Sleep in Children with Attention Deficit Hyperactivity Disorder (ADHD): Difference between revisions

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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, behavior, metabolism, and immune function<ref>Ophoff D, Slaats MA, Boudewyns A, Glazemakers I, Van Hoorenbeeck K, Verhulst SL. [https://link.springer.com/article/10.1007/s00431-018-3116-z Sleep disorders during childhood: a practical review]. European Journal of Pediatrics. 2018; 177: 641-648</ref>. Poorer sleep is associated with worse academic performance<ref>Matsuoka M, Nagamitsu S, Iwasaki M, Iemura A, Yamashita Y, Maeda M. High incidence of sleep problems in children with developmental disorders: results of a questionnaire survey in a Japanese elementary school. Brain & Development. 2014; 36(1): 35-44</ref>.
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, behavior, metabolism, and immune function<ref>Ophoff D, Slaats MA, Boudewyns A, Glazemakers I, Van Hoorenbeeck K, Verhulst SL. [https://link.springer.com/article/10.1007/s00431-018-3116-z Sleep disorders during childhood: a practical review]. European Journal of Pediatrics. 2018; 177: 641-648</ref>. Poorer sleep is associated with worse academic performance<ref>Matsuoka M, Nagamitsu S, Iwasaki M, Iemura A, Yamashita Y, Maeda M. High incidence of sleep problems in children with developmental disorders: results of a questionnaire survey in a Japanese elementary school. Brain & Development. 2014; 36(1): 35-44</ref>.


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<ref>Tsai MH, Hsu JF, Huang YS. Sleep problems in children with attention deficit/hyperactivity disorder: current status of knowledge and appropriate management. Current Psychiatry Reports. 2016; 18(8): 76 </ref>) than in children without ADHD<ref>Owens J, Sangal RB, Sutton VK, Bakken R, Allen AJ, Kelsey D. Subjective and objective measures of sleep in children with attention-deficit/hyperactivity disorder. Sleep Medicine. 2008; 10(4): 446-456</ref><ref name=":0">Yin H, Yang D, Yang L, Wu G. [https://www.frontiersin.org/articles/10.3389/fped.2022.919572/full Relationship between sleep disorders and attention-deficit-hyperactivity disorder in children.] Frontiers in Pediatrics. 2022; 10: 919572</ref><ref>Hosiri T, Punyapas S, Sawangsri W. The Prevalence and Patterns of Sleep Problem in Children with ADHD. Journal of the Medical Association of Thailand. 2018; 101(1): s34-40</ref><ref name=":13">Cortese S, Brown TE, Corkum P, Gruber R, O'Brien LM, Stein M. [https://www.researchgate.net/publication/251568565_Assessment_and_Management_of_Sleep_Problems_in_Youths_With_Attention-DeficitHyperactivity_Disorder Assessment and management of sleep problems in youths with attention-deficit/hyperactivity disorder]. Journal of the American Academy of Child & Adolescent Psychiatry. 2013; 52(8): 784-96</ref><ref>Chiraphadhanakul K, Jaimchariyatam N, Pruksananonda C, Chonchaiya W. Increased Sleep Disturbances in Thai Children With Attention-Deficit Hyperactivity Disorder Compared With Typically Developing Children. Behavioral Sleep Medicine. 2016; 14(6): 677-86</ref><ref>Yoon SY, Jain U, Shapiro C. [https://www.ndsu.edu/pubweb/~hilmert/SPRG/SPRGPapers/Yoon_2012.pdf Sleep in attention-deficit/hyperactivity disorder in children and adults: past, present, and future]. Sleep Medicine Reviews. 2012; 16(4): 371-88</ref><ref>Lycett K, Mensah FK, Hiscock H, Sciberras E. A prospective study of sleep problems in children with ADHD. Sleep Medicine. 2014; 15: 1354-61</ref><ref name=":14">Lee SH, Kim HB, Lee KW. Association between sleep duration and attention-deficit hyperactivity disorder: a systematic review and meta-analysis of observational studies. Journal of Affective Disorders. 2019; 256: 62-9</ref><ref>Efron D, Lycett K, Sciberras E. Use of sleep medication in children with ADHD. Sleep Medicine. 2014; 15: 472–475.</ref><ref name=":15">Hvolby A. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4340974/#CR86 Associations of sleep disturbance with ADHD: implications for treatment.] Attention Deficit and Hyperactivity Disorders. 2015; 7(1): 1-18</ref>. Poor sleep quality and delayed bedtime can result in daytime fatigue, impacting mood, concentration, behavior, and physical health. Numerous studies have indicated a connection between sleep issues and heightened severity of ADHD symptoms or behavioral challenges in school-aged children with ADHD<ref name=":0" /><ref>Paavonen EJ, Raikkonen K, Lahti J, Komsi N, Heinonen K, Pesonen AK. [https://www.researchgate.net/publication/24378329_Short_Sleep_Duration_and_Behavioral_Symptoms_of_Attention-DeficitHyperactivity_Disorder_in_Healthy_7-to_8-Year-Old_Children Short sleep duration and behavioral symptoms of attention-deficit/hyperactivity disorder in health 7- to 8-year-old children]. Pediatrics. 2009; 123(5): e857-64</ref><ref name=":16">Lucas I, Mulraney M, Sciberras E. Sleep problems and daytime sleepiness in children with ADHD: associations with social, emotional, and behavioral functioning at school, a cross-sectional study. Behavioral Sleep Medicine. 2019; 17: 411-22</ref>. It is also associated with depressive symptoms<ref>Becker SP, Langberg JM, Evans SW. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6526027/ Sleep problems predict comorbid externalizing behaviors and depression in young adolescents with attention deficit/hyperactivity disorder.] European Child & Adolescent Psychiatry. 2015; 24(8): 897-907</ref>, and poorer mental health of primary caregivers<ref name=":8">Sung V, Hiscock H, Sciberras E, Efron D. [https://www.researchgate.net/publication/5461696_Sleep_Problems_in_Children_With_Attention-DeficitHyperactivity_Disorder Sleep problems in children with attention-deficit/hyperactivity disorder: prevalence and the effect on the child and family]. Archives of Pediatrics and Adolescents Medicine. 2008; 162(4): 336-42</ref>.
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<ref>Tsai MH, Hsu JF, Huang YS. Sleep problems in children with attention deficit/hyperactivity disorder: current status of knowledge and appropriate management. Current Psychiatry Reports. 2016; 18(8): 76 </ref>) than in children without ADHD<ref>Owens J, Sangal RB, Sutton VK, Bakken R, Allen AJ, Kelsey D. Subjective and objective measures of sleep in children with attention-deficit/hyperactivity disorder. Sleep Medicine. 2008; 10(4): 446-456</ref><ref name=":0">Yin H, Yang D, Yang L, Wu G. [https://www.frontiersin.org/articles/10.3389/fped.2022.919572/full Relationship between sleep disorders and attention-deficit-hyperactivity disorder in children.] Frontiers in Pediatrics. 2022; 10: 919572</ref><ref>Hosiri T, Punyapas S, Sawangsri W. The Prevalence and Patterns of Sleep Problem in Children with ADHD. Journal of the Medical Association of Thailand. 2018; 101(1): s34-40</ref><ref name=":13">Cortese S, Brown TE, Corkum P, Gruber R, O'Brien LM, Stein M. [https://www.researchgate.net/publication/251568565_Assessment_and_Management_of_Sleep_Problems_in_Youths_With_Attention-DeficitHyperactivity_Disorder Assessment and management of sleep problems in youths with attention-deficit/hyperactivity disorder]. Journal of the American Academy of Child & Adolescent Psychiatry. 2013; 52(8): 784-96</ref><ref>Chiraphadhanakul K, Jaimchariyatam N, Pruksananonda C, Chonchaiya W. Increased Sleep Disturbances in Thai Children With Attention-Deficit Hyperactivity Disorder Compared With Typically Developing Children. Behavioral Sleep Medicine. 2016; 14(6): 677-86</ref><ref>Yoon SY, Jain U, Shapiro C. [https://www.ndsu.edu/pubweb/~hilmert/SPRG/SPRGPapers/Yoon_2012.pdf Sleep in attention-deficit/hyperactivity disorder in children and adults: past, present, and future]. Sleep Medicine Reviews. 2012; 16(4): 371-88</ref><ref>Lycett K, Mensah FK, Hiscock H, Sciberras E. A prospective study of sleep problems in children with ADHD. Sleep Medicine. 2014; 15: 1354-61</ref><ref name=":14">Lee SH, Kim HB, Lee KW. Association between sleep duration and attention-deficit hyperactivity disorder: a systematic review and meta-analysis of observational studies. Journal of Affective Disorders. 2019; 256: 62-9</ref><ref>Efron D, Lycett K, Sciberras E. Use of sleep medication in children with ADHD. Sleep Medicine. 2014; 15: 472–475.</ref><ref name=":15">Hvolby A. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4340974/#CR86 Associations of sleep disturbance with ADHD: implications for treatment.] Attention Deficit and Hyperactivity Disorders. 2015; 7(1): 1-18</ref><ref name=":20">Schneider HE, Lam JC, Mahone EM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4568168/ Sleep disturbance and neuropsychological function in young children with ADHD.] Child Neuropsychology. 2015; ''22(4): 493–506.''</ref><ref name=":20" />. Poor sleep quality and delayed bedtime can result in daytime fatigue, impacting mood, concentration, behavior, and physical health<ref>Sciberras E, DePetro A, Mensah F, Hiscock H. Association between sleep and working memory in children with ADHD: a cross-sectional study. Sleep Medicine. 2015; 16(10), 1192–1197.</ref>. Numerous studies have indicated a connection between sleep issues and heightened severity of ADHD symptoms or behavioral challenges in school-aged children with ADHD<ref name=":0" /><ref>Paavonen EJ, Raikkonen K, Lahti J, Komsi N, Heinonen K, Pesonen AK. [https://www.researchgate.net/publication/24378329_Short_Sleep_Duration_and_Behavioral_Symptoms_of_Attention-DeficitHyperactivity_Disorder_in_Healthy_7-to_8-Year-Old_Children Short sleep duration and behavioral symptoms of attention-deficit/hyperactivity disorder in health 7- to 8-year-old children]. Pediatrics. 2009; 123(5): e857-64</ref><ref name=":16">Lucas I, Mulraney M, Sciberras E. Sleep problems and daytime sleepiness in children with ADHD: associations with social, emotional, and behavioral functioning at school, a cross-sectional study. Behavioral Sleep Medicine. 2019; 17: 411-22</ref><ref>Gruber R, Wiebe S, Montecalvo L, Brunetti B, Amsel R, Carrier J. Impact of sleep restriction on neurobehavioral functioning of children with attention deficit hyperactivity disorder. Sleep.  2011; 34(3): 315–323.</ref>. It is also associated with depressive symptoms<ref>Becker SP, Langberg JM, Evans SW. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6526027/ Sleep problems predict comorbid externalizing behaviors and depression in young adolescents with attention deficit/hyperactivity disorder.] European Child & Adolescent Psychiatry. 2015; 24(8): 897-907</ref>, and poorer mental health of primary caregivers<ref name=":8">Sung V, Hiscock H, Sciberras E, Efron D. [https://www.researchgate.net/publication/5461696_Sleep_Problems_in_Children_With_Attention-DeficitHyperactivity_Disorder Sleep problems in children with attention-deficit/hyperactivity disorder: prevalence and the effect on the child and family]. Archives of Pediatrics and Adolescents Medicine. 2008; 162(4): 336-42</ref>. Sleep problems also have a significant impact on a child's quality of life<ref name=":21" />.


== Physiological factors ==
== Physiological factors ==
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The higher the ADHD symptoms. the more sleep problems a child has. Behavioral disruptions may affect sleep at night and functioning in the daytime in the following ways:
The higher the ADHD symptoms. the more sleep problems a child has. Behavioral disruptions may affect sleep at night and functioning in the daytime in the following ways:


* Insomnia<ref name=":0" /><ref name=":1">Um YH, Jeong JH, Hong SC, Kim TW, Lim HK, Seo HJ. [https://www.researchgate.net/publication/321345871_PT555_Association_between_Sleep_Parameters_and_Cognitive_Function_in_Drug-naive_Children_with_Attention-deficit_Hyperactivity_Disorder_A_Polysomnographic_Study Association between sleep parameters and cognitive function in drug-naïve children with attention-deficit hyperactivity disorder: a polysomnographic study]. Sleep Medicine. 2016; 21: 165-70</ref><ref name=":4" /><ref name=":6">Shur-Fen GS. [https://teensneedsleep.files.wordpress.com/2011/03/gau-prevalence-of-sleep-problems-and-their-association-with-inattention-hyperactivity.pdf Prevalence of sleep problems and their association with inattention/hyperactivity among children aged 6–15 in Taiwan.] Journal of Sleep Research. 2006;15:403–414.</ref>
* Insomnia<ref name=":0" /><ref name=":1">Um YH, Jeong JH, Hong SC, Kim TW, Lim HK, Seo HJ. [https://www.researchgate.net/publication/321345871_PT555_Association_between_Sleep_Parameters_and_Cognitive_Function_in_Drug-naive_Children_with_Attention-deficit_Hyperactivity_Disorder_A_Polysomnographic_Study Association between sleep parameters and cognitive function in drug-naïve children with attention-deficit hyperactivity disorder: a polysomnographic study]. Sleep Medicine. 2016; 21: 165-70</ref><ref name=":4" /><ref name=":6">Shur-Fen GS. [https://teensneedsleep.files.wordpress.com/2011/03/gau-prevalence-of-sleep-problems-and-their-association-with-inattention-hyperactivity.pdf Prevalence of sleep problems and their association with inattention/hyperactivity among children aged 6–15 in Taiwan.] Journal of Sleep Research. 2006;15:403–414.</ref><ref name=":21" />
* Struggling before falling asleep<ref name=":0" /><ref name=":8" /><ref name=":1" /><ref name=":2">Cortese S, Faraone SV, Konofal E, Lecendreux M. Sleep in children with attention deficit/hyperactivity disorder: meta-analysis of subjective and objective studies. Journal of the American Academy of Child & Adolescent Psychiatry, 2009; 48(9): 894-908</ref><ref name=":15" /><ref name=":17">Spruyt K, Gozal D. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3129712/ Sleep disturbances in children with attention-deficit/hyperactivity disorder.] Expert Review of Neurotherapeutics. 2011; 11(4): 565-577</ref>
* Struggling before falling asleep<ref name=":0" /><ref name=":8" /><ref name=":1" /><ref name=":2">Cortese S, Faraone SV, Konofal E, Lecendreux M. Sleep in children with attention deficit/hyperactivity disorder: meta-analysis of subjective and objective studies. Journal of the American Academy of Child & Adolescent Psychiatry, 2009; 48(9): 894-908</ref><ref name=":15" /><ref name=":17">Spruyt K, Gozal D. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3129712/ Sleep disturbances in children with attention-deficit/hyperactivity disorder.] Expert Review of Neurotherapeutics. 2011; 11(4): 565-577</ref>
* Bedtime anxiety<ref name=":6" /><ref name=":17" />
* Bedtime anxiety<ref name=":6" /><ref name=":17" />
* Bedtime resistance<ref name=":8" /><ref name=":2" /><ref name=":15" />
* Bedtime resistance<ref name=":8" /><ref name=":2" /><ref name=":15" />
* Poor sleep quality<ref name=":0" /><ref name=":1" />
* Poor sleep quality<ref name=":0" /><ref name=":1" />
* Insufficient sleep duration<ref name=":0" /><ref name=":1" /><ref name=":15" /><ref name=":14" />
* Insufficient sleep duration<ref name=":0" /><ref name=":1" /><ref name=":15" /><ref name=":14" /><ref name=":22">Tandon PS, Sasser T, Gonzalez ES, Whitlock KB, Christakis DA, Stein MA. [https://www.researchgate.net/publication/332883890_Physical_Activity_Screen_Time_and_Sleep_in_Children_With_ADHD Physical Activity, Screen Time, and Sleep in Children With ADHD.] Journal of Physical Activity and Health. 2019; 16(6): 1–7.</ref><ref name=":22" />
* Awakening at night<ref name=":8" /><ref name=":6" /><ref name=":2" /><ref name=":15" /><ref name=":3">Stickley A, Shirama A, Kitamura S, Kamio Y, Takahashi H, Saito A. [https://pdf.sciencedirectassets.com/272127/1-s2.0-S1389945721X00068/1-s2.0-S1389945721002653/am.pdf?X-Amz-Security-Token=IQoJb3JpZ2luX2VjELX%2F%2F%2F%2F%2F%2F%2F%2F%2F%2FwEaCXVzLWVhc3QtMSJIMEYCIQD%2BmrvpA34iQDeri3pc1jrhE8iw7YHWRdoymQjeKrp1jAIhAKfvrMw8HJFugAXUycmHkvZAOXvSUMyyqkDqGClj9k%2BYKrwFCK7%2F%2F%2F%2F%2F%2F%2F%2F%2F%2FwEQBRoMMDU5MDAzNTQ2ODY1IgwdpKdpbLbhZlSahGYqkAVFRH8XW7%2BC6j7Oy1nwfcaXIT93EumX1YZPULeRlDPkBzsLTfBdLx87HWZB3W0MRR3NMa2j6KUXpvhCgJjQ8OF3bdHND6ciuzJGP2%2FUcakBasblDmFGvRsEiYoe%2F92kpepcNBBGdtbpZzWvC%2FuK%2FVGsHJ6RfnbNxGlJht1ZqndZH%2BxrU8f4T31no9%2Fq9A1hZXvzZwKa5RVdKtTSYGML%2BsLUxBOQIDPCXL0opR%2BF7qW8MjNkfChOfVkoy%2Bd289KbslXDUerIfeZ%2BhRIgmg%2BBhuIt9TucyBr3QQXWbhqv3GbJVpOBPzQXI%2F3Jq8TEaTjYhpdwfK1CmJG0wBFV0%2BE8Lbeut3%2B7iiB5ESLVJvT9Hq4yp5KS0D2nhWSrsJANvCWR%2BPujdWhuu9TTtIQr5X7kxz%2FBJiWyNlO48RApQCTMEBhSI6aj03Tk%2F89YVT7HM%2FezM8uqLfjz2y4WVHGFU7WjIOFFaMMY3bBuTu8LkvqYerV0%2FGX1HmmxOQLqIclNXB20uX3qZ7%2FjBswgSxCLHg7s%2FgJ0OJ35frL92yBafwmXBhCcRyClVav3NOdYSrx6%2FtRz1g7LxZyVD6%2FgAj25NlhtB%2FgxiXVF%2FemP9eB0mUqkxImSI8ceWxHXBhJsdaiomPvib4TucEIlI1W93R%2Bg8tcKTifGbG4QfsDre%2B6xel8wqf0l6WEpY4ESv1Z8gYA%2B3oQuhJj8NH8FI9u5OwulWi6hXqMeII9HMonpne4R1bX88Gdw72RBESqeUHLwQE%2F2cECh6skPRhc7%2FzjjXWKzU1%2FQcvhLBXtFypAONI8Jd4q2S2%2FcbEWvBWW4nI%2Fuf1YyUq38y5y2WlAzITRcAjnzo1QRATQVk7vxItPYEQZZhlntHYjkmjC9q6OvBjqwAQOebxnvf1SLhD96hj8LI09BB0oMntqAI%2F9V7m3%2FVvkyC2x4Yykv%2Bof2brTOLUDwcHpN83bISAr2XIFwQJKK4JowTCLXgfity1w%2B%2BM2iYcftF%2F8wKtqE0feuS1FN1lfGCZ7PmX4xLMKlnDDDNoMGJZngMzLeOYO7oXJYe5orONU9bzEiQ%2BU0ZY%2Bb0upBrdWvfDY2Nm9EMIYeEhSAmVbM6ehTZhZbJjYa%2FdP9xvYgOtWh&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20240306T220547Z&X-Amz-SignedHeaders=host&X-Amz-Expires=300&X-Amz-Credential=ASIAQ3PHCVTY7WWG2ZE2%2F20240306%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Signature=c22eda64fa9df047fde9f6164f3de4b87d15ad19cc79c418eabafc3901d208eb&hash=2c078c53095bad2484be1ab7fb14f5a4285498f5ccd869f412913bac50a9326f&host=68042c943591013ac2b2430a89b270f6af2c76d8dfd086a07176afe7c76c2c61&pii=S1389945721002653&tid=pdf-05dcaacb-b6f9-49e5-bbca-057a4c02cdd6&sid=c79a9c884e2be543e2292dd-2bdad6c21295gxrqb&type=client Attention deficit/hyperactivity disorder symptoms and sleep problems in preschool children: the role of autistic traits]. Sleep Medicine. 2021; 83: 214-21</ref><ref name=":17" />
* Awakening at night<ref name=":8" /><ref name=":6" /><ref name=":2" /><ref name=":15" /><ref name=":3">Stickley A, Shirama A, Kitamura S, Kamio Y, Takahashi H, Saito A. [https://pdf.sciencedirectassets.com/272127/1-s2.0-S1389945721X00068/1-s2.0-S1389945721002653/am.pdf?X-Amz-Security-Token=IQoJb3JpZ2luX2VjELX%2F%2F%2F%2F%2F%2F%2F%2F%2F%2FwEaCXVzLWVhc3QtMSJIMEYCIQD%2BmrvpA34iQDeri3pc1jrhE8iw7YHWRdoymQjeKrp1jAIhAKfvrMw8HJFugAXUycmHkvZAOXvSUMyyqkDqGClj9k%2BYKrwFCK7%2F%2F%2F%2F%2F%2F%2F%2F%2F%2FwEQBRoMMDU5MDAzNTQ2ODY1IgwdpKdpbLbhZlSahGYqkAVFRH8XW7%2BC6j7Oy1nwfcaXIT93EumX1YZPULeRlDPkBzsLTfBdLx87HWZB3W0MRR3NMa2j6KUXpvhCgJjQ8OF3bdHND6ciuzJGP2%2FUcakBasblDmFGvRsEiYoe%2F92kpepcNBBGdtbpZzWvC%2FuK%2FVGsHJ6RfnbNxGlJht1ZqndZH%2BxrU8f4T31no9%2Fq9A1hZXvzZwKa5RVdKtTSYGML%2BsLUxBOQIDPCXL0opR%2BF7qW8MjNkfChOfVkoy%2Bd289KbslXDUerIfeZ%2BhRIgmg%2BBhuIt9TucyBr3QQXWbhqv3GbJVpOBPzQXI%2F3Jq8TEaTjYhpdwfK1CmJG0wBFV0%2BE8Lbeut3%2B7iiB5ESLVJvT9Hq4yp5KS0D2nhWSrsJANvCWR%2BPujdWhuu9TTtIQr5X7kxz%2FBJiWyNlO48RApQCTMEBhSI6aj03Tk%2F89YVT7HM%2FezM8uqLfjz2y4WVHGFU7WjIOFFaMMY3bBuTu8LkvqYerV0%2FGX1HmmxOQLqIclNXB20uX3qZ7%2FjBswgSxCLHg7s%2FgJ0OJ35frL92yBafwmXBhCcRyClVav3NOdYSrx6%2FtRz1g7LxZyVD6%2FgAj25NlhtB%2FgxiXVF%2FemP9eB0mUqkxImSI8ceWxHXBhJsdaiomPvib4TucEIlI1W93R%2Bg8tcKTifGbG4QfsDre%2B6xel8wqf0l6WEpY4ESv1Z8gYA%2B3oQuhJj8NH8FI9u5OwulWi6hXqMeII9HMonpne4R1bX88Gdw72RBESqeUHLwQE%2F2cECh6skPRhc7%2FzjjXWKzU1%2FQcvhLBXtFypAONI8Jd4q2S2%2FcbEWvBWW4nI%2Fuf1YyUq38y5y2WlAzITRcAjnzo1QRATQVk7vxItPYEQZZhlntHYjkmjC9q6OvBjqwAQOebxnvf1SLhD96hj8LI09BB0oMntqAI%2F9V7m3%2FVvkyC2x4Yykv%2Bof2brTOLUDwcHpN83bISAr2XIFwQJKK4JowTCLXgfity1w%2B%2BM2iYcftF%2F8wKtqE0feuS1FN1lfGCZ7PmX4xLMKlnDDDNoMGJZngMzLeOYO7oXJYe5orONU9bzEiQ%2BU0ZY%2Bb0upBrdWvfDY2Nm9EMIYeEhSAmVbM6ehTZhZbJjYa%2FdP9xvYgOtWh&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20240306T220547Z&X-Amz-SignedHeaders=host&X-Amz-Expires=300&X-Amz-Credential=ASIAQ3PHCVTY7WWG2ZE2%2F20240306%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Signature=c22eda64fa9df047fde9f6164f3de4b87d15ad19cc79c418eabafc3901d208eb&hash=2c078c53095bad2484be1ab7fb14f5a4285498f5ccd869f412913bac50a9326f&host=68042c943591013ac2b2430a89b270f6af2c76d8dfd086a07176afe7c76c2c61&pii=S1389945721002653&tid=pdf-05dcaacb-b6f9-49e5-bbca-057a4c02cdd6&sid=c79a9c884e2be543e2292dd-2bdad6c21295gxrqb&type=client Attention deficit/hyperactivity disorder symptoms and sleep problems in preschool children: the role of autistic traits]. Sleep Medicine. 2021; 83: 214-21</ref><ref name=":17" /><ref name=":23">Yürümez E, Kilic BG. [https://www.researchgate.net/publication/236063815_Relationship_Between_Sleep_Problems_and_Quality_of_Life_in_Children_With_ADHD Relationship Between Sleep Problems and Quality of Life in Children With ADHD.] Journal of Attention Disorders. 2016; 20(1): 34-40</ref>
* Circadian rhythm sleep-wake disorders<ref name=":4" /><ref name=":15" />
* Circadian rhythm sleep-wake disorders<ref name=":4" /><ref name=":15" />
* Nightmares<ref name=":17" /><ref name=":3" /><ref>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</ref>
* Nightmares<ref name=":17" /><ref name=":3" /><ref>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</ref>
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* Restless Leg Syndrome (RLS)<ref name=":4" /><ref name=":9" /><ref name=":15" />
* Restless Leg Syndrome (RLS)<ref name=":4" /><ref name=":9" /><ref name=":15" />
* Morning awakenings problems<ref name=":2" /><ref name=":15" />
* Morning awakenings problems<ref name=":2" /><ref name=":15" />
* Daytime sleepiness<ref name=":6" /><ref name=":2" /><ref name=":15" /><ref name=":17" /><ref>Craig SG, Weiss MD, Hudec KL, Gibbons C. [https://www.researchgate.net/publication/312521991_The_Functional_Impact_of_Sleep_Disorders_in_Children_With_ADHD The Functional Impact of Sleep Disorders in Children With ADHD. Journal of Attention Disorders.] 2017; 24(4)</ref>
* Daytime sleepiness<ref name=":20" /><ref name=":6" /><ref name=":2" /><ref name=":15" /><ref name=":17" /><ref name=":21">Craig SG, Weiss MD, Hudec KL, Gibbons C. [https://www.researchgate.net/publication/312521991_The_Functional_Impact_of_Sleep_Disorders_in_Children_With_ADHD The Functional Impact of Sleep Disorders in Children With ADHD. Journal of Attention Disorders.] 2017; 24(4)</ref><ref name=":23" /><br>
* Emotional and behavioral functioning problems<ref name=":16" /><br>
The influence of sleep issues in children with ADHD can be intensified by their impact on parents. 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<ref name=":10" />. 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<ref name=":10" />. The link between child sleep problems and family functioning may be directional, where parent behavior influences child sleep, in turn, impacts parent mental health, thereby influencing family functioning<ref>El-Sheikh M, Kelly RJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5931738/ Family functioning and children’s sleep.] Child Development Perspectives. 2017; 11(4), 264–269</ref>.
The influence of sleep issues in children with ADHD can be intensified by their impact on parents. 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<ref name=":10" />. 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<ref name=":10" />.


The following issues can be experienced by their parents:
The following issues can be experienced by their parents:
Line 74: Line 73:
* Co-sleeping (bed and room sharing): it has been linked to various sleep problems in children<ref>Li S, Jin X, Yan C, Wu S, Jiang F, Shen X. Bed- and room-sharing in Chinese school-aged children: prevalence and association with sleep behaviors. Sleep Medicine. 2008; 9: 555-63</ref>.
* Co-sleeping (bed and room sharing): it has been linked to various sleep problems in children<ref>Li S, Jin X, Yan C, Wu S, Jiang F, Shen X. Bed- and room-sharing in Chinese school-aged children: prevalence and association with sleep behaviors. Sleep Medicine. 2008; 9: 555-63</ref>.
* <br>
* <br>
== Sleep and screen time ==
Children with ADHD are found to have high amounts of screen time<ref name=":22" />. These children are less likely than typically developing children to stop playing at their own<ref>Mazurek MO, Engelhardt CR. Video game use in boys with autism spectrum disorder, ADHD, or typical development. Pediatrics. 2013; 132(2): 260–266.</ref><ref>Bioulac S, Arfi L, Bouvard MP. Attention deficit/hyperactivity disorder and video games: a comparative study of hyperactive and control children. European Psychiatry. 2008; 23(2): 134–141.</ref>. Parents may have difficulty in limiting screen time. Children with ADHD are especially susceptible to excessive media use, potentially influenced by altered reinforcement mechanisms<ref>Tripp G, Wickens JR. [https://www.researchgate.net/publication/5766442_Research_Review_Dopamine_transfer_deficit_a_neurobiological_theory_of_altered_reinforcement_mechanisms_in_ADHD Research review: dopamine transfer deficit: a neurobiological theory of altered reinforcement mechanisms in ADHD]. Journal of Child Psychology and Psychiatry, and Allied Disciplines. 2008; 49(7): 691–704.</ref>. There is a moderate association between ADHD and excessive internet use<ref>Wang B, Yao N, Zhou X, Liu J, Lv Z. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5517818/ The association between attention deficit/hyperactivity disorder and Internet addiction: A systematic review and meta-analysis.] BMC Psychiatry. 2017; 17: 260</ref>.Media use might be employed as a coping mechanism to alleviate stress of handle negative emotions<ref>Elhai JD, Dvorak RD, Levine JC, Hall BJ. [https://www.researchgate.net/publication/307135165_Problematic_smartphone_use_A_conceptual_overview_and_systematic_review_of_relations_with_anxiety_and_depression_psychopathology Problematic smartphone use: A conceptual overview and systematic review of relations with anxiety and depression psychopathology]. Journal of Affective Disorders in Press. 2017; 207: 251–259.</ref>.


== Other poor sleep associated factors ==
== Other poor sleep associated factors ==
Line 80: Line 82:
* Parents' own sleep behavior (sleep timing) might be associated with poorer quality sleep<ref>Iwata S, Iwata O, Matsuishi T. [https://www.researchgate.net/publication/235657709_Sleep_patterns_of_Japanese_preschool_children_and_their_parents_Implications_for_co-sleeping Sleep patterns of Japanese preschool children and their parents: implications for co-sleeping]. Acta Peadiatrica. 2013; 102: e257-62</ref>.
* Parents' own sleep behavior (sleep timing) might be associated with poorer quality sleep<ref>Iwata S, Iwata O, Matsuishi T. [https://www.researchgate.net/publication/235657709_Sleep_patterns_of_Japanese_preschool_children_and_their_parents_Implications_for_co-sleeping Sleep patterns of Japanese preschool children and their parents: implications for co-sleeping]. Acta Peadiatrica. 2013; 102: e257-62</ref>.
* Co-morbidities: mood disorders, anxiety disorders and tic disorders have been linked with significant sleep problems<ref>American Academy of Pediatrics (AAP). Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics 2000; 105: 1158-70</ref><ref>Ivanenko A, Crabtree VM, Obrien LM, Gozal D. [https://www.researchgate.net/publication/6280324_Sleep_Complaints_and_Psychiatric_Symptoms_in_Children_Evaluated_at_a_Pediatric_Mental_Health_Clinic Sleep complaints and psychiatric symptoms in children evaluated at a pediatric mental health clinic.] Journal of Clinical Sleep Medicine. 2006; 2(1): 42-8</ref><ref>Ivanenko A, Johnson K. Sleep disturbances in children with psychiatric disorders. Seminars in Pediatric Neurology. 2008; 15(2): 70-8</ref>. In children with ADHD, psychiatric comorbidities are very common: up to 87% have a comorbidity and 20% have three or more comorbidities<ref>Hodgkins P, Setyawan J, Mitra D, Davis K, Quintero J, Fridman M, Shaw M, Harpin V. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3701791/ Management of ADHD in children across Europe: patient demographics, physician characteristics and treatment patterns]. European Journal of Pediatrics. 2013; 172(7): 895-906</ref>. Problems with sleep may also contribute to the development of comorbid anxiety or depression<ref>Hvolby A, Jorgensen J, Bilenberg N. Actigraphic and parental reports of sleep difficulties in children with attention-deficit/hyperactivity disorder. Archives of Pediatrics & Adolescent Medicine. 2008; 162: 323–329.</ref>.  
* Co-morbidities: mood disorders, anxiety disorders and tic disorders have been linked with significant sleep problems<ref>American Academy of Pediatrics (AAP). Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics 2000; 105: 1158-70</ref><ref>Ivanenko A, Crabtree VM, Obrien LM, Gozal D. [https://www.researchgate.net/publication/6280324_Sleep_Complaints_and_Psychiatric_Symptoms_in_Children_Evaluated_at_a_Pediatric_Mental_Health_Clinic Sleep complaints and psychiatric symptoms in children evaluated at a pediatric mental health clinic.] Journal of Clinical Sleep Medicine. 2006; 2(1): 42-8</ref><ref>Ivanenko A, Johnson K. Sleep disturbances in children with psychiatric disorders. Seminars in Pediatric Neurology. 2008; 15(2): 70-8</ref>. In children with ADHD, psychiatric comorbidities are very common: up to 87% have a comorbidity and 20% have three or more comorbidities<ref>Hodgkins P, Setyawan J, Mitra D, Davis K, Quintero J, Fridman M, Shaw M, Harpin V. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3701791/ Management of ADHD in children across Europe: patient demographics, physician characteristics and treatment patterns]. European Journal of Pediatrics. 2013; 172(7): 895-906</ref>. Problems with sleep may also contribute to the development of comorbid anxiety or depression<ref>Hvolby A, Jorgensen J, Bilenberg N. Actigraphic and parental reports of sleep difficulties in children with attention-deficit/hyperactivity disorder. Archives of Pediatrics & Adolescent Medicine. 2008; 162: 323–329.</ref>.  
* Obesity: there seems to be an association between ADHD and obesity<ref>Cortese S, Angriman M, Maffeis C, Isnard P, Konofal E, Lecendreux M, Purper-Ouakil D, Vincenzi B, Bernardina BD, Mouren MC. Attention-deficit/hyperactivity disorder (ADHD) and obesity: a systematic review of the literature. Critical Reviews in Food Science and Nutrition. 2008; 48(6): 524-37</ref>. Obesity is correlated with sleep-disordered breachting and other sleep disorders<ref>Cortese S, Konofal E, Dalla Bernardina B, Mouren MC, Lecendreux M. Does excessive daytime sleepiness contribute to explaining the association between obesity and ADHD symptoms? Medical Hypotheses. 2008; 70(1): 12–16.</ref>, a short sleep duration<ref name=":15" /> and a shorter time in bed<ref>Hart CN, Larose JG, Fava JL, James BL, Wing RR. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3644344/ The association between time in bed and obesity risk in young adults.] Behavioural Sleep Medicine. 2013; 11(5): 321–327.</ref>.
* Obesity: there seems to be an association between ADHD and obesity<ref>Cortese S, Angriman M, Maffeis C, Isnard P, Konofal E, Lecendreux M, Purper-Ouakil D, Vincenzi B, Bernardina BD, Mouren MC. Attention-deficit/hyperactivity disorder (ADHD) and obesity: a systematic review of the literature. Critical Reviews in Food Science and Nutrition. 2008; 48(6): 524-37</ref><ref name=":22" />. Obesity is correlated with sleep-disordered breachting and other sleep disorders<ref>Cortese S, Konofal E, Dalla Bernardina B, Mouren MC, Lecendreux M. Does excessive daytime sleepiness contribute to explaining the association between obesity and ADHD symptoms? Medical Hypotheses. 2008; 70(1): 12–16.</ref>, a short sleep duration<ref name=":15" /> and a shorter time in bed<ref>Hart CN, Larose JG, Fava JL, James BL, Wing RR. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3644344/ The association between time in bed and obesity risk in young adults.] Behavioural Sleep Medicine. 2013; 11(5): 321–327.</ref>.
* Irregular schedules<ref name=":17" />
* Irregular schedules<ref name=":17" />
* Parents with ADHD themselfs often have troubles fostering healthy sleep habits and limiting screen time<ref>Chronis AM, Lahey BB, Pelham Jr WE, Kipp HL, Baumann BL, Lee SS. Psychopathology and substance abuse in parents of young children with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry. 2003; 42(12): 1424-32</ref>.
* Poorer parent mental health is associated with child sleep problems<ref>Martin CA, Papadopoulos N, Chellew T, Rinehart NJ, Sciberras E. Associations between parenting stress, parent mental health and child sleep problems for children with ADHD and ASD: Systematic review. Research in Developmental Disabilities. 2019; 93: 103463.</ref>.


== Measurements of sleep functioning==
== Measurements of sleep functioning==
Line 102: Line 106:
==Interventions==
==Interventions==


The severity of ADHD can be reduced by improving the sleep of children with behavioral sleep interventions<ref name=":0" />. 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<ref name=":4" />. Other interventions might be:
Correct treatment of sleep problems increase the life quality of the child with ADHD and also of the family<ref name=":23" />. The severity of ADHD can be reduced by improving the sleep of children with behavioral sleep interventions<ref name=":0" />, 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<ref name=":4" />. Other interventions might be:


* Drug treatments: medication management is frequently employed alongside behavioral and non-pharmacological interventions.
* Drug treatments: medication management is frequently employed alongside behavioral and non-pharmacological interventions.
Line 122: Line 126:
* 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 eduction<ref name=":4">Ramtekkar UP. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5575584/ DSM-5 changes in attention deficit hyperactivity disorder and autism spectrum disorder: implications for comorbid sleep issues.] Children. 2017; 4: 62</ref>.
* 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 eduction<ref name=":4">Ramtekkar UP. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5575584/ DSM-5 changes in attention deficit hyperactivity disorder and autism spectrum disorder: implications for comorbid sleep issues.] Children. 2017; 4: 62</ref>.
** Established sleep hygiene practices tailored for children have demonstrated to be effective for children with ADHD<ref name=":19" />. 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<ref name=":13" /><ref name=":4" /><ref name=":10" /><ref name=":15" /><ref>Owens JA. The ADHD and sleep conundrum redux: Moving forward. Sleep Medicine Reviews. 2006; 10: 377–379.</ref>.
** Established sleep hygiene practices tailored for children have demonstrated to be effective for children with ADHD<ref name=":19" />. 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<ref name=":13" /><ref name=":4" /><ref name=":10" /><ref name=":15" /><ref>Owens JA. The ADHD and sleep conundrum redux: Moving forward. Sleep Medicine Reviews. 2006; 10: 377–379.</ref>.
*** 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<ref>Becker SP, Lienesch JA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6431533/ Nighttime media use in adolescents with ADHD: links to sleep problems and internalizing symptoms]. Sleep Medicine. 2018; 51: 171–178</ref><ref>Engelhardt CR, Mazurek MO, Sohl K. [https://www.researchgate.net/publication/258703121_Media_Use_and_Sleep_Among_Boys_With_Autism_Spectrum_Disorder_ADHD_or_Typical_Development Media use and sleep among boys with autism spectrum disorder, ADHD, or typical development.] Pediatrics. 2013; 132(6): 1081–1089</ref>.
** For children with hyperactivity, it is crucial to emphasize the importance of steering clear of activities that may stimulate behavior 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<ref name=":4" />.
** For children with hyperactivity, it is crucial to emphasize the importance of steering clear of activities that may stimulate behavior 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<ref name=":4" />.
** Sensory interventions are helping children who tend to be easily over-aroused by sensory stimuli. The utilization of tools like weighted blankets 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<ref>Hvolby A, Bilenberg N. [https://www.researchgate.net/profile/Niels-Bilenberg/publication/45387649_Use_of_Ball_Blanket_in_attention-deficithyperactivity_disorder_sleeping_problems/links/00b495372376ddec5e000000/Use-of-Ball-Blanket-in-attention-deficit-hyperactivity-disorder-sleeping-problems.pdf Use of Ball Blanket in attention-deficit/hyperactivity disorder sleeping problems]. Nordic Journal of Psychiatry. 2011; 65: 89–94.</ref>.
** Sensory interventions are helping children who tend to be easily over-aroused by sensory stimuli. The utilization of tools like weighted blankets 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<ref>Hvolby A, Bilenberg N. [https://www.researchgate.net/profile/Niels-Bilenberg/publication/45387649_Use_of_Ball_Blanket_in_attention-deficithyperactivity_disorder_sleeping_problems/links/00b495372376ddec5e000000/Use-of-Ball-Blanket-in-attention-deficit-hyperactivity-disorder-sleeping-problems.pdf Use of Ball Blanket in attention-deficit/hyperactivity disorder sleeping problems]. Nordic Journal of Psychiatry. 2011; 65: 89–94.</ref>.

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Background[edit | edit source]

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most prevalent neurodevelopmental disorder 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, behavior, metabolism, and immune function[3]. Poorer sleep is associated with worse academic performance[4].

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[5]) than in children without ADHD[6][7][8][9][10][11][12][13][14][15][16][16]. Poor sleep quality and delayed bedtime can result in daytime fatigue, impacting mood, concentration, behavior, and physical health[17]. Numerous studies have indicated a connection between sleep issues and heightened severity of ADHD symptoms or behavioral challenges in school-aged children with ADHD[7][18][19][20]. It is also associated with depressive symptoms[21], and poorer mental health of primary caregivers[22]. Sleep problems also have a significant impact on a child's quality of life[23].

Physiological factors[edit | edit source]

There are several factor 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 observerd in children with ADHD[24],may play a significant role. This is because REM is linked to parasomnias like nightmare disorder, which often lead to awakenings[25], and it also affects neurobehavioral functioning in children with ADHD[26]. Behaviors indicative of parasomnias often include night terrors, confusional arousals, episodes of waking up screaming, increased motor activity such as sleepwalking, and enuresis (bedwetting)[27][28]. The use of medication and comorbidities (like anxiety) also increase the risk of parasomnias[28].
  • 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[29].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[30].
  • 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[28].
  • 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[28]. Sleep disordered breathing often results in sleep fragmentation and excessive daytime sleepiness[29].
  • 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[31].

Environmental factors[edit | edit source]

Environmental factors also play a significant role in the initiation of sleep[32].

  • Exposure to light[32]

Sleep problems[edit | edit source]

The higher the ADHD symptoms. the more sleep problems a child has. Behavioral 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. 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[31]. 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[31]. The link between child sleep problems and family functioning may be directional, where parent behavior influences child sleep, in turn, impacts parent mental health, thereby influencing family functioning[41].

The following issues can be experienced by their parents:

  • Less sleep for the parents[42]
  • Parental daytime fatigue[42]
  • Mood disturbances in parents[42]
  • Decreased level of effective parenting[42]
  • Clinically depression or anxiety[22]
  • Poorer parent-related daily functioning[19]

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[43][44][45]. The degree of time it takes to fall asleep varies with different drugs, the dosis and the time of administration[45]. Commonly reported are >30 minutes[46][47]. For some children it is easier to fall asleep while on stimulants than off[31]. 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[31].

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%)[48], but there is also evidence that there is no significant difference between male and female children with sleep disorders[7].

Sleep hygiene[edit | edit source]

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[49].

Sleep and screen time[edit | edit source]

Children with ADHD are found to have high amounts of screen time[37]. These children are less likely than typically developing children to stop playing at their own[50][51]. Parents may have difficulty in limiting screen time. Children with ADHD are especially susceptible to excessive media use, potentially influenced by altered reinforcement mechanisms[52]. There is a moderate association between ADHD and excessive internet use[53].Media use might be employed as a coping mechanism to alleviate stress of handle negative emotions[54].

Other poor sleep associated factors[edit | edit source]

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

  • Parents' own sleep behavior (sleep timing) might be associated with poorer quality sleep[55].
  • Co-morbidities: mood disorders, anxiety disorders and tic disorders have been linked with significant sleep problems[56][57][58]. In children with ADHD, psychiatric comorbidities are very common: up to 87% have a comorbidity and 20% have three or more comorbidities[59]. Problems with sleep may also contribute to the development of comorbid anxiety or depression[60].
  • Obesity: there seems to be an association between ADHD and obesity[61][37]. Obesity is correlated with sleep-disordered breachting and other sleep disorders[62], a short sleep duration[15] and a shorter time in bed[63].
  • Irregular schedules[36]
  • Parents with ADHD themselfs often have troubles fostering healthy sleep habits and limiting screen time[64].
  • Poorer parent mental health is associated with child sleep problems[65].

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[31]. There are several tools available, such as psychometrically validated questionnaires for both parents and children, and sleep diaries[66]. These tools can aid in identifying sleep problems:

  • Questionnaires:
    • The Sleep Disorders Questionnaire (SDQ)[67]
    • Pediatric Sleep Questionnaire (PSQ)[68]
    • The Children's Sleep Habits Questionnaire (CSHQ)[69]
    • The Sleep Disturbance Scale for Children[70]
    • Bedtime Routines Questionnaire[71]
    • Teacher's Daytime Sleepiness Questionnaire (TDSQ)[69]
  • Sleep diaries: these diaries entail having the parent or child (or both) document a child's sleeping and waking times along with relevant information, typically spanning over a period of several weeks[31]. Two weeks of baseline sleep diary recordings are adequate for outlining sleep patterns[72].
  • Clinical Interviews: a simple user-friendly screening tool is the BEARS. B = Bedtime issues, E = Excessive day-time sleepiness, A = Awakenings, R = Regularity and duration of sleep, S = Snoring. By using this format, every therapist can easily screen children for the most common sleep problems[31] and this tool significantly increased the amount of sleep information compared to other checklists[73].
  • Tools for Sleep Hygiene: sleep hygiene training begins with a baseline assessment of sleep patterns with the help of an assessment tool such as:
    • Children's Sleep Hygiene Scale[74]
    • Sleep Hygiene Index[75]

Interventions[edit | edit source]

Correct treatment of sleep problems increase the life quality of the child with ADHD and also of the family[39]. The severity of ADHD can be reduced by improving the sleep of children with behavioral sleep interventions[7], 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[28]. Other interventions might be:

  • Drug treatments: medication management is frequently employed alongside behavioral 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[76][77]. Prolonged use of melatonin has been considered safe for children with ADHD[77].Side effects are: bedwetting, headaches, nightmares, daytime sedation, abdominal pain or constipation[28].
    • Clonidine: studies involving clonidine in children with ADHD have indicated reductions in sleep latency en nighttime awakenings[28]. 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[28].
    • Iron supplements: in children with ADHD and increased motor symptoms in sleep who have low ferritin levels, supplementation with iron might be beneficial[78].
  • Suggested approaches for adressing sleep disruptions while using ADHD medication[79]:
    • Monitoring: insomnia linked with stimulant use may diminish after 1-2 months[80].
    • Assessing the possibility to discontinue using the medication.
    • Implementing sleep hygiene and behavioral 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 eduction[28].
    • Established sleep hygiene practices tailored for children have demonstrated to be effective for children with ADHD[79]. 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[9][28][31][15][81].
      • 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[82][83].
    • For children with hyperactivity, it is crucial to emphasize the importance of steering clear of activities that may stimulate behavior 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[28].
    • Sensory interventions are helping children who tend to be easily over-aroused by sensory stimuli. The utilization of tools like weighted blankets 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[84].
    • 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 behavioral interventions to address sleep issues in children[28].

Differential Diagnosis[edit | edit source]

add text here relating to the differential diagnosis of this condition

Resources[edit | edit source]

add appropriate resources here

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
  2. ↑ Thomas R, Sanders S, Doust J, Beller E, Glasziou P. Prevalence of attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Pediatrics. 2015; 135: e994-1001
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