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Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-20 17-313583 on 5 June 2019. Downloaded from Best practice Fifteen-minute consultation: Managing sleep problems in children and young people with ADHD sally Hobson, Max Davie, Michael Farquhar 2 1 Community Paediatrics, MarAbstrAct Sleep disruption is common in the Sheridan Centre, Evelina LoSleep difficulties are common in children and paediatric population 2 3 and can lead Children’s Hospital, London, UK 2Children’s Sleep Medicine,young people presenting with features of to difficulties with learning, behaviour, Evelina London Children’s attention-deficit/hyperactivity disorder (ADHD). family functioning and parental mental Hospital, London, UK Sleep problems may be both an effect of and a health.2–5 Developmental consequences contributor to ADHD symptomatology, as well of disrupted sleep in early childhood may Correspondence to as having a significant impact on both individualpersist even after sleep has improved. 2 Dr Sally Hobson, Community Paediatrics, Mary Sheridan and family functioning and well-being. There Centre, Evelina London are often complex interacting contributing Why is An unDerstAnDing of Children’s Hospital, Londonfactors. Assessment of children presenting with sleep importAnt for cliniciAns Sally.bson@gstt.nhs.uk symptoms suggestive of possible ADHD should Working With chilDren With Received 8 November 2018 include routine enquiry about sleep. Ongoing ADhD? Revised 5 February 2019 management of children with diagnosed ADHD ► Sleep deprivation can cause difficulties Accepted 17 February 2019 with emotions, behaviour and a cognitive should include regular reassessment and review 2–4 6 7 of sleep. When sleep difficulties are present, we profile which may mimic ADHD, and discuss how to further assess these, including lead children to be referred and assessed for this diagnosis. Treating sleep difficul - the role of investigations, and a structured ties may improve or ameliorate the prob- management strategy. 3 5 6 8–10 lems. ► Children with ADHD are more likely to have problems with sleep than their normally developing peers. 4 6Difficulties WhAt is ADhD? are reported in between 50% and 80% 2 3 5 8 Attention-deficit/hyperactivity disorder of those with an ADHD diagnosis. This (ADHD) is a neurodevelopmental has been documented using both subjec- condition defined by developmentally tive (parent reported) and objective labo- ratory measures of sleep. 6 11 inappropriate, pervasive and impairing symptoms of inattention and impul- ► In children diagnosed with ADHD, slee10 11 http://ep.bmj.com/ sivity/hyperactivity, with symptoms difficulties may also worsen symptoms. In children with ADHD, sleep deprivation apparent before the age of 12 years. It is has been demonstrated to cause poorer a common reason for referral of school- aged children to Community Paediatri- quality-of-life outcomes and to worsen both caregiver’s mental health and family cians and Child and Adolescent Mental functioning. Effects remain significant Health Services, with ADHD affecting even when ADHD symptom severity is on 15 July 2019 by guest. Protected by copyright. 3%–9% of school-age children and controlled for. 1 young people in the UK. ► Sleep problems are likely to persist throughout the lifetime of the person diag- nosed with ADHD. 10 WhAt is sleep? ©Author(s) (or their Exploration of sleep must therefore employer(s)) 2019. No Sleep is the foundation of physical and form a key part of the assessment of a commercial re-use. See rightsntal health. It is a reversible neurolog- child presenting with potential ADHD. and permissions. Published ical state of reduced responsiveness, with by BMJ. Assessing clinicians must know how to characteristic changes in brain and body institute initial management strategies for To cite: Hobson S, Davie M,ctivity occurring during different stages poor or disrupted sleep. Monitoring and Farquhar M. Arch Dis Childof sleep. It serves many vital functions Educ Pract Ed Epub ahead management of sleep should constitute of print: [please include Dayluding physical growth and repair, part of ongoing management of ADHD Month Year]. doi:10.1136/ immunity, cognition, development, after diagnosis to get best outcomes for archdischild-2017-313583 behaviour and weight regulation. 6 8 10 the child and their family. Hobson S, et al. Arch Dis Child Educ Pract Ed 2019;0:1–6. doi:10.1136/archdischild-2017-313583 1 Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-20 17-313583 on 5 June 2019. Downloaded from Best practice Box 1 Why does ADHD disturb sleep? Box 2 What to ask about sleep ADHD and disordered sleep physiology The BEARS questionnaire can be used as an initial screen, ► It has been suggested that a shared neurobiological asking about the following: pathway (involving areas of the brain cortex responsible► Bedtime issues for regulation and arousal) underpins bothADHD and ► Excessive daytime sleepiness 12 disordered sleep. 2 11 ► Awakening at night ► Increased sleep latency exists in children withADHD, ► Regularity and duration of sleep which may be linked to delay in dim light melatonin ► Snoring, gasps, grunts or respiratory pauses (although onset. clinical history alone is unreliable for sleep disordered 8 ► ADHD may be associated with a tendency to evening breathing) chronotype (‘night owls’), which itself is linked to behavioural, emotional and sleep problems. If sleep problems are present, the clinician should ask about: ► ADHD as a ‘24hours disorder16is associated with ► Sleeping environment: room and bed sharing, access to increased motor activity at nightwithout consistent electronic screens, noise, light evidence that this worsens sleep. ► Medical problems that may affect sleep, including ► Children withADHD have more disruptive nightwakings asthma, eczema, constipation, and so on and fragmented nighttime sleep at all ages compared ► Behavioural difficulties and emotional well-being with typically developing peers; they are likely to find► RLS: ‘Do you ever have any uncomfortable feeling in your it more difficult to settle back into sleep after a normal legs at bedtime? Or,‘Do your legs bother you at night?’ nightwaking. ‘Does anything make it better?’ (RLS symptoms will ► An association exists betweenADHD and cooccuring RLS classically improve with movement). Older children may (though probably less than the 44% reported talk of ‘creepy-crawlies, burning, or fizzy legs’, but this is and PLMD (in around 10%). 10 Iron deficiency often described more non-specifically. may be a contributary factor to both RLS and ► Exercise/caffeine/nicotine and substance misuse in older ADHD. children ► A link exists betweenADHD and mild/moderate sleep ► Medications:ADHD/psychiatric and other—dose/ disordered breathing. 6 10 11 preparation/timing/duration of treatment/anyother side 2 6 10 11 16 ► Excessive daytime sleepiness may be present effects in a subset of patients independent of poor sleep at night 1 in children with predominantly inattentiveADHD It is important for clinicians to enquire the following: representing physiological under-arousal. ► How long the sleep difficulties have been present for? ► Patients with narcolepsy have a higher incidence of ► What have the parents tried already? concurrentADHD diagnosis (around 35% vs 5% of those ► What are their goals and expectations for sleep? without a narcolepsy diagnosis). ADHD, attention-deficit/hyperactivity disorder; RLS, restless leg syndrome. Psychological/behaviouraland social factors ► Parents of children withADHD are more likely to have disrupted sleep themselves.This may be a secondary consequence of their children’s disrupted sleep pattern on their own sleep, but, given the high heritability hoW Do sleep Difficulties present in http://ep.bmj.com/ ofADHD, parents themselves may have primary chilDren With ADhD? disrupted sleep, diff2 11ty in establishing routines anThe most common sleep problem is difficulty falling inconsistent limit setting. ► Oppositional behaviour is common and may manifest as asleep, although problems with maintaining sleep, resistance to complying at bedtime.0 11 16 early waking, and tiredness during the day are also 5 8 10 11 ► Psychiatric comorbidities, particularly anxiety and commonly reported. on 15 July 2019 by guest. Protected by copyright. depression, are common and themselves cause sleep The characteristic and prevalent changes in sleep disruption.6 8 10 16 ► Alcohol, cigarette and other substance misuse are associated with ADHD suggest that the primary abnormality may be a primary circadian rhythm commoner inADHD and linked to disrupted sleep. abnormality. There are likely to be complex and interacting Iatrogenic factors contributory factors at play for each individual child ► Medications used to treatADHD themselves affect and family (box 1).6Children with ADHD and sleep sleep. 16 ► Medications used to treat psychiatric comorbidity affectroblems will often have characteristics of several 6 different sleep disorders, 10 though ‘behavioural’ sleep, for example, SSRIs. 12 ADHD, attention-deficit/hyperactivity disorder; PLMD, periodic limbies are a common feature. A thorough, holistic assessment of a child in their movement disorder; RLS, restless leg syndrome; SSRIs, selective serotonin reuptake inhibitors. psychosocial context is invaluable for unpicking the conundrum and supporting improvements. 2 Hobson S, et al. Arch Dis Child Educ Pract Ed 2019;0:1–6. doi:10.1136/archdischild-2017-313583 Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-20 17-313583 on 5 June 2019. Downloaded from Best practice Table 1 Management of specific sleep disorders Diagnostic evidence and investigation Treatment Behavioural insomnia of History Behavioural intervention childhood: Sleep-onset association and limit setting disorders RLS/PLMD Ferritin Exclude and treat iron deficiency (some authors treat ferritin <50 μ▯g/L Polysomnography Our policy is to aim for target ferritin of 50–80 mcg/L Behavioural intervention Avoid triggers—caffeine, nicotine, alcohol, pain If these strategies do not result in improvement, discuss with a specialist Sleep disordered breathing Cardiorespiratory sleep study Medical treatment for milder symptoms (eg, montelukast and nasal steroid (full polysomnography is gold spray) standard) Refer to ENT for consideration of surgical interventions (eg, adenotonsillectomy) Circadian rhythm disorders Actigraphy may be necessary Behavioural intervention, alongside use of melatonin and light therapy to phase advance or delay (treat in conjunction with sleep specialist) Sleep-related behaviours/movements which are abnormal, narcolepsy or hypersomnolence of unknown origin should be fully medical▯ly evaluated and referred to a sleep specialist.The child may require detailed investigation with PSG, EEG telemetry, multiple sleep latency tests, and so on. PLMD, periodic limb movement disorder; RLS, restless leg syndrome. case study 1 In some cases, actigraphy may be needed to objec- Kaden lives in cramped accommodation with his moth- tively clarify sleep patterns. er and three brothers. There is no access to outside space, and so by bedtime Kaden has had little exercise. He shares a room with his brothers, not all of whom investigAtion have the same bedtime. Ifassessment is suggestive of a particular sleep disorder, His mother has been told about sleep hygiene and has then further investigation may be appropriate. Treat- ment should be targeted at identified disorders 2 8 tried to implement this, but Kaden’s oppositional be- haviour has proved impossible for her to overcome. (table 1) This is in part because his lack of sleep has exacerbat- ed his daytime attention-deficit/hyperactivity disorder case study 2 symptoms, meaning that his mother is exhausted by the Hayley's restless leg symptoms complicate her ADHD in end of the day and wanting to minimise the impact of the following ways: Kaden’s disrupted sleep on his siblings also means she often ‘gives in’ to his behaviour. She is both frequently distracted during the day and has delayed sleep onset due to the discomfort and urge to http://ep.bmj.com/ mAnAgement of sleep move her legs. In addition, anticipation of discomfort makes her unwilling to go to bed, which encourages op- A thorough history is essential (box 2). Clinicians positional behaviour. treating children with ADHD ask about sleep less than half the time. Parents may not mention sleep unless Once she is asleep, her sleep quality is affected by fre- 3 specific enquiry is made. quent wakenings caused by the movements Enquiry/management of sleep is not part of the Daytime tiredness leads to a worsening of her ADHD on 15 July 2019 by guest. Protected by copyright. National Institute for Health and Care Excellence 1 symptoms. guidance for ADHD, although it is mentioned in AAP guidance for ADHD in terms of excluding sleep 13 interventions apnoea. The detailed psychosocial history, which is part of 1. Establishing good core sleep routine and habits is the an ADHD assessment, should identify many of the foundation of interventionto improve sleep. Explanation of normal sleep to families, including sleep cycles and psychosocial factors that contribute to sleep difficulties including housing, limited opportunities for outdoor normal nightwakings, underpins this. Improving core physical activity and reliance on screen-based activi- sleep routine and habits is known to facilitate sleep qual- ity and duration in typically developing children. 2 5 12 ties, domestic violence and parental mental health. – A recent RCT has demonstrated that a short be- Sleep diaries, kept over 2weeks due to high night-to- havioural intervention for sleep consisting of two night variability of ADHD, can be useful if parents can clinical appointments a fortnight apart and a fol- comply with completing them. Although subjective, low-up telephone call led to sustained improvement they can often provide useful information. in multiple sleep and ADHD outcomes. 12 Hobson S, et al. Arch Dis Child Educ Pract Ed 2019;0:1–6. doi:10.1136/archdischild-2017-313583 3 Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-20 17-313583 on 5 June 2019. Downloaded from Best practice – Behavioural difficulties are often a feature of sleep problems in children, even if there are concurrent Box 3 ADHD medications medical causes. – It is possible that programmes which help parents Stimulants with limit setting may improve parenting generally,14 ► Immediate and extended release stimulant medications which may have more wide-reaching benefits. (methylphenidate and amphetamines) are most frequently used, bestunderstood10with strongest – Set an age-appropriate sleep-onset time. Bedtimes 13 1 that are too early relative to the child’s own body evidence to support their usend greatest effect size. clock are likely to result in secondary anxiety about ► Their most common side effect is prolonged sleep sleep and bedtime resistance. onset. 10 1Some children may need 6–8hours post stimulant to sleep. However, some children have a – Set a consistent wake time, with exposure to bright (preferably natural) light as early in the day as pos- ‘rebound’ effect of worsenedADHD symptoms when the sible; this helps to encourage an earlier sleep time in stimulant dose wears off and therefore may benefit from an additional small dose of a rapid-acting stimulant in the evening. 6 8 10 For a summary of further core sleep routine and habit the afternoon/early evening to facilitate sleep.10 intervention measures, see Turnbull and Farquhar,3 with ► Some children sleep better on stimulant medication. links to further resources. ► Stimulant-naïve, younger and smaller children and those with a pre-existing sleep problem seem to be more 2. Treat contributory medical and emotional problems, par 10 ticularly anxiety, proactively. susceptible to sleep problems with stimulants. 3. Review ADHD (and other) medications. ► Higher doses are associated with more frequent reports of insomnia.0 – Establish sleep baselinebefore starting medication for ► Insomnia may wear off with time on medication. ADHD. – R eview sleep with dose titration and at each fol- low-up. Non stimulants: atomoxetine ► There is ‘sufficient but less strong’ evidence to support – Manage pharmacological interventions to optimise 13 sleep profile (see box 3). the use of atomoxetine inADHD (vs methylphenidate). 4. Consider use of melatonin. ► There are some reports of insomnia but somnolence – Melatonin can decrease sleep latency 14but does not is more common during the early stages of 3 treatment. 8 10 13 significantly increase total sleep durationor reduce nightwaking and is not associated with decrease in ► Clinicians may decide to give atomoxetine in the evening behaviour problems in ADHD. 14 to improve sleep or decrease daytime somnolence, but that may reduce the daytime efficacy of the drug. – A time-limited prescription of melatonin may , by making the child feel more ready for sleep at bed- time, facilitate introducing behavioural programmes Guanfacine for sleep. ► Guanfacine was introduced in the UK in 2016 as a non- stimulant medication for management ofADHD. – To support sleep onset, melatonin should be given 30min before the intended bedtime. Our practice is ► Guanfacine is a selective alpha2–adrenergic receptor to start at a dose of 2mg, though for some children a agonist. Its side-effect profile includes increased somnolence, and it may help support children withADHD smaller dose may be effective. Doses >6mg arerarely with sleep difficulties. Anecdotally, some clinicians find needed; lack of efficacy of melatonin is more likely due to other factors overriding its effect, or an overly that Guanfacine administered in the evening can i1prove optimistic expectation on melatonin of advancing the sleep while still addressing daytimeADHD symptoms. http://ep.bmj.com/ sleep time. Establishing a consistent bedtime, even if ADHD, attention-deficit/hyperactivity disorder. relatively late, is a key first step in those with an er - ratic sleep routine. – For children prescribed melatonin, regular breaks in preparation (Slenyto) is expected to be available in administration should be agreed to assess the need the UK soon. for ongoing prescription. Three to five days break 5. Medications widely used in treatment of ADHD affect on 15 July 2019 by guest. Protected by copyright. once per year is usually sufficient; the dose should sleep both directly, causing sleep to be worse, better or then be retitrated up to ensure the smallest possible have a variable effect, and indirectly, by improving or effective dose continues to be used. worsening a comorbidity that effects sleep.10 – In children with significant anxiety , or an ‘over-ac- tive’ mind in the evening, melatonin may provide a Other less frequently used ADHD medications are outside the remit of this article; for further informa- secondary calming effect, which in turn encourages tion, see Cortese et al and Stein and Weiss. 8 10 earlier sleep onset. In this circumstance, sleep onset, though quicker than without melatonin use, is usu- sedatives ally longer than 30 min after the dose. Alternative Decision to use sedative medications should always calming and settling support strategies should be ex- plored. be carefully considered between the principal paedi- – Melatonin is not currently licensed for use in chil- atrician and the family. They should usually only be dren in the UK, although is commonly prescribed considered where there is significant secondary conse- off-licence for sleep disturbance, predominantly by quence of disrupted nighttime sleep, either to the child secondary care consultant paediatricians. A licensed themselves or, more commonly, to the wider family. All 4 Hobson S, et al. Arch Dis Child Educ Pract Ed 2019;0:1–6. doi:10.1136/archdischild-2017-313583 Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-20 17-313583 on 5 June 2019. Downloaded from Best practice other interventions should usually have been consid- further non-pharmacological interventions/support ered and attempted first. If all other interventions have been attempted and secondary sleep disruption persists, it is often worth Antihistamines returning and reviewing all other factors that may be contributing. Following this, further support options The sedating antihistamines (eg, promethazine) can be should be explored, for example, social care support, used on an intermittent basis for some children with persistently disruptive nighttime sleep, usually in the respite. context of other neurodevelopmental difficulties, particu- conclusion larly where this leads to significant family disruption. These medications are not universally effective, The relationship between ADHD and sleep is funda- mental and often overlooked. Strategies to assess can cause hyperactivity (which may be related in and manage sleep difficulties, as well as a consistent some cases to a partial sedation effect) and tolerance emphasis on developing good core sleep routine and commonly develops if given regularly. They can also habits, are likely to result in improvement in overall cause significant next-day ‘hangover’ drowsiness. Use symptomatic presentation. is therefore often best limited to weekend (Friday/ Significant benefits can often be achieved through rela- Saturday) nights. tively straightforward interventions; for those where Dose should be titrated to effect, and starting doses this is not effective in its own right, more advanced should follow BNFC guidance for short-term sedation interventions may be needed. A minority will benefit use. from referral to a paediatric sleep specialist. Clonidine Contributors SH drafted the article and compiled the tables and boxes. MD assisted with the literature search. MF and MD provided advice and editing. Clonidine, given at sleep onset, can improve both sleep SH, MD and MF contributed equally to initial discussion and planning of the▯ onset and sleep maintenance and, if effective, can be article, including structural framework, and agreed significant points of content. given every night. SH acted as the lead author, with substantial contribution from MD. MF revised and redrafted the manuscript.All authors contributed to the final review and Doses of between 25 and 125 μg, 30 min before redrafting of the completed article, and agreed for final co-approval. intended sleep time, may help if all other strategies have been unsuccessful. 15 Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Competing interests None declared. Patient consent for publication Not required. Test your knowledge Provenance and peer review Commissioned; externally peer reviewed. A. Include an assessment of sleep at the initial assessment, RefeRences if it is normal then the clinician does not need to review 1 NICE Clinical Guidance CG72 2008 Attention Deficit at later appointments. Hyperactivity Disorder: diagnosis and management B. Institute behavioural management of sleep in children in 2 Van der Heijden K, Stoffelsen R, Popma A, et al. chronotype whom oppositional behaviour noted. and sleep hygiene in children with attention deficit/ C. Refer to ENT. hyperactivity disorder, autism spectrum disorder and controls http://ep.bmj.com/ D. Start atomoxetine medication. Eur Child Adolesc Psychiatry, 2017. published online open E. Consider a trial of melatonin treatment. access. F. Stop stimulant medication and restart after a short break. 3 Turnbull JR, Farquhar M. Fifteen-minute consultation on G. Institute behavioural management of sleep as first line. problems in the healthy child: sleep. Arch Dis Child Educ Pract H. Refer to a specialist sleep service Ed 2016;101:175–80. I. Rule out starting stimulant medication. 4 Engelhardt CR, Mazurek MO, Sohl K. Media use and sleep J. Refer for a cardiorespiratory sleep study. among boys with autism spectrum disorder, ADHD, or typical on 15 July 2019 by guest. Protected by copyright. development. Pediatrics 2013;132:1081–9. Which of the above is the best management option in the 5 Sung V, Hiscock H, Sciberras E, et al. Sleep problems in case of the following: children with attention-deficit/hyperactivity disorder. Arch 1 A child with ADHD who snores loudly and sweats at Pediatr Adolesc Med 2008;162:336–42. night. 6 Konofal E, Lecendreux M, Cortese S. Sleep and ADHD. Sleep 2. A child with poor concentration who is waking four times Med 2010;11:652–8. a night on average. 7 Sciberras E, Fulton M, Efron D, et al. Managing sleep 3. A child withADHD on stimulant medication who falls problems in school aged children with ADHD: A pilot asleep easily during the day, including while horseriding. randomised controlled trial. Sleep Med 2011;12:932–5. 4. A child withADHD who takes 90 min to fall asleep after 8 Cortese S, Brown TE, Corkum P, et al. Assessment and sleep hygiene reviewed. management of sleep problems in youths with attention-deficit/ 5. A child withADHD who may need stimulant medication hyperactivity disorder. J Am Acad Child Adolesc Psychiatry and who has delayed sleep onset. 2013;52:784–96. 9 Verkuijl N, Perkins M, Fazel M. Childhood attention-deficit/ Answers to the quiz are at the end of the references hyperactivity disorder. BMJ 2015;350:h2168–31. Hobson S, et al. Arch Dis Child Educ Pract Ed 2019;0:1–6. doi:10.1136/archdischild-2017-313583 5 Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-20 17-313583 on 5 June 2019. Downloaded from Best practice 10 Stein M, Weiss M. Hlavaty L ADHD treatments. Sleep and 18 Lecendreux M, Lavault S, Lopez R, et al. Attention-deficit/ Sleep Problems: Complex Associations Neurotherapeutics, hyperactivity disorder (adhd) symptoms in pediatric 2012:9;509–17. narcolepsy: A cross-sectional study. Sleep 2015;38:1285–95. 11 Cortese S, Faraone SV, Konofal E, et al. Sleep in children with attention-deficit/hyperactivity disorder: meta-analysis of subjective and objective studies. J Am Acad Child Adolesc Answers to the multiple choice questions Psychiatry 2009;48:894–908. 12 Hiscock H, Sciberras E, Mensah F, et al. Impact of a behavioural sleep intervention on symptoms and sleep in 1. (J) Hyperhidrosis is present in up to 11% of children, and children with attention deficit hyperactivity disorder, and snoring is a relatively common finding in sleep history; however, this scenario warrants further investigation to parental mental health: randomised controlled trial. BMJ 2015;350:h68. ascertain whether breathing at night is compromised. 13 Wolriach M,et al. (Subcommittee on Attention deficit/ A cardiorespiratory sleep study would delineate this (although PSG is the gold standard as it documents the Hyperactivity Disorder, Steering Committee on quality accompanying arousal from sleep). Referral to ENT would improvement and Management) ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of be first line in case of witnessed apnoeas/obstructive episodes and so on. Attention-Deficit/Hyperactivity Disorder in Children and 2. (G) This child may have a primary sleep disorder and/ Adolescents Pediatrics. 2011;128:1007–22. 14 Corkum P, Moldofsky H, Hogg-Johnson S, et al. Sleep orADHD. Behavioural management of the sleep problems in children with attention-deficit/hyperactivity problem should be instituted and then see if sleep and concentration difficulties improve. disorder: impact of subtype, comorbidity, and stimulant 3. (H) While excessive daytime sleepiness can be a feature medication. J Am Acad Child Adolesc Psychiatry 1999;38:1285–93. ofADHD, falling asleep very frequently in the day, especially when engaged in an enjoyable and stimulating 15 MacLeod RL, Keen DV. Innovations in practice: &Lsquo;off- activity, warrants further assessment by a sleep specialist label’ clonidine: Uk paediatric and child and adolescent psychiatry prescribing practice for sleep problems. Child to exclude narcolepsy. Adolesc Ment Health 2014;19(2):147–50. 4. (E) In a child withADHD with good sleep hygiene and routines, melatonin medication may shorten the duration 16 Mayes S, Calhoun S, Bixler E, et al. Parvin M ADHD Subtypes of sleep latency, although it will not significantly and Comorbid Anxiety. Depression and Oppositional-Defiant Disorder: Differences in Sleep Problems Journal of Pediatric lengthen the amount of time asleep or prevent nightwakings. Psychology:34;328–37. 5. (G) The first line of management should always be 17 Cortese S, Konofal E, Lecendreux M, et al. Restless legs syndrome and attention-deficit/hyperactivity disorder: a review institution of good sleep hygiene and routines, whether of the literature. Sleep 2005;28:1007–13. or not a child has underlyingADHD. http://ep.bmj.com/ on 15 July 2019 by guest. Protected by copyright. 6 Hobson S, et al. Arch Dis Child Educ Pract Ed 2019;0:1–6. doi:10.1136/archdischild-2017-313583