Brief sleep intervention helps children with ADHD
David Rabiner of Duke University published “Brief Sleep Intervention Helps Children with ADHD” in the Attention Research Update newsletter March 2022.
Rabiner begins by noting that sleep problems are common and more persistent in children with ADHD, in part because poor sleep enhances attention and concentration difficulties. He proceeds to describe a randomized controlled study of the impact of brief sleep intervention in children who have both ADHD and sleep difficulties. In 2015, Hiscock et al. studied brief sleep intervention.
Their definition of sleep disorder is needing someone in one’s room, not falling asleep within two hours of normal sleep time, difficulty falling to sleep or maintaining it. They studied 244 children aged 5-12 who had ADHD and met diagnostic criteria for at least one sleep disorder. The brief sleep intervention involved two sessions and a follow-up phone consultation. Participants were randomly assigned to the intervention or control condition. They collected data at baseline, then 3-6 months after the intervention. They gathered parent reports of the child’s sleep problems, ADHD symptoms, and working memory; teacher ratings of classroom behavior; parents’ reports of the child’s quality of life and daily functioning as well as their own mental health and work attendance; and school attendance records.
Rabiner reports that, at both 3- and 6-months after the intervention, the children in the intervention condition, when compared to the control children, had ADHD symptoms rated as modestly lower by parents and teachers reported reductions in behavioral difficulties at both 3 and 6 months though there was no difference in teacher ratings of core ADHD symptoms. He adds that, “intervention children had fewer sleep difficulties, improved quality of life scores, fewer daily functioning difficulties, and improvement in at least one measure of working memory. Although school attendance did not differ, intervention children were less likely to be late to school at the 6-month follow-up.” At 3-months post-intervention, parents reported fewer late days for work and fewer missed work days. While most effects of the intervention were in the small to moderate range, reductions in sleep difficulties were larger. “Additional analyses indicated that reductions in children's ADHD symptoms were related to improvements in their sleep.”
A recent follow-up reports outcomes at 12-month post-intervention. “Intervention children were less likely to have moderate to severe sleep problems based on parent report (28.4% vs. 46.5%). Parents of intervention subjects also reported significantly lower ADHD symptoms, improved behavior overall, and better quality of life and daily functioning. Although statistically significant, the magnitude of the differences was modest. . . . An interesting and somewhat unexpected finding was that the benefits over time on children's sleep were reduced in children not taking medication.”
The original study link is https://www.bmj.com/content/350/bmj.h68. The intervention involved training regarding normal sleep, sleep cycles, sleep cues, sleep hygiene (e.g., set bed time, bedtime routine, keeping the bedroom media-free, and avoiding caffeine after 3 pm). “For example, limit setting disorder was managed by ignoring child protests and rewarding compliance with bedtime routines. Delayed sleep phase was managed using bedtime fading whereby the child’s bedtime is temporarily set later and gradually brought forward, while continuing to wake the child at a preset time in the morning. Anxiety related insomnia was managed by visual imagery and relaxation techniques. Parents were asked to complete a sleep diary between the first and second consultation. The second consultation and follow-up telephone call were used to review the sleep diary, reinforce suggested strategies, and troubleshoot any problems.”
I am not surprised by the finding that children with combined medication and the sleep intervention fared better. Young children often benefit from medication even if they ultimately can be weaned from it. It also makes sense that, when parents and teachers collaborate to help children with ADHD fare better, the children benefit. This also illustrates the value of telemedicine in that the training and monitoring can occur remotely.