Working with children under 3 years old, 40 hours per week for the last 5 years creates a unique opportunity to study the possible origins of ADHD. Most of the powers that be aver that it is strictly a neurological problem. There must be considerable doubt about this, because the common treatment with medication can cause more problems than it actually treats. Looking at older children, one notes that a high percentage of children (and adults) diagnosed with ADHD have sleep problems.
There is something of a statement regarding sleep and ADHD at http://www.sleepfoundation.org/ Another good website, with links to tons of educational articles is http://www.sleepeducation.com/ You can see it on that site if you look hard enough, or you can examine the results of a large survey of parents of children under ten years old at www.sleepfoundation.org/sites/default/files/2004SleepPollFinalReport.pdf . Perhaps not amazingly, the treatment of the sleep problems literally cures a high percentage of the children who have been diagnosed with ADHD. Where, in heavens name, do sleep problems in tiny children originate? There are four main sources of child sleep problems, and host of minor connections. Before I generate a host of critical comments, yes, I realize that the sleep problems MIGHT be neurological. However, the sleep problems start somewhere else in most cases. Make yourselves comfortable because this has the potential of becoming a long blog. I am going to spend some time with it before I publish it.
Pretty close to 100% of new parents have no idea what sleep hygiene means. The lack of knowledge about this interacts with how parents freely provide small children with access to television, DVDs, and video games. Sprinkle in poor dietary management, and there is a huge opportunity to create an epic movie, with multiple sequels entitled "Sleepless in America." Such a film would not be romantic.
Sleep hygiene, at its most basic level, refers to specific organized sleep routines. The sequence and events can be engineered according to family needs. The approximate amounts of sleep that children need at each age level is readily available on the internet. Suffice it to say that up to age of 2 years, children need to spend more than 50% of a 24 hour period sleeping. Significantly less than that creates behavior problems that include hyperactivity, mood swings that are NOT bipolar disorder, and acting out. Start by establishing a set bedtime that has very little variability. This needs to be early enough to allow a child to get almost all of their night time sleep in an uninterrupted sequence (with the exception of changes and feedings). Children should be sleeping straight through the night when they are no older than 9 months. I once saw a 7 year old in private practice whose parents claimed that he had never slept through the night. The referral was for - - - ADHD and aggressive acting out behavior at school. The use of Melatonin on the night before he started school for the term resulted in his first "A" for behavior on the next day. His parents were overjoyed! Small children need more in the routines for sleep. Cut off all visual electronic stimulation at least one hour before the established bedtime. The last meal for the day should be finished. Then, it should be time for a bath with warm, soothing water, and quiet music. Drying off after a bath needs to be a pleasant time, possibly followed with a smooth lotion rub if it is okay with your child's physician (and if the child tolerates it). Put the child in bed, without toys, and read a child oriented story in a soft voice. Turn down the lights, say a prayer. If you don't believe in prayers, say things like, "Today was the day before tomorrow. Tomorrow is a day full of things to do and learn. I/we love you. Have a good night." Give your child a gentle kiss, and leave. You can also refer to www.cantfalltosleep.com/sleepintoddlers.html
Television is one of the most overlooked sources of behavioral difficulty in children. The moving images and sound are very attractive to children because they don't have to do anything. Images on the television screen move by themselves. Many researchers believe that television interferes with falling to sleep because the nerve cells involved in watching keep firing for at least an hour if it is cut off. The continuous firing delivers the message, "I am still awake." The American Academy of Pediatrics recommends limiting the viewing of television to an hour or less per day for children under 2 years old. I concur strongly with that recommendation with the added advisory that background television (viewed by adults) contributes to disruption of sleep onset. There should be no television in a child's room, ever. Why should a child socialize with parents when they have their own television (and video games)? The purpose of a bedroom is for sleeping (homework should be done elsewhere, as well).
Caffeine is a drug. The stimulant effects help to keep people alert. However, caffeine in young children creates a host of dangers. The primary danger of caffeine consumption in young children is sleep disruption. Would it surprise anyone to learn that this author has known of parents who put tea (has caffeine) in baby bottles? A recent case involving a two year old who had tremendous tantrums revealed that the child was consuming Mountain Dewtm throughout the day just like his parents. Mountain Dewtm contains 55 mg of caffeine per 12 ounce can according to most sources. The United States does not publish guidlines concerning recommended limits for caffeine amounts per age group. Canada has such guidelines, with the recommended limited being 45 mg for children under 5 years old. The Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-R-TR) of the American Psychiatric Association lists three separate caffeine related disorders. The criteria for Caffeine Intoxication (for adults) includes consumption of more than 250 mg (defined as more than 2-3 cups of brewed coffee). Soft drinks other than Mountain Dewtm also contain caffeine. There are resources for the amounts of caffeine in various beverages www.energyfiend.com/the-caffeine-database Lest we forget, chocolate contains various amounts of caffeine as well. Many decongestants and cough medicines contain caffeine. Check the label for ingredients. One could also imagine that mood swings could be associated with caffeine consumption in small children. Can we envision small children stepping up to the bar and requesting a Bipolar Cola?
We must not forget the physical problems that disrupt sleep. Swollen tonsils and adenoids can contribute to sleep interruption in small children. These problems can cause behavioral difficulty. Parents need to watch their children for snoring and hitches (hesitations) in breathing. Ear, nose and throat specialists (otolaryngologists) are a good place to start considering ways of improving a child's sleep. There are also sleep specialists that can perform sleep studies on children.
Another connection to sleep problems in children relates to parents who smoke. If the parents smoke in the home, then the children do the same. I refer you to http://sleepeducation.blogspot.com/2010/01/secondhand-smoke-sleep-in-children-with.html
1. Don't entertain (I love that word) a diagnosis of ADHD without first considering the world of sleep.
2. Discuss the amount of sleep each child needs with your pediatrician.
3. Eliminate caffeine from your child's diet.
4. Reduce all exposure to television, especially during the hour before bedtime.
5. The last daytime nap needs to END at least five hours before the night time sleep period.
6. Establish sleep routines with a fixed, set bedtime.
7. Monitor your child for physical causes of sleep problems (for example, snoring).
Part II written March 21, 2010
People with profound vision impairment tend to have more sleep problems than those who can see. This is especially true for children. The other interesting fact is that there are differences between those who have ocular based visual impairments, and those with vision impairments caused by cortical problems (cvi). Those children with cvi are more likely to have sleep problems.
There is probably a need to be more attention to premature infants who have had grade 3 or grade 4 intraventicular hemorrhages (IVH) and associated visual impairment. One important factor to consider would be treatment parameters. While Clonidine has been used to treat many sleep problems, it is probably a lot wiser to use Melatonin whenever possible. Do not rely on the word of pharmaceutical representatives on this one. They have only one purpose in mind, and that is to sell their product. Those allopathic preparations should be a last resort. Evidence based research also reveals that behavioral interventions combined with Melatonin make for easier cessation of the supplement.
There is one publication that I found online at www.icevi.org/publications/ICEVI-WC2002/papers/10-topic/10-verv/oed.html
Other online and medical library searches will undoubtedly yield more information.