**4.4.2 Rhythmic Movement Disorder (RMD)**

RMD consists of head banging or body rocking behaviors primarily occurring in young children prior to sleep onset or during subsequent sleep.

The disorder often disappears with age over 18 months, but it is estimated to last sometimes in adolescents or adults with psychiatric problems or epilepsy (Simonds & Parraga, 1984; Mayer et al., 2007). Other PSG studies in pediatric populations disclosed RMD in 6/10 ADHD children, mostly with CADHD (Stepanova et al., 2005).

Sleep Disorders Diagnosis and Management in

childhood.

2008).

the world.

cases.

Guilleminault et al., 2005).

and oppositional behaviors.

**disorders in ADHD** 

and beyond the purpose of this review.

sleep disorders such as SDB or PLMD.

to the International Classification of Sleep Disorders (ICSD-2).

ever presented evidence of diurnal paroxysmal disorders.

nocturnal seizures in these children, even when co-occurring with IEDs.

Children with Attention Deficit/Hyperactivity Disorder (ADHD) 39

One patient reporting both dream enactment and SW episodes had a PSG evidence of CAs and REM without atonia, thus matching criteria for parasomnia overall disorder according

Interictal epileptic discharges (IEDs), mostly on centro-temporal or frontal leads were seen in >50% of these unmedicated ADHD subjects and among them, in >40% of the DOA+ children, with nocturnal hypermotor seizures occurring in three children, none of which had

Complex behaviors during the DOA episodes were, however, easy to distinguish from

Vulnerability of ADHD children to rolandinc seizures and foci is well known (Holtmann et al., 2003), along with an increased rate of DOA in patients with benign focal epilepsy of

A positive significant association of DOA with SDB in the form of snoring and with increased sleep instability was also described by the same authors (Silvestri et al., 2009), akin to previous reports emphasizing the same associations (Lopes & Guilleminault, 2006;

A preferential impact on the cognitive domain rather than behavioral indicators is most typical of children with DOA and slow wave sleep (SWS) dysfunction, opposite to the effect of nocturnal hyperactivity which seems to preferentially influence daytime hyperactivity

Levitiracetam 750-1000 mg/day effectively controlled seizures and lead to total cessation of DOA with a >50% reduction of IEDs during a follow-up period of 24 months (Walters et al.,

The effect of immediate (IR) or extended (ER) release stimulants in ADHD is well known

Stimulants still represent the first line of treatment of ADHD in pediatric populations across

The majority of subjective report studies indicate increased parental complaints of sleep disturbance in medicated versus unmedicated ADHD children, irrespective of stimulant type or regimen (Cohen-Zion & Ancoli-Israel, 2004). However, objective studies, whether actigraphic or PSG, show overall conflicting results as far as sleep measures, continuity and architecture, major differences going in opposite directions with regard, in particular, to REM sleep (Chatoor et al., 1983; Greenhill et al., 1983); no influence, though, on specific

A consistent co-morbidity with depression in many ADHD children could account for increased subjective and actigraphically confirmed sleep fragmentation in the most severe

Besides stimulants (Smoot et al., 2007), nonstimulant drugs have been successfully employed for the treatment of ADHD including atomoxetine (Kemner et al., 2005), bupropion and now less commonly used, tri-cyclic antidepressants. Clonidine, Guanfacine and other adrenergic -1 agonists along with modafinil might help IADHD children with the hypoarousal phenotype, whereas SSRIs and venlafaxine could be used to fight depression/anxiety-related sleep symptoms. Also, atypical anti-psychotic drugs such as

**5. Therapeutic management and options to address co-morbid sleep** 

A percentage (21.8) similar to that of RLS (25.4) was reported in a group of 55 unmedicated ADHD children evaluated by means of PSG (Silvestri et al., 2009) co-occurring with other sleep related movement disoders, in particular PLMD and bruxism, but not SDB, at odds with previous records (Mayer et al., 2007).

A functional impairment of the pre-motor and striatal circuitry akin to that responsible for RLS could be hypothesized as a link between RMD and ADHD.
