Brief CommunicationManaging sleep problems in school aged children with ADHD: A pilot randomised controlled trial
Introduction
Attention-Deficit/Hyperactivity Disorder (ADHD) affects about 5% of children worldwide [1] and places children at risk for poorer long-term functioning in social, academic, and family domains [2]. ADHD is most commonly treated using stimulant medication, however, there have been concerns about the potential adverse effects of stimulant medication, including poor growth and cardiac effects [3]. Therefore, strategies which may reduce the need for medication would be regarded as desirable [3]. Identifying and managing sleep problems in children with ADHD may be one such strategy. This is because there is considerable overlap in consequences of disrupted sleep and ADHD symptoms (e.g., difficulty paying attention and focusing, hyperactivity, irritability, poor impulse control, etc.). Some children diagnosed with ADHD may actually have a primary sleep disorder which accounts for their symptoms [4].
Up to 70% of parents of children with ADHD report sleep problems in their child, such as difficulties initiating and maintaining sleep [5], [6], [7], [8], [9], [10]. In a 2006 survey of 239 school-aged children with ADHD, we found that moderate/severe sleep problems were associated with increasing ADHD severity and poorer child quality of life (QoL), daily functioning and caregiver mental health [10]. Compared to children with no sleep problems, children with moderate/severe sleep problems were also more likely to miss/be late for school, and their caregivers were more likely to be late for work.
Many of the sleep problems experienced by children with ADHD occur at or around sleep onset and are of a behavioral nature [10]. The efficacy of behavioral sleep interventions has been demonstrated in the general population [11], however, no controlled trials of behavioral sleep interventions have been reported in children with ADHD. Only one study (n = 3) evaluated behavioral interventions for sleep problems in unmedicated children with ADHD [12], and it showed improvement in sleep but no change in ADHD symptoms. Behavioral sleep trials in children with challenging behaviors (i.e., learning disabilities and autism) suggest that behavioral sleep interventions can be effective [13], [14]. A recent review of ADHD and sleep problems in this journal highlights the need for research assessing the effectiveness of behavioral strategies for sleep problems in children with ADHD [15].
Before embarking on a definitive randomized controlled trial, we needed to determine the most suitable behavioral sleep intervention program for children with ADHD. We therefore aimed to determine the feasibility and acceptability of a brief vs. an extended behavioral sleep program for children with ADHD, and the impact of each program on child and caregiver outcomes.
Section snippets
Study design and sample
We identified families of children aged 5–14 years with pediatrician-diagnosed ADHD from our 2006 survey of children with ADHD [10] and from two outpatient clinics at the Royal Children’s Hospital, Melbourne. We contacted families to establish whether their child had a moderate/severe sleep problem that fulfilled American Academy of Sleep Medicine diagnostic criteria for at least one sleep disorder (i.e., sleep onset association disorder, limit setting disorder, delayed sleep phase, primary
Sample characteristics
Of the 80 eligible families, we could not contact 17 and excluded 20 as the child did not have moderate/severe sleep problems and/or meet American Academy of Sleep Medicine diagnostic criteria for a sleep disorder. Of the remaining 43 families, 27 consented to take part (63% response rate, Fig. 1). Inability to travel to the hospital was the main barrier to participation. There were no significant differences in child gender, age or mean Socio-Economic Indexes for Areas (SEIFA) [21] scores for
Discussion
In this first randomized controlled trial of a behavioral sleep intervention for children with ADHD, both brief and extended sleep programs were found to be feasible to deliver and acceptable to caregivers. Both programs resulted in a reduction in child sleep problems at five months post-randomisation. Compared to the brief program, the extended program showed additional benefits of improved child psychosocial QoL, child daily functioning, and parental anxiety.
Our study had a number of
Conflict of interest
The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: doi:10.1016/j.sleep.2011.02.006.
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