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

The Interventions for Sleep Disorders in Children with Attention Deficit and Hyperactivity Disorder: A Narrative Review

BACKGROUND: Attention deficit and hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder in childhood. Children with ADHD have more frequent comorbid sleep disorders than healthy children. The current methods of treating sleep disorders in ADHD children are still focused on pharmacological interventions which in fact only provide little benefit. AIM: This study aims to identify existing studies regarding the types of nonpharmacological and complementary interventions for sleep disorders in children with ADHD using a narrative review approach. METHODS: This was a narrative review. Inclusion criteria included articles in English and Bahasa, full-text articles, primary studies, and children with ADHD aged 18 years with or without comorbidities as the research sample, and the article having been published in the last 10 years. Searches were performed in several databases: PubMed, Springer, Web of Science, and Google Scholar. RESULTS: The result showed that programs for managing sleep disorder in ADHD are behavioral therapy, behavioral parent training (BPT), behavioral sleep intervention, neurofeedback, mind-body therapy, L-theanine supplementation, horse milk supplementation, and play therapy. The programs are found to be effective in improving sleep. CONCLUSION: The program most comprehensive with a high level of ease of implementation was BPT.

Sleepiness and impulsivity: Findings in non-treatment seeking young adults

BACKGROUND AND AIMS

Although inadequate sleep has been linked to problematic behaviors, such as poor impulse control and emotion dysregulation, little research interest has been the role of sleep and sleep deprivation on impulsive behaviors in young adults. To further examine the relationship of sleepiness to impulsivity and impulsive behaviors, this study was designed to collect data on sleepiness, and a range of impulse control disorders and cognitive measures.

METHODS

Young non-treatment-seeking adults were recruited from two US cities and completed a screening form for sleepiness, along with demographic, clinical, and cognitive measures relevant to impulsivity. Relationships between these explanatory variables and total sleepiness scores were analyzed using partial least squares. Significant explanatory variables were identified (p < .05, bootstrap).

RESULTS

Higher levels of sleepiness were significantly associated with higher ADHD symptoms, gambling disorder symptoms, Internet addiction symptoms, and personality-related impulsiveness. Sleepiness was also associated with set-shifting errors, and with gambling more points (abnormal decision-making), but not with significant impairment in response to inhibition, or other aspects of decision-making.

CONCLUSIONS

This study confirms a cross-sectional relationship between sleepiness and a range of impulsive measures at the level of behavior (ADHD, gambling, and Internet addiction) and personality traits. Longitudinal research would be required to explore causal mechanisms and the direction of any such effects. Screening for such mental health diagnoses in people with sleep problems may be valuable, as enquiring patients with such impulsive symptoms about sleep, in order to maximize quality of life.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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.

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.