Examining bidirectional associations between sleep and behavior among children with attention-deficit/hyperactivity disorder.

Background: Children with attention-deficit/hyperactivity disorder (ADHD) have more sleep problems than their peers which contribute to behavioral and functional impairments. This study examines the bidirectional relationship between nightly sleep (i.e., total sleep time and sleep efficiency) and daily behavior of children with ADHD. Method: Forty-three children (ages 6-13 [mean = 9.05, 54% male, 77% medicated]) participated in a 2-week study during an ADHD Summer Treatment Program (STP). Sleep was measured with actigraphy. Behavior was assessed using STP clinical data and daily parent and counselor ratings of ADHD symptoms, oppositional defiant disorder behaviors, and emotion regulation (e.g., difficulty regulating emotional disposition and controlling emotions). We hypothesized that healthier night's sleep measured by actigraphy (i.e., sleep efficiency and total sleep time [TST]) would relate to less ADHD symptoms, less emotional dysregulation, and better academic performance the next day. Additionally, we hypothesized that less ADHD symptoms, less emotional dysregulation, and greater academic performance would relate to healthier sleep that night. Results: Higher nightly sleep efficiency was related to improved parent-ratings of ADHD the next day (R 2 = 0.04, p = 0.04) and improved parent-ratings of ADHD during the day lead to higher sleep efficiency that night (R 2 = 0.002, p = 0.02). Higher rates of daily assignment completion were related to higher sleep efficiency at night (R 2 = 0.035, p = 0.03). TST was not related to any behavioral outcomes. Conclusion: Sleep efficiency may be more relevant than TST to behavioral performance the next day. Additionally, a bidirectional relationship exists between sleep efficiency and parent ratings of ADHD. Findings highlight the importance of assessing for manifestations of poor sleep efficiency, waking minutes, and wakings after sleep onset when diagnosing and treating ADHD.

Online Intervention for Caregivers of Children with Early Traumatic Brain Injury: Pilot Trial.

OBJECTIVE: To assess the feasibility and acceptability of an online parenting-skills program for caregivers of young children with traumatic brain injury (TBI). Positive parenting contributes to recovery following early TBI and social and emotional development in typically developing children. Yet, few interventions have been designed to support psychosocial recovery and subsequent development after early TBI. METHODS: This study protocol was registered with clinicaltrials.gov (NCT05160194). We utilized an academic hospital's Trauma Registry to recruit caregivers of children, ages 0-4 years, previously hospitalized for TBI. The GROW intervention integrated six online learning modules with videoconference meetings with a coach to review and practice skills while receiving in vivo coaching and feedback. Interactive modules addressed strategies for responsive parenting, stimulating cognition, and managing parenting stress. Enrollment and retention rates served as feasibility metrics and satisfaction surveys assessed acceptability. RESULTS: 18 of 72 families contacted (25%) consented, and 11 of 18 (61%) completed the intervention and follow-up assessments. All participants rated the intervention as helpful and indicated that they would recommend the intervention to others. All endorsed a better understanding of brain injury and how to optimize their child's recovery and development. Both coaches rated intervention delivery as comparable to traditional face-to-face treatment. CONCLUSIONS: Low levels of uptake and initial engagement underscore the challenges of intervening with caregivers following early TBI, which likely were exacerbated due to the COVID-19 pandemic. High levels of acceptability and perceived benefit support the potential utility of GROW while highlighting the need to improve accessibility and early engagement.

Impact of a Behavioral Sleep Intervention in Adolescents With ADHD: Feasibility, Acceptability, and Preliminary Effectiveness From a Pilot Open Trial.

OBJECTIVE: An open trial tested the feasibility, acceptability, and preliminary effectiveness of a behavioral sleep intervention in adolescents with ADHD. METHOD: Fourteen adolescents (ages 13-17 years; 50% male) with ADHD and co-occurring sleep problems received the cognitive-behavioral-based Transdiagnostic Sleep and Circadian Intervention for Youth (TranS-C). Adolescent, parent, and teacher ratings, actigraphy, and daily sleep diaries were collected at pre-intervention, post-intervention, and 3-month follow-up. RESULTS: Adolescents experienced moderate to large improvements in sleep, mental health symptoms, and daily life executive functioning from pre-treatment to post-treatment, and improvements were generally maintained at 3 months. Pre-intervention, 71.4% of adolescents were classified as poor sleepers and this was reduced to 21.4% and 28.6% at post-treatment and follow-up, respectively. CONCLUSION: This study provides strong preliminary evidence that TranS-C improves sleep and associated outcomes in adolescents with ADHD and co-occurring sleep problems. A randomized controlled trial is needed to rigorously test the efficacy of TranS-C in this population.

Attention-Deficit/Hyperactivity Disorder-Related Deficits and Psychostimulant Medication Effects on Comprehension of Audiovisually Presented Educational Material in Children.

Objective: We aimed to (1) examine differences in observed visual attention and motor activity, as well as comprehension of a science video between children with and without attention-deficit/hyperactivity disorder (ADHD) and (2) explore if psychostimulant medication improves ADHD behaviors and comprehension of a science video in children with ADHD. Method: Children aged 7-11 with (n = 91) and without (n = 45) ADHD watched a science video and then completed a comprehension test. Then, children with ADHD began a 4-week within-subject, randomized, double-blind crossover trial of methylphenidate (MPH). At post-testing, children were randomized to receive placebo or their optimal dosage, watched another science film, and completed a comprehension test. Results: Children with ADHD exhibited higher rates of motor activity during, and worse comprehension of material discussed within, the science video. Mediation models revealed that increased motor activity suppressed between-group differences in comprehension. MPH improved comprehension and visual attention, but not motor activity during the science video. Conclusion: Children with ADHD may benefit from MPH to improve comprehension of and sustained attention during audiovisually presented learning material.

The impact of comorbid mental health symptoms and sex on sleep functioning in children with ADHD.

Children with attention-deficit/hyperactivity disorder (ADHD) display more sleep problems than their peers, but it remains unclear whether comorbid mental health symptoms [i.e., anxiety, depression, oppositional-defiant disorder (ODD)] are uniquely related to sleep functioning. It is also largely unknown whether boys and girls with ADHD differ in their sleep functioning. This study (1) examined whether boys or girls with ADHD differ in their sleep functioning, (2) evaluated comorbid symptoms as uniquely related to sleep functioning domains, and (3) explored whether sex moderated associations between comorbid symptoms and sleep. Participants were 181 children (ages 7-13; 69% male; 82% White) diagnosed with ADHD. Parents completed measures assessing their child's ADHD symptoms, comorbid symptoms, and sleep functioning. Girls had poorer sleep functioning than boys across most sleep functioning domains. Sixty percent of children met cutoff criteria for having sleep problems, though rates differed significantly between girls (75%) and boys (53%). No differences in rates of sleep problems were found between ADHD subtypes/presentations or between younger and older children. In path models including ADHD and comorbid symptom dimensions, anxiety symptoms were uniquely associated with increased bedtime resistance and sleep anxiety, ADHD hyperactive-impulsive symptoms were associated with more night wakings and more parasomnia behaviors, and ODD and depressive symptoms were associated with shorter sleep duration. Depression was also uniquely associated with increased daytime sleepiness and overall sleep problems. Sex did not moderate associations between comorbid symptoms and sleep problems. This study provides important preliminary evidence that girls with ADHD experience more sleep problems than boys with ADHD. Findings also demonstrate that the associations between comorbid symptoms and sleep functioning in children with ADHD vary based on both the specific symptoms and sleep domains examined.

Effect of sleep extension on sluggish cognitive tempo symptoms and driving behavior in adolescents with chronic short sleep.

OBJECTIVE/BACKGROUND: Few adolescents report obtaining adequate amounts of sleep. Correlational studies have linked adolescent short sleep with driving crashes and sluggish cognitive tempo (SCT), a cluster of symptoms that include sluggishness and low persistence that are related to but distinct from inattention and sleepiness. The relationship between SCT and driving is understudied, and no study has experimentally examined the relationship between SCT and sleep. We examined the relationship between SCT and driving problems in a sample of chronically short-sleeping adolescents. We also examined whether experimentally extending sleep improved SCT and driving behaviors. PARTICIPANTS/METHODS: Licensed 16- to 18-year-old adolescents who regularly obtained five to seven hours of sleep completed a five-week at-home experimental protocol: a baseline week to determine typical sleep (TYP), followed in a counterbalanced order by two-week spans in which school-night bedtimes and rise times were (a) matched to TYP or (b) modified to extend (EXT) time in bed by 1.5 h/night. Sleep was monitored by actigraphy. Self- and parent-reported SCT and inattention and self-reported driving problems were recorded at baseline and following each condition. Of the 38 eligible participants who completed the baseline session, 24 completed all five weeks of the protocol. RESULTS: After controlling for inattention, only parent-reported SCT was significantly positively associated with self-reported purposeful driving violations at baseline. Adolescents reported lesser SCT during EXT than during TYP. Further, after controlling for inattention, participants who reported improvement in SCT demonstrated fewer driving problems during EXT than during TYP. CONCLUSIONS: Preliminary findings suggest that extending sleep in short-sleeping adolescents may help alleviate SCT symptoms and improve driving.

Intraindividual variability of sleep/wake patterns in relation to child and adolescent functioning: A systematic review.

Substantial research attention has been devoted to understanding the importance and impact of sleep in children and adolescents. Traditionally, this has focused on mean sleep variables (e.g., a child's "typical" or average sleep duration), yet research increasingly suggests that intraindividual variability (IIV) of sleep/wake patterns (sometimes referred to as sleep variability or night-to-night variability) regularly occurs and may have implications for adjustment. A systematic search of five electronic databases identified 52 empirical studies published between 2000 and 2015 that examined correlates of sleep IIV in children and adolescents, with a recent increase in the publication rate of such studies. Identified studies were often atheoretical and included post hoc analyses, though IIV in select aspects of sleep does appear to be associated with increasing age/pubertal status, non-White race, physical and neurodevelopmental conditions (e.g., attention-deficit/hyperactivity disorder; autism), psychopathology symptoms (e.g., anxiety, depression, inattention), body weight, stress, aspects of cognitive functioning, and poorer sleep functioning/habits. The limited intervention work examining sleep IIV in adolescents is promising, though studies are needed using more rigorous intervention designs. Clinical sleep recommendations may not only need to address overall sleep duration and sleep habits but also the stability of sleep duration and timing. It will be important for future research examining sleep IIV in children and adolescents to use a developmental framework in advancing theory pertaining to the causes, mechanisms, moderators, and outcomes of sleep IIV in youth, and a conceptual model is proposed to help guide such efforts.