Sleep problems in the child with attention-deficit hyperactivity disorder: defining aetiology and appropriate treatments

A randomized controlled trial of effects of sleep hygiene training and progressive muscle relaxation training in children with ADHD

OBJECT

Sleep problems often accompany ADHD and negatively affect ADHD symptoms, however, there are not enough intervention studies on sleep interventions in children with ADHD. The present study investigated the effects of sleep hygiene training (SH) and progressive muscle relaxation exercises (PMR) in children with ADHD.

METHOD

57 children aged 6-12 years with ADHD were randomly assigned to the SH and SH + PMR groups and completed the intervention consisting of group training and eight weeks of telephone interviews. The effects of both intervenitons were evaluated via parent, child and clinician report scales and neuropsychological tests.

RESULTS

Both interventions resulted in significant positive changes in child sleep, ADHD symptoms, functioning, neuropsychological tests and parental sleep quality. Significant differences were found between the interventions in selective attention, peer problems and anxiety scores in favor of the SH + PMR group.

CONCLUSION

SH may have positive effects on various clinical parameters as well as sleep problems in children with ADHD. Addition of PMR to SH may lead to further improvements in anxiety, peer problems and selective attention. SH and PMR may be a useful tool in the clinical management of children with ADHD with sleep problems.

The effectiveness of weighted blankets on sleep and everyday activities - A retrospective follow-up study of children and adults with attention deficit hyperactivity disorder and/or autism spectrum disorder

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) and Autism Spectrum Disorder (ASD) are often accompanied by sleep problems influencing social, emotional and cognitive functioning in everyday activities.

AIM

The aim of this study was to investigate whether the use of a weighted blanket has a positive impact on sleep and everyday activities in individuals with ADHD and/or ASD.

MATERIAL AND METHODS

The study included 85 individuals diagnosed with ADHD and/or ASD, 48 children aged ≤17 (57%) and 37 adults ≥18 years (44%), who were prescribed with a weighted blanket. The participants responded via a telephone interview.

RESULTS

Findings demonstrated that a weighted blanket improved abilities related to falling asleep, sleeping the whole night, and relaxing during the day. Using a weighted blanket improved morning/evening daily routine, including preparing/going to sleep and waking up in the morning.

CONCLUSIONS

Weighted blankets showed positive impact on falling asleep, sleeping the whole night, and relaxing during the day, and they were used frequently by children and adults with ADHD and/or ASD. Findings indicate that a weighted blanket improved morning/evening routine, however this research area needs further investigation using both subjective and objective parameters.

Understanding the Impact of Insufficient Sleep in Children with Behavior Problems on Caregiver Stress: Results from a U.S. National Study

Research indicates strong connections between child ADHD, child ODD/CD, and sleep. Children experiencing these concerns also have caregivers who report feeling more stress. However, no studies have examined how child ADHD and ODD/CD interact together and with insufficient sleep to potentially exacerbate caregiver stress. Data were acquired from the 2018/2019 National Survey of Children's Health, a nationally representative survey of parents or caregivers conducted across the United States (U.S.). The current study used data for children 6-17 years old with a final analytic sample size of 41,541, representing a total of 47,357,862 U.S. youth. Overall child ADHD and ODD/CD were each uniquely associated with increased caregiver stress, while adequate child sleep duration was related to decreased caregiver stress. However, these findings were qualified by a significant two-way interaction that revealed that caregiver stress among children with comorbid ADHD and ODD/CD was not significantly greater than that of children with ODD/CD alone. Significant interactions between sleep and ODD/CD on caregiver stress were generally not observed, except potentially in females with ADHD. Our findings underscore the importance of considering strategies to reduce both youth symptoms and caregiver stress simultaneously. Additionally, ensuring adequate sleep for all children is recommended.

Sleep Disorders during Adolescence

Sleep disorders during adolescence period increase each year and adversely affect the physical and mental health of adolescents. After-school social activities and various work outside the school may cause delays in bedtime. In addition, there can be shifts in the circadian rhythm due to a number of biological changes seen in the transition to adolescence, which can result in a wide range of sleep problems, such as not being able to fall asleep at night, difficulty waking up in the morning, daytime sleepiness, sleep deprivation and deterioration in sleep quality. It is important to know the causes of sleep disorders, possible effects on physical health and mental health, and protective and risk-forming factors seen in adolescent period; to intervene in these disorders and to develop preventive measures. Preventive measures, such as increasing awareness about sleep disorders in adolescents, informing families and adolescents about the issue, and organizing school start-up times for this age group, may contribute significantly to solving this important issue, which has increased year-to-year.

Evaluation of children with ADHD and their psychiatric symptoms

" Background: Mental disorders, especially in children, can be manifested in different ways, which is of great importance to them, so the purpose of this evaluation was to evaluate the changes in psychiatric symptoms in children with ADHD. Method: This evaluation was performed as a descriptive-analytic study on 141 children with ADHD who were followed up for 6 months. At the beginning of the study and the third and sixth months after, patients' symptoms were assessed with the CBCL Behavior Checklist and the ADHD rating scale questionnaire, as well as the course of illness and association with other disorders. Finally, the data were entered into SPSS statistical software and analyzed. Results: The mean age of the children was 5.89±0.81 years and the prevalence of males was 68.8%. Among the two treatment groups, only the mean score below the ADHD-RS questionnaire score in the non-Ritalin group at the end of the third and sixth months was significantly lower than the Ritalin group. During the study in both treatment groups, the overall ADHD-RS questionnaire and both subscales of attention deficit hyperactivity disorder (ADHD) had a significant decrease from baseline to the end of the sixth month. In relation to the CBCL behavioral checklist, the mean score of the total checklist except for anxiety/depression in the non-Ritalin group and the somatic complaints subscale in the Ritalin group decreased significantly from baseline to the end of the sixth month. Conclusion: Based on the results observed in this evaluation, Ritalin had a significant effect on the symptoms of patients with ADHD, although these symptoms improved in both groups, however, further studies are needed"

Association between CLOCK gene polymorphisms and ADHD in Mexican teenagers: A comprehensive assessment

This study aimed to evaluate markers of the CLOCK gene rs1801260 and rs4864548 in Mexican adolescents, addressing clinical and biological aspects previously associated with ADHD. 347 Mexican adolescents were assessed for mental disorders, metabolic disruption and related conditions, circadian preference, as well as genotyping for the CLOCK. We found a significant association between ADHD and the AA and AG genotypes of rs1801260. Also, we identified in the ADHD group that the total Triiodothyronine and total Thyroxine values were respectively 10 ng/dl units and 0.58 ug/dl units lower in females than in males. Previously reported common variations of the CLOCK gene have been associated with ADHD like the Rs1801260 polymorphism hereby we could consider it as risk factor, but genetic, biochemical and clinical studies in the Mexican population are entailed.

Increased behavioral problems in children with sleep-disordered breathing

Background

Healthy sleep is essential for the cognitive, behavioral and emotional development of children. Therefore, this study aimed to assess the behavioral consequences of sleep disturbances by examining children with sleep-disordered breathing compared with control participants.

Methods

Seventy-eight children with SDB (average age: 6.7 years (SD = 1.83); 61 had OSA and 17 had primary snoring) and 156 control subjects (average age: 6.57 years (SD = 1.46) participated in the study. We matched the groups in age (t(232) = 0.578, p = 0.564) and gender (χ²(1) = 2.192, p = 0.139). In the SDB group, the average Apnea–Hypopnea Index was 3.44 event/h (SD = 4.00), the average desaturation level was 87.37% (SD = 6.91). Parent-report rating scales were used to measure the children’s daytime behavior including Attention Deficit Hyperactivity Disorder Rating Scale, Strengths and Difficulties Questionnaire, and Child Behavior Checklist.

Results

Our results showed that children with SDB exhibited a higher level of inattentiveness and hyperactive behavior. Furthermore, the SDB group demonstrated more internalizing (anxiety, depression, somatic complaints, social problems) (p < 0.001) and externalizing (aggressive and rule-breaking behavior) problems compared with children without SDB, irrespective of severity.

Conclusions

Based on our findings we supposed that snoring and mild OSA had a risk for developing behavioral and emotional dysfunctions as much as moderate-severe OSA. Therefore, clinical research and practice need to focus more on the accurate assessment and treatment of sleep disturbances in childhood, particularly primary snoring, and mild obstructive sleep apnea.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Role of Iron and Zinc in the Treatment of ADHD among Children and Adolescents: A Systematic Review of Randomized Clinical Trials

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder common from childhood to adulthood, affecting 5% to 12% among the general population in developed countries. Potential etiological factors have been identified, including genetic causes, environmental elements and epigenetic components. Nutrition is currently considered an influencing factor, and several studies have explored the contribution of restriction and dietary supplements in ADHD treatments. Iron is an essential cofactor required for a number of functions, such as transport of oxygen, immune function, cellular respiration, neurotransmitter metabolism (dopamine production), and DNA synthesis. Zinc is also an essential trace element, required for cellular functions related to the metabolism of neurotransmitters, melatonin, and prostaglandins. Epidemiological studies have found that iron and zinc deficiencies are common nutritional deficits worldwide, with important roles on neurologic functions (poor memory, inattentiveness, and impulsiveness), finicky appetite, and mood changes (sadness and irritability). Altered levels of iron and zinc have been related with the aggravation and progression of ADHD. Objective: This is a systematic review focused on the contribution of iron and zinc in the progression of ADHD among children and adolescents, and how therapies including these elements are tolerated along with its effectiveness (according to PRISMA guidelines). Method: The scientific literature was screened for randomized controlled trials published between January 2000 to July 2021. The databases consulted were Medline, PsycINFO, Web of Science, and Google Scholar. Two independent reviewers screened studies, extracted data, and assessed quality and risk of bias (CONSORT, NICE, and Cochrane checklists used). Conclusion: Nine studies met the eligibility criteria and were selected. Evidence was obtained regarding the contribution of iron-zinc supplementation in the treatment of ADHD among young individuals. The discussion was focused on how the deficits of these elements contribute to affectation on multiple ADHD correlates, and potential mechanisms explaining the mediational pathways. Evidence also suggested that treating ADHD with diet interventions might be particularly useful for specific subgroups of children and adolescents, but further investigations of the effects of these diet interventions are needed.

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.

Associations between parenting stress, parent mental health and child sleep problems for children with ADHD and ASD: Systematic review

BACKGROUND

Children with attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) experience high rates of sleep problems. Their parents experience higher parenting stress and more mental health difficulties than parents of typically developing children.

AIM

To examine the association between child sleep problems, parenting stress and parent mental health for children with ADHD or ASD.

METHODS

MEDLINE Complete, EMBASE, PsycINFO and CINAHL Complete databases were searched. Studies needed to include: children aged 5-18 with ADHD or ASD, a child sleep measure, and a parenting stress or adult mental health measure.

RESULTS

Eleven studies were identified (four ADHD, seven ASD). Six studies examined parenting stress (five cross-sectional, one longitudinal) and five found associations, of varying strengths, with child sleep problems. Six studies examined parent mental health (four cross-sectional, two longitudinal) and five found associations, of differing magnitudes, with child sleep problems.

CONCLUSIONS

These studies demonstrate child sleep problems are associated with poorer parent mental health and higher parenting stress.

IMPLICATIONS

Future longitudinal research including multiple measurements of child sleep problems and family functioning is required to clarify the directionality of associations. Such knowledge is key in adapting sleep interventions to better meet the needs of children with ADHD or ASD and their families.

CLOCK Polymorphisms in Attention-Deficit/Hyperactivity Disorder (ADHD): Further Evidence Linking Sleep and Circadian Disturbances and ADHD

Circadian and sleep disorders, short sleep duration, and evening chronotype are often present in attention-deficit/hyperactivity disorder (ADHD). CLOCK, considered the master gene in the circadian rhythm, has been explored by few studies. Understanding the relationship between ADHD and CLOCK may provide additional information to understand the correlation between ADHD and sleep problems. In this study, we aimed to explore the association between ADHD and CLOCK, using several genetic markers to comprehensively cover the gene extension. A total of 259 ADHD children and their parents from a Brazilian clinical sample were genotyped for eight single nucleotide polymorphisms (SNPs) in the CLOCK locus. We tested the individual markers and the haplotype effects using binary logistic regression. Binary logistic and linear regressions considering ADHD symptoms among ADHD cases were conducted as secondary analysis. As main result, the analysis showed a risk effect of the G-A-T-G-G-C-G-A (rs534654, rs1801260, rs6855837, rs34897046, rs11931061, rs3817444, rs4864548, rs726967) haplotype on ADHD. A suggestive association between ADHD and rs534654 was observed. The results suggest that the genetic susceptibility to circadian rhythm attributed to the CLOCK gene may play an important role on ADHD.

Melatonin, adolescence, and the brain: An insight into the period-specific influences of a multifunctional signaling molecule

Melatonin is a neurohormone that is involved in the modulation of a wide range of physiological processes, including maintenance of the circadian rhythm, mediation of photoperiodic information, regulation of the sleep-wake cycle, synchronization of cell physiology, antioxidant defense, and immune-modulation. Although there are reports of increasing use of melatonin in the management of a number of health conditions, evidence exists that is suggestive of deleterious effects of melatonin administration on brain and reproductive development in the prepubertal and pubertal periods that are within the teenage years. In this review, we examine the influences of endogenous and exogenous melatonin on the adolescent brain, with specific reference to its involvement in the evolution of brain functions, brain structure, sleep regulation, and modulation of behaviors in health or disease.

Evaluation of the Relationship Between Attention Deficit Hyperactivity Disorder Symptoms and Chronotype

INTRODUCTION

The aim of the study is to investigate the relationship between circadian characteristics and behavioral problems in children with Attention Deficit Hyperactivity Disorder (ADHD) (n=53), and to compare this group with healthy controls (n=38).

METHOD

Fifty-three medication-free children with ADHD, aged 6-12 years, and 38 healthy children, age and sex matched, participated. Parents completed the Conners' Parent Rating Scale-Revised, the Children's Chronotype Questionnaire (CCTQ), and the Children's Sleep Habits Questionnaire (CSHQ) to assess sleep variables.

RESULTS

ADHD children had more sleep-onset problems and parasomnias (in CSHQ) compared to healthy controls. However, circadian preferences did not differ between the groups in CCTQ scores. Another important finding was a mild correlation between parasomnia, bedtime on schooldays, and ADHD symptoms.

CONCLUSION

Our study showed that children with ADHD showed more resistance to going to bed than did controls on school days. However, in contrast to our hypothesis, morningness/eveningness preference did not differ from controls in ADHD children.

Effect on Primary Sleep Disorders When Children With ADHD Are Administered Guanfacine Extended Release

OBJECTIVE

To evaluate children with ADHD and sleep problems with polysomnography (PSG) after guanfacine extended-release (GXR) administration.

METHOD

Double-blind, randomized, placebo-controlled study was terminated early due to treatment-emergent concerns after enrolling 29 children aged 6 to 12 years. After >4 weeks dose adjustment and >1 week dose stabilization, 11 children received GXR and 16 controls underwent analyses with PSG.

RESULTS

Although GXR improved ADHD symptoms, the primary outcome variable, total sleep time, was shorter in contrast to placebo (-57.32, SD = 89.17 vs. +31.32, SD = 59.54 min, p = .005). Increased time awake after sleep onset per hour of sleep was the primary factor for the reduction. Although rapid eye movement (REM), non-REM, and N3/slow wave sleep times were reduced, these were proportional to the overall sleep reduction. Sedation was common with GXR (73% vs. 6%).

CONCLUSION

Morning-administered GXR resulted in decreased sleep and may contribute to sedation.

DSM-5 Changes in Attention Deficit Hyperactivity Disorder and Autism Spectrum Disorder: Implications for Comorbid Sleep Issues

Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) are the most common neurodevelopmental disorders. Despite significant comorbidity, the previous diagnostic criteria prohibited the simultaneous diagnosis of both disorders. Sleep problems are highly prevalent in both disorders; however, these have been studied independently for ADHD and ASD. In the context of revised criteria in the Diagnostic Statistical Manual of Mental Disorders 5th edition (DSM-5) that allows combined diagnosis of ADHD and ASD, this short review presents an overview of relationship between sleep problems, ADHD and ASD, as well as conceptualizing the shared pathophysiology. The practical considerations for clinical management of sleep problems in combination with ADHD and ASD are also discussed.

Characteristics of sleep in socially vulnerable adolescents

IMPORTANCE

This study may help understand the effects of an unfavorable environment in sleep quality of adolescents.

OBJECTIVE

To investigate sleep quality in socially vulnerable adolescents, correlating the results with cognitive problems and attention deficit/hyperactivity disorder, and assessing the effectiveness of sleep hygiene and an educational intervention.

DESIGN

Cross-sectional and interventional study.

SETTING

an educational charitable center supported by a Catholic institution, in Porto Alegre, southern Brazil.

PARTICIPANTS

125 male and female high school students.

INTERVENTIONS

As first step the subjects were administered specific questionnaires, the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS), followed by an educational activity that was combined with an unblinded, randomized interventional study. Next, a cross-sectional study was conducted to determine the influence of cognition and ADHD on the sleep.

MAIN OUTCOME AND MEASURES

Sleep was evaluated using PSQI and ESS. Cognitive assessment was based on the Wechsler Abbreviated Scale of Intelligence and ADHD by a clinical interview the Multimodal Treatment Study for ADHD (MTA-SNAP-IV).

RESULTS

The average duration of sleep per night were 6 h 30 m. 80% of the sample presented sleep complains. Of these, 44% had excessive daytime sleepiness and 69.6% had poor sleep quality related to use of electronic media, environmental violence, and emotional issues. There were no significant associations between sleep problems and cognitive problems or ADHD. Sleep quality improved in 17% of the 53 students with previous sleep complains who participated in any of the two interventions.

CONCLUSIONS

A high prevalence of sleep deprivation and sleep complains was found in the study sample. The interventions showed some positive effects on the improvement of sleep quality.

Safety, Tolerability and Efficacy of Drugs for Treating Behavioural Insomnia in Children with Attention-Deficit/Hyperactivity Disorder: A Systematic Review with Methodological Quality Assessment

OBJECTIVE

A large proportion of paediatric patients with attention-deficit/hyperactivity disorder (ADHD) have associated sleep problems which not only affect the child's wellbeing but also impact family functioning. Management of sleep problems is consequently an important aspect of overall ADHD management in paediatric patients. Although some drugs are being used off-label for the management of paediatric insomnia, there is scant clinical evidence supporting their use. Our aim was to identify and assess the quality of published studies reporting the safety, tolerability and efficacy of drugs used for treating behavioural insomnia in children with ADHD.

METHODS

After an initial screen to determine which drugs were most commonly used, we conducted a systematic review of English-language publications from searches of PubMed, EMBASE, PsycINFO and two trial register databases to February 2017, using keywords 'clonidine', 'melatonin', 'zolpidem', 'eszopiclone', 'L-theanine', 'guanfacine', 'ADHD', 'sleep disorder' and 'children'. For quality assessment of included studies, we used the CONSORT checklist for randomised control trials (RCTs) and the Downs and Black checklist for non-RCTs.

RESULTS

Twelve studies were included. Two case series for clonidine, two RCTs and four observational studies for melatonin and one RCT each for zolpidem, eszopiclone, L-theanine and guanfacine. Of the 12 included studies, only one on eszopiclone scored excellent for quality. The quality of the rest of the studies varied from moderate to low. For clonidine, melatonin and L-theanine, improvements in sleep-onset latency and total sleep duration were reported; however, zolpidem, eszopiclone and guanfacine failed to show any improvement when compared with placebo. Clonidine, melatonin, L-theanine, eszopiclone and guanfacine were well tolerated with mild to moderate adverse events; zolpidem was associated with neuropsychiatric adverse effects.

CONCLUSION

There is generally poor evidence for prescribing drugs for behavioural insomnia in children with ADHD. Further controlled studies are warranted.

The relationship between epilepsy, sleep disorders, and attention deficit hyperactivity disorder (ADHD) in children: A review of the literature

Objective

To analyze the relationship between epilepsy, sleep disorders, and attention deficit hyperactivity disorder (ADHD).

Bibliographic search

A literature search of the PubMed database was performed using the following key words: epilepsy, sleep, and ADHD. In total, 91 articles were located in PubMed, 34 were selected for abstract reading and twelve articles were reviewed, in which the main objectives were examine the relationship between epilepsy, sleep and ADHD from several perspectives, including epidemiology, effect of comorbidities on academic performance and the factors leading to diagnostic difficulties among these three disorders

Results

Among the main findings, there were difficulties to start and maintain sleep in patients with epilepsy and ADHD, reduction in sleep efficiency, decreased seizure threshold, as well as behavioral and cognitive deficits in both groups.

Conclusions

It is important to know which symptom is the predominant one. For this reason, children and adolescents with epilepsy, ADHD and sleep disorders need to be assessed carefully before initiating treatment. Our review concluded that there is an important link in this pathological triad.

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.

Melatonin as add-on treatment for epilepsy

BACKGROUND

This is an updated version of the original Cochrane review published in Issue 6, 2012.Epilepsy is one of the most common chronic neurological disorders. Despite the plethora of antiepileptic drugs (AEDs) currently available, 30% of people continue having seizures. This group of people requires a more aggressive treatment, since monotherapy, the first choice scheme, fails to control seizures. Nevertheless, polytherapy often results in a number of unwanted effects, including neurological disturbances (somnolence, ataxia, dizziness), psychiatric and behavioural symptoms, and metabolic alteration (osteoporosis, inducement or inhibition of hepatic enzymes, etc.). The need for better tolerated AEDs is even more urgent in this group of people. Reports have suggested an antiepileptic role of melatonin with a good safety profile.

OBJECTIVES

To assess the efficacy and tolerability of melatonin as add-on treatment for epilepsy.

SEARCH METHODS

For the latest update, we searched the Cochrane Epilepsy Group's Specialized Register (12 January 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (CRSO, 12 January 2016), and MEDLINE (Ovid, 11 January 2016). We searched the bibliographies of any identified study for further references. We handsearched selected journals and conference proceedings. We applied no language restrictions. In addition, we contacted melatonin manufacturers (i.e. Nathura) and original investigators to identify any unpublished studies.

SELECTION CRITERIA

Randomized controlled trials; double, single, or unblinded trials; parallel group or cross-over studies. People with epilepsy regardless of age and gender, including children and adults with disabilities. Administration of melatonin as add-on treatment to any AED(s) compared to add-on placebo or no add-on treatment.

DATA COLLECTION AND ANALYSIS

Review authors independently selected trials for inclusion according to pre-defined criteria, extracted relevant data, and evaluated the methodological quality of trials. We assessed the following outcomes: at least 50% seizure reduction, seizure freedom, adverse events, and quality of life.

MAIN RESULTS

We included six publications, with 125 participants (106 aged under 18 years). Two different comparisons were available: melatonin versus placebo and melatonin 5 mg versus melatonin 10 mg. Despite our primary intention, due to insufficient information on outcomes, we were unable to perform any meta-analyses, but summarized data narratively. Four studies were randomized, double-blind, cross-over, placebo-controlled trials and two were randomized, double-blind, parallel, placebo-controlled trials. Only two studies provided the exact number of seizures during the trial compared to the baseline: none of the participants with seizures during the trial had a change in seizure frequency compared with the baseline. Two studies systematically evaluated adverse effects (worsening of headache was reported in a child with migraine under melatonin treatment). Only one study systematically evaluated quality of life, showing no statistically significant improvement in quality of life in the add-on melatonin group.

AUTHORS' CONCLUSIONS

Included studies were of poor methodological quality, and did not systematically evaluate seizure frequency and adverse events, so that it was impossible to summarize data in a meta-analysis. It is not possible to draw any conclusion about the role of melatonin in reducing seizure frequency or improving quality of life in people with epilepsy.

Sleep Problems in Children with Attention Deficit/Hyperactivity Disorder: Current Status of Knowledge and Appropriate Management

Attention deficit hyperactivity disorder (ADHD) affects approximately 5 % of children and adolescents, and sleep problems are common in these patients. There is growing evidence informing the significant importance of sleep problems in youth with ADHD. The sleep problems in children with ADHD include specific sleep disorders and sleep disturbances due to comorbid psychiatric disorders or ADHD medications. The specific sleep disorders of ADHD children include behaviorally based insomnia, sleep-disordered breathing, and restless legs syndrome/periodic limb movement disorder. Current practices on the management of sleep problems for ADHD children are based mostly on expert consensus, whereas more evidence-based literature can be found only recently. Assessment of the sleep conditions in ADHD children before initiation of pharmacotherapy is the currently recommended guideline, and good sleep hygiene can be considered as the first-line treatment option. In addition to modifying the dose regimens, formulation, or alternative stimulants when sleep problems are encountered in ADHD children, atomoxetine, once daily guanfacine extended release, and melatonin are potential choices for ADHD children with more severe sleep problems. In this review, we aimed to provide the most updated information, preferably based on meta-analyses, systemic review, and randomized controlled trials published in the latest 3 years, in order to be clinically useful for practitioners and clinicians.

Sleep Problem Trajectories and Well-Being in Children with Attention-Deficit Hyperactivity Disorder: A Prospective Cohort Study

OBJECTIVE

Sleep problems affect up to 70% of children with attention-deficit/hyperactivity disorder (ADHD) and are associated with poorer child and family well-being in cross-sectional studies. However, whether these associations hold longitudinally is unclear. The authors aimed to examine the longitudinal relationship between sleep problem trajectories and well-being in children with ADHD.

METHOD

Children with ADHD (n = 186), aged 5 to 13 years, were recruited from 21 pediatric practices across the state of Victoria, Australia. Sleep problem severity data were collected at 3 time points (baseline, 6, and 12 mo) and were used to classify sleep problem trajectories. Child and family well-being (e.g., child emotional and behavioral problems, quality of life [QoL]) were measured at baseline and 12 months by teacher and/or caregiver-report. The well-being of children with "transient" and "persistent" sleep problems was compared with those "never" experiencing sleep problems using a series of hierarchical linear regression models.

RESULTS

After accounting for socio-demographic factors, children with transient and persistent sleep trajectories experienced more caregiver-reported behavioral and emotional problems (effect size [ES] both 0.7) and poorer child QoL (ES: -0.7 and -1.2, respectively). These associations remained after also accounting for ADHD medication and symptom severity and comorbidities, but after accounting for baseline measures many associations weakened to the point of nonsignificance. In the fully adjusted model-transient sleep problems were associated with behavioral and emotional problems (ES: 0.2). These associations were not evident by teacher-report.

CONCLUSION

Children with ADHD experiencing transient or persistent sleep problems have poorer caregiver-reported well-being. Managing sleep problems in children with ADHD may improve child well-being.

Melatonin as add-on treatment for epilepsy

BACKGROUND

This is an updated version of the original Cochrane review published in Issue 6, 2012.Epilepsy is one of the most common chronic neurological disorders. Despite the plethora of antiepileptic drugs (AEDs) currently available, 30% of people continue having seizures. This group of people requires a more aggressive treatment, since monotherapy, the first choice scheme, fails to control seizures. Nevertheless, polytherapy often results in a number of unwanted effects, including neurological disturbances (somnolence, ataxia, dizziness), psychiatric and behavioural symptoms, and metabolic alteration (osteoporosis, inducement or inhibition of hepatic enzymes, etc.). The need for better tolerated AEDs is even more urgent in this group of people. Reports have suggested an antiepileptic role of melatonin with a good safety profile.

OBJECTIVES

To assess the efficacy and tolerability of melatonin as add-on treatment for epilepsy.

SEARCH METHODS

For the latest update, we searched the Cochrane Epilepsy Group's Specialized Register (12 January 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (CRSO, 12 January 2016), and MEDLINE (Ovid, 11 January 2016). We searched the bibliographies of any identified study for further references. We handsearched selected journals and conference proceedings. We applied no language restrictions. In addition, we contacted melatonin manufacturers (i.e. Nathura) and original investigators to identify any unpublished studies.

SELECTION CRITERIA

Randomized controlled trials; double, single, or unblinded trials; parallel group or cross-over studies. People with epilepsy regardless of age and gender, including children and adults with disabilities. Administration of melatonin as add-on treatment to any AED(s) compared to add-on placebo or no add-on treatment.

DATA COLLECTION AND ANALYSIS

Review authors independently selected trials for inclusion according to pre-defined criteria, extracted relevant data, and evaluated the methodological quality of trials. We assessed the following outcomes: at least 50% seizure reduction, seizure freedom, adverse events, and quality of life.

MAIN RESULTS

We included six publications, with 125 participants (106 aged under 18 years). Two different comparisons were available: melatonin versus placebo and melatonin 5 mg versus melatonin 10 mg. Despite our primary intention, due to insufficient information on outcomes, we were unable to perform any meta-analyses, but summarized data narratively. Four studies were randomized, double-blind, cross-over, placebo-controlled trials and two were randomized, double-blind, parallel, placebo-controlled trials. Only two studies provided the exact number of seizures during the trial compared to the baseline: none of the participants with seizures during the trial had a change in seizure frequency compared with the baseline. Two studies systematically evaluated adverse effects (worsening of headache was reported in a child with migraine under melatonin treatment). Only one study systematically evaluated quality of life, showing no statistically significant improvement in quality of life in the add-on melatonin group.

AUTHORS' CONCLUSIONS

Included studies were of poor methodological quality, and did not systematically evaluate seizure frequency and adverse events, so that it was impossible to summarize data in a meta-analysis. It is not possible to draw any conclusion about the role of melatonin in reducing seizure frequency or improving quality of life in people with epilepsy.

Association Between Childhood Sleep-Disordered Breathing and Disruptive Behavior Disorders in Childhood and Adolescence

We examined the association between sleep-disordered breathing (SDB) and disruptive behavior disorders in 605 children participating in a population-based cohort study. Nineteen percent of children snored (sometimes or often) and 10% had obstructive sleep apnea (OSA) symptoms. Thirteen percent had an ADHD diagnosis or symptoms and 5-9% had behavioral problems or a conduct disorder. Snoring or OSA symptoms were associated with a twofold difference in the odds of ADHD diagnosis or symptoms. OSA symptoms were associated with a threefold to fourfold difference in the odds of behavioral problems or conduct disorder. Clinicians should consider inquiring about SDB in children with disruptive behavior disorders and should also consider disruptive behavior disorders as potential sequelae of SDB.

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.

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.

Non-Pharmacological Treatments for ADHD in Youth

BACKGROUND

Complementary and alternative medicine (CAM) in psychiatry or integrative psychiatry covers a wide range of biological, psychological and mind-body treatments that enhance standard medical practices and patient outcomes. While CAM approaches are popular amongst patients in their practice as well as in self-report because of their ease of use, health professionals have received limited education in these interventions and often are unaware of their patients' use of CAM treatments.

METHOD

This overview highlights evidence-based CAM treatments for attention deficit hyperactivity disorder (ADHD) including dietary interventions, phytomedicines, mind-body practices and neurofeedback.

RESULTS

While conventional treatments are the mainstays for ADHD, there are a large number of available treatments that can be used to enhance treatment response.

CONCLUSION

With improved education and further scientific and clinical research, validated integrative treatments will provide more effective, lower risk and lower cost care for patients with ADHD.

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.

The relationships between sensory modulation and sleep among adolescents with ADHD

OBJECTIVE

The purpose of this study was to investigate the effect of sensory modulation and sleeping among 30 adolescents diagnosed with ADHD, compared with 28 adolescents without ADHD.

METHOD

Two questionnaires were completed by parents to assess the participants' level of ADHD symptoms. Two other questionnaires were completed by the participants assessing difficulties in sensory modulation and sleep.

RESULTS

The ADHD group had more sensory difficulties in Activity Level, Hearing, and Low Registration, and more difficulties in the Sleep Behavior variables. Higher correlations between the sensory variables and the sleep measures were found in the ADHD group as compared with the non-ADHD group. Significant differences between correlations were found between three sleep measures and four sensory variables.

CONCLUSION

The discussion is devoted to an assessment of the relationships between the measures, with the conclusion that among adolescents with ADHD, it is important to assess and treat possible sensory and sleep difficulties.

Sleep-wake patterns reported by parents in hyperactive children diagnosed according to ICD-10, as compared to paired controls

This study aimed primarily to compare the parent-reported sleep of children with ICD-10 hyperkinetic disorder (HKD) versus community children. Thirty children aged 5-13 years (83.3% boys) diagnosed with HKD by their child and adolescent psychiatrists took part in this study, plus 30 community children, matched for sex, age, and school year. Compared to the controls, the HKD children showed significantly later bedtimes, stronger bedtime resistance, longer sleep latency, shorter sleep; more frequent behaviors and symptoms concerning falling asleep into parents bed, needing something special to initiate sleep, nightmares, sleep talking, sleep bruxism, fear from darkness, bedwetting, and, most notably, loud snoring (26.7%); they also tended to show higher daytime somnolence. Attention deficit/hyperactivity disorder (ADHD)/HKD children may thus have more sleep-related problems than typically developing children. Alternatively, our results may reflect misdiagnoses; thus, special attention should be directed to comorbidity and differential diagnosis issues between sleep disturbances and ADHD/HKD.

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.

To sleep or not to sleep: a systematic review of the literature of pharmacological treatments of insomnia in children and adolescents with attention-deficit/hyperactivity disorder

OBJECTIVE

This systematic review assessed current evidence on sleep medication for attention-deficit/hyperactivity disorder (ADHD) patients, to establish appropriate guidance for clinicians faced with prescribing such medications.

METHODS

Five articles (based on four pharmacological compounds) out of a total 337 were identified as evidence to guide pharmacological treatment of ADHD-related sleep disorders. Data regarding participant characteristics, measures of ADHD diagnosis, measures of sleep, and outcome data were extracted.

RESULTS

Zolpidem and L-theanine both displayed a poor response in reducing sleep latency and increasing total sleep time, however L-theanine did produce an increase in sleep efficiency. Zolpidem produced high levels of side effects, leading to the largest dropout rate of all five studies. Clonidine reduced insomnia; and melatonin also exhibited a positive response, with reduced sleep latency, higher total sleep time, and higher sleep efficiency.

CONCLUSIONS

There is a relative paucity of evidence for the pharmacological treatment of ADHD-related sleep disorders; therefore, further research should be conducted to replicate these findings and obtain reliable results.

Deletion of Rictor in neural progenitor cells reveals contributions of mTORC2 signaling to tuberous sclerosis complex

Tuberous sclerosis complex (TSC) is a multisystem genetic disorder with severe neurologic manifestations, including epilepsy, autism, anxiety and attention deficit hyperactivity disorder. TSC is caused by the loss of either the TSC1 or TSC2 genes that normally regulate the mammalian target of rapamycin (mTOR) kinase. mTOR exists within two distinct complexes, mTOR complex 1 (mTORC1) and mTOR complex 2 (mTORC2). Loss of either TSC gene leads to increased mTORC1 but decreased mTORC2 signaling. As the contribution of decreased mTORC2 signaling to neural development and homeostasis has not been well studied, we generated a conditional knockout (CKO) of Rictor, a key component of mTORC2. mTORC2 signaling is impaired in the brain, whereas mTORC1 signaling is unchanged. Rictor CKO mice have small brains and bodies, normal lifespan and are fertile. Cortical layering is normal, but neurons are smaller than those in control brains. Seizures were not observed, although excessive slow activity was seen on electroencephalography. Rictor CKO mice are hyperactive and have reduced anxiety-like behavior. Finally, there is decreased white matter and increased levels of monoamine neurotransmitters in the cerebral cortex. Loss of mTORC2 signaling in the cortex independent of mTORC1 can disrupt normal brain development and function and may contribute to some of the neurologic manifestations seen in TSC.

Attention-deficit/hyperactivity disorder and adverse health outcomes

Attention-deficit/hyperactivity disorder (ADHD) is defined by extreme levels of inattention-disorganization and/or hyperactivity-impulsivity. In DSM-IV, the diagnostic criteria required impairment in social, academic, or occupational functioning. With DSM-5 publication imminent in 2013, further evaluation of impairment in ADHD is timely. This article reviews the current state of knowledge on health-related impairments of ADHD, including smoking, drug abuse, accidental injury, sleep, obesity, hypertension, diabetes, and suicidal behavior. It concludes by suggesting the need for new avenues of research on mechanisms of association and the potential for ADHD to be an early warning sign for secondary prevention of some poor health outcomes.

Melatonin as add-on treatment for epilepsy

BACKGROUND

Epilepsy is one of the most common chronic neurologic disorders. Despite the plethora of antiepileptic drugs (AEDs) currently available, 30% of patients continue having seizures. This group of patients requires a more aggressive treatment, since monotherapy, the first choice scheme, fails to control seizures. Nevertheless, polytherapy often results in a number of unwanted effects, including neurologic disturbances (somnolence, ataxia, dizziness), psychiatric and behavioral symptoms, and metabolic alteration (osteoporosis, inducement or inhibition of hepatic enzymes, etc.). The need for better tolerated AEDs is even more urgent in this group of patients. Reports have suggested an antiepileptic role of melatonin with a good safety profile.

OBJECTIVES

To assess the efficacy and tolerability of melatonin as add-on treatment for epilepsy.

SEARCH METHODS

We searched the Cochrane Epilepsy Group Specialized Register (May 2012), the Cochrane Central Register of Controlled Trials (CENTRAL Issue 4 of 12, The Cochrane Library 2012), and MEDLINE (1946 to April 2012). The bibliographies of any identified study were searched for further references. We handsearched selected journals and conference proceedings. No language restrictions were imposed. In addition, we contacted melatonin manufacturers (i.e. Nathura) and original investigators to identify any unpublished study.

SELECTION CRITERIA

Randomized controlled trials; double, single, or unblinded trials; parallel group or cross-over studies. People with epilepsy regardless of age and sex, including children and adults with disabilities. Administration of melatonin as add-on treatment to any AED(s) compared to add-on placebo or no add-on treatment.

DATA COLLECTION AND ANALYSIS

Review authors independently selected trials for inclusion according to predefined criteria, extracted relevant data, and evaluated the methodologic quality of trials. The following outcomes were assessed: at least 50% seizure reduction, seizure freedom, adverse events, and quality of life.

MAIN RESULTS

Four publications, with a total of 102 participants (90 aged under 18 years), were included. Two different comparisons were available: 1. melatonin versus placebo and 2. melatonin 5 mg versus melatonin 10 mg. Despite our primary intention, due to insufficient information on outcomes, we were unable to perform any meta-analysis, but summarized data narratively. Two studies were randomized, double-blind, cross-over, placebo-controlled trials and two were randomized, double-blind, parallel, placebo-controlled trials. Only one study provided the exact number of seizures during the trial compared to the baseline: none of the patients with seizures during the trial had a change in seizure frequency compared with the baseline. Adverse events were systematically evaluated in only one study (no adverse events observed). Only one study systematically evaluated quality of life, showing no statistically significant improvement in quality of life in the add-on melatonin group.

AUTHORS' CONCLUSIONS

Included studies were of poor methodologic quality, and did not systematically evaluate seizure frequency and adverse events, so that it was impossible to summarize data in a meta-analysis. It is not possible to draw any conclusion about the role of melatonin in reducing seizure frequency or improving quality of life in patients with epilepsy.

The sleep phenotypes of attention deficit hyperactivity disorder: the role of arousal during sleep and implications for treatment

About 25-50% of children and adolescents with attention-deficit hyperactivity disorder (ADHD) experience sleep problems. An appropriate assessment and treatment of such problems might improve the quality of life in such patients and reduce both the severity of ADHD and the impairment it causes. According to data in the literature and to the overall complexity of the interaction between ADHD and sleep, five sleep phenotypes may be identified in ADHD: (i) a sleep phenotype characterized mainly by a hypo-arousal state, resembling narcolepsy, which may be considered a "primary" form of ADHD (i.e. without the interference of other sleep disorders); (ii) a phenotype associated with delayed sleep onset latency and with a higher risk of bipolar disorder; (iii) a phenotype associated with sleep disordered breathing (SDB); (iv) another phenotype related to restless legs syndrome (RLS) and/or periodic limb movements; (v) lastly, a phenotype related to epilepsy/or EEG interictal discharges. Each sleep phenotype is characterized by peculiar sleep alterations expressed by either an increased or decreased level of arousal during sleep that have important treatment implications. Treatment with stimulants is recommended above all in the primary form of ADHD, whereas treatment of the main sleep disorders or of co-morbidities (i.e. bipolar disorders and epilepsy) is preferred in the other sleep phenotypes. All the sleep phenotypes, except the primary form of ADHD and those related to focal benign epilepsy or focal EEG discharges, are associated with an increased level of arousal during sleep. Recent studies have demonstrated that both an increase and a decrease in arousal are ascribable to executive dysfunctions controlled by prefrontal cortical regions (the main cortical areas implicated in the pathogenesis of ADHD), and that the arousal system, which may be hyperactivated or hypoactivated depending on the form of ADHD/sleep phenotype.

Diurnal melatonin patterns in children: ready to apply in clinical practice?

Experimental and clinical studies suggest that endogenous melatonin plays an important role in pediatric sleep regulation. This finding led to the introduction of exogenous melatonin to treat sleep disturbances. Optimizing the treatment algorithm involves a review of melatonin measurements and interpretations in clinical practice. Diurnal patterns of salivary melatonin and urinary metabolite 6-sulfatoxymelatonin were investigated in 29 children and adolescents (age, 5.5-17.3 years) by measuring concentrations every 3 hours. Relationships between melatonin parameters (peak concentrations and area under the time curve) and anthropometric measures (height, weight, and body mass index), age, and sleep scores (Sleep Disturbance Scale for Children) were investigated. High interindividual variability was evident in melatonin diurnal profiles. Melatonin production (adjusted to body weight) decreased with age and sexual maturation (P < 0.00). Both salivary melatonin and its urinary metabolite measurements can be used to evaluate the melatonin system in children. However, the high interindividual variability of diurnal melatonin concentrations challenges clinical applications in regard to diagnostic purposes and the criteria for initiating exogenous melatonin therapy. Further investigations and the development of criteria for clinical evaluations of the pediatric melatonin system are needed.

Sleep disturbances in children with attention-deficit/hyperactivity disorder

In this article, we advocate the need for better understanding and treatment of children exhibiting inattentive, hyperactive, impulsive behaviors, by in-depth questioning on sleepiness, sleep-disordered breathing or problematic behaviors at bedtime, during the night and upon awakening, as well as night-to-night sleep duration variability. The relationships between sleep and attention-deficit/hyperactivity disorder (ADHD) are complex and are routinely overlooked by practitioners. Motricity and somnolence, the most consistent complaints and objectively measured sleep problems in children with ADHD, may develop as a consequence of multidirectional and multifactorial pathways. Therefore, subjectively perceived or reported restless sleep should be evaluated with specific attention to restless legs syndrome or periodic limb movement disorder, and awakenings should be queried with regard to parasomnias, dyssomnias and sleep-disordered breathing. Sleep hygiene logs detailing sleep onset and offset quantitatively, as well as qualitatively, are required. More studies in children with ADHD are needed to reveal the 24-h phenotype, or its sleep comorbidities.

When brain clocks lose track of time: cause or consequence of neuropsychiatric disorders

Patients suffering from neuropsychiatric disorders often exhibit a loss of regulation of their biological rhythms which leads to altered sleep/wake cycle, body temperature rhythm and hormonal rhythms. Whereas these symptoms have long been considered to result from the pathology of the underlying disease, increasing evidence now indicates that the circadian system may be more directly involved in the etiology of psychiatric disorders. This emerging view originated with the discovery that the genes involved in the generation of biological rhythms are expressed in many brain structures where clocks function-and perhaps malfunction. It is also due to the interesting phenotypes of clock mutant mice. Here we summarize recent reports showing that alteration of circadian clocks within key brain regions associated with neuropsychiatric disorders may be an underlying cause of the development of mental illness. We discuss how these alterations take place at both systems and molecular levels.

Clinical uses of melatonin in pediatrics

This study analyzes the results of clinical trials of treatments with melatonin conducted in children, mostly focused on sleep disorders of different origin. Melatonin is beneficial not only in the treatment of dyssomnias, especially delayed sleep phase syndrome, but also on sleep disorders present in children with attention-deficit hyperactivity, autism spectrum disorders, and, in general, in all sleep disturbances associated with mental, neurologic, or other medical disorders. Sedative properties of melatonin have been used in diagnostic situations requiring sedation or as a premedicant in children undergoing anesthetic procedures. Epilepsy and febrile seizures are also susceptible to treatment with melatonin, alone or associated with conventional antiepileptic drugs. Melatonin has been also used to prevent the progression in some cases of adolescent idiopathic scoliosis. In newborns, and particularly those delivered preterm, melatonin has been used to reduce oxidative stress associated with sepsis, asphyxia, respiratory distress, or surgical stress. Finally, the administration of melatonin, melatonin analogues, or melatonin precursors to the infants through the breast-feeding, or by milk formula adapted for day and night, improves their nocturnal sleep. Side effects of melatonin treatments in children have not been reported. Although the above-described results are promising, specific studies to resolve the problem of dosage, formulations, and length of treatment are necessary.