Sleep quality in children with attention deficit hyperactivity disorder: An actigraphic study

Abstract  The aim of the present study was to compare the sleep of 12 children with attention deficit hyperactivity disorder (ADHD) with that of 12 normal controls. The children were examined in their natural environment, using continuous actigraphic monitoring over several consecutive nights, as well as undergoing subjective parental reports. It was hypothesized that children diagnosed with ADHD would suffer from reduced sleep quality than children without ADHD. This hypothesis was supported by the actigraphic measures, but not supported by the subjective parental reports. It was also found that the sleep quality of the two groups differed over the course of the night, which suggests a difference in sleep architecture. Various possible explanations for these findings, their implications regarding the relationship between sleep and ADHD, and the resulting treatment ramifications are discussed, and suggestions for further research are provided.     

Sleep in children with attention-deficit hyperactivity disorder: a meta-analysis of polysomnographic studies

The links between sleep and attention-deficit hyperactivity disorder (ADHD) have been a topic for intense ongoing research and clinical interest. Previous narrative literature reviews conveyed a consensus that parents of children with ADHD are more likely to report sleep problems in their children in comparison to parents of control children. However, when objective measures are considered the results appear to be more complex and inconsistent. This review is based on a meta-analysis of relevant polysomnographic studies. We assessed measures related to sleep architecture, breathing disorders, and periodic limb movements in sleep (PLMS), and the role of potential moderators such as age, gender, and other methodological factors. The meta-analysis revealed only one significant combined effect that indicates that children with ADHD are more likely than controls to suffer from PLMS. Factors such as age, gender, inclusion of adaptation night, and comorbidity appear to play a moderating role in the associations between sleep characteristics and ADHD. To provide new insight regarding the links between sleep and ADHD research in this field should adopt new strict guidelines and consider the role of multiple pertinent moderating factors.     

Parental rating of sleep in children with attention deficit/hyperactivity disorder

Objective  Sleep problems have often been associated with attention deficit/hyperactivity disorder (ADHD). Parents of those with ADHD and children with ADHD report sleep difficulties more frequently than healthy children and their parents. The primary objective of this paper is to describe sleep patterns and problems of 5 to 11-year-old children suffering from ADHD as described by parental reports and sleep questionnaires. Method  The study included 321 children aged 5–11 years (average age 8.4 years); 45 were diagnosed with ADHD, 64 had other psychiatric diagnoses, and 212 were healthy. One hundred and ninety-six of the test subjects were boys and 125 were girls. A semi-structured interview (Kiddie-SADS-PL) was used to DSM-IV diagnose ADHD and comorbidity in the clinical group. Sleep difficulties were rated using a structured sleep questionnaire (Children Sleep Behaviour Scale). Results  Children diagnosed with ADHD had a significantly increased occurrence of sleep problems. Difficulties relating to bedtime and unsettled sleep were significantly more frequent in the ADHD group than in the other groups. Children with ADHD showed prolonged sleep onset latency, but no difference was shown regarding numbers of awakenings per night and total sleep time per night. Comorbid oppositional defiant disorder appeared not to have an added effect on problematic behaviour around bedtime. Conclusion  Parents of children with ADHD report that their children do not sleep properly more often than other parents. The ADHD group report problems with bedtime resistance, problems with sleep onset latency, unsettled sleep and nightmares more often than the control groups. It may therefore be relevant for clinicians to initiate a closer examination of those cases reporting sleep difficulties.     

Attention-deficit/hyperactivity disorder (ADHD) and adaptation night as determinants of sleep patterns in children

Sleep problems are a prominent feature in children with attention-deficit/hyperactivity disorder (ADHD) but their relationships to sleep structure are not consistent across studies. We aimed at further examining the sleep architecture in children with ADHD, while considering the role of the first-night effect (FNE) as a possible confounder. Twenty unmedicated children with ADHD combined type (8?C15?years old; mean 11.24, SD 2.31) and 19 healthy controls, matched for age and gender, underwent polysomnography during an adaptation and a consecutive second night. ADHD and controls displayed a typical FNE without group differences. Independently of testing night, children with ADHD spent more time in sleep and had shortened rapid eye movement (REM) sleep latency and a greater amount of REM sleep relative to controls. However, the increased REM sleep amount in ADHD children was more expressed in the second night when it was also significantly related to scores of inattention and hyperactivity. Our results (1) document similar sleep adaptation processes in children with ADHD and typically developing children, (2) reveal that REM sleep changes in association with ADHD-specific psychopathology may characterize sleep in ADHD children, which is evident only when the FNE is accounted for, (3) indicate that ADHD psychopathology and adaptation night may exert opposite effects on REM sleep in children. These results may prompt the awareness of clinicians about the importance of actual sleep alterations and their precise evaluation in children with ADHD, which could significantly contribute to better diagnostic, treatment and early prevention strategies.     

Shorter rapid eye movement sleep duration in children with attention-deficit /hyperactivity disorder: the impact on quality of life

ObjectivesThe relationship of sleep with attention deficit hyperactivity disorder (ADHD) remains complex and unclear. The current study aimed to compare the subjective and objective sleep parameters among children with and without ADHD. Moreover, to address the effect of sleep parameters on the quality of life (QoL).MethodsWe assessed 42 participants who were children with ADHD (aged 6–12 years), with predominant combined presentation (23), compared to 42 healthy children, who underwent a sleep study assessment subjectively (the Children's Sleep Habits Questionnaire), and objectively (one-night Polysomnographic recording). Also, parents completed the pediatric quality of life inventory (PedsQL-P).ResultsChildren with ADHD had more subjective sleep problems. ADHD patients also had a significant decrease in total sleep time and sleep efficiency, spending more time in wake and N1 sleep stages. Moreover, they had significantly lower rapid eye movement (REM)sleep duration and less duration of deep sleep stages. Multivariate regression analysis showed that REM sleep duration was the most contributing and predictive factor to QoL and school function impairment.ConclusionChildren with ADHD have a significantly lower sleep quantity and poor sleep quality. In addition, short REM sleep duration independently contributes to further deterioration in different areas of QoL.     

Evaluation of sleep organization in patients with attention deficit hyperactivity disorder (ADHD) and ADHD as a comorbidity of epilepsy

Objective/backgroundEpilepsy or attention deficit hyperactivity disorder (ADHD) can influence sleep organization in different ways. The aim of this study was to evaluate sleep organization in children and adolescents with ADHD and epilepsy, and to analyze the influence of methylphenidate.MethodsThis was an observational, cross-sectional study of children and adolescents with epilepsy, who were seizure free for at least three months, and were also diagnosed with ADHD. They were selected from the epilepsy and child neurology outpatient clinic of a university hospital in Brazil. After sample size calculation, patients were consecutively included into four different groups, with 21 patients each: epilepsy + ADHD using methylphenidate, epilepsy + ADHD not using methylphenidate, only ADHD, and a healthy control group. All participants were evaluated with the Sleep Disturbance Scale for Children (SDSC) and monitored with actigraphy for five nights/days.ResultsActigraphic analysis showed a higher number of night awakenings in the epilepsy + ADHD groups; they were most prominent in the group without methylphenidate (p = 0.001). Parental reports demonstrated a higher risk for sleep disturbances in the epilepsy + ADHD without methylphenidate and the ADHD groups (p < 0.001).ConclusionPrimary ADHD as a comorbidity of epilepsy impairs sleep organization in children, and the use of short-acting methylphenidate seems to improve it. Both objective (actigraphic) and subjective (SDSC) measures showed significant sleep alterations between primary ADHD and ADHD as a comorbidity of epilepsy; this was most prominent in the group without methylphenidate.     

Instability of sleep patterns in children with attention-deficit/hyperactivity disorder

OBJECTIVE: To compare the stability of the sleep-wake system of children with attention-deficit/hyperactivity disorder (ADHD) and controls by objective and subjective measures. METHOD: Thirty-eight school-age boys with diagnosed ADHD and 64 control school-age boys were examined using actigraphic monitoring and sleep diaries, over 5 consecutive nights. RESULTS: Increased instability in sleep onset, sleep duration, and true sleep were found in the ADHD group compared with the control group. Discriminant analysis revealed that children's classification (ADHD versus control) could be significantly predicted on the basis of their sleep measures. CONCLUSIONS: The findings support the hypothesis that instability of the sleep-wake system is a characteristic of children with ADHD. Given the potential negative effects of disturbed or unstable sleep on daytime functioning, it is recommended that a thorough sleep assessment be conducted when a sleep disturbance is suspected or when symptoms associated with daytime sleepiness or decreased arousal level are present.     

Sleep and COMT polymorphism in ADHD children: preliminary actigraphic data

OBJECTIVE: To examine whether COMT (catechol-O-methyltransferase) polymorphism modulates aspects of sleep in children diagnosed with attention-deficit/hyperactivity disorder (ADHD). METHOD: Nightly sleep actigraphic recordings during a double-blind, placebo-controlled, crossover clinical study (1 week of 0.5 mg/kg MPH; 1 week of placebo) were obtained for 34 children, 7.4 to 12 years old, diagnosed with ADHD (DSM-IV). Diagnosis was generated by the Diagnostic Interview Schedule for Children and was confirmed by multidisciplinary consensus. RESULTS: Children who were Val allele carriers had poorer sleep continuity compared with children with the Met-Met genotype while receiving a placebo and while receiving methylphenidate. CONCLUSIONS: The findings of the present study support the hypothesis that sleep disturbances in children with ADHD are related to the underlying pathophysiology of the disorder.     

Objective Sleep Measurement in Typically and Atypically Developing Preschool Children with ADHD-Like Profiles

Objective This study investigated the association between preschool children’s sleep patterns measured by actigraphy and parent-reported hyperactivity symptoms. Many previous studies have reported sleep problems in children with attention deficit hyperactivity disorder (ADHD)-like symptoms. Methods This study examined a cross-sectional sample of 186 preschoolers age 2–5 years in three groups: children with autism, children with developmental delay without autism, and typically developing children recruited from the general population. One week of actigraphic sleep data plus a parent report of the presence or absence of a current sleep problem were collected. Parents completed the child behavior checklist; a subset of children in preschool had teachers who completed the caregiver-teacher report form. Sleep behavior was compared for those children with and without clinical levels of attention-deficit/hyperactivity symptoms (T scores ≥65). Results The prevalence of a parent-defined sleep problem across the entire sample was 36.1%. Thirty-four percent of the sample had a parent-reported ADHD composite in the clinical range. Those children with a clinical ADHD profile were more likely to be described by parents as having a sleep problem. However, no significant differences in actigraphic sleep patterns or night-to-night sleep-wake variability were found for children with an ADHD profile in the clinical range. Conclusions In this non-clinical sample of preschool age children, parental reports of clinical ADHD profiles were significantly associated with parental reports of sleep problems but not with actigraphically recorded sleep-wake data.     

Comparing subjective measures of behavioral sleep problems in children with ADHD: a cross-sectional study

AimBehavioral sleep problems are ideally measured using a combination of objective and subjective measures. However, this is not always feasible. Thus, a global subjective measure has been used to assess sleep problems in children with attention deficit hyperactivity disorder (ADHD), yet it is unclear how this relates to more detailed multidimensional measures of sleep problems. In children with ADHD, parent report of a global measure of sleep problem severity (classified no/mild versus moderate/severe) is compared with the following: (1) a 7-Day Sleep Log and (2) the validated Children's Sleep Habits Questionnaire (CSHQ).MethodThis study recruited 392 children with ADHD (aged 5–13 years) from 50 pediatric practices across Victoria, Australia. All caregivers completed the CSHQ, and 257 children prospectively completed the 7-Day Sleep Logs.ResultsSleep log data identified distinct sleep patterns according to parent-reported sleep problem severity; children with moderate/severe sleep problems slept 30 min less per day, took longer to fall asleep, and experienced more night awakenings. This pattern was also repeated across the CSHQ, where children with moderate/severe sleep problems experienced more problematic sleep symptoms across all domains (effect sizes: 0.5–1.1; all p < 0.001).ConclusionA subjective, global measure of sleep problem severity appears to be a useful tool for the initial assessment of sleep problems in children with ADHD when more extensive measures are not feasible, as it is reflective of well-established multidimensional measures. However, further research is required to determine its validity.     

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

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

ADHD subtypes are associated differently with circadian rhythms of motor activity,sleep disturbances,and body mass index in children and adolescents: a case–control study

To date, few studies have examined the circadian pattern of motor activity in children and adolescents newly diagnosed with attention-deficit/hyperactivity disorder (ADHD). The objective was to study the circadian pattern of motor activity in subjects with ADHD (medication naïve) and to investigate the relationships between alterations in circadian patterns, the ADHD subtype (combined or inattentive), sleep disturbances and body mass index (BMI). One-hundred twenty children and adolescents (60 medication naïve ADHD and 60 controls) were included in a gender- and age-matched case–control study. ADHD was diagnosed according to the DSM-IV-TR, the Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version, and the Conner’s Parents Rating Scale-Revised. Circadian rhythms of motor activity and sleep parameters were measured using actigraphy and the Sleep Disturbance Scale for Children. BMI and dietary intake were also evaluated. ADHD patients showed a trend towards eveningness and greater sleep disturbances than controls. Additionally, patients with ADHD-combined had significantly higher mean values of motor activity and showed a significant delay in bedtime. Furthermore, among ADHD-C patients hyperactivity symptoms were significantly associated with the least 5 h of activity. Regarding patients with ADHD-inattentive, increased fragmentation of the circadian pattern was associated with inattention symptoms, and they also showed a significant increase in BMI of 2.52 kg/m² [95% CI 0.31, 4.73] in comparison with controls. Our findings highlight the potential use of actigraphy as a clinical tool to aid in the diagnosis of ADHD. It should be noted that evaluating motor activity variables could also allow the differentiation between ADHD subtypes.

     

Post-traumatic stress disorder and sleep-what a nightmare!

According to DSM IV criteria, sleep disturbances are incorporated in the definition of post-traumatic stress disorder (PTSD). These include the re-experiencing symptoms (nightmares, criteria B) and a hyperarousal state (difficulty initiating and maintaining sleep, criteria D). PTSD patients commonly complain of sleep disturbances. Moreover, insomnia, restless sleep and trauma-related dreams might be the primary complaint of some patients. However, although subjective sleep disturbances are considered characteristic of PTSD, sleep laboratory studies have provided inconsistent evidence of objective sleep disorders. A variety of sleep architectures and sleep patterns has been reported in PTSD. However, only a few studies have controlled for comorbidities. Thus, uncertainty exists to what extent the sustained complaints of sleep disturbances in chronic PTSD are specifically related to the impact of exposure to traumatic stress, or rather are a consequence of comorbid disorders. Specific changes in REM sleep suggest a pathophysiologic role of REM sleep abnormality in PTSD (e.g. anxiety dreams, increased REM density, exaggerated startle response, decreased dream recall and elevated awakening thresholds from REM sleep). However, again, studies have failed to show consistent changes in percentage of REM sleep or in REM latency. There might be a coexistence of pressure to REM along with inhibitory forces of REM that result in high variability of REM parameters across patients. Alternatively, changes in REM sleep might reflect the effect of comorbid psychiatric disorders that results in inconsistent findings between patients. The current review tries to address these issues based on recent studies carried out in this field.     

Sleep disturbances and serum ferritin levels in children with attention-deficit/hyperactivity disorder

Background  A subset of children with attention-deficit/hyperactivity disorder (ADHD) may present with impairing sleep disturbances. While preliminary evidence suggests that iron deficiency might be involved into the pathophysiology of daytime ADHD symptoms, no research has been conducted to explore the relationship between iron deficiency and sleep disturbances in patients with ADHD. The aim of this study was to assess the association between serum ferritin levels and parent reports of sleep disturbances in a sample of children with ADHD. Methods  Subjects: Sixty-eight consecutively referred children (6–14 years) with ADHD diagnosed according to DSM-IV criteria using the semi-structured interview Kiddie-SADS-PL. Measures: parents filled out the Sleep Disturbance Scale for Children (SDSC) and the Conners Parent Rating Scale (CPRS). Serum ferritin levels were determined using the Tinaquant method. Results  Compared to children with serum ferritin levels ≥45 μg/l, those with serum ferritin levels <45 μg/l had significantly higher scores on the SDSC subscale “Sleep wake transition disorders” (SWTD) (P = 0.042), which includes items on abnormal movements in sleep, as well as significantly higher scores on the CPRS–ADHD index (P = 0.034). The mean scores on the other SDSC subscales did not significantly differ between children with serum ferritin ≥45 and <45 μg/l. Serum ferritin levels were inversely correlated to SWTD scores (P = 0.043). Conclusion  Serum ferritin levels <45 μg/l might indicate a risk for sleep wake transition disorders, including abnormal sleep movements, in children with ADHD. Our results based on questionnaires set the basis for further actigraphic and polysomnographic studies on nighttime activity and iron deficiency in ADHD. Research in this field may suggest future trials of iron supplementation (possibly in association with ADHD medications) for abnormal sleep motor activity in children with ADHD.     

Further studies on periodic limb movement disorder and restless legs syndrome in children with attention-deficit hyperactivity disorder.

Fourteen consecutive children who were newly diagnosed with attention-deficit hyperactivity disorder (ADHD) and who had never been exposed to stimulants and 10 control children without ADHD underwent polysomnographic studies to quantify Periodic Limb Movements in Sleep (PLMS) and arousals. Parents commonly gave both false-negative and false-positive reports of PLMS in their children, and a sleep study was necessary to confirm their presence or absence. The prevalence of PLMS on polysomnography was higher in the children with ADHD than in the control subjects. Nine of 14 (64%) children with ADHD had PLMS at a rate of >5 per hour of sleep compared with none of the control children (p <0.0015). Three of 14 children with ADHD (21%) had PLMS at a rate of >20 per hour of sleep. Many of the PLMS in the children with ADHD were associated with arousals. Historical sleep times were less for children with ADHD. The children with ADHD who had PLMS chronically got 43 minutes less sleep at home than the control subjects (p = 0.0091). All nine children with ADHD who had a PLMS index of >5 per hour of sleep had a long-standing clinical history of sleep onset problems (>30 minutes) and/or maintenance problems (more than two full awakenings nightly) thus meeting the criteria for Periodic Limb Movement Disorder (PLMD). None of the control children had a clinical history of sleep onset or maintenance problems. The parents of the children with ADHD were more likely to have restless legs syndrome (RLS) than the parents of the control children. Twenty-five of 28 biologic parents of the children with ADHD and all of the biologic parents of the control children were reached for interview. Eight of twenty-five parents of the children with ADHD (32%) had symptoms of RLS as opposed to none of the control parents (p = 0.011). PLMS may directly lead to symptoms of ADHD through the mechanism of sleep disruption. Alternative explanations for the association between ADHD and RLS/PLMS are that they are genetically linked, they share a common dopaminergic deficit, or both.     

Mise au point des études cliniques sur le rapport « veille-sommeil » dans le trouble déficit de l’attention/hyperactivité de l’enfant

Since 1970, a certain number of studies have reported sleep disturbances in children with ADHD. Data from questionnaires and parental reports showed behavioural difficulties occurring at wake-sleep transition such as bed-time refusal, delayed sleep-onset, early awakenings, suggesting the occurrence of specific abnormalities in the mechanisms of alertness maintainance.Few polysomnographic studies have been conducted in ADHD children considering the prevalence and the importance of the disorder in the field of child psychopathology. The majority of these studies produced heterogenous and conflicting data and no clear abnormalities of non-rapid eye movement or REM sleep were found.Polysomnographic data, however supports the evidence of sleep-wake-transition abnormalities in ADHD children. Modifications in sleep-onset-latencies, number of stage shifts, have previously been reported using all-night polysomnography.One study performed Multiple latency tests in ADHD children and concluded that ADHD had daytime sleep abnormalities when compared with controls.One other important issue concerns motor activity during sleep in hyperactive children which was found to be increased in studies using actigraphy or video analysis. These findings could lead to important clinical and therapeutic applications as stimulants could help to normalise sleep or motor behaviour during sleep in some ADHD children.     

Sleep disturbances associated with attention deficit hyperactivity disorder: the impact of psychiatric comorbidity and pharmacotherapy

OBJECTIVE: To estimate the relative risk of sleep problems associated with attention deficit hyperactivity disorder (ADHD), its pharmacotherapy, and its comorbid psychopathology. METHOD: Standard sleep questionnaires were used to assess sleep problems and characteristics in ADHD (n = 122) and non-ADHD (n = 105) comparison youths. RESULTS: ADHD was associated with 10 of 19 sleep problems assessed. However, after controlling for psychiatric comorbidity and pharmacotherapy with stimulants, the majority of these differences were no longer evident. Rather, treatment with stimulants and comorbidity with anxiety and behavior disorders were significantly associated with sleep disturbances. Positive family history of ADHD was associated with none of the sleep problems assessed here after adjusting for age, psychiatric comorbidity, and treatment with anti-ADHD medication. CONCLUSIONS: Although subjective sleep difficulties are common in ADHD youths, they are frequently accounted for by comorbidity and pharmacotherapy. Furthermore, the lack of an association between a positive family history of ADHD and sleep difficulties suggests that ADHD is not a misdiagnosis of the consequences of disruption of normal sleep.     

Sleep and ADHD

This paper, intended to provide useful insights for the clinical management of sleep disturbances in attention-deficit/hyperactivity disorder (ADHD), presents a critical, updated overview of the most relevant studies on the prevalence, etiopathophysiology and treatment strategies of sleep problems associated with ADHD, including restless legs syndrome, periodic limb movements in sleep, sleep-onset delay, increased nocturnal motor activity, sleep-disordered breathing, deficit in alertness, and sleep alterations accounted for by comorbid psychiatric disorders or ADHD medications. We also discuss some possible avenues for future research in the field.     

Effect of transdermal methylphenidate wear times on sleep in children with attention deficit hyperactivity disorder

Sleep disturbances are common among children and adolescents with attention deficit hyperactivity disorder. This study sought to evaluate the effects of individualizing wear times of the methylphenidate transdermal system on sleep parameters. In this open-label, randomized trial, 26 children with attention deficit hyperactivity disorder and sleep disturbances were randomized (after dose optimization) to one of four groups with different sequences of patch wear times (i.e., 9, 10, 11, and 12 hours per day wear times each for week in different sequences). The primary endpoint comprised sleep latency. Secondary endpoints included total sleep time, sleep quality, and attention deficit hyperactivity disorder and related signs (assessed with Attention Deficit Hyperactivity Disorder Rating Scale-IV and Connor's Global Impression-Parent). A mixed-effects regression model evaluated the effects of patch wear time on sleep and symptom measures. Patch wear time exerted no significant effect on sleep latency or total sleep time, although a trend toward improved sleep quality was evident (P = 0.059) with longer patch wear times. Sleep parameters were not adversely affected by longer methylphenidate transdermal system patch wear times. Thus, if replicated in larger samples, the individualization of patch wear times should be considered according to the needs and responses of patients.