Associations between psychiatric comorbidities and sleep disturbances in children with attention-deficit/hyperactivity disorder

An Open-Label Pilot Trial of a Brief, Parent-Based Sleep Intervention in Children With ADHD

OBJECTIVE

To assess the effects of a brief parent-based behavioral sleep intervention in children with ADHD.

METHODS

Families with a child with ADHD and parent-reported sleep problems received a brief parent-based sleep intervention, which involved two one-to-one consultation sessions and one telephone follow-up with the parent/caregiver. Child's sleep and clinical symptoms, and parental sleep and daytime functioning were assessed at baseline, 2-week post-intervention, and 3-month follow-up.

RESULTS

Sixty eligible families (mean age of the child: 9.4 ± 1.5 years; boys: 75%) were recruited, and 43 (72%) completed the whole intervention. The intervention resulted in significant improvements in the child's sleep, clinical symptoms, and parental sleep and parenting stress, and these improvements were generally maintained at 3-month follow-up.

CONCLUSION

The findings supported the promising effects of a brief parent-based sleep intervention on improving sleep and clinical symptoms in children with ADHD and parental sleep and parenting stress. Further randomized clinical trials with long-term follow-up are needed to test the robustness of the effectiveness of the intervention.

Associations between sleep problems in children with ADHD and parental insomnia and ADHD symptoms

Sleep problems are common in children with attention deficit hyperactivity disorder (ADHD). Children's sleep problem may influence, and be influenced by, parents' sleep problems as well as parents' ADHD symptoms. In the current study we examined the associations of parent-rated sleep quality and sleep timing of pre-adolescent children with parental insomnia symptoms, parental ADHD symptoms and dysfunctional attitudes and beliefs about sleep in a convenience sample recruited by advertisement (N = 120). Childhood sleep problems were common in the sample, with 82% of children exceeding the threshold for the presence of a paediatric sleep disorder. Children's sleep quality showed minimal association with their sleep timing and chronotype. Parental insomnia symptoms, ADHD symptoms and dysfunctional beliefs and attitudes about sleep all associated with their children's sleep quality, and with the sleep subdomains of sleep anxiety and parasomnias. In multiple regression analysis only parental insomnia score was a significant predictor of children's sleep quality. Children's bedtimes, wake times, sleep duration, chronotype or social jetlag did not associate with parents' ADHD or insomnia symptoms. Sleep quality was significantly poorer in children whose parents scored as both consistent for adult ADHD and probable for insomnia disorder compared to parents who scored as either ADHD consistent or insomnia probable, or those who parents scored as neither. We discuss the putative nature of the relationships between sleep quality of children with ADHD and parental ADHD and insomnia symptoms, and suggest that clinicians consider parental sleep when attending to children with ADHD.

Sleep and internalizing problems in primary school children with attention-deficit hyperactivity disorder

BACKGROUND

Internalizing and externalizing problems have received great attention, and children with ADHD exhibit high rates of comorbid internalizing and externalizing disorders. This study aimed to explore the relationship between sleep and internalizing problems in children with attention-deficit hyperactivity disorder (ADHD) and the probable mediating role of externalizing problems.

METHODS

A total of 203 primary school children diagnosed with ADHD for the first time were recruited for this study. Children with ADHD were evaluated by Children's Sleep Habits Questionnaire (CSHQ), Strengths and Difficulties Questionnaire (SDQ). Internalizing problems were represented by emotional symptoms and peer problems of SDQ, and externalizing problems were represented by conduct problems and hyperactivity-inattention problems of SDQ. Multi-step linear regression analysis was used to investigate the mediating effect of externalizing problems on the relationship between sleep and internalizing problems.

RESULTS

Sleep in children with ADHD was associated with emotional problems in internalizing problems, and conduct problems in externalizing problems mediated the association between sleep and emotional problems.

CONCLUSION

For children with ADHD, when it is difficult to identify internalizing problems, especially emotional problems, we can take sleep and externalizing problems as clues to improve our clinical ability to recognize and deal with emotional problems.

IMPACT

1. We first explored the possible mediating role of conduct problems between sleep and emotional problems in primary school children with ADHD. 2. When it is difficult to identify internalizing problems, especially emotional problems, we can take sleep and externalizing problems as clues to improve our clinical ability to recognize emotional problems for children with ADHD. 3. For children with ADHD with potential internalizing problems, especially emotional problems, interventions for their sleep and externalizing problems may be the possible methods to deal with.

Association of Time in Bed, Social Jetlag, and Sleep Disturbances With Cognitive Performance in Children With ADHD

OBJECTIVES

Children with ADHD commonly exhibit sleep disturbances, but there is limited knowledge about how sleep and sleep timing are associated with cognitive dysfunction in children with ADHD.

METHODS

Participants were 350 children aged 5 to 12 years diagnosed with ADHD. Three sleep-related constructs-time in bed, social jetlag (i.e., discrepancy in sleep timing pattern between school nights and weekend nights), and sleep disturbances were measured using a caregiver-report questionnaire. Linear regression models assessed the associations between sleep-related constructs and cognitive performance.

RESULTS

After adjustment for sociodemographic variables, there were few associations between time in bed or sleep disturbances and cognitive performance, however, greater social jetlag was negatively associated with processing speed (β = -.20, 95% CI [-0.35, -0.06]), visually-based reasoning (β = -.13, 95% CI [-0.27, 0.00]), and language-based reasoning (β = -.22, 95% CI [-0.36, -0.08]); all p < .05).

CONCLUSION

Social jetlag, but not time in bed or disturbances, was associated with lower cognitive performance among children with ADHD.

Methods to Develop an in silico Clinical Trial: Computational Head-to-Head Comparison of Lisdexamfetamine and Methylphenidate

Regulatory agencies encourage computer modeling and simulation to reduce the time and cost of clinical trials. Although still not classified in formal guidelines, system biology-based models represent a powerful tool for generating hypotheses with great molecular detail. Herein, we have applied a mechanistic head-to-head in silico clinical trial (ISCT) between two treatments for attention-deficit/hyperactivity disorder, to wit lisdexamfetamine (LDX) and methylphenidate (MPH). The ISCT was generated through three phases comprising (i) the molecular characterization of drugs and pathologies, (ii) the generation of adult and children virtual populations (vPOPs) totaling 2,600 individuals and the creation of physiologically based pharmacokinetic (PBPK) and quantitative systems pharmacology (QSP) models, and (iii) data analysis with artificial intelligence methods. The characteristics of our vPOPs were in close agreement with real reference populations extracted from clinical trials, as did our PBPK models with in vivo parameters. The mechanisms of action of LDX and MPH were obtained from QSP models combining PBPK modeling of dosing schemes and systems biology-based modeling technology, i.e., therapeutic performance mapping system. The step-by-step process described here to undertake a head-to-head ISCT would allow obtaining mechanistic conclusions that could be extrapolated or used for predictions to a certain extent at the clinical level. Altogether, these computational techniques are proven an excellent tool for hypothesis-generation and would help reach a personalized medicine.

Sleep quality in children and adolescents with attention-deficit and hyperactivity disorder

Sleep disturbances are associated with an increased risk of attention-deficit and hyperactivity disorder (ADHD), which can also lead to sleep problems. In this study we aimed to determine the variables that affect the relationship between ADHD and sleep quality. Moreover, we aimed to compare these variables in children and adolescents with ADHD and healthy controls. This cross-sectional study was conducted using a random sample of 122 ADHD patients and 100 healthy children in Turkey. A self-administered questionnaire was distributed to assess sleep quality using the Pittsburgh Sleep Quality Index (PSQI). The risk of impairment in sleep quality was associated with the presence of ADHD (OR: 13.3; 95% CI: 6.1-29.1), the presence of somatic disease (OR: 4.9; 95% CI: 1.9-12.2), and a family history of the psychiatric disorder (OR: 4.2; 95% CI: 1.3-13.1). The PSQI total score was higher in children with parental separation compared to those without parental separation (p=0.006). As the economic level of the participants decreased, the PSQI total score increased significantly (p=0.006). It was determined that combined-type ADHD was associated with impairment in sleep quality more than the other subtypes (p<0.001 and p=0.031, respectively). Our findings show that children with ADHD have significantly more sleep problems than healthy controls and that sociodemographic variables and familial characteristics affect sleep quality in healthy children and children with ADHD.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Attention-deficit/hyperactivity disorder symptoms and sleep problems in preschool children: the role of autistic traits

BACKGROUND

Sleep problems are elevated in children with attention-deficit/hyperactivity disorder (ADHD). However, until now there has been comparatively little research on the role of autistic traits in this association. The current study examined the association between ADHD symptoms and sleep problems in Japanese preschool children and whether autistic traits might also be important for this relationship.

METHODS

Data were analyzed from 1053 children (average age 64.14 months, range 58-71; 50.3% male) that were drawn from the Tama Children's Survey (TCS). Parent-reported information was obtained on ADHD symptoms using the Strengths and Difficulties Questionnaire (SDQ) and autistic traits with the Social Responsiveness Scale Second Edition (SRS-2). Parents also provided information on three different categories of sleep problems experienced by their children - parasomnias, sleep disordered breathing and awakening/daytime problems. Ordinal logistic regression analysis was used to examine the associations.

RESULTS

In analyses adjusted for sociodemographic factors, the mother's mental health and child's emotional problems, compared to children with no ADHD symptoms or autistic traits, children with only ADHD symptoms had significantly increased odds for only one of 11 individual sleep problems - waking in a negative mood. In contrast, children with comorbid ADHD symptoms and autistic traits had elevated odds for five sleep problems with odds ratios ranging from 2.10 (takes time to become alert in the morning) to 3.46 (excessive body movement while sleeping).

CONCLUSIONS

Sleep problems may be especially elevated in children with comorbid ADHD symptoms and autistic traits.

SLEEP AND CHILDHOOD MENTAL HEALTH: ROLE OF PHYSICAL ACTIVITY AND CARDIORESPIRATORY FITNESS

ABSTRACT Introduction: Sleep is considered an important health indicator and plays a key role in brain development and plasticity. Objective: To ascertain whether there is a relationship between sleep quality and mental health indicators and whether organized physical activity (PA) or cardiorespiratory fitness (CRF) act as moderators of this association. Methods: This is a cross-sectional study with a quantitative approach. The sample consisted of 226 students between six and 11 years of age, male and female, in the early years of elementary education at a public school in Porto Alegre, Brazil, which was selected for convenience. CRF was measured by running test and six-minute walk. Sleep quality and organized physical activity outside of school were verified through an anamnesis, socioeconomic status through an adaptation of the ABEP (Brazilian Association of Research Companies) questionnaire, and mental health indicators with the assistance of the Strengths and Difficulties Questionnaire, all answered by parents. Frequencies, means, standard deviations and generalized linear models were used for the data analysis, while a 95% confidence interval was used for the analyses. Results: Sleep quality was associated with total difficulties (β=7.659, p<0.001), emotional symptoms (β= 1.754; p=0.001), hyperactivity/inattentiveness (β=3.054, p <0.001), conduct problems (β=1.619, p<0.001) and peer relationship problems (β=1.231; p=0.007) in boys. In girls it was related to total difficulties (β=3.421; p=0.006), and conduct problems (β=1.235; p=0.003). However, the interactions were not significant. Conclusion: Although they occur independently, stress is placed on the importance of sleeping well, engaging in organized PA and having good CRF levels for the improvement and maintenance of mental health. Level of evidence III; Case-control study.

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-disordered breathing and comorbidities: role of the upper airway and craniofacial skeleton

Obstructive sleep-disordered breathing (SDB), which includes primary snoring through to obstructive sleep apnea syndrome (OSAS), may cause compromise of respiratory gas exchange during sleep, related to transient upper airway narrowing disrupting ventilation, and causing oxyhemoglobin desaturation and poor sleep quality. SDB is common in chronic disorders and has significant implications for health. With prevalence rates globally increasing, this condition is causing a substantial burden on health care costs. Certain populations, including people with sickle cell disease (SCD), exhibit a greater prevalence of OSAS. A review of the literature provides the available normal polysomnography and oximetry data for reference and documents the structural upper airway differences between those with and without OSAS, as well as between ethnicities and disease states. There may be differences in craniofacial development due to atypical growth trajectories or extramedullary hematopoiesis in anemias such as SCD. Studies involving MRI of the upper airway illustrated that OSAS populations tend to have a greater amount of lymphoid tissue, smaller airways, and smaller lower facial skeletons from measurements of the mandible and linear mental spine to clivus. Understanding the potential relationship between these anatomical landmarks and OSAS could help to stratify treatments, guiding choice towards those which most effectively resolve the obstruction. OSAS is relatively common in SCD populations, with hypoxia as a key manifestation, and sequelae including increased risk of stroke. Combatting any structural defects with appropriate interventions could reduce hypoxic exposure and consequently reduce the risk of comorbidities in those with SDB, warranting early treatment interventions.

Child and Adolescent Depression: A Review of Theories, Evaluation Instruments, Prevention Programs, and Treatments

Depression is the principal cause of illness and disability in the world. Studies charting the prevalence of depression among children and adolescents report high percentages of youngsters in both groups with depressive symptoms. This review analyzes the construct and explanatory theories of depression and offers a succinct overview of the main evaluation instruments used to measure this disorder in children and adolescents, as well as the prevention programs developed for the school environment and the different types of clinical treatment provided. The analysis reveals that in mental classifications, the child depression construct is no different from the adult one, and that multiple explanatory theories must be taken into account in order to arrive at a full understanding of depression. Consequently, both treatment and prevention should also be multifactorial in nature. Although universal programs may be more appropriate due to their broad scope of application, the results are inconclusive and fail to demonstrate any solid long-term efficacy. In conclusion, we can state that: (1) There are biological factors (such as tryptophan-a building block for serotonin-depletion, for example) which strongly influence the appearance of depressive disorders; (2) Currently, negative interpersonal relations and relations with one's environment, coupled with social-cultural changes, may explain the increase observed in the prevalence of depression; (3) Many instruments can be used to evaluate depression, but it is necessary to continue to adapt tests for diagnosing the condition at an early age; (4) Prevention programs should be developed for and implemented at an early age; and (5) The majority of treatments are becoming increasingly rigorous and effective. Given that initial manifestations of depression may occur from a very early age, further and more in-depth research is required into the biological, psychological and social factors that, in an interrelated manner, may explain the appearance, development, and treatment of depression.

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

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

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

Children with attention-deficit/hyperactivity disorder (ADHD) display more sleep problems than their peers, but it remains unclear whether comorbid mental health symptoms [i.e., anxiety, depression, oppositional-defiant disorder (ODD)] are uniquely related to sleep functioning. It is also largely unknown whether boys and girls with ADHD differ in their sleep functioning. This study (1) examined whether boys or girls with ADHD differ in their sleep functioning, (2) evaluated comorbid symptoms as uniquely related to sleep functioning domains, and (3) explored whether sex moderated associations between comorbid symptoms and sleep. Participants were 181 children (ages 7-13; 69% male; 82% White) diagnosed with ADHD. Parents completed measures assessing their child's ADHD symptoms, comorbid symptoms, and sleep functioning. Girls had poorer sleep functioning than boys across most sleep functioning domains. Sixty percent of children met cutoff criteria for having sleep problems, though rates differed significantly between girls (75%) and boys (53%). No differences in rates of sleep problems were found between ADHD subtypes/presentations or between younger and older children. In path models including ADHD and comorbid symptom dimensions, anxiety symptoms were uniquely associated with increased bedtime resistance and sleep anxiety, ADHD hyperactive-impulsive symptoms were associated with more night wakings and more parasomnia behaviors, and ODD and depressive symptoms were associated with shorter sleep duration. Depression was also uniquely associated with increased daytime sleepiness and overall sleep problems. Sex did not moderate associations between comorbid symptoms and sleep problems. This study provides important preliminary evidence that girls with ADHD experience more sleep problems than boys with ADHD. Findings also demonstrate that the associations between comorbid symptoms and sleep functioning in children with ADHD vary based on both the specific symptoms and sleep domains examined.

Sleep disorder prevalence in at-risk adolescents and potential effects of nightmare triad syndrome

Objective At-risk high school students, those considered to have a higher probability for academic failure or dropping out, were assessed for various sleep disorders. Effects were compared between students with and without the nightmare triad syndrome (NTS+), the sleep disorders' cluster of frequent nightmares, insomnia disorder and suspected sleep-disordered breathing (SDB). Methods Data were gathered at a charter school for at-risk youth using: computer based surveys, physical airway exams, and mental health interviews by school social worker. Ninety-two students were enrolled, and 70 completed all study components. Results Students were teenaged [17.10 (1.50) years], male (52.2%) slightly overweight [BMI 25.50 (6.41)] Hispanics (87.0%); two-thirds (65 of 92) subjectively reported a sleep problem. Frequent nightmares (39.1%), insomnia (ISI ≥ 12, 41.3%), and SDB risk (79.3%) were common. Several presumptive sleep disorders (insomnia, SDB risk, parasomnia, or nightmares) were associated with worse sleep quality and lower quality of life. Nineteen students met criteria for NTS. Compared to NTS-, NTS+ showed significantly lower quality of life (p < 0.003, g = 0.84). Regression analyses revealed higher levels of depression and anxiety symptoms in NTS+ students. NTS was associated with reduced quality of life independent of anxiety symptoms. Conclusion Prevalence of presumptive sleep disorders was high with a tendency for clusters of sleep disorders in the same individual. Students with NTS+ showed worse outcomes and reduced quality of life, mediated partially by depression and anxiety. To examine relationships between sleep disorders and mental health in at-risk adolescents, research investigations must include both subjective and objective measurements of sleep.

Comorbidity prevalence and treatment outcome in children and adolescents with ADHD

Although ADHD comorbidity has been widely studied, some issues remain unsolved. This multicenter observational study aims to examine comorbid psychiatric disorders in a clinical sample of newly diagnosed, treatment naïve children and adolescents with and without ADHD and, to compare treatment efficacy based on the type of comorbidity. We performed an analysis of the medical records of patients identified from the Regional ADHD Registry database, enrolled in 18 ADHD centers in the 2011-2016 period. 1919 of 2861 subjects evaluated (67%) met the diagnostic criteria for ADHD: 650 (34%) had only ADHD, while 1269 (66%) had at least one comorbid psychiatric disorder (learning disorders, 56%; sleep disorders, 23%; oppositional defiant disorder, 20%; anxiety disorders, 12%). Patients with ADHD of combined type and with severe impairment (CGI-S ≥5) were more likely to present comorbidity. 382 of 724 (53%) followed up patients improved after 1 year of treatment. ADHD with comorbidity showed greater improvement when treated with combined interventions or methylphenidate alone. Specifically, combined treatment showed significant superiority for ADHD with learning disorders (ES 0.66) and ODD (ES 0.98), lower for ADHD with sleep or anxiety disorders. Training intervention alone showed only medium efficacy (ES 0.50) for ADHD and learning disorders. This study was the first describing comorbidity patterns of ADHD in Italy, confirming, in a multicenter clinical setting, that ADHD is more often a complex disorder. Findings highlight important diagnostic, therapeutic, and service organization aspects that should be broadly extended to ensure an appropriate and homogenous ADHD management.

Sleep problems in children with attention-deficit hyperactivity disorder: associations with parenting style and sleep hygiene

We aimed to examine the association between sleep problems and parenting and sleep hygiene in children with attention-deficit/hyperactivity disorder (ADHD). Participants included 5-13-year-old children with DSM 5 defined ADHD and a parent-reported moderate-to-severe sleep problem (N = 361). Sleep was assessed using the parent-reported Children's Sleep Habits Questionnaire. Parents also completed checklists assessing sleep hygiene, parenting consistency, and parenting warmth. Linear regression established prediction models controlling for confounding variables including child age and sex, ADHD symptom severity, comorbidities, medication use, and socio-demographic factors. More consistent parenting was associated with decreased bedtime resistance (β = -0.16) and decreased sleep anxiety (β = -0.14), while greater parental warmth was associated with increased parasomnias (β = +0.18) and sleep anxiety (β = +0.13). Poorer sleep hygiene was associated with increased bedtime resistance (β = +0.20), increased daytime sleepiness (β = +0.12), and increased sleep duration problems (β = +0.13). In conclusion, sleep hygiene and parenting are important modifiable factors independently associated with sleep problems in children with ADHD. These factors should be considered in the management of sleep problems in children with ADHD.

Is emotional lability a marker for attention deficit hyperactivity disorder, anxiety and aggression symptoms in preschoolers?

BACKGROUND

Emotional lability (EL) is frequent in school-aged children with attention deficit hyperactivity disorder (ADHD) and is associated with more frequent comorbidities and more severe impairment. However, little research has investigated the association between EL, ADHD and comorbid symptoms in preschoolers. This study assessed dimensional EL in preschoolers and its link with ADHD symptoms (e.g. hyperactivity-impulsivity and inattention) and behavioural and emotional problems (e.g. aggression and anxiety).

METHOD

One hundred and fifty-four preschoolers aged 3-6 years old were rated on questionnaires by parents. EL was assessed with the index from the Conners Rating Scale-Revised and behavioural and emotional problems with an adapted version of the Social Behavior Questionnaire. Multiple linear regressions analyses were conducted.

RESULTS

Higher EL was associated with higher hyperactivity-impulsivity, inattention, anxiety and aggression problems. After controlling for other behavioural and emotional problems and sociodemographic variables, EL remained associated with hyperactivity-impulsivity and anxiety.

CONCLUSIONS

Emotional lability seems to be a potential marker for ADHD symptoms with internalizing problems in preschoolers and could be a target for diagnosis and early interventions. This finding should be treated with caution as the study was limited by the low response rate of the participants and consequently the small sample size.

Effect of Aptensio XR (Methylphenidate HCl Extended-Release) Capsules on Sleep in Children with Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

To evaluate measures of sleep (exploratory endpoints) in two pivotal studies of a multilayer bead extended-release methylphenidate (MPH-MLR) treatment of attention-deficit/hyperactivity disorder in children.

METHODS

Study 1 evaluated the time course of response to MPH-MLR (n = 26) patients in an analog classroom setting through four phases: screening (≤28 days), open label (OL) dose optimization (4 weeks), double-blind (DB) crossover (2 weeks; placebo vs. optimized dose), and follow-up call. Study 2 was a forced-dose parallel evaluation of MPH-MLR (n = 230) in four phases: screening (≤28 days), DB (1 week; placebo or MPH-MLR 10, 15, 20, or 40 mg/day), OL dose optimization (11 weeks), and follow-up call. Sleep was evaluated by parents using the Children's or Adolescent Sleep Habits Questionnaire (CSHQ or ASHQ) during the DB and OL phases. DB analysis: Study 1 (crossover), analysis of variance; Study 2, analysis of covariance. OL analysis: paired t-test.

RESULTS

DB: treatments were significantly different in Study 1 only for CSHQ Sleep Onset Delay (MPH-MLR, 1.90 vs. placebo, 1.34; p = 0.0046, placebo was better), and Study 2 for CSHQ Parasomnias (treatment, p = 0.0295), but no MPH-MLR treatment was different from placebo (pairwise MPH-MLR treatment to placebo, all p ≥ 0.170). OL: CSHQ total and Bedtime Resistance, Sleep Duration, Sleep Anxiety, Night Wakings, Parasomnias, and Sleep-disordered Breathing subscales decreased (improved, Study 1) significant only for CSHQ Night Wakings (p < 0.05); in Study 2 CSHQ total and Bedtime Resistance, Sleep Duration, Night Wakings, Parasomnias, and Daytime Sleepiness, and ASHQ total, Bedtime, Sleep Behavior, and Morning Waking all significantly improved (p < 0.05).

CONCLUSIONS

In both studies, there was minimal negative impact of MPH-MLR on sleep during the brief DB phase and none during the longer duration OL phase. Some measures of sleep improved with optimized MPH-MLR dose.

School Maladjustment and External Locus of Control Predict the Daytime Sleepiness of College Students With ADHD

OBJECTIVE

The primary aim of this study was to evaluate whether school maladjustment longitudinally predicts the daytime sleepiness of college students with ADHD above and beyond symptoms of ADHD and to determine whether internalizing dimensions mediate the relationship between maladjustment and sleepiness.

METHOD

A prospective longitudinal study of 59 college students comprehensively diagnosed with ADHD who completed ratings at the beginning, middle, and end of the school year.

RESULTS

School maladjustment at the beginning of the year significantly predicted daytime sleepiness at the end of the year above and beyond symptoms of ADHD. Locus of control mediated the relationship between maladjustment and daytime sleepiness.

CONCLUSION

The significant school maladjustment difficulties that students with ADHD experience following the transition to college may lead to the development of problems with daytime sleepiness, particularly for those students with high external locus of control. This pattern is likely reciprocal, whereby sleep problems in turn result in greater school impairment, reinforcing the idea that life events are outside of one's control.

The ADHD Concomitant Difficulties Scale (ADHD-CDS), a Brief Scale to Measure Comorbidity Associated to ADHD

Introduction: Although the critical feature of attention-deficit/hyperactivity disorder (ADHD) is a persistent pattern of inattention and/or hyperactivity/impulsivity behavior, the disorder is clinically heterogeneous, and concomitant difficulties are common. Children with ADHD are at increased risk for experiencing lifelong impairments in multiple domains of daily functioning. In the present study we aimed to build a brief ADHD impairment-related tool -ADHD concomitant difficulties scale (ADHD-CDS)- to assess the presence of some of the most important comorbidities that usually appear associated with ADHD such as emotional/motivational management, fine motor coordination, problem-solving/management of time, disruptive behavior, sleep habits, academic achievement and quality of life. The two main objectives of the study were (i) to discriminate those profiles with several and important ADHD functional difficulties and (ii) to create a brief clinical tool that fosters a comprehensive evaluation process and can be easily used by clinicians.

Methods: The total sample included 399 parents of children with ADHD aged 6–18 years (M = 11.65; SD = 3.1; 280 males) and 297 parents of children without a diagnosis of ADHD (M = 10.91; SD = 3.2; 149 male). The scale construction followed an item improved sequential process.

Results: Factor analysis showed a 13-item single factor model with good fit indices. Higher scores on inattention predicted higher scores on ADHD-CDS for both the clinical sample (β = 0.50; p < 0.001) and the whole sample (β = 0.85; p < 0.001). The ROC curve for the ADHD-CDS (against the ADHD diagnostic status) gave an area under the curve (AUC) of.979 (95%, CI = [0.969, 0.990]).

Discussion: The ADHD-CDS has shown preliminary adequate psychometric properties, with high convergent validity and good sensitivity for different ADHD profiles, which makes it a potentially appropriate and brief instrument that may be easily used by clinicians, researchers, and health professionals in dealing with ADHD.

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.

Are ASD and ADHD a Continuum? A Comparison of Pathophysiological Similarities Between the Disorders

OBJECTIVE

The objective of this study was to review and compare the similarities between autism spectrum disorder (ASD) and ADHD with regard to symptomatology, neurological deficits, metabolic and endocrine-related conditions, and brain pathology.

METHOD

A comprehensive review of the relevant research literature was carried out.

RESULTS

A number of important similarities between ASD and ADHD were identified, including recent increases in prevalence, male-biased incidence, shared involvement of sensory processing, motor and impulse control, abnormal patterns of neural connectivity, and sleep disturbances. Studies suggest involvement of androgen metabolism, impaired methylation, and heavy metal toxicity as possible contributing factors for both disorders.

CONCLUSION

ASD and ADHD share a number of features and pathophysiological conditions, which suggests that the two disorders may be a continuum and have a common origin.

Sleep problems predict comorbid externalizing behaviors and depression in young adolescents with attention-deficit/hyperactivity disorder

Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) experience high rates of sleep problems and are also at increased risk for experiencing comorbid mental health problems. This study provides an initial examination of the 1-year prospective association between sleep problems and comorbid symptoms in youth diagnosed with ADHD. Participants were 81 young adolescents (75 % male) carefully diagnosed with ADHD and their parents. Parents completed measures of their child's sleep problems and ADHD symptoms, oppositional defiant disorder (ODD) symptoms, and general externalizing behavior problems at baseline (M age = 12.2) and externalizing behaviors were assessed again 1 year later. Adolescents completed measures of anxiety and depression at both time-points. Medication use was not associated with sleep problems or comorbid psychopathology symptoms. Regression analyses indicated that, above and beyond demographic characteristics, ADHD symptom severity, and initial levels of comorbidity, sleep problems significantly predicted greater ODD symptoms, general externalizing behavior problems, and depressive symptoms 1 year later. Sleep problems were not concurrently or prospectively associated with anxiety. Although this study precludes making causal inferences, it does nonetheless provide initial evidence of sleep problems predicting later comorbid externalizing behaviors and depression symptoms in youth with ADHD. Additional research is needed with larger samples and multiple time-points to further examine the interrelations of sleep problems and comorbidity.

Behavioral sleep problems and internalizing and externalizing comorbidities in children with attention-deficit/hyperactivity disorder

Behavioral sleep problems are common in children with attention-deficit/hyperactivity disorder (ADHD), as are internalizing and externalizing comorbidities. The prevalence of these difficulties and the extent to which they co-exist in children with ADHD could inform clinical practice, but remains unclear. Therefore, we examined the association between sleep problems and internalizing and externalizing comorbidities in children with ADHD. Children aged 5-13 years were recruited from 21 pediatric practices across Victoria, Australia (N = 392). Internalizing and externalizing comorbidities (none, internalizing, externalizing, co-occurring) were assessed by the telephone-administered Anxiety Disorders Interview Schedule for Children IV/Parent version. Sleep problem severity was assessed by primary caregiver report (no, mild, moderate or severe problem). Moderate/severe sleep problems were confirmed using International Classification of Sleep Disorders. Seven specific sleep problem domains (bedtime resistance, sleep anxiety, sleep onset delay, sleep duration, night waking, parasomnias and daytime sleepiness) were assessed using the Children's Sleep Habits Questionnaire. Data were analyzed using adjusted logistic and linear regression models. Compared to children without comorbidities, children with co-occurring internalizing and externalizing comorbidities were more likely to have moderate/severe sleep problems (adjusted OR 2.4, 95 % CI 1.2; 4.5, p = 0.009) and problematic sleep across six of seven sleep domains. Children with either comorbidity alone were not at risk of moderate/severe sleep problems, but at the sleep domain level, children with internalizing alone had more sleep anxiety, and those with externalizing alone had less night waking. In conclusion, children with ADHD experiencing co-occurring internalizing and externalizing comorbidities are at an increased risk of sleep problems.

Advancing a biopsychosocial and contextual model of sleep in adolescence: a review and introduction to the special issue

Sleep problems in adolescence have been identified as an international public health issue. Over the past few decades, notable advances have been made in our understanding of the patterns and consequences of sleep in adolescence. Despite these important gains, there is much about the role of sleep in adolescence that remains to be understood. This Special Issue brings together studies that examine sleep as it specifically pertains to adolescent development and adjustment. In this introductory article, we argue for the importance of grounding the study of sleep and adolescence in developmental science and a developmental psychopathology framework. First, a review of the literature is used to outline a biopsychosocial and contextual model of sleep in adolescence. Second, attention-deficit/hyperactivity disorder (ADHD) is used as an exemplar of the proposed model given the pervasiveness of sleep problems among youth with ADHD and the likelihood that sleep problems and ADHD symptoms are interconnected in complex ways. Finally, a brief introduction to the empirical articles included in the Special Issue is provided, with particular attention given to how these articles fit within the proposed biopsychosocial and contextual model. Along with the framework proposed in this article, the studies included in this Special Issue advance the current literature and point to critical directions for future research.

Behavioural sleep problems in children with attention-deficit/hyperactivity disorder (ADHD): protocol for a prospective cohort study

INTRODUCTION

Children with attention-deficit/hyperactivity disorder (ADHD) commonly experience behavioural sleep problems, yet these difficulties are not routinely assessed and managed in this group. Presenting with similar symptoms to ADHD itself, sleep problems are complex in children with ADHD and their aetiology is likely to be multifactorial. Common internalising and externalising comorbidities have been associated with sleep problems in children with ADHD; however, this relationship is yet to be fully elucidated. Furthermore, limited longitudinal data exist on sleep problems in children with ADHD, thus their persistence and impact remain unknown. In a diverse sample of children with ADHD, this study aims to: (1) quantify the relationship between sleep problems and internalising and externalising comorbidities; (2) examine sleep problem trajectories and risk factors; and (3) examine the longitudinal associations between sleep problems and child and family functioning over a 12-month period.

METHODS AND ANALYSIS

A prospective cohort study of 400 children with ADHD (150 with no/mild sleep problems, 250 with moderate/severe sleep problems) recruited from paediatric practices across Victoria, Australia. The children's parents and teacher provide data at baseline and 6-month and 12-month post enrolment.

KEY MEASURES

Parent report of child's sleep problem severity (no, mild, moderate, severe); specific sleep domain scores assessed using the Child Sleep Habits Questionnaire; internalising and externalising comorbidities assessed by the Anxiety Disorders Interview Schedule for Children IV/Parent version.

ANALYSES

Multiple variable logistic and linear regression models examining the associations between key measures, adjusted for confounders identified a priori.

ETHICS AND DISSEMINATION

Ethics approval has been granted. Findings will contribute to our understanding of behavioural sleep problems in children with ADHD. Clinically, they could improve the assessment and management of sleep problems in this group. We will seek to publish in leading paediatric journals, present at conferences and inform Australian paediatricians through the Australian Paediatric Research Network.

Pearls, perils, and pitfalls in the assessment and treatment of attention-deficit/hyperactivity disorder in adolescents

PURPOSE OF REVIEW

To provide clinicians with an updated overview of key considerations related to the clinical assessment and management of attention-deficit/hyperactivity disorder (ADHD) in adolescents.

RECENT FINDINGS

The American Psychiatric Association's recently revised Diagnostic and Statistical Manual of Mental Disorders-5 included significant changes regarding diagnostic criteria for ADHD in adolescents. The American Academy of Pediatrics (AAP) also recently revised their Clinical Practice Guidelines for ADHD; whereas prior guidelines were focused on children aged 6-12, the new guidelines extend up to age 17. An understanding of these revised diagnostic criteria and clinical guidelines is essential for pediatricians and others who care for adolescents. In addition to providing an updated review of the clinical approach to assessment and treatment of ADHD in adolescents, recent findings are briefly described relating to common comorbidities, psychosocial risks, and long-term outcome.

SUMMARY

Diagnosis and treatment of adolescents with ADHD present unique challenges and obstacles. Clinicians need to be careful and deliberate in their evaluation of a teenager with recent-onset symptoms suggestive of ADHD, giving consideration to other conditions that could mimic ADHD and screening for common comorbid conditions. In terms of treatment of adolescents, the AAP recommends medication as the first-line intervention, noting that stimulants have a much broader evidence base and larger effect size than nonstimulants. Although clinicians now have a multitude of medication formulations to choose among, they must also be vigilant to the potential for stimulant misuse and diversion.

Correlation between sleep disorder screening and executive dysfunction in children with attention deficit-hyperactivity disorder

Objective To compare frequency of sleep disorders (SD) and executive dysfunction (ED) in children with attention deficit-hyperactivity disorder (ADHD) and a control group. Method We studied 156 children with ADHD with a mean age of 8.5 years, and a control group with 111 children with a mean age of 8.3 years. We utilized the Pediatric Sleep Questionnaire (PSQ) to screen SD and the working memory measurement from the Wechsler intelligence scale for children (WISC-IV) to screen ED. Results We did not observe an increased frequency of SD in children with ADHD compared with the controls. However, we did identify ED in children with ADHD; additionally a significant correlation was observed between the type of ADHD and SD and among ED, WISC-IV measurements, and type of SD in children with ADHD. Conclusion An increase of SD frequency in children with ADHD was not observed, but we did identify ED in children with ADHD. Additionally, a correlation among ADHD types, SD, ED, and WISC-IV measurements was observed in children with ADHD.

Sleep disorders in preschoolers: prevalence and comorbidity with psychiatric symptoms

OBJECTIVES

This study provides data on the prevalence of diagnosable sleep disorders in preschoolers and examined the relationship between specific sleep disorders and a range of DSM-4-defined psychiatric symptoms.

METHODS

All children born in 2003 or 2004 in Trondheim, Norway, who attended regular community health checkups for 4 year olds were asked to participate (97.2% attendance; 82.0% consent rate, N = 2475). A screen-stratified subsample of 1250 children was recruited to participate in an additional comprehensive study that included a structured diagnostic interview (the Preschool-Age Psychiatric Assessment). Nine hundred ninety-five parents (79.6%) completed the interview.

RESULTS

The estimated sleep disorder rate was 19.2%. Rates of specific disorders were as follows: primary insomnia (16.6%), primary hypersomnia (0.8%), nightmare disorder (2.2%), and sleepwalking disorder (0.7%). When adjusted for a range of common psychiatric symptoms, primary insomnia was specifically related to symptoms of depression, generalized anxiety disorder, separation anxiety, and specific phobia. When sleep problems were excluded as a symptom of depression, the association between depression and primary insomnia was no longer significant. Nightmare disorder was significantly related to generalized anxiety disorder.

CONCLUSIONS

This first study of the prevalence and comorbidity of diagnosable sleep disorders in preschoolers indicates that primary insomnia is common in young children, whereas other sleep disorders are rare. Sleep disorders are related to psychiatric symptoms, particularly symptoms of anxiety disorders.

ADHD treatments, sleep, and sleep problems: complex associations

ADHD, sleep, and ADHD treatments are highly interrelated. In this review, we describe the effects of stimulants and non stimulant medications on sleep in children, adolescents, and adults with ADHD. Clinical predictors of sleep problems during pharmacotherapy include age, sleep problems prior to initiating treatment, and dose and dosing schedule. As yet, we have little understanding of the biological or genetic factors related to individual variation in drug response and sleep.