Abstract
An estimated 25–50% of children and adolescents with attention-deficit hyperactivity disorder (ADHD) experience problems with sleep. The most common sleep problems reported in children with ADHD include delayed sleep onset, sleep or bedtime resistance, prolonged tiredness upon waking and daytime sleepiness. Higher incidences of sleep disorders such as restless legs syndrome, periodic limb movement disorder and sleep-disordered breathing have been reported in paediatric ADHD populations compared with control populations. In some cases, medications for ADHD and/or co-morbid disorders may also contribute to sleep disturbances. Assessment tools, such as parent-child questionnaires and sleep diaries, can help clinicians evaluate sleep disturbances. Sleep problems may potentially exacerbate ADHD symptoms, and interventions targeted at ensuring adequate sleep (including behavioural, dietary, specific pharmacological agents for treatment-induced insomnia, and melatonin) could in turn potentially attenuate symptoms associated with ADHD, such as irritability. Whether metabolic or neurological pathways common to both sleep and ADHD may be disrupted, and whether targeting treatments to these pathways may simultaneously improve both ADHD and sleep symptoms, needs further elucidation
Similar content being viewed by others
References
Polanczyk G, de Lima MS, Horta BL, et al. The worldwide prevalence of ADHD: a systematic review and meta-regression analysis. Am J Psychiatry 2007; 164: 942–8
American Academy of Pediatrics (AAP). Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics 2000; 105: 1158–70
Biederman J, Faraone SC. Attention-deficit hyperactivity disorder. Lancet 2005; 367: 237–48
Klassen AF, Miller A, Fine S. Health-related quality of life in children and adolescents who have a diagnosis of attention-deficit/hyperactivity disorder. Pediatrics 2004; 114: e541–7
Corkum P, Tannock R, Moldofsky H. Sleep disturbances in children with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 1998; 37: 637–46
Sung V, Hiscock H, Sciberras E, et al. Sleep problems in children with attention-deficit/hyperactivity disorder: prevalence and the effect on the child and family. Arch Pediatr Adolesc Med 2008; 162: 336–42
Lecendreux M, Cortese S. Sleep problems associated with ADHD: a review of current therapeutic options and recommendations for the future. Expert Rev Neurother 2007; 7: 1799–806
Owens J, Sangal RB, Sutton VK, et al. Subjective and objective measures of sleep in children with attention-deficit/ hyperactivity disorder. Sleep Med 2009; 10: 446–56
Van der Heijden KB, Smits MG, Gunning WB. Sleep-related disorders in ADHD: a review. Clin Pediatr (Phila) 2005; 44: 201–10
Bullock GL, Schall U. Dyssomnia in children diagnosed with attention deficit hyperactivity disorder: a critical review. Aust N Z J Psychiatry 2005; 39: 373–7
Kirov R, Banaschewski T, Uebel H, et al. REM-sleep alterations in children with tic disorder and attention-deficit/ hyperactivity disorder comorbidity: impact of hypermotor symptoms. Eur Child Adolesc Psychiatry 2007; 16 Suppl. 1: 45–50
Kirov R, Kinkelbur J, Banaschewski T, et al. Sleep patterns in children with attention-deficit/hyperactivity disorder, tic disorder, and comorbidity. J Child Psychol Psychiatry 2007; 48: 561–70
Konofal E, Lecendreux M, Bouvard MP, et al. High levels of nocturnal activity in children with attention-deficit hyperactivity disorder: a video analysis. Psychiatry Clin Neurosci 2001; 55: 97–103
Chervin RD, Archbold KH, Dillon JE, et al. Inattention, hyperactivity, and symptoms of sleep-disordered breathing. Pediatrics 2002; 109: 449–56
Chervin RD, Archbold KH, Dillon JE, et al. Associations between symptoms of inattention, hyperactivity, restless legs, and periodic leg movements. Sleep 2002; 25: 213–8
Cortese S, Konofal E, Lecendreux M, et al. Restless legs syndrome and attention-deficit/hyperactivity disorder: a review of the literature. Sleep 2005; 28: 1007–13
Konofal E. Relationship between ADHD and sleep disturbances. Advances ADHD 2008; 2: 85–94
Cortese S, Faraone SV, Konofal E, et al. Sleep in children with attention-deficit/hyperactivity disorder: meta-analysis of subjective and objective studies. J Am Acad Child Adolesc Psychiatry 2009; 48: 894–908
Johnson EO, Breslau N, Roth T, et al. Psychometric evaluation of daytime sleepiness and nocturnal sleep onset scales in a representative community sample. Biol Psychiatry 1999; 45: 764–70
Gelman VS, King NJ. Wellbeing of mothers with children exhibiting sleep disturbance. Austrian J Psychol 2001; 53: 18–22
Walters AS, Mandelbaum DE, Lewin DS, et al. Dopaminergic therapy in children with restless legs/periodic limb movements in sleep and ADHD: Dopaminergic Therapy Study Group. Pediatr Neurol 2000; 22: 182–6
Chervin RD, Ruzicka DL, Giordani BJ, et al. Sleep-disordered breathing, behavior, and cognition in children before and after adenotonsillectomy. Pediatrics 2006; 117: e769–78
Huang YS, Guilleminault C, Li HY, et al. Attention-deficit/hyperactivity disorder with obstructive sleep apnea: a treatment outcome study. Sleep Med 2007; 8: 18–30
Wei JL, Mayo MS, Smith HJ, et al. Improved behavior and sleep after adenotonsillectomy in children with sleep-disordered breathing. Arch Otolaryngol Head Neck Surg 2007; 133: 974–9
Faries DE, Yalcin I, Harder D, et al. Validation of the ADHD Rating Scale as a clinician administered and scored instrument. J Atten Disord 2001; 5: 39–47
Ivanenko A, Crabtree VM, Obrien LM, et al. Sleep complaints and psychiatric symptoms in children evaluated at a pediatric mental health clinic. J Clin Sleep Med 2006 15; 2: 42–8
Ivanenko A, Johnson K. Sleep disturbances in children with psychiatric disorders. Semin Pediatr Neurol 2008; 15: 70–8
Liu X, Buysse DJ, Gentzler AL, et al. Insomnia and hyper-somnia associated with depressive phenomenology and comorbidity in childhood depression. Sleep 2007; 30: 83–90
Quine L. Sleep problems in children with mental handicap. J Ment Defic Res 1991; 35 (Pt 4): 269–90
Douglass AB, Bornstein R, Nino-Murcia G, et al. The Sleep Disorders Questionnaire: I. Creation and multivariate structure of SDQ. Sleep 1994; 17: 160–7
Chervin RD, Hedger K, Dillon JE, et al. Pediatric Sleep Questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Med 2000; 1: 21–32
Owens JA, Spirito A, McGuinn M. The Children’s Sleep Habits Questionnaire (CSHQ): psychometric properties of a survey instrument for school-aged children. Sleep 2000; 23: 1043–51
National Sleep Foundation. Sleep diary [online]. Available from URL: http://www.sleepfoundation.org [Accessed 2008 Nov 24]
National Institutes of Health. Star sleeper for kids [online]. Available from URL: http://www.nhlbi.nih.gov/health/public/sleep/starslp/ [Accessed 2008 Nov 24]
Mindell JA, Owens JA. A clinical guide to pediatric sleep: diagnosis and management of sleep problems. Baltimore (MD): Lippincott Williams & Wilkins, 2003
Morgenthaler TI, Lee-Chiong T, Alessi C, et al. Standards of Practice Committee of the American Academy of Sleep Medicine: practice parameters for the clinical evaluation and treatment of circadian rhythm sleep disorders. An American Academy of Sleep Medicine report. Sleep 2007; 30: 1445–59
Van der Heijden KB, Smits MG, Van Someren EJ, et al. Idiopathic chronic sleep onset insomnia in attention-deficit/ hyperactivity disorder: a circadian rhythm sleep disorder. Chronobiol Int 2005; 22: 559–70
Allen RP, Picchietti D, Hening WA, et al. Restless legs syndrome: diagnostic criteria, special considerations, and epidemiology. A report from the restless legs syndrome diagnosis and epidemiology workshop at the National Institutes of Health. Sleep Med 2003; 4: 101–19
Cortese S, Lecendreux M, Bernardina BD, et al. Attention-deficit/hyperactivity disorder, Tourette’s syndrome, and restless legs syndrome: the iron hypothesis. Med Hypotheses 2008; 70: 1128–32
Bruni O, Ottaviano S, Guidetti V, et al. The Sleep Disturbance Scale for Children (SDSC): construction and validation of an instrument to evaluate sleep disturbances in childhood and adolescence. J Sleep Res 1996; 5: 251–61
Chervin RD, Hedger KM. Clinical prediction of periodic leg movements during sleep in children. Sleep Med 2001; 2: 501–10
Archbold KH. Sleep disorders and attention-deficit hyperactivity disorder in children: a missing differential diagnosis. J Am Psychiatr Nurses Assoc 2006; 12: 216–24
Owens JA, Dalzell V. Use of the ‘BEARS’ sleep screening tool in a pediatric residents’ continuity clinic: a pilot study. Sleep Med 2005; 6: 63–9
Morin CM, Espie CA. Insomnia: a clinical guide to assessment and treatment. New York: Springer, 2003
Cohen-Zion M, Ancoli-Israel S. Sleep in children with attention-deficit hyperactivity disorder (ADHD): a review of naturalistic and stimulant intervention studies. Sleep Med Rev 2004; 8: 379–402
Gruber R, Sadeh A, Raviv A. Instability of sleep patterns in children with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2000; 39: 495–501
Hvolby A, Jorgensen J, Bilenberg N. Actigraphic and parental reports of sleep difficulties in children with attention-deficit/hyperactivity disorder. Arch Pediatr Adolesc Med 2008; 162: 323–9
Weiss MD, Wasdell MB, Bomben MM, et al. Sleep hygiene and melatonin treatment for children and adolescents with ADHD and initial insomnia. J Am Acad Child Adolesc Psychiatry 2006; 45: 512–9
Van Veen MM, Kooij JJ, Boonstra AM, et al. Delayed circadian rhythm in adults with attention-deficit/ hyperactivity disorder and chronic sleep-onset insomnia. Biol Psychiatry 2010; 67(11): 1091–6
Pliszka S, for the AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2007; 46: 894–921
Stein MA, Weiss M, Leventhal BL. ADHD by night: sleep problems and ADHD medications. Child Adolesc Pharmacol News 2007; 12: 1–5
Stein MA. Unravelling sleep problems in treated and untreated children with ADHD. J Child Adolesc Psycho-pharmacol 1999; 9: 157–68
Day HD, Abmayr SB. Parent reports of sleep disturbances in stimulant-medicated children with attention-deficit hyperactivity disorder. J Clin Psychol 1998; 54: 701–16
Kent JD, Blader JC, Koplewicz HS, et al. Effects of late-afternoon methylphenidate administration on behavior and sleep in attention-deficit hyperactivity disorder. Pediatrics 1995; 96: 320–5
O’Brien LM, Ivanenko A, Crabtree VM, et al. The effect of stimulants on sleep characteristics in children with attention deficit/hyperactivity disorder. Sleep Med 2003; 4: 309–16
Sangal RB, Owens J, Allen AJ, et al. Effects of atomoxetine and methylphenidate on sleep in children with ADHD. Sleep 2006; 29: 1573–85
Schwartz G, Amor LB, Grizenko N, et al. Actigraphic monitoring during sleep of children with ADHD on methylphenidate and placebo. J Am Acad Child Adolesc Psychiatry 2004; 43: 1276–82
Kratochvil CJ, Lake M, Pliszka SR, et al. Pharmacological management of treatment-induced insomnia in ADHD. J Am Acad Child Adolesc Psychiatry 2005; 44: 499–501
Ahmann PA, Waltonen SJ, Olson KA, et al. Placebo-controlled evaluation of ritalin side effects. Pediatrics 1993; 91: 1101–6
Stein MA, Blondis TA, Schnitzler ER, et al. Methylphenidate dosing: twice daily versus three times daily. Pediatrics 1996; 98: 748–56
Carlson GA, Kelly KL. Stimulant rebound: how common is it and what does it mean? J Child Adolesc Psycho-pharmacol 2003; 13: 137–42
Golan N, Shahar E, Ravid S, et al. Sleep disorders and daytime sleepiness in children with attention-deficit/ hyperactive disorder. Sleep 2004; 27: 261–6
Lecendreux M, Konofal E, Bouvard M, et al. Sleep and alertness in children with ADHD. J Child Psychol Psychiatry 2000; 41: 803–12
Oosterloo M, Lammers GJ, Overeem S, et al. Possible confusion between primary hypersomnia and adult attention-deficit/hyperactivity disorder. Psychiatr Res 2006; 143: 293–7
Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 1991; 14: 540–5
Biederman J, Pliszka SR. Modafinil improves symptoms of attention-deficit/hyperactivity disorder across subtypes in children and adolescents. J Pediatr 2008; 152: 394–9
Wigal SB, Biederman J, Swanson JM, et al. Efficacy and safety of modafinil film-coated tablets in children and adolescents with or without prior stimulant treatment for attention deficit/hyperactivity disorder: pooled analysis of 3 randomized, double-blind, placebo controlled studies. Prim Care Companion J Clin Psychiatry 2006; 8: 352–60
Amiri S, Mohammadi MR, Mohammadi M, et al. Modafinil as a treatment for attention-deficit/hyperactivity disorder in children and adolescents: a double blind, randomized clinical trial. Prog Neuropsychopharmacol Biol Psychiatry 2008; 32: 145–9
Kumar R. Approved and investigational uses of modafinil: an evidence-based review. Drugs 2008; 68: 1803–39
Harsh JR, Easley A, LeBourgeois MK. An instrument to measure children’s sleep hygiene [abstract]. Sleep 2002; 25: A316
Hryshko-Mullen AS, Broeckl LS, Haddock CK, et al. Behavioral treatment of insomnia: the Wilford Hall Insomnia Program. Mil Med 2000; 165: 200–7
LeBourgeois MK, Giannotti F, Cortesi F, et al. The relationship between reported sleep quality and sleep hygiene in Italian and American adolescents. Pediatrics 2005; 115(1 Suppl. ): 257–65
American Academy of Sleep Medicine. Sleep hygiene: the healthy habits of good sleep, 2008 [online]. Available from URL: http://www.sleepeducation.com/Hygiene.aspx [Accessed 2009 Dec 18]
Mastin DF, Bryson J, Corwyn R. Assessment of sleep hygiene using the Sleep Hygiene Index. J Behav Med 2006; 29: 223–7
Jan JE, Owens JA, Weiss MD, et al. Sleep hygiene for children with neurodevelopmental disabilities. Pediatrics 2008; 122: 1343–50
Currie SR, Wilson KG, Pontefract AJ, et al. Cognitive-behavioral treatment of insomnia secondary to chronic pain. J Consult Clin Psychol 2000; 68: 407–16
Morawetz D. Insomnia and depression: which comes first? Sleep Res Online 2003; 5: 77–81
Smith MT, Huang MI, Manber R. Cognitive behavior therapy for chronic insomnia occurring within the context of medical and psychiatric disorders. Clin Psychol Rev 2005; 25: 559–92
Efron D, Jarman F, Barker M. Side effects of methylpheni-date and dexamphetamine in children with attention deficit hyperactivity disorder: a double-blind, crossover trial. Pediatrics 1997; 100(4): 662–6
Sikich L, Frazier JA, McClellan J, et al. Double-blind comparison of first- and second-generation antipsychotics in early-onset schizophrenia and schizo-affective disorder: findings from the Treatment of Early-Onset Schizophrenia Spectrum Disorders (TEOSS) study. Am J Psychiatry 2008; 165: 1420–31
Correll CU, Manu P, Olshanskiy V, et al. Cardiometabolic risk of second-generation antipsychotic medications during first-time use in children and adolescents. JAMA 2009; 302: 1765–73
Weiss M, Panagiotopoulos D, Giles L, et al. A naturalistic study of predictors and risks of atypical antipsychotic use in an attention-deficit/hyperactivity disorder clinic. J Child Adolesc Psychopharmacol 2009; 19: 575–82
Van der Heijden KB, Smits MG, Van Someren EJ, et al. Prediction of melatonin efficacy by pretreatment dim light melatonin onset in children with idiopathic chronic sleep onset insomnia. J Sleep Res 2005; 14: 187–94
Van der Heijden KB, Smits MG, Van Someren EJ, et al. Effect of melatonin on sleep, behavior, and cognition in ADHD and chronic sleep-onset insomnia. J Am Acad Child Adolesc Psych 2007; 46: 233–41
Corkum P, Moldofsky H, Hogg-Johnson S, et al. Sleep problems in children with attention-deficit/hyperactivity disorder: impact of subtype, comorbidity, and stimulant medication. J Am Acad Child Adolesc Psychiatry 1999; 38: 1285–93
Hoebert M, van der Heijden KB, van Geijlswijk IM, et al. Long-term follow-up of melatonin treatment in children with ADHD and chronic sleep onset insomnia. J Pineal Res 2009 Aug; 47(1): 1–7
National Sleep Foundation. Melatonin and sleep [online]. Available from URL: http://www.sleepfoundation.org [Accessed 2008 Nov 24]
Acknowledgements
Editorial support was provided by Ann T. Yeung, PhD (Phase Five Communications Inc., New York, NY, USA) with funding from Novartis Pharmaceuticals. Ann Yeung reviewed each draft for consistency, references and errors; facilitated conference calls in which the outline of the paper was drafted; and coordinated changes made at each stage. Dr Weiss has received funds from Eli Lilly, Shire, Purdue and Janssen for investigator initiated research, and honoraria for talks and consultation.The authors have no conflicts of interest that are directly relevant to the content of this review.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Weiss, M.D., Salpekar, J. Sleep Problems in the Child with Attention-Deficit Hyperactivity Disorder. CNS Drugs 24, 811–828 (2010). https://doi.org/10.2165/11538990-000000000-00000
Published:
Issue Date:
DOI: https://doi.org/10.2165/11538990-000000000-00000