Study: A brief sleep intervention can bring measurable and sustained benefits to children with ADHD

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 Sleep prob­lems are com­mon in chil­dren with ADHD, are more per­sis­tent than in the gen­er­al pop­u­la­tion, and often exac­er­bate dif­fi­cul­ties asso­ci­at­ed with ADHD. For exam­ple, poor sleep can enhance dif­fi­cul­ties with atten­tion and con­cen­tra­tion that most youth with ADHD experience.

Research has shown that brief sleep inter­ven­tions can improve sleep in youth with­out ADHD who expe­ri­ence sleep dif­fi­cul­ties. How­ev­er, until recent­ly, there have been no ran­dom­ized con­trolled tri­als on the impact of brief sleep inter­ven­tions in youth with both ADHD and sleep difficulties.

A study pub­lished in the British Med­ical Jour­nal in 2015, and with a fol­low-up pub­lished in Psy­cho­log­i­cal Med­i­cine in 2018, pro­vides an impor­tant inves­ti­ga­tion demon­strat­ing that many youth with ADHD and sleep dif­fi­cul­ties can be helped by a rel­a­tive­ly brief sleep intervention. 

The Study:

Par­tic­i­pants were 244 chil­dren with ADHD ages 5–12 and their parent(s) who also met the Amer­i­can Acad­e­my of Sleep Med­i­cine diag­nos­tic cri­te­ria for at least one sleep dis­or­der, e.g., need­ing some­one in the same room to fall asleep, not fall asleep for 2 or more hours beyond social­ly acceptable/conventional time, dif­fi­cul­ty falling and/or main­tain­ing sleep.

Fam­i­lies were ran­dom­ly assigned to receive a brief sleep inter­ven­tion or to the con­trol con­di­tion. The inter­ven­tion was lim­it­ed to 2 ses­sions and a sin­gle fol­low-up phone consultation.

In the first ses­sion, clin­i­cians assessed the child’s sleep prob­lem, devel­oped par­ents’ goals for sleep man­age­ment, pro­vid­ed infor­ma­tion about nor­mal sleep and sleep hygiene strate­gies, and devel­oped a behav­ioral man­age­ment plan spe­cif­ic to the child’s sleep issues. Par­ents were also asked to begin keep­ing a sleep diary for their child.

Dur­ing the sec­ond ses­sion and phone con­sul­ta­tion one-week lat­er, clin­i­cians reviewed the child’s sleep diary, reviewed and rein­forced strate­gies par­ents were imple­ment­ing to improve their child’s sleep, and addressed any dif­fi­cul­ties they were hav­ing imple­ment­ing the sleep plan.

A range of mea­sures were col­lect­ed at base­line, and again 3 and 6 months after the brief inter­ven­tion end­ed, and also (for the fol­low-up study), 12 months later.

The pri­ma­ry out­come mea­sure was par­ents’ and teach­ers report of chil­dren’s ADHD symptoms.

Addi­tion­al mea­sures includ­ed par­ents’ report of chil­dren’s sleep prob­lems, teacher rat­ings of chil­dren’s class­room behav­ior, par­ents’ reports of their child’s qual­i­ty of life and dai­ly func­tion­ing, and chil­dren’s school atten­dance. Chil­dren’s work­ing mem­o­ry was also assessed.

Par­ents also report­ed on their own men­tal health and work attendance.

The short-term results:

At both 3- and 6‑months, ADHD symp­toms as rat­ed by par­ents were mod­est­ly low­er in chil­dren who received the sleep inter­ven­tion than in con­trol chil­dren. Although there was no group dif­fer­ence in teach­ers’ rat­ings of core ADHD symp­toms; how­ev­er, teach­ers report­ed greater reduc­tions in behav­ioral dif­fi­cul­ties at both time points.

Com­pared to con­trol chil­dren, inter­ven­tion chil­dren had few­er sleep dif­fi­cul­ties, improved qual­i­ty of life scores, few­er dai­ly func­tion­ing dif­fi­cul­ties, and improve­ment in at least one mea­sure of work­ing mem­o­ry. Although school atten­dance did not dif­fer, inter­ven­tion chil­dren were less like­ly to be late to school at the 6‑month follow-up.

The mag­ni­tude of the effects dif­fered by mea­sure but were gen­er­al­ly in the small to mod­er­ate range, expect for reduc­tions in sleep dif­fi­cul­ties which were larg­er. Addi­tion­al analy­ses indi­cat­ed that reduc­tions in chil­dren’s ADHD symp­toms were relat­ed to improve­ments in their sleep.

Beyond the inter­ven­tion’s impact on chil­dren, at 3‑months par­ents report­ed few­er late days for work and few­er missed work days as a result of their child’s behavior.

The long-term results:

In the recent­ly pub­lished fol­low-up, the researchers exam­ined out­comes at 12-months post-intervention.

Inter­ven­tion chil­dren were less like­ly to have mod­er­ate to severe sleep prob­lems based on par­ent report (28.4% vs. 46.5%). Par­ents of inter­ven­tion sub­jects also report­ed sig­nif­i­cant­ly low­er ADHD symp­toms among their chil­dren, improved behav­ior over­all, and bet­ter qual­i­ty of life and dai­ly func­tion­ing. Although sta­tis­ti­cal­ly sig­nif­i­cant, the mag­ni­tude of the dif­fer­ences was modest.

An inter­est­ing and some­what unex­pect­ed find­ing was that the ben­e­fits over time on chil­dren’s sleep were reduced in chil­dren not tak­ing medication.

Summary and implications:

There are sev­er­al impor­tant take aways from this study.

First, chil­dren’s sleep should be eval­u­at­ed as part of an ADHD eval­u­a­tion as sleep dif­fi­cul­ties are more com­mon among youth with ADHD. These dif­fi­cul­ties can both exac­er­bate ADHD symp­toms and have their own inde­pen­dent adverse affect on chil­dren’s functioning.

Sec­ond, at least for ADHD youth who also have sleep dif­fi­cul­ties, a very brief sleep inter­ven­tion can yield sus­tained ben­e­fits in mul­ti­ple domains. Although the mag­ni­tude of these ben­e­fits may be mod­est, so is the time required to coach par­ents on ways to improve their child’s sleep. And, these ben­e­fits were obtained above and beyond any ben­e­fits pro­vid­ed by med­ica­tion for those chil­dren who were tak­ing it.

It is pos­si­ble that these mod­est ben­e­fits may lead to larg­er cumu­la­tive gains over time, In addi­tion, a more sus­tained sleep inter­ven­tion in the form of more fre­quent coach­ing and fol­low-up may have yield­ed larg­er gains.

Over­all, the find­ings from these stud­ies indi­cate that address­ing sleep issues in chil­dren with ADHD is a fea­si­ble and rel­a­tive­ly low-cost approach that can be a valu­able treat­ment com­po­nent for many children.

– 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.

The Study in Context: