attention deficit hyperactivity disorder, inattention, sleep, sleep disorder, and polysomnography.

Section snippets

Prevalence of sleep complaints and sleep EEG changes in adult ADHD

To date, there are no primary epidemiological studies that investigate subjective sleep complaints or large-scale polysomnographic investigations that focus on sleep changes in adult ADHD.

An open-label case-control study was performed by Kooij and coauthors in 2001.8 Her group investigated objective and subjective sleep parameters in eight adult patients with ADHD before and two weeks after pharmacological treatment with either methylphenidate or dextroamphetamine. None of the objective sleep

Spectral power analyses of the sleep EEG in adult ADHD

Lindberg et al. reported increased stage 4 sleep as well as increased delta and theta power from a spectral analysis of the sleep EEG in fourteen homicidal men with antisocial personality disorders and Cloninger type II alcoholism who had suffered from childhood ADHD.15 Interestingly, the absolute and relative amount of stage 4 sleep as well as delta and theta power in this stage were positively correlated with the severity of childhood ADHD, which was retrospectively measured with the Wender

Sleep apnea syndrome

Not only is ADHD a frequent disorder, but so is Obstructive Sleep Apnea Syndrome (OSA). It affects up to 3% of the population17 and is characterized by snoring, frequent nocturnal breathing pauses, curtailed sleep, excessive daytime sleepiness and cognitive deficits.18 Thus, some of the ADHD symptoms, particularly short attention span, may be mimicked by OSA.

To date, three studies have been published investigating the prevalence of OSA in adult ADHD patients.19, 20, 21

In 1998, Scammell et al.19

Discussion

To date, with regard to sleep, the most consistent finding in adult ADHD without sleep disordered breathing is a discrepancy between subjective and objective sleep measurements with essentially normal standard polysomnographic parameters (e.g., sleep latency, wake time, REM and non-REM sleep parameters8, 10). Interestingly, sleep studies in adults with ADHD documented a significantly increased nocturnal motor activity8 and an enhanced frequency of arousals associated with periodic leg movements,

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