Clinical review
Assessment and Management of Sleep Problems in Youths With Attention-Deficit/Hyperactivity Disorder

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Objective

To provide evidence- or consensus-based recommendations concerning the assessment and management of sleep problems in youths with attention-deficit/hyperactivity disorder (ADHD).

Method

PubMed, Ovid, EMBASE, and Web of Knowledge were searched through October 31, 2012. When no evidence was available, consensus of the authors was achieved. The evidence-level of the recommendations on the management of sleep disturbances was based on the Scottish Intercollegiate Guidelines Network (SIGN) system.

Results

A total of 139 original articles on sleep and childhood ADHD were retrieved, including 22 on treatment of sleep disturbances. This review focuses on behaviorally based insomnia, circadian rhythm disorder, sleep-disordered breathing, restless legs syndrome/periodic limb movement disorder, and sleep disturbances due to comorbid psychiatric disorders or ADHD medications. Healthy sleep practices are recommended as the foundation of management strategies. Behavioral interventions should be considered as first-line treatment of insomnia, although further evidence from randomized controlled trials (RCTs) is needed to prove their efficacy in ADHD. Among pharmacological treatments, RCTs support the use of melatonin to reduce sleep-onset delay, whereas there is more limited evidence for other medications.

Conclusion

Growing empirical evidence is informing assessment/management strategies of sleep problems in youths with ADHD. However, further RCTs are warranted to support current recommendations.

Section snippets

Method

PubMed, Ovid, EMBASE, and Web of Knowledge were searched from their inception to October 31, 2012 (search strategy available from corresponding author). We opted not to search for unpublished, non–peer-reviewed data because, as pointed out by the Cochrane group,6 the inclusion of unpublished data may introduce bias. Grades of evidence for recommendation on the management of sleep problems were assessed using the Scottish Intercollegiate Guidelines Network (SIGN) system (http://www.sign.ac.uk/).

Literature Search Results

After selection, 139 original articles were retained, including 22 papers on treatment (Figure 1). Building on this body of evidence, the following sections present our recommendations, preceded by an introductory section on sleep problems in youths with ADHD.

Sleep Problems in Youths With ADHD

As many as 70% of children with ADHD have been reported to display mild to severe sleep problems.8 Prevalence rates differ as a function of ADHD subtype (highest prevalence in the combined subtype,9 although sleepiness may be more frequent in the inattentive subtype5), psychiatric comorbidities, and medication use (both increasing the prevalence of sleep problems)9.

The most recent meta-analysis on sleep in ADHD10 found that children and/or their parents reported bedtime resistance, sleep-onset

Assessment of Sleep Problems in Children With ADHD in the Mental Health Setting

We recommend a baseline sleep evaluation during the initial assessment of ADHD as well as regular systematic screening for sleep problems as a necessary component of ongoing ADHD care. Although this review focuses on the management of sleep problems in children with an established diagnosis of ADHD, it is important to bear in mind that sleep disorders may mimic ADHD symptoms. Therefore, it is fundamental to screen for sleep disorders also in children referred for ADHD-like symptoms who do not

Behaviorally Based Insomnia

(Note: Because the term “behavioral insomnia” will disappear from the next edition of the ICSD, here “insomnia” refers to sleep-onset association and limit-setting disorders [Table 1]).

If impairing symptoms of insomnia are reported during the screening phase, a 2-week sleep diary should be kept to more clearly identify behaviors and patterns associated with insomnia (for diagnostic criteria of insomnia, see the American Acedemy of Sleep Medicine criteria13). Because individuals with ADHD may

Management of Sleep Problems in Children With ADHD

Management of sleep problems in children/youth with ADHD needs to be tailored to the specific conditions underlying sleep complaints. Before discussing the specific management of such conditions, we present a section on healthy sleep practices, the implementation of which should precede the targeted management of specific sleep disorders/conditions.

Tips for Adolescents and Young Adults

Several factors (e.g., hormonal, emotional, and social) make sleep problems in adolescents and young adults more problematic than in younger children. One factor that may contribute to sleep problems of adolescents and young adults is use of electronic media. Another factor that may complicate sleep and exacerbate arousal problems in this population is substance use. Some adolescents with ADHD report that they frequently make use of marijuana before bedtime to help them relax and fall asleep

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    This article was reviewed under and accepted by ad hoc editor James J. Hudziak, M.D.

    This Consensus Conference was supported by an unrestricted educational grant from Shire Pharmaceuticals. Dr. Cortese is supported by a Marie Curie International Outgoing Fellowship (PIOF-253103) from the European Commission Research Executive Agency.

    The authors are very grateful to Mara Pasetto of CtpVerona for her assistance with figure editing.

    Clinical guidance is available at the end of this article.

    Disclosure: Dr. Brown has received research support from Eli Lilly and Co. and from Shire. Dr. Stein has received support from Shire and has served as a consultant to Novartis and Next Wave Pharmaceuticals. Dr. Weiss has received honoraria, speaker board fees, research funds, and consultant fees from Eli Lilly and Co., Janssen, Purdue, and Shire. Dr. Owens has received grants from UCB; has served as a consultant to Takeda, Purdue, UCB, Transcept, and Shire; and has served on the advisory board of Jazz. Drs. Cortese, Corkum, Gruber, and O’Brien report no biomedical financial interests or potential conflicts of interest.

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