Daytime Sleepiness in Adults With ADHD: A Pilot Trial With a Multiple Sleep Latency Test

Attention-Deficit/Hyperactivity Disorder and Delayed Sleep Phase Syndrome in Adults: A Randomized Clinical Trial on the Effects of Chronotherapy on Sleep

Delayed sleep phase syndrome (DSPS) is the most common sleep disturbance in adults with attention-deficit/hyperactivity disorder (ADHD). We previously showed that chronotherapy with melatonin effectively advanced the dim-light melatonin onset (DLMO), a biomarker for the internal circadian rhythm, by 1.5 h and reduced ADHD symptoms by 14%. Melatonin combined with bright light therapy (BLT) advanced the DLMO by 2 h, but did not affect ADHD symptoms. This article explores whether sleep times advanced along with DLMO, leading to longer sleep duration and better sleep in general, which might explain the working mechanism behind the reduction in ADHD symptoms after treatment with melatonin. This article presents exploratory secondary analysis on objective and self-reported sleep characteristics from a three-armed double-blind randomized placebo-controlled clinical trial (RCT), which included 49 adults (18-55 years) with ADHD and DSPS. Participants were randomized to receive sleep education and 3 weeks of (1) 0.5 mg/day placebo, (2) 0.5 mg/day melatonin, or (3) 0.5 mg/day melatonin plus 30 min of bright light therapy (BLT) between 0700 and 0800 h. Sleep was assessed at baseline, directly after treatment, and 2 weeks after the end of treatment. Objective measures were obtained by actigraphy, self-reported measures by various sleep questionnaires and a sleep diary. Melatonin with or without BLT did not advance sleep times, improve sleep in general, or strengthen wake-activity rhythms. So even though the DLMO had advanced, sleep timing did not follow. Adding extensive behavioral coaching to chronotherapy is necessary for advancing sleep times along with DLMO and to further alleviate ADHD symptoms.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

GOV IDENTIFER

NCT02139124 and NCT02168127.

Objective Level of Alertness and Inhibitory Control Predict Highway Driving Impairment in Adults With ADHD

Objective: It remains unclear whether daytime impairments in ADHD patients are better explained by an altered level of alertness and/or by cognitive deficits. The aim of this study was to determine the respective contribution of these factors on driving performance in ADHD adults. Method: ADHD adults (n = 39) and healthy controls (n = 18) underwent a nocturnal polysomnography (PSG) followed by a Maintenance of Wakefulness Test (MWT), a simulated driving task, and a neuropsychological evaluation. Results: ADHD patients had shorter mean sleep latency on the MWT and worse driving performance than controls. They also made more errors on attention and executive functioning tests. Logistic regression analyses showed that inhibition deficits and objective daytime sleepiness predicted highway driving performance in ADHD. Conclusion: Our study shows that not only inhibitory control deficits but also pathological level of alertness independently contribute to highway driving impairment in ADHD patients, providing a better understanding of the pathophysiological mechanisms involved in ADHD.

Sleep in adults with autism spectrum disorder and attention deficit/hyperactivity disorder: A systematic review and meta-analysis

Sleep-related problems have been frequently reported in neurodevelopmental disorders, with special emphasis in Autism Spectrum Disorder (ASD) and Attention Deficit/Hyperactivity Disorder (ADHD). The aim of the present study is to conduct a systematic review and meta-analysis on sleep disturbances in adults with ASD and/or ADHD (PROSPERO's CRD42019132916). PubMed and PsycINFO were searched for studies reporting data on sleep objective/subjective measures, as well as prevalence data of sleep disorders, in adults with ASD and/or ADHD. A manual search was conducted throughout reference lists of eligible studies. A total of 1126 studies and 66 references were identified by electronic and manual searches, respectively. Of these, 42 studies were included in the meta-analysis. Results showed that both disorders share a similar sleep-impaired profile with higher sleep onset latency, poorer sleep efficiency, greater number of awakenings during sleep, and a general lower self-perceived sleep quality compared with healthy controls. A higher proportion of N1 sleep was found in ASD participants, while a greater Periodic Limb Movements in Sleep is specific in ADHD adults. More studies are needed, especially those directly comparing ASD and ADHD participants. Controlling for medication, intellectual disability, and concurrent psychiatric disorders is mandatory.

Mind-wandering and sleepiness in adults with attention-deficit/hyperactivity disorder

Sleepiness and mind-wandering are frequently experienced by patients with attention-deficit/hyperactivity disorder (ADHD), without ever having been jointly explored. We aimed to investigate the co-occurrence of these two phenomena in ADHD adults. Drug-free ADHD adults (n = 25) and healthy controls (n = 28) underwent an online experience sampling of mind-wandering episodes and subjective sleepiness. Participants completed self-reported measures of mind-wandering and sleepiness in daily life. Higher trait of mind-wandering was observed in ADHD patients compared to controls. On the whole sample, self-reported mind-wandering propensity was strongly associated with the severity of inattentive, impulsive and hyperactive symptoms. During the probes, patients reported more frequent episodes of mind-wandering and mind-blanking, and higher sleepiness. Their mind-wandering episodes were less intentional and belonged less frequently to a structured succession of thoughts. In both groups, mind-wandering and mind-blanking were associated with higher sleepiness. On the SART, patients were less accurate than controls. We provide first initial evidence for higher propensity of mind-wandering and mind-blanking using experience sampling in patients with formal ADHD diagnosis. This propensity was associated with sleepiness without negatively impacting attention performances. Mind-wandering and sleepiness have common determinants potentially involved in ADHD pathophysiology. Correlates of mind-blanking in ADHD adults remain to be characterized.

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

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

A Study to Assess the Relationship between Attention Deficit Hyperactivity Disorder and Obstructive Sleep Apnea in Adults

The association between obstructive sleep apnea (OSA) and attention deficit hyperactivity disorder (ADHD) is well-established in children. However, there is a paucity of literature regarding this association in adults. The aim of this study was to determine if ADHD is more common in adult patients with OSA. All patients referred to a sleep center for sleep evaluation were administered the Adult ADHD Self-Report Scale and diagnostic polysomnogram. The ADHD screen is considered positive if 4 of 6 questions in part A of the screening questionnaire were answered abnormally. The study population consisted of 194 participants, predominantly male (62%), Caucasian (54%), and Hispanic (44%). OSA was identified in 160 (83%) of participants, with 116 (60%) having moderate to severe OSA. The ADHD screen was positive in 37 (19%) of participants. There was no significant association between the severity of OSA and presence of ADHD symptoms. Patients with OSA who screened positive for ADHD had higher Epworth Sleepiness Scale scores than those that did not. These data suggest that ADHD is more prevalent in patients with OSA, but do not demonstrate a relationship between OSA severity and ADHD symptoms. Interestingly, sleepiness is more prominent in patients with ADHD.

Sleep and mental disorders: A meta-analysis of polysomnographic research

Investigating sleep in mental disorders has the potential to reveal both disorder-specific and transdiagnostic psychophysiological mechanisms. This meta-analysis aimed at determining the polysomnographic (PSG) characteristics of several mental disorders. Relevant studies were searched through standard strategies. Controlled PSG studies evaluating sleep in affective, anxiety, eating, pervasive developmental, borderline and antisocial personality disorders, attention-deficit-hyperactivity disorder (ADHD), and schizophrenia were included. PSG variables of sleep continuity, depth, and architecture, as well as rapid-eye movement (REM) sleep were considered. Calculations were performed with the "Comprehensive Meta-Analysis" and "R" software. Using random effects modeling, for each disorder and each variable, a separate meta-analysis was conducted if at least 3 studies were available for calculation of effect sizes as standardized means (Hedges' g). Sources of variability, that is, sex, age, and mental disorders comorbidity, were evaluated in subgroup analyses. Sleep alterations were evidenced in all disorders, with the exception of ADHD and seasonal affective disorders. Sleep continuity problems were observed in most mental disorders. Sleep depth and REM pressure alterations were associated with affective, anxiety, autism and schizophrenia disorders. Comorbidity was associated with enhanced REM sleep pressure and more inhibition of sleep depth. No sleep parameter was exclusively altered in 1 condition; however, no 2 conditions shared the same PSG profile. Sleep continuity disturbances imply a transdiagnostic imbalance in the arousal system likely representing a basic dimension of mental health. Sleep depth and REM variables might play a key role in psychiatric comorbidity processes. Constellations of sleep alterations may define distinct disorders better than alterations in 1 single variable. (PsycINFO Database Record

Associations of pineal volume, chronotype and symptom severity in adults with attention deficit hyperactivity disorder and healthy controls

The pineal gland, as part of the human epithalamus, is the main production site of peripheral melatonin, which promotes the modulation of sleep patterns, circadian rhythms and circadian preferences (morningness vs. eveningness). The present study analyses the pineal gland volume (PGV) and its association with circadian preferences and symptom severity in adult ADHD patients compared to healthy controls. PGV was determined manually using high-resolution 3T MRI (T1-magnetization prepared rapid gradient echo) in medication free adult ADHD patients (N=74) compared to healthy controls (N=86). Moreover, the Morningness-Eveningness Questionnaire (MEQ), the ADHD Diagnostic Checklist and the Wender-Utah Rating Scale were conducted. PGV differed between both groups (patients: 59.9±33.8mm(3); healthy controls: 71.4±27.2mm(3), P=0.04). In ADHD patients, more eveningness types were revealed (patients: 29%; healthy controls: 17%; P=0.05) and sum scores of the MEQ were lower (patients: 45.8±11.5; healthy controls 67.2±10.1; P<0.001). Multiple regression analyses indicated a positive correlation of PGV and MEQ scores in ADHD (β=0.856, P=0.003) but not in healthy controls (β=0.054, P=0.688). Patients' MEQ scores (β=-0.473, P=0.003) were negatively correlated to ADHD symptoms. The present results suggest a linkage between the PGV and circadian preference in adults with ADHD and an association of the circadian preference to symptom severity. This may facilitate the development of new chronobiological treatment approaches for the add-on treatment in ADHD.

Sleep propensity in psychiatric hypersomnolence: A systematic review and meta-analysis of multiple sleep latency test findings

Hypersomnolence plays a sizeable role in the course and morbidity of psychiatric disorders. Current sleep medicine nosology is reliant on the multiple sleep latency test (MSLT) to segregate hypersomnolence associated with psychiatric disorders from other central nervous system causes. However, the evidence base regarding sleep propensity in psychiatric hypersomnolence as measured by the MSLT has not been systematically evaluated, which is vital to clarify the utility and validity of current nosological schema. In this review, the use of sleep propensity assessed by the MSLT in patients with psychiatric hypersomnolence is systematically evaluated, using both qualitative and quantitative assessment. Findings demonstrate high heterogeneity and potential for bias among studies, with a pooled estimate of sleep propensity among patients with psychiatric hypersomnolence similar to normative values. Additionally, approximately 25% of patients with psychiatric hypersomnolence demonstrate a mean sleep latency below 8 min, the current cutpoint to define pathologic sleepiness. These data underscore the limitations of the MSLT in segregating psychiatric hypersomnolence from other central nervous system hypersomnias. Further research is warranted to evaluate novel measures and biomarkers of excessive sleepiness to advance clinical practice, as well as dimensional approaches to classification of hypersomnolence disorders.

Excessive daytime sleepiness in patients with ADHD--diagnostic and management strategies

The links between attention-deficit hyperactivity disorder (ADHD) and sleep disorders remain unclear. Specific sleep disorders are a frequent comorbid condition associated with ADHD according to a categorical approach. However, sleep disorders can also induce ADHD-like symptoms according to a dimensional approach and are thought to be the consequence of excessive daytime sleepiness. It may thus be difficult for clinicians to differentiate the diagnosis of ADHD comorbid with a sleep disorder from sleep disorders with ADHD-like symptoms. This distinction could be important for the appropriate management of patients with dual complaints of trouble maintaining attention and daytime sleepiness. This paper summarizes the main sleep disorders associated with ADHD: sleep-related breathing disorders, sleep-related movement disorders, circadian rhythm sleep-wake disorders, and central disorders of hypersomnolence (aka hypersomnias). The history of presenting symptoms should be taken into account since ADHD is a neurodevelopmental disorder whereas ADHD symptoms comorbid with sleep disorder are not. Finally, we propose a model to clarify the links between ADHD, ADHD symptoms, and excessive daytime sleepiness induced by sleep disorders. Clinicians should therefore routinely assess, monitor, and manage the sleep problems of patients with ADHD who have both comorbidities and should search for the presence of ADHD symptoms in subjects with sleep disorders.