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.     

Iron deficiency in children with attention-deficit/hyperactivity disorder

BACKGROUND: Iron deficiency causes abnormal dopaminergic neurotransmission and may contribute to the physiopathology of attention-deficit/hyperactivity disorder (ADHD). OBJECTIVE: To evaluate iron deficiency in children with ADHD vs iron deficiency in an age- and sex-matched control group. DESIGN: Controlled group comparison study. SETTING: Child and Adolescent Psychopathology Department in European Pediatric Hospital, Paris, France. PATIENTS: Fifty-three children with ADHD aged 4 to 14 years (mean +/- SD, 9.2 +/- 2.2 years) and 27 controls (mean +/- SD, 9.5 +/- 2.8 years). MAIN OUTCOME MEASURES: Serum ferritin levels evaluating iron stores and Conners' Parent Rating Scale scores measuring severity of ADHD symptoms have been obtained. RESULTS: The mean serum ferritin levels were lower in the children with ADHD (mean +/- SD, 23 +/- 13 ng/mL) than in the controls (mean +/- SD, 44 +/- 22 ng/mL; P < .001). Serum ferritin levels were abnormal (<30 ng/mL) in 84% of children with ADHD and 18% of controls (P < .001). In addition, low serum ferritin levels were correlated with more severe general ADHD symptoms measured with Conners' Parent Rating Scale (Pearson correlation coefficient, r = -0.34; P < .02) and greater cognitive deficits (r = -0.38; P < .01). CONCLUSIONS: These results suggest that low iron stores contribute to ADHD and that ADHD children may benefit from iron supplementation.     

Health complaints in children with attention-deficit/hyperactivity disorder

AIM: To assess recurrent subjective health complaints in Swedish schoolchildren with attention-deficit/hyperactivity disorder (ADHD). METHODS: Cohort study of 577 fourth-graders (10-y-olds) in one municipality in Stockholm County. All children were screened for attention and behaviour problems through interviews with their parents and teachers. Children with high scores underwent further clinical and cognitive assessments. Information about health complaints was collected from the children themselves in a classroom questionnaire. The 516 children for whom there was information from all three data sources were included in the final study population. Hypotheses were tested in multivariate analyses with adjustment for sex and parental education. RESULTS: Recurrent abdominal pain (RAP), sleeping problems and tiredness were associated with ADHD (stratified relative risks: 2.2 [1.4-3.4], 1.7 [1.1-2.7] and 2.7 [1.7-4.1], respectively), while there was no association with headache. CONCLUSION: This study indicates that treatment strategies for children with ADHD need to include an effective evaluation and treatment of RAP, tiredness and sleeping disturbances. Evaluation of ADHD should be considered in children with recurrent health complaints.     

The link between health-related quality of life and clinical symptoms among children with attention-deficit hyperactivity disorder

Clinical research on attention-deficit hyperactivity disorder (ADHD) has begun to integrate measures of health-related quality of life (HRQL) as part of the overall assessment of treatment outcomes. This study examines the association between HRQL and measures of clinical symptoms of ADHD. Data were gathered from 297 children and adolescents in an 8-week, randomized, double-blind, placebo-controlled, clinical trial of atomoxetine treatment for ADHD. HRQL was assessed with the Child Health Questionnaire 50-item Parent Form. ADHD symptoms were assessed with the ADHD Rating Scale-IV; Parent Version and Clinical Global Impressions-ADHD-Severity. Associations between HRQL and clinical symptoms were assessed with correlations, analyses of variance with post hoc comparisons, and t tests. The Child Health Questionnaire 50-item Parent Form scales assessing psychosocial domains of HRQL were significantly negatively correlated with clinical measures. Improvement in clinical symptoms was associated with corresponding improvement in psychosocial aspects of HRQL. The findings suggest that HRQL instruments can add important information to efficacy measures in clinical trials of ADHD treatment.     

Management of stimulant medications in children with attention-deficit/hyperactivity disorder

In the United States, considerable media attention has been given to the growing number of youth diagnosed with ADHD and treated with psychotropic medications. The efficacy of stimulant medications long has been recognized clinically and is well documented in research. Studies suggest that treatment with stimulant therapy, when properly done, is more effective than psychosocial interventions that did not yield any significant benefits on a range of behavioral, emotional, psychosocial, and academic measures. The purpose of this article is to provide clinicians with everything they need to know but were afraid to ask about stimulant therapy for children and adolescents with ADHD.     

Predictors of long-term outcome in children with attention-deficit/hyperactivity disorder

In determining the influence of various factors on outcome, one must keep in mind that these parameters do not act alone but probably exert their influence in a cumulative and interactive manner. Thus, characteristics of the child such as severity of symptoms, comorbidity, and IQ interact with family parameters such as parental pathology, socioeconomic status, family adversity, and treatment to influence long-term outcome. Some of these variables (e.g., comorbid CD, low IQ, parental pathology) have been important in influencing negative outcome. Treatment, particularly stimulant treatment, has been shown to be effective in many short-term studies, but the long-term impact of treatment remains uncertain. The continuation of treatment may be crucial in influencing positive long-term outcome. Particular treatment modalities or combinations (e.g., multimodal treatment) may be required for specific patient subgroups (e.g., subjects comorbid for LD, CD, or anxiety; subjects with low socioeconomic status or high parental pathology). Research in the area continues to evolve. New findings hopefully will continue to improve both the quality of life for patients and families and positive influence of long-term outcome.     

Treatment experiences of children and adolescents with attention-deficit/hyperactivity disorder

Aim: To gain insight into the treatment experiences of children and adolescents diagnosed with attention‐deficit/hyperactivity disorder (ADHD). Methods: Convenience sampling was used to recruit eligible parents and carers at paediatric clinics of the Children's, Youth and Women's Health Service to participate in an interview to discuss experiences, using a semi‐structured questionnaire. Results: Thirty‐five interviews were conducted. Twenty‐five subjects had trialled an average of 1.5 interventions prior to receiving an ADHD diagnosis, namely, dietary modifications (46%), behavioural therapy (24%), learning assistance (8%) and natural remedies (8%). Following an ADHD diagnosis, 25 subjects tried an average of 2.8 interventions, most commonly behavioural therapies (48%), expressive therapies (48%) and fish oil (36%). All subjects started psychostimulant medication after receiving an ADHD diagnosis. Despite 52% of parents expressing initial reluctance towards psychostimulants, 97% reported positive experiences with use in terms of schooling, social interaction and family life. Of those being treated with psychostimulants, 22 (73%) were concurrently using other treatments at the time of interview. Conclusions: Few patients use psychostimulant medication in isolation, with the majority of parents using multiple approaches to manage their child's behaviour. Parents tried a variety of therapies before commencing psychostimulant medication, often because of fears regarding psychostimulant safety. Parents were generally happy with the results gained; however adolescents interviewed were less convinced of the benefits of psychostimulants.     

Parental and self-report of sleep in children with attention-deficit/hyperactivity disorder

OBJECTIVE: To determine the prevalence of parent-reported and self-reported sleep disturbances in a sample of school-aged children with attention-deficit/ hyperactivity disorder (ADHD). DESIGN: Cross-sectional survey questionnaire. SETTING: A multidisciplinary ADHD evaluation clinic in a children's teaching hospital (ADHD sample) and 3 elementary schools in southern New England (control sample). PARTICIPANTS: Forty-six unmedicated, school-aged children (mean age, 89.4 +/- 18.7 months; 74% male) diagnosed as having ADHD by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria who had been screened for marked symptoms of sleep-disordered breathing, and 46 normal control children (mean age, 86.5 +/- 16.9 months; 70% male). INTERVENTION: None. MAIN OUTCOME MEASURE: Sleep habits and sleep disturbances reported by parents and children. RESULTS: Children with ADHD had significantly higher (more sleep-disturbed) scores on all sleep subscales of the Children's Sleep Habits Questionnaire (parent measure) than did controls; average sleep duration as reported by parents was also significantly shorter in the ADHD group. Children with ADHD also reported their own sleep to be more disturbed than controls did on the Sleep Self-report, particularly on items relating to bedtime struggles (P range, .05-.001). There was a much higher correlation between parent and child sleep report items for the children with ADHD (mean correlation, 0.55) than for the control children. CONCLUSIONS: Sleep disturbances, particularly at bedtime, are frequently reported by both parents and children with ADHD. Children undergoing evaluation for ADHD should be routinely screened for sleep disturbances, especially symptoms of sleep-disordered breathing. The causes of sleep-onset delay in children with ADHD should be considered in designing intervention strategies for children with difficulty falling and staying asleep.     

儿童注意缺陷多动障碍诊疗建议

本建议主要参考美国精神障碍诊断和统计手册第4版（DSM-IV）的诊断标准,旨在规范我国临床诊疗工作,并为今后更深入的研究儿童注意缺陷多动障碍（attention deficit hyperactivity disorder,ADHD）提供参考。     

Long-term school outcomes for children with attention-deficit/hyperactivity disorder: a population-based perspective

OBJECTIVE: The purpose of this study was to compare long-term school outcomes (academic achievement in reading, absenteeism, grade retention, and school dropout) for children with attention-deficit/hyperactivity disorder (AD/HD) versus those without AD/HD. METHODS: Subjects included 370 children with research-identified AD/HD from a 1976-1982 population-based birth cohort (N = 5718) and 740 non-AD/HD control subjects from the same birth cohort, matched by gender and age. All subjects were retrospectively followed from birth until a median age of 18.4 years (AD/HD cases) or 18.3 years (non-AD/HD controls). The complete school record for each subject was reviewed to obtain information on reading achievement (last available California Achievement Test reading score), absenteeism (number/percentage of school days absent at each grade level), grade retention (having to repeat an entire grade in the subsequent school year), and school dropout (failure to graduate from high school). RESULTS: Median reading achievement scores at age 12.8 years (expressed as a national percentile) were significantly different for AD/HD cases and non-AD/HD controls (45 vs 73). Results were similar for both boys and girls with AD/HD. Median percentage of days absent was statistically significantly higher for children with AD/HD versus those without AD/HD, although the difference was relatively small in absolute number of days absent. Subjects with AD/HD were three times more likely to be retained a grade. Similarly, subjects with AD/HD were 2.7 times more likely to drop out before high school graduation (22.9%) than non-AD/HD controls (10.0%). CONCLUSIONS: The results of this population-based study clearly demonstrate the association between AD/HD and poor long-term school outcomes.     

注意缺陷多动障碍儿童的社会适应行为特征

目的探讨了解注意缺陷多动障碍(ADHD)儿童社会适应行为特征、个性特征及其相关关系。方法采用国内修订版儿童适应行为评定量表(ADQ)、Achenbach儿童行为量表(CBCL)和艾森克个性问卷儿童版(EPQ),对2003-04—2004-01在广州市儿童医院精神康复科就诊的67例7~12岁ADHD儿童(ADHD组)和相同年龄的85例正常儿童(对照组)进行了测评比较分析。结果ADHD组在ADQ量表中感觉运动分低于对照组(P<0.05),语言发展、个人取向、社会责任、社会自制因子、适应能力商数分低于对照组(P<0.01)。在CBCL中,ADHD组的活动能力、交际能力、学校情况分值均低于对照组(P<0.01),ADHD组有明显的社交退缩倾向(P<0.05),他们更容易发生抑郁、体诉、多动、攻击等行为表现(P<0.01),其中体诉、违纪两个因子是ADHD的危险因子,对ADHD的发生具有预测性。在EPQ中,ADHD组的P分、N分值明显高于对照组(P<0.01),而L分则低于对照组(P<0.01),E维度对ADHD儿童有社会自制行为影响明显。结论ADHD儿童社会适应水平低下和不良人格倾向,并且伴随多种与适应不良有关的问题行为。     

Sleep patterns in children with attention-deficit/hyperactivity disorder, tic disorder, and comorbidity

BACKGROUND: In children, attention-deficit/hyperactivity disorder (ADHD), tic disorder (TD), and their coexistence (ADHD + TD comorbidity) are very common and clinically important. Associated sleep patterns and their clinical role are still insufficiently investigated. This study aimed at characterizing these sleep patterns in children with ADHD, TD, and ADHD + TD comorbidity and determining whether, in ADHD + TD, the factors ADHD and TD may affect the sleep pattern in an independent (additive) or in a complex (interactive) manner. METHOD: By means of polysomnography, sleep patterns were investigated in 4 groups of unmedicated 8.0-16.4-year-old children (healthy controls, ADHD-only, TD-only, and ADHD + TD). Each group consisted of 18 subjects matched for age, gender, and intelligence. RESULTS: ADHD was primarily characterized by increase in rapid eye movement (REM) sleep, whereas TD patients displayed lower sleep efficiency and elevated arousal index in sleep. In children with ADHD + TD, both effects appeared. No interaction between the ADHD and TD factors was found for any of the sleep parameters. Significant correlations between sleep patterns and clinical symptoms were found. CONCLUSIONS: ADHD and TD are characterized by specific sleep alterations. When coexisting, the two disorders alter the sleep pattern in an additive manner, suggesting a high impact on clinical and therapeutic perspectives.