Sleep problems and disorders among adolescents with persistent and subthreshold attention-deficit/hyperactivity disorders

A systematic review of Nightmare prevalence in children

The purpose of this narrative review was to describe prevalence rates of nightmares and nightmare disorder in school-aged youth according to sample characteristics and methods used to assess nightmares. We searched PsychINFO, PubMed, and CINAHL databases to identify empirical peer-reviewed articles and grey literature published between 2001 and 2021. Sixty-nine studies from 23 countries were included. The prevalence of nightmares was between 1% and 11% in the past week and 25% to 35% in the past month in pediatric developmental samples and between 27% and 57% in the past week and 18%-22% in the past month in psychiatric samples. The prevalence of nightmare disorder was approximately between 3% and 6% in pediatric developmental samples and 10%-12% in psychiatric samples. Nightmare prevalence peaks between ages 10 and 14 then decreases with older age. Generally, prevalence was higher in girls than boys, and one study suggested gender divergence started around age 14. Children's self-reports were higher than parent reports, except in samples with comorbid psychiatric problems where there was more parent-child agreement. Inconsistencies in nightmare definitions and measurement were observed across the literature and indicate a need for standardized measurement of nightmares.

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.

Changes in sleep duration and disturbances during Covid-19 lockdown and internalizing-externalizing behaviors in children with attention deficit hyperactivity disorders

OBJECTIVE

To examine how changes in sleep patterns and sleep problems occurring between the pre-pandemic and the Covid-19 lockdown period influenced mood-behavioral functioning of children with Attention Deficit Hyperactivity Disorder (ADHD).

METHODS

Parents of 992 children with ADHD (85.4% boys, mean age: 11.52 years, SD = 3.17), recruited from the Italian ADHD family association, completed a modified version of the Sleep Disturbance Scale for Children and filled out 11 emotional behavioral items selected from the Child Behavior Checklist (CBCL) 6-18 questionnaire. Subgroups identified based on sleep duration changes ("maintained", "increased", "reduced") and of sleep problems during lockdown ("onset", "remission", "maintained", "no sleep problem") were analyzed to evaluate the association with internalizing and externalizing scores.

RESULTS

Sleep duration showed no or low influence on internalizing and externalizing behaviors after control for age, sex, and socioeconomic status. Patients with ADHD with "no sleep problem" showed significant lower scores in internalizing and externalizing behaviors than those who "maintained" or had "onset" of different sleep problems. The effect sizes were higher for internalizing than externalizing behaviors. Lower internalizing scores were found in those who remitted difficulty in falling asleep, daytime sleepiness, nightmares, vs. the "maintained" or "onset" groups and those who remitted hypnic jerks vs. the "onset" group. Children with ADHD who "maintained" sleep terrors reported higher internalizing and mainly externalizing scores than the other groups.

CONCLUSION

Sleep problems negatively influence daytime functioning of patients with ADHD. but mood and behavioral domains show different susceptibility to the changes of sleep problems, and different vulnerability to specific sleep problems.

Digital solutions for sleep problems in children: A pilot study

Children with sleep difficulties have limited options for treatment. Advancements in technology allow for the digital delivery of evidence-based sleep strategies developed with a focus on cognitive behavioral therapy (CBT) approaches for insomnia. An initial survey study was conducted to assess the need and current management of sleep problems in pediatric populations. A secondary pilot study evaluated the effect of a digitally-delivered sleep strategy for the treatment of pediatric sleep problems. In the pilot study, participants had access to a mobile application which provided individualized CBT-focused sleep solutions delivered over 6-10 weeks. A total of 218 participants were surveyed to determine their need and approach for pediatric sleep problems. Approximately 74% reported sleep problems in children aged 0-1 (46%), 2-4 (67%), 5-12 (85%), and 13-17 (73%). In the pilot study, 11 families with pediatric sleep problems (children categorized as baby, toddler and school-aged) were enrolled and received the DrLullaby digital intervention. An improvement in key sleep behavior was observed including "time to fall asleep" (n = 8; 72.7%), "total time asleep" (n = 6; 54.5%) and "time awake" (n = 7; 63.6%). Within group analysis for time awake and time to fall asleep showed a mean change from baseline of 75.6% and 31.3%, respectively. Within group analysis for total time asleep showed a mean improvement of 1 h and 3 min compared to baseline. The collective distress scale score was decreased by 35%. These results suggest viability of the digital delivery of evidence-based sleep strategies for treatment of pediatric sleep problems.

Maternal Emotion Dysregulation Predicts Emotion Socialization Practices and Adolescent Emotion Lability: Conditional Effects of Youth ADHD Symptoms

Maternal emotional functioning and emotion socialization practices can facilitate or hinder children's emotional development, and youth with symptoms of attention-deficit/hyperactivity disorder (ADHD) are at increased risk for emotion lability. However, little is known about the independent and interactive effects of maternal emotion dysregulation and adolescent ADHD symptoms on maternal emotion socialization and adolescent emotion lability over time. Using secondary data analyses of a longitudinal community sample of youth and their mothers (Nbaseline = 247; 43.7% female), the current study examined direct and indirect effects of maternal emotion dysregulation on adolescent emotion lability via supportive and non-supportive emotion socialization practices as mediators, and the extent to which adolescent ADHD symptoms moderated these longitudinal pathways. Mothers reported on all study constructs. Results showed that non-supportive parenting responses to adolescents' negative emotional expressions partially mediated the association between maternal emotion dysregulation and adolescent emotion lability, and the effect was stronger at higher levels of youth ADHD symptom severity. Results suggest that parent- and youth-level characteristics interact to confer risk for non-supportive emotion socialization practices and adolescent emotion lability. This research contributes uniquely to theory and research on ADHD and emotional functioning across adolescence. Future research should extend this work by utilizing multi-modal assessment.

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.

Sleep problems among adolescents within child and adolescent mental health services. An epidemiological study with registry linkage

Sleep problems are prevalent among adolescents, especially among those diagnosed with mental health disorders. There is insufficient knowledge about sleep among adolescents within child and adolescent mental health services (CAMHS) in comparison to the general population. The data are drawn from the youth@hordaland study, a large population-based study conducted in 2012, linked to the Norwegian Patient Registry (NPR) (n = 9077). Psychiatric disorders were based on clinical diagnoses from the NPR, while insomnia, delayed sleep-wake-phase disorder (DSWPD), and other sleep problems/patterns were assessed by self-report questionnaires from youth@hordaland. The prevalence of diagnosed sleep disorders among adolescents seeking mental health services was 0.6%, yielding an estimated prevalence of 0.07% of the population. However, questionnaire-based measurement of insomnia from the youth@hordaland study indicated that insomnia was highly prevalent across disorders in comparison to a reference group of adolescents who were not within mental health care. Insomnia ranged from 29% among adolescents diagnosed with ADHD (PR = 1.79; 95% CI 1.41-2.29) to 48% among adolescents diagnosed with depression (PR = 2.53, 95% CI 2.19-2.92). All diagnostic groups had a mean sleep efficiency below (85%), indicating poor sleep quality. Insomnia, delayed sleep-phase wake disorder, and poor sleep efficiency were confirmed as transdiagnostic sleep problems across psychiatric disorders. In addition, some disorder-specific patterns emerged, such as a higher prevalence of insomnia among adolescents with depression, and DSWPS among adolescents with conduct disorder. This underscores the need for treating sleep problems in CAMHS, and transdiagnostic treatment approaches are warranted.

Effect of a Multilayer, Extended-Release Methylphenidate Formulation (PRC-063) on Sleep in Adolescents with Attention-Deficit/Hyperactivity Disorder: A Randomized, Double-Blind, Fixed-Dose, Placebo-Controlled Trial Followed by a 6-Month Open-Label Follow-Up

Objectives: We analyzed patient-reported sleep parameters for an extended-release methylphenidate formulation (PRC-063) in adolescents with attention-deficit/hyperactivity disorder. Methods: Clinical efficacy and long-term safety/tolerability data from a 4-week, double-blind, placebo-controlled, fixed-dose study (NCT02139111) and a subsequent 6-month, optimized-dose, open-label extension (OLE) study (NCT02168127) were used. In the double-blind study, participants were randomly assigned 1:1:1:1:1 to one of four doses of PRC-063 (25, 45, 70, or 85 mg/day) or placebo. In both the double-blind and OLE studies, sleep outcomes were assessed using the Pittsburgh Sleep Quality Index (PSQI). Results: During double-blind treatment, no statistically significant least-squares mean difference in change from baseline between PRC-063 (all doses combined; N = 293) and placebo (N = 74) was found for either global PSQI score (-0.3 vs. -0.5; p = 0.6110) or scores for any of the seven PSQI subscales. Compared with the placebo group, a marginally higher proportion of patients in the PRC-063 group (all doses combined) went from being poor to good sleepers (global PSQI score ≤5; 14.4% vs. 11.3%). In a logistic regression analysis, study treatment was not a predictor of poor sleep (p = 0.5368) at the end of the double-blind study. In the OLE study, there was a trend of improvement in sleep after 1 month of individualized dosing that was maintained through 6 months. Sleep efficiency (time asleep as a proportion of time in bed) showed improvement at the end of the OLE study. Conclusion: While individual patients may experience changes in sleep as an adverse event, group data evaluating sleep as an outcome found there were no differences between PRC-063 and placebo in self-reported sleep outcomes on the PSQI.

Screen exposure exacerbates ADHD symptoms indirectly through increased sleep disturbance

OBJECTIVES

The aim of this study was twofold. First, to confirm the deleterious aspect of evening screen exposure in school-aged children, in particular the effect of screens in the bedroom. Second, to explore the three-way association between degree of screen exposure, sleep disturbance, and ADHD symptoms. Solid evidence exists on the link between sleep disturbance and ADHD symptoms, and screen exposure and sleep disturbance. However, no studies have formally assessed the impact of screen exposure on ADHD symptoms in children, as a function of sleep disturbance.

METHODS

Parents of 374 French children (201 girls, 173 boys, mean age of 10.8 ± 2.8 years old) completed the Sleep Disturbance Scale for Children (SDSC), the Attention-Deficit/Hyperactivity Disorder (ADHD) Rating Scale, and a questionnaire about their children's screen habits (total hours in the morning, afternoon, and evening per day). Correlational analyses between evening screen exposure, sleep quality and behavioral problems were conducted. Then, formal mediation analyses were run in order to quantify the relationship between variables.

RESULTS

School-aged children with screens in their bedrooms demonstrated more sleep and behavioral problems. Evening TV exposure was associated with higher SDSC and ADHD scores. Furthermore, the Structural Equation Modelling approach confirmed that evening screen exposure is directly associated with more disrupted sleep, which in turn is directly associated with behavioral problems.

CONCLUSIONS

These findings encourage families to avoid putting screens in their children's bedrooms, and limit evening screen exposure. They furthermore demonstrate the importance of taking into account screen exposure time (morning, afternoon, evening) and location (bedroom or elsewhere) in future studies.

Disorders of Arousal: A Chronobiological Perspective

Non-rapid eye movement (NREM) sleep parasomnias are characterized by motor and emotional behaviors emerging from incomplete arousals from NREM sleep and they are currently referred to as disorders of arousal (DoA). Three main clinical entities are recognized, namely confusional arousal, sleep terror and sleepwalking. DoA are largely present in pediatric populations, an age in which they are considered as transitory, unhabitual physiological events. The literature background in the last twenty years has extensively shown that DoA can persist in adulthood in predisposed individuals or even appear de novo in some cases. Even though some episodes may arise from stage 2 of sleep, most DoA occur during slow wave sleep (SWS), and particularly during the first two sleep cycles. The reasons for this timing are linked to the intrinsic structure of SWS and with the possible influence on this sleep phase of predisposing, priming and precipitating factors for DoA episodes. The objective of this paper is to review the intrinsic sleep-related features and chronobiological aspects affecting SWS, responsible for the occurrence of the majority of DoA episodes during the first part of the night.

Association of self-regulation with white matter correlates in boys with and without autism spectrum disorder

Previous studies demonstrated distinct neural correlates underpinning impaired self-regulation (dysregulation) between individuals with autism spectrum disorder (ASD) and typically developing controls (TDC). However, the impacts of dysregulation on white matter (WM) microstructural property in ASD and TDC remain unclear. Diffusion spectrum imaging was acquired in 59 ASD and 62 TDC boys. We investigated the relationship between participants’ dysregulation levels and microstructural property of 76 WM tracts in a multivariate analysis (canonical correlation analysis), across diagnostic groups. A single mode of brain-behavior co-variation was identified: participants were spread along a single axis linking diagnosis, dysregulation, diagnosis-by-dysregulation interaction, and intelligence to a specific WM property pattern. This mode corresponds to diagnosis-distinct correlates underpinning dysregulation, which showed higher generalized fractional anisotropy (GFA) associated with less dysregulation in ASD but greater dysregulation in TDC, in the tracts connecting limbic and emotion regulation systems. Moreover, higher GFA of the tracts implicated in memory, attention, sensorimotor processing, and perception associated with less dysregulation in TDC but worse dysregulation in ASD. No shared WM correlates of dysregulation between ASD and TDC were identified. Corresponding to previous studies, we demonstrated that ASD and TDC have broad distinct white matter microstructural property underpinning self-regulation.

Medications and addictive substances potentially inducing or attenuating sleep bruxism and/or awake bruxism

Bruxism is a repetitive jaw‐muscle activity characterised by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible. It can occur during sleep, indicated as sleep bruxism, or during wakefulness, indicated as awake bruxism. Exogenous risk indicators of sleep bruxism and/or awake bruxism are, among others, medications and addictive substances, whereas also several medications seem to have the potential to attenuate sleep bruxism and/or awake bruxism. The objective of this study was to present a narrative literature on medications and addictive substances potentially inducing or aggravating sleep bruxism and/or awake bruxism and on medications potentially attenuating sleep bruxism and/or awake bruxism. Literature reviews reporting evidence or indications for sleep bruxism and/or awake bruxism as an adverse effect of several (classes of) medications as well as some addictive substances and literature reviews on medications potentially attenuating sleep bruxism and/or awake bruxism were used as starting point and guidelines to describe the topics mentioned. Additionally, two literature searches were established on PubMed. Three types of bruxism were distinguished: sleep bruxism, awake bruxism and non‐specified bruxism. Generally, there are insufficient evidence‐based data to draw definite conclusions concerning medications and addictive substances inducing or aggravating sleep bruxism and/or awake bruxism as well as concerning medications attenuating sleep bruxism and/or awake bruxism. There are insufficient evidence‐based data to draw definite conclusions concerning medications and addictive substances inducing or aggravating sleep bruxism and/or awake bruxism as well as concerning medications attenuating sleep bruxism and/or awake bruxism.

Is there an association between attention deficit hyperactivity disorder in children and adolescents and the occurrence of bruxism? A systematic review and meta-analysis

Aim of the present systematic review was to evaluate whether children and adolescents with attention-deficit/hyperactivity disorder (ADHD) are at greater chance of developing bruxism compared to individuals without this disorder. Observational studies that evaluated the occurrence of bruxism in children and adolescents with ADHD were included. The quality of the evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluation criteria. Thirty-two studies involving a total of 2629 children/adolescents with ADHD and 1739 with bruxism (1629 with sleep bruxism and 110 with awake bruxism) were included. The prevalence of bruxism, irrespective of type, in the children/adolescents was 31% (95% CI: 0.22-0.41, I² = 93%). ADHD was associated with an increased chance of bruxism (OR: 2.94, 95% CI: 2.12-4.07, I² = 61%), independently of the type [sleep bruxism (OR: 2.77, 95% CI: 1.90-4.03, I² = 66%) or awake bruxism (OR: 10.64, 95% CI: 2.41-47.03, I² = 65%)]. The presence of signs of ADHD without a diagnostic confirmation was not associated with an increased chance of bruxism (OR: 3.26, 95% CI: 0.76-14.04, I² = 61%). Children and adolescents with a definitive diagnosis of ADHD are at greater chance of developing sleep and awake bruxism than those without this disorder.

Prevalence, Patterns, and Predictors of Sleep Problems and Daytime Sleepiness in Young Adolescents With ADHD

Objective: The primary objective of this study was to evaluate the prevalence of multiple types of sleep problems in young adolescents with ADHD. Method: Adolescents comprehensively diagnosed with ADHD (N = 262) and their caregivers completed well-validated measures of sleep problems and daytime sleepiness. Participants also completed measures related to medication use, comorbidities, and other factors that could predict sleep problems. Results: Daytime sleepiness was by far the most common sleep problem, with 37% of adolescents meeting the clinical threshold according to parent report and 42% according to adolescent report. In contrast, prevalence rates for specific nighttime sleep problems ranged from 1.5% to 7.6%. Time spent in bed, bedtime resistance, ADHD inattentive symptoms, and Sluggish Cognitive Tempo (SCT) symptoms were significant in the final model predicting daytime sleepiness. Conclusion: Adolescents with ADHD commonly experience problems with daytime sleepiness that may significantly affect their functioning, but this may not be directly attributable to specific sleep problems.

Sleep Terrors: An Updated Review

BACKGROUND

Sleep terrors are common, frightening, but fortunately benign events. Familiarity with this condition is important so that an accurate diagnosis can be made.

OBJECTIVE

To familiarize physicians with the clinical manifestations, diagnosis, and management of children with sleep terrors.

METHODS

A PubMed search was completed in Clinical Queries using the key terms "sleep terrors" OR "night terrors". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

It is estimated that sleep terrors occur in 1 to 6.5% of children 1 to 12 years of age. Sleep terrors typically occur in children between 4 and 12 years of age, with a peak between 5 and 7 years of age. The exact etiology is not known. Developmental, environmental, organic, psychological, and genetic factors have been identified as a potential cause of sleep terrors. Sleep terrors tend to occur within the first three hours of the major sleep episode, during arousal from stage three or four non-rapid eye movement (NREM) sleep. In a typical attack, the child awakens abruptly from sleep, sits upright in bed or jumps out of bed, screams in terror and intense fear, is panicky, and has a frightened expression. The child is confused and incoherent: verbalization is generally present but disorganized. Autonomic hyperactivity is manifested by tachycardia, tachypnea, diaphoresis, flushed face, dilated pupils, agitation, tremulousness, and increased muscle tone. The child is difficult to arouse and console and may express feelings of anxiety or doom. In the majority of cases, the patient does not awaken fully and settles back to quiet and deep sleep. There is retrograde amnesia for the attack the following morning. Attempts to interrupt a sleep terror episode should be avoided. As sleep deprivation can predispose to sleep terrors, it is important that the child has good sleep hygiene and an appropriate sleeping environment. Medical intervention is usually not necessary, but clonazepam may be considered on a short-term basis at bedtime if sleep terrors are frequent and severe or are associated with functional impairment, such as fatigue, daytime sleepiness, and distress. Anticipatory awakening, performed approximately half an hour before the child is most likely to experience a sleep terror episode, is often effective for the treatment of frequently occurring sleep terrors.

CONCLUSION

Most children outgrow the disorder by late adolescence. In the majority of cases, there is no specific treatment other than reassurance and parental education. Underlying conditions, however, should be treated if possible and precipitating factors should be avoided.

Evening circadian preference is associated with sleep problems and daytime sleepiness in adolescents with ADHD

Adolescence is a developmental period characterized by disruptions in sleep and changes in circadian preferences. Although adolescents with attention-deficit/hyperactivity disorder (ADHD) are at even higher risk of sleep disruption than their peers, no study has examined whether circadian preference is associated with sleep problems and daytime sleepiness in adolescents with ADHD. This study provides an initial test of the hypothesis that greater evening preference would be associated with more sleep problems and daytime sleepiness in adolescents diagnosed with ADHD. Participants were 80 adolescents (69% male), aged 13-17 years, with ADHD. Adolescents completed measures assessing circadian preference, pubertal development, anxiety/depressive symptoms and weeknight sleep duration. Both adolescents and parents completed measures of sleep problems and daytime sleepiness. In regression analyses controlling for a number of other variables (i.e., age, sex, pubertal development, ADHD medication use, and ADHD, oppositional defiant disorder and internalizing symptom severity), greater evening preference was associated with both adolescent- and parent-reported sleep problems and daytime sleepiness. Greater evening preference remained significantly associated with each of these sleep problems and daytime sleepiness when also controlling for weeknight sleep duration. This is the first study to demonstrate that evening circadian preference is associated with both sleep problems and daytime sleepiness in adolescents with ADHD. The results indicate that it is important to consider circadian function as research examining sleep in adolescents with ADHD continues to advance.

Neurological and psychiatric adverse effects of long-term methylphenidate treatment in ADHD: A map of the current evidence

Methylphenidate (MPH), the most common medication for children with Attention Deficit/Hyperactivity Disorder (ADHD) in many countries, is often prescribed for long periods of time. Any long-term psychotropic treatment in childhood raises concerns about possible adverse neurological and psychiatric outcomes. We aimed to map current evidence regarding neurological and psychiatric outcomes, adverse or beneficial, of long-term MPH (> 1 year) treatment in ADHD. We coded studies using a "traffic light" system: Green: safe/favours MPH; Amber: warrants caution; Red: not safe/not well-tolerated. Un-categorisable study findings were coded as "Unclear". Although some evidence suggests an elevated risk of psychosis and tics, case reports describe remission on discontinuation. Several studies suggest that long-term MPH may reduce depression and suicide in ADHD. Evidence suggests caution in specific groups including pre-school children, those with tics, and adolescents at risk for substance misuse. We identified a need for more studies that make use of large longitudinal databases, focus on specific neuropsychiatric outcomes, and compare outcomes from long-term MPH treatment with outcomes following shorter or no pharmacological intervention.

Subjective and objective assessments of sleep problems in children with attention deficit/hyperactivity disorder and the effects of methylphenidate treatment

BACKGROUND

to investigate the sleep problems in children with different ADHD presentations and effects of methylphenidate (MPH) on the sleep problems of children with ADHD by both subjective and objective measurements.

METHODS

71 children with ADHD and 30 controls were included. 35 had ADHD with predominantly inattentive presentation (ADHD-I) and 36 with predominantly hyperactive/impulsive or combined presentation (ADHD-C). We used the pediatric sleep questionnaire (PSQ) and a nocturnal polysomnography (PSG) to assess the sleep problems in children with ADHD before and 6 months after being treated with methylphenidate (0.3-0.7 mg/kg/dose).

RESULTS

PSG showed significantly higher apnea-hypopnea index and hypopnea counts, and lower slow-wave sleep percentage in children with ADHD. The results of PSQ reported by parents showed significantly higher rates of delay initiation of sleep, sleep onset latency, sleep fragment, daytime sleepiness, enuresis, bruxism, nightmares, periodic limb movement disorder (PLMD), and snoring in children with ADHD compared to normal controls. Comparisons of ADHD presentations revealed no significant difference between ADHD-I and ADHD-C by either PSG or PSQ measurements. After 6-month MPH treatment, the PSG showed significantly increased total sleep time and reduced periodic limb movement index (PLMI). The PSQ indicated significant reduction in bruxism and snoring in ADHD-I, as well as nightmares in ADHD-C, and both subgroups showed significant reduction in PLMD.

CONCLUSION

subjective and objective approaches produced inconsistent findings regarding the sleep problems in children with ADHD. Besides, MPH didn't worsen the sleep problems in children with ADHD.

Attention deficit hyperactivity disorder symptom severity and sleep problems in adult participants of the Netherlands sleep registry

BACKGROUND

We examined whether current overall attention deficit hyperactivity disorder (ADHD), inattention, or hyperactivity symptom severities are associated with the current presence and persistent history of sleep problems.

METHODS

N = 942 participants of the Netherlands Sleep Registry filled out online several validated questionnaires. Regression analyses were performed to assess the association between (1) current overall ADHD symptom severity and the current presence of sleep problems, (2) current ADHD symptom-severity groups and the persistent history of sleep problems, and (3) current inattention or hyperactivity symptom severities and the current presence of sleep problems.

RESULTS

(1) Current overall ADHD symptom severity was associated with the odds of suffering from probable obstructive sleep apnea syndrome (OSAS), restless legs syndrome (RLS), periodic limb movement disorder (PLMD), insomnia disorder (ID) with predominant difficulties initiating sleep (DIS) and maintaining sleep (DMS), but not with the odds of suffering from narcolepsy or ID with predominant early-morning awakening (EMA). Current overall ADHD symptom severity was also associated with an extreme evening chronotype but not with short sleep. (2) The group with the most severe current ADHD symptoms was more likely to have a history of persistent OSAS, RLS, and ID. (3) The severity of symptoms of hyperactivity, but not of inattention, was specifically associated with probable RLS, PLMD, ID with DIS or DMS, and short sleep. Inattention symptom severity was only related to the probability of being an extreme evening chronotype.

CONCLUSION

ADHD severity, especially the severity of hyperactivity, is associated with the current presence and persistent history of sleep problems.

Relationship between subtypes and symptoms of ADHD, insomnia, and nightmares in connection with quality of life in children

OBJECTIVES

This study examined the links between sleep disorders and subtypes of attention deficit-hyperactivity disorder (ADHD-inattention, ADHD-combined, ADHD-hyperactive/impulsive) in childhood. We set up a hypothetical model linking different symptoms of both disorders to construct the underlying and shared pathways. By examining a sample of children with ADHD we firstly tested parts of the model.

METHODS

A total of 72 children with symptoms of ADHD (aged 6-13 years; 79.2% boys) were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition and the International Classification of Sleep Disorders, third edition in regards to ADHD and sleep disorders via standardized parent-rated questionnaires. Additionally, quality of life (QoL) was assessed. Overall, 46 children fulfilled the criteria of ADHD and were medication-naive.

RESULTS

On average, the whole sample had clinically elevated total scores of the Children's Sleep Habits Questionnaire in the validated German version (CSHQ-DE), indicating an increased prevalence of sleep disorders in children with ADHD. In accordance to our hypothetical model, children with primarily hyperactive-impulsive ADHD showed the highest CSHQ-DE scores. Moreover, we found a high impact for insomnia in this subgroup and a high comorbid load for the mutual occurrence of insomnia and nightmares. Furthermore, QoL was reduced in our whole sample, and again intensified in children with comorbid insomnia and nightmares.

CONCLUSION

We verified an elevated occurrence of sleep disorders in children with ADHD and were able to link them to specific subtypes of ADHD. These results were in line with our hypothetical model. Moreover, we found a clinically reduced QoL in mean for the whole sample, indicating the strong impact of ADHD in the lives of affected children, even intensified if children exhibited comorbid insomnia and nightmares. These results should be kept in mind regarding the treatment and therapy of this subgroup of children. Specific treatment strategies should be considered for these children.

The Mandarin version of the Kiddie-Schedule for Affective Disorders and Schizophrenia-Epidemiological version for DSM-5 - A psychometric study

BACKGROUND/PURPOSE

Changes of diagnostic coverage and criteria for psychiatric disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published in 2013 cause a need for updating the Kiddie-Schedule for Affective Disorders and Schizophrenia-Epidemiological version (K-SADS-E). This study examined the preliminary psychometric properties, including inter-rater reliability, and convergent and divergent validity of the modified K-SADS-E for DSM-5.

METHODS

A national survey of a school-based sample of 3242 students in grade 3, 5, and 7 from 44 schools was conducted in Northern, Central, and Southern Taiwan. Psychiatric diagnoses were made by the K-SADS-E interviews. Clinical questionnaires for attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and emotional and behavioral problems were examined using the Chinese version of the Swanson, Nolan, and Pelham IV scale, Social Responsiveness Scale, and Child Behavior Checklist.

RESULTS

The K-SADS-E showed satisfactory inter-rater reliability (prevalence adjusted bias adjusted kappa = 0.80-1.00) among eight interviewers. The diagnoses of K-SADS-E demonstrated good convergent and divergent validity with most corresponding clinical questionnaires.

CONCLUSION

Our finding suggests that the K-SADS-E is a reliable and valid instrument for diagnosing child and adolescent psychiatric disorders based on DSM-5. Further study will examine the sensitivity, specificity, and test-retest reliability of the K-SADS-E in clinical and community samples.

An Open-Label, Randomized Trial of Methylphenidate and Atomoxetine Treatment in Adults With ADHD

OBJECTIVE

To directly compare the efficacy of methylphenidate and atomoxetine in improving symptoms, social functions, and quality of life among adults with ADHD.

METHOD

This was an 8-to-10-week, open-label, head-to-head, randomized clinical trial with two treatment arms: immediate-release methylphenidate (IR-methylphenidate; n = 31) and atomoxetine once daily ( n = 32). The outcome measures included ADHD symptom severity, quality of life, and functional impairments.

RESULTS

We found a significant reduction in overall ADHD symptoms and improvement in social functions and quality of life for both groups at Weeks 4 to 5 and Weeks 8 to 10. There was no significant difference in the slope of improvements over time except that atomoxetine was superior to IR-methylphenidate in reducing hyperactive/impulsive symptoms at Weeks 4 to 5. There was no significant group difference in the rates of adverse effects.

CONCLUSION

Both IR-methylphenidate and atomoxetine are well tolerated and efficacious in ethnic Chinese adults with ADHD.

Sleep disturbances in adolescents with ADHD: A systematic review and framework for future research

BACKGROUND

Biological mechanisms underlying symptom and prognostic heterogeneity in Attention-Deficit/Hyperactivity Disorder (ADHD) are unclear. Sleep impacts neurocognition and daytime functioning and is disrupted in ADHD, yet little is known about sleep in ADHD during adolescence, a period characterized by alterations in sleep, brain structure, and environmental demands as well as diverging ADHD trajectories.

METHODS

A systematic review identified studies published prior to August 2016 assessing sleep in adolescents (aged 10-19years) with ADHD or participating in population-based studies measuring ADHD symptoms.

RESULTS

Twenty-five studies were identified (19 subjective report, 6 using actigraphy/polysomnography). Findings are mixed but overall suggest associations between sleep disturbances and 1) ADHD symptoms in the population and 2) poorer clinical, neurocognitive, and functional outcomes among adolescents with ADHD. Common limitations of studies included small or non-representative samples, non-standardized sleep measures, and cross-sectional methodology.

CONCLUSIONS

Current data on sleep in adolescent ADHD are sparse and limited by methodological concerns. Future studies are critical for clarifying a potential role of sleep in contributing to heterogeneity of ADHD presentation and prognosis. Potential mechanisms by which sleep disturbances during adolescence may contribute to worsened symptom severity and persistence of ADHD into adulthood and an agenda to guide future research are discussed.

Association Between Sleep Problems and Symptoms of Attention Deficit Hyperactivity Disorder in Adolescence: Results From a Large Population-Based Study

Sleep problems and symptoms of ADHD are common in adolescence, but detailed epidemiological assessment of their association is lacking. Using data from a recent population-based study, 9,846 adolescents aged 16 to 19 provided detailed information on sleep and symptoms of ADHD. Results confirmed a large overlap between self-reported symptoms of ADHD and all sleep variables studied. Symptoms of ADHD were linked to shorter sleep duration, longer sleep latency, and nocturnal wake time, as well as larger sleep deficiency. ADHD symptoms also increased the odds of insomnia and delayed sleep phase syndrome. The associations were only partially explained by confounders (mainly depression). The findings suggest that sleep problems should be included as a treatment target in efforts to reduce symptoms of ADHD in adolescence.

Atomoxetine could improve intra-individual variability in drug-naïve adults with attention-deficit/hyperactivity disorder comparably with methylphenidate: A head-to-head randomized clinical trial

OBJECTIVE

Intra-individual variability in reaction time (IIV-RT) is common in individuals with attention-deficit/hyperactivity disorder (ADHD). It can be improved by stimulants. However, the effects of atomoxetine on IIV-RT are inconclusive. We aimed to investigate the effects of atomoxetine on IIV-RT, and directly compared its efficacy with methylphenidate in adults with ADHD.

METHODS

An 8-10 week, open-label, head-to-head, randomized clinical trial was conducted in 52 drug-naïve adults with ADHD, who were randomly assigned to two treatment groups: immediate-release methylphenidate (n=26) thrice daily (10-20 mg per dose) and atomoxetine once daily (n=26) (0.5-1.2 mg/kg/day). IIV-RT, derived from the Conners' continuous performance test (CCPT), was represented by the Gaussian (reaction time standard error, RTSE) and ex-Gaussian models (sigma and tau). Other neuropsychological functions, including response errors and mean of reaction time, were also measured. Participants received CCPT assessments at baseline and week 8-10 (60.4±6.3 days).

RESULTS

We found comparable improvements in performances of CCPT between the immediate-release methylphenidate- and atomoxetine-treated groups. Both medications significantly improved IIV-RT in terms of reducing tau values with comparable efficacy. In addition, both medications significantly improved inhibitory control by reducing commission errors.

CONCLUSION

Our results provide evidence to support that atomoxetine could improve IIV-RT and inhibitory control, of comparable efficacy with immediate-release methylphenidate, in drug-naïve adults with ADHD. Shared and unique mechanisms underpinning these medication effects on IIV-RT awaits further investigation.

Sleep habits in children with attention-deficit/hyperactivity disorder predominantly inattentive type and associations with comorbid psychopathology symptoms

OBJECTIVES

Much of what is currently known about the sleep functioning of children with attention-deficit/hyperactivity disorder (ADHD) is based on samples of children with ADHD combined type, and no study to date has examined the association between sluggish cognitive tempo (SCT) and sleep functioning in children diagnosed with ADHD. Accordingly, the objectives of this study were to (1) describe the sleep habits of children diagnosed with ADHD predominantly inattentive type (ADHD-I) and (2) examine whether comorbid internalizing, oppositional, and/or SCT symptoms are associated with poorer sleep functioning in children with ADHD-I. This study extends the current literature by using a large, clinical sample of children with ADHD-I to examine the association between SCT and other psychopathology symptoms with children's sleep functioning.

METHODS

Participants included 147 children (age: 6-11, 59% male, 55% White) diagnosed with ADHD-I using a semi-structured diagnostic interview. Parents completed measures assessing their child's sleep habits as well as comorbid anxiety, depression, oppositionality, and SCT symptoms.

RESULTS

Fourteen percent of children with ADHD-I obtain less sleep than recommended and 31% have a sleep onset latency of greater than 20 minutes. The few children taking medication for ADHD had a longer sleep onset latency than those without medication. Twenty-seven percent of parents indicated that it is "difficult" to get their child out of bed on school days and 41% of parents indicated that their child needs to catch-up on sleep on the weekend "at least a little". Regression analyses found anxiety and SCT sleepy/tired symptoms to be the most consistent dimensions of psychopathology associated with sleep functioning, with little support for depression or oppositionality being associated with sleep.

CONCLUSIONS

A sizeable minority of children with ADHD-I experience impaired sleep. In addition to SCT sleepy/tired symptoms, comorbid anxiety was most consistently associated with poorer sleep functioning in children with ADHD-I. SCT daydreaming and working memory symptoms were unassociated with sleep functioning, and the size of the effects between SCT sleepy/tired and sleep functioning indicates that these are not overlapping constructs. Longitudinal studies are needed to evaluate the interrelations of sleep problems and comorbid psychopathology symptoms and their impact on the daytime functioning of children with ADHD-I.

Health correlates of insomnia symptoms and comorbid mental disorders in a nationally representative sample of US adolescents

STUDY OBJECTIVES

To estimate the prevalence and health correlates of insomnia symptoms and their association with comorbid mental disorders in a nationally representative sample of adolescents in the United States.

DESIGN

National representative cross-sectional study.

SETTING

Population-based sample from the US adolescents.

MEASUREMENTS AND RESULTS

A total of 6,483 individuals aged between 13–18 y in the National Comorbidity Survey-Adolescent Supplement (NCS-A) with both individual and parental reports of mental health were included in this study. Participants were classified with insomnia symptoms if they reported difficulty initiating sleep, difficulty maintaining sleep, and/or early morning awakening, nearly every day for at least 2 w in the past year. Nearly one-third of adolescents reported insomnia symptoms for at least 2 w during the previous year. Hispanic and black youth were significantly more likely to report insomnia symptoms (42.0% and 41.3%, respectively) than non-Hispanic white youth (30.4%). Adolescents with insomnia symptoms were at a higher risk for all classes of mental disorders {odds ratio [OR] (95% confidence interval [CI]: 3.4 (2.9–4.0)} including mood, anxiety, behavioral, substance use, and eating disorders, suicidality [OR (95% CI): 2.63 (1.34–5.16)], poor perceived mental health [OR (95% CI): 2.01 (1.02–3.96)], chronic medical conditions [OR (95% CI): 1.94 (1.55–2.43)], smoking [OR (95% CI: 2.60 (1.00–6.72)], and obesity [OR (95% CI: 1.46 (1.10–1.93)] than those without insomnia symptoms. Adolescents with insomnia symptoms and comorbid mental disorders manifested even greater rates of these indicators of negative health behaviors and disorders than those with mental disorders alone (P < 0.05).

CONCLUSIONS

Insomnia symptoms are reported by one-third of adolescents in the general population. Insomnia symptoms, even in the absence of concomitant depression or other mental disorders, are associated with serious health conditions, risk factors, and suicidality. Comorbid mental disorders potentiate the effect of insomnia symptoms on both physical and mental health. Further evaluation of the causes and effective interventions to reduce insomnia symptoms may have a significant effect on public health.

Interval timing deficits assessed by time reproduction dual tasks as cognitive endophenotypes for attention-deficit/hyperactivity disorder

The literature has suggested timing processing as a potential endophenotype for attention deficit/hyperactivity disorder (ADHD); however, whether the subjective internal clock speed presented by verbal estimation and limited attention capacity presented by time reproduction could be endophenotypes for ADHD is still unknown. We assessed 223 youths with DSM-IV ADHD (age range: 10-17 years), 105 unaffected siblings, and 84 typically developing (TD) youths using psychiatric interviews, intelligence tests, verbal estimation and time reproduction tasks (single task and simple and difficult dual tasks) at 5-second, 12-second, and 17-second intervals. We found that youths with ADHD tended to overestimate time in verbal estimation more than their unaffected siblings and TD youths, implying that fast subjective internal clock speed might be a characteristic of ADHD, rather than an endophenotype for ADHD. Youths with ADHD and their unaffected siblings were less precise in time reproduction dual tasks than TD youths. The magnitude of estimated errors in time reproduction was greater in youths with ADHD and their unaffected siblings than in TD youths, with an increased time interval at the 17-second interval and with increased task demands on both simple and difficult dual tasks versus the single task. Increased impaired time reproduction in dual tasks with increased intervals and task demands were shown in youths with ADHD and their unaffected siblings, suggesting that time reproduction deficits explained by limited attention capacity might be a useful endophenotype of ADHD.

Attention-deficit/hyperactivity disorder dimensions and sluggish cognitive tempo symptoms in relation to college students' sleep functioning

This study examined separate inattentive, hyperactive, and impulsive dimensions of attention-deficit/hyperactivity disorder (ADHD), as well as sluggish cognitive tempo (SCT) symptoms, in relation to college students' sleep functioning. Participants were 288 college students (ages 17-24; 65 % female; 90 % non-Hispanic White; 12 % self-reported having an ADHD diagnoses) who completed measures of ADHD/SCT symptoms and sleep functioning. Participants reported obtaining an average of 6.8 h of sleep per night (only 26 % reported obtaining ≥8 h of sleep) and having a sleep onset latency of 25 min. 63 % were classified as "poor sleepers," and poor sleepers had higher rates of ADHD and SCT symptoms than "good sleepers". Path analysis controlling for ADHD status and psychiatric medication use was used to determine associations between psychopathology and sleep functioning domains. Above and beyond covariates and other psychopathologies, hyperactivity (but not impulsivity) was significantly associated with poorer sleep quality, longer sleep latency, shorter sleep duration, and more use of sleep medications. SCT symptoms (but not inattention) were significantly associated with poorer sleep quality and increased nighttime sleep disturbance (e.g., having bad dreams, waking up in the middle of the night, feeling too cold or too hot). Both inattention and SCT were associated with greater daytime dysfunction. Regression analyses demonstrated that hyperactivity predicted sleep quality above and beyond the influence of daytime dysfunction, and inattention and SCT predicted daytime dysfunction above and beyond sleep quality. Further studies are needed to examine the interrelations of nighttime sleep functioning, ADHD/SCT, and daytime dysfunction, as well to elucidate mechanisms contributing to related functional impairments.

Prospective relationships between sleep problems and substance use, internalizing and externalizing problems

While research has shown that sleep problems and substance use are reciprocally associated in adults, much less is known about this association in early adolescence. The main aim of the current longitudinal study was to explore bidirectional relationships between sleep problems, substance use, internalizing and externalizing problems in young adolescents. A prospective design was used incorporating two waves (approximately 1 year interval). A total of 555 young adolescents (290 females, M age = 13.96) participated in this study. All participants completed self-report measures in classrooms during regular school hours (questionnaires about sleep quality and sleep hygiene were used to measure sleep problems). The results indicated that sleep problems predicted changes in substance use, internalizing and externalizing problems over time, but problem behaviours did not predict changes in sleep problems, adjusted for gender, age and puberty. One exception was that alcohol use negatively predicted changes in sleep problems. This study suggests that sleep problems are important precursors of substance use, internalizing and externalizing problems in adolescence.

The diagnosis and management of common sleep disorders in adolescents

PURPOSE OF REVIEW

Sleep problems in adolescents are very common and negatively impact the quality of their health and lives, yet often go undiagnosed. This review is meant to familiarize pediatricians with some of the more commonly encountered sleep disorders in this age group, and to review their diagnosis and management.

RECENT FINDINGS

Recent findings reinforce the ubiquity of insufficient and poor-quality sleep in teens and their consequences on physical and mental health, cognition, and behavior. Increasing use of technology by teens, especially at night, plays a growing role in this. Parentally set bedtimes can be effective in increasing the sleep duration, thereby diminishing the consequences of insufficient sleep. Parasomnias, common in early childhood, usually diminish with the transition into adolescence. An almost 10-fold increase in the incidence of narcolepsy has been reported following the use of one type of vaccination against influenza H1N1 in Europe. Recent guidelines for the diagnosis and management of obstructive sleep apnea are reviewed, as are recent guidelines pertaining to the management of sleep disorders of children on the autism spectrum.

SUMMARY

Sleep disorders in adolescents are both very common and underdiagnosed, adversely affecting their overall well being.

Sex differences and the interaction of age and sleep issues in neuropsychological testing performance across the lifespan in an ADD/ADHD sample from the years 1989 to 2009

Chart review of population (9 to 80 years) neuropsychological test battery for ADHD diagnosis, questionnaires with multiple responders were evaluated in outpatient setting from 1989-2009. The focus was gender differences across age, diagnostic group (ADHD-Inattentive/ADHD plus), neuropsychological test performance, and reported sleep symptoms over the lifespan. Individuals were assigned to ADHD-I group or ADHD plus group (based upon secondary diagnosis of sleep, behavioral, emotional disturbance); ADHD not primary was excluded (brain insult, psychosis). Among these were 1,828 children (ages 9 to 14), adolescents (ages 15 to 17), and adults (ages 18 and above); 446 children (312 diagnosed ADHD-I), 218 adolescents (163 diagnosed ADHD-I), and 1,163 adults (877 ADHD-I). Sleep was problematic regardless of age, ADHD subtype, and gender. The type and number of sleep problems and fatigue were age dependent. ADHD subtype, gender, fatigue, age, and sleep (sleep onset, unrefreshing sleep, sleep maintenance) were significant variables affecting neuropsychological test performance (sequencing, cognitive flexibility, slow- and fast-paced input, divided attention, whole brain functioning). Findings suggest that ADHD involves numerous factors and symptoms beyond attention, such as sleep which interacts differently dependent upon age.

Subthreshold attention deficit hyperactivity in children and adolescents: a systematic review

Subthreshold disorders, conditions with relevant psychiatric symptoms which do not meet the full criteria of a disorder according to the prevailing classification systems, have received increased attention recently. The current paper aims to present a systematic review of subthreshold attention-deficit/hyperactivity disorder (ADHD) in children and adolescents. Searching five computerised databases (Ovid MEDLINE, Psychinfo, PubMed, Scopus, Web of Science) with two categories of search terms [(1) subclinical; subsyndromal; subthreshold (2) ADHD] the authors examined the prevalence of subthreshold ADHD among children and adolescents, the comorbidity of subthreshold ADHD and whether there was already any impact of subthreshold ADHD on functioning. Before these questions were answered, the included articles were examined to see what kinds of definitions of child and adolescent subthreshold ADHD are used and what kinds of assessments are used for measuring subthreshold ADHD among children and adolescents. The results of the 18 articles included show that different definitions of subthreshold ADHD in children and adolescents exist, a large variety of instruments are used, the prevalence rate of subthreshold ADHD is wide-ranging (0.8-23.1 %), the comorbidity of subthreshold ADHD is high and there are several areas where subthreshold ADHD has a meaningful impact on functioning. All these suggest that focusing on subthreshold ADHD can be important in preventative interventions. The results of this systematic review support the dimensional approach of ADHD. Further research on uniform criteria of subthreshold ADHD is needed to support the inclusion of this condition in classification systems.

Neuropsychological functions among adolescents with persistent, subsyndromal and remitted attention deficit hyperactivity disorder

BACKGROUND

Previous studies have reported mixed results on neuropsychological deficits in attention deficit hyperactivity disorder (ADHD) and only a few studies have focused on adolescents. There is also a debate about whether the executive function (EF) impairments in ADHD are primary deficits or have some contribution from the underlying non-EF processes. The aim of this study was to investigate the impairments in EF and neuropsychological function with relatively low executive demand (low-EF) in adolescents with childhood diagnosis of ADHD as a function of current ADHD status.

METHOD

Psychiatric diagnostic interviews and computerized neuropsychological tests classified into EF and low-EF tasks were completed by 435 adolescents with a childhood diagnosis of ADHD (300 adolescents classified as persistent ADHD, 109 as subsyndromal ADHD and 26 as remitted ADHD based on the current diagnosis) and 263 typically developing (TD) adolescents.

RESULTS

There were significant EF (spatial working memory, spatial planning and verbal working memory) and low-EF (signal detectability, spatial span and visual recognition memory) impairments in persistent and subsyndromal ADHD. The impairments in EF were independent of low-EF despite significant moderate correlations between any two of these tasks. Adolescents with remitted ADHD showed no deficit in either EF or low-EF.

CONCLUSIONS

This study suggests that adolescents with persistent and subsyndromal ADHD have EF and low-EF impairments that might contribute to ADHD independently.

Impact of executive functions on school and peer functions in youths with ADHD

Youths with attention-deficit/hyperactivity disorder (ADHD) are more likely to have social dysfunction at school. The authors explored the role of key executive functions (EF, i.e., spatial working memory and spatial planning) on school and peer functions in 511 youths with persistent ADHD according to the DSM-IV diagnostic criteria and 124 non-ADHD controls without any EF deficits. All the participants were assessed by a semi-structured psychiatric interview to confirm their previous and current diagnosis of ADHD and other psychiatric disorders and by the Spatial Working Memory (SWM) and Stocking of Cambridge (SOC) tasks. The participants and their parents reported the participants' school functions and peer relationships. There were three ADHD subgroups: (1) ADHD with deficits in both SWM and SOC tasks (n=121); (2) ADHD with deficit in either SWM or SOC task (n=185); (3) ADHD without deficits in SWM or SOC task (n=205). All the three ADHD groups, regardless of EF deficits, had lower school grade, poorer attitude toward school work, poorer school interactions, more behavioral problems at school, and more severe problems in peer relationships than non-ADHD controls. Multivariate analyses revealed positive associations between deficit in the SWM task and school and peer dysfunctions, and between deficits in the SOC task and impaired peer interactions. Older age and psychiatric comorbidity also contributed to increased risk of school and peer dysfunctions. Our findings suggest that deficits in EF, such as spatial working memory and planning, might be associated with school and peer dysfunctions.

Association between the DAT1 gene and spatial working memory in attention deficit hyperactivity disorder

An association between attention deficit hyperactivity disorder (ADHD) and the dopamine transporter gene (DAT1) was reported in clinical samples. This study aimed to explore whether there was an association between DAT1 and spatial working memory (SWM), a promising endophenotype for ADHD. This family-based association sample consisted of 382 probands with DSM-IV ADHD and their family members (n = 1298) in Taiwan. The SWM task of the Cambridge Neuropsychological Test Automated Battery (CANTAB) was used to measure SWM of all participants. We screened 15 polymorphisms across the DAT1 gene, including 14 single nucleotide polymorphisms (SNPs) and the variable number of tandem repeat polymorphism in the 3'-untranslated region. We used the Family-Based Association Test (FBAT) to test the associations of genetic polymorphisms with the SWM measures. In single locus association analyses, two SNPs (rs2617605 and rs37020) were significantly associated with the double errors (adjusted p = 0.03 and 0.03, respectively) after adjustment for multiple testing. In haplotype analyses, a haplotype rs403636 (G)/rs463379 (C)/rs393795 (C)/rs37020 (G) was significantly associated with total within-search errors (minimal p = 0.001), within-search errors in eight boxes (minimal p = 0.002), total double errors (minimal p = 0.001) and double errors in eight boxes (minimal p = 0.004). Our finding of the haplotype rs403636 (G)/rs463379 (C)/rs393795 (C)/rs37020 (G) as a novel genetic marker for spatial working memory suggests that variation in DAT1 may provide insight into the pathways leading from genotype to phenotype of ADHD.

Rapid visual information processing as a cognitive endophenotype of attention deficit hyperactivity disorder

BACKGROUND

Deficits in sustained attention and reaction time are core features of attention deficit hyperactivity disorder (ADHD). However, little is known about attention performance in unaffected siblings. Hence, we examined sustained attention and reaction time in youths with ADHD, unaffected siblings and controls to test whether impaired performance in attention tasks can be a potential endophenotype of ADHD.

METHOD

We recruited 438 probands with clinical diagnosis of ADHD according to DSM-IV criteria, 180 unaffected siblings, and 173 healthy controls without lifetime ADHD. They were assessed using psychiatric interviews, Conners' Continuous Performance Test, and the tasks involving attention performance of the Cambridge Neuropsychological Test Automated Battery (CANTAB): Rapid Visual Information Processing (RVP), Reaction Time (RTI) and Match to Sample Visual Search (MTS). Multi-level models were used for data analysis.

RESULTS

Compared with the controls, probands with ADHD and unaffected siblings had significantly higher total misses, lower probability of hits in the RVP task and probands with ADHD performed worse in the RTI and MTS tasks after controlling for sex, age, co-morbidity, parental educational levels and IQ. The duration of methylphenidate use and IQ but not psychiatric co-morbidity or current use of methylphenidate were associated with deficits in sustained attention in probands with ADHD.

CONCLUSIONS

Our findings suggest that attention performance assessed by the RVP task, but not the RTI or MTS tasks, of the CANTAB may be a useful cognitive endophenotype for ADHD genetic studies.

Prediction of ADHD to anxiety disorders: an 11-year national insurance data analysis in Taiwan

OBJECTIVE

To prospectively investigate prediction of ADHD to anxiety disorders (ANXs) in a national sample of Taiwan.

METHOD

From the Taiwan National Health Insurance Dataset (1997-2007), we collected 2,385 cases of new diagnoses of ADHD from 1999 to 2003 and 9,540 sex-, age- and index dates of the first diagnosis of ADHD-matched cohort controls without ADHD. The outcome is age of the first diagnosis of ANXs until December 31, 2007.

RESULTS

More cases of ADHD (17.7%) developed ANXs than did matched controls (1.9%) with a younger age onset (12.7 years vs. 17.9 years) and a shorter "survival time" (1.4 years vs. 5.0 years). Cox models revealed a significant prediction of ADHD to ANXs controlling for other psychiatric comorbidities [Hazard ratio (HR) = 15.83]. The magnitude of such association was greater in males and decreased with older age of first ADHD diagnosis.

CONCLUSION

The findings imply that early detection and treatment for ADHD may offset later development of ANXs.

The ex-Gaussian distribution of reaction times in adolescents with attention-deficit/hyperactivity disorder

We investigated the three parameters (mu, sigma, tau) of ex-Gaussian distribution of RT derived from the Conners' continuous performance test (CCPT) and examined the moderating effects of the energetic factors (the inter-stimulus intervals (ISIs) and Blocks) among these three parameters, especially tau, an index describing the positive skew of RT distribution. We assessed 195 adolescents with DSM-IV ADHD, and 90 typically developing (TD) adolescents, aged 10-16. Participants and their parents received psychiatric interviews to confirm the diagnosis of ADHD and other psychiatric disorders. Participants also received intelligence (WISC-III) and CCPT assessments. We found that participants with ADHD had a smaller mu, and larger tau. As the ISI/Block increased, the magnitude of group difference in tau increased. Among the three ex-Gaussian parameters, tau was positively associated with omission errors, and mu was negatively associated with commission errors. The moderating effects of ISIs and Blocks on tau parameters suggested that the ex-Gaussian parameters could offer more information about the attention state in vigilance task, especially in ADHD.

A head-to-head randomized clinical trial of methylphenidate and atomoxetine treatment for executive function in adults with attention-deficit hyperactivity disorder

Results regarding the effects of methylphenidate and atomoxetine on executive functions were inconsistent and no study has directly compared the efficacy of these two medications in improving executive functions in adults with attention-deficit hyperactivity disorder (ADHD). We conducted an 8-10 wk, open-label, head-to-head, randomized clinical trial involving adults with a clinical diagnosis of ADHD confirmed by psychiatric interview. The two treatment arms were immediate-release methylphenidate (IR-methylphenidate) (n = 31) and atomoxetine once daily (n = 32). Executive functions were assessed by the Cambridge Neuropsychological Test Automated Battery (CANTAB), including spatial working memory, spatial span, intra-extra dimensional set shifts, rapid visual information processing and Stockings of Cambridge (SOC). In addition to the symptom assessments at baseline (week 0), visit 2 (week 4-5) and visit 3 (week 8–10), they received CANTAB assessments at baseline and visit 3 (60.4 ± 6.3 d). Compared to baseline, adults treated with atomoxetine showed significant improvement in spatial working memory, spatial short-term memory, sustained attention and spatial planning at visit 3; adults treated with IR-methylphenidate showed significant improvement in spatial working memory at visit 3. Comparing the magnitude of improvement in executive functions between these two medications, the effect was generally similar for the two groups, although atomoxetine might have significantly greater efficacy than IR-methylphenidate in terms of improving spatial planning (SOC). Our results provide evidence to support that both IR-methylphenidate and atomoxetine improved various executive functions in adults with ADHD with greater improvement in atomoxetine than IR-methylphenidate in spatial planning.

Associations of symptoms and subtypes of attention-deficit hyperactivity disorder with visuospatial planning ability in youth

Little is known about which ADHD core symptom or subtype is most associated with visuospatial planning deficit. This issue was investigated in a sample of 408 youths with current DSM-IV diagnosis of ADHD, and 332 youths without lifetime ADHD, aged 8-17 years (mean age 12.02±2.24). All the participants and their mothers were interviewed using the Chinese Kiddie Epidemiologic version of the Schedule for Affective Disorders and Schizophrenia to obtain information about ADHD symptoms and diagnosis and other psychiatric disorders. In addition to clinical assessments, the participants were assessed with the WISC-III and the Stocking of Cambridge task of the Cambridge Neuropsychological Test Automated Battery. Multi-level regression models were used for data analysis. The results showed that univariate analyses revealed that inattention, hyperactivity, and impulsivity were significantly associated with visuospatial planning, and the magnitude of such association was amplified with increased task difficulties. Only inattention independently predicted visuospatial planning in a model that included all three ADHD symptoms. After further controlling for comorbidity, age of assessment, treatment with methylphenidate, and Full-scale IQ, inattention was still independently associated with visuospatial planning indexed by mean moves needed to solve problems. In subtype comparison, participants with combined subtype and those with prominently inattentive subtype, rather than prominently hyperactivity/impulsivity subtype, had poorer visuospatial planning performance. Our findings indicate that inattention is independently associated with impaired visuospatial planning, and dimensional approach retains the important distinction among ADHD symptoms than subtype approach in understanding the neuropsychological functioning of ADHD.

Psychometric properties of the Chinese version of Strength and Difficulties Questionnaire

This study aimed to establish the norms and to examine the psychometric properties of the Chinese version of the Strengths and Difficulties Questionnaire (SDQ). Sample included a representative sample of 3534 students (grades 1 to 8) from one city and one suburb each in Northern and Southern Taiwan by using a multistage sampling method and 211 psychiatric outpatients diagnosed with attention-deficit hyperactivity disorder (ADHD), aged 6 to 15, consecutively recruited from a medical center in Taipei. All the parents and teachers and participants with grade 4 or higher completed the SDQ. Parents and teachers also completed the Child Behavior Checklist and the measures about inattention, hyperactivity, and oppositional symptoms. Similar to Western studies, principal component analyses confirmed the five psychological dimensions of the SDQ for the parent, teacher, and student forms. The three forms of the Chinese SDQ showed satisfactory test-retest reliability, internal consistency, concurrent validity, and discriminant validity. All the subscales of the three forms of the Chinese SDQ clearly distinguished clinical participants with ADHD from school-based participants. Like Western studies, our findings indicate that the Chinese SDQ demonstrates a reliable and valid instrument for measuring internalizing, externalizing, and prosocial behaviors in Taiwanese child and adolescent population.

Maternal parenting styles and mother-child relationship among adolescents with and without persistent attention-deficit/hyperactivity disorder

We investigated mothering and mother-child interactions in adolescents with and without persistent attention-deficit/hyperactivity disorder (ADHD) in a sample of 190 adolescents with persistent DSM-IV ADHD, 147 without persistent ADHD, and 223 without ADHD. Both participants and their mothers received psychiatric interviews for diagnosis of ADHD and other mental disorders; and reported on the Parental Bonding Instrument about mother's parenting style, the Social Adjustment Inventory for Children and Adolescents for interactions with mothers and home behavioral problems. The mothers also reported on their ADHD and neurotic/depressive symptoms. Our results based on both informants showed that both ADHD groups obtained less affection/care and more overprotection and control from the mothers, and perceived less family support than those without ADHD. Child's inattention and comorbidity, and maternal depression were significantly correlated with decreased maternal affection/care and increased maternal controls; child's hyperactivity-impulsivity and maternal neurotic trait were significantly correlated with maternal overprotection; and child's inattention and comorbidity, and maternal neurotic/depressive symptoms were significantly correlated with impaired mother-child interactions and less family support. Our findings suggested that, regardless of persistence, childhood ADHD diagnosis, particularly inattention symptoms and comorbidity, combining with maternal neurotic/depressive symptoms was associated with impaired maternal process.

Associations between sleep characteristics, seasonal depressive symptoms, lifestyle, and ADHD symptoms in adults

OBJECTIVE

The authors explored associations between ADHD symptoms, seasonal depressive symptoms, lifestyle, and health.

METHOD

Adult ADHD patients (n = 202) and controls (n = 189) completed the ASESA questionnaire involving lifestyle, eating pattern, and physical and psychological health, and validated measures on ADHD and sleep. ASESA is the Dutch acronym for inattention, sleep, eating pattern, mood, and general health questionnaire.

RESULTS

Indication for delayed sleep phase syndrome (DSPS) was 26% in patients and 2% in controls (p < .001). Patients reported shorter sleep, longer sleep-onset latency, and later midsleep. Shorter (R (2) = .21) and later (R (2) = .27) sleep were associated with hyperactivity, male gender, younger age, and seasonal depressive symptoms. Seasonal depressive symptoms were related to hyperactivity, female gender, unemployment, and late sleep (pseudo R (2) = .28). Higher body mass index (BMI) was associated with shorter sleep in patients (ρ = -.16; p = .04) and controls (ρ = -.17; p = .02). Longer sleep showed lower odds for indication of metabolic syndrome (OR = -0.17; p = .053).

CONCLUSION

DSPS is more prevalent in ADHD and needs further investigation to establish treatment to prevent chronic health issues.

Correlates for academic performance and school functioning among youths with and without persistent attention-deficit/hyperactivity disorder

Childhood attention-deficit hyperactivity disorder (ADHD) is associated with academic underachievement and school dysfunction. Little is known whether such association varies with the persistence of ADHD symptoms. The authors investigated school functioning among youths with and without persistent ADHD and identified the clinical correlates for school functioning in a large sample of 333 youths with persistent ADHD, 166 with non-persistent ADHD, and 266 without ADHD. The participants and their mothers received structured interviews for diagnosis of ADHD and other psychiatric conditions according to the DSM-IV diagnostic criteria by using the Kiddie epidemiologic version of the Schedule for Affective Disorders and Schizophrenia, and for school functioning by using the Chinese Social Adjustment Inventory for Children and Adolescents. The results showed that both ADHD groups had more impairment in all domains of school functioning than youths without ADHD with a gradient relationship in the order of persistent ADHD, non-persistent ADHD, and non-ADHD. The most consistent correlates for all domains of impaired school functioning were youth- and mother-reported inattention symptoms and increased age. Childhood hyperactivity-impulsivity symptoms also predicted more severe problems in social interactions and school behaviors. Psychiatric comorbid conditions also predicted poorer attitudes toward school works and interactions at school. Our findings indicate that lifetime diagnosis of ADHD, regardless of persistence of ADHD, associate with the impairment of overall school functioning sustaining from childhood into adolescence, and imply that early intervention of childhood inattention may offset school dysfunction at late childhood and adolescence.

Improving visual memory, attention, and school function with atomoxetine in boys with attention-deficit/hyperactivity disorder

OBJECTIVE

Atomoxetine is efficacious in reducing symptoms of attention- deficit/hyperactivity disorder (ADHD), but its effect on visual memory and attention needs more investigation. This study aimed to assess the effect of atomoxetine on visual memory, attention, and school function in boys with ADHD in Taiwan.

METHOD

This was an open-label 12 week atomoxetine treatment trial among 30 drug-naíve boys with ADHD, aged 8-16 years. Before administration of atomoxetine, the participants were assessed using psychiatric interviews, the Wechsler Intelligence Scale for Children, 3rd edition (WISC-III), the school function of the Chinese version of the Social Adjustment Inventory for Children and Adolescents (SAICA), the Conners' Continuous Performance Test (CPT), and the tasks of the Cambridge Neuropsychological Test Automated Battery (CANTAB) involving visual memory and attention: Pattern Recognition Memory, Spatial Recognition Memory, and Reaction Time, which were reassessed at weeks 4 and 12.

RESULTS

Our results showed there was significant improvement in pattern recognition memory and spatial recognition memory as measured by the CANTAB tasks, sustained attention and response inhibition as measured by the CPT, and reaction time as measured by the CANTAB after treatment with atomoxetine for 4 weeks or 12 weeks. In addition, atomoxetine significantly enhanced school functioning in children with ADHD.

CONCLUSION

Our findings suggested that atomoxetine was associated with significant improvement in visual memory, attention, and school functioning in boys with ADHD.