Original ArticleNighttime media use in adolescents with ADHD: links to sleep problems and internalizing symptoms
Introduction
There is increasing empirical and clinical interest regarding the role of technology and media use on adolescent functioning [1], [2], [3], [4]. A recent systematic review found that screen time is associated with poorer sleep in children and adolescents, including shorter sleep duration and delayed sleep timing [5]. There is also an indication that media use is associated with youth internalizing symptoms such as anxiety and depression [6], [7]. However, the vast majority of studies have been conducted in school- and community-based samples [4], [5], leaving it unknown if media use is associated with sleep and internalizing symptoms in clinical samples of youth with mental disorders such as attention-deficit/hyperactivity disorder (ADHD).
There are several reasons why it is important to examine media use in relation to sleep and functional outcomes in youth with ADHD specifically. First, there is growing evidence that youth with ADHD are particularly prone to excessive media use, perhaps due to altered reinforcement mechanisms [8]. A systematic review recently reported a moderate association between ADHD symptoms and excessive Internet use [9]. In line with these findings, adolescents with ADHD are more likely than their peers to be classified with Facebook overuse (42.2% and 12.2%, respectively) [10], and ADHD symptoms are also associated with adolescents' time spent playing video games [11]. Second, compared to their typically developing peers, youth with ADHD experience more sleep problems [12], [13] and internalizing symptoms [14], [15]. It is therefore necessary to identify factors that contribute to these comorbidities, which in turn may be important targets for intervention. For example, media use may be used as a coping mechanism to relieve stress or (mis)manage negative emotions [16]. If this is indeed the case for some adolescents with ADHD, it may be significant in intervention to identify the underlying reasons for nighttime media use; and, as warranted, target cognitive-emotional processes and associated maladaptive strategies while also building healthy coping strategies. Third, most studies examining either sleep [13] or internalizing problems [15] in youth with ADHD have been conducted with school-aged children, although both sleep and internalizing problems increase in adolescence [1], [17], [18]. Adolescents also have increasing independence over the use of electronic media [19], [20]. Fourth, it is necessary for clinicians working with adolescents with ADHD to understand the potential impact of media use on sleep and emotional functioning. This is notable since current ADHD practice guidelines to not address sleep (aside from brief mention of comorbidities and potential medication side effects) or technology use [21], [22]. Yet, clinically, parents of children and adolescents with ADHD frequently ask for guidance regarding media/technology use and its potential impact on their child's functioning. Although the growing literature in typically developing samples is certainly useful, a documented link between media use and sleep and internalizing problems in adolescents diagnosed with ADHD would be clinically informative.
Accordingly, the primary objective of the present study was to examine nighttime media use in relation to sleep-relevant constructs (ie, sleep duration, sleep problems, circadian preference, daytime sleepiness) in adolescents diagnosed with ADHD. A secondary objective was to examine nighttime media use in relation to internalizing symptoms (ie, anxiety, depression). We focused on nighttime media use, as opposed to more broad media use; as media use in the evening hours before bed has been particularly linked to sleep and internalizing domains in community-based samples [7], [23]. We assessed sleep duration, sleep problems, and internalizing symptoms across adolescent and parent reports; building from previous studies that have almost always used a single (typically adolescent) informant [4], [5] and may thus be limited by mono-informant biases. Since parents may not be optimal informants of their adolescent child's sleep [24], adolescent self-reported sleep was the primary focus in our study. Parent-reported sleep was also included to examine whether consistent findings would be identified across raters. Finally, the only other study we are aware of that examined media use in adolescents diagnosed with ADHD considered only Facebook and did not examine media use in relation to sleep or internalizing symptoms [10]. In the present study, we examined electronic media use across multiple devices after 9:00PM and its association with multiple sleep and internalizing domains. Based on extant literature in typically developing samples [4], [5] and youth with ADHD [10], [25], we hypothesized that nighttime media use would be associated with shorter sleep duration, more sleep problems and daytime sleepiness, greater eveningness circadian preference, and increased internalizing symptoms. We further hypothesized that these associations would be robust across adolescent and parent informants (for sleep duration and internalizing variables) and when controlling for important covariates (ie, age, sex, pubertal status, stimulant medication use, ADHD symptom severity).
Section snippets
Participants
Participants were 81 adolescents (69% male) ages 13–17 years diagnosed with ADHD. All participants had an IQ ≥ 70 (Range = 79–132) based on the Kaufman Brief Intelligence Scale, Second Edition (KBIT-2) [26]. Sample characteristics, including ADHD and comorbid diagnoses based on the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) [27] interview conducted separately with the adolescent and their parent, are provided in Table 1.
Procedures
This study was approved by
Rates of technology in bedroom and nighttime media use
As summarized in Table 2, 93% of participants reported owning their own cell phone, with approximately half of participants having a computer/laptop/tablet, television, and/or MP3 player/iPod in their room. Of the four technology devices, 3.7% of participants reported having 0 devices, 17.3% reported having only one device, 33.3% reporting having two devices, 30.9% reported having three devices, and 14.8% reported having all four devices.
The average duration of nighttime media use among
Discussion
To our knowledge, this is the first study to examine nighttime media use in relation to sleep problems and internalizing symptoms in adolescents diagnosed with ADHD. Compared to their peers, adolescents with ADHD experience higher rates of both sleep problems [12], [13] and internalizing symptoms [14], [15], making it necessary to identify correlates of these comorbidities. The current study used a multi-informant design and found nighttime media use to be linked to more daytime sleepiness,
Acknowledgements
This research was supported by grant R03MH109787 from the National Institute of Mental Health (NIMH). Stephen Becker is supported by award number K23MH108603 from the NIMH. Jessica Lienesch's work on this project was supported in part through the University of Cincinnati Women in Science and Engineering (WISE) program. The content is solely the responsibility of the authors and does not necessarily represent the official views of the University of Cincinnati or the U.S. National Institutes of
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