The impact of comorbid mental health symptoms and sex on sleep functioning in children with ADHD

Changed sleep according to weighted blanket adherence in a 16-week sleep intervention among children with attention-deficit/hyperactivity disorder

STUDY OBJECTIVES

To examine differences in sample characteristics and longitudinal sleep outcomes according to weighted blanket (WB) adherence.

METHODS

Children with attention-deficit/hyperactivity disorder (n = 94), mean age 9.0 (standard deviation 2.2, range 6-14) participated in a 16-week sleep intervention with WBs. Children were classified as WB adherent (use of WB ≥ 4 nights/wk) or nonadherent (use of WB ≤ 3 nights/wk). Changes in objectively measured sleep by actigraphy, parent-reported sleep problems (Children's Sleep Habits Questionnaire) and child-reported Insomnia Severity Index were evaluated according to adherence with mixed effect models. Sex, age, and attention-deficit/hyperactivity disorder subtype were examined as potential moderators.

RESULTS

Children adherent to WBs (48/94) showed an early response in sleep outcomes and an acceptance of the WB after 4 weeks of use as well as a decrease in parent-reported (Children's Sleep Habits Questionnaire) (-5.73, P = .000) and child-reported (Insomnia Severity Index) (-4.29, P = .005) sleep problems after 16 weeks. The improvement in sleep was larger among WB adherent vs nonadherent (between-group difference: Children's Sleep Habits Questionnaire: -2.09, P = .038; Insomnia Severity Index: -2.58, P = .007). Total sleep time was stable for children adherent to WB but decreased for nonadherent (between-group difference: +16.90, P = .019).

CONCLUSIONS

An early response in sleep and acceptance of the WB predicted later adherence to WBs. Improvements in sleep were more likely among WB adherents vs nonadherents. Children with attention-deficit/hyperactivity disorder may thus benefit from using WBs to handle their sleep problems.

CITATION

Lönn M, Svedberg P, Nygren J, Jarbin H, Aili K, Larsson I. Changed sleep according to weighted blanket adherence in a 16-week sleep intervention among children with attention-deficit/hyperactivity disorder. J Clin Sleep Med. 2024;20(9):1455-1466.

Later ("evening") circadian preference is associated with poorer executive, academic, and attentional functioning in adolescents with and without ADHD

BACKGROUND

Adolescents vary considerably in their circadian phase preference; those with greater "eveningness" (also known as "night owls") have later bedtimes, wake times, and peak arousal compared to those with greater "morningness." Prior research suggests that (a) greater eveningness is associated with worse academic, executive, and attentional functioning; and (b) adolescents with attention-deficit/hyperactivity disorder (ADHD) tend to be high in eveningness and to have deficits in these school-related constructs. However, few studies have examined circadian preference alongside two potential confounds-sleep duration and sleep quality-as predictors of daytime functioning, or whether the strength of associations differs across adolescents with and without ADHD.

METHODS

Participants were 302 adolescents (Mage = 13.17 years; 44.7% female; 81.8% White); approximately half (52%) had ADHD. A multi-method, multi-informant design was used. Specifically, adolescents reported on their circadian preference, school night sleep duration, and sleep quality. Adolescents provided ratings of their academic motivation (intrinsic, extrinsic, and amotivation) and were administered standardized achievement tests in reading and math. Adolescents and parents completed ratings of daily life executive functioning (behavioral, emotion, and cognitive regulation), and they and teachers also provided ratings of ADHD inattentive symptoms.

RESULTS

Above and beyond sleep duration, sleep quality, and covariates (sex, family income, pubertal development, medication use), greater eveningness was uniquely associated with poorer academic, executive, and attentional functioning across most measures. Sleep quality was uniquely associated with a handful of outcomes, and sleep duration was not significantly uniquely associated with any outcome in the regression analyses. ADHD status did not moderate effects.

CONCLUSIONS

This study provides compelling evidence that poorer academic, executive, and attentional functioning are more closely associated with greater eveningness than with sleep duration or quality in adolescents. Findings suggest that targeting circadian preference may be important to reduce these problems in adolescents, especially in clinical samples such as ADHD for whom academic, executive, and attentional difficulties are exceptionally common.

Sex Differences in Children with Uncomplicated Attention Deficit/Hyperactivity Disorder and Sleep Problems

BACKGROUND

Approximately 7.6% of children are diagnosed with attention deficit/hyperactivity disorder (ADHD), and sleep impairments affect 25-85%. There is a noticeable lack of research on girls and sex differences. The aim of this study was to examine sex differences in children with uncomplicated ADHD and sleep problems.

METHODS

Cross-sectional baseline data were retrieved from a randomized controlled trial with weighted blankets (55 boys and 41 girls, 6-14 years) on a cohort recently diagnosed with uncomplicated ADHD and sleep problems. Differences between boys and girls in ADHD symptoms, objectively and subjectively measured sleep, anxiety, and functioning were examined via parent- or self-reported validated instruments.

RESULTS

Girls reported significantly lower (worse) satisfaction with well-being, life overall, and school, but not for family. Parents reported more sleep anxiety and night-time wakings among boys, but no sex differences in other measures and also not in self-reported measures or objective sleep measures. Children who reported worry, sadness, or unhappiness had more sleep problems.

CONCLUSIONS

Boys with ADHD and sleep problems may need support with sleep-related anxiety and night-time wakings, while girls may require support with overall functioning. Additionally, children who express feelings of worry, sadness, or unhappiness alongside their ADHD symptoms should have attention given to their sleep.

The efficacy of weighted blankets for sleep in children with attention-deficit/hyperactivity disorder-A randomized controlled crossover trial

Weighted blankets are a non-pharmacological intervention for treating sleep and anxiety problems in children with attention-deficit/hyperactivity disorder. However, research on the efficacy of weighted blankets is sparse. The aim of this randomized controlled trial with a crossover design (4 + 4 weeks) was to evaluate the efficacy of weighted blankets on sleep among children with attention-deficit/hyperactivity disorder and sleeping problems. Children diagnosed with uncomplicated Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition attention-deficit/hyperactivity disorder with verified sleep problems were randomized to start with either a weighted blanket or a lighter control blanket. Data collection was performed at weeks 0, 4 and 8 using actigraphy, questionnaires and a daily sleep diary. T-tests were used to evaluate efficacy. The study included 94 children with attention-deficit/hyperactivity disorder (mean age 9.0 [sd 2.2] years; 54 [57.4%] boys). Weighted blankets had a significant effect on total sleep time (mean diff. 7.72 min, p = 0.027, Cohen's d = 0.24), sleep efficiency (mean diff. 0.82%, p = 0.038, Cohen's d = 0.23) and wake after sleep onset (mean diff. -2.79 min, p = 0.015, Cohen's d = -0.27), but not on sleep-onset latency (p = 0.432). According to our exploratory subgroup analyses, weighted blankets may be especially beneficial for improving total sleep time in children aged 11-14 years (Cohen's d = 0.53, p = 0.009) and in children with the inattentive attention-deficit/hyperactivity disorder subtype (Cohen's d = 0.58, p = 0.016). Our results suggest that weighted blankets may improve children's sleep and could be used as an alternative to pharmacological sleep interventions.

Examining the associations between attention-deficit/hyperactivity disorder, sleep problems, and other mental health conditions in adolescents

Adolescents with attention-deficit/hyperactivity disorder (ADHD) often experience greater sleep difficulties compared to those without. However, findings are mixed, and other mental health conditions are often overlooked. This study aimed to examine the relationship between sleep problems, ADHD, and other mental health conditions in a sample of adolescents. Data from 373 adolescents aged 10-19 years was used as part of the wider 'Healthy Brain Network' study, which targets children and adolescents experiencing mental health and neurodevelopmental difficulties. Mental health conditions were assessed via a comprehensive assessment. Sleep was measured by self- and parent-report, as well as via up to a month of actigraphy data. Actigraphy data were analysed using mixed-methods modelling, while subjective sleep data were analysed using multiple regression. Subjectively-reported sleep was generally worse in adolescents who had ADHD and other mental health conditions compared to those with ADHD but no other conditions. There were no associations between ADHD status and objective sleep measures or self-reported measures, but a significant association was found between ADHD status and parent-reported sleep difficulties, even when accounting for other conditions. Parent-reported sleep problems were associated not only with ADHD, but also with anxiety, depression, and externalising disorders. The strength of association between ADHD and sleep problems is potentially not as strong as previously thought when considering the role of other mental health conditions. Clinicians should consider the role of other mental health conditions when sleep problems are present, and vice versa. The study also highlights the importance of comprehensive, multi-informant assessment of mental health conditions, including sleep.

Methylphenidate and Sleep Difficulties in Children and Adolescents With ADHD: Results From the 2-Year Naturalistic Pharmacovigilance ADDUCE Study

OBJECTIVE

Short-term RCTs have demonstrated that MPH-treatment significantly reduces ADHD-symptoms, but is also associated with adverse events, including sleep problems. However, data on long-term effects of MPH on sleep remain limited.

METHODS

We performed a 2-year naturalistic prospective pharmacovigilance multicentre study. Participants were recruited into three groups: ADHD patients intending to start MPH-treatment (MPH-group), those not intending to use ADHD-medication (no-MPH-group), and a non-ADHD control-group. Sleep problems were assessed with the Children's-Sleep-Habits-Questionnaire (CSHQ).

RESULTS

1,410 participants were enrolled. Baseline mean CSHQ-total-sleep-scores could be considered clinically significant for the MPH-group and the no-MPH-group, but not for controls. The only group to show a significant increase in any aspect of sleep from baseline to 24-months was the control-group. Comparing the MPH- to the no-MPH-group no differences in total-sleep-score changes were found.

CONCLUSION

Our findings support that sleep-problems are common in ADHD, but don't suggest significant negative long-term effects of MPH on sleep.

Sleep in Autism Spectrum Disorder and Attention Deficit Hyperactivity Disorder

SLEEP IN AUTISM SPECTRUM DISORDER AND ATTENTION DEFICIT HYPERACTIVITY DISORDER: Kanwaljit Singh, Andrew W. Zimmerman Seminars in Pediatric Neurology Volume 22, Issue 2, June 2015, Pages 113-125 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.

Differential Effects of ADHD Polygenic Risk on Cognitive Performance in Later Life

OBJECTIVE

Understanding the association between polygenic risk for ADHD and cognition throughout aging has not been widely studied. This study aimed to determine whether ADHD risk influences cognitive performance among individuals at both young-old and middle-old age.

METHOD

Participants from the Health and Retirement Study, a biennial survey of 20,000 Americans, were compared on executive function and delayed recall measures using regression analyses.

RESULTS

There was no significant effect of ADHD risk on memory at both age waves for African-ancestry (AA; n = 403) and European-ancestry (EA; n = 2,286). There was, however, a significant association between ADHD risk and performance on executive function for EA at middle-old age (p = .028), but not young-old age; no such association was observed for AA adults.

CONCLUSION

This finding suggests that ADHD risk may differentially influence cognition among older adults throughout the aging process, with important implications for future research.

Prevalence of sleep disorder diagnoses and sleep medication prescriptions in individuals with ADHD across the lifespan: a Swedish nationwide register-based study

BACKGROUND

Consistent evidence suggests a strong association between attention-deficit/hyperactivity disorder (ADHD) and subjectively reported sleep problems. However, the prevalence of clinically ascertained sleep disorder diagnoses and sleep medication prescriptions in individuals with ADHD remains unclear.

OBJECTIVE

To determine the rates of sleep disorder diagnoses and sleep medication prescriptions in children, adolescents and adults with ADHD.

METHODS

We linked Swedish national registers to create a cohort of individuals born 1945-2008. We estimated the absolute and relative risks (using logistic regression models) of different sleep disorder diagnoses and medication prescriptions in individuals with and without ADHD. The analyses were performed across five different age groups: children (5-11 years), adolescents (12-17 years), young adults (18-30 years), middle-aged adults (31-45 years) and older adults (46-60 years).

FINDINGS

Among individuals with ADHD (N=145 490, 2.25% of the cohort), 7.5% had a sleep disorder diagnosis and 47.5% had been prescribed sleep medication. Individuals with ADHD, across all age groups, had a statistically significantly increased risk of having any sleep disorder diagnosis (ORrange=6.4-16.1) and any sleep medication prescription (ORrange=12.0-129.4) compared with individuals without ADHD. While rates of sleep disorders were highest in older adults, the relative risks were highest in youth.

CONCLUSIONS

Individuals with ADHD have a substantially increased risk of sleep disorder diagnoses and sleep medication prescriptions, from childhood into older adulthood.

CLINICAL IMPLICATIONS

More clinical efforts are needed to tackle impairing sleep problems in individuals with ADHD via systematic sleep assessment, appropriate diagnosis, and pharmacological and non-pharmacological interventions. Sleep medication use should be informed by sleep disorder diagnosis.

Sleep disorders related to index and comorbid mental disorders and psychotropic drugs

PURPOSE

Mental disorders positively associate with sleep disorders. This study will explore the moderating influence of comorbid mental disorders and whether selected psychotropic drugs correlate with sleep disorders after adjusting for mental disorders.

METHODS

A retrospective cohort study design was employed using medical claim data from the Deseret Mutual Benefit Administrators (DMBA). Mental disorders, psychotropic drug use, and demographic data were extracted from claim files for ages 18-64, years 2016-2020.

RESULTS

Approximately 11.7% filed one or more claims for a sleep disorder [insomnia (2.2%) and sleep apnea (9.7%)]. Rates for selected mental disorders ranged from 0.09% for schizophrenia to 8.4% for anxiety. The rate of insomnia is greater in those with bipolar disorder or schizophrenia than in other mental disorders. The rate of sleep apnea is greater in those with bipolar disorder and depression. There is a significantly positive association between mental disorders and insomnia and sleep apnea, more so for insomnia, especially if they had other comorbid mental disorders. Psychotropic drugs other than CNS stimulants, primarily sedatives (non-barbiturate) and psychostimulants, explain much of the positive association between anxiety, depression, and bipolar disorder with insomnia. Psychotropic drugs with the largest effect on sleep disorders are sedatives (non-barbiturate) and psychostimulants for insomnia and psychostimulants and anticonvulsants for sleep apnea.

CONCLUSION

Mental disorders positively correlate with insomnia and sleep apnea. The positive association is greater when multiple mental illness exists. Bipolar disorder and schizophrenia are most strongly associated with insomnia, and bipolar disorder and depression are most strongly associated with sleep disorders. Psychotropic drugs other than CNS stimulants, primarily sedatives (non-barbiturate) and psychostimulants for treating anxiety, depression, or bipolar disorder are associated with higher levels of insomnia and sleep apnea.

Associations Between ADHD, Sleep Problems, and Mental Health Symptoms in Adolescents

OBJECTIVE

This study examined associations between objective and subjective sleep parameters, and mental health symptoms (internalizing symptoms, externalizing symptoms, and irritability) and whether these relationships differed for adolescents with and without ADHD.

METHOD

Participants were 373 adolescents aged 10 to 19 years (M = 13.21, SD = 2.37). Sleep was measured both via actigraphy and self- and parent-report scales. Mental health symptoms were measured via a range of validated measures.

RESULTS

Few relationships were detected when examining actigraphy variables. Subjective sleep parameters were associated with almost all mental health variables. Some relationships were moderated by ADHD status, generally consistent with stronger relationships between subjective sleep quality and mental health in the non-ADHD group.

CONCLUSION

Sleep problems, particularly subjective difficulties, are associated with a range of mental health outcomes, regardless of the presence of ADHD. Sleep problems may be a beneficial intervention target for adolescents experiencing mental health issues.

Associations Between Dimensional Persistence of ADHD and Adult Sleep Quality in a Prospective Study of Girls

OBJECTIVES

We investigated the prospective association between (a) ADHD symptom dimensions, including their persistence and (b) adult sleep quality in a female sample, covarying adult depressive symptoms.

METHODS

Participants comprised four persistence groups (persisters, partials, desisters, and comparison) based on overall ADHD diagnosis and separate dimensions of inattention and hyperactivity/impulsivity (HI) in childhood, late adolescence, and early adulthood, featuring girls with (n = 140) and without (n = 88) carefully diagnosed ADHD.

RESULTS

Only persistence of inattention predicted lower adult sleep quality when covarying young-adult depression, which was also a significant predictor. When additionally covarying stimulant medication use in adulthood, inattention persistence lost significance, although depression maintained significance, with medication use predicting worse sleep quality.

CONCLUSIONS

Persistence of inattentive (but not HI) symptoms was significantly related to adult sleep quality in the context of concurrent depression. Sleep quality is an important outcome for research on and treatment for ADHD.

Experiences of Using Weighted Blankets among Children with ADHD and Sleeping Difficulties

Introduction

Sleeping difficulties are common in children with attention deficit hyperactivity disorder (ADHD). A sleep intervention with weighted blankets was designed to increase current understanding of using weighted blankets to target children's individual needs in connection with sleep and daytime functioning.

Aim

To explore how children with ADHD and sleeping difficulties experience the use of weighted blankets.

Methods

An explorative qualitative design in which 26 children with ADHD and sleeping difficulties, 6-15 years old, were interviewed about a sleep intervention with weighted blankets. Four categories emerged from qualitative content analysis.

Results

Children's experiences revealed that the use of weighted blankets 1) requires a commitment, by adjusting according to needs and preferences and adapting to the environment; 2) improves emotional regulation by feeling calm and feeling safe; 3) changes sleeping patterns by creating new routines for sleep and improving sleep quality; and 4) promotes everyday participation by promoting daily function and balancing activity and sleep.

Conclusions

Using weighted blankets promoted children's management of daily life with ADHD and sleeping difficulties. Occupational therapists can improve the assessment and delivery of weighted blankets tailored to individual needs based on increased knowledge from the children themselves.

Sleep interventions for children with attention deficit hyperactivity disorder (ADHD): A systematic literature review

OBJECTIVE/BACKGROUND

Healthy sleep is particularly important for children with attention deficit hyperactivity disorder (ADHD), as sleep disturbances might aggravate disease symptoms. This review aims to synthesize and report evidence on the effectiveness of sleep interventions in increasing sleep, quality of life (QoL), and ADHD symptoms among children with ADHD.

PATIENTS/METHODS

The systematic literature review follows the Cochrane Collaboration methodology recommendations for literature reviews. Four databases were used based on the population, intervention, control and outcome (PICO) framework. Controlled trials with minimum 20 children in each group, aged 6-18, and published from 2005 and onwards were included. Results from the studies were reported in forest plots and three of the seven review outcomes were synthesized in meta-analyses.

RESULTS

The search identified 7710 records; of which 4808 abstracts were screened. After fulltext-screening of 99 papers, eight papers from five studies were included. The studies included behavioral sleep interventions and pharmacological interventions using melatonin and eszopiclone. For six of the seven outcomes, the effect sizes were small to moderate and the certainty of the evidence was low. For one outcome, sleep disturbances, the effect size was a moderate -0.49 standardized mean differences (95% confidence interval -0.65;-0.33), with a moderate certainty of evidence for the behavioral interventions for children aged 5-13 years with ADHD.

CONCLUSIONS

This review identified few and heterogeneous studies. A moderate certainty of evidence for a moderate effect size was only obtained for sleep disturbances from the behavioral interventions. A low certainty of the evidence for a moderate effect size was found for the total sleep time from the pharmacological intervention using melatonin and one behavioral intervention, which indicates that these sleep interventions impact sleep quantity and quality among children with ADHD.

Parents' Experiences of Direct and Indirect Implications of Sleep Quality on the Health of Children with ADHD: A Qualitative Study

Sleep problems represent a significant challenge for children with ADHD. However, lack of knowledge about how sleep affects children with ADHD in terms of their health and everyday life prevents the development and implementation of interventions to promote sleep. The aim of this study was to explore parents' experiences of direct and indirect implications of sleep quality on the health of children with ADHD. The study used an abductive qualitative design, with Tengland's two-dimensional theory of health as a deductive analysis framework. Semi-structured interviews were conducted with 21 parents of children aged 6-13 with ADHD and sleep problems. The parents experienced that sleep influenced their children's abilities to control emotional behaviour related to ADHD and to manage everyday life. Sleep also had an impact on the children's well-being, in relation to both vitality and self-esteem. In conclusion, the results show important direct and indirect implications of sleep quality on the health of children with ADHD. This implies a need for greater focus on sleep, to target both abilities and well-being in promoting health among children with ADHD.

Comorbidities Associated With Attention-Deficit/Hyperactivity Disorder in Children and Adolescents at a Tertiary Care Setting

Studies have revealed high rates of neurodevelopmental and psychiatric comorbid conditions among individuals diagnosed with attention-deficit/hyperactivity disorder (ADHD). However, research on this topic in the Arab world has been limited. This study evaluates the medical, neurodevelopmental, and psychiatric comorbidities in children and adolescents diagnosed with ADHD in Dubai, United Arab Emirates (UAE). A total of 428 pediatric patients diagnosed with ADHD were included. Children and adolescents with ADHD had high rates of comorbid disorders. Twenty comorbid conditions were identified. More than 3 quarters of the study sample had at least 1 comorbid disorder. The most common comorbidity among children was autism spectrum disorder, and among adolescents was anxiety disorders. Comprehensive assessments are highly warranted to identify and manage associated comorbid conditions. Further research is needed in exploring the biopsychosocial factors contributing to the elevated rate of comorbidity in children and adolescents with ADHD.

Treatment with RehaCom computerized rehabilitation program improves response control, but not attention in children with attention-deficit/hyperactivity disorder (ADHD)

Attention-deficit/hyperactivity disorder (ADHD) is a common psychiatric disorder in children. ADHD impairs attention, response control, emotion regulation, and other cognitive functions. On the other hand, RehaCom is a cognitive rehabilitation software that has therapeutic effects on cognitive dysfunctions in many diseases such as stroke, multiple sclerosis, and schizophrenia. The goal of the present study was to investigate the effect of treatment with RehaCom on auditory and visual response control, and auditory and visual attention in children with ADHD. Forty patients were selected. The participants were assigned to control (n = 20) and experimental (n = 20) groups, while only the participants in the experimental group were trained by RehaCom for five weeks (ten 45-min sessions, two sessions per week). At weeks 0 and 5, performance of the participants of experimental group was compared with the participants of control group. The results showed that treatment with RehaCom significantly improved auditory and visual response control in children with ADHD, with no effect on auditory and visual attention. In conclusion, RehaCom may alter brain's structural and functional properties that are related to response control. We suggest that attention deficit in ADHD may be a result of more complicated dysfunctions in the brain, that are not affected by RehaCom.

The Role of Comorbid Symptoms in Perceived Stress and Sleep Problems in Adolescent ADHD

We examined perceived stress and sleep problems in adolescent ADHD and whether this varies as a function of ADHD presentation and sex. Further, we mapped structural associations between ADHD symptoms, comorbid symptoms, perceived stress, and sleep problems. Participants were 306 adolescents aged 13-19 years (66.8% females, 193 had an ADHD diagnosis, 113 were controls). Parents rated ADHD symptoms, all other constructs were self-rated. Adolescents with ADHD had elevated levels of perceived stress and sleep problems. Girls with ADHD reported the highest levels of perceived stress. Emotional symptoms mediated the effect of inattention whereas conduct problems mediated the effect of hyperactivity/impulsivity on stress and sleep. Perceived stress and sleep problems should be considered when mapping ADHD-related problems. Comorbid symptoms are potential intervention targets that may increase treatment response.

SLEEP: intervention with weighted blankets for children with attention deficit hyperactivity disorder (ADHD) and sleep problems: study protocol for a randomised control trial

INTRODUCTION AND OBJECTIVES

Children with attention deficit hyperactivity disorder (ADHD) have an increased risk of sleep problems. Weighted blankets are one possible non-pharmacological intervention for these problems in this group of children. However, the effectiveness of weighted blankets is insufficiently investigated. This study aims to investigate the effectiveness of weighted blankets in terms of sleep, health-related outcomes and cost-effectiveness as well as to explore children's and parents' experiences of a sleep intervention with weighted blankets.

METHODS AND ANALYSIS

This study is a randomised placebo-controlled crossover trial comparing the effect of weighted fibre blankets (active) with fibre blankets without weight (control). Children aged 6-13 years, recently diagnosed with uncomplicated ADHD with verified sleep problems, were included in the study. The study period is 4 weeks for each condition, respectively, and then an 8-week follow-up. A total of 100 children diagnosed with ADHD and sleep problems will enter the study. The primary outcomes are sleep and cost per quality-adjusted life years. The secondary outcomes are health-related quality of life, ADHD symptoms, psychological distress and anxiety. Interviews with a subsample of the participating children and parents will be conducted for exploring the experiences of the intervention.

ETHICS AND DISSEMINATION

Ethical approval of the trial has been obtained from the Swedish Ethical Review Authority (number 2019--2158) and conforms to the principles outlined in the Declaration of Helsinki (WMA, 2013). Results will be reported as presentations at peer-review conferences, in articles in peer-review journals and meetings with healthcare providers.

TRIAL REGISTRATION NUMBER

NCT04180189.

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.

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.

Do Children of Patients with Bipolar Disorder have a Worse Perception of Sleep Quality?

INTRODUCTION

The offspring of bipolar parents (BO) is a high-risk population for inheriting the bipolar disorder (BD) and other early clinical manifestations, such as sleep disturbances.

OBJECTIVE

To compare the presence of psychiatric disorders and sleep disturbances of BO versus offspring of control parents (OCP).

METHODS

A cross-sectional analytical study was conducted that compared BO versus OCP. The participants were assessed using valid tools to determine the presence of psychiatric symptoms or disorders. The "Sleep Evaluation Questionnaire" and "School Sleep Habits Survey" were used to determine sleep characteristics and associated factors. Sleep records (7-21 days) were also obtained by using an actigraphy watch.

RESULTS

A sample of 42 participants (18 BO and 24 OCP) was recruited. Differences were found in the presentation of the psychiatric disorder. The BO group showed a higher frequency of major depression disorder (MDD; P = .04) and Disruptive Mood Dysregulation Disorder (DMDD; P = .04). The OCP group showed a higher frequency of Attention Deficit and Hyperactivity Disorder (ADHD; P = .65), and Separation Anxiety Disorder (SAD; P = .46). Differences were also found in sleep by using subjective measurements. Compared to the OCP group, BO had a worse perception of quality of sleep (P = .02), a higher frequency of nightmares (P = .01), a shorter total sleep time, and a higher sleep latency. Nevertheless, no differences were found between groups in the actigraphy measurements.

CONCLUSIONS

The BO group had a higher frequency of Mood Disorders, and at the same time a higher number of sleep disturbances in the subjective measurements. It is possible that there is an association between mood symptoms, sleep disturbances, and coffee intake. No differences were found in the sleep profile by using actigraphy.

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.

Night-sleep Duration Trajectories and Behavior in Preschoolers: Results from a Prospective Birth Cohort Study

Background: Short sleep duration is associated with concomitant behavioral difficulties, but the longitudinal association between sleep duration and later behavior in early childhood remains unclear. The aim was to study the association between sleep duration trajectories throughout preschool and behavior at age 5-6 years.Participants: 1021 children of the French birth-cohort EDEN were included in this study.Methods: Night-sleep duration trajectories were modeled on the basis of repeated measures collected at age 2, 3 and 5-6 years by parental questionnaires. Behavior was assessed with the Strengths and Difficulties Questionnaire (SDQ), with five subscales measuring conduct problems, emotional symptoms, peer relation problems, antisocial behavior, and hyperactivity-inattention problems. The subscales were dichotomized by the 25th percentile. Multivariable logistic regression, adjusted for baseline behavior, and assessment of multiple confounding factors allowed for studying the independent association between night-sleep duration trajectories from age 2 to 5-6 and behavior at age 5-6.Results: Five distinct sleep-duration trajectories were identified. At age 5-6 years, probability of hyperactivity-inattention problems was increased for boys belonging to the "short sleep" and "medium-low sleep" duration trajectory and girls belonging to the "changing sleep" duration trajectory as compared with children with the medium-high sleep duration trajectory (boys: OR 2.69 [95% CI 1.18-6.16], p = .03 and 1.95 [1.25-3.03], p = .003, and girls: OR 2.79 [1.09- 7.17], p = .03). No associations were observed with the other SDQ subscales.Conclusion: The persistence of short night-sleep durations in preschool years as well as a sudden decrease at age 3 are risk factors of hyperactivity-inattention problems at school start.Abbreviations: SS: short-sleep duration trajectory; MLS: medium-low-sleep duration trajectory; MHS: medium-high-sleep duration trajectory; LS: long-sleep duration trajectory; CS: changing-sleep duration trajectory.

Association between sensory modulation and sleep difficulties in children with Attention Deficit Hyperactivity Disorder (ADHD)

BACKGROUND

Sleep difficulties have been reported in up to 85% of children with Attention Deficit hyperactivity disorder (ADHD). Children with ADHD exhibit commonly sensory modulation difficulties (SMD) and experience more significant functional difficulties. Sleep difficulties have also been associated with SMD. The aim of this study was to evaluate whether SMD are associated with sleep difficulties in children with ADHD.

METHODS

We assessed sleep difficulties using the Children's Sleep Habits Questionnaire, and SMD using the Short Sensory Profile (SSP) questionnaire. A total of 25 children with ADHD and atypical sensory profiles, 13 children with ADHD and typical sensory profiles and 38 children used as controls (all children aged 8-11 years) were included.

RESULTS

Sleep difficulties were detected in 86.4% of children with ADHD and atypical SSPs, as compared to 30.8% of children with ADHD and typical SSPs, and 16.7% of controls. A multivariate logistic regression revealed that children with ADHD and atypical SSPs had significantly increased odds for sleep difficulties as compared to controls (OR = 32.4; 95% CI 4.0-260.1, p = 0.001), while children with ADHD and typical SSPs were indistinguishable from controls. Suspected confounders (gender, age, mother's education, and stimulant therapy) did not contribute to sleep difficulties.

CONCLUSION

In this pilot study, SMD were associated with sleep difficulties in children with ADHD.

Do Children of Patients with Bipolar Disorder have a Worse Perception of Sleep Quality?

INTRODUCTION

The offspring of bipolar parents (BO) is a high-risk population for inheriting the bipolar disorder (BD) and other early clinical manifestations, such as sleep disturbances.

OBJECTIVE

To compare the presence of psychiatric disorders and sleep disturbances of BO versus offspring of control parents (OCP).

METHODS

A cross-sectional analytical study was conducted that compared BO versus OCP. The participants were assessed using valid tools to determine the presence of psychiatric symptoms or disorders. The "Sleep Evaluation Questionnaire" and "School Sleep Habits Survey" were used to determine sleep characteristics and associated factors. Sleep records (7-21 days) were also obtained by using an actigraphy watch.

RESULTS

A sample of 42 participants (18 BO and 24 OCP) was recruited. Differences were found in the presentation of the psychiatric disorder. The BO group showed a higher frequency of major depression disorder (MDD; P=.04) and Disruptive Mood Dysregulation Disorder (DMDD; P=.04). The OCP group showed a higher frequency of Attention Deficit and Hyperactivity Disorder (ADHD; P=.65), and Separation Anxiety Disorder (SAD; P=.46). Differences were also found in sleep by using subjective measurements. Compared to the OCP group, BO had a worse perception of quality of sleep (P=.02), a higher frequency of nightmares (P=.01), a shorter total sleep time, and a higher sleep latency. Nevertheless, no differences were found between groups in the actigraphy measurements.

CONCLUSIONS

The BO group had a higher frequency of Mood Disorders, and at the same time a higher number of sleep disturbances in the subjective measurements. It is possible that there is an association between mood symptoms, sleep disturbances, and coffee intake. No differences were found in the sleep profile by using actigraphy.

Cumulative incidence and relative risk of sleep problems among children and adolescents with newly diagnosed neurodevelopmental disorders: A nationwide register-based study

We estimated the absolute and relative risk of sleep problems in children and adolescents with newly diagnosed neurodevelopmental disorders. This was a population-based cohort study of individuals born in Denmark in 1993-2014 and followed in nationwide registers in 2011-2016. We estimated the 5-year cumulative incidence of sleep problems in incident cases of attention-deficit/hyperactivity disorder (ADHD; n = 12,844), autism spectrum disorder (ASD; n = 8,073), oppositional defiant disorder/conduct disorder (ODD/CD; n = 2,234) and epilepsy (n = 3,709). Hazard ratios (HRs) for sleep problems were estimated by Cox regression. The 5-year risk of sleep problems was highest in ADHD (29.2%; 95% CI, 28.4-30.1), ASD (24.2%; 95% CI, 23.1-25.3) and ODD/CD (27.1% 95% CI, 25.0%-29.2%) and lowest in epilepsy (11.3%; 95% CI, 10.2%-12.6%). For ADHD and ASD, sleep problems were more common in females than in males. Furthermore, sleep problems were predicted by high parental socioeconomic status and varied with the geographical region of residence, suggesting that different clinical practices exist across Denmark and that sleep problems may be more likely to go undetected in families of lower socioeconomic position. Compared with individuals without these disorders, the likelihood of sleep problems was increased in individuals with ADHD (HR, 33.81; 95% CI, 32.78-34.87), ASD (HR, 16.77; 95% CI, 16.15-17.41), ODD/CD (HR, 14.73; 95% CI, 13.88-15.64) and epilepsy (HR, 6.01; 95% CI, 5.67-6.37). After mutual adjustment for comorbidity, HRs were attenuated, especially in ASD, ODD/CD and epilepsy when adjusted for ADHD, suggesting that the increased risk of sleep problems in individuals with ASD, ODD/CD and epilepsy is driven largely by comorbid ADHD.

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.

Effects of Sleep Extension on Inhibitory Control in Children With ADHD: A Pilot Study

Objective: Children with ADHD often have sleep complaints and cognitive deficits. The aim of this pilot study was to determine whether sleep extension improves inhibitory control, a primary cognitive deficit in ADHD. Method: Children with (n = 11) and without (n = 15) ADHD participated in a within-subject sleep extension intervention that targeted nocturnal sleep duration. Sleep was assessed with actigraphy and polysomnography. Inhibitory control was assessed with a Go/No-Go task. Results: For children without ADHD, there was a significant main effect of time, such that morning inhibitory control was 10% greater than evening inhibitory control. However, inhibitory control did not differ between the baseline and extension conditions in this group. For children with ADHD, although morning inhibitory control did not differ from evening inhibitory control, sleep extension improved inhibitory control by 13% overall. Conclusion: These results suggest that a sleep extension intervention improves inhibitory control in children with ADHD.

Sleep among presentations of Attention-Deficit/Hyperactivity Disorder: Analysis of objective and subjective measures

To examine subjective and objective sleep patterns in children with different Attention-Deficit/Hyperactivity Disorder (ADHD) presentations.

METHOD

We assessed 92 children diagnosed with ADHD (29 ADHD-Inattentive [ADHD-I], 31 ADHD-Hyperactive/Impulsive [ADHD-H/I], and 32 ADHD-Combined [ADHD-C)]) aged 7-11 years. The Pediatric Sleep Questionnaire (PSQ), Pediatric Daytime Sleepiness Scale (PDSS), and a sleep diary were used as subjective sleep measures, and polysomnography was used to objectively assess sleep quantity, quality, and fragmentation.

RESULTS

Subjective data showed impaired sleep in 12.7% of the sample. No significant differences were found between ADHD presentations in any objective and subjective sleep variable. Nevertheless, data on sleep fragmentation suggested a worse sleep continuity for the ADHD-H/I group, and correlation analyses confirmed that sleep is affected by age.

CONCLUSIONS

Children with ADHD may suffer from sleep breathing problems and daytime sleepiness, as reported by their parents, even when their total sleep time and sleep efficiency are not affected. It seems that sleep in this population does not largely vary as a function of the ADHD presentation. Sleep in children with ADHD evolves with age.

Mental Health Diagnoses and Symptoms in Preschool and School Age Youth Presenting to Insomnia Evaluation: Prevalence and Associations with Sleep Disruption

Objective/Background: Sleep problems and emotional and behavioral difficulties are highly correlated in community samples of youth and in youth presenting to mental health treatment. However, fewer studies have characterized the associations between sleep and psychopathology symptoms in youth presenting to pediatric sleep clinics. This retrospective, cross-sectional study examined the prevalence of psychopathology symptoms and their associations with sleep disruption in youth presenting to a behavioral sleep medicine clinic. Participants: Participants were 373 preschoolers (1.5 to 5 years old) and 300 school age youth (6 to 10 years old) presenting to a pediatric behavioral sleep medicine clinic with a primary insomnia diagnosis. Methods: As a part of routine clinical care, parents completed a battery of pre-evaluation measures assessing insomnia severity, sleep disturbance, history of mental health diagnosis, and psychopathology symptoms. Results: Both preschool and school age youth had high rates of parent-reported mental health diagnoses (35% and 74%, respectively) and clinically elevated psychopathology symptoms (69% of preschoolers and 77% of school age youth) at initial insomnia evaluation. These symptoms were significantly associated with sleep disruption, with ADHD and affective problems most consistently associated with sleep problems in preschoolers and symptoms of anxiety, affective, and behavioral problems most consistently associated with sleep problems in school age youth. Conclusions: Psychopathology symptoms should be regularly assessed in youth presenting to behavioral sleep medicine clinics. Further, the role of psychopathology should be considered in insomnia conceptualization and treatment and, when appropriate, psychopathology symptoms should be targeted in treatment or appropriate referrals should be made.

Changes in Sleep Problems Across Attention-Deficit/Hyperactivity Disorder Treatment: Findings from the Multimodal Treatment of Attention-Deficit/Hyperactivity Disorder Study

Objective: Stimulant medication and behavior therapy are efficacious for youth with attention-deficit/hyperactivity disorder (ADHD). However, research suggests that stimulants may start and/or worsen sleep problems for youth. Further, the impact of behavior therapy for ADHD on sleep is unknown. This study examined the frequency of sleep problems and effects of stimulant medication, behavior therapy, and their combination on sleep problems in youth with ADHD. This study also explored the influence of dimensional baseline ratings of ADHD symptom subtype and psychiatric comorbidity on sleep outcomes. Methods: Participants were 576 children (aged 7-9 years) with ADHD-Combined type from the Multimodal Treatment of ADHD study that compared methylphenidate, behavior therapy, and their combination to community care. Before treatment, parents completed the Child Behavior Checklist used to derive a total sleep problems score. Parents also completed ratings of oppositionality and ADHD symptom severity, whereas youth completed ratings of depression and anxiety. These ratings were readministered after treatment. Results: General linear mixed-effects models were used to assess change in total sleep problems across treatment. The combined group exhibited a statistically significant reduction in total sleep problems (z = -5.81, p < 0.001). Reductions in total sleep problems in methylphenidate (z = -3.11, p = 0.05), behavior therapy (z = -2.99, p = 0.08), or community care (z = -1.59, p > 0.99) did not reach statistical significance. Change in psychiatric symptoms did not significantly moderate change in total sleep problems by treatment assignment. Greater baseline oppositional defiant disorder severity predicted less reduction in total sleep problems, χ²(1) = 3.86, p < 0.05. Conclusions: Findings suggest that combination of methylphenidate and behavior therapy is efficacious for reducing parent-reported sleep problems in young children with ADHD-Combined type relative to community care. However, potential ameliorative effects of monotherapy treatments (i.e., methylphenidate, behavior therapy) should be examined. Future replication is needed to confirm findings.