Sleep problems in children with attention-deficit hyperactivity disorder: associations with parenting style and sleep hygiene

Associations between sleep problems in children with ADHD and parental insomnia and ADHD symptoms

Sleep problems are common in children with attention deficit hyperactivity disorder (ADHD). Children's sleep problem may influence, and be influenced by, parents' sleep problems as well as parents' ADHD symptoms. In the current study we examined the associations of parent-rated sleep quality and sleep timing of pre-adolescent children with parental insomnia symptoms, parental ADHD symptoms and dysfunctional attitudes and beliefs about sleep in a convenience sample recruited by advertisement (N = 120). Childhood sleep problems were common in the sample, with 82% of children exceeding the threshold for the presence of a paediatric sleep disorder. Children's sleep quality showed minimal association with their sleep timing and chronotype. Parental insomnia symptoms, ADHD symptoms and dysfunctional beliefs and attitudes about sleep all associated with their children's sleep quality, and with the sleep subdomains of sleep anxiety and parasomnias. In multiple regression analysis only parental insomnia score was a significant predictor of children's sleep quality. Children's bedtimes, wake times, sleep duration, chronotype or social jetlag did not associate with parents' ADHD or insomnia symptoms. Sleep quality was significantly poorer in children whose parents scored as both consistent for adult ADHD and probable for insomnia disorder compared to parents who scored as either ADHD consistent or insomnia probable, or those who parents scored as neither. We discuss the putative nature of the relationships between sleep quality of children with ADHD and parental ADHD and insomnia symptoms, and suggest that clinicians consider parental sleep when attending to children with ADHD.

Bedtime Regularity and Sleep Sufficiency in Children With Tourette Syndrome

BACKGROUND

Despite research demonstrating sleep disturbance in children with Tourette syndrome (TS), few studies have examined bedtime regularity and sleep sufficiency, two important sleep health dimensions. Therefore, this study examined bedtime regularity and sleep sufficiency in children with TS relative to matched healthy control subjects, and its associated demographic, clinical, and behavioral factors.

METHODS

Participants were 384 parents or caregivers of children aged three to 17 years, including 192 with current TS and 192 matched healthy control subjects drawn from the 2020-2021 cycle of the National Survey of Children's Health. Parents completed questions assessing demographic (i.e., age, race, sex), clinical (i.e., attention-deficit/hyperactivity disorder [ADHD], autism spectrum disorder, anxiety, depression, tic severity, behavioral or conduct problems, ADHD medication, health condition-related impairment), and behavioral (i.e., screen time) characteristics. Mann-Whitney U test and chi-square test of independence were performed to compare groups on bedtime regularity and sleep sufficiency, respectively. Ordinal regression and binary logistic regression without and with backward elimination were performed to evaluate indicators of bedtime regularity and sleep sufficiency, respectively, in children with TS.

RESULTS

Children with current TS had significantly poorer bedtime regularity, but not sleep sufficiency, relative to matched healthy control subjects. In children with TS, anxiety and two or more hours of daily screen time were associated with higher likelihood of poor bedtime regularity. Autism was associated with lower likelihood of insufficient sleep, and depression was associated with increased likelihood of insufficient sleep.

CONCLUSIONS

Findings put forth screen time, anxiety, and depression as intervention targets to optimize sleep health in children with TS.

Childhood sleep: assessments, risk factors, and potential mechanisms

BACKGROUND

Sleep problem is a highly prevalent health issue among pediatric populations across the world. In this review, we aimed to identify risk factors contributing to sleep deficiency and poor sleep hygiene in children. Potential biological, psychosocial, and environmental mechanisms as well as research gaps in the literature are also discussed.

DATA SOURCES

A comprehensive search for relevant English language full-text, peer-reviewed publications was performed focusing on pediatric sleep studies from prenatal to childhood and adolescence in a variety of indexes in PubMed, SCOPUS, and Psych Info. Both relevant data based and systematic reviews are included.

RESULTS

This paper summarizes many risk factors for childhood sleep problems, including biological (e.g., genetics, gender, age and puberty, prenatal factors, postnatal factors); nutritional (e.g., macronutrients, micronutrients, omega-3 fatty acids, obesity); environmental (e.g., heavy metals, noise, light, air pollution); interpersonal (e.g., family, exposure to violence, screen media use, physical injury); and community/socioeconomic variables (e.g., racial/ethnicity and cultural factors, neighborhood conditions and socioeconomic status, school factors, public health disasters/emergencies), to better understand the development of sleep problems in children.

CONCLUSIONS

Poor childhood sleep is a multifactorial issue affected by a wide range of prenatal and early-life biological, environmental, and psychosocial risk factors and contributors. A better understanding of these risk factors and their mechanisms is an important first step to develop future research and prevention programs focusing on pediatric sleep problems.

Sleep and daytime functioning in children with tourette syndrome: A two-week case-control study with actigraphy and cognitive assessments

There is increasing recognition of the high prevalence of sleep issues in children with Tourette syndrome (TS), a condition characterised by motor and vocal tics. Overnight polysomnography (PSG) has been the primary mode of sleep assessment in the TS literature, despite the extensive use of actigraphy in other neurodevelopmental populations. As a result, there are existing research gaps surrounding day-to-day variability of sleep in TS and links to daytime functioning. This study adopts a naturalistic, intensive longitudinal design to examine sleep in children with TS while considering potential links to tic severity and daytime functioning. Participants were 34 children aged between 8 and 12 years (12 with TS, 22 neurotypical controls). Wrist actigraphs tracked sleep-wake cycles across two weeks and a battery of scales and cognitive assessments measured sleep disturbances and daytime functioning. Mixed models using N = 476 nights of actigraphy data found that relative to controls, children with TS had significantly increased time in bed, increased sleep onset latency, reduced sleep efficiency, lower subjective sleep quality, but comparable actual sleep time. Higher self-report tic severity at bedtime did not predict increased sleep onset latency. In the sleep disturbance scale, 83.33 % of children with TS met the clinical cut-off for a sleep disorder. Parent-report emotional, behavioural, and executive difficulties were greater in the TS group relative to controls, but performance on cognitive tasks was comparable between groups. Together, findings highlight sleep disturbances as an important clinical factor to consider in the management of TS, though further research is required to substantiate findings in larger-scale studies. This study demonstrates the feasibility of assessing sleep via actigraphy in children with TS, supporting more widespread use in the future.

Parent-Report Sleep Disturbances and Everyday Executive Functioning Difficulties in Children with Tourette Syndrome

There is an increasing need to identify and treat sleep disturbances in Tourette syndrome (TS), a neurodevelopmental condition characterized by tics. This study explored sleep, tics, and executive functioning in children with TS (n=136) and neurotypical controls (n=101) through parent-report scales and open-ended questions. 85% of children with TS scored in the clinical range for a sleep disorder. Higher tic severity predicted increased sleep disturbances and executive difficulties. Qualitative insights indicated a bidirectional link between sleep and tics, which warrants consideration in clinical settings. Further research is needed to explore causal links.

A longitudinal investigation of sleep hygiene as a mediator linking parental warmth with adolescent sleep

STUDY OBJECTIVES

Parental warmth in adolescence protects sleep in early adulthood, yet the nature, directions, and mechanisms of this association across adolescence are unknown. This study examined parental warmth, adolescent sleep hygiene and sleep outcomes (morning/eveningness, school night sleep duration, and daytime sleepiness) across five annual waves, spanning four years, using a cross-lagged panel design.

METHODS

Adolescents and one primary caregiver (96% mothers) completed questionnaires assessing parental warmth (child- and parent-report) and adolescent sleep hygiene and sleep (child-report), across five annual waves: Wave 1 (N = 531, Mage = 11.18, SD = 0.56, 51% male), Wave 2 (N = 504, Mage = 12.19, SD = 0.53, 52% male), Wave 3 (N = 478, Mage = 13.19, SD = 0.53, 52% male), Wave 4 (N = 440, Mage = 14.76, SD = 0.47, 51% male), and Wave 5 (N = 422, Mage = 15.75, SD = 0.49, 51% male).

RESULTS

Greater child-reported parental warmth was indirectly associated with better adolescent sleep (greater morningness, longer school night sleep duration, less sleepiness) through healthier sleep hygiene. The inverse was also often observed. Warmth had a direct relationship with sleep duration and sleepiness, independent of sleep hygiene. Parent-reported parental warmth did not predict, nor was predicted by child-reported adolescent sleep.

CONCLUSIONS

Parental warmth may protect against developmental changes in adolescent sleep, partially by improving sleep hygiene practices. Similarly, inadequate adolescent sleep may negatively impact parental warmth via deteriorating sleep hygiene. Sleep hygiene emerged as a key mechanism for protecting adolescent sleep and parent-child relationships.

Sleeping Sound Autism Spectrum Disorder (ASD): a randomised controlled trial of a brief behavioural sleep intervention in primary school-aged autistic children

BACKGROUND

Behavioural sleep problems are common in children with autism spectrum disorder (ASD); however, evidence for the efficacy of behavioural sleep interventions is limited. This study examined the efficacy of a brief behavioural sleep intervention in autistic children. It was hypothesised that the intervention would reduce overall child sleep problems (primary outcome), in addition to improvements in children's social, emotional, cognitive, academic functioning, and quality of life, and parent/caregivers' stress, quality of life, and mental health (secondary outcomes).

METHODS

A randomised controlled trial was conducted with participants randomised via a computer-generated sequence to the sleeping sound intervention (n = 123) or treatment as usual (n = 122) group. Participants comprised 245 children with an ASD diagnosis. Inclusion criteria were as follows: confirmation of DSM IV or DSM-5 diagnosis of ASD, participants aged between 5 and 13 years and parent/caregiver report of moderate-severe sleep problems. Exclusion criteria were as follows: parent/caregiver intellectual disability or lacking sufficient English to complete questionnaires; and child participant with co-occurring medical conditions known to impact sleep. The intervention group received the sleeping sound intervention (2 × 50-min face-to-face sessions plus follow-up phone call) by a trained clinician.

RESULTS

Change in children's sleep problems was measured by the Children's Sleep Habits Questionnaire (CSHQ) at 3 months post randomisation. Parents/caregivers of children in the intervention group reported a reduction in child sleep problems at 3 months post randomisation (effect size: E.S -0.7). There were also small effects in a number of child (internalising symptoms, emotional behavioural disturbance and quality of life) and parent/caregiver (mental health, parenting stress and quality of life) outcomes; however, these did not remain significant when controlling for multiple comparisons.

CONCLUSIONS

The sleeping sound ASD intervention is an efficacious and practical way to reduce sleep problems for autistic children. This brief behavioural intervention has the potential to be embedded easily into the Australian healthcare system.

Children's behavioral problems, screen time, and sleep problems' association with negative and positive parenting strategies during the COVID-19 outbreak in Brazil

Families' health, safety, and economic stability were jeopardized during the pandemic. Parental stress is a risk factor for hostile and less supportive parenting. Parenting styles are a set of attitudes, feelings and behaviors related to parenting that modulate the child's psychosocial functioning and might impact on the adaptability to a stressful time.

OBJECTIVE

To investigate the group differences among children raised by negative and positive parenting families during COVID-19 pandemic.

METHODS

We have done an online survey with 329 parents. Parents answer about parenting strategies and styles, children's behavior, Covid related questions, socio-economic information, sleep and gaming disorders.

RESULTS

Parents' frequent use of negative strategies were a risk factor to have a negative outcome related to mental health, games, sleep, and children behavior.

DISCUSSION

Parenting strategies are some targets pointed in this study for intervention. Parents' styles and strategies training to better manage children might be even more important to avoid negative consequences for children in stressful times.

Impact of a Behavioral Sleep Intervention in Adolescents With ADHD: Feasibility, Acceptability, and Preliminary Effectiveness From a Pilot Open Trial

OBJECTIVE

An open trial tested the feasibility, acceptability, and preliminary effectiveness of a behavioral sleep intervention in adolescents with ADHD.

METHOD

Fourteen adolescents (ages 13-17 years; 50% male) with ADHD and co-occurring sleep problems received the cognitive-behavioral-based Transdiagnostic Sleep and Circadian Intervention for Youth (TranS-C). Adolescent, parent, and teacher ratings, actigraphy, and daily sleep diaries were collected at pre-intervention, post-intervention, and 3-month follow-up.

RESULTS

Adolescents experienced moderate to large improvements in sleep, mental health symptoms, and daily life executive functioning from pre-treatment to post-treatment, and improvements were generally maintained at 3 months. Pre-intervention, 71.4% of adolescents were classified as poor sleepers and this was reduced to 21.4% and 28.6% at post-treatment and follow-up, respectively.

CONCLUSION

This study provides strong preliminary evidence that TranS-C improves sleep and associated outcomes in adolescents with ADHD and co-occurring sleep problems. A randomized controlled trial is needed to rigorously test the efficacy of TranS-C in this population.

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 in Individuals with ADHD: Prevalence, Impacts, Causes, and Treatments

Sleep problems are common in children and adolescents with ADHD. This chapter covers the basics of sleep and the prevalence and types of sleep problems experienced by children and adolescents with ADHD. The impacts of sleep problems on the day-to-day lives of children with ADHD and their families are covered including impacts on child daily functioning and cognition, as well as family well-being. There is no one cause of sleep problems in children with ADHD with both biological and environmental factors implicated. There are a small number of randomized controlled trials that support the efficacy of treating sleep problems in children with ADHD using behavioral strategies. A small number of studies also have found improvements in sleep onset delay in children with ADHD following treatment with melatonin. Little is known about how to best support adolescents and adults with ADHD with sleep, although a small emerging literature largely in adults with ADHD suggests that bright light therapies could potentially be helpful given the extent of circadian involvement in the sleep problems experienced by individuals with ADHD. This chapter ends with consideration of future research directions largely related to approaches to supporting individuals with ADHD and sleep difficulties.

Actigraphy-Derived Sleep Profiles of Children with and without Attention-Deficit/Hyperactivity Disorder (ADHD) over Two Weeks-Comparison, Precursor Symptoms, and the Chronotype

Although sleep problems are common in children with ADHD, their extent, preceding risk factors, and the association between neurocognitive performance and neurobiological processes in sleep and ADHD, are still largely unknown. We examined sleep variables in school-aged children with ADHD, addressing their intra-individual variability (IIV) and considering potential precursor symptoms as well as the chronotype. Additionally, in a subgroup of our sample, we investigated associations with neurobehavioral functioning (n = 44). A total of 57 children (6-12 years) with (n = 24) and without ADHD (n = 33) were recruited in one center of the large ESCAlife study to wear actigraphs for two weeks. Actigraphy-derived dependent variables, including IIV, were analyzed using linear mixed models in order to find differences between the groups. A stepwise regression model was used to investigate neuropsychological function. Overall, children with ADHD showed longer sleep onset latency (SOL), higher IIV in SOL, more movements during sleep, lower sleep efficiency, and a slightly larger sleep deficit on school days compared with free days. No group differences were observed for chronotype or sleep onset time. Sleep problems in infancy predicted later SOL and the total number of movements during sleep in children with and without ADHD. No additional effect of sleep problems, beyond ADHD symptom severity, on neuropsychological functioning was found. This study highlights the importance of screening children with ADHD for current and early childhood sleep disturbances in order to prevent long-term sleep problems and offer individualized treatments. Future studies with larger sample sizes should examine possible biological markers to improve our understanding of the underlying mechanisms.

Paternal adverse childhood experiences: Associations with infant DNA methylation

Adverse childhood experiences (ACEs), or cumulative childhood stress exposures, such as abuse, neglect, and household dysfunction, predict later health problems in both the exposed individuals and their offspring. One potential explanation suggests exposure to early adversity predicts epigenetic modification, especially DNA methylation (DNAm), linked to later health. Stress experienced preconception by mothers may associate with DNAm in the next generation. We hypothesized that fathers' exposure to ACEs also associates with their offspring DNAm, which, to our knowledge, has not been previously explored. An epigenome-wide association study (EWAS) of blood DNAm (n = 45) from 3-month-old infants was regressed onto fathers' retrospective ACEs at multiple Cytosine-phosphate-Guanosine (CpG) sites to discover associations. This accounted for infants' sex, age, ethnicity, cell type proportion, and genetic variability. Higher ACE scores associated with methylation values at eight CpGs. Post-hoc analysis found no contribution of paternal education, income, marital status, and parental postpartum depression, but did with paternal smoking and BMI along with infant sleep latency. These same CpGs also contributed to the association between paternal ACEs and offspring attention problems at 3 years. Collectively, these findings suggested there were biological associations with paternal early life adversity and offspring DNAm in infancy, potentially affecting offspring later childhood outcomes.

Association between Compliance with Movement Behavior Guidelines and Obesity among Malaysian Preschoolers

A daily balance of physical activities, sedentary behaviors and sleep are important for maintaining the health of young children. The aim of this study is to explore the association between 24-h movement behavior of Malaysian children aged 4 to 6 years with weight status. A total of 230 preschoolers were recruited from 22 kindergartens in Kuala Lumpur. Physical activity was assessed by Actical accelerometer while screen time and sleep duration were proxy-reported by parents. Children spent on average 5.5 ± 1.3 h on total physical activity (including 1.0 ± 0.4 h of moderate- vigorous physical activity), 3.0 ± 1.6 h on screen activities and 9.5 ± 1.3 h sleeping daily. The proportion of children who complied with physical activity and sleep guidelines were 48.7% and 55.2%, respectively. About 25.2% of children met screen time recommendation. Only 6.5% of children met all three age-specific physical activity, screen time and sleep guidelines. Children who met any two guidelines were less likely to be overweight or obesity compared to those who did not meet any of the guidelines (OR: 0.276; 95% CI: 0.080–0.950). In conclusion, Malaysian preschoolers have low compliance to movement behavior guidelines, especially in meeting screen time recommendations. Compliance to movement behavior guidelines was associated with lower odds of overweight and obesity.

A brief clinician training program to manage sleep problems in ADHD: what works and what do clinicians and parents think?

OBJECTIVE/BACKGROUND

Brief behavioural sleep interventions have been shown to be effective in treating sleep problems in children with ADHD. Little research, however, has focused on the translational aspects of these programs from the consumer perspective. This study aimed to explore clinician and parent views of a brief training program in managing sleep problems in children with ADHD.

PARTICIPANTS

Fifty-nine community-based clinicians (32 paediatricians, 27 psychologists) were trained to deliver a brief behavioural sleep intervention as part of the Sleeping Sound with ADHD translational trial; 183 families were allocated to receive the sleep intervention and 115 provided follow-up data.

METHODS

Clinicians reported on competency, confidence and perceived barriers pre- and post-training. Parents reported on usefulness of the program and frequency of sleep strategy use at 3 months post-randomisation. Parent-report of severity of the child sleep problem was also measured at 3 and 6 months post-randomisation.

RESULTS

Clinicians' feelings of competency and confidence in managing sleep difficulties increased from pre-to post-training, while perceptions of barriers decreased. Parent-reported usefulness of the program and frequency of sleep use varied by program domain and sleep strategy. Increased parent-reported use of sleep strategies was associated with improved sleep at 3 and 6 months post-randomisation.

CONCLUSIONS

A brief sleep training program leads to improvements in clinician confidence and competence in managing sleep problems in children with ADHD and positive parent perspectives. The findings highlight the potential for the Sleeping Sound with ADHD program to be optimized to better help parents in their implementation of sleep strategies.

Associations Between Sleep Hygiene and Sleep Problems in Adolescents With ADHD: A Cross-Sectional Study

Objective: To determine whether self-reported sleep hygiene practices are associated with self- and parent-reported behavioral sleep problems in adolescents with ADHD. Method: Participants included 79 adolescents with ADHD (13-17 years) and their parents. Adolescents were asked to report on their sleep hygiene (Adolescent Sleep Hygiene Scale) and sleep (Adolescent Sleep Wake Scale). Parents also reported on their adolescent's sleep (Sleep Disturbance Scale for Children). Results: Poorer sleep hygiene was associated with higher total self-reported behavioral sleep problems and most self-reported sleep problems: falling asleep, reinitiating sleep, and returning to wakefulness. The association was also apparent for total parent-reported behavioral sleep problems, problems with initiating and maintaining sleep, and excessive somnolence. Conclusion: This study demonstrates small-to-moderate relationships between poor sleep hygiene practices and sleep problems in adolescents with ADHD, by both self- and parent-report.

The Relationship Between Maternal Stress and Boys' ADHD Symptoms and Quality of Life: An Australian Prospective Cohort Study

PURPOSE

This study prospectively examined the role of maternal stress in boys' attention deficit hyperactivity disorder (ADHD) symptoms and quality of life (QoL).

METHODS

Children with ADHD (5-13 years) were recruited from 21 pediatric practices and followed up 12 months later (n = 166). Maternal stress was examined at baseline, and boys' ADHD symptoms and QoL were examined at baseline and 12 months later. Linear regressions examined whether baseline maternal stress predicted child ADHD symptoms and QoL 12 months later in a series of adjusted models that accounted for child age, ADHD medication use, neighborhood disadvantage, comorbidities and baseline ADHD symptoms or QoL (full model).

RESULTS

In the unadjusted model, maternal stress at baseline was significantly associated with more severe parent-reported ADHD symptoms at 12 months, accounting for 5.7% of the variance in ADHD symptoms, but this association was attenuated after adjustments in the full model. Baseline maternal stress was associated with poorer QoL at 12 months in boys in the unadjusted model, accounting for 12.4% of the variance, which remained significant in the full adjusted model.

CONCLUSIONS

Maternal stress is associated with lowered QoL in boys, and may pose a risk for boys' later QoL.

PRACTICE IMPLICATIONS

Stress management interventions with mothers of children with ADHD experiencing heightened stress are warranted, and are likely to have a positive impact on mothers as well as children.

Sleep in children with neurodevelopmental difficulties

Sleep disorders in children with neurodevelopmental disorders are complex and reflect underlying genetic/biological and behavioural components. The sleep disorders are the same as in the typically developing child, although there may be some modifications to the presentation or the frequency depending on the phenotype. Consideration of the known phenotypes and environmental issues are important in defining management strategies. Despite this complexity, defined behavioural strategies with good sleep hygiene can have a significant effect on the sleep problem and on parental management of the behaviours.