Sleep in children with attention-deficit/hyperactivity disorder: meta-analysis of subjective and objective studies

Change in Sleep Latency as a Mediator of the Effect of Physical Activity Intervention on Executive Functions Among Children with ADHD: A Secondary Analysis from a Randomized Controlled Trial

This study aimed to explore the potential mediating role of sleep quality in the effect of physical activity (PA) intervention for improving executive functions (EFs) in children with attention-deficit hyperactivity disorder (ADHD). Participants aged 6 to 12 years old with a formal ADHD diagnosis were recruited from a local hospital. A total of 80 eligible children with ADHD were randomized to an intervention group for 12 consecutive weeks of PA training (three times per week, 60 min per session) (n = 40; Mage = 8.37, 75% boys) or a wait-list control group (n = 40; Mage = 8.29, 80% boys). Three core EFs (inhibitory control, working memory, and cognitive flexibility) were assessed by neurocognitive tasks, and sleep quality was measured by the Chinese version of the Pittsburgh Sleep Quality Index. The bootstrapping method was used to test PA intervention effects on EFs and on potential variables of sleep quality after intervention and to test whether there were indirect effects of the intervention on EFs via mediators of sleep. The results showed that the PA intervention had a direct effect on sleep latency reduction (β = - 0.26, 95%CI - 0.47 to - 0.06) and cognitive flexibility improvement (decrease in completion time) (β = - 0.30, 95%CI - 0.50 to - 0.09). Furthermore, change in sleep latency significantly mediated the effects of PA intervention on cognitive flexibility (β = - 0.084, 95%CI - 0.252 to - 0.001). The findings suggest that sleep latency could be a crucial behavioral mediator of PA intervention in improving cognitive flexibility among children with ADHD.

The role of circadian rhythms and sleep in the aetiology of autism spectrum disorder and attention-deficit/hyperactivity disorder: New evidence from bidirectional two-sample Mendelian randomization analysis

LAY ABSTRACT

Research shows that people with autism spectrum disorder and attention-deficit/hyperactivity disorder often have sleep issues and problems with the body's natural daily rhythms, known as circadian rhythms. By exploring the genetic variants associated with these rhythms and the conditions, this study reveals that these rhythm changes and sleep patterns are directly linked to autism spectrum disorder and attention-deficit/hyperactivity disorder. It found that the timing of one's most active hours can increase the likelihood of having both autism spectrum disorder and attention-deficit/hyperactivity disorder. Importantly, it also shows that good sleep quality might protect against autism spectrum disorder, while disturbed sleep in people with attention-deficit/hyperactivity disorder seems to be a result rather than the cause of the condition. This understanding can help doctors and researchers develop better treatment approaches that focus on the specific ways sleep and body rhythms affect those with autism spectrum disorder and attention-deficit/hyperactivity disorder, considering their unique associations with circadian rhythms and sleep patterns. Understanding these unique links can lead to more effective, personalized care for those affected by these conditions.

Sleep disturbance in children with attention-deficit hyperactivity disorder: relationship with melatonin and behavior

AIM

To evaluate the prevalence and types of sleep problems and their correlations with melatonin content and behavior in Attention-Deficit Hyperactivity Disorder (ADHD) children.

METHOD

Sleep in ADHD children and typically developing children (TD) aged 6-14 was assessed by the Sleep Disorders Scale for Children (SDSC) and actigraphy, salivary melatonin quantified by ELISA, and behavior was analyzed using the Strengths and Difficulties Questionnaire.

RESULTS

ADHD children showed a higher frequency of sleep disturbances, higher sleep latency, and lower sleep efficiency than in the TD group. The ADHD group presented lower melatonin nocturnal content compared to the TD group. Disorders of Initiating and Maintaining Sleep (DIMS) was moderately associated with nocturnal melatonin. The total behavior difficulties were correlated with Disorders of Initiating and Maintaining Sleep (DIMS), Sleep/Wake Transition Disorders (SWTD), Disorders of Excessive Somnolence (DES), Sleep Hyperhidrosis (SHY) and Total SDSC Score. The behavior was the only determinant of the total SDSC score (R2 = 0.499; p < 0.002).

CONCLUSION

This study provides, for the first time, evidence that among the frequent sleep disturbances in ADHD, the disorders in initiating and maintaining sleep are associated with the low levels of melatonin found in this population. Additionally, these, along with other sleep disturbances, are linked to behavioral problems in ADHD.

Are all ADHD medications created equal? Exploring the differences that enable evening dosing

With more than 30 available stimulant medications, choosing among therapeutic options for attention-deficit/hyperactivity disorder (ADHD) has become increasingly complex and patient specific. All ADHD stimulants owe their action to variants of either amphetamine or methylphenidate, yet formulation and delivery system differences create unique pharmacokinetic and clinical profiles for each medication. A benefit of the diversity within ADHD pharmacotherapy is that it facilitates tailoring treatment to meet patient needs. Historically, there has been a constant among long-acting stimulant options, regardless of formulation, which was morning dosing. The introduction of delayed-release and extended-release methylphenidate (DR/ER-MPH) is the first long-acting stimulant that patients take in the evening, with the clinical effect delayed until awakening in the morning. This paradigm shift has generated questions among clinicians and continued interest in real-world experience and data. This review used available clinical data, real-world evidence, emerging analyses, and clinical experience to evaluate the characteristics of DR/ER-MPH and its clinical utility within the greater context of ADHD medications and to provide clinicians with practical guidance on the use of DR/ER-MPH in children, adolescents, and adults with ADHD.

The management of sleep disturbances in children with attention-deficit/hyperactivity disorder (ADHD): an update of the literature

INTRODUCTION

Sleep disorders represent an important comorbidity in individuals with ADHD. While the links between ADHD and sleep disturbances have been extensively investigated, research on the management of sleep disorders in individuals with ADHD is relatively limited, albeit expanding.

AREAS COVERED

The authors searched PubMed, Medline, PsycInfo, Embase+Embase Classic, Web of Sciences databases, and clinicaltrials.gov up to 4 January 2024, for randomized controlled trials (RCTs) of any intervention for sleep disorders associated with ADHD. They retained 16 RCTs (eight on pharmacological and eight on non-pharmacological interventions), supporting behavioral intervention and melatonin, and nine ongoing RCTs registered on clinicaltrials.gov.

EXPERT OPINION

The pool of RCTs testing interventions for sleep disorders in individuals with ADHD is expanding. However, to inform clinical guidelines, there is a need for additional research in several areas, including 1) RCTs based on a precise phenotyping of sleep disorders; 2) pragmatic RCTs recruiting neurodevelopmental populations representative of those seen in clinical services; 3) trials testing alternative interventions (e.g. suvorexant or light therapy) or ways to deliver them (e.g. online); 4) sequential and longer-term RCTs; 5) studies testing the impact of sleep interventions on outcomes other than sleep; 6) and implementation of advanced evidence synthesis and precision medicine approaches.

The impacts associated with having ADHD: an umbrella review

Introduction

Attention Deficit Hyperactivity Disorder (ADHD) affects up to 5% of the population and is characterised by symptoms of impulsivity, hyperactivity and inattention. These symptoms are significantly impairing and carry additional risks for children and adults with ADHD, including negative mental health (e.g. depression), physical health (e.g. obesity) and societal outcomes (e.g. imprisonment, divorce). Very few studies have attempted to synthesise these risks in one publication due to the breadth of evidence published on the adverse outcomes of ADHD.

Methods

An umbrella review was performed to identify reviews (systematic, meta-analysis and narrative) that investigate the risks arising from having ADHD. We conducted a narrative synthesis of the findings and conducted a quality review of the included publications.

Results

Upon searching five databases, 16,675 records were identified. Of these, 125 reviews met the criteria for inclusion. A narrative synthesis of these findings highlighted three key domains of risks associated with ADHD: mental health, physical health, social and lifestyle. Most reviews were of good and moderate quality.

Discussion

This review highlights the many risks associated with having ADHD, beyond its three key symptom domains and the impact of the condition on daily functioning.

Registration

International Prospective Register of Systematic Reviews (PROSPERO CRD42023404073).

Characteristics of sleep in children with heavy prenatal alcohol exposure

BACKGROUND

Sleep plays an important role in neurodevelopment. However, the effects of prenatal alcohol exposure on sleep quality have been understudied, despite reports of sleep disturbance in infants prenatally exposed to alcohol and elevated levels of sleep problems reported by caregivers of children with fetal alcohol spectrum disorders. The current study characterizes sleep in children with prenatal alcohol exposure using both objective (actigraphy) and subjective (questionnaires, sleep diaries) methods.

METHODS

Participants aged 6-10 years, with and without prenatal alcohol exposure, were included in the study (alcohol-exposed [AE]: n = 35; control [CON]: n = 39). Objective sleep was measured via 24-h actigraphy for 2 weeks. Parents completed sleep diaries and sleep questionnaires (Children's Sleep Habits Questionnaire, Pediatric Sleep Questionnaire). Multivariate analysis of variance was used to characterize the sleep profile (objective, subjective) and examine group differences.

RESULTS

There were no group differences on actigraphy metrics averaged across 2 weeks. However, the AE group showed significantly greater intraindividual variability on most actigraphy measures, particularly total sleep time, percent sleep, wake after sleep onset, and number of wake bouts. Parents reported significantly more sleep problems in the AE group than in the CON group, primarily driven by night wakings, parasomnias (e.g., sleepwalking), snoring, and daytime sleepiness. These effects were more severe in children >8.5 years of age.

CONCLUSIONS

Despite similar 2-week average sleep outcomes, children with prenatal alcohol exposure showed greater intraindividual sleep variability and parents reported more sleep problems related to sleep behavior and snoring. These difficulties with sleep may be related to other cognitive and behavioral outcomes. Importantly, sleep is a modifiable behavior, and interventions that focus on variability in sleep, particularly in sleep duration, can impact the quality of life in children with prenatal alcohol exposure and their families.

Developmental pyrethroid exposure disrupts molecular pathways for MAP kinase and circadian rhythms in mouse brain

Neurodevelopmental disorders (NDDs) are a category of pervasive disorders of the developing nervous system with few or no recognized biomarkers. A significant portion of the risk for NDDs, including attention deficit hyperactivity disorder (ADHD), is contributed by the environment, and exposure to pyrethroid pesticides during pregnancy has been identified as a potential risk factor for NDD in the unborn child. We recently showed that low-dose developmental exposure to the pyrethroid pesticide deltamethrin in mice causes male-biased changes to ADHD- and NDD-relevant behaviors as well as the striatal dopamine system. Here, we used an integrated multiomics approach to determine the broadest possible set of biological changes in the mouse brain caused by developmental pyrethroid exposure (DPE). Using a litter-based, split-sample design, we exposed mouse dams during pregnancy and lactation to deltamethrin (3 mg/kg or vehicle every 3 days) at a concentration well below the EPA-determined benchmark dose used for regulatory guidance. We raised male offspring to adulthood, euthanized them, and pulverized and divided whole brain samples for split-sample transcriptomics, kinomics and multiomics integration. Transcriptome analysis revealed alterations to multiple canonical clock genes, and kinome analysis revealed changes in the activity of multiple kinases involved in synaptic plasticity, including the mitogen-activated protein (MAP) kinase ERK. Multiomics integration revealed a dysregulated protein-protein interaction network containing primary clusters for MAP kinase cascades, regulation of apoptosis, and synaptic function. These results demonstrate that DPE causes a multi-modal biophenotype in the brain relevant to ADHD and identifies new potential mechanisms of action.

NEW & NOTEWORTHY

Here, we provide the first evidence that low-dose developmental exposure to the pyrethroid pesticide, deltamethrin, results in molecular disruptions in the adult mouse brain in pathways regulating circadian rhythms and neuronal growth (MAP kinase). This same exposure causes a neurodevelopmental disorder (NDD) relevant behavioral changes in adult mice, making these findings relevant to the prevention of NDDs.

ADHD Symptoms and Sleep Problems During Middle Childhood: The Indirect Effect of Peer Victimization

The present cross-sectional study evaluated whether traditional and/or cyber peer victimization served as mechanisms linking ADHD symptoms to sleep disturbance and sleep impairment in a sample of 284 third- through fifth-grade students (51.9% boys; 50.4% Hispanic/Latine) from two elementary schools in the United States. ADHD symptoms were assessed using teacher ratings. Children provided reports of their traditional and cyber victimization as well as their sleep disturbance and impairment. Results from path analysis models revealed significant indirect effects of traditional victimization on the links from ADHD symptoms to sleep disturbance and impairment. There was also a significant indirect effect of cyber victimization on the link from ADHD symptoms to sleep impairment. These findings suggest that experiences of traditional and cyber peer victimization may need to be addressed among children exhibiting ADHD symptoms in order to mitigate their risk for sleep problems and downstream effects on other domains of psychosocial functioning.

In-person versus online delivery of a behavioral sleep intervention (Sleeping Sound©) for children with ADHD: protocol for a parallel-group, non-inferiority, randomized controlled trial

BACKGROUND

Children with Attention-Deficit/Hyperactivity Disorder (ADHD) often experience sleep difficulties such as difficulty initiating and maintaining sleep. Problem sleep may impact children's daily functioning and behaviors and exacerbate ADHD symptoms. Most effective behavioral interventions to improve sleep are conducted in person, limiting accessibility to treatment for individuals in remote or rural communities or those who are unable to attend a clinic. This trial aims to assess the efficacy of delivering an established behavioral intervention online, Sleeping Sound with ADHD©, compared to a face-to-face delivery mode.

METHODS

This parallel group, non-inferiority, randomized controlled trial (RCT) will include at least 68 children, aged 5-12 years old with ADHD. Families of children will be recruited from private developmental and psychological clinics and social media, within the state of Western Australia (WA). Once written informed consent and baseline questionnaires are completed, families are randomized to receive the behavioral intervention either in-person or online via Telehealth services. The intervention targets the assessment and management of reported sleep problems, through two individual consultations and a follow-up phone call with a trained clinician. The sleep outcomes assessed consist of a parent-reported sleep questionnaire and actigraphy.

DISCUSSION

To the best of our knowledge, this is the first RCT to investigate sleep treatment modality for children with ADHD. If effective, clinicians can provide an evidence-based sleep intervention in an accessible manner.

TRIAL REGISTRATION

ANZCTR, ACTRN12621001681842 . Registered 9 December 2021-Retrospectively registered.

Sleep parameters and problems in adolescents with and without ADHD: A systematic review and meta-analysis

Background

Adolescence is characterized by an increase in the rate of sleep problems, which might be even more pronounced in adolescents with ADHD. This systematic review with meta-analysis aimed to compare sleep in adolescents with and without ADHD, including sleep parameters, both subjectively and objectively measured, sleep problems and sleep hygiene.

Methods

Medline, CINAHL, PsycINFO, EMBASE, ERIC, Web of Science, and PubMed databases were searched for studies with case-control designs (published between 1980 and 2022) directly comparing sleep in adolescents (12-25 years) with ADHD to typically developing controls. Standardized mean differences were calculated and a random-effects model was implemented using RevMan.

Results

Overall, 6974 titles/abstracts and 205 full texts were screened, resulting in 13 eligible studies. The sample sizes range from 35 to 9846 with in total 2465 adolescents with ADHD and 18,417 controls. The data suggests that adolescents with ADHD report significantly more disturbed subjective sleep parameters (e.g., total sleep time; n = 7, SMD = 0.47, p < .001) and experience more sleep problems compared to typically developing peers (e.g., daytime sleepiness; n = 5, SMD = 0.54, p = .01). Only few studies objectively measured sleep and no significant differences were found between both groups (n = 3) in any parameter. Differences in sleep hygiene could not be examined due to a limited number of studies.

Conclusions

Adolescents with ADHD report significantly worsened subjectively sleep parameters and more sleep problems compared to controls. These findings are still preliminary as a limited number of studies was identified. Nevertheless, it is advised to routinely include sleep assessment in the ADHD diagnostic process. More research is needed with a focus on objective measurement and sleep hygiene in ADHD.

Transcranial random noise stimulation combined with cognitive training for treating ADHD: a randomized, sham-controlled clinical trial

Non-invasive brain stimulation has been suggested as a potential treatment for improving symptomology and cognitive deficits in Attention-Deficit/Hyperactivity Disorder (ADHD), the most common childhood neurodevelopmental disorder. Here, we examined whether a novel form of stimulation, high-frequency transcranial random noise stimulation (tRNS), applied with cognitive training (CT), may impact symptoms and neural oscillations in children with ADHD. We conducted a randomized, double-blind, sham-controlled trial in 23 unmedicated children with ADHD, who received either tRNS over the right inferior frontal gyrus (rIFG) and left dorsolateral prefrontal cortex (lDLPFC) or sham stimulation for 2 weeks, combined with CT. tRNS + CT yielded significant clinical improvements (reduced parent-reported ADHD rating-scale scores) following treatment, compared to the control intervention. These improvements did not change significantly at a 3-week follow-up. Moreover, resting state (RS)-EEG periodic beta bandwidth of the extracted peaks was reduced in the experimental compared to control group immediately following treatment, with further reduction at follow-up. A lower aperiodic exponent, which reflects a higher cortical excitation/inhibition (E/I) balance and has been related to cognitive improvement, was seen in the experimental compared to control group. This replicates previous tRNS findings in adults without ADHD but was significant only when using a directional hypothesis. The experimental group further exhibited longer sleep onset latencies and more wake-up times following treatment compared to the control group. No significant group differences were seen in executive functions, nor in reported adverse events. We conclude that tRNS + CT has a lasting clinical effect on ADHD symptoms and on beta activity. These results provide a preliminary direction towards a novel intervention in pediatric ADHD.

Pediatric attention deficit hyperactivity disorder (ADHD): 2022 updates on pharmacological management

INTRODUCTION

Pediatric attention-deficit disorder (ADHD) impacts a significant percentage of the population world-wide. Pharmacologic treatments have been shown to be safe and effective for managing symptoms. Various medication formulations exist, and new medication agents are continually approved each year.

AREAS COVERED

This article offers an overview of ADHD, an overview of both stimulant and non-stimulant medication options as well as an overview of stimulant misuse. It explores the medication mechanisms of action and side effect profiles, as well as offering an in-depth summary of the novel agents recently approved and soon-to-be approved for use in youth. PubMed and Medline were utilized. Search terms included children, adolescents, ADHD, and medication. FDA package inserts were reviewed for all medications.

EXPERT OPINION

New formulations of medications include an evening administered, extended, and delayed-release form of methylphenidate (DR/ER MPH), a methylphenidate pro-drug (serdexmethylphenidate) and an amphetamine patch. The availability of a new SNRI (selective norepinephrine reuptake inhibitor), viloxazine extended-release (VER), and the pending approval of a triple reuptake inhibitor (centanafadine) provides welcome additions to the prescriber's toolbox.

Examining the Impact of Physical Activity on Sleep Quality in Children With ADHD

OBJECTIVE

Sleep problems have been commonly observed in children with attention deficit hyperactivity disorder (ADHD). The aim of current study was to investigate the impact of physical activity on sleep quality in young adolescent with attention deficit hyperactivity disorder.

METHOD

A total of 33 children diagnosed with attention deficit hyperactivity disorder (mean age = 10.12 years) were randomized into intervention group and control group respectively. Mention the intervention detail here. Four specific sleep parameters, including sleep efficiency, sleep onset latency, sleep duration, and wake after sleep onset, were assessed before and after the intervention period in both groups.

RESULTS

Results revealed the significant improvements in sleep efficiency, sleep onset latency and wake after sleep onset in the intervention group but not in the control group.

CONCLUSION

Current findings highlight the benefits of PA on enhancing sleep quality among children with ADHD.

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.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Owner-rated hyperactivity/impulsivity is associated with sleep efficiency in family dogs: a non-invasive EEG study

Subjective sleep disturbances are reported by humans with attention-deficit/hyperactivity disorder (ADHD). However, no consistent objective findings related to sleep disturbances led to the removal of sleep problems from ADHD diagnostic criteria. Dogs have been used as a model for human ADHD with questionnaires validated for this purpose. Also, their sleep physiology can be measured by non-invasive methods similarly to humans. In the current study, we recorded spontaneous sleep EEG in family dogs during a laboratory session. We analyzed the association of sleep macrostructure and deep sleep (NREM) slow-wave activity (SWA) with a validated owner-rated ADHD questionnaire, assessing inattention (IA), hyperactivity/impulsivity (H/I) and total (T) scores. Higher H/I and T were associated with lower sleep efficiency and longer time awake after initial drowsiness and NREM. IA showed no associations with sleep variables. Further, no association was found between ADHD scores and SWA. Our results are in line with human studies in which poor sleep quality reported by ADHD subjects is associated with some objective EEG macrostructural parameters. This suggests that natural variation in dogs' H/I is useful to gain a deeper insight of ADHD neural mechanisms.

Sleep Disturbances in Adolescents with Attention-Deficit/Hyperactivity Disorder

Introduction

Delayed sleep phase syndrome (DSPS) and insomnia disorders are prevalent in adolescents and are comorbid with attention-deficit/hyperactivity disorder (ADHD), but only limited information is available regarding the prevalence of DSPS and insomnia in adolescents with ADHD. Moreover, previous studies comparing objective sleep parameters averaged the findings across all participants of each group (ADHD, control) regardless of each individual's level of reported sleep disturbance. This might have resulted in inconsistency between information obtained by objective and subjective sleep measures in adolescents with ADHD. The objectives of the present study were 1) to compare the prevalence of risk for DSPS and insomnia in adolescents with ADHD and control adolescents in our samples; 2) to compare objectively measured sleep characteristics of adolescents with ADHD and controls while taking into consideration their levels of risk for DSPS or their level of insomnia; and 3) to compare the ADHD symptom levels of adolescents with moderate/high and low risk for DSPS or insomnia.

Methods

Seventy-three adolescents (37 ADHD, 36 controls) aged 12-15 years participated in a cross-sectional study. Actigraphy was used to characterize objective sleep parameters and parents' or adolescents' reports were used to characterize subjective sleep parameters.

Results

Of the participants in the ADHD and control groups, 33.33% and 27%, respectively, had moderate/high levels of risk for DSPS. Adolescents in the high-risk group for DSPS had an objectively measured delayed sleep schedule and more variable sleep duration, time in bed, and sleep efficiency compared to adolescents in the low-risk group for DSPS, regardless of their ADHD diagnosis. Adolescents with higher levels of insomnia spent more time in bed and had more variable sleep efficiency compared to adolescents with no insomnia, regardless of their diagnosis.

Conclusion

The prevalence of moderate/high risk for DSPS was similarly high in adolescents with ADHD and controls. Participants' subjective reports of sleep disturbances were consistent with their objective sleep parameters when the type and level of subjectively defined sleep disturbance were considered. ADHD symptom levels were not different in adolescents with moderate/high or low risk for DSPS or insomnia.

Distance learning during the COVID-19 pandemic for children with ADHD and/or ASD: a European multi-center study examining the role of executive function deficits and age

BACKGROUND

One of the COVID-19 pandemic consequences that has affected families the most is school lockdowns. Some studies have shown that distance learning has been especially challenging for families with a child with neurodevelopmental disorders such as ADHD or ASD. However, previous studies have not taken the heterogeneity of these disorders into account. The aim of the present study was therefore to investigate differences between families with a child with ADHD, ASD, or both conditions, and to examine the role of underlying deficits in executive functioning (EF) in both children and parents in relation to negative and positive effects of distance learning.

METHODS

Survey data assessing both negative and positive experiences of distance learning were collected from parents with a child aged 5-19 years in seven Western European countries: the UK, Germany, Spain, Sweden, the Netherlands, Italy, and Belgium. Altogether, the study included 1010 families with a child with ADHD and/or ASD and an equally large comparison group of families with a child without mental health problems. We included measures of three different types of negative effects (i.e., effects on the child, effects on the parent, and lack of support from school) and positive effects on the family.

RESULTS

Results confirmed that families with a child with ADHD, ASD or a combination of ADHD and ASD showed higher levels of both negative and positive effects of distance learning than the comparison group. However, few differences were found between the clinical groups. Group differences were more pronounced for older compared to younger children. Regarding the role of both ADHD/ASD diagnosis and EF deficits, primarily children's EF deficits contributed to high levels of negative effects. Parent EF deficits did not contribute significantly beyond the influence of child EF deficits. Families of children with ADHD/ASD without EF deficits experienced the highest levels of positive effects.

CONCLUSIONS

School closings during COVID-19 have a major impact on children with EF problems, including children with neurodevelopmental disorders. The present study emphasizes that schools should not focus primarily on whether a student has a neurodevelopmental disorder, but rather provide support based on the student's individual profile of underlying neuropsychological deficits.

Melatonin Treatment for Pediatric Patients with Insomnia: Is There a Place for It?

Sleep is a vital physiological function that is impaired in ranges from 10% in the typically developing pediatric population to over 80% in populations of children with neurodevelopmental disorders and/or psychiatric comorbidities. Pediatric insomnia disorder is an increasing public health concern given its negative impact on synaptic plasticity involved in learning and memory consolidation but also on mood regulation, hormonal development and growth, and its significant impact on quality of life of the child, the adolescent and the family. While first-line treatment of pediatric insomnia should include parental education on sleep as well as sleep hygiene measures and behavioural treatment approaches, pharmacological interventions may be necessary if these strategies fail. Melatonin treatment has been increasingly used off-label in pediatric insomnia, given its benign safety profile. This article aims to identify the possible role of melatonin treatment for pediatric insomnia, considering its physiological role in sleep regulation and the differential effects of immediate release (IR) versus prolonged release (PR) melatonin. For the physician dealing with pediatric insomnia, it is particularly important to be able to distinguish treatment rationales implying different dosages and times of treatment intake. Finally, we discuss the benefit-risk ratio for melatonin treatment in different pediatric populations, ranging from the general pediatric population to children with different types of neurodevelopmental disorders, such as autism spectrum disorder or ADHD.

Sleep EEG in young people with 22q11.2 deletion syndrome: A cross-sectional study of slow-waves, spindles and correlations with memory and neurodevelopmental symptoms

Background

Young people living with 22q11.2 Deletion Syndrome (22q11.2DS) are at increased risk of schizophrenia, intellectual disability, attention-deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). In common with these conditions, 22q11.2DS is also associated with sleep problems. We investigated whether abnormal sleep or sleep-dependent network activity in 22q11.2DS reflects convergent, early signatures of neural circuit disruption also evident in associated neurodevelopmental conditions.

Methods

In a cross-sectional design, we recorded high-density sleep EEG in young people (6-20 years) with 22q11.2DS (n=28) and their unaffected siblings (n=17), quantifying associations between sleep architecture, EEG oscillations (spindles and slow waves) and psychiatric symptoms. We also measured performance on a memory task before and after sleep.

Results

22q11.2DS was associated with significant alterations in sleep architecture, including a greater proportion of N3 sleep and lower proportions of N1 and REM sleep than in siblings. During sleep, deletion carriers showed broadband increases in EEG power with increased slow-wave and spindle amplitudes, increased spindle frequency and density, and stronger coupling between spindles and slow-waves. Spindle and slow-wave amplitudes correlated positively with overnight memory in controls, but negatively in 22q11.2DS. Mediation analyses indicated that genotype effects on anxiety, ADHD and ASD were partially mediated by sleep EEG measures.

Conclusions

This study provides a detailed description of sleep neurophysiology in 22q11.2DS, highlighting alterations in EEG signatures of sleep which have been previously linked to neurodevelopment, some of which were associated with psychiatric symptoms. Sleep EEG features may therefore reflect delayed or compromised neurodevelopmental processes in 22q11.2DS, which could inform our understanding of the neurobiology of this condition and be biomarkers for neuropsychiatric disorders.

Funding

This research was funded by a Lilly Innovation Fellowship Award (UB), the National Institute of Mental Health (NIMH 5UO1MH101724; MvdB), a Wellcome Trust Institutional Strategic Support Fund (ISSF) award (MvdB), the Waterloo Foundation (918-1234; MvdB), the Baily Thomas Charitable Fund (2315/1; MvdB), MRC grant Intellectual Disability and Mental Health: Assessing Genomic Impact on Neurodevelopment (IMAGINE) (MR/L011166/1; JH, MvdB and MO), MRC grant Intellectual Disability and Mental Health: Assessing Genomic Impact on Neurodevelopment 2 (IMAGINE-2) (MR/T033045/1; MvdB, JH and MO); Wellcome Trust Strategic Award 'Defining Endophenotypes From Integrated Neurosciences' Wellcome Trust (100202/Z/12/Z MO, JH). NAD was supported by a National Institute for Health Research Academic Clinical Fellowship in Mental Health and MWJ by a Wellcome Trust Senior Research Fellowship in Basic Biomedical Science (202810/Z/16/Z). CE and HAM were supported by Medical Research Council Doctoral Training Grants (C.B.E. 1644194, H.A.M MR/K501347/1). HMM and UB were employed by Eli Lilly & Co during the study; HMM is currently an employee of Boehringer Ingelheim Pharma GmbH & Co KG. The views and opinions expressed are those of the author(s), and not necessarily those of the NHS, the NIHR or the Department of Health funders.

Sleep and physical activity: results from a long-term actigraphy study in adolescents

PURPOSE

Research to date suggests that physical activity is associated with improved sleep, but studies have predominantly relied on self-report measures and have not accounted for school day/free day variability. To address these gaps in the literature, the aim of the present study was to (a) quantify physical activity in adolescents using long-term daily actigraphy measurement and (b) to examine the association between actigraphically assessed steps and sleep behavior in a sample of healthy adolescents. To be able to capture intra- and inter-individual differences in the daily physical activity of adolescents, we examined within as well as between subjects effects and its association with sleep.

METHODS

Fifty adolescents between 10 and 14 years of age were included in the present study. In total 5989 days of actigraphy measurement (average of 119 ± 40 days per participant; range = 39-195 days) were analyzed. We use multilevel modeling to disentangle the within and between subject effects of physical activity on sleep. In this way, we examine within an individual, the association between steps during the day and subsequent sleep on a day-to-day basis. On the other hand, our between subjects' analysis allows us to ascertain whether individuals with more overall physical activity have better sleep.

RESULTS

Within a subject more steps on school and free days were associated with later bed times on school and free days as well as later rise times on school days only. On the other hand, comparing between subjects' effects, more steps were associated with lower sleep efficiency on free and school days. No other significant associations were found for the other sleep variables.

CONCLUSION

Our results obtained through objective and long-term measurement of both sleep and number of steps suggest weak or non-significant associations between these measures for most sleep variables. We emphasize the importance of the methodology and the separation of within subject from between subject features when examining the relationship between physical activity and sleep.

Sleep and mental health in childhood: a multi-method study in the general pediatric population

BACKGROUND

Sleep problems, altered sleep patterns and mental health difficulties often co-occur in the pediatric population. Different assessment methods for sleep exist, however, many studies only use one measure of sleep or focus on one specific mental health problem. In this population-based study, we assessed different aspects of sleep and mother-reported mental health to provide a broad overview of the associations between reported and actigraphic sleep characteristics and mental health.

METHODS

This cross-sectional study included 788 children 10-11-year-old children (52.5% girls) and 344 13-14-year-old children (55.2% girls). Mothers and children reported on the sleep of the child and wrist actigraphy was used to assess the child's sleep patterns and 24 h activity rhythm. Mental health was assessed via mother-report and covered internalizing, externalizing and a combined phenotype of internalizing and externalizing symptoms, the dysregulation profile.

RESULTS

Higher reported sleep problems were related to more symptoms of mental health problems in 10-11- and 13-14-year-old adolescents, with standardized ß-estimates ranging between 0.11 and 0.35. There was no association between actigraphy-estimated sleep and most mental health problems, but earlier sleep onset was associated with more internalizing problems (ß = - 0.09, SE = 0.03, p-value = 0.002), and higher intra-daily variability of the 24 h activity rhythm was associated with more dysregulation profile symptoms at age 10-11 (ß = 0.11, SE = 0.04, p-value = 0.002).

DISCUSSION

Reported sleep problems across informants were related to all domains of mental health problems, providing evidence that sleep can be an important topic to discuss for clinicians seeing children with mental health problems. Actigraphy-estimated sleep characteristics were not associated with most mental health problems. The discrepancy between reported and actigraphic sleep measures strengthens the idea that these two measures tap into distinct constructs of sleep.

Medical conditions and Attention-Deficit/Hyperactivity Disorder symptoms from early childhood to adolescence

The comorbidity between physical and mental health conditions is challenging and frequently goes unrecognized in practice. Associations between Attention-Deficit/Hyperactivity Disorder (ADHD) and physical conditions have been reported in youth. However, prior research failed to: (1) address the patterns of associations in early childhood, middle childhood, and adolescence within the same population sample; (2) consider a large set of physical disorders at the same time; (3) take confounders into account. Our goal was to assess the associations between ADHD symptoms and a broad set of physical conditions across developmental periods. This birth cohort study (n = 2057) is the first to explore the associations between ADHD and a wide range of medical conditions by encompassing the whole early development from 5 months to 17 years in the same sample and relying on innovative network analyses. We found significant associations between ADHD symptoms and several physical conditions, some of which were observed in early childhood, middle childhood, and adolescence (e.g., asthma, sleep problems) or were confounded by socioeconomic status or psychiatric comorbidities (e.g., body mass index, dental caries). The study calls for an effective integrated care model encompassing mental and general healthcare across the developmental period.

Identification and Characterization of Influential Factors in Susceptibility to Attention Deficit Hyperactivity Disorder Among Preschool-Aged Children

Attention deficit hyperactivity disorder (ADHD) is the most common childhood-onset neurodevelopmental disorder. Currently, increasing amounts of attention have been focused on the epidemiologic profiling of ADHD in children, viewed as a continuously distributed risk dimension throughout the whole lifespan. This study aimed to identify and characterize potential influential factors susceptible to ADHD-related symptoms among preschool-aged children. A comprehensive questionnaire was self-designed for both children and their parents or guardians and was distributed to 30 kindergartens from Beijing and Hebei, collecting potential influential factors in susceptibility to ADHD. ADHD was assessed by the Conner’s Abbreviated Symptom Questionnaire (C-ASQ), and 7,938 children were analyzed. Least absolute shrinkage and selection operator (LASSO) regression and hierarchical degree of adjustment were used to control possible covariates. Five factors, namely, children’s secondhand smoking exposure, breastfeeding duration, sleep mode, maternal pregnancy smoking exposure, and parental self-rating for patience, were identified to be independently and significantly associated with ADHD susceptibility. Meanwhile, dose–response relationships were observed between breastfeeding duration, parental self-rating for patience, and ADHD-related symptoms. Finally, a nomogram model was created for predicting ADHD susceptibility based on significant and conventional attributes under each criterion.

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-related traits and attention-deficit/hyperactivity disorder comorbidity: Shared genetic risk factors, molecular mechanisms, and causal effects

OBJECTIVES

To evaluate the shared genetic components, common pathways and causal relationship between ADHD and sleep-related phenotypes.

METHODS

We used the largest genome-wide association summary statistics available for attention-deficit/hyperactivity disorder (ADHD) and various sleep-related phenotypes (insomnia, napping, daytime dozing, snoring, ease getting up, daytime sleepiness, sleep duration and chronotype). We estimated the genomic correlation using cross-trait linkage disequilibrium score regression (LDSR) and investigated the potential common mechanisms using gene-based cross-trait metanalyses and functional enrichment analyses. The causal effect was estimated using two-sample Mendelian randomisation (TSMR), using the inverse variance weighted method as the main estimator.

RESULTS

A positive genomic correlation between insomnia, daytime napping, daytime dozing, snoring, daytime sleepiness, short and long sleep duration, and ADHD was observed. Insomnia, daytime sleepiness, and snoring shared genes with ADHD, that are involved in neurobiological functions and regulatory signalling pathways. The TSMR supported a causal effect of insomnia, daytime napping, and short sleep duration on ADHD, and of ADHD on long sleep duration and chronotype.

CONCLUSION

Comorbidity between sleep phenotypes and ADHD may be mediated by common genetic factors that play an important role in neuronal signalling pathways. A causal effect of sleep disturbances and short sleep duration on ADHD reinforced their role as predictors of ADHD.

Sensitivity of the child behaviour checklist sleep items and convergent validity with the Sleep Disorders Scale for Children in a paediatric ADHD sample

OBJECTIVE

The Child Behavior Checklist (CBCL) is a commonly used measure of child and adolescent functioning, which includes seven items that can be aggregated to provide a purportedly valid measure of sleep functioning. The objective of this study was to examine the convergent validity of the CBCL in a paediatric ADHD population and to evaluate the sensitivity of the instrument when benchmarked against the Sleep Disorders Scale for Children (SDSC).

METHODS

The parents of 215 individuals (ages 6-17 years, 86% male) completed the CBCL and SDSC as part of a battery of measured administered as part of a specialised ADHD service located in Perth, Western Australia. All participants had a diagnosis of ADHD confirmed by a paediatrician or psychiatrist prior to attending the service.

RESULTS

The CBCL Sleep Composite Scale was strongly correlated with the SDSC, but reported below adequate internal reliability. Receiver Operating Characteristic (ROC) suggests that a cut-off score of 4 may have good diagnostic accuracy compared to SDSC.

CONCLUSIONS

The CBCL Sleep Composite Scale may be reasonable to use if no purpose-developed sleep screening tool is available. The CBCL sleep items demonstrated good convergent validity, however, did not otherwise demonstrate acceptable psychometric properties that would endorse its use in an ADHD sample. The development of a specific measure of sleep in children with ADHD children is recommended.

Children's mental and behavioral health, schooling, and socioeconomic characteristics during school closure in France due to COVID-19: the SAPRIS project

COVID-19 limitation strategies have led to widespread school closures around the world. The present study reports children's mental health and associated factors during the COVID-19 school closure in France in the spring of 2020. We conducted a cross-sectional analysis using data from the SAPRIS project set up during the COVID-19 pandemic in France. Using multinomial logistic regression models, we estimated associations between children's mental health, children's health behaviors, schooling, and socioeconomic characteristics of the children's families. The sample consisted of 5702 children aged 8-9 years, including 50.2% girls. In multivariate logistic regression models, children's sleeping difficulties were associated with children's abnormal symptoms of both hyperactivity-inattention (adjusted Odds Ratio (aOR) 2.05; 95% Confidence Interval 1.70-2.47) and emotional symptoms (aOR 5.34; 95% CI 4.16-6.86). Factors specifically associated with abnormal hyperactivity/inattention were: male sex (aOR 2.29; 95% CI 1.90-2.76), access to specialized care prior to the pandemic and its suspension during school closure (aOR 1.51; 95% CI 1.21-1.88), abnormal emotional symptoms (aOR 4.06; 95% CI 3.11-5.29), being unschooled or schooled with assistance before lockdown (aOR 2.13; 95% CI 1.43-3.17), and tutoring with difficulties or absence of a tutor (aOR 3.25; 95% CI 2.64-3.99; aOR 2.47; 95% CI 1.48-4.11, respectively). Factors associated with children's emotional symptoms were the following: being born pre-term (aOR 1.34; 95% CI 1.03-1.73), COVID-19 cases among household members (aOR 1.72; 95% CI 1.08-2.73), abnormal symptoms of hyperactivity/inattention (aOR 4.18; 95% CI 3.27-5.34) and modest income (aOR 1.45; 95% CI 1.07-1.96; aOR 1.36; 95% CI 1.01-1.84). Multiple characteristics were associated with elevated levels of symptoms of hyperactivity-inattention and emotional symptoms in children during the period of school closure due to COVID-19. Further studies are needed to help policymakers to balance the pros and cons of closing schools, taking into consideration the educational and psychological consequences for children.

Evaluating the Feasibility and Acceptability of the Lifestyle Enhancement for ADHD Program

OBJECTIVE

To evaluate the feasibility and acceptability of the Lifestyle Enhancement for Attention Deficit Hyperactivity Disorder (ADHD) Program (LEAP), a novel parent behavior management training program that promotes physical activity (PA) and positive health behaviors and is enhanced with mobile health technology (Garmin) and a social media (Facebook) curriculum for parents of children with ADHD.

METHODS

The study included parents of children ages 5-10 years diagnosed with ADHD who did not engage in the recommended >60 min/day of moderate to vigorous PA based on parent report at baseline. Parents participated in the 8-week LEAP group and joined a private Facebook group. Children and one parent wore wrist-worn Garmin activity trackers daily. Parents completed the Treatment Adherence Inventory, Client Satisfaction Questionnaire, and participated in a structured focus group about their experiences with various aspects of the program.

RESULTS

Of 31 children enrolled, 51.5% had ADHD combined presentation, 36.3% with ADHD, predominately inattentive presentation, and 12.1% had unspecified ADHD (age 5-10; M = 7.6; 48.4% female). Parents attended an average of 86% of group sessions. On average, parents wore their Garmins for 5.1 days/week (average step count 7,092 steps/day) and children for 6.0 days/week (average step count 9,823 steps/day). Overall, parents and children were adherent to intervention components and acceptability of the program was high.

CONCLUSIONS

Findings indicate that the LEAP program is an acceptable and feasible intervention model for promoting PA among parents and their children with ADHD. Implications for improving ADHD symptoms and enhancing evidence-based parent training programs are discussed.

Links between parent-reported measures of poor sleep and executive function in childhood autism and attention deficit hyperactivity disorder

OBJECTIVES

This study sought to assess whether poor sleep is associated with aspects of executive function (EF) among children with autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), or typical development (TD), after adjusting for demographic variables, stimulant medications, intelligence, anxiety, inattention, and hyperactivity.

DESIGN

Cross-sectional.

SETTING

Children recruited through ongoing studies at the Kennedy Krieger Institute.

PARTICIPANTS

We studied 735 children (323 TD; 177 ASD; 235 ADHD) aged 8 to 12 years.

MEASUREMENTS

We investigated associations of parent-reported sleep measures from the Children's Sleep Habits Questionnaire (CSHQ) with parent-report measures of EF and performance-based processing speed with each clinical population. EF was measured using 8 clinical T scores that fall under 2 domains (behavioral regulation and metacognition) from the Behavior Rating Inventory of EF (BRIEF) and the processing speed index from the Wechsler Intelligence Scale for Children-IV or -V.

RESULTS

Higher CSHQ scores were associated with poorer EF on all BRIEF scales, across all child groups, after adjustment for demographic factors, stimulant medications, and IQ. Among children with ADHD, these associations largely remained after adjusting for anxiety. Among those ASD, anxiety partially accounted for these associations, especially for behavioral regulation EF outcomes. Co-occurring symptoms of inattention and hyperactivity/impulsivity further accounted for the associations between sleep and EF. Poor sleep was not significantly associated with processing speed.

CONCLUSIONS

Strong links exist between parent-reported poor sleep and executive dysfunction in children with typical development. Targeting anxiety may alleviate executive dysfunction, especially among children with ASD.

Association between sleep habits/disorders and emotional/behavioral problems among Japanese children

Actual sleep status and the association between sleep habits/disorders and emotional/behavioral problems among children in the development stage have not been fully clarified. A questionnaire survey was conducted on the sleep habits/disorders (Brief Child Sleep Questionnaire; BCSQ) and emotional/behavioral problems (Strengths and Difficulties Questionnaire; SDQ) of 87,548 children enrolled in ordinary classes in nine grade levels from the first grade of elementary school to the third grade of junior high school from December 2009 to April 2010. As school grade increased, children's bedtimes were delayed and sleep duration was reduced by 2.0 h over the nine grade levels. Based on the BCSQ, 18.3% of children were judged to have some type of sleep disorder, and about 30% to 40% of children had sleep symptoms at bedtime, during sleep, and at wake time. Multiple regression analysis showed that emotional and behavioral problems were associated with presence of any sleep symptom, longer sleep latency, and longer awake time after sleep onset, whereas total sleep time was not. Sleep symptoms at wake time were most strongly associated with emotional and behavioral problems. Status of sleep habits/disorders should be considered when interpreting emotional/behavioral problems in school-age children.

Mental health and sleep habits/problems in children aged 3-4 years: a population study

Background

Sleep is essential for mental health at all ages, but few studies have investigated the importance of sleep for mental health in early childhood. Therefore, this study examined the association between mental health and sleep habits/problems in children aged 34 years.

Methods

Children aged 3 to 4 years who were living in the community (n=415; 211/204 boys/girls) were recruited for this study. Their mental health was assessed using the Strengths and Difficulties Questionnaire (SDQ), and their sleep habits/problems were evaluated using the Child and Adolescent Sleep Checklist.

Results

Based on the total difficulties score of the SDQ, the children were divided into two groups: a poor mental health group (n=76) and a control group (n=339). In terms of sleep habits, which included total sleep time, bedtime, wake time, and nap conditions, there were no differences between the two groups. Regarding sleep-related problems, however, anxiety before going to sleep (p=0.026), circadian rhythm abnormalities (p=0.014), and sleepiness during classes outside of naptimes (p=0.031) were significantly higher in the poor mental health group than in the control group. Multiple regression analysis showed that poor mental health status was significantly associated with sleepiness and snoring (p=0.017 and p=0.018, respectively).

Conclusions

The mental health status of 34-year-old children was associated with sleep-related problems, namely sleepiness and snoring. Healthcare providers should pay attention to childrens irregular sleep-wake patterns; moreover, interventions for appropriate sleep hygiene will reduce the psychological burden on both children and their families.

Characterization of Sleep Disturbances in Children and Adolescents with Down Syndrome and Their Relation with Cognitive and Behavioral Features

Despite sleep disturbances are common among youths with Down syndrome (DS), the cognitive and behavioral features associated with sleep problems have not yet been studied extensively. The present study investigated the presence of sleep disturbances in a group of children and adolescents with DS and their cognitive and behavioral correlates. Seventy-one children and adolescents with DS underwent a neuropsychological evaluation, whereas parents completed questionnaires for the screening of the child's sleep, emotional and behavioral problems. We found no association between sleep disturbances and sex, nonverbal IQ, nor adaptive abilities. However, we found that age was positively associated with disorders in initiating and maintaining sleep (DIMS) and disorders of excessive somnolence (DOES), while body mass index was related with DOES. We also detected a relationship between visual-motor integrations and DIMS, as well as multiple associations between sleep disturbances and psychopathological and behavioral problems, mainly externalizing symptoms. The present study provided a detailed characterization of sleep problems in relation to several features of youths with DS. The proper identification of sleep disturbances profile in the DS population could support the process of clinical evaluation, in particular for psychopathological aspects.

Vitamin D levels in children with attention deficit hyperactivity disorder: Association with seasonal and geographical variation, supplementation, inattention severity, and theta:beta ratio

We examined seasonal and geographic effects on vitamin D [25(OH)D] levels, association with attention-deficit/hyperactivity disorder (ADHD) symptom severity, and effects of supplementation in 222 children age 7-10 with rigorously diagnosed ADHD. 25(OH)D insufficiency rates were 47.2 % in Ohio and 28.5 % 400 miles south in North Carolina. Nadir of 25(OH)D levels was reached by November in Ohio, not until January in NC. Thirty-eight children with insufficiency/deficiency took vitamin D (1000-2000 IU/day for a month); levels rose 52 %. Although inattention did not correlate with 25(OH)D at screen nor improve significantly with supplementation, inattention improvement after supplementation correlated with 25(OH)D increase (rho = 0.41, p = 0.012). A clinically significant proportion of children with ADHD have insufficient 25(OH)D even at summer's end, more so in the winter and north of the 37th parallel. The significant correlation of inattention improvement with 25(OH)D increase suggests further research on 25(OH)D as ADHD treatment.

Neuropsychiatric Symptoms in Pediatric Chronic Pain and Outcome of Acceptance and Commitment Therapy

Considerable heterogeneity among pediatric chronic pain patients may at least partially explain the variability seen in the response to behavioral therapies. The current study tested whether autistic traits and attention-deficit/hyperactivity disorder (ADHD) symptoms in a clinical sample of children and adolescents with chronic pain are associated with socioemotional and functional impairments and response to acceptance and commitment therapy (ACT) treatment, which has increased psychological flexibility as its core target for coping with pain and pain-related distress. Children and adolescents aged 8–18 years (N = 47) were recruited. Patients and their parents completed questionnaires pre- and post-ACT of 17 sessions. Correlational analyses and mixed-effects models were used to assess the role of autistic traits and ADHD symptoms in pretreatment functioning and ACT-treatment response. Outcome variables were degree to which pain interfered with daily activities (i.e., pain interference, sleep, and physical and school functioning), socioemotional functioning (i.e., depressive symptoms, emotional, and social functioning), psychological inflexibility, and pain intensity. Autistic traits and ADHD symptoms, pain frequency, and pain duration were measured at pretreatment only. Higher autistic traits were associated with greater pain interference, higher depression, and greater psychological inflexibility. Higher ADHD symptomatology was associated with greater pretreatment pain interference, lower emotional functioning, greater depression, and longer duration of pain. Across patients, all outcome variables, except for sleep disturbances and school functioning, significantly improved from pre- to post-ACT. Higher autistic traits were associated with greater pre- to post-ACT improvements in emotional functioning and sleep disturbance and non-significant improvements in pain interference. ADHD symptomatology was not associated with treatment outcome. The current results showed that neuropsychiatric symptoms in pediatric chronic pain patients are associated with lower functioning, particularly pain interfering with daily life and lower socioemotional functioning. The results suggest that not only pediatric chronic pain patients low in neuropsychiatric symptoms may benefit from ACT, but also those high in autism traits and ADHD symptoms. With the present results in mind, pediatric chronic pain patients higher in autistic traits may actually derive extra benefit from ACT. Future research could assess whether increased psychological flexibility, the core focus of ACT, enabled those higher in autism traits to cope relatively better with pain-related distress and thus to gain more from the treatment, as compared to those lower in autism traits. Moreover, to address specific effects of ACT, inclusion of an appropriate control group is key.

Current Evidence on the Role of the Gut Microbiome in ADHD Pathophysiology and Therapeutic Implications

Studies suggest that the bidirectional relationship existent between the gut microbiome (GM) and the central nervous system (CNS), or so-called the microbiome–gut–brain axis (MGBA), is involved in diverse neuropsychiatric diseases in children and adults. In pediatric age, most studies have focused on patients with autism. However, evidence of the role played by the MGBA in attention deficit/hyperactivity disorder (ADHD), the most common neurodevelopmental disorder in childhood, is still scanty and heterogeneous. This review aims to provide the current evidence on the functioning of the MGBA in pediatric patients with ADHD and the specific role of omega-3 polyunsaturated fatty acids (ω-3 PUFAs) in this interaction, as well as the potential of the GM as a therapeutic target for ADHD. We will explore: (1) the diverse communication pathways between the GM and the CNS; (2) changes in the GM composition in children and adolescents with ADHD and association with ADHD pathophysiology; (3) influence of the GM on the ω-3 PUFA imbalance characteristically found in ADHD; (4) interaction between the GM and circadian rhythm regulation, as sleep disorders are frequently comorbid with ADHD; (5) finally, we will evaluate the most recent studies on the use of probiotics in pediatric patients with ADHD.

Effects of Sleep on the Academic Performance of Children with Attention Deficit and Hyperactivity Disorder

Attention deficit and hyperactivity disorder (ADHD) is commonly associated with disordered or disturbed sleep and the association of sleep problems with ADHD is complex and multidirectional. The purpose of this study was to analyze the relationship between sleep and academic performance, comparing children with ADHD and a control group without ADHD. Academic performance in Spanish, mathematics, and a foreign language (English) was evaluated. Different presentations of ADHD were considered as well as the potential difference between weekday and weekend sleep habits. The sample consisted of 75 children aged 6–12 in primary education. Accelerometry was used to study sleep, and school grades were used to gather information about academic performance. The results showed that ADHD influenced the amount of sleep during weekends, the time getting up at the weekends, weekday sleep efficiency, as well as academic performance. Given the effects that were seen in the variables linked to the weekend, it is necessary to consider a longitudinal design with which to determine if there is a cause and effect relationship.

Associations Between Child Sleep Problems and Maternal Mental Health in Children with ADHD

Objective/Background: Children with attention-deficit/hyperactivity disorder (ADHD) experience more sleep problems than typically developing children. In addition, higher rates of depression are experienced by mothers of children with ADHD compared to mothers of children without ADHD. This study aimed to determine whether particular sleep problems in children with ADHD are associated with specific maternal mental health difficulties. Participants: Female caregivers of 379 children with ADHD (5-13 years) participated. The child's ADHD diagnosis was reconfirmed during recruitment by caregivers completing the ADHD Rating Scale-IV. Method: Caregivers reported on their mental health using the Depression Anxiety Stress Scale and their child's sleep using the Children's Sleep Habits Questionnaire. Unadjusted and adjusted regression analyzes were undertaken. Results: In the adjusted analyzes, there were small significant associations between most aspects of child sleep (i.e. Bedtime Resistance, Night Waking, Parasomnias, Sleep Duration, Daytime Sleepiness and Total Sleep Problems) and maternal Anxiety and Stress, with the exception of Sleep-Onset Delay. Bedtime Resistance, Sleep Duration, Daytime Sleepiness and Total Sleep Problems also had small significant associations with maternal Depression. Sleep Anxiety had a small significant association with maternal Anxiety only. Conclusions: This study demonstrates important connections between many child sleep problems and particular aspects of maternal mental health, suggesting adaptations to behavioral sleep interventions for children and mental health interventions for parents to take a family approach may be beneficial. Future research should consider the longitudinal associations between child sleep and parent mental health in an effort to inform future intervention approaches.

What Is the Link Between Attention-Deficit/Hyperactivity Disorder and Sleep Disturbance? A Multimodal Examination of Longitudinal Relationships and Brain Structure Using Large-Scale Population-Based Cohorts

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) comorbid with sleep disturbances can produce profound disruption in daily life and negatively impact quality of life of both the child and the family. However, the temporal relationship between ADHD and sleep impairment is unclear, as are underlying common brain mechanisms.

METHODS

This study used data from the Quebec Longitudinal Study of Child Development (n = 1601, 52% female) and the Adolescent Brain Cognitive Development Study (n = 3515, 48% female). Longitudinal relationships between symptoms were examined using cross-lagged panel models. Gray matter volume neural correlates were identified using linear regression. The transcriptomic signature of the identified brain-ADHD-sleep relationship was characterized by gene enrichment analysis. Confounding factors, such as stimulant drugs for ADHD and socioeconomic status, were controlled for.

RESULTS

ADHD symptoms contributed to sleep disturbances at one or more subsequent time points in both cohorts. Lower gray matter volumes in the middle frontal gyrus and inferior frontal gyrus, amygdala, striatum, and insula were associated with both ADHD symptoms and sleep disturbances. ADHD symptoms significantly mediated the link between these structural brain abnormalities and sleep dysregulation, and genes were differentially expressed in the implicated brain regions, including those involved in neurotransmission and circadian entrainment.

CONCLUSIONS

This study indicates that ADHD symptoms and sleep disturbances have common neural correlates, including structural changes of the ventral attention system and frontostriatal circuitry. Leveraging data from large datasets, these results offer new mechanistic insights into this clinically important relationship between ADHD and sleep impairment, with potential implications for neurobiological models and future therapeutic directions.

Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women

BACKGROUND

There is evidence to suggest that the broad discrepancy in the ratio of males to females with diagnosed ADHD is due, at least in part, to lack of recognition and/or referral bias in females. Studies suggest that females with ADHD present with differences in their profile of symptoms, comorbidity and associated functioning compared with males. This consensus aims to provide a better understanding of females with ADHD in order to improve recognition and referral. Comprehensive assessment and appropriate treatment is hoped to enhance longer-term clinical outcomes and patient wellbeing for females with ADHD.

METHODS

The United Kingdom ADHD Partnership hosted a meeting of experts to discuss symptom presentation, triggers for referral, assessment, treatment and multi-agency liaison for females with ADHD across the lifespan.

RESULTS

A consensus was reached offering practical guidance to support medical and mental health practitioners working with females with ADHD. The potential challenges of working with this patient group were identified, as well as specific barriers that may hinder recognition. These included symptomatic differences, gender biases, comorbidities and the compensatory strategies that may mask or overshadow underlying symptoms of ADHD. Furthermore, we determined the broader needs of these patients and considered how multi-agency liaison may provide the support to meet them.

CONCLUSIONS

This practical approach based upon expert consensus will inform effective identification, treatment and support of girls and women with ADHD. It is important to move away from the prevalent perspective that ADHD is a behavioural disorder and attend to the more subtle and/or internalised presentation that is common in females. It is essential to adopt a lifespan model of care to support the complex transitions experienced by females that occur in parallel to change in clinical presentation and social circumstances. Treatment with pharmacological and psychological interventions is expected to have a positive impact leading to increased productivity, decreased resource utilization and most importantly, improved long-term outcomes for girls and women.

Caffeine Use and Associations With Sleep in Adolescents With and Without ADHD

OBJECTIVE

The objective of this study was to compare caffeine consumption in the morning, afternoon, and evening in adolescents with and without attention-deficit/hyperactivity disorder (ADHD) and examine associations with sleep functioning.

METHODS

Participants were 302 adolescents (ages 12-14) with (N = 140) and without (N = 162) ADHD. Adolescents wore actigraph watches to assess total sleep time and wake after sleep onset and reported on sleep-wake problems and the number of caffeinated beverages consumed per day in the morning, afternoon, and evening. Parents reported on adolescents' difficulties initiating and maintaining sleep. Chi-square tests, odds ratios, and path analyses were conducted.

RESULTS

Analyses controlled for sex, medication status, and pubertal development. Adolescents with ADHD were 2.47 times more likely to consume caffeine in the afternoon and evening than adolescents without ADHD. Path analyses indicated significant associations between afternoon caffeine use and more self-reported sleep problems for adolescents with and without ADHD, and an association between evening caffeine use and self-reported sleep problems only in adolescents with ADHD. Afternoon caffeine use was associated with parent-reported sleep problems in adolescents with ADHD only. Caffeine use was not associated with actigraphy-assessed sleep.

CONCLUSION

This is the first study to show that adolescents with ADHD consume more caffeine than peers during later times of the day. Additionally, caffeine use is more consistently associated with poorer subjective sleep functioning in adolescents with ADHD. Pediatricians and mental health professionals should assess for caffeine use in adolescents with ADHD and co-occurring sleep problems.

Featured Article: Technology Use and Sleep in Adolescents With and Without Attention-Deficit/Hyperactivity Disorder

OBJECTIVES

This study used a multi-informant approach to examine differences in types and rates of technology used by adolescents with and without attention-deficit/hyperactivity disorder (ADHD), associations between technology use and sleep/daytime sleepiness, and whether technology use was differentially related to sleep/daytime sleepiness in adolescents with and without ADHD.

METHODS

Eighth graders with (n = 162) and without (n = 140) ADHD were recruited. Adolescents completed questionnaires assessing time spent using technology, sleep-wake problems, school-night time in bed, and daytime sleepiness. Parents and teachers reported on adolescents' technology use and daytime sleepiness, respectively.

RESULTS

Adolescents with ADHD had significantly greater total technology, television/movie viewing, video game, and phone/video chatting use than adolescents without ADHD. Adolescents with ADHD engaged in twice as much daily video game use compared to those without ADHD (61 vs. 31 min). Controlling for medication use, ADHD status, pubertal development, sex, and internalizing symptoms, greater parent- and adolescent-reported technology use was associated with more sleep-wake problems and less time in bed. ADHD status did not moderate the relations between technology use and these sleep parameters. In contrast, ADHD status moderated the association between parent-reported technology use and teacher-reported daytime sleepiness, such that this association was significant only for adolescents with ADHD.

CONCLUSIONS

Technology use, although more prevalent in adolescents with ADHD, is linked with more sleep problems and reduced school-night sleep duration regardless of ADHD status. Technology use is associated with teacher-rated daytime sleepiness only in adolescents with ADHD. Clinicians should consider technology usage when assessing and treating sleep problems.

Sleep disturbance in children with attention-deficit hyperactivity disorder: A systematic review

The aim of the present systematic review was to compare sleep disorders in children, from 7 to 12 years old, with and without an attention-deficithyperactivity disorder (ADHD) diagnosis. Electronic literature search of PubMed, LILACS, Scopus, Web of Science and Cochrane Library databases was conducted in September 2017. We included cross-sectional observational studies comparing the sleep of children between 7 and 12 years old, with and without an ADHD diagnosis, reported according to the Diagnostic and Statistical Manual of Mental Disorders criteria. The studies with other research designs, those that included adolescents and/or adults in the sample and those who evaluated the sleep of children with ADHD and other associated comorbidities were excluded. A total of 1911 articles were identified. After analyzing, 8 articles were compatible with the theme and included in the review. For sleep evaluation, most of the studies used an objective measure together with another subjective measure. Three out of six studies that used objective measures did not observe any differences between children with and without ADHD diagnosis. Children with ADHD presented more sleep disturbances when compared to children without the diagnosis. These disorders were diverse, yet inconsistent among the surveys. More studies are needed to clarify and for robust results.

Efficacy and Safety of Melatonin Treatment in Children with Autism Spectrum Disorder and Attention-Deficit/Hyperactivity Disorder-A Review of the Literature

Autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) are neurodevelopmental disorders with disturbed melatonin secretion profile and sleep problems. The growing incidence of ASD and ADHD inspires scientists to research the underlying causes of these conditions. The authors focused on two fundamental aspects, the first one being the presentation of the role of melatonin in ASD and ADHD and the second of the influence of melatonin treatment on sleep disorders. The authors present the use of melatonin both in the context of causal and symptomatic treatment and discuss melatonin supplementation: Dosage patterns, effectiveness, and safety. Sleep disorders may have a different clinical picture, so the assessment of exogenous melatonin efficacy should also refer to a specific group of symptoms. The review draws attention to the wide range of doses of melatonin used in supplementation and the need to introduce unified standards especially in the group of pediatric patients.

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.

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

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

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.

Effects of 16 Weeks of Methylphenidate Treatment on Actigraph-Assessed Sleep Measures in Medication-Naive Children With ADHD

Methylphenidate (MPH) improves behavioral symptoms of attention-deficit/hyperactivity disorder (ADHD). Its effects on sleep, however, are insufficiently known, as trials with MPH in medication-naive children were so far restricted to relatively short trial durations. Here, we assessed effects of prolonged MPH treatment on sleep in medication-naive boys in a 16-weeks double-blind, placebo controlled, multicenter clinical trial with immediate-release MPH (ePOD-MPH trial, NTR3103). Seventy-five medication-naive boys, aged 10-12 years, were screened for eligibility using ADHD DSM-IV criteria. Sleep was assessed using actigraphy, diaries and questionnaires prior to randomization, in week 8, and 1 week after trial end. Fifty boys (mean age 11.4y, SD 0.9) were randomized to MPH or placebo. Linear mixed model analysis demonstrated a significant time-by-treatment interaction effect (p = 0.007) on sleep efficiency. Post-hoc analyses demonstrated that the two groups did not differ from each other (p = 0.94) during treatment (week 8), but that sleep efficiency was significantly improved in the MPH (p = 0.005), but not placebo group (p = 0.87) 1 week after trial end. The lack of MPH's negative effects on sleep during treatment differ from most previous studies and could be explained by the relatively long trial duration in our study and the medication-naive status of our sample; suggesting that evaluating sleep problems only shortly after treatment onset presents an incomplete picture, because it might not be representative for sleep quality after longer treatment periods. Our findings of improved sleep after trial end could be due to rebound effects or longer-term effects of MPH treatment and therefore require replication.

CLINICAL TRIAL REGISTRATION

Central Committee on Research Involving Human Subjects (an independent registry, identifier NL34509.000.10) before enrollment of the first subject and The Netherlands National Trial Register, identifier NTR3103.

Association Between Objectively Measured Sleep Duration and Symptoms of Psychiatric Disorders in Middle Childhood

Importance

The long-term association between sleep duration and mental health in children is currently unknown.

Objective

To investigate the prospective associations between sleep duration and symptoms of emotional and behavioral disorders at ages 6, 8, 10, and 12 years.

Design, Setting, and Participants

This population-based cohort study obtained data from the Trondheim Early Secure Study in Trondheim, Norway. A representative, stratified random sample of children born between January 1, 2003, and December 31, 2004, were invited to participate. Participants were followed up biennially from age 4 years (2007-2008) to 12 years (2013-2014). Data analysis was conducted from January 2, 2019, to May 28, 2019.

Main Outcomes and Measures

Sleep duration was assessed with 1 week of continuous use of a triaxial accelerometer. Symptoms of emotional (anxiety and depression) and behavioral (oppositional defiant, conduct, and attention-deficit/hyperactivity) disorders were measured by semistructured clinical interviews (using the Preschool Age Psychiatric Assessment and the Child and Adolescent Psychiatric Assessment) with parents (at all ages) and children (from age 8 years).

Results

The analytical sample comprised 799 children (mean [SD] age at time point 2, 6.0 [0.2] years; 405 [50.7%] boys; and 771 [96.5%] Norwegian). Shorter sleep duration at age 6 years (β [unstandardized regression coefficient] = -0.44; 95% CI, -0.80 to -0.08; P = .02) and 8 years (β = -0.47; 95% CI, -0.83 to -0.11; P = .01) forecasted symptoms of emotional disorders 2 years later. Comparatively short sleep duration at age 8 years (β = -0.65; 95% CI, -1.22 to -0.08; P = .03) and 10 years (β = -0.58; 95% CI, -1.07 to -0.08; P = .02) was associated with symptoms of behavioral disorders 2 years later among boys but not among girls at age 8 years (β = -0.14; 95% CI,- 0.52 to 0.24; P = .48) or 10 years (β = -0.05; 95% CI, = -0.49 to 0.40; P = .84). These associations were statistically significant among boys compared with girls at age 8 years (Δχ21 = 13.26; P < .001) and 10 years (Δχ21 = 10.25; P = .001). Symptoms of psychiatric disorders did not forecast sleep duration at any age.

Conclusions and Relevance

This study found an association between short sleep duration and increased risk of future occurrence of emotional disorder symptoms in both boys and girls and between reduced sleep and behavioral disorder symptoms in boys. These results suggest that improving sleep in children may help protect against the development of symptoms of common psychiatric disorders and may be advantageous in the treatment of such disorders.