Sleep in Children with Attention Deficit Hyperactivity Disorder (ADHD)

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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]. 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[7][14][15]. It is also associated with depressive symptoms[16], and poorer mental health of primary caregivers[17].

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[18],may play a significant role. This is because REM is linked to parasomnias like nightmare disorder, which often lead to awakenings[19], and it also affects neurobehavioral functioning in children with ADHD[20]. Behaviors indicative of parasomnias often include night terrors, confusional arousals, episodes of waking up screaming, increased motor activity such as sleepwalking, and enuresis (bedwetting)[21][22]. The use of medication and comorbidities (like anxiety) also increase the risk of parasomnias[22].
  • 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[23].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[24].
  • 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[22].
  • 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[22]. Sleep disordered breathing often results in sleep fragmentation and excessive daytime sleepiness[23].
  • 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[25].

Environmental factors[edit | edit source]

Environmental factors also play a significant role in the initiation of sleep[26].

  • Exposure to light[26]

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[25]. 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[25].

The following issues can be experienced by their parents:

  • Less sleep for the parents[31]
  • Parental daytime fatigue[31]
  • Mood disturbances in parents[31]
  • Decreased level of effective parenting[31]
  • Clinically depression or anxiety[17]

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[32][33][34]. The degree of time it takes to fall asleep varies with different drugs, the dosis and the time of administration[34]. Commonly reported are >30 minutes[35][36]. For some children it is easier to fall asleep while on stimulants than off[25]. 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[25].

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%)[37], 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[38].

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[39].
  • Co-morbidities: mood disorders, anxiety disorders and tic disorders have been linked with significant sleep problems[40][41][42].

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[25]. There are several tools available, such as psychometrically validated questionnaires for both parents and children, and sleep diaries[43]. These tools can aid in identifying sleep problems:

  • Questionnaires:
    • The Sleep Disorders Questionnaire (SDQ)[44]
    • Pediatric Sleep Questionnaire (PSQ)[45]
    • The Children's Sleep Habits Questionnaire (CSHQ)[46]
    • The Sleep Disturbance Scale for Children[47]
  • 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[25]. Two weeks of baseline sleep diary recordings are adequate for outlining sleep patterns[48].
  • 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[25] and this tool significantly increased the amount of sleep information compared to other checklists[49].
  • 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[50]
    • Sleep Hygiene Index[51]

Interventions[edit | edit source]

The severity of ADHD can be reduced by improving the sleep of children with behavioral sleep interventions[7]. 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[22]. 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[52][53]. Prolonged use of melatonin has been considered safe for children with ADHD[53].Side effects are: bedwetting, headaches, nightmares, daytime sedation, abdominal pain or constipation[22].
    • Clonidine: studies involving clonidine in children with ADHD have indicated reductions in sleep latency en nighttime awakenings[22]. 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[22].
    • Iron supplements: in children with ADHD and increased motor symptoms in sleep who have low ferritin levels, supplementation with iron might be beneficial[54].
  • 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[22].
    • Established sleep hygiene practices tailored for children have demonstrated to be effective for children with ADHD. 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[22][25][55].
    • 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[22].
    • 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[56].
    • 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[22].

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
  3. ↑ Ophoff D, Slaats MA, Boudewyns A, Glazemakers I, Van Hoorenbeeck K, Verhulst SL. Sleep disorders during childhood: a practical review. European Journal of Pediatrics. 2018; 177: 641-648
  4. ↑ 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
  5. ↑ 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
  6. ↑ 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
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 Yin H, Yang D, Yang L, Wu G. Relationship between sleep disorders and attention-deficit-hyperactivity disorder in children. Frontiers in Pediatrics. 2022; 10: 919572
  8. ↑ 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
  9. ↑ Cortese S, Brown TE, Corkum P, Gruber R, O'Brien LM, Stein M. 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
  10. ↑ 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
  11. ↑ Yoon SY, Jain U, Shapiro C. Sleep in attention-deficit/hyperactivity disorder in children and adults: past, present, and future. Sleep Medicine Reviews. 2012; 16(4): 371-88
  12. ↑ Lycett K, Mensah FK, Hiscock H, Sciberras E. A prospective study of sleep problems in children with ADHD. Sleep Medicine. 2014; 15: 1354-61
  13. ↑ 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
  14. ↑ Paavonen EJ, Raikkonen K, Lahti J, Komsi N, Heinonen K, Pesonen AK. 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
  15. ↑ 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
  16. ↑ Becker SP, Langberg JM, Evans SW. 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
  17. ↑ 17.0 17.1 17.2 17.3 17.4 17.5 Sung V, Hiscock H, Sciberras E, Efron D. 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
  18. ↑ Scarpelli S, Gorgoni M, D'atri A, Reda F, De Gennaro L. Advances in understanding the relationship between sleep and attention deficit-hyperactivity disorder (ADHD). Journal of Clinical Medicine. 2019; 8(10): 1737
  19. ↑ Bruni O, DelRosso LM, Melegari MG, Ferri R. The parasomnias. Child and Adolescent Psychiatric Clinics of North America. 2021; 30(1): 131-142
  20. ↑ Kirov R, Brand S, Banaschewski T, Rothenberger A. Opposite impact of REM sleep on neurobehavioral functioning in children with common psychiatric disorders compared to typically developing children. Frontiers in Psychology. 2017; 7: 2059
  21. ↑ Silvestri R, Gagliano A, Aricò I, Cedro C, Bruni O, Condurso R, Germano E, Siracusano R, Vita G, Bramanti P. Sleep disorders in children with Attention-Deficit/Hyperactivity Disorder (ADHD) recorded overnight by video-polysomnography. Sleep Medicine. 2009; 10: 1132–1138
  22. ↑ 22.00 22.01 22.02 22.03 22.04 22.05 22.06 22.07 22.08 22.09 22.10 22.11 22.12 22.13 22.14 22.15 22.16 Ramtekkar UP. DSM-5 changes in attention deficit hyperactivity disorder and autism spectrum disorder: implications for comorbid sleep issues. Children. 2017; 4: 62
  23. ↑ 23.0 23.1 23.2 23.3 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
  24. ↑ Kohyama J. Possible neuronal mechanisms of sleep disturbances in patients with autism spectrum disorders and attention-deficit/hyperactivity disorder. Medical Hypotheses. 2016; 97: 131-133
  25. ↑ 25.0 25.1 25.2 25.3 25.4 25.5 25.6 25.7 25.8 Weiss MD, Salpekar J. Sleep problems in the child with attention-deficit hyperactivity disorder: defining aetiology and appropriate treatments. CNS Drugs. 2010; 24(10): 811-28
  26. ↑ 26.0 26.1 26.2 26.3 26.4 Malow BA, Byars K, Johnson K, Weiss S, Bernal P, Goldman SE, Panzer R, Coury DL, Glaze DG. A Practice Pathway for the Identification, Evaluation, and Management of Insomnia in Children and Adolescents With Autism Spectrum Disorders. Pediatrics. 2012; 130: 106-124
  27. ↑ 27.0 27.1 27.2 27.3 Um YH, Jeong JH, Hong SC, Kim TW, Lim HK, Seo HJ. 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
  28. ↑ 28.0 28.1 28.2 28.3 28.4 28.5 Shur-Fen GS. 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.
  29. ↑ 29.0 29.1 29.2 29.3 29.4 29.5 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
  30. ↑ 30.0 30.1 30.2 Stickley A, Shirama A, Kitamura S, Kamio Y, Takahashi H, Saito A. Attention deficit/hyperactivity disorder symptoms and sleep problems in preschool children: the role of autistic traits. Sleep Medicine. 2021; 83: 214-21
  31. ↑ 31.0 31.1 31.2 31.3 Gelman VS, King NJ. Wellbeing of mothers with children exhibiting sleep disturbance. Australian Journal of Psychology. 2001; 53(1): 18-22
  32. ↑ Ramtekkar U, Ivanenko A. Sleep in Children With Psychiatric Disorders. Seminars in Pediatric Neurology. 2015; 22(2): 148-55
  33. ↑ Coghill DR, Caballero B, Sorooshian S, Civil RA. Systematic review of the safety of lisdexamfetamine dimesylate. CNS Drugs. 2014; 28: 497–511.
  34. ↑ 34.0 34.1 Stein MA, Weiss M, Leventhal BL. ADHD by night: sleep problems and ADHD medications. Child and Adolescent Psychopharmacology News. 2007; 12(6): 1-5
  35. ↑ O’Brien LM, Ivanenko A, Crabtree VM, Holbrook CR, Bruner JL, Klaus CJ, Gozal D. The effect of stimulants on sleep characteristics in children with attention deficit/hyperactivity disorder. Sleep Medicine. 2003; 4: 309-316
  36. ↑ Sangal RB, Owens J, Allen AJ, Sutton V, Schuh K, Kelsey D. Effects of atomoxetine and methylphenidate on sleep in children with ADHD. Sleep. 2006; 29(12): 1573-85
  37. ↑ Huang MM, Qian Z, Wang J, Vaughn MG, Lee YL, Dong GH. Validation of the sleep disturbance scale for children and prevalence of parent-reported sleep disorder symptoms in Chinese children. Sleep Medicine. 2014; 15: 923-8
  38. ↑ 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
  39. ↑ Iwata S, Iwata O, Matsuishi T. Sleep patterns of Japanese preschool children and their parents: implications for co-sleeping. Acta Peadiatrica. 2013; 102: e257-62
  40. ↑ American Academy of Pediatrics (AAP). Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics 2000; 105: 1158-70
  41. ↑ Ivanenko A, Crabtree VM, Obrien LM, Gozal D. Sleep complaints and psychiatric symptoms in children evaluated at a pediatric mental health clinic. Journal of Clinical Sleep Medicine. 2006; 2(1): 42-8
  42. ↑ Ivanenko A, Johnson K. Sleep disturbances in children with psychiatric disorders. Seminars in Pediatric Neurology. 2008; 15(2): 70-8
  43. ↑ Morgenthaler TI, Lee-Chiong T, Alessi C, Friedman L, Aurora RN, Boehlecke B, Brown T, Chesson AL, Kapur V, Maganti R, Owens J, Pancer J, Swick TJ, Zak R. Practice parameters for the clinical evaluation and treatment of circadian rhythm sleep disorders. An American Academy of Sleep Medicine report. Sleep. 2007; 30(11): 1445-59
  44. ↑ Douglass AB, Bornstein R, Nino-Murcia G, Keenan S, Miles L, Zarcone Jr VP, Guilleminault C, Dement WC. The Sleep Disorders Questionnaire: I. Creation and multivariate structure of SDQ. Sleep. 1994; 17(2): 160-7
  45. ↑ Chervin RD, Hedger K, Dillon JE, Pituch KJ. Pediatric Sleep Questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Medicine. 2000; 1(1): 21-32
  46. ↑ Owens JA, Spirito A, McGuinn M. The Children’s Sleep Habits Questionnaire (CSHQ): psychometric properties of a survey instrument for school-aged children. Sleep 2001; 23: 1043-51
  47. ↑ Bruni O, Ottaviano S, Guidetti V, Romoli M, Innocenzi M, Cortesi F, Giannotti F. The Sleep Disturbance Scale for Children (SDSC): construction and validation of an instrument to evaluate sleep disturbances in childhood and adolescence. Journal of Sleep Research. 1996; 5(4): 251-61
  48. ↑ Mindell JA, Owens JA. A clinical guide to pediatric sleep: diagnosis and management of sleep problems. Baltimore (MD): Lippincott Williams & Wilkins. 2003
  49. ↑ Owens JA, Dalzell V. Use of the ‘BEARS’ sleep screening tool in a pediatric residents’ continuity clinic: a pilot study. Sleep Medicine. 2005; 6(1): 63-9
  50. ↑ Harsh JR, Easley A, LeBourgeois MK. An instrument to measure children’s sleep hygiene. Sleep. 2002; 25: A316
  51. ↑ Mastin DF, Bryson J, Corwyn R. Assessment of sleep hygiene using the Sleep Hygiene Index. Journal of Behavioral Medicine. 2006; 29: 223-7
  52. ↑ Van der Heijden KB, Smits MG, van Someren EJW, Ridderinkhof KR, Gunning WB. Effect of Melatonin on Sleep, Behavior, and Cognition in ADHD and Chronic Sleep-Onset Insomnia. Journal of the American of Child and Adolescent Psychiatry. 2007; 46(2): 233–241.
  53. ↑ 53.0 53.1 Hoebert M, Van Der Heijden KB, Van Geijlswijk IM, Smits MG. Long-term follow-up of melatonin treatment in children with ADHD and chronic sleep onset insomnia. Journal of Pineal Research. 2009; 47(1): 1–7.
  54. ↑ Villagomez A, Ramtekkar U. Iron, Magnesium, Vitamin D, and Zinc Deficiencies in Children Presenting with Symptoms of Attention-Deficit/Hyperactivity Disorder. Children. 2014; 1(3): 261-279
  55. ↑ Owens JA. The ADHD and sleep conundrum redux: Moving forward. Sleep Medicine Reviews. 2006; 10: 377–379.
  56. ↑ Hvolby A, Bilenberg N. Use of Ball Blanket in attention-deficit/hyperactivity disorder sleeping problems. Nordic Journal of Psychiatry. 2011; 65: 89–94.
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