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Question
Question: What evidence-based or consensus-based recommendations can be made for the assessment and management of sleep problems in children and adolescents with attention deficit hyperactivity disorder (ADHD)?
Outcomes: The assessment and management of sleeping problems are as reported.
Methods
Design: Systematic review.
Data sources: PubMed, Ovid, EMBASE and Web of Knowledge were searched for peer-reviewed articles (study type not specified) published up to 31 October 2012.
Study selection and analysis: Study eligibility criteria were not specified. The authors report that they excluded studies where there was no formal ADHD diagnosis, studies in adults, non-human studies and abstracts alone. Where possible the Scottish Intercollegiate Guidelines Network system was used to grade evidence on the management of sleeping problems. If limited empirical data were available, consensus recommendations were formed between the authors using the Delphi method. Individual statements within the review are referenced to the included publications.
Main results
Recommendations were based on 22 eligible studies on the treatment of sleep problems in children or adolescents with ADHD. The prevalence of mild to severe sleep problems in children with ADHD is reported to be 70%, with the most common reported difficulty being ‘difficulty in falling asleep’.
Assessment: A baseline sleep evaluation is recommended during the initial assessment of ADHD, including the use of specific sleep questionnaires or tools (eg, the Children's Sleep Habits Questionnaire), with a 2-week sleep diary completed by the parent or child if problems are identified. Sleep disorders should be diagnosed according to formal criteria (eg, the International Classification of Sleep Disorders) with polysomnography used if symptoms suggest sleep-disordered breathing or movement disorders. Sleep screening is recommended, particularly before initiation of pharmacological treatment and during dose titration or medication follow-up (randomised control trials (RCTs) report variable effects of the non-stimulant medications methylphenidate and atomoxetine upon sleep onset latency and night-time awakenings).
Management: A range of healthy sleeping practices are recommended, centring on a regular sleep/wake cycle (based on the non-randomised phase of an RCT). There is insufficient evidence to recommend a specific dietary regimen. For the treatment of insomnia, behavioural interventions, adapted for ADHD, are recommended (based on two ongoing RCTs), and if these are not effective, melatonin may be beneficial (based on two RCTs). For disorders of the sleep–wake cycle, these two RCTs also support the use of melatonin, while two case reports have found benefits of phototherapy and chronotherapy. For sleep apnoea, adenotonsillectomy is suggested if the apnoea–hypopnoea index on polysomnography is greater than one (based on two non-randomised studies). For the restless legs syndrome, behavioural modifications are recommended; if symptoms are severe, dopaminergic treatments may be considered by a sleep specialist (evidence from one RCT). If sleep disorders are suspected to be due to ADHD medications, alternative dosing regimens, formulations or treatments may be considered if there is no response to healthy sleeping practices.
Conclusions
The authors report that there is a growing body of evidence available to inform the assessment and management of sleep disorders in children and adolescents with ADHD. However, further RCTs are needed.
Abstracted from
Commentary
Although sleep problems have been viewed as an epiphenomenon of attention deficit/hyperactivity disorder (ADHD), evidence now suggests that ADHD and sleep problems are bidirectional and mutually exacerbating conditions both of which warrant independent clinical attention. This paradigm shift is reflected in Diagnostic and Statistical Manual of Mental Disorders fifth edition, which has eliminated the inherent causal attributions in the sleep diagnosis, ‘primary’ or ‘secondary’, to other conditions.1 This opens a window of opportunity for mental health services to implement evidence-based interventions for sleep problems in ADHD.
Cortese and colleagues aim to provide evidence-based recommendations for assessment and management of sleep problems in youths with ADHD. While there is still a need for more randomised controlled trials on sleep interventions in ADHD, the study's recommendations are based on a thorough review of the current literature. However, there are still obstacles for implementing these recommendations in everyday practice. In adults, the use of sleep diagnosis in the mental health clinic is almost non-existent,2 and a similar practice most likely exists in clinical practice involving youths. Furthermore, as highlighted in the review, sleep medication has usually been the treatment of choice for sleep problems in clinical practice. Still, the recommendations stress the importance of healthy sleep habits as the foundation for management of all sleep problems, specifically demonstrating behavioural interventions as a first choice in insomnia treatment. This approach will require training of healthcare professionals in evidence-based sleep interventions. Education in sleep assessment and interventions should also be included in the professional training of mental health professionals.
This study represents an important first step in providing treatment knowledge for one of the conditions to most frequently coexist with one of the most common mental health disorders among youths. This may help improve the quality of life for many children and adolescents with ADHD and their families.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online supplement
Footnotes
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Sources of funding Shire Pharmaceuticals.
Footnotes
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Competing interests None.