Sleep Problems for People with ADHD
Abstract
Children with Attention Deficit Hyperactivity Disorder (ADHD) often experience high rates of sleep problems and are at an increased risk for developing internalizing problems.
The study aimed to examine the association between sleep problems, physical activity, and internalizing symptoms in children with ADHD.
Conducted with 188 children with ADHD (M age = 8.60 ± 1.38, 78.7% boys).
Tools used: Pittsburgh Sleep Quality Index (PSQI) to assess sleep problems and Depression Anxiety Stress Scale 21 (DASS 21) for internalizing symptoms.
Findings:
111 children (59%) exhibited sleep problems (defined as PSQI score > 5).
Children with sleep issues had:
Less daily moderate-to-vigorous physical activity (MVPA): F = 15.35, η² = .079.
Lower percentage meeting WHO’s recommended 60 minutes of daily MVPA: F = 9.57, η² = .050.
More internalizing symptoms: depression (F = 10.09, η² = .053), anxiety (F = 15.84, η² = .081), stress (F = 6.98, η² = .037).
BMI, daytime dysfunction (PSQI), and MVPA guideline attainment were significantly associated with internalizing symptoms.
Daytime dysfunction was linked to more severe internalizing symptoms, while meeting MVPA guidelines may reduce likelihood of depression/anxiety.
Recommendations for future studies include long-term assessments of sleep impacts and effects of PA-based interventions on both sleep and internalizing symptoms.
Introduction
ADHD characteristics include persistent inattention, impulsivity, and hyperactivity, affecting around 5-6% of school-aged children.
ADHD often coexists with comorbidities that exacerbate psychological and physical conditions, including:
Internalizing symptoms (depression, anxiety, withdrawal).
Externalizing symptoms (aggression, conduct problems).
Sleep disturbances and physical inactivity.
Prevalence of sleep problems in children with ADHD ranges from 25% to 50%.
Common subjective sleep complaints:
Sleep latency delay.
Bedtime resistance.
Nocturnal awakenings.
Daytime sleepiness.
Studies show sleep issues worsen ADHD symptoms, academic performance, and overall quality of life.
Behavioral sleep problems correlate strongly with both internalizing and externalizing behavioral issues.
Evidence of the influence of sleep problems on daytime functioning in children with ADHD remains limited.
Study Objective
The current research intends to:
Compare internalizing symptoms and physical activity levels between children with ADHD who have sleep problems and those who do not.
Analyze the correlation between sleep problems, physical activity, and internalizing symptoms.
Methods
Study Design and Participants
Cross-sectional study involving 188 children aged 6-12 with ADHD from a children’s hospital in Lanzhou, China.
Clinical diagnosis of ADHD confirmed according to DSM-5 guidelines.
Inclusion criteria:
Minimum IQ of 75 as assessed by WISC-IV.
No significant medical conditions affecting physical capability (e.g., asthma, cardiac issues).
Absence of neuropsychiatric disorders (e.g., bipolar disorder, autism).
Recruitment and screening conducted by pediatricians.
Procedure
Ethical standards adhered to Declaration of Helsinki and approved by the Institutional Review Board for Human Subjects.
Informed consent acquired from parents or guardians.
Participants underwent:
Assessments of weight and height for BMI calculation.
Completion of PSQI and DASS 21 with trained assistants.
Wearing of an Actigraphy device to record physical activity for 7 days (5 weekdays, 2 weekend days).
Measures
Behavioural Sleep Disturbances
Sleep assessed by Chinese version of PSQI (18 questions, 7 components).
PSQI total score ranges 0-21, score > 5 indicates behavioral sleep disturbances.
Internal consistency of PSQI in this study: α = 0.784.
Internalizing Symptoms
Measured by Chinese version of DASS 21 (21 items assessing depression, anxiety, and stress across one week).
DASS 21 scoring: 0 (never) - 3 (almost always). Internal consistency:
Depression: α = 0.77
Anxiety: α = 0.73
Stress: α = 0.75
Physical Activity
Recorded using ActiGraph GT9X Link for MVPA assessment.
MVPA guideline: minimum of 60 minutes/day according to WHO recommendations.
Data Analysis
Statistical analyses performed using SPSS (version 29.0).
Groups categorized as poor sleepers (PS, PSQI ≥ 5) and good sleepers (GS, PSQI < 5).
Independent t-tests/chi-square tests for background information comparison.
Multivariate analysis of covariance controlled for age, sex, IQ, BMI, comorbidity, medication, and ADHD subtype to assess internalizing symptoms, physical activity, and sleep characteristics.
Bivariate correlations calculated among PSQI, MVPA, guideline attainment, and internalizing symptoms.
Hierarchical regression models to predict internalizing symptoms.
Statistical significance set at p < 0.05.
Results
Characteristics of Participants
Data set primarily comprised 188 children with valid accelerometer data:
148 (78.7%) boys, 40 (21.3%) girls.
Mean age 8.60 ± 1.38 years.
ADHD subtype breakdown:
Inattention: 105 (55.9%)
Combined: 61 (32.4%)
Hyperactivity: 22 (11.7%)
Comorbid conditions:
Oppositional Defiant Disorder (ODD) in 28.2% of participants;
10.6% were on medication for ADHD.
Comparisons Between Good Sleepers and Poor Sleepers
Poor sleepers exhibited:
Less time in MVPA: PS group (66.70 min/day) compared to GS (78.11 min/day), F = 15.35, η² = 0.079.
Higher internalizing symptoms across all measures (depression, anxiety, stress).
Detailed PSQI comparisons indicated significant deficiencies in sleep quality, latency, duration, efficiency, disturbances, medication usage, and daytime dysfunction.
Associations
Relationship of Sleep Problems and Physical Activity with Internalizing Symptoms
Positive correlation between sleep disturbances and internalizing symptoms (anxiety, stress).
Daily MVPA was negatively associated with depression, while increased MVPA guideline attainment also correlated with reduced internalizing symptoms.
Regression Analysis of Internalizing Symptoms
Hierarchical regression identified key predictors for:
Depression: significant contributions from daytime dysfunction and MVPA guideline attainment.
Anxiety: predictors included BMI and sleep disturbances.
Stress: significantly linked to BMI and daytime dysfunction.
Discussion
The study reinforced that sleep problems affect both internalizing symptoms and physical activity in children with ADHD:
59% of participants had sleep problems, consistent with prior research.
Children with sleep issues were less physically active and presented more severe internalizing symptoms.
Implications point toward the shared physiological mechanisms between sleep disturbances and ADHD.
Conclusion
Children with ADHD and sleep problems are less active and have more severe internalizing symptoms than those without sleep problems.
Daytime dysfunction and MVPA guideline adherence emerged as significant predictors of internalizing symptoms.
Further research should target the implementation of PA interventions for potential improvements in sleep-related issues and internalizing symptoms in children with ADHD.
Acknowledgments
Thanks to contributors in data collection and participants who took part in the study. The document stresses ethical handling of results without data manipulation.
Funding
Supported by The Hong Kong Polytechnic University and the Research Institute for Sports Science and Technology.
Conflict of Interest
No conflicts of interest reported.
References
A comprehensive list is provided as detailed in the original text, including studies related to ADHD, sleep disorders, internalizing symptoms, and physical activity.
Some potentially confusing parts of the article may include:
The definition and significance of behavioral sleep disturbances according to the PSQI.
Clarifying how the study determined the participants' physical activity levels, especially in relation to daily MVPA guidelines.
Understanding the role of comorbid conditions in children with ADHD and their potential impact on study outcomes.
The statistical analyses methods used, such as multivariate analysis of covariance and hierarchical regression, which might require familiarity with advanced statistical techniques to fully understand.
The implications of the findings regarding the physiological mechanisms between sleep disturbances and ADHD, which could require further clarification to appreciate the broader context.
One surprising aspect of the article is the high prevalence of sleep problems among children with ADHD, with 59% of the participants experiencing such issues. This is particularly notable given that the general understanding may not fully capture how significantly sleep disturbances affect children with ADHD. Additionally, the study's finding that poor sleepers engage in less physical activity and exhibit more severe internalizing symptoms (like depression and anxiety) suggests a strong link between sleep quality and overall mental health in these children. This indicates the potential need for greater focus on sleep issues as an area of intervention in managing ADHD.
The article may not address the following areas well enough:
Definition and Significance of Sleep Disturbances: More clarity is needed on how behavioral sleep disturbances are defined according to the Pittsburgh Sleep Quality Index (PSQI) and their clinical significance.
Physical Activity Assessment: The methodology used to determine participants' physical activity levels, particularly in relation to daily MVPA guidelines, requires further elaboration for better understanding.
Comorbid Conditions: The impact of comorbid conditions in children with ADHD and how they influence the outcomes could be explained in more detail. Comorbid conditions refer to the presence of two or more disorders or illnesses occurring in the same individual. In the context of children with ADHD, these can include conditions such as Oppositional Defiant Disorder (ODD), Anxiety Disorders, Depression, and Learning Disabilities. The influence of these comorbid conditions on outcomes can be significant, potentially exacerbating the ADHD symptoms and affecting the child's overall functioning. For example, children with ADHD who also experience anxiety may struggle more with impulsivity and inattention compared to those with ADHD alone. Additionally, the interaction between ADHD and these other conditions can complicate diagnosis and treatment, making it essential to explore how these comorbidities affect the effectiveness of interventions and overall well-being in children with ADHD. Understanding this interaction provides a clearer picture of the challenges faced by these children and can guide more tailored treatment approaches.
Statistical Methods: A breakdown of statistical analyses, such as multivariate analysis of covariance and hierarchical regression, may require more explanation for readers unfamiliar with these advanced techniques.
Physiological Mechanisms: Implications regarding the physiological links between sleep disturbances and ADHD could benefit from further context to appreciate the broader significance of the findings.
59% of children with ADHD exhibited sleep problems, with a PSQI score greater than 5 indicating behavioral disturbances.
Poor sleepers engaged in less daily moderate-to-vigorous physical activity (MVPA) compared to good sleepers.
Children with sleep issues experienced higher internalizing symptoms, including:
- Depression: Significant measure (F = 10.09, η² = .053)
- Anxiety: Significant measure (F = 15.84, η² = .081)
- Stress: Significant measure (F = 6.98, η² = .037)Daytime dysfunction was linked to more severe internalizing symptoms.
Meeting WHO guidelines for MVPA was associated with a reduced likelihood of depression and anxiety.
The study emphasizes the need for future research to focus on long-term effects of sleep on children with ADHD and the potential role of physical activity interventions on improving sleep and internalizing symptoms.