Dr. Barbara C. Fisher

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Dr. Barbara C. Fisher Clinic Director United
Psychological Services 47818 Van Dyke Shelby
Twp., MI 48317 586-323-3620
Brainevaluation.com
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How Sleep Influences the Clinical Presentation of
ADD/ADHD
WASM 2nd Congressional Meeting Bangkok, 4 -8
February 2007
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Objectives

• Symptom manifestation of ADD/ADHD, the Real ADD
  versus ADHD Combined and Hyperactive Type
• ADD versus Sleep Increasing severity of symptoms
  seen with the addition of Sleep Deprivation and
  Sleep Apnea/UARS
• Neuropsychological evaluation Differentiating
  impact of Sleep Apnea/UARS versus Sleep
  Deprivation (RLS/PLMS, Insomnia)
• Early sleep apnea Impact of frontal deficits and
  acquisition of language
• Case examples Long lasting effects upon the
  brain due to Sleep Apnea/UARS

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Symptom Manifestations of ADD Defining The Real
ADD

• ADHD Inattentive Type
• Genetic biochemical disorder
• Generalized anxiety as substrate
• Major issues are reading, motivation,
  and time management
• Major symptoms are poor sustained attention,
  information processing deficits and
  distractibility
• Use of logic and memory as primary compensatory
  mechanisms
• Analysis of 17 years data revealed primary
  patient reported symptoms of distractibility and
  inattention

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• DSM IV, DSM IV-TR
• ADHD Inattentive Type
• ADHD Combined Subtype
• ADHD Hyperactive Subtype

Hypothesis ADHD ADD Plus Sleep Disorder as one
primary causal factor ADD without Hyperactivity
The Real ADD
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Symptoms characteristic of ADD in multiple
settings Home, School, Work

• Reading comprehension, multiple choice Q
• Dreamy, out to lunch, in own world
• Poor grades, feeling neutral or disliking school
• Paperwork/assignments not turned in
• Tasks not completed, poor follow through
• Avoidance, procrastination, promises not kept
• Need directions instructions repeated
• Time management poor, always late

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Childhood versus Adult ADD/ADHD

• Diagnosed in Childhood
• Pre-School Extreme behavioral problem, failure
  to acquire language (Autism)
• Additional disorder ADD Plus (TBI, sleep apnea,
  seizure)
• 3rd, 6th, 9th grade Dislike school, grades,
  reading Diagnosed in Adulthood
• Loss of job, terminated due to paperwork,
  deadlines
• lack of upward job mobility
• Problems in college, poor grades
• Marital problems, depression/anxiety
• ADD symptoms exacerbated by undiagnosed sleep
  disorder, menopause, some type of brain insult

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The Real ADD Symptoms in Life

• Information processing Missing parts/pieces of
  directions, instructions, conversation-You never
  told me that-logichands on, dont read
  directions, just figure it out
• Distractibility Multi-tasking, thinking of too
  many things at one time-logicself talk,
  structure
• Slow thinking speed Problem with timed testing
• Spatial Reading comprehension, dislike reading,
  time management, logiccontextual reader, sound
  out using syllables/read word incorrectly(super-fl
  ous, bouquet, colonel, sidereal)

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Neuropsychological Evaluation for ADD

• Distractibility Stroop Color Word Test and
  Cancellation Test
• Information Processing CHIPASAT, PASAT, WCST
• Input Seashore Rhythm, Speech Sounds
• Cognitive Speed SDMT, Trails A B, Symbol
  Search
• Spatial Bender, WRAT-3, NARDT-R, WTAR

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Stability of ADD/ADHD Testing over 12 years Only
two measures revealed significant differences
adult female evaluated from age 41 to 53 years
Stimulant Medication For 12 years
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ADHD Look Alikes

• Of 189 children, ages 2 to 15 years, referred for
  evaluation of ADHD, only 43 percent had a
  diagnosis of ADHD after completing evaluation via
  an interdisciplinary team
• Children (below age 5) primarily diagnosed with
  Mental retardation (35) other disabilities
  (49)
• Children (above age 5) primarily diagnosed with
  Specific Language Disability (41)

• Kube, Petersen, Palmer 2002 Sep41(7)461-9.

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Trends seen clinically ADD Plus Sleep

• Behavior like ADHD Hyperactive and Combined Type
• Frontal deficits
• Selective Attention
• Integration
• Perseveration
• Abstract Reasoning
• Learning negated, loss of building blocks
• Pediatric DX Early and Severe Failure to Acquire
  Language (Autism Spectrum) and/or language
  problems
• Child DX Apnea UARS Primarily Frontal, Memory
• Adult DX Apnea UARS Memory, Residual frontal
• Child/Adult DX Sleep apnea only Memory,
  processing
• Sleep Deprivation DX Mild exacerbation of ADD
  symptoms (RLS/PLMS, Insomnia, Nocturnal motor
  activity, medication effects)

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ADD ADD Sleep Deprivation ADD
Sleep Apnea

• ADD Sleep Deprivation Non-Restorative Sleep
• Exacerbation of primary symptoms of ADD speed,
  distractibility
• Word retrieval
• Mild memory short term, unrelated stimuli, pure
  memory (math facts, fluency)

• The Real ADD
• Distractibility
• Information processing
• Slow thinking speed
• Good logic
• Good Memory
• Visuospatial Deficits

• ADD Sleep Apnea/UARS
• Primary impact of frontal deficits Selective
  attention, integration, perseveration, sequential
  analysis, abstract reasoning, problem solving,
  word retrieval, efficiency of memory, working
  memory
• Language deficits Acquisition of language,
  phonological processing, forming sentences,
  semantics, aphasias
• Visuospatial Distortions, visuoconstructive,
  visuoperceptual

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UARS/Sleep Apnea or Sleep Deprivation/Restorative
Sleep?

• Loss of Learning Negated by frontal processes
• Memory moderate to severe problem of detail and
  sequencing
• Visuospatial Distortions, visuoconstructive and
  visuoperceptual
• Emotional Impulsive, limit setting (sleep/life)
  conseq.
• Language Deficits Acquisition, pragmatic,
  phonological, auditory reasoning/processing,
  output

• Learning slowed Negated by memory math facts
• Exacerbated attention symptoms (distractibility,
  speed, info processing)
• Emotionally labile Easily depressed, low
  frustration tolerance, gives up easily
• Reading comprehension problems increased by
  distractibility, alertness ?
• Time management worse
• Interposing of numbers
• Word retrieval, fluency

ADD is the least of the problems!
UARS/Sleep Apnea
Sleep Deprivation
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Symptom Comparisons

• Autism
• Difficulty acquiring language due to problem of
  frontal processes
• Problem with peer play
• Minimal eye contact
• Continual movement

• Brain
• Hyperactive, impulsive,
• Aphasia, language problems
• Language pragmatic skills
• Integration, perseveration, sequential, abstract
  thinking

• Seizure Disorder
• Hyperactive, impulsive,
• Aphasia, language problems
• Language pragmatic skills
• Integration, perseveration, sequential, abstract
  thinking

• Moderate/Severe Sleep Apnea
• Hyperactive, impulsive,
• Aphasia, language problems
• Language pragmatic skills
• Integration, perseveration, sequential, abstract
  thinking

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ADHD Look Alikes Specific Language Disability

• Reading comprehension
• Dislike of reading
• Difficulty acquiring phonetics, syllables
• Contextual reader

• Pragmatic skills
• Word retrieval
• Communicating thoughts
• Forming sentences

• Aphasias dyslexia, dysgraphia, dyscalculia,
  auditory verbal dysgnosia spelling dyspraxia,
  constructional dyspraxia, dysarthria, visual
  letter agnosia

• Phonological processing substitution, rapid
  naming
• Auditory processing and reasoning
• Malaproprisms (beach, bleach)

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Sleep Deprivation Enhances ADD Symptoms

• Social, sports activities, high school
• 2006 National Sleep foundation For ages 11-17
  years Only one in five gets optimal 9 hours
• Sixth graders average 8.4 hours
• Twelfth graders average 6.9 hours
• Over a one week period high school seniors miss
  11.7 hours of sleep

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ADHD and Movement, RLS, PLMS

• Un-medicated ADHD children nocturnal movement
• Children with RLS/PLMS
• Leg discomfort, need to walk around, affects
  ability to attend and focus
• Serum Ferritin ? hyperactivity, inattention
• Finding of ADD/ADHD in older RLS population
• Brown as self-report screening neurometric
  evaluation
• RLS greater in patients diagnosed with ADHD
  (plt0.001)
• Finding of RLS in ADD population
• RLS and ADHD were co-related disorders
• Screen for both disorders RLS, ADD/ADHD

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Case Study ADD and Insomnia

• Predisposing Generalized anxiety, depression
• Precipitating Failure at job, school or marriage
• Perpetuating Worry about performance
• Sleep onset Review period, over-analysis
• Sleep maintenance Light sleeper, easily
  awakened,
• Case example 40 yr man, Adult DX ADD, (mild
  memory, ?Distractibility) 6 years college, 12
  years (teaching degree) 2 years for MA, 2
  children, OCD, RLS. Sleeps only in guest bedroom,
  not RLS, son, sleep onset association disorder,
  sleep hygiene/education, bedtime hour, CBT, child
  bedroom, bless room, bedtime routine, limits

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10 yr. old ADD Plus Sleep Apnea/UARSSchool
referred Symptoms of uncontrolled emotionality,
dysgraphia, word retrieval and severe written
output problem

• 2005 DX ADD plus
• Stroop 42, no CHIPASAT, Speech/Seashore ok,
  Trail A (ave) B (low ave) SS8, SDMTAve written
  and oral, distortions on Bender
• Memory Testing
• WRAML-2 SS range 3 to 15 (3Design Memory,
  Finger windows)
• CVLT-C T-37, Delayed trials 1.5 to 2.0 SD below
  mean
• Rey Integration difficulties
• Cognitive Testing
• Woodcock Cog SS cluster 70 to 113 grade Proc
  sp, Cog flu, LT Retrieval
• CAS Scaled scores 5 to 14 (Plan codes, Num
  detection, Match numbers)
• Achievement Woodcock SS cluster grade 81 to
  112 (math calc)
• Language Testing Pragmatic problems
• TAPS-R (Aud reas, proc) SS 7 to 15 (Aud num rev,
  Aud interpret direct)
• CTOPP SS 5 to 15 (Elision, Rapid digit, color,
  object, letter naming)

4-2006 PSG Stage 3 34.8, Stage 4 0
REM15.2 AHI 14.79, REM 28.80 lowest de-sat 93,
T A already done, 6-2006 CPAP study Stage 3
30.1, Stage 4 0, REM 8.9, AHI 17.85, REM
8.66 lowest de-sat 77, 7/ 8-2006 Camp, hit
head, scream, 1-2007 24 hr EEG normal
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ADD Plus Sleep Apnea/UARS, Seizure

• Age 7 2003 DX ADD plus subtle frontal deficits
  
• Sleep study in 2003 Sleep apnea and abnormal
  frontal functioning-seizure DX, Intervention T
  and A, medication
• Age 8 2004 Re-Evaluation ADD to check on
  medication (Strattera/AED) Stroop 42 to 58, CF
  PF Ave, Trail A-Ave, B-Above Ave, Symbol S 8
  to 12, Unable- CHIPASAT
• 24 hour EEG in 2005 Bi-frontal temporal seizure
  foci
• Age 9 Pulled out of school (missing building
  blocks)
• KABC-II scaled scores 4 to 13 (word order)
• WRAML-2 scaled scores 7 to 14 (DM, VL delayed,
  NL)
• NEPSY2003 to 2004
• Memory for Faces 13 to 17
• Delayed Memory for Faces 14 to 16
• Memory for Names 12 to 16
• Delayed Memory for Names 9 to 12
• Narrative Memory 14 to 12

Frontal deficits subtle Growing into
deficits Bright child
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DX ADD plus, Sleep Apnea/UARS, Seizure

• Age 7 2004 DX ADD plus Re-Evaluated Age 9 2006
  (TA, AED, Training)
• 2004 ADD testing Scores ranged from Ave to low
  Ave, could not do CHIPASAT Cognitive Training
  Program improved personality and ADD scores
• 2006 Re-admin ADD testing Stroop 35 to 51
  T-score, no CHIPASAT in 2006, Trails A B in
  2006 Ave, SDMT2006 0.93 4.26 SD above mean
  written and oral
• Age 7 2004 Memory Testing Re-Evaluated Age 8
  2005 (TA, AED, Training/PSG)
• WRAML-2 2004 SS from 5 to 14 (Design memory, DM
  Recognition)
• WRAML-2 SS 2004 to 2005 (DM 5 to 3) (PM 14 to
  7) (SM 12 to 9) (SM Recog. 8 to 11) (DM
  Recognition 5 to 8) (PM Recognition 7 to 7)
• CVLT-C 2004 Delayed trials 1.5 to 2.0 SD below
  mean
• CVLT-C 2004-2005 Learning 59 to 52, Long del
  free Ave/ Above, Long del cued Ave
• Age 7 11-2004 School meet Dysgraphia, Spell
  Dyspraxia Lang Evaluation, (TA, AED, Training)
• CELF-4 Index 69 to 108 (Exp. language) SS 2
  to 12, (Form Sent)
• GORT-4 SS 5 to 11 (Comprehension)
• CTOPP SS 5 to 10 (Memory for digits, Elision)
• TAPS-R SS 80 to 110 (Auditory interpret of
  directions)
• Age 9 2006 School decision KABC-II 5 to 13
  (Rebus-memory)

PSG 2004 Sleep apnea, TA, 2004 24 hour EEG
abnormal, PSG 2005 Sleep Apnea, neurologist
indicate CPAP and referred to dentist
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DX ADD/Autism ADD Plus TBI, Sleep Apnea/UARS,
Seizure

• Birth Apgar 8 9, 4 weeks early, TBI at 9
  months, auto
• Age 3 DX Autism and ADHD
• 2002 SPECT ? perfusion bilaterally, lateral
  prefrontal, parietal, temporal, anterior
  cingulate, basal ganglia, insula, focal
  thalamo-limbic
• 2005 24-hour EEG Bi-temporal structural lesion,
  paroxysmal feature, left temporal ?
• 2005 PSG Stage 3 6, Stage 4 13, REM 17,
  AHI 2.1 REM 3.9, (1/3 back, 2/3 side) lowest
  de-sat 90
• 5-2005 Tonsils 2 Uvula moderate, T A in June
• 3-2006 PSG Stage 3 23.5, Stage 40 REM10.9
  AHI 12.16 REM 35.45, (side study), lowest
  de-sat 93
• 10-2006 24 hour EEG Abnormal for subcortical
  paroxysmal disturbance

Pervasive brain problems ongoing
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DX ADD/Autism ADD Plus TBI, Sleep Apnea/UARS,
Seizure Evaluation 2004/2006 Age 11-12 years

• Total NDS 71 (cutoff 43/44) Dysphasia, Level of
  Performance
• Aphasia Screening Dysarthria, Dysgraphia,
  Spelling Dyspraxia, Dyslexia, Right Left
  Confusion, Dyscalculia, Visual Letter Dysgnosia,
  Auditory Verbal Dysgnosia, and Constructional
  Dyspraxia
• Speech Spontaneous paraphasias, word
  finding/retrieval
• Woodcock Cog Cluster scores grade Range of 59
  to 84
• 59 to 71 Long term retrieval, Cognitive
  fluency, Cognitive efficiency, Processing speed,
  Executive processes
• Woodcock Ach Cluster scores grade 44 to 91
• Lang, Math vs. Science, Soc. Studies, Broad
  Knowledge
• Cognitive Assessment Scale Index Range of 54 to
  70
• WISC IV IQ scores Range of 65 to 82 (Working
  memory)
• CELF-4 Index Range of 54 to 80 (Working memory)

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Patterns seen on Case Studies

1. IQ tests are not reliable, use cognitive
   evaluation
2. Impact of frontal deficits of perseveration,
   selective attention, integration, and abstract
   reasoning vary based upon severity
3. Memory Problem of sequencing, detail, efficiency
   
4. Visuospatial distortions, perceptual,
   construction
5. Auditory Reasoning, processing, comprehension
6. Reading, phonological processing
7. Output, expressive language, word retrieval,
   sentences
8. Learning difficulties, cognitive efficiency,
   fluency
9. Problem may appear subtle Scores regress to
   mean, grow into frontal deficits

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ADD/ADHD and Sleep Disorders

• Separate out the issues and causal factors What
  is ADD and What is Sleep
• Rule out additional neurological issues
• Recognize the long-lasting impact of sleep apnea
  and UARS especially early pediatric
• Isolate out variables with insomnia
• Treat RLS/PLMS if needed, check ferretin
• Sleep Hygiene and Education Address nationwide
  problem of sleep deprivation