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Sleep in Children with Attention-Deficit Hyperactivity Disorder (ADHD): a Review of Naturalistic and Stimulant Intervention Studies

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Sleep in Children with Attention-Deficit Hyperactivity Disorder (ADHD): a Review of Naturalistic and Stimulant Intervention Studies Pediatric OSA Research Abstracts compiled by David Shirazi DDS MS MA LAc Sleep Medicine Reviews Volume 8, Issue 5, October 2004, Pages 379-402 Clinical Review Sleep in children with attention-deficit hyperactivity disorder (ADHD): a review of naturalistic and stimulant intervention studies Mairav Cohen-Ziona, b, c, 1, , Sonia Ancoli-Israelb, c, San Diego State University/University of California, San Diego Joint Doctoral Program in a Clinical Psychology, San Diego, CA, USA b Department of Psychiatry, University of California, San Diego, CA, USA Veterans Affairs San Diego Healthcare System (VASDHS), Department of Psychiatry, c University of California, 116A, 3350 La Jolla Village Drive, San Diego, CA 92161, USA Abstract Attention-Deficit Hyperactivity Disorder (ADHD) is the most common behavioral disorder of childhood. Multiple clinical and research reports suggest extensive sleep disturbances in children with ADHD, however, current data is contradictory. This paper reviewed 47 research studies (13 stimulant intervention and 34 naturalistic) on ADHD that were published since 1980. The main objectives of this review were to provide pediatric clinicians and researchers a clear and concise summary of published sleep data in children with ADHD, to provide a more accurate description of the current knowledge of the relationship between sleep and ADHD, and to provide current information on the effect of stimulant medication on sleep. Twenty-five of the reviewed studies used subjective reports of sleep, six were actigraphic studies, and 16 were overnight polysomnographic sleep studies (two of which also included Multiple Sleep Latency Tests). All participants were between the age of 3 and 19, and 60% were male. The results indicate high rates of parental reports of sleep disturbances in medicated and unmedicated children with ADHD, however, the majority of these findings have not been confirmed by objective sleep data. Although, agreement among objective studies is not absolute, the data suggest increased nighttime activity, reduced rapid eye movement sleep, and significant daytime somnolence in unmedicated children with ADHD when compared to controls. Data also suggest a possible increased prevalence of periodic limb movements in sleep in children with ADHD, however, little differences in sleep-disordered breathing. The limited number of studies, small and heterogeneous samples, and other methodological limitations make definite results difficult to determine. Future research will need to further clarify the relationship between sleep and ADHD and the effects of stimulants on sleep of children with ADHD. Keywords: Sleep; Children; Attention-deficit hyperactivity disorder; ADHD; Stimulants; Review; Alertness ___________________________________________________________________________________ Sleep Medicine Volume 8, Issue 1, January 2007, Pages 18-30 Original article Attention-deficit/hyperactivity disorder with obstructive sleep apnea: A treatment outcome study Yu-Shu Huanga, b, f, Christian Guilleminaultf, , , Hsueh-Yu Lib, c, Chien-Ming Yange, Yu-Yu Wua, Ning-Hung Chenb, d Department of Child Psychiatry, Chang Gung Memorial University Hospital, Tao-Yuan, a Taipei, Taiwan Department of Sleep Medicine, Chang Gung Memorial University Hospital, Tao-Yuan, Taipei, b Taiwan Department of Otolaryngology, Chang Gung Memorial University Hospital, Tao-Yuan, Taipei, c Taiwan Department of Pulmonary Medicine, Chang Gung Memorial University Hospital, Tao-Yuan, d Taipei, Taiwan e Department of Psychology, National Chengchi University, Taipei, Taiwan Stanford University Sleep Disorders Clinic, 401 Quarry Road, suite 3301, Stanford, CA 94305, f USA Abstract Background Children diagnosed with attention-deficit/hyperactivity disorder (ADHD), based on Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV) criteria, may also have obstructive sleep apnea (OSA), but it is unclear whether treating OSA has similar results as methylphenidate (MPH), a commonly used treatment for ADHD. Methods This study enrolled 66 school-age children, referred for and diagnosed with ADHD, and 20 healthy controls. Polysomnography (PSG) performed after ADHD diagnosis showed the presence of mild OSA. After otolaryngological evaluation, parents and referring physicians of the children could select treatment of ADHD with MPH, treatment of OSA with adenotonsillectomy or no treatment. Systematic follow-up was performed six months after initiation of treatment, or diagnosis if no treatment. All children had pre- and post-clinical interviews; pediatric, neurologic, psychiatric and neurocognitive evaluation; PSG; ADHD rating scale, child behavior checklist (CBCL) filled out by parents and teacher; test of variables of attention (TOVA); and the quality of life in children with obstructive sleep disorder questionnaire (OSA-18). Results ADHD children had an apnea-hypopnea index (AHI) > 1 < 5 event/hour; 27 were treated with MPH, 25 had adenotonsillectomy, and 14 had no treatment. The surgical and MPH groups improved more than the non-treatment group. When comparing MPH to post-surgery, the PSG and questionnaire sleep variables, some daytime symptoms (including attention span) and TOVA subscales (impulse control, response time and total ADHD score) improved more in the surgical group than the MPH group. The surgical group had an ADHD total score of 21.16 ± 7.13 on the ADHD rating scale (ADHD-RS) post-surgery compared to 31.52 ± 7.01 pre-surgery (p = 0.0001), and the inattention and hyperactivity subscales were also significantly lower (p = 0.0001). Finally, the results were significantly different between surgically and MPH-treated groups (ADHD-RS p = 0.007). The surgical group also had a TOVA ADHD score lower than −1.8 and close to those obtained in normal controls. Conclusion A low AHI score of > 1 considered abnormal is detrimental to children with ADHD. Recognition and surgical treatment of underlying mild sleep-disordered breathing (SDB) in children with ADHD may prevent unnecessary long-term MPH usage and the potential side effects associated with drug intake. Keywords: Attention-deficit/hyperactivity disorder; Methylphenidate; Adenotonsillectomy; Obstructive sleep apnea; Polysomnography; Outcome _________________________________________________________________________________ Sleep Medicine Volume 10, Issue 4, April 2009, Pages 446-456 Original Article Subjective and objective measures of sleep in children with attention- deficit/hyperactivity disorder Judith Owensa, , , , R. Bart Sangalb, Virginia K. Suttonc, 1, Rosalie Bakkend, Albert J. Allend, Douglas Kelseyd Brown Medical School, Ambulatory Pediatrics, Potter 200, 593 Eddy Street, Providence, RI a 02903, United States b Clinical Neurophysiology Services PC, Troy, MI, United States c i3 Research, Cary, NC, United States Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, United d States Abstract Objective To compare objective and subjective measures of sleep in children with attention- deficit/hyperactivity disorder (ADHD) and healthy control subjects. Methods Included were 107 unmedicated children with ADHD and 46 healthy control subjects, all aged 6–14. Sleep–wake patterns were monitored with actigraphy for at least five consecutive days. Subjects and parents completed daily electronic diaries assessing sleep and daytime behavior. Results Actigraphy data from 80 ADHD patients and 45 control subjects showed that, compared to the healthy control group, the ADHD group experienced shorter actual sleep time (defined as time in minutes [from sleep onset to final morning awakening] of all epochs scored as sleep [i.e., excluding total duration of all epochs scored as ―wake‖]) (489.39 vs. 460.30 min, p = .001), significantly fewer sleep interruptions (44.45 vs. 35.33, p < .001), but more total interrupted sleep time (44.49 vs. 56.70 min, p = .002). Child diaries indicated children with ADHD had significantly more daytime sleepiness and difficulty getting up and less refreshing sleep. Parent diaries indicated children with ADHD had significantly more behavioral difficulties than the control group. Conclusions Results suggest children with ADHD have reduced sleep quantity and more disturbed sleep on actigraphic measures, reduced sleep quality on the self report, and more problematic behaviors on the parent report. Clinical interventions for children with ADHD who present with sleep problems should include screening for etiologic and exacerbating factors, institution of behavioral-management strategies, and consideration of pharmacologic treatment targeted toward evening ADHD symptoms. Keywords: Children; ADHD; Actigraphy; Behavior; Sleep patterns; Sleep problems _____________________________________________________________________________________ Pediatrics. 2004 Jul;114(1):44-9. Neurobehavioral implications of habitual snoring in children. O'Brien LM, Mervis CB, Holbrook CR, Bruner JL, Klaus CJ, Rutherford J, Raffield TJ, Gozal D. Kosair Children's Hospital Research Institute and Division of Pediatric Sleep Medicine, Department of Pediatrics, University of Louisville, Louisville, Kentucky 40202, USA. OBJECTIVE: Current guidelines for the treatment of children with obstructive sleep apnea (OSA) suggest that primary snoring (PS) in children is benign. However, PS has not been well evaluated, and it is unknown whether PS is associated with serious morbidity. This study investigated whether PS is associated with neurobehavioral deficits in children. METHODS: Parents of 5- to 7-year-old snoring
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