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Disordered sleep, daytime vigilance, and attention deficit hyperactivity disorder
EDITORIAL CORRESPONDENCE
Disordered sleep, daytime vigilance, and attention deficit hyperactivity disorder To the Editor." Weinberg and Brumback J recently described primary disorder of vigilance as a novel explanation for symptoms surprisingly similar to attention deficit hyperactivity disorder (ADHD). They should be congratulated for their efforts to promote the idea that motor restlessness and other symptoms thought to characterize ADHD may, in fact, have other causes. Symptoms of ADHD may therefore be a final common pathway for a multitude of underlying disorders that regularly go unrecognized or are misdiagnosed. Guilleminault2 described daytime symptoms of obstructive sleep apnea syndrome (OSAS) in childhood, including motor restlessness, daytime sleepiness, and poor school performance. A cardinal symptom of OSAS is snoring. How often is the presence of significant snoring at night obtained in the evaluation of an overactive child's condition? Manifestations of daytime sleepiness from many causes, such as sleep deprivation, biologic rhythm disturbances, and narcolepsy in childhood, frequently include motor restlessness and poor school performance. Typical signs and symptoms that one associates with sleepiness are often absent during childhood. Extremes are usually obvious, but more subtle manifestations of sleepiness are recurrently missed by both parents and practitioners. Even if nocturnal sleep appears to be normal, disruption of the continuity or architecture of sleep may result in daytime sleepiness. At the present time, polysomnography is the only method available to determine the objective characteristics of sleep, and the multiple sleep latency test is the most widely accepted procedure to assess daytime sleepiness and alertness objectively. Only two of Weinberg and Brumback's patients underwent polysomnography and a multiple sleep latency test; mean sleep-onset latencies were not reported. Sleep patterns for the 2-week period before the studies (as revealed by sleep diaries) may have provided additional important objective information about the children's sleep-wake pattern. The sleepy child is frequently overlooked until school performance is affected. Many disorders of excessive daytime somnolence may be successfully treated; child health care practitioners should include comprehensivesleep-wake information during the course of all clinical evaluations for complete assessment and management of their patients. Stephen H. Sheldon, DO, FAAP, ACP Director, Center for Childhood Sleep Disorders Studies Department o f Pediatrics Mount Sinai Hospital Medical Center Chicago, IL 60608 REFERENCES
1. Weinberg WA, Brumback RA. Primary disorder of vigilance: a novel explanation of inattentiveness, daydreaming, boredom, restlessness, and sleepiness. J PEDIATR 1990;116:720-5.
2. Guilleminault C. Obstructive sleep apnea in children. In: Guilleminault C, ed. Sleep and its disorders in children. New York: Raven Press, 1987:213-24.
To the Editor." The recent article by Weinberg and Brumback, 1 regarding a disorder of vigilance, brings to the attention of the medical community an important component in academic success, namely, wakefulness. The first question is whether disorders of wakefulness or nonalertness are a factor in academic underachievement. The answer appears to be yes. Beginning in the mid-1970s, when narcolepsy in adults was being evaluated at Mayo Clinic, Rochester, Minn., some of the patients reported having children who had been labeled by their pediatricians as "hyperactive." A method of determining alertness in these sleepy adults is pupillometry.2 When the Learning Disabilities Assessment Program was put in place at the Mayo Clinic, pupillometry was occasionally performed to assess pediatric patients' alertness. In some instances, students who failed to meet criteria for attention deficit hyperactivity disorder (ADHD) or learning disability (LD), but who were low achievers, proved to be nonalert; alerting medications often improved classroom performance. However, other students who met criteria for ADHD or isolated disorders of reading, spelling, or mathematics also demonstrated nonalertness. Pupillometry and sleep-wake histories have been incorporated into our assessment of school-age patients since 1988. Preliminary data with respect to the occurrence of nonalertness in the LD and ADHD population have been presented. Levels of alertness, as in adult narcolepsy, can be used as a means by which dosage for alerting agents (e.g., methylphenidate, D-amphetamine, or pemoline) may be titrated. 3 The second question is whether there is a specific disorder of vigilance that qualifies as a separate nosologic entity. The common concurrence of daytime sleepiness despite adequate nocturnal rest and no apparent disorder of sleep as judged by sleep logs, polysomnography, and multiple sleep latency studies, in otherwise rigidly defined attention deficit disorder with or without hyperactivity, nonverbal learning disorders, and disorders of reading or writing, raises the possibility of a distinct disorder that may be acquired but can occur on a familial basis, as Weinberg and Brumback suggest. My associates and I are presently investigating the frequency of daytime nonalertness in patients with ADHD, nonverbal LD, and dyslexia and in control patients. Our preliminary data, based on a review of almost 100 patients evaluated in the past year, all of whom have had sleep studies and pupillometry, suggest that approximately 50% of those with academic underachievement or ADHD or both demonstrate daytime nonalertness (abstract submitted at the 1991 American Academy of Neurology meeting). Our studies of personality development in the isolated syndrome
489
Disordered sleep, daytime vigilance, and attention deficit hyperactivity disorder To the Editor." Weinberg and Brumback J recently described primary disorder of vigilance as a novel explanation for symptoms surprisingly similar to attention deficit hyperactivity disorder (ADHD). They should be congratulated for their efforts to promote the idea that motor restlessness and other symptoms thought to characterize ADHD may, in fact, have other causes. Symptoms of ADHD may therefore be a final common pathway for a multitude of underlying disorders that regularly go unrecognized or are misdiagnosed. Guilleminault2 described daytime symptoms of obstructive sleep apnea syndrome (OSAS) in childhood, including motor restlessness, daytime sleepiness, and poor school performance. A cardinal symptom of OSAS is snoring. How often is the presence of significant snoring at night obtained in the evaluation of an overactive child's condition? Manifestations of daytime sleepiness from many causes, such as sleep deprivation, biologic rhythm disturbances, and narcolepsy in childhood, frequently include motor restlessness and poor school performance. Typical signs and symptoms that one associates with sleepiness are often absent during childhood. Extremes are usually obvious, but more subtle manifestations of sleepiness are recurrently missed by both parents and practitioners. Even if nocturnal sleep appears to be normal, disruption of the continuity or architecture of sleep may result in daytime sleepiness. At the present time, polysomnography is the only method available to determine the objective characteristics of sleep, and the multiple sleep latency test is the most widely accepted procedure to assess daytime sleepiness and alertness objectively. Only two of Weinberg and Brumback's patients underwent polysomnography and a multiple sleep latency test; mean sleep-onset latencies were not reported. Sleep patterns for the 2-week period before the studies (as revealed by sleep diaries) may have provided additional important objective information about the children's sleep-wake pattern. The sleepy child is frequently overlooked until school performance is affected. Many disorders of excessive daytime somnolence may be successfully treated; child health care practitioners should include comprehensivesleep-wake information during the course of all clinical evaluations for complete assessment and management of their patients. Stephen H. Sheldon, DO, FAAP, ACP Director, Center for Childhood Sleep Disorders Studies Department o f Pediatrics Mount Sinai Hospital Medical Center Chicago, IL 60608 REFERENCES
1. Weinberg WA, Brumback RA. Primary disorder of vigilance: a novel explanation of inattentiveness, daydreaming, boredom, restlessness, and sleepiness. J PEDIATR 1990;116:720-5.
2. Guilleminault C. Obstructive sleep apnea in children. In: Guilleminault C, ed. Sleep and its disorders in children. New York: Raven Press, 1987:213-24.
To the Editor." The recent article by Weinberg and Brumback, 1 regarding a disorder of vigilance, brings to the attention of the medical community an important component in academic success, namely, wakefulness. The first question is whether disorders of wakefulness or nonalertness are a factor in academic underachievement. The answer appears to be yes. Beginning in the mid-1970s, when narcolepsy in adults was being evaluated at Mayo Clinic, Rochester, Minn., some of the patients reported having children who had been labeled by their pediatricians as "hyperactive." A method of determining alertness in these sleepy adults is pupillometry.2 When the Learning Disabilities Assessment Program was put in place at the Mayo Clinic, pupillometry was occasionally performed to assess pediatric patients' alertness. In some instances, students who failed to meet criteria for attention deficit hyperactivity disorder (ADHD) or learning disability (LD), but who were low achievers, proved to be nonalert; alerting medications often improved classroom performance. However, other students who met criteria for ADHD or isolated disorders of reading, spelling, or mathematics also demonstrated nonalertness. Pupillometry and sleep-wake histories have been incorporated into our assessment of school-age patients since 1988. Preliminary data with respect to the occurrence of nonalertness in the LD and ADHD population have been presented. Levels of alertness, as in adult narcolepsy, can be used as a means by which dosage for alerting agents (e.g., methylphenidate, D-amphetamine, or pemoline) may be titrated. 3 The second question is whether there is a specific disorder of vigilance that qualifies as a separate nosologic entity. The common concurrence of daytime sleepiness despite adequate nocturnal rest and no apparent disorder of sleep as judged by sleep logs, polysomnography, and multiple sleep latency studies, in otherwise rigidly defined attention deficit disorder with or without hyperactivity, nonverbal learning disorders, and disorders of reading or writing, raises the possibility of a distinct disorder that may be acquired but can occur on a familial basis, as Weinberg and Brumback suggest. My associates and I are presently investigating the frequency of daytime nonalertness in patients with ADHD, nonverbal LD, and dyslexia and in control patients. Our preliminary data, based on a review of almost 100 patients evaluated in the past year, all of whom have had sleep studies and pupillometry, suggest that approximately 50% of those with academic underachievement or ADHD or both demonstrate daytime nonalertness (abstract submitted at the 1991 American Academy of Neurology meeting). Our studies of personality development in the isolated syndrome
489