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Shortened Sleep Duration Causes Sleepiness, Inattention, and Oppositionality in Adolescents With Attention-Deficit/Hyperactivity Disorder: Findings From a Crossover Sleep Restriction/Extension Study

https://doi.org/10.1016/j.jaac.2018.09.439Get rights and content

Objective

Although poor sleep is often reported in adolescents with attention-deficit/hyperactivity disorder (ADHD), prior studies have been correlational. This study investigated whether sleep duration is causally linked to sleepiness, inattention, and behavioral functioning in adolescents with ADHD.

Method

A total of 72 adolescents (aged 1417 years) entered a 3-week sleep protocol using an experimental crossover design. The protocol included a phase stabilization week, followed in randomized counterbalanced order by 1 week of sleep restriction (6.5 hours) and 1 week of sleep extension (9.5 hours). Sleep was monitored with actigraphy and daily sleep diaries, with laboratory visits at the end of each week. Analyses included 48 adolescents who had complete actigraphy data and successfully completed the sleep protocol (defined a priori as obtaining ≥1 hour actigraphy-measured sleep duration during extension compared to restriction). Parent and adolescent ratings of daytime sleepiness, ADHD symptoms, sluggish cognitive tempo (SCT), and oppositional behaviors were the primary measures. The A-X Continuous Performance Test (CPT) was a secondary measure.

Results

Compared to the extended sleep week, parents reported more inattentive and oppositional symptoms during the restricted sleep week. Both parents and adolescents reported more SCT symptoms and greater daytime sleepiness during restriction compared to extension. Adolescents reported less hyperactivity-impulsivity during sleep restriction than extension. No effects were found for parent-reported hyperactivity-impulsivity, adolescent-reported ADHD inattention, or CPT performance.

Conclusion

This study provides the first evidence that sleep duration is a causal contributor to daytime behaviors in adolescents with ADHD. Sleep may be an important target for intervention in adolescents with ADHD.

Clinical trial registration information

Cognitive and Behavioral Effects of Sleep Restriction in Adolescents With ADHD; https://clinicaltrials.gov/; NCT02732756.

Section snippets

Participants

Participants were 72 adolescents (71% male and 29% female) aged 14 to 17 years (mean ± SD, 15.10 ± 1.06 years) diagnosed with ADHD. All participants had an IQ ≥70 (range, 79−132) based on the Kaufman Brief Intelligence Scale, Second Edition.21 Sample characteristics, including comorbid diagnoses based on the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS)22 interview conducted separately with the adolescent and parent, are provided in Table 1.

Full DSM-5

Participant Recruitment, Retention, and Adherence

Figure 2 provides a flow diagram of study recruitment and retention. A total of 64 participants completed the sleep protocol and had complete actigraph data to determine adherence. As shown in Figure 2 and as detailed in Figure S1, available online, 48 of these 64 adolescents (75%) were adherent to the sleep protocol and were included in primary analyses. Additional details regarding adherence can be found in the Supplemental Materials, available online, including analyses indicating no

Discussion

This study provides the first evidence that insufficient sleep causes impairments in self- and parent-reported daytime functioning in adolescents with ADHD. Restricted sleep worsens attentional functioning and increases oppositional behaviors and daytime sleepiness in adolescents with ADHD.

The impact of restricted sleep on attention was found for parent-reported inattentive symptoms and for both parent- and adolescent-reported SCT symptoms. This is robust evidence for restricted sleep worsening

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    This research was supported by the National Institute of Mental Health (NIMH; grant R03MH109787; Dr. Becker). Dr. Becker is supported by grant K23MH108603 from the NIMH. The content is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. National Institutes of Health (NIH).

    This study was presented in a symposium at the American Academy of Child and Adolescent Psychiatry's 65th Annual Meeting; Seattle, WA; October 22−27, 2018.

    Disclosure: Dr. Becker has received research support from the Institute of Education Science (IES), the Cincinnati Children's Research Foundation (CCRF), and the Secretariat of State for Research, Development and Innovation, Ministry of Economy, Industry and Competitiveness (Spanish Government). Dr. Epstein has received research support from the National Institutes of Health (NIH), the Agency for Healthcare Research and Quality (AHRQ), the IES, and Akili Interactive Labs. He has received royalties from Multi-Health Systems, Inc., received consulting fees from the American Academy of Pediatrics and American Board of Pediatrics, and received licensing fees from Optimal Medicine, Inc. and IXICO. Dr. Tamm has received research support from the NIH, the IES, the AHRQ, the Brady Foundation, and the CCRF. Dr. Beebe has received research support from the NIH, the IES, the American Diabetes Association, Canadian Institutes of Public Health, University of Otega, and CCRF. Ms. Tilford, Ms. Tischner, Mr. Isaacson, and Mr. Simon report no biomedical financial interests or potential conflicts of interests.

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