Sleep patterns among children with attention-deficit hyperactivity disorder: a reexamination of parent perceptions

The Associations Between Sleep and Externalizing and Internalizing Problems in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: Empirical Findings, Clinical Implications, and Future Research Directions

Sleep problems are common in youth with attention-deficit/hyperactivity disorder (ADHD). Externalizing and internalizing problems contribute to dysfunction in youth with ADHD and are amplified by disrupted sleep. This objective of this article is to synthesize empirical studies that examined the associations between sleep and internalizing or externalizing problems in individuals with ADHD. The main findings are that sleep problems precede, predict, and significantly contribute to the manifestation of internalizing and externalizing behavior problems among children and adolescents with ADHD. Clinicians should assess sleep and integrate sleep interventions into the management of youth with ADHD.

Understanding the Impact of Insufficient Sleep in Children with Behavior Problems on Caregiver Stress: Results from a U.S. National Study

Research indicates strong connections between child ADHD, child ODD/CD, and sleep. Children experiencing these concerns also have caregivers who report feeling more stress. However, no studies have examined how child ADHD and ODD/CD interact together and with insufficient sleep to potentially exacerbate caregiver stress. Data were acquired from the 2018/2019 National Survey of Children's Health, a nationally representative survey of parents or caregivers conducted across the United States (U.S.). The current study used data for children 6-17 years old with a final analytic sample size of 41,541, representing a total of 47,357,862 U.S. youth. Overall child ADHD and ODD/CD were each uniquely associated with increased caregiver stress, while adequate child sleep duration was related to decreased caregiver stress. However, these findings were qualified by a significant two-way interaction that revealed that caregiver stress among children with comorbid ADHD and ODD/CD was not significantly greater than that of children with ODD/CD alone. Significant interactions between sleep and ODD/CD on caregiver stress were generally not observed, except potentially in females with ADHD. Our findings underscore the importance of considering strategies to reduce both youth symptoms and caregiver stress simultaneously. Additionally, ensuring adequate sleep for all children is recommended.

The Associations between the Homeostatic and Circadian Sleep Processes and the Neurobehavioral Functioning (NBF) of Individuals with ADHD-A Systematic Review

The objective of the present review was to systematically examine associations between perturbations of the homeostatic or circadian sleep processes and the neurobehavioral functioning (NBF) of individuals with ADHD. Electronic databases were searched for articles published between December 2013 and March 2023. Studies were included if they used objective measures of NBF, used objective or subjective measures of sleep, and focused on individuals with ADHD. Ten studies met these inclusion criteria. Of these, eight studies found perturbations in the interplay between NBF and Process S or Process C, and three studies did not. The quality of the studies was degraded because they failed to address key factors that affect the sleep processes and by the presence of methodological weaknesses. Our review suggests that homeostatic and circadian sleep processes are associated with NBF in individuals with ADHD. However, to confirm the validity of this conclusion, future studies should examine or control for confounders and utilize experimental designs that allow causality to be inferred.

A Systematic Review of Sleep and Circadian Rhythms in Children with Attention Deficit Hyperactivity Disorder

OBJECTIVE

Children and adults with ADHD often report sleep disturbances that may form part of the etiology and/or symptomatology of ADHD. We review the evidence for sleep changes in children with ADHD.

METHODS

Systematic review with narrative synthesis assessing sleep and circadian function in children aged 5 to 13 years old with a diagnosis of ADHD.

RESULTS

148 studies were included for review, incorporating data from 42,353 children. We found that sleep disturbances in ADHD are common and that they may worsen behavioral outcomes; moreover, sleep interventions may improve ADHD symptoms, and pharmacotherapy for ADHD may impact sleep.

CONCLUSION

Sleep disturbance may represent a clinically important feature of ADHD in children, which might be therapeutically targeted in a useful way. There are a number of important gaps in the literature. We set out a manifesto for future research in the area of sleep, circadian rhythms, and ADHD.

Sleep quality in children and adolescents with attention-deficit and hyperactivity disorder

Sleep disturbances are associated with an increased risk of attention-deficit and hyperactivity disorder (ADHD), which can also lead to sleep problems. In this study we aimed to determine the variables that affect the relationship between ADHD and sleep quality. Moreover, we aimed to compare these variables in children and adolescents with ADHD and healthy controls. This cross-sectional study was conducted using a random sample of 122 ADHD patients and 100 healthy children in Turkey. A self-administered questionnaire was distributed to assess sleep quality using the Pittsburgh Sleep Quality Index (PSQI). The risk of impairment in sleep quality was associated with the presence of ADHD (OR: 13.3; 95% CI: 6.1-29.1), the presence of somatic disease (OR: 4.9; 95% CI: 1.9-12.2), and a family history of the psychiatric disorder (OR: 4.2; 95% CI: 1.3-13.1). The PSQI total score was higher in children with parental separation compared to those without parental separation (p=0.006). As the economic level of the participants decreased, the PSQI total score increased significantly (p=0.006). It was determined that combined-type ADHD was associated with impairment in sleep quality more than the other subtypes (p<0.001 and p=0.031, respectively). Our findings show that children with ADHD have significantly more sleep problems than healthy controls and that sociodemographic variables and familial characteristics affect sleep quality in healthy children and children with ADHD.

Parental perceived child sleep problems: A concept analysis

PURPOSE

This paper aims to delineate a conceptual analysis of parental perceived child sleep problems.

DESIGN AND METHODS

Rodger's evolutionary approach to concept analysis was employed. A systematic literature search of PubMed, CINAHL, Medline, and PsycINFO was conducted from inception to June 2020. Peer-reviewed papers written in English focusing on parental perception of their children's sleep problems were included.

RESULTS

A total of 47 papers were included for analysis. Parental perceived child sleep problems can be defined as parental reliance on their observations and beliefs, and perceived locus of control to appraise an array of children's sleep-related signs and behaviors, which may contain bias but still reflects certain aspects of children's sleep health status. A wide range of physiological, psychosocial, familial, environmental, and cultural factors may contribute to parental perceived child sleep problems, which may further contribute to parent-child dyads' physical and mental health as well as the whole family's general wellness.

PRACTICE IMPLICATIONS

Defining the concept of parental perceived child sleep problems facilitate health professionals a foundation for consistent use, understanding, and evaluation of parent-reported child sleep outcome. Future research on the standard conceptual and operational definition of parental perceived child sleep problem, and its potential antecedents and consequences is warranted. The characteristic of parental perceived sleep problems, together with child sleep history and objective sleep measures should be integrated to evaluate child sleep health.

Sleep's role in memory consolidation: What can we learn from atypical development?

Research conducted over the last century has suggested a role for sleep in the processes guiding healthy cognition and development, including memory consolidation. Children with intellectual and developmental disabilities (IDDs) tend to have higher rates of sleep disturbances, which could relate to behavior issues, developmental delays, and learning difficulties. While several studies examine whether sleep exacerbates daytime difficulties and attention deficits in children with IDDs, this chapter focuses on the current state of knowledge regarding sleep and memory consolidation in typically developing (TD) groups and those at risk for learning difficulties. In particular, this chapter summarizes the current literature on sleep-dependent learning across developmental disabilities, including Down syndrome, Williams syndrome, Autism Spectrum Disorder, and Learning Disabilities (Attention-Deficit/Hyperactivity Disorder and Dyslexia). We also highlight the gaps in the current literature and identify challenges in studying sleep-dependent memory in children with different IDDs. This burgeoning new field highlights the importance of considering the role of sleep in memory retention across long delays when evaluating children's memory processes. Further, an understanding of typical and atypical development can mutually inform recent theories of sleep's role in memory.

The Associations Between Sleep and Externalizing and Internalizing Problems in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: Empirical Findings, Clinical Implications, and Future Research Directions

Sleep problems are common in youth with attention-deficit/hyperactivity disorder (ADHD). Externalizing and internalizing problems contribute to dysfunction in youth with ADHD and are amplified by disrupted sleep. This objective of this article is to synthesize empirical studies that examined the associations between sleep and internalizing or externalizing problems in individuals with ADHD. The main findings are that sleep problems precede, predict, and significantly contribute to the manifestation of internalizing and externalizing behavior problems among children and adolescents with ADHD. Clinicians should assess sleep and integrate sleep interventions into the management of youth with ADHD.

The Role of the Circadian System in Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental condition characterised by the core symptoms of inattention, impulsivity and hyperactivity. Similar to many other neuropsychiatric conditions, ADHD is associated with very high levels of sleep disturbance. However, it is not clear whether such sleep disturbances are precursors to, or symptoms of, ADHD. Neither is it clear through which mechanisms sleep and ADHD are linked. One possible link is via modulation of circadian rhythms. In this chapter we overview the evidence that ADHD is associated with alterations in circadian processes, manifesting as later chronotype and delayed sleep phase in ADHD, and examine some mechanisms that may lead to such changes. We also interrogate how the circadian clock may be a substrate for therapeutic intervention in ADHD (chronotherapy) and highlight important new questions to be addressed to move the field forward.

Impact of a behavioral intervention, delivered by pediatricians or psychologists, on sleep problems in children with ADHD: a cluster-randomized, translational trial

BACKGROUND

We have demonstrated the efficacy of a brief behavioral intervention for sleep in children with ADHD in a previous randomized controlled trial and now aim to examine whether this intervention is effective and cost-effective when delivered by pediatricians or psychologists in community settings.

METHODS

Translational, cluster-randomized trial of a behavioral intervention versus usual care from 19th January, 2015 to 30th June, 2017. Participants (n = 361) were children aged 5-13 years with ADHD and parent report of a moderate/severe sleep problem who met criteria for American Academy of Sleep Medicine criteria for chronic insomnia disorder, delayed sleep-wake phase disorder, or were experiencing sleep-related anxiety. Participants were randomized at the level of the pediatrician (n = 61) to intervention (n = 183) or usual care (n = 178). Families in the intervention group received two consultations with a pediatrician or a psychologist covering sleep hygiene and tailored behavioral strategies.

RESULTS

In an intention-to-treat analysis, at 3 and 6 months respectively, the proportion of children with moderate to severe sleep problems was lower in the intervention (28.0%, 35.8%) compared with usual care group (55.4%, 60.1%; 3 month: risk ratio (RR): 0.51, 95% CI 0.37, 0.70, p < .001; 6 month: RR: 0.58; 95% CI 0.45, 0.76, p < .001). Intervention children had improvements across multiple Children's Sleep Habits Questionnaire subscales at 3 and 6 months. No benefits of the intervention were observed in other domains. Cost-effectiveness of the intervention was AUD 13 per percentage point reduction in child sleep problem at 3 months.

CONCLUSIONS

A low-cost brief behavioral sleep intervention is effective in improving sleep problems when delivered by community clinicians. Greater sample comorbidity, lower intervention dose or insufficient clinician supervisions may have contributed to the lack benefits seen in our previous trial.

Evaluation of the Relationship Between Attention Deficit Hyperactivity Disorder Symptoms and Chronotype

INTRODUCTION

The aim of the study is to investigate the relationship between circadian characteristics and behavioral problems in children with Attention Deficit Hyperactivity Disorder (ADHD) (n=53), and to compare this group with healthy controls (n=38).

METHOD

Fifty-three medication-free children with ADHD, aged 6-12 years, and 38 healthy children, age and sex matched, participated. Parents completed the Conners' Parent Rating Scale-Revised, the Children's Chronotype Questionnaire (CCTQ), and the Children's Sleep Habits Questionnaire (CSHQ) to assess sleep variables.

RESULTS

ADHD children had more sleep-onset problems and parasomnias (in CSHQ) compared to healthy controls. However, circadian preferences did not differ between the groups in CCTQ scores. Another important finding was a mild correlation between parasomnia, bedtime on schooldays, and ADHD symptoms.

CONCLUSION

Our study showed that children with ADHD showed more resistance to going to bed than did controls on school days. However, in contrast to our hypothesis, morningness/eveningness preference did not differ from controls in ADHD children.

Sleep in Autism Spectrum Disorder and Attention Deficit Hyperactivity Disorder

Sleep problems are common in autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD). Sleep problems in these disorders may not only worsen daytime behaviors and core symptoms of ASD and ADHD but also contribute to parental stress levels. Therefore, the presence of sleep problems in ASD and ADHD requires prompt attention and management. This article is presented in 2 sections, one each for ASD and ADHD. First, a detailed literature review about the burden and prevalence of different types of sleep disorders is presented, followed by the pathophysiology and etiology of the sleep problems and evaluation and management of sleep disorders in ASD and ADHD.

Attitudes, beliefs, and perceptions of caregivers and rehabilitation providers about disabled children's sleep health: a qualitative study

BACKGROUND

Children with disabilities are more likely to have sleep disturbances than children without disabilities. Identifying attitudes, beliefs, knowledge, and perceptions of caregivers and health professionals is essential in developing effective intervention programs to improve disabled children's sleep health. However, no such qualitative data about adults who have key roles in the life and daytime activities of children with disabilities are available. This qualitative study aimed to understand attitudes, beliefs, knowledge, and perceptions about disabled children's sleep hygiene among caregivers and rehabilitation providers of children with disabilities.

METHODS

Twenty seven adults, including nine primary caregivers and eighteen rehabilitation providers, participated in five focus group discussions between September and December 2012 at the Rehabilitation Center in Punta Arenas, Chile. A trained facilitator guided focus group discussions using a semi-structured script. Audiotapes and transcripts of focus group discussions were reviewed and analyzed for recurrent themes.

RESULTS

Participants identified seven themes related to children's sleep hygiene: lifestyle behaviors, family factors, children's disabilities and/or comorbidities, environmental factors, adults' responsibilities for children's sleep, perception of good sleep, and parental distress about children's sleep problems. While both caregivers and rehabilitation providers recognized the importance of sleep for children's health and functioning, they differed in their understanding of how sleep hygiene practices influence sleep. Rehabilitation providers recognized the negative influence of electronics on sleep and the positive influence of sleep routines. In contrast, caregivers reported use of television/movie watching and stimulants as coping strategies for managing children's sleep problems.

CONCLUSIONS

Caregivers may benefit from better understanding the influence of electronics and stimulant use on child sleep health. Rehabilitation providers are well positioned to provide educational messages to both children and caregivers in order to change their attitudes, perceptions, and practices surrounding sleep. These qualitative data are valuable in developing intervention programs aimed at improving sleep health among children with disabilities.

Sleep of children with attention deficit hyperactivity disorder: actigraphic and parental reports

The objectives of this study were to characterize the sleep of children with attention deficit hyperactivity disorder (ADHD), using actigraphy and parental questionnaires, and examine the potentially moderating role of psychostimulant medication and psychiatric comorbidity. Children with ADHD significantly differed from controls on parental and actigraphic measures of sleep, with parental reports indicating more severe sleep disturbances, and actigraphic recordings of longer sleep onset latency, lower sleep efficiency, and lower total sleep time. Both medicated and unmedicated ADHD subgroups differed from the control group on sleep measures, but did not differ from each other. Only the subgroup with comorbid psychiatric symptoms differed from the control group on actigraphic measures. The presence of psychiatric comorbidity, but not psychostimulant medication use, was associated with more severe sleep disturbances. The main implication of these findings is that clinicians should systematically attend to sleep disturbances in children with ADHD, particularly when other psychiatric symptoms are also present.

Contributions of circadian tendencies and behavioral problems to sleep onset problems of children with ADHD

BACKGROUND

Children with attention-deficit/hyperactivity disorder (ADHD) are two to three times more likely to experience sleep problems. The purpose of this study is to determine the relative contributions of circadian preferences and behavioral problems to sleep onset problems experienced by children with ADHD and to test for a moderation effect of ADHD diagnosis on the impact of circadian preferences and externalizing problems on sleep onset problems.

METHODS

After initial screening, parents of children meeting inclusion criteria documented child bedtime over 4 nights, using a sleep log, and completed questionnaires regarding sleep, ADHD and demographics to assess bedtime routine prior to PSG. On the fifth night of the study, sleep was recorded via ambulatory assessment of sleep architecture in the child's natural sleep environment employing portable polysomnography equipment. Seventy-five children (26 with ADHD and 49 controls) aged 7-11 years (mean age 8.61 years, SD 1.27 years) participated in the present study.

RESULTS

In both groups of children, externalizing problems yielded significant independent contributions to the explained variance in parental reports of bedtime resistance, whereas an evening circadian tendency contributed both to parental reports of sleep onset delay and to PSG-measured sleep-onset latency. No significant interaction effect of behavioral/circadian tendency with ADHD status was evident.

CONCLUSIONS

Sleep onset problems in ADHD are related to different etiologies that might require different interventional strategies and can be distinguished using the parental reports on the CSHQ.

Associations between psychiatric comorbidities and sleep disturbances in children with attention-deficit/hyperactivity disorder

OBJECTIVE

Children with attention-deficit/hyperactivity disorder (ADHD) often have sleep complaints and also higher rates of psychiatric comorbidities such as mood and anxiety disorders that may affect sleep. The authors hypothesized that children with ADHD and psychiatric comorbidities would have higher overall sleep disturbance scores as measured by a sleep questionnaire than children with ADHD without comorbidities.

METHODS

This cross-sectional analysis in an academic center studied 317 children with ADHD; 195 subjects had no comorbid conditions, 60 were anxious and 62 were depressed. Participants completed the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present State, 4th Revised Edition and the Children's Sleep Habits Questionnaire.

RESULTS

Median age (range) was 8.9 (6-18.7) years; 78% were male. Median (interquartile range) Total Sleep Disturbance Score (TSDS) on Children's Sleep Habits Questionnaire for subjects with no comorbidities was 44 (40-49); anxiety, 48 (43-54); and depression, 46 (41-52). Compared with subjects without comorbidities, TSDS in anxious subjects was greater (p = .008). TSDS in depressed subjects was not significantly different. Compared with subjects without comorbidities, anxious subjects had higher Bedtime Resistance, Sleep Onset Delay, and Night Wakings subscales (p = .03, .007, and .007, respectively); depressed subjects had higher Sleep Onset Delay and Sleep Duration subscales (p = .003 and .01, respectively).

CONCLUSIONS

Anxiety in children with ADHD contributed to higher overall sleep disturbance scores, compared with children with ADHD alone. Both comorbidities were associated with higher Sleep Onset Latency subscale scores. Further study of the impact of psychiatric comorbidities on sleep in children with ADHD is warranted.

Sleep disturbances in children with attention-deficit/hyperactivity disorder

In this article, we advocate the need for better understanding and treatment of children exhibiting inattentive, hyperactive, impulsive behaviors, by in-depth questioning on sleepiness, sleep-disordered breathing or problematic behaviors at bedtime, during the night and upon awakening, as well as night-to-night sleep duration variability. The relationships between sleep and attention-deficit/hyperactivity disorder (ADHD) are complex and are routinely overlooked by practitioners. Motricity and somnolence, the most consistent complaints and objectively measured sleep problems in children with ADHD, may develop as a consequence of multidirectional and multifactorial pathways. Therefore, subjectively perceived or reported restless sleep should be evaluated with specific attention to restless legs syndrome or periodic limb movement disorder, and awakenings should be queried with regard to parasomnias, dyssomnias and sleep-disordered breathing. Sleep hygiene logs detailing sleep onset and offset quantitatively, as well as qualitatively, are required. More studies in children with ADHD are needed to reveal the 24-h phenotype, or its sleep comorbidities.

Sleep in attention-deficit/hyperactivity disorder in children and adults: past, present, and future

The understanding that sleep can give rise to, or exacerbate symptoms of attention-deficit/hyperactivity disorder (ADHD), and that good sleep hygiene improves attention and concentration tasks has sparked interest in the investigation of possible etiological relationships between sleep disorders and ADHD. Studies indicate that 30% of children and 60-80% of adults with ADHD have symptoms of sleep disorders such as daytime sleepiness, insomnia, delayed sleep phase syndrome, fractured sleep, restless legs syndrome, and sleep disordered breathing. The range and diversity of findings by different researchers have posed challenges in establishing whether sleep disturbances are intrinsic to ADHD or whether disturbances occur due to co-morbid sleep disorders. As a result, understanding of the nature of the relationship between sleep disturbances/disorders and ADHD remains unclear. In this review, we present a comprehensive and critical account of the research that has been carried out to investigate the association between sleep and ADHD, as well as discuss mechanisms that have been proposed to account for the elusive relationship between sleep disturbances, sleep disorders, and ADHD.

Managing sleep problems in school aged children with ADHD: a pilot randomised controlled trial

OBJECTIVE

To evaluate the feasibility and helpfulness of a behavioral sleep program for children with ADHD, and explore the impact of different program dosages on child and family outcomes.

METHODS

Randomised trial comparing a brief (1 session, n=13) and extended (2-3 sessions, n=14) sleep program in children with ADHD (aged 5-14 years) and at least one behavioral sleep disorder (American Academy of Sleep Medicine Criteria). Outcomes included helpfulness and use of interventions, child sleep (parent-reported sleep problem; Child Sleep Habits Questionnaire), ADHD symptoms (ADHD IV Rating Scale), daily functioning (Daily Parent Rating of Evening and Morning Behavior), quality of life (Pediatric Quality of Life Inventory), and caregiver mental health (Depression Anxiety Stress Scales).

RESULTS

Twenty-seven families (63% of those eligible) took part. Most parents would recommend the program to others (95%) and found the strategies helpful. Five months post-randomisation, 67% of parents in both groups reported that their child's sleep problems had resolved. Child quality of life, daily functioning, and parental anxiety also improved in the extended group only (Cohen's d: 0.39, 0.47 and 0.50, respectively). There was minimal change in ADHD symptom scores from baseline to 5 months in either group.

CONCLUSIONS

A behavioral sleep intervention in children with ADHD is feasible to deliver and improves child sleep by parent report. The extended program resulted in greater improvements in child and caregiver outcomes.

Use of Ball Blanket in attention-deficit/hyperactivity disorder sleeping problems

OBJECTIVES

Based on actigraphic surveillance, attention-deficit/hyperactivity disorder (ADHD) symptom rating and sleep diary, this study will evaluate the effect of Ball Blanket on sleep for a sample of 8-13-year-old children with ADHD.

DESIGN

Case-control study.

SETTING

A child and adolescent psychiatric department of a teaching hospital.

PARTICIPANTS

21 children aged 8-13 years with a diagnosis of ADHD and 21 healthy control subjects.

INTERVENTION

Sleep was monitored by parent-completed sleep diaries and 28 nights of actigraphy. For 14 of those days, the child slept with a Ball Blanket.

MAIN OUTCOME MEASURES

The sleep latency, number of awakenings and total length of sleep was measured, as was the possible influence on parent- and teacher-rated ADHD symptom load.

RESULTS

The results of this study will show that the time it takes for a child to fall asleep is shortened when using a Ball Blanket. The time it takes to fall asleep when using the Ball Blanket is found to be at the same level as the healthy control subjects. Teacher rating of symptoms show an improvement in both activity levels and attention span of approximately 10% after using the Ball Blankets.

CONCLUSIONS

The results of this study show that the use of Ball Blankets is a relevant and effective treatment method with regard to minimizing sleep onset latency. We find that the use of Ball Blankets for 14-days improves the time it takes to fall asleep, individual day-to-day variation and the number of awakenings to a level that compares with those found in the healthy control group. Furthermore, we find that the use of Ball Blankets significantly reduces the number of nights that the ADHD child spends more than 30 min falling asleep from 19% to 0%.

Feeding and sleeping problems in infancy--a follow-up at early school age

BACKGROUND

Feeding and sleeping problems are common during infancy. Many regulatory problems of this kind are connected to various child and family factors. This study is a follow-up of children with early feeding and/or sleeping problems, 6 years after clinical contacts.

METHODS

A total of 230 families (72%) participated in the questionnaire follow-up. Children and parents were compared with 227 (71%) reference families regarding sleeping and feeding problems, health factors in parent and child, psychosocial problems, stressful life events, social support, life satisfaction, and externalizing and internalizing behaviour in the child.

RESULTS

Six years after clinical contacts the children with early feeding and/or sleeping problems still had more problems of this kind compared with the reference children. Early child health problems were more frequent within the clinical group, but recent health problems did not separate the two groups. Mothers in the clinical sample reported more health problems than mothers in the reference group and clinical parents were less content with their social support and had more psychosocial problems, including stressful life events. Children in the clinical sample had more internalizing problems than comparison children. Recent feeding and sleeping problems were connected to more externalizing and internalizing problems.

CONCLUSIONS

  Early regulatory problems, concerning sleeping or feeding, are less frequent when the child grows up, but nevertheless tend to remain. A clinical recommendation for child health care is to take both child and family factors into account, to individualize contacts, work with an all-inclusive perspective and have close follow-ups.

Study protocol: the sleeping sound with attention-deficit/hyperactivity disorder project

BACKGROUND

Up to 70% of children with Attention-Deficit/Hyperactivity Disorder (ADHD) experience sleep problems including difficulties initiating and maintaining sleep. Sleep problems in children with ADHD can result in poorer child functioning, impacting on school attendance, daily functioning and behaviour, as well as parental mental health and work attendance. The Sleeping Sound with ADHD trial aims to investigate the efficacy of a behavioural sleep program in treating sleep problems experienced by children with ADHD. We have demonstrated the feasibility and the acceptability of this treatment program in a pilot study.

METHODS/DESIGN

This randomised controlled trial (RCT) is being conducted with 198 children (aged between 5 to 12 years) with ADHD and moderate to severe sleep problems. Children are recruited from public and private paediatric practices across the state of Victoria, Australia. Upon receiving informed written consent, families are randomised to receive either the behavioural sleep intervention or usual care. The intervention consists of two individual, face-to-face consultations and a follow-up phone call with a trained clinician (trainee consultant paediatrician or psychologist), focusing on the assessment and management of child sleep problems. The primary outcome is parent- and teacher-reported ADHD symptoms (ADHD Rating Scale IV). Secondary outcomes are child sleep (actigraphy and parent report), behaviour, daily functioning, school attendance and working memory, as well as parent mental health and work attendance. We are also assessing the impact of children's psychiatric comorbidity (measured using a structured diagnostic interview) on treatment outcome.

DISCUSSION

To our knowledge, this is the first RCT of a behavioural intervention aiming to treat sleep problems in children with ADHD. If effective, this program will provide a feasible non-pharmacological and acceptable intervention improving child sleep and ADHD symptoms in this patient group.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN68819261. ISRCTN: ISRCTN68819261.

Impairments in attention in occasionally snoring children: an event-related potential study

OBJECTIVE

To determine whether minimal snoring is benign in children.

PROCEDURE

22 rarely snoring children (mean age = 6.9 years, 11 females) and age- and sex-matched controls participated in an auditory oddball task wearing 128-electrode nets. Parents completed the Conners Parent Rating Scales-Revised Long (CPRS-R:L).

RESULTS

Snorers scored significantly higher on four CPRS-R:L subscales. Stepwise regression indicated that two ERP variables from a region of the ERP that peaked at 844 msec post-stimulus onset predicted CPRS-R:L Attention Deficit Hyperactivity Disorder (ADHD) Index scores.

CONCLUSIONS

Occasional snorers, according to parental report, do exhibit ADHD-like behaviors. Basic sensory processing is longer than in controls, suggesting that delayed frontal activation requires more effort in snorers.

The sleep of children with attention deficit hyperactivity disorder on and off methylphenidate: a matched case-control study

In the present study, we assessed the effects of regular use of methylphenidate medication in children diagnosed with attention deficit hyperactivity disorder (ADHD) on sleep timing, duration and sleep architecture. Twenty-seven children aged 6-12 years meeting diagnostic criteria for Diagnostic and Statistical Manual version IV ADHD and 27 control children matched for age (+/-3 months) and gender. Two nights of standard polysomnographic (PSG) recordings were conducted. ADHD children were allocated randomly to an on- or 48 h off-methylphenidate protocol for first or second recordings. Control children's recordings were matched for night, but no medication was used. Mixed modelling was employed in the analyses so that the full data set was used to determine the degree of medication effects. Methylphenidate in ADHD children prolonged sleep onset by an average of 29 min [confidence interval (CI) 11.6, 46.7], reduced sleep efficiency by 6.5% (CI 2.6, 10.3) and shortened sleep by 1.2 h (CI 0.65, 1.9). Arousal indices were preserved. Relative amounts of stages 1, 2 and slow wave sleep were unchanged by medication. Rapid eye movement sleep was reduced (-2.4%) on the medication night, an effect that became non-significant when control data were incorporated in the analyses. PSG data from ADHD children off-medication were similar to control data. Our findings suggest that methylphenidate reduces sleep quantity but does not alter sleep architecture in children diagnosed with ADHD. An adequate amount of sleep is integral to good daytime functioning, thus the sleep side effects of methylphenidate may affect adversely the daytime symptoms the drug is targeted to control.

The Role of Sleep in Childhood Psychiatric Disorders

Although sleep problems often comprise core features of psychiatric disorders, inadequate attention has been paid to the complex, reciprocal relationships involved in the early regulation of sleep, emotion, and behavior. In this paper, we review the pediatric literature examining sleep in children with primary psychiatric disorders as well as evidence for the role of early sleep problems as a risk factor for the development of psychopathology. Based on these cumulative data, possible mechanisms and implications of early sleep disruption are considered. Finally, assessment recommendations for mental health clinicians working with children and adolescents are provided toward reducing the risk of and improving treatments for sleep disorders and psychopathology in children and adolescents.

Actigraphic recording of manic symptoms induced by methylphenidate

Objective. Attention-deficit hyperactivity disorder (ADHD) is a developmental disorder characterized by a long-standing pattern of impulsive behavior, hyperkinesia, and inattention. Psychostimulants, for example, methylphenidate, are the treatment of choice for ADHD both in children, adolescents, and adults. Method. The effect of methylphenidate on sleep structure is not well known. We studied the effect of long-acting methylphenidate on sleep in adult ADHD patients, in a naturalistic treatment setting, using actigraphic and polysomnographic recordings. Results. One of our patients experienced manic episode after starting methylphenidate. A wrist-worn accelerometer recording demonstrated a decrease in the duration and quality of sleep. After discontinuation of methylphenidate treatment, the patient's symptoms subsided and there was no need for hospital admission. Actigraphic recording showed a decrease in the amount and quality of the patient's sleep as triggering factor for the manic symptoms. Conclusions. Disruptions of the sleep-wake cycle are probably important etiologic factors in mood disorders, especially bipolar disorder. The changes in length and quality of sleep described in this case report bear close resemblance to those of patients with a manic episode, although these symptoms were induced by methylphenidate.

Parental rating of sleep in children with attention deficit/hyperactivity disorder

OBJECTIVE

Sleep problems have often been associated with attention deficit/hyperactivity disorder (ADHD). Parents of those with ADHD and children with ADHD report sleep difficulties more frequently than healthy children and their parents. The primary objective of this paper is to describe sleep patterns and problems of 5 to 11-year-old children suffering from ADHD as described by parental reports and sleep questionnaires.

METHOD

The study included 321 children aged 5-11 years (average age 8.4 years); 45 were diagnosed with ADHD, 64 had other psychiatric diagnoses, and 212 were healthy. One hundred and ninety-six of the test subjects were boys and 125 were girls. A semi-structured interview (Kiddie-SADS-PL) was used to DSM-IV diagnose ADHD and comorbidity in the clinical group. Sleep difficulties were rated using a structured sleep questionnaire (Children Sleep Behaviour Scale).

RESULTS

Children diagnosed with ADHD had a significantly increased occurrence of sleep problems. Difficulties relating to bedtime and unsettled sleep were significantly more frequent in the ADHD group than in the other groups. Children with ADHD showed prolonged sleep onset latency, but no difference was shown regarding numbers of awakenings per night and total sleep time per night. Comorbid oppositional defiant disorder appeared not to have an added effect on problematic behaviour around bedtime.

CONCLUSION

Parents of children with ADHD report that their children do not sleep properly more often than other parents. The ADHD group report problems with bedtime resistance, problems with sleep onset latency, unsettled sleep and nightmares more often than the control groups. It may therefore be relevant for clinicians to initiate a closer examination of those cases reporting sleep difficulties.

Sleep disturbances in prepubertal children with attention deficit hyperactivity disorder: a home polysomnography study

STUDY OBJECTIVE

To examine sleep architecture and reported sleep problems in children with ADHD and normal controls, while considering the roles of pertinent moderating factors.

DESIGN

Overnight sleep recordings were conducted in 15 children diagnosed with ADHD (DSM-IV) without comorbid psychiatric problems and in 23 healthy controls aged 7 to 11 years. Children were on no medication, in good health and did not consume products containing caffeine > or = 7 days prior to the polysomnography (PSG) study. PSG evaluation was performed at each child's home; children slept in their regular beds and went to bed at their habitual bedtimes.

MEASUREMENTS

Standard overnight multichannel PSG evaluation was performed using a portable polysomnography device. In addition, parents were asked to complete a sleep questionnaire.

RESULTS

Compared to controls, children in the ADHD group had significantly shorter duration of REM sleep, smaller percentage of total sleep time spent in REM sleep, and shorter sleep duration. In addition, the ADHD group had higher scores on the insufficient sleep and sleep anxiety factors than children in the control group.

CONCLUSION

The present findings support the hypothesis that children with ADHD present sleep disturbances.

CREM mutations and ADHD symptoms

CREM mutant mice have behaviors similar to symptoms seen in ADHD such as the increased level of physical activity as well as altered emotional and stress responses. Our results demonstrate that all the four participants with ADHD had elevated levels of nocturnal melatonin in urine samples before starting the methylphenidate treatment. We hypothesize that abnormalities in CREM protein functions or mutations in the CREM gene may be underlying at least some of the symptoms in patients with ADHD.

ADHD subtypes and comorbid anxiety, depression, and oppositional-defiant disorder: differences in sleep problems

OBJECTIVE

Sleep problems were analyzed in children with ADHD (Attention-deficit hyperactivity disorder).

METHODS

Scales were completed by parents of 135 control children and 681 children with ADHD combined type (ADHD-C) or inattentive type (ADHD-I) with or without comorbid oppositional defiant disorder (ODD), anxiety, or depression.

RESULTS

Children with ADHD-I alone had the fewest sleep problems and did not differ from controls. Children with ADHD-C had more sleep problems than controls and children with ADHD-I. Comorbid anxiety/depression increased sleep problems, whereas ODD did not. Daytime sleepiness was greatest in ADHD-I and was associated with sleeping more (not less) than normal. Medicated children had greater difficulty falling asleep than unmedicated children.

CONCLUSIONS

Differences in sleep problems were found as a function of ADHD subtype, comorbidity, and medication.

Nonsignificance of sleep relative to IQ and neuropsychological scores in predicting academic achievement

OBJECTIVE

The goal of the study was to determine the relative importance of sleep, IQ, neuropsychological, and attention-deficit/hyperactivity disorder (ADHD) scores in predicting academic achievement.

METHOD

Objective overnight polysomnograph sleep scores, parent ratings of sleep problems, IQ, neuropsychological test scores, and parent ratings of ADHD were used to predict academic achievement in a general population sample of 412 elementary schoolchildren, 6 to 12 years of age with IQs of 71 to 147.

RESULTS

Using stepwise linear regression analysis, IQ was the best single predictor of reading and math achievement test scores. The most powerful combined predictors of achievement were IQ and some of the neuropsychological test scores. Subjective parent-reported sleep problems and objective polysomnograph scores (apnea-hypopnea index, mean oxygen saturation and lowest saturation percentage during sleep, snoring frequency and severity, sleep latency, minutes to rapid eye movement (REM) sleep, arousal index, number of awakenings, sleep efficiency, and percentage of stage 1, 2, 3, 4, and REM sleep) did not contribute significantly more to the prediction of achievement. Children with and without sleep problems did not differ from each other in achievement. IQ, neuropsychological test scores, and ADHD ratings were all significantly related to achievement, but correlations between achievement and objective and subjective sleep scores were all nonsignificant.

CONCLUSIONS

There may be individual children for whom sleep problems affect achievement, but for a large group of community children, sleep was not significantly related to academic functioning. In contrast, IQ and neuropsychological test scores were powerful predictors of achievement.

Sleep and behavioral/emotional problems in children: a population-based study

BACKGROUND

The potential relationships between sleep-wake behaviors and emotional/disruptive problems in otherwise healthy school-aged children are unclear.

METHODS

A parental questionnaire was developed for the epidemiologic survey of children's sleep and wake behavioral patterns. The questions covered a wide range of features including sleep length (school days, weekends), time to fall asleep, night awakenings, bedtime and nighttime sleep-related behaviors, daytime sleepiness, irritability, and tiredness. To assess psychiatric symptomatology, the Rutter Scale B2 was completed by teachers. In addition to the total score, sub-scores of emotional, hyperactivity, and conduct problems were obtained. The representative population sample comprised 779 children (403 girls), with an age range of 6-11 years.

RESULTS

Hyperactivity and conduct problems at school in boys were both associated with parental reports of bedtime resistance. Hyperactivity was also associated with longer sleep duration during weekends. Conduct and emotional problems in girls were associated with earlier bedtime during school days. Emotional problems in girls were also associated with longer sleep durations in school days and weekends.

CONCLUSION

Bedtime resistance was the only sleep behavior associated with either hyperactivity or conduct problems in children, and longer sleep durations appear to occur more frequently in children with both hyperactive or emotional problems. Information about good sleep hygiene at bedtime may help parents setting sleep limits.

Trastorno por déficit de atención con hiperactividad y alteraciones del sueño

The attention deficit hyperactivity disorder (ADHD) is an heterogeneous, complex and common childhood disorder that causes significant impairment of child's functioning. This paper reviews the epidemiology, etiology, diagnosis, comorbidity, course and treatment of ADHD. Special attention is paid to sleep problems both because these 2 conditions frequently co-exist and because there is substantial evidence that ADHD psychopathology and sleep-wake regulation share common neurobiologic mechanisms. Moreover, there could be an overlap between symptoms of ADHD and certain sleep problems such as obstructive sleep apnea syndrome, restless leg syndrome and periodic limb movements of sleep. Children undergoing evaluation for ADHD should be systematically assessed for sleep disturbances because treatment of sleep disorders is often associated with improved symptomatology and decreased need for stimulants.

The ADHD and sleep conundrum: a review

The relationship between attention-deficit hyperactivity disorder (ADHD) and sleep is a complex one that poses many challenges in clinical practice. Recent studies have helped to elucidate the nature of the brain mechanisms and neuromodulator systems underlying the theoretical associations among sleepiness, arousal, and attention. Studies of sleep disturbances in children with academic and behavioral problems have also underscored the role that primary sleep disorders such as obstructive sleep apnea hypopnea syndrome play in the clinical presentation of symptoms of inattention and behavioral dysregulation. In addition, new methodologies used in examining sleep and sleep patterns in children diagnosed with ADHD have shed further light on the prevalence, type, risk factors for, and impact of sleep disturbances in these children. The following discussion of the multilevel relationships among sleep quality and quantity, neurobehavioral functioning, and the clinical syndrome of ADHD expands on previous reviews of the literature and synthesizes what is currently known about the interaction of sleep and attention/arousal in children to propose possible underlying mechanisms, integrate more recent findings, and highlight important areas for future study. In addition, guidelines are provided for a clinical approach to evaluation and management of children with ADHD and sleep problems.

Excessive sleepiness in adolescents and young adults: causes, consequences, and treatment strategies

Adolescents and young adults are often excessively sleepy. This excessive sleepiness can have a profound negative effect on school performance, cognitive function, and mood and has been associated with other serious consequences such as increased incidence of automobile crashes. In this article we review available scientific knowledge about normal sleep changes in adolescents (13-22 years of age), the factors associated with chronic insufficient sleep, the effect of insufficient sleep on a variety of systems and functions, and the primary sleep disorders or organic dysfunctions that, if untreated, can cause excessive daytime sleepiness in this population.

Sleep in children with attention-deficit hyperactivity disorder (ADHD): a review of naturalistic and stimulant intervention studies

Attention-Deficit Hyperactivity Disorder (ADHD) is the most common behavioral disorder of childhood. Multiple clinical and research reports suggest extensive sleep disturbances in children with ADHD, however, current data is contradictory. This paper reviewed 47 research studies (13 stimulant intervention and 34 naturalistic) on ADHD that were published since 1980. The main objectives of this review were to provide pediatric clinicians and researchers a clear and concise summary of published sleep data in children with ADHD, to provide a more accurate description of the current knowledge of the relationship between sleep and ADHD, and to provide current information on the effect of stimulant medication on sleep. Twenty-five of the reviewed studies used subjective reports of sleep, six were actigraphic studies, and 16 were overnight polysomnographic sleep studies (two of which also included Multiple Sleep Latency Tests). All participants were between the age of 3 and 19, and 60% were male. The results indicate high rates of parental reports of sleep disturbances in medicated and unmedicated children with ADHD, however, the majority of these findings have not been confirmed by objective sleep data. Although, agreement among objective studies is not absolute, the data suggest increased nighttime activity, reduced rapid eye movement sleep, and significant daytime somnolence in unmedicated children with ADHD when compared to controls. Data also suggest a possible increased prevalence of periodic limb movements in sleep in children with ADHD, however, little differences in sleep-disordered breathing. The limited number of studies, small and heterogeneous samples, and other methodological limitations make definite results difficult to determine. Future research will need to further clarify the relationship between sleep and ADHD and the effects of stimulants on sleep of children with ADHD.

Snoring and obstructive sleep apnoea in children: why should we treat?

Frequent and loud snoring is a very frequent condition in prepubertal children affecting approximately 10% of all 2-8 year old children. If polysomnographical evaluations are performed in these snoring children, approximately 10% will be diagnosed with obstructive sleep apnoea (OSA). The pathophysiology of OSA in children is still poorly understood. Indeed, while adenotonsillar hypertrophy is certainly a major contributor to OSA, other factors need to be implicated for OSA to develop. In recent years, it has become apparent that OSA and snoring are not as innocuous as previously thought. Indeed, epidemiological and pre-post treatment analyses have identified substantial morbidities that primarily affect cardiovascular and neurobehavioural systems, namely pulmonary hypertension, systemic elevation of arterial blood pressure, nocturnal enuresis, reduced somatic growth, behavioural problems that resemble attention deficit-hyperactivity disorder, as well as learning and cognitive deficits. These problems are associated with marked increases in healthcare-related costs. More importantly, if timely diagnosis and intervention are not implemented, some of these morbid complications may not be completely reversible, leading to long-lasting residual consequences.

Is there a specific polysomnographic sleep pattern in children with attention deficit/hyperactivity disorder?

The aim of the study was to characterize the sleep pattern in children with attention deficit/hyperactivity disorder (ADHD). By means of polysomnography (PSG), sleep patterns were studied in 17 unmedicated preadolescent boys rigorously diagnosed with ADHD and 17 control boys precisely matched for age and intelligence. Although ADHD children did not display a general sleep alteration, major PSG data showed a significant increase in the duration of the absolute rapid eye movement (REM) sleep and the number of sleep cycles in ADHD group when compared with controls. In addition, REM sleep latency tended to be shorter in ADHD children. These results suggest that in ADHD children, a forced REM sleep initiation may produce a higher incidence of sleep cycles and may also contribute to an increased duration of the absolute REM sleep. The overall pattern of the findings implies that a forced ultradian cycling appears characteristic for the sleep in ADHD children, which may be related to alterations of brain monoamines and cortical inhibitory control accompanying the ADHD psychopathology.

Neurologic disorders masquerading as pediatric sleep problems

Neurologic disorders may present or masquerade as pediatric sleep problems and fool the pediatrician, which may delay diagnosis and treatment. Many of the sleep problems in children with neurologic disorders arise directly from primary dysfunction or delayed maturation of their sleep-wake regulation systems. It is important to realize that nocturnal frontal lobe seizures or cluster headaches can be mistaken for night terrors, and craniopharyngiomas or myotonic dystrophy may present as narcolepsy-cataplexy. Hypothalamic dysfunction may explain not only the impaired circadian rhythm disorders in children with profound mental retardation but also excessive sleepiness and hyperphagia in Prader-Willi and Kleine-Levin syndromes. Intellectually challenged children perform better, learn more, and are better behaved with sufficient restorative sleep.

Boredom proneness and sleep disorders as predictors of adult attention deficit scores

This study examined the extent to which boredom proneness and sleep disturbances were related to attention deficit scores in college-aged adults. In a sample of 148 college students, Attention scores on the Adult Behavior Checklist were best predicted by Boredom Proneness (BP) subscale scores, which assess one's inability to maintain internal stimulation and feelings of constraint, and scores on the Epworth Daytime Sleepiness Scale and Athens Insomnia Scale (R2 = .57). Hyperactivity scores were best predicted by the BP subscales, which assess one's need for a stimulating environment, the perception of time passing slowly, and feelings of constraint, and the Epworth Scale (R2 = .51). The findings contribute to the understanding of the symptomatology of attention deficit in adults and provide further evidence of the validity of this measure.

Sleep disturbances in children with attention deficit hyperactivity disorder

The objective of the study was to compare polysomnographic patterns in two groups of preadolescent children with attention deficit hyperactivity disorder (ADHD) (a sleep clinic referral sample and a community sample) with control children. A prospective and observational study in the sleep clinic and the community was undertaken. Forty-seven ADHD children referred to the sleep clinic (ADHDcl), 53 ADHD children from a community survey (ADHDcom), and 49 control children underwent overnight polysomnography. Significant differences between the groups were observed for rapid-eye-movement (REM) sleep latency and percentage, and periodic limb movement index with associated arousals (PLMa). REM sleep latency was shorter in controls than ADHDcl and ADHDcom (p < 0.01) and REM% was highest in controls and lowest in ADHDcl (p < 0.001). PLMa was higher in ADHDcl than the other groups (p < 0.001), but there were no differences in PLMa between ADHDcom and controls. ADHD children display significant alterations in their sleep patterns, and ADHDcl are more likely to have an elevated PLMa than ADHDcom. In addition, REM sleep is affected by ADHD. We postulate that ADHDcl may represent a subset of children with ADHD at high risk for hyperactivity during sleep.