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Study: Don’t overlook sleep difficulties in children with ADHD; they may impair functioning as much as ADHD itself


Prob­lems with sleep are com­mon in chil­dren with ADHD; in fact, past stud­ies indi­cate that sleep prob­lems occur in between 70 and 85%. Because of this, the Amer­i­can Acad­e­my of Pedi­atrics rec­om­mends that sleep dif­fi­cul­ties should be assessed as part of a com­pre­hen­sive ADHD eval­u­a­tion. In some chil­dren, sig­nif­i­cant sleep dif­fi­cul­ties may be an impor­tant con­trib­u­tor to appar­ent ADHD symp­toms, and could con­tribute to a child being incor­rect­ly diag­nosed. For exam­ple, con­sis­tent insuf­fi­cient sleep would cer­tain­ly con­tribute to trou­ble with atten­tion and focus. For oth­er chil­dren, sleep prob­lems may co-exist with ADHD and con­tribute to sig­nif­i­cant func­tion­al impair­ment on their own.

Although the link between ADHD and sleep dif­fi­cul­ties is well-doc­u­ment­ed, eval­u­at­ing sleep dif­fi­cul­ties dur­ing an ADHD assess­ment may be rou­tine­ly over­looked. In addi­tion, the clin­i­cal impor­tance of this asso­ci­a­tion is not ful­ly clear because pri­or research has not exam­ined whether sleep prob­lems in youth with ADHD con­tribute to impair­ment in their dai­ly func­tion­ing above and beyond their ADHD symp­toms. For exam­ple, a child’s prob­lems in dai­ly func­tion­ing may be pri­mar­i­ly dri­ven by ADHD their symp­toms, with sleep prob­lems con­tribut­ing lit­tle. Alter­na­tive­ly, sleep prob­lems may cre­ate sig­nif­i­cant dif­fi­cul­ties for their dai­ly func­tion­ing beyond what ADHD symp­toms explain; in this case, treat­ing the child’s sleep dif­fi­cul­ties should be an impor­tant treat­ment tar­get.

The Study

A study recent­ly pub­lished online in the Jour­nal of Atten­tion Dis­or­ders, The func­tion­al impact of sleep dis­or­ders in chil­dren with ADHD, took a close look at this impor­tant issue. Par­tic­i­pants were 192 chil­dren — mean age of about 10 — who had been care­ful­ly diag­nosed with ADHD; over three-fourths were male.


Sleep — Par­ents rat­ed chil­dren’s sleep using the Pedi­atric Sleep Ques­tion­naire, which inquires about a broad range of sleep-relat­ed behav­iors. Rat­ings were used to iden­ti­fy youth who strug­gled with exces­sive day­time sleepi­ness (EDS), sleep-relat­ed breath­ing dis­or­der (SRBD), insom­nia, and peri­od­ic limb move­ments (PLMS).

ADHD symp­toms — Core ADHD symp­toms were rat­ed using a stan­dard­ized behav­ior rat­ing scale called the SNAP. Using this mea­sure, par­ents and teach­ers rat­ed chil­dren on each of 18 ADHD symp­toms.

Func­tion­ing — Chil­dren’s dai­ly func­tion­ing was assessed using the 50-item Weiss Func­tion­al Impair­ment Scale; this scale assess­es func­tion­ing in mul­ti­ple domains: fam­i­ly, learn­ing and school, life skills, self-con­cept, social activ­i­ties, and risky activ­i­ties. Par­ents also com­plete a Health-relat­ed qual­i­ty of life mea­sure on their child.


1. What is the nature of sleep prob­lems in youth with ADHD?

The most preva­lent sleep prob­lem — report­ed for 42% of the sam­ple — was exces­sive day­time sleepi­ness. This was fol­lowed by insom­nia (30%), PLMS (26%), and SRBD (25%). In addi­tion, 18% of par­ents report­ed sub­stan­tial vari­abil­i­ty in their child’s sleep from night to night. A num­ber of chil­dren had mul­ti­ple sleep dif­fi­cul­ties but this num­ber was not pro­vid­ed.

2. Do sleep prob­lems impair chil­dren’s dai­ly func­tion­ing above and beyond ADHD symp­toms?

This ques­tion was the crux of the study. Analy­ses indi­cat­ed that sleep prob­lems — specif­i­cal­ly, exces­sive day­time sleepi­ness — con­tributed to sig­nif­i­cant­ly low­er life skills even after con­trol­ling for ADHD symp­toms. For social impair­ment, high­er lev­els of insom­nia pre­dict­ed greater impair­ment, above and beyond impair­ment explained by ADHD symp­toms. When exam­in­ing par­ent reports of their child’s qual­i­ty of life, exces­sive day time sleepi­ness pre­dict­ed low­er rat­ings.

It is impor­tant to note that because all chil­dren had ADHD, the vari­abil­i­ty in func­tion­al impair­ment rat­ings was like­ly com­pressed rel­a­tive to what would be found in a non-clin­i­cal sam­ple. This makes find­ing sig­nif­i­cant asso­ci­a­tions between sleep dif­fi­cul­ties and func­tion­al impair­ment more dif­fi­cult. This may explain, for exam­ple, why a sig­nif­i­cant rela­tion­ship between sleep dif­fi­cul­ties and school func­tion­ing was not found.

Summary and implications

Results from this study reaf­firm that chil­dren with ADHD often strug­gle with sleep prob­lems. And, it extends on pri­or research by doc­u­ment­ing that sleep dif­fi­cul­ties — espe­cial­ly exces­sive day­time sleepi­ness — make sig­nif­i­cant inde­pen­dent con­tri­bu­tions to prob­lems in chil­dren’s dai­ly func­tion­ing and in their over­all qual­i­ty of life. For the qual­i­ty of life mea­sure, in fact, sleep dif­fi­cul­ties appeared to be a more impor­tant deter­mi­nant than ADHD symp­toms.

While these results should be repli­cat­ed, an impor­tant take away mes­sage is that the assess­ment and man­age­ment of sleep dif­fi­cul­ties in youth with ADHD is essen­tial. Fail­ing to iden­ti­fy and address such dif­fi­cul­ties may under­mine a child’s dai­ly func­tion­ing, even when ADHD symp­toms are being effec­tive­ly addressed.

A broad­er issue high­light­ed by these find­ings is the impor­tance of work­ing to iden­ti­fy all fac­tors con­tribut­ing to dif­fi­cul­ties expe­ri­enced by a child with ADHD. Although ADHD symp­toms can impair a child’s func­tion­ing in mul­ti­ple ways, par­ents, edu­ca­tors, and clin­i­cians need to be vig­i­lant about not attribut­ing all a child’s dif­fi­cul­ties to ADHD. Doing so can short-cir­cuit the impor­tant exam­i­na­tion of oth­er pos­si­ble con­trib­u­tors which will there­fore go unad­dressed to the like­ly detri­ment of the child.

Rabiner_David– Dr. David Rabin­er is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. He pub­lishes the Atten­tion Research Update, an online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD, and helped pre­pare the online course How to Nav­i­gate Con­ven­tion­al and Com­ple­men­tary ADHD Treat­ments for Healthy Brain Devel­op­ment.

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