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Parent and Child Report of Sleep Problems in Children with ADHD
In prior issues of ADHD RESEARCH UPDATE studies in which sleep difficulties among children with ADHD were investigated have been reviewed. These studies have found that parents of children with ADHD are more likely to report sleep difficulties in their children. This is an important finding for two reasons. First, some investigators have suggested that in some cases, significant sleep difficulties may explain the ADHD symptoms that a child is displaying. In other words, some apparent cases of ADHD may reflect an undiagnosed and untreated sleep disorder. Second, even when this is not the case, inadequate sleep could exacerbate symptoms in a child who truly has ADHD. Addressing these sleep problems appropriately could thus play an important role in reducing some of the child's difficulties.
In a recently published study in the Archives of Pediatric and Adolescent Medicine interesting new data ion this important issue is presented (Owens, J. eta., (2000). Parental and self-report of sleep in children with ADHD. Archives of Pediatric and Adolescent Medicine, 154, 549-555.) This study adds to existing knowledge in this area because it provides information about sleep difficulties from children with ADHD themselves, rather than relying exclusively on the report of their parents.
Participants in this study were 46 unmedicated school-age children (mean age 89 months; 74% male) diagnosed with ADHD who had been screened for severe symptoms of a sleep-related breathing disorder and 46 matched controls. None of the ADHD children were reported to have a comorbid diagnosis of depression or an anxiety disorder, and very few were reported to have an additional disruptive behavior disorder (i.e. Conduct Disorder or Oppositional Defiant Disorder). The relative absence of these other diagnoses in a population of children with ADHD is somewhat unexpected given the substantially higher rates of such conditions that are generally reported, and suggests that the severity of the symptoms of children in this sample may have been on the mild side.
It is instructive that nearly 20% of the original sample of children with ADHD were excluded because they were determined to have marked symptoms of sleep disordered breathing. These children were excluded because of the concern that this sleep difficulty could possibly explain the ADHD symptoms that they had been displaying, and the authors wanted to examine reports of sleep problems in children with ADHD for whom this potential confound had been eliminated. The fact that such a substantial proportion of ADHD subjected were found to have these strong symptoms of disturbed sleep underscores the importance of attending to such issues in a child's diagnostic evaluation.)
The design and procedures used in this study were quite simple. Parents of ADHD and control children completed the Children's Sleep Habits Questionnaire (CSHQ), a measure that surveys parents about a wide variety of children's sleep behaviors and problems and which has been validated in prior studies. In addition, a corresponding self-report sleep measure was developed to assess many of these same issues from the child's perspective.
Results
Parent Report
The CSHQ contains 8 different subscales including: bedtime resistance, sleep-onset delay, sleep duration, sleep anxiety, night wakings, parasomnias (e.g. wetting the bed, sleep walking, nightmares), sleep-disordered breathing, and daytime sleepiness. Parents of children with ADHD reported more problems than parents of control children in every area except for sleep disordered breathing. (The absence of group differences on this scale is to be expected given that children with ADHD who had clear sleep disordered breathing difficulties had already been screened out.)
Child Report
The self-report measure for children was completed by 36 children with ADHD who were at least 7 years of age and by 24 control children. Children with ADHD also reported themselves to have more sleep-related difficulties than other children, and the areas of difficulty they reported are quite interesting.
First, and not surprisingly, children with ADHD reported more fighting with parents around the issue of bedtime. This may be related to the more-frequent struggles that children with ADHD and their parents are likely to engage in about a variety of issues, and may not necessarily be specific to bedtime. In any event, it does highlight that this is perceived as an area of difficulty by many children with ADHD, and suggests that this may need to be a particular focus of treatment in many families.
Somewhat surprisingly - at least to me - the other sleep- related difficulties that children with ADHD reported centered around fears/anxieties associated with bed time and going to sleep. Children in the ADHD group were more likely to report that they needed a parent in the room with them to fall asleep, that they were afraid of the dark, and that they were bothered by nightmares. Thus, it appears that children with ADHD may be more likely than others to view the period around sleep onset as one "...that frequently engenders anxiety and is often difficult and unpleasant". In fact, these results leads one to wonder whether for some children with ADHD, the struggles that occur around going to bed may partially reflect their fear and anxiety about sleeping alone.
Summary And Implications
Although the authors of this study are careful to note that their relatively small sample size requires that the results obtained be viewed with caution, the finding that sleep-related fears and worries may be more common in children with ADHD is an important one. What the reason for this may be is unclear, but it does suggest an avenue to explore when a child with ADHD is consistently struggling with parents around bedtime or is having problem getting sufficient sleep.
Another important issue highlighted by this study is the importance of screening all children who have symptoms suggesting ADHD for sleep problems. As noted above, this is because in some causes, serious sleep difficulties (i.e. sleep disordered breathing problems such as obstructive sleep apnea) may play an important causative role in those symptoms, while in other cases they may certainly exacerbate the severity of a child's symptoms. Treatment strategies for children with ADHD do not routinely focus on sleep difficulties, and treatment with stimulant medication can actually produce sleep problems as a side effect in some children. Carefully attending to a child's sleep, and making sure that appropriate interventions are in place to address problems that may be apparent, can thus be an important component in the overall treatment plan for many children with ADHD.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.