Excessive daytime sleepiness in adults with possible attention deficit/hyperactivity disorder (ADHD): a web-based cross-sectional study

Diagnostic usefulness of 24-h polysomnography for idiopathic hypersomnia co-occurring with neurodevelopmental disorders: A case report

Background

Although central disorders of hypersomnolence (CDH) and attention-deficit/hyperactivity disorder (ADHD) are frequently comorbid, they often remain underdiagnosed, leading to insufficient treatment and sociopsychological outcomes.

Case Presentation

Here, we present a case of a male in his late 20s with ADHD and autism spectrum disorder who exhibited symptoms suggestive of idiopathic hypersomnia (IH), a subtype of CDH. The patient experienced difficulty waking up and dropped out of university. Additionally, although methylphenidate extended-release was prescribed, he often forgot to take his medication, resulting in difficulty waking up until late afternoon. No symptoms related to rapid eye movements sleep were observed. Considering the possibility of concurrent hypersomnia with neurodevelopmental disorders, we conducted 24-h polysomnography (PSG). The results demonstrated total sleep time of 774.5 min (≥660 min). Together with other criteria, we diagnosed him as having IH. Following discharge and discussion with the patient, we provided sleep hygiene education for him, and he resumed day care attendance to establish a social routine.

Conclusion

In cases where hypersomnia may co-occur with neurodevelopmental disorders, active utilization of 24-h PSG enables detailed evaluation of sleep-wake patterns and behaviors, facilitating effective guidance on sleep hygiene and promoting improvements in social rhythms and sociability.

The circadian system: A neglected player in neurodevelopmental disorders

Patients with neurodevelopmental disorders, such as autism spectrum disorder, often display abnormal circadian rhythms. The role of the circadian system in these disorders has gained considerable attention over the last decades. Yet, it remains largely unknown how these disruptions occur and to what extent they contribute to the disorders' development. In this review, we examine circadian system dysregulation as observed in patients and animal models of neurodevelopmental disorders. Second, we explore whether circadian rhythm disruptions constitute a risk factor for neurodevelopmental disorders from studies in humans and model organisms. Lastly, we focus on the impact of psychiatric medications on circadian rhythms and the potential benefits of chronotherapy. The literature reveals that patients with neurodevelopmental disorders display altered sleep-wake cycles and melatonin rhythms/levels in a heterogeneous manner, and model organisms used to study these disorders appear to support that circadian dysfunction may be an inherent characteristic of neurodevelopmental disorders. Furthermore, the pre-clinical and clinical evidence indicates that circadian disruption at the environmental and genetic levels may contribute to the behavioural changes observed in these disorders. Finally, studies suggest that psychiatric medications, particularly those prescribed for attention-deficit/hyperactivity disorder and schizophrenia, can have direct effects on the circadian system and that chronotherapy may be leveraged to offset some of these side effects. This review highlights that circadian system dysfunction is likely a core pathological feature of neurodevelopmental disorders and that further research is required to elucidate this relationship.

Patient, supporter and primary healthcare professional perspectives on health risks in over 16s with attention deficit hyperactivity disorder (ADHD) in England: a national survey study

BACKGROUND

Current research suggests that people with attention deficit hyperactivity disorder (ADHD) are at higher risk of physical and mental health disorders. This study aimed to explore these health risks in ADHD from the perspectives of multiple stakeholders.

METHODS

This study forms part of the 'Managing young people with ADHD in Primary care (MAP) study'. A survey developed by the study team was distributed to over 16 year olds with ADHD, their supporters, primary healthcare professionals and health commissioners across England, via social media and through patient/clinical networks (September-October 2022). This survey contained two questions on health risks. Question one asked about views on health risks in ADHD (free text). Question two asked about advice given (options list and free text). Descriptive statistics summarised responses to questions one and two, and qualitative analysis (reflexive thematic analysis) was used to explore free text responses from question one.

RESULTS

782 participants responded to the MAP survey. Of these, 206 healthcare professionals, 157 people with ADHD and 88 supporters answered question one. The most mentioned perceived risks were substance misuse, sleep disorders, weight management and smoking. More people with ADHD reported disordered eating as a health risk (n = 32) than healthcare professionals (n = 5). Generated themes included perceived health risks, impact of living with ADHD, lack of adequate healthcare, and need for ADHD awareness. In respect to advice given (question two), based on responses from 258 professionals, 162 people with ADHD and 100 supporters, the most common advice discussed in consultation was mental health (n = 149, n = 50 and n = 17 respectively). High numbers of respondents reported not giving/receiving advice on wider health (n = 38, n = 88 and n = 61 respectively).

CONCLUSIONS

Findings demonstrate that respondents perceived a range of physical and mental health risks posed by ADHD. These related to difficulties with activities of daily living, as well as healthcare interactions and the impact of core features of ADHD (e.g. impulsivity, emotional dysregulation). These risks are not currently explicitly addressed in United Kingdom national guidance on ADHD. More work is needed to examine and address the broader health outcomes of people with ADHD.

ADHD in narcolepsy: A closer look at prevalence and ties

The reported prevalence of attention deficit hyperactivity disorder (ADHD) in narcolepsy varies considerably, while the associated factors remain inadequately established. A systematic search of studies published in PubMed, EMBASE, and the Cochrane Library was performed from inception to March 2023. Ten studies with 839 patients with narcolepsy were included in the study. Utilizing a random effects model, the pooled prevalence of ADHD in narcolepsy was 25% (95% CI, 14-38%). Notably, patients with narcolepsy type 2 showed a significantly higher prevalence of ADHD than that of narcolepsy type 1 (46% vs. 20%, p = 0.045). Furthermore, the rate of ADHD was notably elevated in narcolepsy compared with the healthy controls (odds ratio 9.59, 95% CI, 4.06-22.63, p < 0.001). Several factors such as excessive daytime sleepiness (EDS), fatigue, insomnia severity, and the quality of life were significantly associated with ADHD in narcolepsy (all ps < 0.05). These findings highlight the importance of monitoring and managing ADHD in narcolepsy, and provide a clue to help reducing ADHD by intervening in these associated factors.

Sleep Structure in Untreated Adults With ADHD: A Retrospective Study

OBJECTIVE

Polysomnographic findings in neurodevelopmental disorders have been reported, but previous studies have had several limitations. The purpose of this study was to characterize sleep structure in untreated adults diagnosed with ADHD, excluding ADHD-related sleep disorders as determined by polysomnography and multiple sleep latency testing.

METHODS

This study included 55 patients aged 18 years or older who visited the Kurume University Hospital Sleep Clinic between April 2015 and March 2020. The diagnosis of ADHD was determined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (ADHD group, n = 28; non-ADHD, n = 27).

RESULTS

The ADHD group had significantly longer slow wave sleep (SWS) duration than the non-ADHD group (ADHD: 68.3 ± 31.0 minutes vs. non-ADHD: 43.4 ± 36.6 minutes; p = .0127).

CONCLUSIONS

The increased SWS volume observed in drug-naïve adult patients with ADHD may be related to the pathogenesis of this disorder.

Attention-Deficit/Hyperactivity Disorder, Insomnia, and Sleepiness Symptoms among a Community Adult Sample: The Mediating Effect of Executive Behavioral Regulation and Metacognition Abilities

OBJECTIVE

Adult attention-deficit/hyperactivity disorder (ADHD) is characterized by a dysexecutive syndrome reflected in cognitive, emotional, and behavioral areas. Independently of a formal diagnosis of ADHD, higher ADHD symptoms are associated with higher levels of insomnia and sleepiness symptoms in adult population-based samples. Insomnia and sleepiness are sleep disorders that are both associated with deficits in several aspects of executive functions which in turn are likely to mimic a range of ADHD symptoms. Our objective was to explore the interrelationships between ADHD, insomnia, and sleepiness symptoms and executive functioning in community-dwelling adults.

METHOD

A total of 442 participants (18-89 years, 56% females) underwent a semistructured clinical interview and completed questionnaires for insomnia, sleepiness, and everyday behaviors in which executive functions are implicated. Mediation Models were applied.

RESULTS

Insomnia and sleepiness symptoms did not play a mediating role between ADHD symptoms and executive functioning. Conversely, our results highlighted a mediating effect of daytime insomnia consequences and sleepiness on ADHD symptoms via behavioral regulation executive symptoms (respectively, β = -0.32, p < .001, 95% CI [-0.46, -0.20]; β = 0.09, p < .05, 95% CI [0.02, 0.16]) and metacognitive executive symptoms (respectively, β = -0.30, p < .001, 95% CI [-0.44, -0.18]; β = 0.12, p < .01, 95% CI [0.04, 0.22]).

CONCLUSIONS

Daytime insomnia consequences and sleepiness symptoms could lead to ADHD-like symptoms through their associated executive symptoms expressed in daily life. When faced with symptoms suggestive of ADHD in adults, insomnia and sleepiness should be systematically screened with standardized instruments.

Association of Subjective Quality and Quantity of Sleep with Quality of Life among a General Population

This study aimed to determine whether both subjective sleep quality and sleep duration are directly associated with quality of life (QOL), as well as indirectly associated with QOL through insomnia symptoms. Individuals aged 20–69 years without mental illness (n = 9305) were enrolled in this web-based cross-sectional survey. The Short Form-8 was used to assess physical and mental QOL. We used the Pittsburgh Sleep Quality Index (PSQI) and extracted items related to subjective sleep quality and sleep duration. Insomnia symptoms were also extracted from the PSQI. The hypothesized models were tested using structural equation modeling. Worse sleep quality, but not shorter sleep duration, was related to worse physical QOL. Both worse sleep quality and shorter sleep duration were related to worse mental QOL. Insomnia symptoms mediated these relationships. Subgroup analyses revealed a U-shaped relationship between sleep duration and physical/mental QOL. However, the relationship between sleep quality and physical/mental QOL was consistent regardless of sleep duration. The results suggest that subjective sleep quality has a more coherent association with QOL than subjective sleep duration. Because of its high feasibility, a questionnaire on overall sleep quality could be a useful indicator in future epidemiological studies of strategies for improving QOL.

Sleep Debt and Social Jetlag Associated with Sleepiness, Mood, and Work Performance among Workers in Japan

Although sleep debt and social jetlag (SJL) influence daytime dysfunctions, the effects of both sleep debt and SJL on them have not been analyzed. The aim of this study was to examine the mutual relationship between sleep debt and SJL on daytime sleepiness, mood, and work performance. This study was a cross-sectional study on sleep health conducted on the Japanese general population. A total of 4505 general workers (30% female, aged 43.57 ± 11.63 years) were selected and analyzed. Sleep debt was defined by sleep debt index (SDI), which is the discrepancy between desired and real sleep duration. SJL and SDI scores exhibited a positive but weak coefficient (r = 0.19). In a 4 (SJL) × 3 (SDI) two-way ANOVA, the interaction effects were notable for sleepiness and depression scores, while the group effects were notable for the work performance score. For sleepiness and depression scores, SDI >2 h was not significantly different from SJL. In addition, the impact of SDI was higher than that of SJL on sleepiness (β = 0.17), depression (β = 0.16), and work performance (β = -0.10). The impact of sleep debt was more pronounced than SJL on daytime dysfunctions, although both sleep debt and SJL have negative impacts on them.

Does Homeostatic Sleep Pressure Buildup Explain Objective Excessive Daytime Sleepiness in Adults With ADHD? An Exploratory Study

Background: Excessive daytime sleepiness (EDS) is central in Attention deficit hyperactivity disorder (ADHD) but its causes remain unclear. The aim of this study was to explore objective EDS and homeostatic sleep pressure buildup, evaluated by power theta-alpha frequency (PTAF), in drug-free sleepy adults with ADHD and controls. Methods: Participants were placed during a 36-h period of extended wakefulness under constant routine protocol to strictly control sleep time, sleep duration, and circadian zeitgebers. Results: Eight drug-free sleepy patients with ADHD and 7 matched controls were included. The ADHD group had significantly shorter sleep latency on the Maintenance of Wakefulness Test (MWT) throughout extended wakefulness than the control group. There was no significant difference between the groups in PTAF evolution during extended wakefulness and in kinetic sleep pressure buildup, evaluated by the time constant of saturating exponential function. Limitations: The sample was small, so the findings cannot be generalized. Moreover, psychiatric comorbidities and circadian regulation should be taken into account in future studies. Conclusion: In very controlled conditions, mean sleep latency on the MWT during the whole extended wakefulness was significantly shorter in sleepy patients with ADHD than in control subjects. However, the difficulty to remain awake during soporific circumstances observed in these patients with ADHD cannot be explained by changes in the kinetic of sleep pressure buildup. Clinical Trials Registration: www.clinicaltrials.gov/, Identifier: NCT02217371.

Effect of a Multi-Layer, Extended-Release Methylphenidate Formulation (PRC-063) on Sleep in Adults with ADHD: A Randomized, Double-Blind, Forced-Dose, Placebo-Controlled Trial Followed by a 6-month Open-Label Extension

BACKGROUND

The effects of stimulant treatment on sleep in adults with attention-deficit/hyperactivity disorder (ADHD) are complex and varied, with some individuals experiencing worsening of sleep but others experiencing improvement.

METHODS

Data from previously reported trials of the clinical efficacy and safety of the long-acting methylphenidate formulation PRC-063 (Adhansia XR^® in the USA; Foquest^® in Canada) in adults with ADHD were used to evaluate patient-reported sleep outcomes, as captured using the Pittsburgh Sleep Quality Index (PSQI) and adverse events of insomnia. The trials comprised 4 weeks of randomized, forced-dose PRC-063 treatment at a dose of 0 (placebo), 25, 45, 70, or 100 mg/day followed by an optional 6 months of open-label PRC-063 treatment at an individually optimized dose of 25-100 mg/day.

RESULTS

At the end of double-blind treatment, PRC-063 (all doses combined; N = 297) showed no significant difference versus placebo (N = 78) in least squares mean change in global PSQI score from baseline (- 0.7 vs. - 1.3; P = 0.0972) or in scores for each of the seven subscales of the PSQI. For patients enrolled in the open-label extension (N = 184), mean ± standard deviation global PSQI score improved from 7.8 ± 3.55 at the end of double-blind treatment to 5.8 ± 3.11 at 1 month and 5.4 ± 3.21 at 6 months (P < 0.0001). A greater proportion of patients were good sleepers (global PSQI score ≤ 5) at the end of the open-label extension (57.3%) than at baseline (20.9%) or at the end of double-blind treatment (26.0%). In a logistic regression analysis, baseline global PSQI score (odds ratio 1.491; P < 0.0001), but not randomized study treatment (P = 0.1428), was a significant predictor of poor sleep (global PSQI score > 5) at the end of double-blind treatment. Adverse event rates for insomnia (15.8 vs. 3.8%) and initial insomnia (6.1 vs. 1.3%) during double-blind treatment were higher for PRC-063 (all doses combined) than for placebo. Two patients receiving PRC-063 in the double-blind study and one patient in the open-label study were withdrawn because of insomnia adverse events.

CONCLUSIONS

Our findings indicate that, on average, PRC-063 had no significant impact on overall sleep quality in adults with ADHD. Although insomnia was observed as an adverse event, when sleep was measured over time as an outcome in its own right for patients receiving dose-optimized PRC-063 open-label, more patients showed improvement in sleep than deterioration. CLINICALTRIALS.

GOV IDENTIFER

NCT02139124 and NCT02168127.

The effect of short or long sleep duration on quality of life and depression: an internet-based survey in Japan

BACKGROUND

To date, no previous studies have evaluated the relationship between sleep duration and quality of life (QOL) or depression in the general population after controlling for daytime sleepiness and sleep disturbances.

METHODS

A web-based cross-sectional survey was conducted with 8698 subjects aged 20-69 years. We examined the relationships between weekday sleep duration and daytime sleepiness, sleep disturbance, QOL and depression, using the Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index (without the item for sleep duration), 8-item Short Form and Center for Epidemiological Studies Depression Scale (CES-D).

RESULTS

Daytime sleepiness tended to increase in proportion to shorter weekday sleep durations. Sleep disturbances, physical and mental QOL, and CES-D scores were worse in both the shorter and longer sleep groups compared with the group with 7-8 h of sleep. Hierarchical logistic regression analyses revealed that short sleep duration but not long sleep duration was significantly associated with reduction of both physical and mental QOL, even after controlling for the presence of daytime sleepiness and sleep disturbance. Both short and long sleep duration were independently and significantly correlated with depression after controlling for daytime sleepiness; however, there was no statistically significant association after adjusting for the effects of sleep disturbance.

CONCLUSIONS

The results suggested adverse effects of short sleep but not long sleep on both physical and mental QOL. In addition, the negative impact of specific types of sleep disturbance on depression may be greater than the impact of shortening of sleep duration.

The Sleepiness Curve of Young Men With and Without Attention-Deficit Hyperactivity Disorder (ADHD)

Objectives: The present study aimed at comparing the sleepiness curve of young men with attention-deficit hyperactivity disorder (ADHD) to that of young men without ADHD before, during, and after a night of sleep deprivation. Participants: Thirty young men (age 18-30) of whom 14 were diagnosed with ADHD combined type (ADHD-C) and 16 without ADHD. Methods: The participants' sleep was monitored for 5 days via actigraphy. Subsequently, the participants were kept continuously awake in a controlled environment for 25 hr (8:00 a.m.-9:00 a.m.). The sleepiness of the participants was assessed every hour by the Karolinska Sleepiness Scale (KSS) in order to obtain the sleepiness curve of both study groups. Results: Actigraphy data demonstrated that the two groups did not differ in their total sleep time, sleep onset latency, or sleep efficiency during the 5 nights preceding the experimental session. However, during the experimental session, the ADHD group demonstrated higher sleepiness scores, particularly following midnight and on the morning following the night of sleep deprivation. Moreover, on the morning following sleep deprivation the proportion of participants reporting extreme levels of sleepiness (KSS > 7) was significantly higher in the ADHD group than in the control group. Conclusions: Young men with ADHD suffer from sleepiness more than their counterparts from the general population, and are particularly vulnerable to the effects of sleep deprivation on sleepiness. As excessive daytime sleepiness negatively affects cognition and increases the risk for motor vehicle crash and other accidents, these findings may have important clinical implications.

Excessive Daytime Sleepiness Measurements in Children With Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed neurodevelopmental disorder in childhood. It is a heterogeneous disorder in terms of clinical presentation that is probably due to the frequent occurrence of comorbidity. Children with ADHD more frequently report sleep disorders (notably delayed sleep phase syndrome) and excessive daytime sleepiness (EDS) than typically developing children. The aim of this article is to propose a narrative review of the assessment of EDS in the context of ADHD with first a summary of the subjective and objective tools used to measure it. Secondly, perspectives in terms of electroencephalogram (EEG) markers and neurofeedback are proposed. Then, possibilities for new kinds of evaluation are discussed (virtual reality, ecological momentary assessment, etc.). Lastly, we discuss specific clinical situations with EDS in the context of ADHD as links with narcolepsy, the comorbidity with other psychiatric disorders, and the context of sluggish cognitive tempo.

Hyperactive movement behaviour of athletes with post-concussion symptoms

OBJECTIVE

Observations of hyperactive (/restless, agitated) behaviour as a consequence of mild traumatic brain injuries (mTBI) in sports are inconclusive as reduced or slowed movement behaviour is also commonly described post-concussion. This might be grounded in the fact that the movement behaviour of athletes has not been systematically investigated during standardized settings and with objective methods of nonverbal movement analysis. Thus, we investigate whether symptoms after mTBI in sports are characterized by a hyper- or hypoactive movement behaviour experimentally.

METHODS

Three matched groups of 40 athletes were investigated: 14 symptomatic and 14 asymptomatic athletes with a mTBI; and 12 non-concussed athletes. Four certified raters analysed with a standard analysis system for nonverbal behaviour each athlete's hand movement activity, hand movement contacts, and resting positions that were displayed during a videotaped standardized anamnesis protocol.

RESULTS

Symptomatic athletes spend significantly more time with act apart hand movements and less time with closed rest positions when compared to non-concussed athletes. Post-concussion symptom (PCS) scores positively correlate with act apart hand movements. A linear regression analysis revealed that act apart hand movements significantly predict the PCS score.

CONCLUSIONS

Athletes with increased symptoms after mTBI move their hands in a hyperactive and restless manner. Increased act apart hand movements, i.e., when both hands move simultaneously without touching each other, indicate a motoric destabilization in symptomatic athletes' behaviour that might be related to impaired inhibitory motor control systems. Future diagnoses should concern the systematic analysis of the nonverbal movement behaviour as a potential behavioural marker of symptoms after mTBI.

Association of Inattention, Hyperactivity, and Hypersomnolence in Two Clinic-Based Adult Cohorts

Objective: To assess the relationship between excessive daytime sleepiness (EDS), inattention, and hyperactivity/impulsivity in adults with ADHD and central hypersomnia. Method: Drug-free adult patients with ADHD (n = 100) or hypersomnia (n = 100) were evaluated using a structured clinical interview and self-report questionnaires on ADHD symptoms and EDS. Results: In all, 61% of patients with hypersomnia had clinically significant ADHD symptoms with 25% having an ADHD diagnosis (with both childhood and adulthood ADHD symptoms) and 36% ADHD-like symptoms, without history of childhood ADHD. EDS was reported in 47% of patients with ADHD, among whom 22% had a hypersomnolence disorder. Conclusion: We confirmed the high frequency of ADHD and ADHD-like symptoms in central hypersomnia, and of EDS and hypersomnolence in ADHD in adults. The nature of the link between EDS, inattention, and hyperactivity appears to be complex that may involve either a cause-effect relationship or intrinsic features of a similar neurodevelopmental dysfunction.

Current Pattern of Psychiatric Comorbidity and Psychotropic Drug Prescription in Child and Adolescent Patients

Background: In recent years, patterns of the use of psychotropic drugs vary with increasing rates of psychiatric presentation and diagnosis in children and adolescents. Purpose: In this study, we aimed to investigate distributions of current psychiatric symptoms and diagnosis, patterns of the use of psychotropic drugs, and differences according to age and gender in patients presented to a child and adolescent outpatient clinic. Methods: All patients aged between 0 and 18 years presenting to a child and adolescent psychiatry outpatient clinic between November 1, 2017 and November 1, 2018 were included in the study. Files of all patients were examined in detail, and patients' demographic characteristics, symptoms, psychiatric diagnoses established according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), psychotropic drugs initiated, and side effect profiles were recorded. Psychiatric symptoms and diagnostic features of the patients were determined, and the differences were investigated according to gender. Clinical characteristics were compared between diagnosed and undiagnosed patients, and between patients with and without drug initiation. Results: Of the 2066 patients, 1298 (62.8%) were male and the mean age was 10.14 ± 4.42 years. The most common symptoms were hyperactivity (23.8%) and inattention (21.6%) in males, inattention (15.1%) and irritability (14.2%) in females, and 79% of the patients received one or more psychiatric diagnoses. The most common psychiatric diagnoses in both genders were attention-deficit hyperactivity disorder (ADHD), specific learning disorder (SLD), and conduct disorder, respectively. Of the patients who received a psychiatric diagnosis, 61.8% were using psychotropic drugs, with the majority of them (71.3%) receiving monotherapy. The most frequently initiated drugs included psychostimulants, antipsychotics, and antidepressants, with 28.7% of the drug user patients receiving multiple drug therapy. Conclusion: Our study indicates that rate of presentation to child and adolescent psychiatry outpatient clinics is increasing, and rates of diagnosis and initiation of psychiatry drugs are high among the presented children. The prevalence of ADHD shows an increase in males and females in our country, and psychiatric polypharmacy has reached significant rates.

Is adult-onset attention deficit/hyperactivity disorder frequent in clinical practice?

Recent population-based longitudinal studies concluded that most adults with attention deficit/hyperactivity disorder (ADHD) symptoms would not have a childhood history of ADHD, leading to the concept of adult-onset ADHD. In a large, well-characterized clinical population of 446 adults with a primary complaint of ADHD, we reported a low frequency of adult-onset ADHD (6.9%), being a primary isolated condition in 2.8%. They had less severe symptoms and tendencies for higher hypersomnolence disorder comorbidity than patients with typical childhood-onset ADHD. Our findings reinforce the requirement to exclude other disorders that might overlap with ADHD or mimic ADHD symptoms in adulthood onset patients.