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Behavioral sleep problems and internalizing and externalizing comorbidities in children with attention-deficit/hyperactivity disorder

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Abstract

Behavioral sleep problems are common in children with attention-deficit/hyperactivity disorder (ADHD), as are internalizing and externalizing comorbidities. The prevalence of these difficulties and the extent to which they co-exist in children with ADHD could inform clinical practice, but remains unclear. Therefore, we examined the association between sleep problems and internalizing and externalizing comorbidities in children with ADHD. Children aged 5–13 years were recruited from 21 pediatric practices across Victoria, Australia (N = 392). Internalizing and externalizing comorbidities (none, internalizing, externalizing, co-occurring) were assessed by the telephone-administered Anxiety Disorders Interview Schedule for Children IV/Parent version. Sleep problem severity was assessed by primary caregiver report (no, mild, moderate or severe problem). Moderate/severe sleep problems were confirmed using International Classification of Sleep Disorders. Seven specific sleep problem domains (bedtime resistance, sleep anxiety, sleep onset delay, sleep duration, night waking, parasomnias and daytime sleepiness) were assessed using the Children’s Sleep Habits Questionnaire. Data were analyzed using adjusted logistic and linear regression models. Compared to children without comorbidities, children with co-occurring internalizing and externalizing comorbidities were more likely to have moderate/severe sleep problems (adjusted OR 2.4, 95 % CI 1.2; 4.5, p = 0.009) and problematic sleep across six of seven sleep domains. Children with either comorbidity alone were not at risk of moderate/severe sleep problems, but at the sleep domain level, children with internalizing alone had more sleep anxiety, and those with externalizing alone had less night waking. In conclusion, children with ADHD experiencing co-occurring internalizing and externalizing comorbidities are at an increased risk of sleep problems.

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Acknowledgments

KL is supported by a Murdoch Childrens Research Institute (MCRI) Postgraduate Health Scholarship. ES, FM and HH are supported by the National Health and Medical Research Council (NHMRC), Early Career Development Awards (Grants 1037159, 1037449) and Career Development Award (Grant 607351), respectively. All aspects of the RCT involving children with moderate/severe sleep problems at baseline, including follow-up, are funded by a NHMRC (Grant 607362). All aspects of the cohort study involving children with no/mild sleep problems at baseline are funded by MCRI. MCRI is supported by the Victorian Government’s Operational Infrastructure Support Program. KL, ES, FM, HH conceived the study. KL coordinated the study and conducted the analysis under the supervision of FM. KL had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors contributed to the writing of the manuscript. We thank all families and pediatricians for taking part in the study. We also thank the Sleeping Sound research team for making this study possible.

Conflict of interest

The authors declare that they have no conflicts of interest.

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Authors and Affiliations

  1. Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia

    Kate Lycett, Fiona K. Mensah & Harriet Hiscock

  2. Community Child Health, Murdoch Childrens Research Institute, Parkville, VIC, Australia

    Kate Lycett, Emma Sciberras & Harriet Hiscock

  3. Centre for Community Child Health, The Royal Children’s Hospital, Flemington Road, Parkville, VIC, 3052, Australia

    Kate Lycett, Emma Sciberras, Fiona K. Mensah & Harriet Hiscock

  4. Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, The Royal Children’s Hospital, Flemington Road, Parkville, VIC, Australia

    Fiona K. Mensah

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  1. Kate Lycett
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Correspondence to Kate Lycett.

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Lycett, K., Sciberras, E., Mensah, F.K. et al. Behavioral sleep problems and internalizing and externalizing comorbidities in children with attention-deficit/hyperactivity disorder. Eur Child Adolesc Psychiatry 24, 31–40 (2015). https://doi.org/10.1007/s00787-014-0530-2

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