The role of sleep quality and quantity in moderating the effectiveness of medication in the treatment of children with ADHD

Examining daily stimulant medication use and sleep in adolescents with ADHD

Research has been inconclusive as to whether stimulant treatment causes or exacerbates sleep problems in adolescents with ADHD. This study examined sleep differences in adolescents with ADHD as a function of stimulant use. Participants were adolescents with ADHD (N = 159, ages 12-14). Parents reported on receipt of stimulant treatment (n = 92, 57.86%; n = 47 amphetamines, n = 45 methylphenidate). Adolescents wore actigraphs and completed daily diaries assessing sleep and daily use of stimulants for 2 weeks. Sleep parameters included daily-reported bedtime, sleep onset latency (SOL), sleep duration, daytime sleepiness, and difficulty waking the following morning; and actigraphy-measured sleep onset time, total time in bed, and sleep efficiency. We estimated between- and within-individual associations between stimulant medication use and sleep indices with all stimulants, after removing adolescents using sleep aids and weekend days, and as a function of stimulant type. Adolescent sleep did not differ between those receiving and not receiving stimulant treatment. Within individuals using stimulants, we largely observed no significant differences between medicated and unmedicated days, though findings were most often significant for school days only. Small effects were found indicating longer SOL, later sleep onset time, and more daytime sleepiness related to medication use. In contrast, there were slight improvements to sleep duration and sleep efficiency related to methylphenidate use, though methylphenidate was also associated with later sleep onset time and more daytime sleepiness. Given the inconsistent and small effects, findings suggest that stimulant medication may impact sleep, but does not appear to be a primary contributor to sleep problems in adolescents with ADHD.

Application of non-invasive neuromodulation in children with neurodevelopmental disorders to improve their sleep quality and constipation

BACKGROUND

Children with neurodevelopmental disorders have a very wide clinical variability. A common prevalent factor is problems with stool and sleep quality. Currently, there are multiple studies related to their evaluation, but not so much related to a specific intervention. The aim was to evaluate the effectiveness and safety of the application of non-invasive neuromodulation as a treatment in children with neurodevelopmental disorders to improve constipation and quality of sleep.

METHODS

A total of 23 minors aged between 2 and 16 were included in this cross-sectional study. All participants were applied the microcurrent device for 60 min, 3 times per week for a total of 4 weeks. The technique was based on non-invasive neuromodulation using a surface-applied microcurrent electrostimulation device that administers an external, imperceptible, pulsed electrical stimulation. It is applied to the extremities, in a coordinated manner, using gloves and anklets connected with electrodes to a control console. Sleep latency and microarousals were evaluated through a sleep diary. To assess the evolution and type of defecation, the adapted and validated version in Spanish of the Bristol Stool Form Scale was used.

RESULTS

No adverse events occurred during the study and no incidences were registered. Clinically relevant improvements were registered in defecation frequency and type as well as in sleep related parameters. An increase in the hours of sleep was registered, from 7,35 (0,83) to 9,09 (1,35), and sleep interruptions decreased from 3,83 (1,95) to 1,17 (1,11), (p < .001).

CONCLUSION

Microcurrents can be used as an effective and safe treatment to improve quality of sleep and constipation in children with neurodevelopmental disorders. More studies are needed in order to obtain statistically significant results.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05265702.

FIRST REGISTRATION

03/03/2022 PROTOCOL: https://clinicaltrials.gov/ct2/show/NCT05265702?term=baez+suarez&draw=2&rank=4.

Low Doses of Melatonin to Improve Sleep in Children with ADHD: An Open-Label Trial

OBJECTIVE

Only a few studies assessing the sleep effects of low doses of melatonin (aMT) have been performed in the past, most of them in adults, and only one in subjects with attention-deficit/hyperactivity disorder (ADHD). The aim of this study was to provide evidence of the changes induced by aMT doses as low as 1 mg in the sleep pattern of pediatric patients with ADHD under treatment with methylphenidate (MPH).

METHODS

Children and adolescents (7-15 years) with ADHD who were receiving extended-release MPH were recruited. A seven-week sleep diary was collected prior to starting a four-week treatment with 1 mg of aMT (30 min before bedtime). Seven-day actigraphic assessments of sleep were performed before and after treatment.

RESULTS

Twenty-seven patients (17 males, 62.96%) participated in the study, who had been receiving MPH for 1.57 (1.11) months. A significant increase in sleep duration (TST) was observed after one month of treatment (463 (49) min to 485 (41) min; p < 0.040), with nonsignificant improvements in sleep-onset latency (SOL), nocturnal awakenings, or sleep efficiency. Only minor adverse effects were reported.

CONCLUSION

Low doses of melatonin (1 mg) are able to increase TST in children and adolescents with ADHD receiving treatment with psychostimulants, with an adequate tolerability profile. Further placebo-controlled trials adjusting the time of aMT administration to the individual circadian profile should explore the effects of low doses of this hormone to shorten SOL in this population of patients.

Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD)

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed and treated psychiatric disorders in childhood. Typically, children and adolescents with ADHD find it difficult to pay attention and they are hyperactive and impulsive. Methylphenidate is the psychostimulant most often prescribed, but the evidence on benefits and harms is uncertain. This is an update of our comprehensive systematic review on benefits and harms published in 2015.

OBJECTIVES

To assess the beneficial and harmful effects of methylphenidate for children and adolescents with ADHD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to March 2022. In addition, we checked reference lists and requested published and unpublished data from manufacturers of methylphenidate.

SELECTION CRITERIA

We included all randomised clinical trials (RCTs) comparing methylphenidate versus placebo or no intervention in children and adolescents aged 18 years and younger with a diagnosis of ADHD. The search was not limited by publication year or language, but trial inclusion required that 75% or more of participants had a normal intellectual quotient (IQ > 70). We assessed two primary outcomes, ADHD symptoms and serious adverse events, and three secondary outcomes, adverse events considered non-serious, general behaviour, and quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted data extraction and risk of bias assessment for each trial. Six review authors including two review authors from the original publication participated in the update in 2022. We used standard Cochrane methodological procedures. Data from parallel-group trials and first-period data from cross-over trials formed the basis of our primary analyses. We undertook separate analyses using end-of-last period data from cross-over trials. We used Trial Sequential Analyses (TSA) to control for type I (5%) and type II (20%) errors, and we assessed and downgraded evidence according to the GRADE approach.

MAIN RESULTS

We included 212 trials (16,302 participants randomised); 55 parallel-group trials (8104 participants randomised), and 156 cross-over trials (8033 participants randomised) as well as one trial with a parallel phase (114 participants randomised) and a cross-over phase (165 participants randomised). The mean age of participants was 9.8 years ranging from 3 to 18 years (two trials from 3 to 21 years). The male-female ratio was 3:1. Most trials were carried out in high-income countries, and 86/212 included trials (41%) were funded or partly funded by the pharmaceutical industry. Methylphenidate treatment duration ranged from 1 to 425 days, with a mean duration of 28.8 days. Trials compared methylphenidate with placebo (200 trials) and with no intervention (12 trials). Only 165/212 trials included usable data on one or more outcomes from 14,271 participants. Of the 212 trials, we assessed 191 at high risk of bias and 21 at low risk of bias. If, however, deblinding of methylphenidate due to typical adverse events is considered, then all 212 trials were at high risk of bias.

PRIMARY OUTCOMES

methylphenidate versus placebo or no intervention may improve teacher-rated ADHD symptoms (standardised mean difference (SMD) -0.74, 95% confidence interval (CI) -0.88 to -0.61; I² = 38%; 21 trials; 1728 participants; very low-certainty evidence). This corresponds to a mean difference (MD) of -10.58 (95% CI -12.58 to -8.72) on the ADHD Rating Scale (ADHD-RS; range 0 to 72 points). The minimal clinically relevant difference is considered to be a change of 6.6 points on the ADHD-RS. Methylphenidate may not affect serious adverse events (risk ratio (RR) 0.80, 95% CI 0.39 to 1.67; I² = 0%; 26 trials, 3673 participants; very low-certainty evidence). The TSA-adjusted intervention effect was RR 0.91 (CI 0.31 to 2.68).

SECONDARY OUTCOMES

methylphenidate may cause more adverse events considered non-serious versus placebo or no intervention (RR 1.23, 95% CI 1.11 to 1.37; I² = 72%; 35 trials 5342 participants; very low-certainty evidence). The TSA-adjusted intervention effect was RR 1.22 (CI 1.08 to 1.43). Methylphenidate may improve teacher-rated general behaviour versus placebo (SMD -0.62, 95% CI -0.91 to -0.33; I² = 68%; 7 trials 792 participants; very low-certainty evidence), but may not affect quality of life (SMD 0.40, 95% CI -0.03 to 0.83; I² = 81%; 4 trials, 608 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The majority of our conclusions from the 2015 version of this review still apply. Our updated meta-analyses suggest that methylphenidate versus placebo or no-intervention may improve teacher-rated ADHD symptoms and general behaviour in children and adolescents with ADHD. There may be no effects on serious adverse events and quality of life. Methylphenidate may be associated with an increased risk of adverse events considered non-serious, such as sleep problems and decreased appetite. However, the certainty of the evidence for all outcomes is very low and therefore the true magnitude of effects remain unclear. Due to the frequency of non-serious adverse events associated with methylphenidate, the blinding of participants and outcome assessors is particularly challenging. To accommodate this challenge, an active placebo should be sought and utilised. It may be difficult to find such a drug, but identifying a substance that could mimic the easily recognised adverse effects of methylphenidate would avert the unblinding that detrimentally affects current randomised trials. Future systematic reviews should investigate the subgroups of patients with ADHD that may benefit most and least from methylphenidate. This could be done with individual participant data to investigate predictors and modifiers like age, comorbidity, and ADHD subtypes.

Sleep Disturbances in Children with Attentional Deficit Hyperactivity Disorder and Specific Learning Disorders

Sleep disturbances may be a significant source of distress for children with neurodevelopmental disorders, and consequently also for their families. Crucially, sleep disturbances might be influenced by comorbidity. Attention deficit hyperactivity disorder (ADHD) and specific learning disorder (SLD) often co-occur, and consequently, investigating sleep disturbances in children with comorbidity of ADHD and SLD is essential. Our study aimed at detecting sleep difficulties in a group of 74 children with ADHD, 78 children with SLD, and 76 children with ADHD and SLD by using the Sleep Disturbances Scale for Children. The results showed that sleep difficulties emerge more clearly in children with comorbid ADHD and SLD compared to children with only ADHD or SLD. These sleep difficulties were not due to differences in ages and behavioral/emotional problems. In conclusion, evaluating sleep disturbances is important when assessing and managing children with ADHD, SLD, and particularly with the two comorbid conditions, to better understand their difficulties and develop tailored interventions.

Sleep disturbances in ADHD: investigating the contribution of polygenic liability for ADHD and sleep-related phenotypes

Sleep disturbances are common in attention deficit hyperactivity disorder (ADHD) and associated with poor outcomes. We tested whether, in children with ADHD, (1) polygenic liability for sleep phenotypes is over- or under-transmitted from parents, (2) this liability is linked to comorbid sleep disturbances, and (3) ADHD genetic risk is associated with comorbid sleep disturbances. We derived polygenic scores (PGS) for insomnia, chronotype, sleep duration, and ADHD, in 758 children (5-18 years old) diagnosed with ADHD and their parents. We conducted polygenic transmission disequilibrium tests for each sleep PGS in complete parent-offspring ADHD trios (N = 328) and an independent replication sample of ADHD trios (N = 844). Next, we tested whether insomnia, sleep duration, and ADHD PGS were associated with co-occurring sleep phenotypes (hypersomnia, insomnia, restless sleep, poor sleep quality, and nightmares) in children with ADHD. Children's insomnia and chronotype PGS did not differ from mid-parent average PGS but long sleep duration PGS were significantly over-transmitted to children with ADHD. This was supported by a combined analysis using the replication sample. Insomnia, sleep duration, and ADHD PGS were not associated with comorbid sleep disturbances. There is weak evidence that children with ADHD over-inherit polygenic liability for longer sleep duration and do not differentially inherit polygenic liability for insomnia or chronotype. There was insufficient evidence that childhood sleep disturbances were driven by polygenic liability for ADHD or sleep traits, suggesting that sleep disturbances in ADHD may be aetiologically different to general population sleep phenotypes and do not index greater ADHD genetic risk burden.

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.

Shorter rapid eye movement sleep duration in children with attention-deficit /hyperactivity disorder: the impact on quality of life

OBJECTIVES

The relationship of sleep with attention deficit hyperactivity disorder (ADHD) remains complex and unclear. The current study aimed to compare the subjective and objective sleep parameters among children with and without ADHD. Moreover, to address the effect of sleep parameters on the quality of life (QoL).

METHODS

We assessed 42 participants who were children with ADHD (aged 6-12 years), with predominant combined presentation (23), compared to 42 healthy children, who underwent a sleep study assessment subjectively (the Children's Sleep Habits Questionnaire), and objectively (one-night Polysomnographic recording). Also, parents completed the pediatric quality of life inventory (PedsQL-P).

RESULTS

Children with ADHD had more subjective sleep problems. ADHD patients also had a significant decrease in total sleep time and sleep efficiency, spending more time in wake and N1 sleep stages. Moreover, they had significantly lower rapid eye movement (REM)sleep duration and less duration of deep sleep stages. Multivariate regression analysis showed that REM sleep duration was the most contributing and predictive factor to QoL and school function impairment.

CONCLUSION

Children with ADHD have a significantly lower sleep quantity and poor sleep quality. In addition, short REM sleep duration independently contributes to further deterioration in different areas of QoL.

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.

Sleep Variables as Predictors of Treatment Effectiveness and Side Effects of Stimulant Medication in Newly Diagnosed Children with Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

There is a growing body of research on the impact of stimulant medication on sleep in children with attention-deficit/hyperactivity disorder (ADHD). Negative sleep side effects are a common reason for nonadherence or for discontinuing a course of treatment. However, there is no published evidence as to whether pretreatment sleep can predict responses to treatment and the emergence of side effects.

METHOD

In this study, baseline sleep variables were used to predict therapeutic effect (i.e., reduction of ADHD symptoms) and side effects (both sleep and global side effects) in a sample of newly diagnosed, medication-naive children (n = 50).

RESULTS

The results of hierarchical regression analysis showed that parent-reported shorter sleep duration before medication treatment significantly predicted better response to treatment, independent of pretreatment ADHD symptoms. Baseline sleep features did not significantly predict global (nonsleep) side effects but did predict increased sleep side effects during treatment.

CONCLUSION

These results indicate that baseline sleep variables may be helpful in predicting therapeutic response to medication and sleep disturbance as a side effect of stimulant medication.

Associations between cognitive performance and sigma power during sleep in children with attention-deficit/hyperactivity disorder, healthy children, and healthy adults

Sigma power during sleep is associated with cognitive abilities in healthy humans. We examined the relationship between sigma power in sleep EEG and intelligence and alertness in schoolchildren with ADHD (n = 17) in comparison to mentally healthy children (n = 16) and adults (n = 23). We observed a positive correlation between sigma power in sleep stage 2 and IQ in healthy adults but a negative correlation in children with ADHD. Furthermore, children with ADHD showed slower reaction times in alertness testing than both control groups. In contrast, only healthy children displayed a positive correlation between sigma power and reaction times. These data suggest that the associations between sigma power and cognitive performance underlie distinct developmental processes. A negative association between IQ and sigma power indicates a disturbed function of sleep in cognitive functions in ADHD, whereas the function of sleep appears to be matured early in case of motor-related alertness performance.

Impact of adult attention deficit hyperactivity disorder and medication status on sleep/wake behavior and molecular circadian rhythms

Attention deficit hyperactivity disorder (ADHD) is a common neuropsychiatric condition that has been strongly associated with changes in sleep and circadian rhythms. Circadian rhythms are near 24-h cycles that are primarily generated by an endogenous circadian timekeeping system, encoded at the molecular level by a panel of clock genes. Stimulant and non-stimulant medication used in the management of ADHD has been shown to potentially impact on circadian processes and their behavioral outputs. In the current study, we have analyzed circadian rhythms in daily activity and sleep, and the circadian gene expression in a cohort of healthy controls (N = 22), ADHD participants not using ADHD-medication (N = 17), and participants with ADHD and current use of ADHD medication (N = 17). Rhythms of sleep/wake behavior were assessed via wrist-worn actigraphy, whilst rhythms of circadian gene expression were assessed ex-vivo in primary human-derived dermal fibroblast cultures. Behavioral data indicate that patients with ADHD using ADHD-medication have lower relative amplitudes of diurnal activity rhythms, lower sleep efficiency, more nocturnal activity but not more nocturnal wakenings than both controls and ADHD participants without medication. At the molecular level, there were alterations in the expression of PER2 and CRY1 between ADHD individuals with no medication compared to medicated ADHD patients or controls, whilst CLOCK expression was altered in patients with ADHD and current medication. Analysis of fibroblasts transfected with a BMAL1:luc reporter showed changes in the timing of the peak expression across the three groups. Taken together, these data support the contention that both ADHD and medication status impact on circadian processes.

Sleep and circadian rhythm function and trait impulsivity: An actigraphy study

We report the relationship between daily rest-activity patterns and trait impulsivity in healthy young adults. The Barratt Impulsiveness Scale was used to identify high and low impulsive individuals among a group of 51 volunteers. Participants' sleep behaviour and circadian rhythm function was assessed using week-long actigraphy. High impulsive individuals displayed phase-delayed patterns of sleep, a decreased total sleep time and sleep efficiency, and disrupted circadian function. Such outcomes were also associated with greater self-reported attention deficit hyperactivity disorder symptoms. The results highlight that sleep and circadian rhythm disturbances may be associated with impulsive traits replicating relationships described in psychiatric illnesses in which impulsivity is a core feature.

[Sleep and cognition in children and adolescents]

Sleep and cognition in children and adolescents Abstract. In this review, one of the most important functions of sleep was described: Its role in promoting cognitive processes in children and adolescents. Particularly, studies of older children and adolescents revealed that sleep interacts in a complex manner with cognitive performance. Moreover, it was shown that sleep supports long-term memory even in young children. This is true for many different long-term memory systems such as memory of factual information (declarative memory), language acquisition, and for reward-related learning, but less so for learning motor skills. Clinical implications arise from observing the consequences of sleep deficits in children and adolescents due to early school hours or due to clinical conditions like attention deficits hyperactive disorder (ADHD), sleep apnea syndrome or other sleep disturbances. Current research has only partially shown that the treatment of sleep problems also benefits cognitive and memory performance. Filling this gap remains an opportunity for further research.

Correcting delayed circadian phase with bright light therapy predicts improvement in ADHD symptoms: A pilot study

Attention-deficit/hyperactivity disorder (ADHD) is a common condition with comorbid insomnia reported in >70% of children and adults. These patients demonstrate delays in sleep-wake rhythms, nocturnal rise in melatonin, and early morning rise in cortisol. Given that standard psychopharmacologic treatments for ADHD often do not completely control symptoms in participants with circadian rhythm delay, we sought to test whether bright light therapy (BLT) advances circadian rhythms and further reduces ADHD symptoms over standard treatments. In addition to standard of care, participants with ADHD diagnosis underwent 1 week of baseline assessment followed by 2-weeks of 30-min morning 10,000-lux BLT beginning 3 h after mid-sleep time. Participants minimized overhead light after 4 p.m., wore an actigraphy watch, and recorded BLT time on daily sleep logs. Dim Light Melatonin Onset (DLMO) was assessed at baseline and after 2-week treatment. ADHD symptoms were measured by the ADHD-Rating Scales (ADHD-RS). BLT significantly advanced the phase of DLMO by 31 min [mean time (SEM), 20:36 (0:21) advanced to 20:05 (0:20)] and mid-sleep time by 57 min [4:37 (0:22) advanced to 3:40 (0:16); paired t-tests, p = 0.002 and 0.004, respectively). Phase advances (in DLMO or mid-sleep time) were significantly correlated with decreased ADHD-RS total scores (p = 0.027 and 0.044) and Hyperactive-Impulsive sub-scores (p = 0.014 and 0.013, respectively). Actigraphy analysis for a subset of 8 participants with significant DLMO phase advance revealed no significant changes in total sleep time, sleep efficiency, wake after sleep onset, or percent wake during sleep interval. This is the first successful use of BLT for advancing melatonin phase and improving ADHD symptoms in adults. BLT may be a complementary treatment for both delayed sleep timing and ADHD symptoms in adults.

Future Directions in Sleep and Developmental Psychopathology

It is critical for psychologists to gain a better understanding about the intersection between sleep and developmental psychopathology. However, while many strive to answer the question of whether sleep causes developmental psychopathology, or vice versa, ultimately the relationship between sleep and developmental psychopathology is complex and dynamic. This article considers future directions in the field of clinical child and adolescent psychology that go beyond this mechanistic question, highlighting areas important to address for clinicians and researchers who strive to better understand how best to serve children and adolescents with developmental psychopathology. Questions are presented about what is normal in terms of sleep across development, the role of individual variability in terms of sleep needs and vulnerability to sleep loss, and how sleep may serve as a risk or resilience factor for developmental psychopathology, concluding with considerations for interventions.