Sleep in Children with Attention Deficit Hyperactivity Disorder (ADHD)


Original Editor - Romy Hageman
Top Contributors - Romy Hageman

Background[edit | edit source]

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most prevalent neurodevelopmental disorders in childhood. The prevalence of ADHD among preschool children is around 8%[1], with the disorder being three to nine times more common in males than females[2].

Quality sleep plays a crucial role in body repair, memory integration, brain information processing, and emotional regulation. All these aspects collectively have substantial effects on children's physical development, cognitive growth, emotional regulation, attention, behaviour, metabolism, and immune function[3][4]. Poor sleep is associated with worse academic performance[5]. At a neurobiological level, the effect of sleep disorders is to heighten activity in the brain networks associated with emotions, potentially resulting in increased emotional lability[6].

Sleep problems are more common in children with ADHD (prevalence range from 30 to 74.6%, based on gender, age, ADHD subtype, co-morbidities, and use of medication[7]) than in children without ADHD[8][9][10][11][12][13][14][15][16][17]. Poor sleep quality and delayed bedtime can result in daytime fatigue, impacting mood, concentration, behaviour, and physical health[18]. Numerous studies have indicated a connection between sleep issues and heightened severity of ADHD symptoms or behavioural challenges in school-aged children with ADHD[8][17][19][20][21][22][23]. It is also associated with depressive symptoms[24], and poorer mental health of primary caregivers[25]. Sleep problems also have a significant impact on a child's quality of life[4][26][27][28]. Children experiencing moderate to severe sleep difficulties are more prone to miss school or be late for school, and their caregivers are more likely to be late for work when compared to children who didn't have sleep issues[25].

Sleep problems[edit | edit source]

Sleep problems and ADHD

The higher the ADHD symptoms, the more sleep problems a child has[17]. behavioural disruptions may affect sleep at night and functioning in the daytime in the following ways:

The influence of sleep issues in children with ADHD can be intensified by their impact on parents[52][53]. Parents usually require their children to sleep for ten hours to have some personal time, and at least eight hours to maintain the patience needed for raising a child with ADHD[54]. When a child sleeps considerably less than this, and the parent must be awake while the child is to ensure their safety, the impact on parental well-being is significant[54]. The link between child sleep problems and family functioning may be directional, where parent behaviour influences child sleep, in turn, impacts parent mental health, thereby influencing family functioning[55].

The following issues can be experienced by their parents:

  • Clinically depression or anxiety[25][53]
  • Decreased level of effective parenting[56]
  • Less sleep for the parents[51][56]
  • Mood disturbances in parents[56]
  • Parental daytime fatigue[56]
  • Poorer parent-related daily functioning[20]

Physiological factors[edit | edit source]

There are several factors that can play a role in the sleep problems in children with ADHD:

  • It is possible that factors such as rapid eye movement (REM) sleep abnormalities, which are frequently observed in children with ADHD[57], may play a significant role. This is because REM is linked to parasomnias like nightmare disorder, which often lead to awakenings[58], and it also affects neurobehavioural functioning in children with ADHD[59]. Behaviours indicative of parasomnias often include night terrors, confusional arousals, episodes of waking up screaming, increased motor activity such as sleepwalking, and enuresis (bedwetting)[37][60]. The use of medication and comorbidities (like anxiety) also increase the risk of parasomnias[37].
  • Melatonin, a neurohormone, and its byproducts play a crucial role in circadian physiology, particularly in the initiation and maintenance of sleep. It is suggested that changes in melotonin levels contribute to disorders related to insomnia. Irregularities in the circadian release of melatonin have been observed in children with ADHD[45]. Apart from the melatonergic system, heightened activity in the orexinergic system and decreased serotonin activity are believed to contribute to insomnia in children with ADHD[61].
  • Children with ADHD spend relatively more time in shallow sleep compared to typically developing children[43]. Due to the diminished sleep quality, children may experience heightened daytime sleepiness[26][62].
  • Children with ADHD can develop nutritional deficiencies due to poor eating habits. The reduction in appetite caused by stimulant medication used for treating ADHD symptoms can result in inadequate food intake, which may also be a contributing factor to Restless Legs Syndrome. This disorder is associated with insomnia, poor sleep efficiency and daytime sleepiness[37].
  • Sleep-related breathing disorders can have a significant impact on the symptoms of ADHD. Risk factors include low muscle tone, motor delays, and obesity, which are also common in ADHD[37]. Sleep disordered breathing often results in sleep fragmentation and excessive daytime sleepiness[45].
  • It has been observed that children with ADHD have a difficulty transitioning from a state of stimulus-seeking alertness to the passive state of sleep. This difficulty in transitioning contributes to the onset of sleep insomnia[54].

Environmental factors[edit | edit source]

Environmental factors also play a significant role in the initiation of sleep[16][63]:

  • Bedtime rituals
  • Exposure to light
  • Meal times
  • Socials cues

Gender[edit | edit source]

The occurrence of symptoms related to sleep problems differs based on gender. In the age group of 6-14 years, parents report a higher prevalence of sleep disorder symptoms in boys (5.19%) compared to girls of the same age (3.67%)[64]. However, there is also evidence indicating that there is no significant difference between male and female children with sleep disorders[8]. Other literature provides information suggesting that girls have poorer sleep functioning than boys across most sleep functioning domains[65].

Sleep and medication[edit | edit source]

Certain medications, like stimulants prescribed for addressing hyperactivity/impulsivity symptoms or other psychotropic drugs used to manage concurrent psychiatric symptoms like anxiety, can potentially disrupt and prolong the time it takes to fall asleep[66][67][68][69][70]. Among children, an elevated dose of Methylphenidate is linked to an increase in sleep-related issues, especially among those with lower weight or BMI[71]. The degree of time it takes to fall asleep varies with different drugs, the dosis and the time of administration[67]. Commonly reported are >30 minutes[72][73]. For some children it is easier to fall asleep while on stimulants than off[54]. There are various reasons for this, firstly, for some children, the act of going to bed is an attention-demanding activity or routine that is more manageable when they are medicated. Another possible explanation is that the mechanism through which stimulants disrupt sleep may be linked not only to the alerting properties of the medication but also to interference with the onset of sleep as the drug's effects diminish and the child experiences a 'rebound' effect. Rebound is characterized by a period in which children become more irritable, reactive, and agitated, all of which may be considered contrary to the state of restfulness and calm required for inducing sleep[54].

Sleep hygiene[edit | edit source]

Sleep hygiene involves a series of behavioural, environmental, or cognitive adjustments designed to enhance sleep. There seems to be a relationship between poor sleep hygiene practices and sleep problems in children with ADHD[40][74]. Poor sleep hygiene is associated with increased bedtime resistance, increased daytime sleepiness and increased sleep duration problems[75].

There are several sleep hygiene factors associated with the sleep quality of children with ADHD:

  • Co-sleeping (bed and room sharing): it has been linked to various sleep problems in children[76]
  • Caffeinated drinks just before bedtime[77]
  • Delayed or irregular bedtimes[77]
  • Inconsistend bedtime routine[77]
  • Television in the bedroom[77]

Sleep and screen time[edit | edit source]

Children with ADHD are found to have high amounts of screen time[39][78][79]. These children are less likely than typically developing children to stop playing at their own[80][81]. Parents may have difficulty in limiting screen time. Children with ADHD are especially susceptible to excessive media use, potentially influenced by altered reinforcement mechanisms[82]. There is a moderate association between ADHD and excessive internet use[83][84]. Media use might be employed as a coping mechanism to alleviate stress of handle negative emotions[85]. Children and adolescents with media devices in their bedroom have a shorter sleep duration and more daytime sleepiness[40][86][87]. Technology use is associated with more sleep problems and less time in bed[78].

Sleep and physical activity[edit | edit source]

Evidence suggests that participation in regular physical activity is associated with improved sleep problems[39][88]. Participation in physical activity and exercise may facilitate sleep regulation. It stimulates alterations in body temperature and triggers the production of melatonin before sleep, leading to subsequent changes in body thermoregulation during sleep cycles[89]. The rise in body temperature during exercise stimulates increased melatonin production, leading to a reduction in time it takes to fall asleep and an enhancement in both the quality and quantity of sleep[90].

Other poor sleep associated factors[edit | edit source]

There are more factors that might contribute to sleep problems in children with ADHD:

  • Co-morbidities: mood disorders, anxiety disorders and tic disorders have been linked with significant sleep problems[40][91][92][93]. In children with ADHD, psychiatric comorbidities are very common: up to 87% have a comorbidity and 20% have three or more comorbidities[94]. Problems with sleep may also contribute to the development of comorbid anxiety or depression[95]. Depression is also associated with increased daytime sleepiness and overall sleep problems[65].
  • Obesity: there seems to be an association between ADHD and obesity[39][96]. Obesity is correlated with sleep-disordered breachting and other sleep disorders[97], a short sleep duration[35] and a shorter time in bed[98].
  • Sensory difficulties are associated with sleep difficulties in children with ADHD[99]. The challenges in regulation sensory perceptions result in difficulties when trying to initiate and sustain sleep[100].
  • Children with more severe ADHD symptoms and lower motor proficiency may face an elevated risk of encountering sleep problems[101]. ADHD severity is associated with greater sleep problems[17].
  • Parents' own sleep behaviour (sleep timing) might be associated with poorer quality sleep[102].
  • Parents with ADHD themselfs often have troubles fostering healthy sleep habits and limiting screen time[103][104][105]. Consistent parenting has shown to decrease bedtime resistance and sleep anxiety[92].
  • Poorer parent mental health is associated with child sleep problems[106].
  • Parents tend to be less diligent in enforcing their children's bedtime routines on days without school compared to school days[16][75]. This inconsistency may impact the circadian rhythm and contribute to delayed sleep onset in general.
  • Irregular schedules[34][107].
  • Exposure at night to blue light sources (LED lights and light-emitting sources like smartphones or tablets[108][109][110]) and social media activities delay bedtimes and lead to shorter sleep duration[111].
  • Children (ages 12-14) are 2.47 times more likely to consume more caffeine (soda, coffee, energy drinks) than their peers during later times of the day. Also, their caffeine use is associated with poorer subjective sleep functioning[112]. They may be using caffeine as a form of self-medication to enhance concentration[112][113].

Measurements of sleep functioning[edit | edit source]

Recognizing connections between sleep problems and ADHD is crucial for a comprehensive care plan in managing children with ADHD. Practitioners should regularly assess clinicall sleep issues by conducting a thorough sleep history and baseline measurements of sleep functioning[54]. There are several tools available, such as psychometrically validated questionnaires for both parents and children, and sleep diaries[114]. These tools can aid in identifying sleep problems:

Interventions[edit | edit source]

Correct treatment of sleep problems increase the life quality of the child with ADHD and also of the family[30]. The severity of ADHD can be reduced by improving the sleep of children with behaviouroral sleep interventions[8], or a sleep extension intervention[125], but using conventional interventions designed for typically developing children without addressing the fundamental deficits in ADHD may prove ineffective and might potentially exacerbate sleep-related challenges[37]. Sleep interventions may increase total sleep time and slightly increase quality of life, while behaviouroral sleep interventions probably decrease sleep disturbances and slightly decrease ADHD symptoms[126]. Even a brief behaviouroral sleep intervention can improve sleep problems[127][128].

Possible interventions might be:

  • Drug treatments: medication management is frequently employed alongside behaviouroral and non-pharmacological interventions.
    • Melatonin: studies of melatonin treatment demonstrate that in children with ADHD the use of melatonin is associated with increased sleep duration and decreased sleep latency[129][130][131][132]. Prolonged use of melatonin has been considered safe for children with ADHD[130][133]. Side effects are: bedwetting, headaches, nightmares, daytime sedation, abdominal pain or constipation[37].
    • Clonidine: studies involving clonidine in children with ADHD have indicated reductions in sleep latency en nighttime awakenings[37]. Clonidine is classified as an alpha agonist. Side effects are: severe sedation at night, morning fatique, rebound awakening, early morning awakening and inability to return to sleep[37].
    • Iron supplements: in children with ADHD and increased motor symptoms in sleep who have low ferritin levels, supplementation with iron might be beneficial[134].
  • Suggested approaches for adressing sleep disruptions while using ADHD medication[135]:
    • Monitoring: insomnia linked with stimulant use may diminish after 1-2 months[136].
    • Assessing the possibility to discontinue using the medication.
    • Implementing sleep hygiene and behaviouroral measures.
    • Reviewing potential causes of sleep issues.
    • Treating Restless Legs Syndrome.
    • Adding small, short-acting stimulant doses in the early evening (if a rebound effects occurs).
    • Reducing stimulant dosage.
    • Switching to an alternative class of stimulant.
    • Switching to an alternative formulation of the stimulant.
    • Contemplating the use of a non-stimulant (for example: atomoxetine).
    • Considering starting a melatonin treatment.
  • Non-pharmacological sleep-related interventions might be important for treating sleep problems including those that focus on sleep hygiene, sensory based factors, parental stress and education[37].
    • Sleep hygiene interventions seek to enhance sleep by education caregivers about factors that influence both the duration and quality of sleep[125]. Established sleep hygiene practices tailored for children have demonstrated to be effective for children with ADHD[92][137][138][139][140][141]. These practices include maintaining a consistent sleep-wake schedule, engaging in calming bedtime routines, having a appropriate bedroom environment (dark, quiet and comfortable in temperature), implementing a structured transition to sleep, steering clear of caffeine and excessive liquids, avoiding naps, refraining from strenuous exercise right before bedtime, minimizing exposure to electronic media close to bedtime, using the bed solely for sleeping and exposure to natural light during the daytime[37][54][142].
      • Children with ADHD could benefit from strategies aimed at reducing problematic media use, such as removing screens from bedrooms and limiting late-night screen time. Studies have shown associations between problematic screen use and sleep issues[143][144].
      • Relaxation strategies can be used to engage in calming bedtime routines[145][146][147]. Insomnia can be managed with progressive muscle relaxation techniques and visual imagery[148].
      • Faded bedtime is a strategy where parents adjust the child's sleep schedule, moving this 15 minutes earlier each night[145][149][150]. It is important that children are not allowed to take a nap and parents set a time to wake up in the morning, making sure the child is exposed to sun in the morning. This strategy is helpful for children with a delayed sleep phase[148].
      • Weekly feedback and reviewing the day's highlights in bed[146].
      • Rewards for succesful nights of sleep[145][147][150][151]. For example: a child can earn tokens for a succesful night and ''cash-out'' for special rewards[148].
    • Behaviouroral therapy is an intervention based on modifying behaviour to enhance individual well-being[148]. A behavioural sleep intervention is associated with small sustained improvements in child well-being[152]. Children who are not using ADHD medication or have parents experiencing depression might benefit from additional follow-up sleep sessions[152]. Research also suggest that a brief, individualized intervention might be more effective than a standardized intervention[128].
      • Key behavioural sleep management strategies[153]:
        • Sleep-onset problems: 'Adult fading' (a phased reduction of parental presence in the child's bedroom over a span of 7-10 days) and 'Checking method' (parents periodically check on the child at specified time intervals (2, 5, or 10 minutes, with increasing intervals over time)).
        • Delayed sleep phase: 'Bedtime fading' (the child's bedtime is temporarily adjusted to a later time, corresponding with when they typically fall asleep, and is gradually shifted earlier. The child is then awakened at a predetermined morning time) and 'Early morning light exposure'.
        • Limit setting sleep problems: 'Parent management strategies': (ignoring the child's protests and reinforcing compliance with bedtime routines. A 'Bedtime pass', allowing the child to leave the bedroom only once before falling asleep, can be utilized to encourage compliant behaviour), 'Bedtime fading' and 'Checking method'.
        • Primary insomnia: 'Visual imagery and relaxation techniques', and 'Limiting time spent in bed (temporarily adjusting bedtime according to delayed sleep phase or engaging in a relaxing activity if the child struggles to sleep).
        • Night-time anxiety: 'Visual imagery and relaxation techniques', 'Talking about the fears of the child during daytime instead of bedtime', 'Rewarding brave behaviour of the child' and 'Using a book to record worries'.
    • For a succesful behavioural sleep intervention, parent education is also important, as parents of children with sleep problems have high levels of stress and poor sleep. It is essential to tackle parental stress and offer education and training to parents. This is vital not only for minimizing risks but also for succesfully implementing behavioural interventions to address sleep issues in children[37]. Behavioural Parent Training could significantly improve various sleep domains in children with ADHD[154]. A brief parent-based sleep intervention also improves parental sleep and parenting stress[155].
    • Sensory interventions are helping children who tend to be easily over-aroused by sensory stimuli. The utilization of tools like weighted blankets[156] or specific items such as ball-blankets, which engage sensory receptors and transmit inhibitory signals to the central nervous system, has demonstrated effectiveness in reducing sleep onset latency and intermittent awakenings[157].
      • A weighted blanket is recognized as a cognitive aid that stimulated the senses, providing deep pressure on the body. The pressure exerted by the weighted blanket induces a sensation of being enveloped and enhances body awareness[158]. Parents noted positive effects when their children used weighted blankets, including: experiencing satisfactory sleep with improvements in falling asleep, uninterrupted sleep, and better sleep routines, achieving overall well-being with increased relaxation and reduced anxiety, and excelling in daily life with improvements in life balance, family functioning, and participation in school and leisure activities[159]. Children's experiences revealed that using weighted blankets improved their sleep, sleeping patterns, and the balance between sleep and activity, emotional regulation and daily functioning[160].
    • For children with hyperactivity, it is crucial to emphasize the importance of steering clear of activities that may stimulate behaviour that result in motor activity and challenges in 'settling down'. Establishing calming routines is key to aiding these children in making an effective transition from wakefulness to sleep[37].
    • For children with anxiety, it could be helpful to get treated with cognitive behavioural therapy for their anxiety, because this leads to a significant decrease in anxiety and improvements in sleep latency[161].
    • Cognitive behavioural play therapy is an approach for teaching coping skills to children by combining cognitive behavioural therapy with pretend play[162]. Cognitive behavioural play therapy results could be effective for reducing anxiety and sleeping problems[162].
    • Mindfulness meditation is a new approach to sleep disturbances and insomnia-related problems[163][164]. Evidence has demonstrated that mindfulness interventions significantly enhance attention and reduce hyperactivity and impulsivity in individuals with ADHD[165]. The Headspace digital mindfulness application significantly reduced anxiety and increased sleep in children with ADHD[166].
    • Exercise interventions: since serveral studies linked exercise to better sleep it could be beneficial to provide an exercise intervention for children with ADHD[39][88]. Exercise interventions with higher levels of intensities should be provided to improve sleep quality[167]. Physical activity could improve sleep efficiency, sleep onset latency and wake after sleep onset[168][169].
    • White noise (75dB of continuous white noise) decrease bedtime sleep latency and awakenings during the night. Results are the same wheter or not children were on ADHD medication[170].
    • Other specific interventions:
      • Better Nights/Better Days is a distance intervention for insomnia in school-aged children (with and without ADHD). Research demonstrate a significant reduction in sleep problems and it improved psychosocial functioning[151].
      • MOBERO is a smartphone-based system to help families establish healthy morning and bedtime routines. It is associated with improvement in sleep habits, less bedtime resistance, increased sleep duration, less sleep anxiety and night wakenings, less parasomnias, less sleep disordered breathing and less daytime sleepiness[171].

References[edit | edit source]

  1. ↑ Addanki SS, Chandradekaran V, Kandasamy P. Attention Deficit Hyperactivity Disorder in Preschool Children: A Cross-Sectional Study of Clinical Profile and Co-morbidity. Indian Journal of Psychological Medicine. 2023; 45(3): 257-262
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  41. ↑ Melegari MG, Vittori E, Mallia L, Devoto A, Lucidi F, Ferri R, Bruni O. Actigraphic Sleep Pattern of Preschoolers With ADHD. Journal of Attention Disorders. 2020; 24(4): 611-624.
  42. ↑ Hvolby A, Jørgensen J, Bilenberg N. Parental rating of sleep in children with attention deficit/hyperactivity disorder. European Child & Adolescent Psychiatry. 2009; 18(7): 429–438
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  44. ↑ Hong GCC, Conduit R, Wong J, Di Benedetto M, Lee E. Diet, Physical Activity, and Screen Time to Sleep Better: Multiple Mediation Analysis of Lifestyle Factors in School-Aged Children with and without Attention Deficit Hyperactivity Disorder. Journal of Attention Disorders. 2021; 25(13): 1847-1858
  45. ↑ 45.0 45.1 45.2 Van der Heijden KB, Smits MG, Van Someren EJW, Gunning WB. Idiopathic chronic sleep onset insomnia in attention-deficit/hyperactivity disorder: a circadian rhythm sleep disorder. Chronobiology International. 2005; 22(3): 559-70
  46. ↑ Cameli N, BeatriceA, Cinnante EM, Gullace C, Lentini G, Occhipinti S, Ferri R, Bruni O. Restless Sleep Disorder and the Role of Iron in Other Sleep-Related Movement Disorders and ADHD. Clinical and Translational Neuroscience. 2023; 7(3): 18
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  170. ↑ Rosalez E, Johnson CM, Bradley-Johnson SB, Kanouse S. Effects of White Noise on Off-Task Behavior and Sleep for Elementary-Age Students with ADHD. Child & Family Behavior Therapy. 2020; 42(1): 20-36
  171. ↑ Sonne T, Müller J, Marshall P, Obel C, Grønbæk K. Changing family practices with assistive technology: MOBERO improves morning and bedtime routines for children with ADHD. In Proceedings of the 2016 CHI conference on human factors in computing systems, Santa Clara. 2016
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