Helene Emsellem is one of our leading experts on how to understand and treat sleep disorders. As the director of The Center for Sleep & Wake Disorders, in Maryland, and the author of Snooze...or Lose!, she is especially interested how sleep affects adolescents' ability to not only live healthy lives but to focus, think, and make good decisions.
In answer to my questions, Emsellem shared her insights on how sleep deprivation affects young people's health, what she's learned in decades of clinical experience, and how sleep is related to diagnoses of ADD and ADHD.
Describe your research on ADHD and sleep.
Most of my work is based on clinical experience, not formal research trials, in adolescents and adults with sleep, alertness, and attention difficulties. In practice as a neurologist and sleep specialist it is clear that there are overlapping symptoms between ADD/ADHD and sleepiness and that teasing these disorders apart is necessary before beginning treatment.
Why is it difficult for doctors to separate the symptoms of sleepiness and ADHD when diagnosing someone?
As a clinician and sleep specialist, I interface frequently with patients who have been diagnosed with ADD/ADHD and have learned that it is important to determine if the patient was well rested when they were diagnosed. The cardinal symptoms of ADD/ADHD are difficulties with focus, attention, and concentration. The cardinal symptoms of sleepiness, aside from the feeling of sleepiness, are difficulties with focus, attention, and concentration. Not only do the symptom profiles overlap considerably, but with the exception of a few drugs, most medications will treat both issues (i.e. a trial of a particular medication will not aid in the differential diagnosis). This becomes an issue both when dealing with tired teenagers who frequently do not get enough sleep to begin with, as well as in the new diagnosis of ADD/ADHD in adults.
How many cases of ADHD do you think are misdiagnosed due to sleep deprivation?
ADHD cannot be successfully diagnosed or treated in the presence of sleep deprivation. One must fulfill the biological sleep requirement in order to appreciate the alerting or attention focusing effects of the medication. Misdiagnosed cases are not uncommon in my practice. ADD is a more common disorder than excessive daytime sleepiness, and thus there is a tendency to think of it first. Additionally, I believe it is not common knowledge that the symptom profiles for ADHD and excessive daytime sleepiness overlap so dramatically; thus questions about sleep pattern, timing, and amount are not always asked at the time of the ADHD diagnosis. It is important to review sleep hygiene in all patients. Stimulant medications won't work unless the patient is getting enough sleep. The effect of stimulants can spill over and disrupt an individual's nighttime sleep potentially making the ADD patient worse. A lack of improvement could prompt an increase in the stimulant dose, further aggravating the issue.
How can sleep be an effective treatment for those with ADHD?
For patients with true ADHD, where there is thought to be an abnormality of the brain, sleep alone may not be an effective treatment. Adequate sleep will allow the individual to function at their optimal level given the underlying problem. Sleep restriction will certainly make functional deficits much worse.