Sleep disturbances in children with attention-deficit/hyperactivity disorder: a comparative study with healthy siblings

Prevalence of high impulsivity and its relation to sleep indices in opioid use disorder patients receiving methadone maintenance treatment

BACKGROUND

The relation between impulsivity and sleep indices is not well determined in patients receiving methadone maintenance treatment (MMT).

AIMS

to evaluate high impulsivity prevalence, its risk factors and relation with sleep indices.

METHODS

a random MMT sample (n = 61) plus MMT current cocaine users (n = 20) were assessed for impulsivity (Barratt impulsivity scale [BIS-11] and Balloon Analogue Risk task [BART]), sleep quality (Pittsburg Sleep Quality Index [PSQI]), sleepiness (The Epworth sleepiness scale [ESS]), and substance in urine.

RESULTS

81 patients, aged 56.6 ± 10, 54.3% tested positive to any substance, 53.1% with poor sleep (PSQI>5) and 43.2% with daytime sleepiness (ESS >7) were studied. Impulsivity (BIS-11 ≥ 72) prevalence was 27.9% (of the representative sample), and 30.9% of all participants. These patients characterized with any substance and shorter duration in MMT with no sleep indices or other differences including BART balloon task performance (that was higher only in any substance than non-substance user group). However, impulsive score linearly correlated with daytime sleepiness (R = 0.2, p = 0.05). Impulsivity proportion was lowest among those with no cocaine followed by cocaine use and the highest in those who used cocaine and opiates (20.8%, 33.3% and 60% respectively, p = 0.02), as daily sleep (38.3%, 42.1% and 60%, p = 0.3) although not statistically significant.

CONCLUSION

Daytime sleepiness correlated with impulsivity, but cocaine usage is the robust factor. Further follow-up is warranted to determine whether substance discontinuing will lead to a reduction in impulsivity, and improved vigilance. Sleep quality did not relate to daytime sleepiness and impulsivity and need further research.

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

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

Sleep in Autism Spectrum Disorder and Attention Deficit Hyperactivity Disorder

Sleep problems are common in autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD). Sleep problems in these disorders may not only worsen daytime behaviors and core symptoms of ASD and ADHD but also contribute to parental stress levels. Therefore, the presence of sleep problems in ASD and ADHD requires prompt attention and management. This article is presented in 2 sections, one each for ASD and ADHD. First, a detailed literature review about the burden and prevalence of different types of sleep disorders is presented, followed by the pathophysiology and etiology of the sleep problems and evaluation and management of sleep disorders in ASD and ADHD.

Management of psychotropic medication side effects in children and adolescents

This article is a review of several of the most concerning side effects of psychotropic medications in children and adolescents. An emphasis is placed on review of the prevalence, presentation, monitoring, and evidence-based management of these side effects.

The role of sleep problems and circadian clock genes in childhood psychiatric disorders

CLOCK gene research and the analysis of circadian rhythmicity on the behavioural, cellular and molecular level are increasingly contributing to accumulate clinically relevant knowledge in the fields of neuroscience, psychopharmacology and adult psychiatry. However, the role of circadian phenomena, including sleep alterations in mental disorders during childhood and adolescence remains largely enigmatic. Fortunately, recent publications have addressed this problem and there is now some evidence available highlighting the relevance of CLOCK genes in conditions, such as ADHD, mood disorders, schizophrenia and anxiety disorders.

Sleep in attention-deficit/hyperactivity disorder in children and adults: past, present, and future

The understanding that sleep can give rise to, or exacerbate symptoms of attention-deficit/hyperactivity disorder (ADHD), and that good sleep hygiene improves attention and concentration tasks has sparked interest in the investigation of possible etiological relationships between sleep disorders and ADHD. Studies indicate that 30% of children and 60-80% of adults with ADHD have symptoms of sleep disorders such as daytime sleepiness, insomnia, delayed sleep phase syndrome, fractured sleep, restless legs syndrome, and sleep disordered breathing. The range and diversity of findings by different researchers have posed challenges in establishing whether sleep disturbances are intrinsic to ADHD or whether disturbances occur due to co-morbid sleep disorders. As a result, understanding of the nature of the relationship between sleep disturbances/disorders and ADHD remains unclear. In this review, we present a comprehensive and critical account of the research that has been carried out to investigate the association between sleep and ADHD, as well as discuss mechanisms that have been proposed to account for the elusive relationship between sleep disturbances, sleep disorders, and ADHD.

Comorbidity and confounding factors in attention-deficit/hyperactivity disorder and sleep disorders in children

Sleep problems are commonly reported in children with attention-deficit/hyperactivity disorder (ADHD) symptoms. Research data regarding the complex and reciprocal relationship between ADHD and sleep disturbances has now accumulated. This paper is focused on the types of sleep problems that are associated with ADHD symptomatology, and attempts to untangle confounding factors and overlapping symptoms. The goal is also to present an updated overview of the pathophysiology of and treatment strategies for sleep problems in children with ADHD. The review also points out that future research will be needed to clarify further the other psychiatric comorbidities and side effects of medication in order to improve treatment outcomes and prevent misdiagnosis in clinical practice.

Hyperactive-impulsive symptoms associated with self-reported sleep quality in nonmedicated adults with ADHD

OBJECTIVE

Individuals with ADHD often report sleep problems. Though most studies on ADHD and sleep examined children or nonclinically diagnosed adults, the present study specifically examines nonmedicated adults with ADHD to determine whether inattentive and hyperactive-impulsive symptoms are associated with sleep problems.

METHOD

A total of 22 nonmedicated adults diagnosed with ADHD are assessed with a DSM-IV-based interview and the Pittsburg Sleep Quality Index (PSQI).

RESULTS

The number of hyperactive-impulsive symptoms indicate a positive correlation with sleep duration, habitual sleep efficiency, and global PSQI score. No significant associations are found between inattentive symptoms and sleep quality.

CONCLUSION

The results show that sleep problems are associated with hyperactive and impulsive symptoms in nonmedicated adults with ADHD. These findings provide information on the nature of sleep problems without the confounding effects of medication associated with ADHD. Treatment of sleep problems, especially in those with hyperactive-impulsive symptoms, may help ameliorate ADHD symptomatology.

Impairments in attention in occasionally snoring children: an event-related potential study

OBJECTIVE

To determine whether minimal snoring is benign in children.

PROCEDURE

22 rarely snoring children (mean age = 6.9 years, 11 females) and age- and sex-matched controls participated in an auditory oddball task wearing 128-electrode nets. Parents completed the Conners Parent Rating Scales-Revised Long (CPRS-R:L).

RESULTS

Snorers scored significantly higher on four CPRS-R:L subscales. Stepwise regression indicated that two ERP variables from a region of the ERP that peaked at 844 msec post-stimulus onset predicted CPRS-R:L Attention Deficit Hyperactivity Disorder (ADHD) Index scores.

CONCLUSIONS

Occasional snorers, according to parental report, do exhibit ADHD-like behaviors. Basic sensory processing is longer than in controls, suggesting that delayed frontal activation requires more effort in snorers.

Dose finding of melatonin for chronic idiopathic childhood sleep onset insomnia: an RCT

RATIONALE

Pharmacokinetics of melatonin in children might differ from that in adults.

OBJECTIVES

This study aims to establish a dose-response relationship for melatonin in advancing dim light melatonin onset (DLMO), sleep onset (SO), and reducing sleep onset latency (SOL) in children between 6 and 12 years with chronic sleep onset insomnia (CSOI).

METHODS

The method used for this study is the randomized, placebo-controlled double-blind trial. Children with CSOI (n = 72) received either melatonin 0.05, 0.1, and 0.15 mg/kg or placebo during 1 week. Sleep was assessed with log and actigraphy during this week and the week before. Outcomes were the shifts in DLMO, SO, and SOL.

RESULTS

Treatment with melatonin significantly advanced SO and DLMO by approximately 1 h and decreased SOL by 35 min. Within the three melatonin groups, effect size was not different, but the circadian time of administration (TOA) correlated significantly with treatment effect on DLMO (r (s) = -0.33, p = 0.022) and SO (r (s) = -0.38, p = 0.004), whereas clock TOA was correlated with SO shift (r = -0.35, p = 0.006) and not with DLMO shift.

CONCLUSIONS

No dose-response relationship of melatonin with SO, SOL, and DLMO is found within a dosage range of 0.05-0.15 mg/kg. The effect of exogenous melatonin on SO, SOL, and DLMO increases with an earlier circadian TOA. The soporific effects of melatonin enhance the SO shift. This study demonstrates that melatonin for treatment of CSOI in children is effective in a dosage of 0.05 mg/kg given at least 1 to 2 h before DLMO and before desired bedtime.

Short nighttime sleep-duration and hyperactivity trajectories in early childhood

OBJECTIVES

Our objectives were to investigate the developmental trajectories of nighttime sleep duration and hyperactivity over the preschool years and to identify the risk factors associated with short nighttime sleep duration and high hyperactivity scores.

DESIGN, SETTING, AND PARTICIPANTS

Nighttime sleep duration and hyperactivity were measured yearly by questionnaires administered to mothers of 2057 children from age 1.5 to 5 years. Developmental trajectories of nighttime sleep duration and hyperactivity throughout early childhood were analyzed to determine interassociations. A multinomial logistic regression was performed to determine which factors among selected child, maternal, and family characteristics and parental practices surrounding sleep periods in early childhood were associated with short nighttime sleep duration and high hyperactivity scores.

RESULTS

The trajectories of nighttime sleep duration and hyperactivity were significantly associated. The odds ratio (OR) of reporting short nighttime sleep duration was 5.1 for highly hyperactive children (confidence interval [CI]: 3.2-7.9), whereas the OR of reporting high hyperactivity scores was 4.2 for persistently short sleepers (CI: 2.7-6.6). The risk factors for reporting short nighttime sleep duration and high hyperactivity scores were (1) being a boy, (2) having insufficient household income, (3) having a mother with a low education, and (4) being comforted outside the bed after a nocturnal awakening at 1.5 years of age.

CONCLUSIONS

The risk of short nighttime sleep duration in highly hyperactive children is greater than the risk of high hyperactivity scores in short sleepers. Preventive interventions that target boys living in adverse familial conditions could be used to address these concomitant behavioral problems.

Controlled clinical trial of zolpidem for the treatment of insomnia associated with attention-deficit/ hyperactivity disorder in children 6 to 17 years of age

OBJECTIVE

The goal was to evaluate the hypnotic efficacy of zolpidem at 0.25 mg/kg per day (maximum of 10 mg/day), compared with placebo, in children 6 through 17 years of age who were experiencing insomnia associated with attention-deficit/hyperactivity disorder.

METHODS

An 8-week, North American, multicenter, double-blind, placebo-controlled, parallel-group study was conducted. Patients underwent stratification according to age (6-11 years [N = 111] or 12-17 years [N = 90]) and were assigned randomly to receive treatment with the study drug or placebo (in a 2:1 ratio). The primary efficacy variable was latency to persistent sleep between weeks 3 and 6. Secondary efficacy variables also were assessed, and behavioral and cognitive components of attention-deficit/hyperactivity disorder were monitored. Safety was assessed on the basis of reports of adverse events, abnormal laboratory data, vital signs, and physical examination findings. The potential for next-day residual effects also was assessed.

RESULTS

The baseline-adjusted mean change in latency to persistent sleep at week 4 did not differ significantly between the zolpidem and placebo groups (-20.28 vs -21.27 minutes). However, differences favoring zolpidem were observed for the older age group in Clinical Global Impression scores at weeks 4 and 8. No next-day residual effects of treatment were associated with zolpidem, and no rebound phenomena occurred after treatment discontinuation. Central nervous system and psychiatric disorders were the most-frequent treatment-emergent adverse events (>5%) that were observed more frequently with zolpidem than with placebo; these included dizziness, headache, and hallucinations. Ten (7.4%) patients discontinued zolpidem treatment because of adverse events.

CONCLUSION

Zolpidem at a dose of 0.25 mg/kg per day to a maximum of 10 mg failed to reduce the latency to persistent sleep on polysomnographic recordings after 4 weeks of treatment in children and adolescents 6 through 17 years of age who had attention-deficit/hyperactivity disorder-associated insomnia.

Sleep disturbances in prepubertal children with attention deficit hyperactivity disorder: a home polysomnography study

STUDY OBJECTIVE

To examine sleep architecture and reported sleep problems in children with ADHD and normal controls, while considering the roles of pertinent moderating factors.

DESIGN

Overnight sleep recordings were conducted in 15 children diagnosed with ADHD (DSM-IV) without comorbid psychiatric problems and in 23 healthy controls aged 7 to 11 years. Children were on no medication, in good health and did not consume products containing caffeine > or = 7 days prior to the polysomnography (PSG) study. PSG evaluation was performed at each child's home; children slept in their regular beds and went to bed at their habitual bedtimes.

MEASUREMENTS

Standard overnight multichannel PSG evaluation was performed using a portable polysomnography device. In addition, parents were asked to complete a sleep questionnaire.

RESULTS

Compared to controls, children in the ADHD group had significantly shorter duration of REM sleep, smaller percentage of total sleep time spent in REM sleep, and shorter sleep duration. In addition, the ADHD group had higher scores on the insufficient sleep and sleep anxiety factors than children in the control group.

CONCLUSION

The present findings support the hypothesis that children with ADHD present sleep disturbances.

Sensory hypersensitivity as a contributing factor in the relation between sleep and behavioral disorders in normal schoolchildren

Despite growing interest in the relationship between sleep disturbances and behavioral disorders-specifically, symptoms of attention deficit/hyperactivity disorder (ADHD) in children-the underlying structure of this relationship is poorly understood. The aim of the study was to explore the contribution of sensory hypersensitivity to this relationship. Parents of 56 schoolchildren completed questionnaires reporting sleep habits, behavior, and sensory processing. Significant correlations were found between global scores of all 3 constructs; however, the relationship between sleep and behavior decreased when controlling for sensory processing. Among different sensory modalities, tactile sensitivity was a significant predictor for sleep, accounting for 25% of the variance, F = 16.30, p < .001; and sensation seeking and tactile sensitivity were significant predictors for behavior, accounting for 42% of the variance, F = 17.56, p < .001. If confirmed by further objective investigation, the results of this study suggest that sensory profiles of children with sleep or behavioral disorders should be routinely assessed in clinical practice.

Effects of once-daily oral and transdermal methylphenidate on sleep behavior of children with ADHD

OBJECTIVE

Methylphenidate is a leading first-line treatment for ADHD (AD/HD). This stimulant has long been suspected to adversely affect sleeping patterns of treated individuals, especially children. There are few studies on the effects of recently developed longer-acting methylphenidate treatments, such as once-daily oral or transdermal formulations, on sleep.

METHOD

The authors examined eight indices of sleep behavior among children treated with either of these two methylphenidate preparations or placebo in a randomized, double-blind, multicenter, parallel-group study.

RESULTS

The main predictor of sleep problems was baseline numbers or severity of preexisting sleep problems, whereas the different treatments and placebo varied little in their propensity to elicit such problems. There was no significant relationship between dosage and severity or frequency of sleep problems.

CONCLUSION

The authors found little evidence that methylphenidate treatment (at least in sustained-release forms) was a significant cause of sleep problems in treated children who were carefully titrated to an optimal dose.

Sleep disorders and attention-deficit/hyperactivity disorder

The relationship between attention-deficit/hyperactivity disorder (ADHD) and sleep is complex and poses many challenges in clinical practice. Recent studies have helped to elucidate the nature of the neuromodulator systems underlying the associations among sleepiness, arousal, and attention. Studies of sleep disturbances in children with academic and behavioral problems have also underscored the role that primary sleep disorders play in the clinical presentation of symptoms of inattention and behavioral dysregulation. Recent research has shed further light on the prevalence, type, risk factors for, and impact of sleep disturbances on children with ADHD. The following discussion of the multilevel and bidirectional relationships among sleep, neurobehavioral functioning, and the clinical syndrome of ADHD synthesizes current knowledge about the interaction of sleep and attention/arousal in these children. Guidelines are provided to outline a clinical approach to evaluating and managing children with ADHD and sleep problems.

ADHD subtypes and comorbid anxiety, depression, and oppositional-defiant disorder: differences in sleep problems

OBJECTIVE

Sleep problems were analyzed in children with ADHD (Attention-deficit hyperactivity disorder).

METHODS

Scales were completed by parents of 135 control children and 681 children with ADHD combined type (ADHD-C) or inattentive type (ADHD-I) with or without comorbid oppositional defiant disorder (ODD), anxiety, or depression.

RESULTS

Children with ADHD-I alone had the fewest sleep problems and did not differ from controls. Children with ADHD-C had more sleep problems than controls and children with ADHD-I. Comorbid anxiety/depression increased sleep problems, whereas ODD did not. Daytime sleepiness was greatest in ADHD-I and was associated with sleeping more (not less) than normal. Medicated children had greater difficulty falling asleep than unmedicated children.

CONCLUSIONS

Differences in sleep problems were found as a function of ADHD subtype, comorbidity, and medication.

Sleep disturbances in children with psychiatric disorders

Sleep disturbances are highly prevalent among children with psychiatric disorders, making recognition and management of pediatric sleep disorders an important step in improving treatment outcome and preventing relapse of mental illness. This chapter will review the research data on the epidemiology, clinical presentation and treatment approaches for sleep disorders frequently seen in the context of common psychiatric conditions in children and adolescents. Readers will learn about interaction between sleep related problems and symptoms of Attention Deficit/Hyperactivity Disorder, Anxiety and Mood Disorders and Autism Spectrum Disorders, and about the impact of sleep loss and sleep fragmentation on the emotional and behavioral development in children.

Nonsignificance of sleep relative to IQ and neuropsychological scores in predicting academic achievement

OBJECTIVE

The goal of the study was to determine the relative importance of sleep, IQ, neuropsychological, and attention-deficit/hyperactivity disorder (ADHD) scores in predicting academic achievement.

METHOD

Objective overnight polysomnograph sleep scores, parent ratings of sleep problems, IQ, neuropsychological test scores, and parent ratings of ADHD were used to predict academic achievement in a general population sample of 412 elementary schoolchildren, 6 to 12 years of age with IQs of 71 to 147.

RESULTS

Using stepwise linear regression analysis, IQ was the best single predictor of reading and math achievement test scores. The most powerful combined predictors of achievement were IQ and some of the neuropsychological test scores. Subjective parent-reported sleep problems and objective polysomnograph scores (apnea-hypopnea index, mean oxygen saturation and lowest saturation percentage during sleep, snoring frequency and severity, sleep latency, minutes to rapid eye movement (REM) sleep, arousal index, number of awakenings, sleep efficiency, and percentage of stage 1, 2, 3, 4, and REM sleep) did not contribute significantly more to the prediction of achievement. Children with and without sleep problems did not differ from each other in achievement. IQ, neuropsychological test scores, and ADHD ratings were all significantly related to achievement, but correlations between achievement and objective and subjective sleep scores were all nonsignificant.

CONCLUSIONS

There may be individual children for whom sleep problems affect achievement, but for a large group of community children, sleep was not significantly related to academic functioning. In contrast, IQ and neuropsychological test scores were powerful predictors of achievement.

A polymorphism at the 3'-untranslated region of the CLOCK gene is associated with adult attention-deficit hyperactivity disorder

Attention-deficit hyperactivity disorder (ADHD) is frequently found in childhood and persists in about 50% of cases into adulthood. Several studies demonstrate a relationship between ADHD, circadian rhythmicity and sleeping disturbances in unmedicated ADHD patients. Since ADHD is a very complex disease with a high genetic load involving multiple genes of moderate effect, we hypothesized a link between adult ADHD and genes involved in the circadian timekeeping system. A 3'-UTR polymorphism of the circadian locomotor output cycles protein kaput (CLOCK) gene, rs1801260, has been linked to disturbed sleep patterns, although both the C-allele and more controversially the T-allele have been proposed as risk factors for different measures of evening preference. This study compared self-rating and interview based measures of ADHD psychopathology of 143 subjects with and without ADHD with their rs1801260 genotype to test the hypothesis that ADHD is linked to one of the alleles of the CLOCK polymorphism. The T > C single nucleotide polymorphism rs1801260 was genotyped in DNA isolated from blood samples. The associations between genotype and ADHD-scores were compared using non-parametric ANCOVA with post hoc pairwise comparisons. There was a strong, significant association (P < 0.001) between each of the adult ADHD assessments and the rs1801260 polymorphism with at least one T-mutation being the risk allele. This is the first study suggesting that a polymorphism of a gene within the circadian "clock" mechanism is a direct or linked contributing factor in adult ADHD.

Sleep and behavioral/emotional problems in children: a population-based study

BACKGROUND

The potential relationships between sleep-wake behaviors and emotional/disruptive problems in otherwise healthy school-aged children are unclear.

METHODS

A parental questionnaire was developed for the epidemiologic survey of children's sleep and wake behavioral patterns. The questions covered a wide range of features including sleep length (school days, weekends), time to fall asleep, night awakenings, bedtime and nighttime sleep-related behaviors, daytime sleepiness, irritability, and tiredness. To assess psychiatric symptomatology, the Rutter Scale B2 was completed by teachers. In addition to the total score, sub-scores of emotional, hyperactivity, and conduct problems were obtained. The representative population sample comprised 779 children (403 girls), with an age range of 6-11 years.

RESULTS

Hyperactivity and conduct problems at school in boys were both associated with parental reports of bedtime resistance. Hyperactivity was also associated with longer sleep duration during weekends. Conduct and emotional problems in girls were associated with earlier bedtime during school days. Emotional problems in girls were also associated with longer sleep durations in school days and weekends.

CONCLUSION

Bedtime resistance was the only sleep behavior associated with either hyperactivity or conduct problems in children, and longer sleep durations appear to occur more frequently in children with both hyperactive or emotional problems. Information about good sleep hygiene at bedtime may help parents setting sleep limits.

Associations between sleep duration patterns and behavioral/cognitive functioning at school entry

OBJECTIVE

The aim of the study was to investigate the associations between longitudinal sleep duration patterns and behavioral/cognitive functioning at school entry.

DESIGN, SETTING, AND PARTICIPANTS

Hyperactivity-impulsivity (HI), inattention, and daytime sleepiness scores were measured by questionnaire at 6 years of age in a sample of births from 1997 to 1998 in a Canadian province (N=1492). The Peabody Picture Vocabulary Test--Revised (PPVT-R) was administered at 5 years of age and the Block Design subtest (WISC-III) was administered at 6 years of age. Sleep duration was reported yearly by the children's mothers from age 2.5 to 6 years. A group-based semi-parametric mixture model was used to estimate developmental patterns of sleep duration. The relationships between sleep duration patterns and both behavioral items and neurodevelopmental tasks were tested using weighted multivariate logistic regression models to control for potentially confounding psychosocial factors.

RESULTS

Four sleep duration patterns were identified: short persistent (6.0%), short increasing (4.8%),10-hour persistent (50.3%), and 11-hour persistent (38.9%). The association of short sleep duration patterns with high HI scores (P=0.001), low PPVT-R performance (P=0.002), and low Block Design subtest performance (P=0.004) remained significant after adjusting for potentially confounding variables.

CONCLUSIONS

Shortened sleep duration, especially before the age of 41 months, is associated with externalizing problems such as HI and lower cognitive performance on neurodevelopmental tests. Results highlight the importance of giving a child the opportunity to sleep at least 10 hours per night throughout early childhood.

Sleepless in America: inadequate sleep and relationships to health and well-being of our nation's children

OBJECTIVE

Our goal was to identify characteristics associated with inadequate sleep for a national random sample of elementary school-aged children (6-11 years) and adolescents (12-17 years).

METHODS

Data from 68418 participants in the 2003 National Survey of Children's Health were analyzed by using weighted bivariate and multivariate regression models. The dependent variable was report of not getting enough sleep for a child of his or her age >or=1 night of the past week. Independent variables included demographic characteristics, child health, school and other activities, and family life.

RESULTS

Parents of elementary school-aged children with inadequate sleep were more likely to report that their child was having problems at school or had a father with fair or poor health. Parents of adolescents with inadequate sleep were more likely to report that their child had an atopic condition, frequent or severe headaches, a parent with less-than-excellent emotional health, or experienced frequent parental anger. Inadequate sleep in both age groups was associated with parental report that their child usually or always displayed depressive symptomatology, family disagreements involved heated arguing, or parental concern that the child was not always safe at home, at school, or in their neighborhood.

CONCLUSIONS

Approximately 15 million American children are affected by inadequate sleep. Primary care providers should routinely identify and address inadequate sleep and its associated health, school, and family factors.

Attention-deficit/hyperactivity disorder with obstructive sleep apnea: a treatment outcome study

BACKGROUND

Children diagnosed with attention-deficit/hyperactivity disorder (ADHD), based on Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV) criteria, may also have obstructive sleep apnea (OSA), but it is unclear whether treating OSA has similar results as methylphenidate (MPH), a commonly used treatment for ADHD.

METHODS

This study enrolled 66 school-age children, referred for and diagnosed with ADHD, and 20 healthy controls. Polysomnography (PSG) performed after ADHD diagnosis showed the presence of mild OSA. After otolaryngological evaluation, parents and referring physicians of the children could select treatment of ADHD with MPH, treatment of OSA with adenotonsillectomy or no treatment. Systematic follow-up was performed six months after initiation of treatment, or diagnosis if no treatment. All children had pre- and post-clinical interviews; pediatric, neurologic, psychiatric and neurocognitive evaluation; PSG; ADHD rating scale, child behavior checklist (CBCL) filled out by parents and teacher; test of variables of attention (TOVA); and the quality of life in children with obstructive sleep disorder questionnaire (OSA-18).

RESULTS

ADHD children had an apnea-hypopnea index (AHI)>1<5 event/hour; 27 were treated with MPH, 25 had adenotonsillectomy, and 14 had no treatment. The surgical and MPH groups improved more than the non-treatment group. When comparing MPH to post-surgery, the PSG and questionnaire sleep variables, some daytime symptoms (including attention span) and TOVA subscales (impulse control, response time and total ADHD score) improved more in the surgical group than the MPH group. The surgical group had an ADHD total score of 21.16+/-7.13 on the ADHD rating scale (ADHD-RS) post-surgery compared to 31.52+/-7.01 pre-surgery (p=0.0001), and the inattention and hyperactivity subscales were also significantly lower (p=0.0001). Finally, the results were significantly different between surgically and MPH-treated groups (ADHD-RS p=0.007). The surgical group also had a TOVA ADHD score lower than -1.8 and close to those obtained in normal controls.

CONCLUSION

A low AHI score of >1 considered abnormal is detrimental to children with ADHD. Recognition and surgical treatment of underlying mild sleep-disordered breathing (SDB) in children with ADHD may prevent unnecessary long-term MPH usage and the potential side effects associated with drug intake.

Prevalence of sleep problems and their association with inattention/hyperactivity among children aged 6?15 in Taiwan

This study investigated the 6-month prevalence rates of sleep-related problems and their association with daytime inadvertent napping, inattention, hyperactivity/impulsivity, and oppositional symptoms in children and adolescents. A representative school-based sample of 2463 first to ninth graders was recruited using a multistage sampling method. The instruments included the Sleep Habits Questionnaire (including dyssomnia, parasomnia, sleep schedules, and sleep-disordered breathing), the Chinese Health Questionnaire, and the Chinese versions of the Conners' Parent and Teacher Rating Scales-Revised: Short forms. The informants were mothers and teachers. The linear and nonlinear mixed models were used for statistical analyses and sex and age were controlled in the model. Results showed that the rates of middle insomnia, disturbed circadian rhythm, mouth breathing, and daytime inadvertent napping increased with age; whereas those of bedwetting, bruxism, sleep terrors decreased with age. Dyssomnia, sleep-disordered breathing problems, daytime inadvertent napping, and sleep schedules were related to attention-deficit/hyperactivity disorder (ADHD)-related symptoms as assessed by mothers' and teachers' ratings. Parasomnia was associated with ADHD-related symptoms as assessed by mothers' ratings. Our findings suggest an age trend of sleep problems similar to those found in the literature and the association of daytime inadvertent napping, inattention, hyperactivity/impulsivity, and oppositional symptoms with sleep-related problems.

Trastorno por déficit de atención con hiperactividad y alteraciones del sueño

The attention deficit hyperactivity disorder (ADHD) is an heterogeneous, complex and common childhood disorder that causes significant impairment of child's functioning. This paper reviews the epidemiology, etiology, diagnosis, comorbidity, course and treatment of ADHD. Special attention is paid to sleep problems both because these 2 conditions frequently co-exist and because there is substantial evidence that ADHD psychopathology and sleep-wake regulation share common neurobiologic mechanisms. Moreover, there could be an overlap between symptoms of ADHD and certain sleep problems such as obstructive sleep apnea syndrome, restless leg syndrome and periodic limb movements of sleep. Children undergoing evaluation for ADHD should be systematically assessed for sleep disturbances because treatment of sleep disorders is often associated with improved symptomatology and decreased need for stimulants.

Attention deficit disorders: are we barking up the wrong tree?

Attention deficit disorder (AAD) and attention deficit/hyperactivity disorder (ADHD) are very frequent and protean developmental disorders without a definite biologic marker. This review proposes a framework to understand the enlarged spectrum of its manifestations based on current knowledge of the mechanisms underlying arousal and attention variations during sleep/wake cycle. The neuro-modulation's pivotal role in this process as well as in the fine tuning of synaptic architecture during development must be taken into account when trying to understand the marked fuzziness of the symptoms and the very high prevalence of reported co-morbidities. The series of related interactions includes a cyclic deactivation of the dorso-lateral portion of the prefrontal cortex (DLPFC) during sleep, suspending executive functions, co-occurring with rhythmic periods of decreased noradrenergic tonus. A protracted unbalance in modulation, with catecholaminergic relative deficiency, could explain less-than-optimum waking DLPFC activation and the most important manifestations of ADD. Beside the well documented dopaminergic effects of stimulant medication used in ADD and ADHD, a more important role must be assigned to noradrenaline (NA). At this light hyperactivity and impulsivity are less important dimensions. Rather, an attention deficit spectrum disorder should probably be regarded as a complication of a core defect in prefrontal cortex dependent inhibitory control, underlying inattention.

The ADHD and sleep conundrum: a review

The relationship between attention-deficit hyperactivity disorder (ADHD) and sleep is a complex one that poses many challenges in clinical practice. Recent studies have helped to elucidate the nature of the brain mechanisms and neuromodulator systems underlying the theoretical associations among sleepiness, arousal, and attention. Studies of sleep disturbances in children with academic and behavioral problems have also underscored the role that primary sleep disorders such as obstructive sleep apnea hypopnea syndrome play in the clinical presentation of symptoms of inattention and behavioral dysregulation. In addition, new methodologies used in examining sleep and sleep patterns in children diagnosed with ADHD have shed further light on the prevalence, type, risk factors for, and impact of sleep disturbances in these children. The following discussion of the multilevel relationships among sleep quality and quantity, neurobehavioral functioning, and the clinical syndrome of ADHD expands on previous reviews of the literature and synthesizes what is currently known about the interaction of sleep and attention/arousal in children to propose possible underlying mechanisms, integrate more recent findings, and highlight important areas for future study. In addition, guidelines are provided for a clinical approach to evaluation and management of children with ADHD and sleep problems.

Excessive sleepiness in adolescents and young adults: causes, consequences, and treatment strategies

Adolescents and young adults are often excessively sleepy. This excessive sleepiness can have a profound negative effect on school performance, cognitive function, and mood and has been associated with other serious consequences such as increased incidence of automobile crashes. In this article we review available scientific knowledge about normal sleep changes in adolescents (13-22 years of age), the factors associated with chronic insufficient sleep, the effect of insufficient sleep on a variety of systems and functions, and the primary sleep disorders or organic dysfunctions that, if untreated, can cause excessive daytime sleepiness in this population.

Sleep disorders in children with attention-deficit hyperactivity disorder

BACKGROUND

Sleep disturbances are frequently associated with attention-deficit hyperactivity disorder (ADHD) though they are not included in the current classification systems such as the DSM-IV and ICD-10. These problems may complicate the course of the illness as they may be associated with the treatment given

AIM

To evaluate children with ADHD for sleep-related problems.

METHODS

The study group comprised 32 children with ADHD and their 20 healthy siblings made up the control group. Sleep-related problems were assessed on a checklist prepared on the basis of the Children Sleep Questionnaire-parent version.

RESULTS

A majority of the children with ADHD had at least one sleep-related problem. Comparison with healthy siblings revealed non-significant differences on the parameters of sleep-related movement disorders and parasomnias.

CONCLUSION

There is a need for more detailed studies involving sensitive parameters.

Effects of transcutaneous electrical nerve stimulation (TENS) on cognition, behavior, and the rest-activity rhythm in children with attention deficit hyperactivity disorder, combined type

OBJECTIVE

The aim of this study was to examine the effects of transcutaneous electrical nerve stimulation (TENS) on cognition, behavior, and the rest-activity rhythm in children with attention deficit hyperactivity disorder, combined type (ADHD-CT).

METHODS

Twenty-two children diagnosed with ADHD-CT received TENS treatment during 6 weeks, 2 times 30 min a day. Neuropsychological tests were administered to assess cognition, parent/teacher behavioral rating scales were used to measure behavior, and actigraphy was used to assess the rest-activity rhythm.

RESULTS

TENS appeared to have a moderate beneficial influence on cognitive functions that load particularly on executive function. There was also improvement in behavior as measured by parent/teacher behavioral rating scales. Moreover, motor restlessness during sleep and motor activity during the day decreased by TENS.

CONCLUSIONS

The effects of TENS in children with ADHD are modest but encouraging and warrant further research.

Sleep in children with attention-deficit hyperactivity disorder (ADHD): a review of naturalistic and stimulant intervention studies

Attention-Deficit Hyperactivity Disorder (ADHD) is the most common behavioral disorder of childhood. Multiple clinical and research reports suggest extensive sleep disturbances in children with ADHD, however, current data is contradictory. This paper reviewed 47 research studies (13 stimulant intervention and 34 naturalistic) on ADHD that were published since 1980. The main objectives of this review were to provide pediatric clinicians and researchers a clear and concise summary of published sleep data in children with ADHD, to provide a more accurate description of the current knowledge of the relationship between sleep and ADHD, and to provide current information on the effect of stimulant medication on sleep. Twenty-five of the reviewed studies used subjective reports of sleep, six were actigraphic studies, and 16 were overnight polysomnographic sleep studies (two of which also included Multiple Sleep Latency Tests). All participants were between the age of 3 and 19, and 60% were male. The results indicate high rates of parental reports of sleep disturbances in medicated and unmedicated children with ADHD, however, the majority of these findings have not been confirmed by objective sleep data. Although, agreement among objective studies is not absolute, the data suggest increased nighttime activity, reduced rapid eye movement sleep, and significant daytime somnolence in unmedicated children with ADHD when compared to controls. Data also suggest a possible increased prevalence of periodic limb movements in sleep in children with ADHD, however, little differences in sleep-disordered breathing. The limited number of studies, small and heterogeneous samples, and other methodological limitations make definite results difficult to determine. Future research will need to further clarify the relationship between sleep and ADHD and the effects of stimulants on sleep of children with ADHD.

Is there a specific polysomnographic sleep pattern in children with attention deficit/hyperactivity disorder?

The aim of the study was to characterize the sleep pattern in children with attention deficit/hyperactivity disorder (ADHD). By means of polysomnography (PSG), sleep patterns were studied in 17 unmedicated preadolescent boys rigorously diagnosed with ADHD and 17 control boys precisely matched for age and intelligence. Although ADHD children did not display a general sleep alteration, major PSG data showed a significant increase in the duration of the absolute rapid eye movement (REM) sleep and the number of sleep cycles in ADHD group when compared with controls. In addition, REM sleep latency tended to be shorter in ADHD children. These results suggest that in ADHD children, a forced REM sleep initiation may produce a higher incidence of sleep cycles and may also contribute to an increased duration of the absolute REM sleep. The overall pattern of the findings implies that a forced ultradian cycling appears characteristic for the sleep in ADHD children, which may be related to alterations of brain monoamines and cortical inhibitory control accompanying the ADHD psychopathology.

Clinical and parental assessment of sleep in children with attention-deficit/hyperactivity disorder referred to a pediatric sleep medicine center

Frequently reported sleep problems in children with attention deficit-hyperactivity disorder (ADHD) referred to a pediatric sleep medicine center were assessed and compared with objective sleep assessments. A retrospective review of 97 children with ADHD (mean age of 8.3+/-3.0 years) was conducted. Polysomnography in 69 children revealed periodic limb movement disorder (PLMD) in 36% and sleep-disordered breathing in 7%, while actigraphy uncovered substantial variability in sleep schedules of 16 patients. Although parental subjective sleep complaints were verified by objective sleep assessments in a small proportion of cases, PLMD and night-to-night variability in sleep patterns were common.

Melatonin improves health status and sleep in children with idiopathic chronic sleep-onset insomnia: a randomized placebo-controlled trial

OBJECTIVE

To investigate the effect of melatonin treatment on health status and sleep in children with idiopathic sleep-onset insomnia.

METHOD

A randomized, double-blind, placebo-controlled trial was conducted in a Dutch sleep center, involving 62 children, 6 to 12 years of age, who suffered more than 1 year from idiopathic chronic sleep-onset insomnia. Patients received either 5 mg melatonin or placebo at 7 pm. The study consisted of a 1-week baseline period, followed by a 4-week treatment. Health status was measured with the RAND General Health Rating Index (RAND-GHRI) and Functional Status II (FS-II) questionnaires. Lights-off time, sleep onset, and wake-up time were recorded in a diary, and endogenous dim light melatonin onset was measured in saliva.

RESULTS

The total scores of the RAND-GHRI and FS-II improved significantly more during melatonin treatment compared to placebo. The magnitude of change was much higher in the melatonin group than in the placebo group, with standardized response means for the RAND-GHRI of 0.69 versus 0.07 and for the FS-II of 1.61 versus 0.64. Melatonin treatment also significantly advanced sleep onset by 57 minutes, sleep offset by 9 minutes, and melatonin onset by 82 minutes, and decreased sleep latency by 17 minutes. Lights-off time and total sleep time did not change.

CONCLUSIONS

Melatonin improves health status and advances the sleep-wake rhythm in children with idiopathic chronic sleep-onset insomnia.

Sleep disturbances in children with attention deficit hyperactivity disorder

The objective of the study was to compare polysomnographic patterns in two groups of preadolescent children with attention deficit hyperactivity disorder (ADHD) (a sleep clinic referral sample and a community sample) with control children. A prospective and observational study in the sleep clinic and the community was undertaken. Forty-seven ADHD children referred to the sleep clinic (ADHDcl), 53 ADHD children from a community survey (ADHDcom), and 49 control children underwent overnight polysomnography. Significant differences between the groups were observed for rapid-eye-movement (REM) sleep latency and percentage, and periodic limb movement index with associated arousals (PLMa). REM sleep latency was shorter in controls than ADHDcl and ADHDcom (p < 0.01) and REM% was highest in controls and lowest in ADHDcl (p < 0.001). PLMa was higher in ADHDcl than the other groups (p < 0.001), but there were no differences in PLMa between ADHDcom and controls. ADHD children display significant alterations in their sleep patterns, and ADHDcl are more likely to have an elevated PLMa than ADHDcom. In addition, REM sleep is affected by ADHD. We postulate that ADHDcl may represent a subset of children with ADHD at high risk for hyperactivity during sleep.

[Sleep disorders in hyperkinetic children--correlation with arousal disorders, differential diagnosis and comorbidity]

OBJECTIVES

Sleep disorders are frequently observed in Attention Deficit-Hyperactivity Disorder (ADHD). At the same time, however, there is little evidence of their prevalence and their specific characteristics. Also unclear is a possible pathogenetic relationship between disturbed sleep and the core symptoms of ADHD. There are still very few findings on the role of comorbid internal and neurological disorders like sleep apnea and restless legs syndrome in the differential diagnosis of ADHD.

METHODS

We present an overview of the current literature, describing the most important results concerning sleep disorders in ADHD.

RESULTS

A principal goal of future assessments is to ascertain whether sleep problems in children with ADHD represent unspecific concurrent symptoms or whether they play a substantial role in the pathogenesis of ADHD.

CONCLUSIONS

Moreover a possibly increased risk of comorbid sleep-disordered breathing disorder might be an important issue in the differential diagnostic considerations with regard to ADHD.

Sleep disturbances in adolescents with symptoms of attention-deficit/hyperactivity disorder

We evaluated 32 nonmedicated male adolescents diagnosed with attention-deficit/hyperactivity disorder (ADHD) in childhood, 35 male adolescents similarly diagnosed who were receiving methylphenidate (MPH), and 77 control boys. Both ADHD groups completed self-report questionnaires assessing sleep disturbances; weekday and holiday sleep duration; and symptoms of ADHD, anxiety, and depression. Parents and teachers rated the severity of the participants' ADHD. The control group completed self-report questionnaires assessing sleep disturbances. We found that nonmedicated participants and controls did not differ in the severity of sleep disturbance. In contrast, the medicated participants demonstrated a significantly greater severity of sleep disturbance compared with the nonmedicated participants and reported elevated levels of symptoms of ADHD, anxiety, and depression. Specific analyses showed that depressive symptoms contributed significantly to the degree of sleep disturbance when controlling for ADHD diagnosis and MPH treatment. These findings suggest that among adolescents with ADHD symptoms, the severity of symptoms of depression may contribute to the degree of sleep disturbance in addition to the effect of their primary disorder and MPH treatment.

Clinical prediction of periodic leg movements during sleep in children

OBJECTIVE

To assess the utility of several symptoms and a questionnaire-based scale in the identification of children with periodic leg movements during sleep (PLMS).

BACKGROUND

PLMS may have important consequences in some children, but the extent to which a diagnosis can be established by clinical history is unknown.

METHODS

Subjects were patients aged 2-18 years who underwent polysomnography to assess for sleep-disordered breathing (SDB). Parents completed a Pediatric Sleep Questionnaire which contained items under consideration for inclusion in the desired scale.

RESULTS

Subjects (n=113) had a mean age of 9.8+/-4.0 (SD) and 73 (65%) were male; 59 (52%) had SDB and 29 (26%) had five or more PLMS per hour of sleep (PLMI> or =5). Severity of SDB was not different among those with and without PLMI> or =5. Yes/no responses to several question-items--about restless legs, growing pains, leaving the bed at night, waking more than twice per night, waking feeling unrefreshed, and morning headaches--showed some association with PLMI> or =5 and were combined into a composite PLMS score artificially weighted toward the first two items. The PLMS score averaged 0.40+/-0.31 and ranged from 0.0 to 1.0; a 1 SD increase was associated with PLMI> or =5 (odds ratio=1.87, 95% confidence interval (1.15, 3.13), P=0.014) after adjustment for age, sex, and SDB severity. Sensitivity of a PLMS score>0.33 for PLMI> or =5 was 0.79, specificity was 0.56, positive predictive value was 0.38, and negative predictive value was 0.89. Internal consistency was reasonable (Cronbach's alpha=0.71), as was test-retest reliability (rho=0.62, P=0.0026, n=21 separate subjects).

CONCLUSIONS

Restless legs, growing pains, sleep-maintenance insomnia, unrefreshing sleep, and morning headaches show moderate associations with polysomnographically-defined PLMS, but several other symptoms do not. These results require confirmation but suggest that clinical assessment and the PLMS score may be helpful but far from definitive.

Nasal bilevel positive airway pressure therapy in children with a sleep-related breathing disorder and attention-deficit hyperactivity disorder: effects on electrophysiological measures of brain function

OBJECTIVE

To examine the effect of nasal bilevel positive airway pressure (BiPAP) treatment for concurrent sleep-related breathing disorders (SRBDs) and attention-deficit hyperactivity disorder (ADHD) on electrophysiological measures of spontaneous brain activity and auditory stimulus processing.

METHODS

Nineteen children diagnosed with both SRBD and ADHD participated. Electroencephalogram (EEG) activity was recorded during a resting period and an auditory oddball task before beginning BiPAP treatment, after 6 months on treatment, and after a subsequent 1 week non-treatment period. Treatment effects on EEG and event-related potentials (ERPs) to target stimuli were examined via topographic analysis.

RESULTS

Thirteen of the initial 19 children completed 6 months of BiPAP therapy, with six lost mainly due to compliance problems. Children on BiPAP therapy showed a significant decrease in slow-wave (delta and theta) and an increase in fast wave (beta) EEG activity. The P3 component of the ERP showed treatment effects in amplitude and latency.

CONCLUSIONS

The electrophysiological data suggest that SRBDs may contribute to ADHD symptomatology. Treatment of SRBD with BiPAP therapy in children with concurrent ADHD can lead to significant changes, in the direction of normalization, of the typical electrophysiological features of ADHD.

Melatonin for chronic sleep onset insomnia in children: a randomized placebo-controlled trial

To establish the efficacy of melatonin treatment in childhood sleep onset insomnia, 40 elementary school children, 6 to 12 years of age, who suffered more than 1 year from chronic sleep onset insomnia, were studied in a double-blind, placebo-controlled study. The children were randomly assigned to receive either 5-mg melatonin or placebo. The study consisted of a 1-week baseline, consecutively followed by a 4-week treatment period. After that period, treatment was continued if the parents wished so. The study's impact was assessed by measurements of lights-off time, sleep onset, and wake-up time, recorded in a diary (n = 33). Sleep onset was also recorded with an actigraph (n = 25). Endogenous dim light melatonin onset was measured in saliva (n = 27). Sustained attention was evaluated with the Bourdon-Vos reaction time test (n = 36). In the melatonin group, mean (95% CI) lights-off time advanced 34 (6-63) minutes, diary sleep onset 63 (32-94) minutes, actigraphic sleep onset 75 (36-114) minutes, and melatonin onset 57 (24 to 89) minutes; total sleep time increased 41 (19-62) minutes. In the placebo group, these parameters did not shift significantly. The change during the 4-week treatment period differed between the treatment groups significantly as to lights-off time, diary and actigraphic sleep onset, sleep duration, and melatonin onset. There were no significant differences between the treatment groups in the change of sleep latency, wake-up time, and sustained attention reaction times. Mild headache occurred in 2 children during the first 2 days of the melatonin treatment. Eighteen months after the start of the trial, in 13 of the 38 children who could be followed up, melatonin treatment was stopped because their sleep problem was solved and in 1 child because sleep was not improved. Twelve children used melatonin 5 mg, the other 1.0 to 2.5 mg. One child developed mild generalized epilepsy 4 months after the start of the trial. The results show that melatonin, 5 mg at 6 PM, was relatively safe to take in the short term and significantly more effective than placebo in advancing sleep onset and dim light melatonin onset and increasing sleep duration in elementary school children with chronic sleep onset insomnia. Sustained attention was not affected.

Attention deficit hyperactivity disorder in adults and obstructive sleep apnea

Attention deficit hyperactivity disorder (ADHD) is a common childhood illness with a prevalence between 3% and 16%. It is characterized by hyperactivity, impulsiveness, impairment in academic, social, and occupational functioning, short attention span, and onset of symptoms before age 7 years. In some patients, this illness can persist into adulthood. Obstructive sleep apnea (OSA) is a common disorder affecting 3% of the population and is characterized by hypersomnolence, snoring, disturbed sleep, and cognitive dysfunction. Some studies have suggested an association between OSA and ADHD in children. Because of the overlap of symptoms, patients with OSA may be considered to have ADHD. Significant improvement in symptoms has been reported with the use of continuous positive airway pressure in patients with OSA. We present reports of three adults who were being treated for ADHD and were found to have OSA.