Therapeutic management and options to address comorbid sleep disorders in ADHD

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The effect of immediate (IR) or extended (ER) release stimulants in ADHD is well known and beyond the purpose of this review.

Stimulants still represent the first line of treatment of ADHD in pediatric populations across the world.

The majority of subjective report studies indicate increased parental complaints of sleep disturbance in medicated versus unmedicated ADHD children, irrespective of stimulant type or regimen (Cohen-Zion & Ancoli-Israel, 2004). However, objective studies, whether actigraphic or PSG, show overall conflicting results as far as sleep measures, continuity and architecture, major differences going in opposite directions with regard, in particular, to REM sleep (Chatoor et al., 1983; Greenhill et al., 1983); no influence, though, on specific sleep disorders such as SDB or PLMD.

A consistent co-morbidity with depression in many ADHD children could account for increased subjective and actigraphically confirmed sleep fragmentation in the most severe cases.

Besides stimulants (Smoot et al., 2007), nonstimulant drugs have been successfully employed for the treatment of ADHD including atomoxetine (Kemner et al., 2005), bupropion and now less commonly used, tri-cyclic antidepressants. Clonidine, Guanfacine and other adrenergic a-1 agonists along with modafinil might help IADHD children with the hypoarousal phenotype, whereas SSRIs and venlafaxine could be used to fight depression/ anxiety-related sleep symptoms. Also, atypical anti-psychotic drugs such as risperidone (Reyes et al., 2006) might be employed to counteract conduct/behavior disorders as aforementioned several melatonin trials have addressed rhythmicity disorders and SOI, whereas levetiracetam, an anti-epileptic drug with antimyoclonic properties has been employed eihter in ADHD-RLS+ children or to treat DOA, seizures and related IEDs in ADHD children.

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