Behavioral, neurocognitive, polysomnographic and cardiometabolic profiles associated with obstructive sleep apnea in adolescents with ADHD.

BACKGROUND: A high comorbidity between attention-deficit/hyperactivity disorder (ADHD) and obstructive sleep apnea (OSA) as well as similar impairments across neurobehavioral outcomes has been described in children. However, there is a paucity of research examining the comorbidity of these two disorders in adolescents. This study examined the association of OSA with sleep, neurobehavioral, and cardiometabolic outcomes in adolescents with ADHD from the general population. METHODS: 421 adolescents (16.9 ± 2.3 years, 53.9% male) underwent 9-hr polysomnography, neurobehavioral, and physical evaluation. ADHD was ascertained by a parent-or-self-report of a lifetime diagnosis/treatment of ADHD. OSA was defined as an apnea hypopnea index of ≥2 events/hour. Groups of controls (n = 208), OSA-alone (n = 115), ADHD-alone (n = 54), and ADHD+OSA (n = 44) were studied. Multivariable-adjusted general linear models tested group differences in PSG parameters, neurobehavioral, and cardiometabolic outcomes after controlling for sex, race/ethnicity, age, and/or body mass index percentile. RESULTS: The ADHD+OSA group had significantly longer sleep onset latency, shorter total sleep time, lower sleep efficiency, and higher percent of stage 1 sleep, as compared with all other groups, however, these differences were diminished by excluding adolescents on psychoactive medication. The ADHD-alone group showed significantly higher periodic limb movements than controls. The ADHD+OSA and ADHD-alone groups did not significantly differ on any measure of neurocognitive or behavioral functioning. The ADHD+OSA and OSA-alone groups showed significantly worse cardiometabolic and inflammatory biomarkers when compared to controls or the ADHD-alone, but did not significantly differ between each other. CONCLUSIONS: Adolescents with a diagnosis ADHD+OSA showed phenotypic risk factors for OSA (i.e., overweight/obesity, visceral adiposity, metabolic syndrome, and inflammation) but not worse neurobehavioral outcomes when compared with ADHD-alone. While comorbidity is possible, these data support that adolescents with a suspicion of ADHD should be screened for OSA, before a diagnosis is reached and psychoactive medication initiated.

Cross-Sectional Age Analysis of Sleep Problems in 2 to 17 Year Olds with ADHD Combined, ADHD Inattentive, or Autism.

Sleep problems are common in autism and ADHD. No study has compared sleep problems by age in 2 to 17 year olds with autism versus ADHD-Combined versus ADHD-Inattentive type. Mothers rated 1415 youth with autism and 1041 with ADHD on 10 Pediatric Behavior Scale sleep items. Nighttime sleep problems were most severe in autism, followed by ADHD-Combined, and then ADHD-Inattentive. Difficulty falling asleep, restless during sleep, and waking during the night were the most common problems. Adolescents slept more at night than other age groups, and youth who slept more at night were sleepier during the day. Sleep problems declined with age, but correlations were small. In adolescence, 63% with autism, 53% with ADHD-Combined, and 57% with ADHD-Inattentive had difficulty falling asleep. Given that the majority of children in all age groups had one or more sleep problem, developmentally appropriate interventions are needed to address sleep difficulties and limit their adverse effects.

Effect of trazodone versus cognitive-behavioural treatment on high- and slow-frequency activity during non-rapid eye movement sleep in chronic insomnia: A pilot, randomized clinical trial.

Trazodone and cognitive-behavioural treatment for insomnia (CBT-I) are widely used to treat patients with chronic insomnia. Although both treatments improve sleep continuity, no study has compared their comparative effectiveness in modifying spectral electroencephalographic (EEG) activity during sleep in humans. In this study, participants included 19 men and women with chronic insomnia who were randomized to either trazodone (n = 8) or CBT-I (n = 11) treatment for 3 months. We examined delta (0.39-3.91 Hz), theta (4.30-7.81 Hz), alpha (8.20-11.72 Hz), sigma (12.11-14.84 Hz), beta (15.23-35.16 Hz) and gamma (35.55-49.61 Hz) relative power during non-rapid eye movement (NREM) sleep at pre-treatment, 3- month post-treatment and 6-month follow-up. This study was registered in Clinical Trials (NCT01348542). We found trazodone but not CBT-I significantly decreased sigma (p = .041, d = 0.88; time × group p = .009) and beta (p = .005, d = 1.41; time × group p = .016) power during NREM sleep at post-treatment. Compared to CBT-I, trazodone increased delta (p = .018) and decreased sigma (p = .013) and beta (p = .023) power during NREM sleep at post-treatment. At follow-up, we did not observe significant changes in relative EEG power during NREM sleep in either the CBT-I or trazodone group compared to pre-treatment. Compared to CBT-I, trazodone decreased alpha (p = .039) and sigma (p = .009) power during NREM sleep at follow-up. In conclusion, trazodone, but not CBT-I, decreased fast-frequency EEG activity during NREM sleep. Compared to CBT-I, trazodone appears to have a stronger impact on cortical and physiological hyperarousal in patients with chronic insomnia.

Clinical Significance and Cut-Off Scores for the Pre-Sleep Arousal Scale in Chronic Insomnia Disorder: A Replication in a Clinical Sample.

Background: In contrast to pre-sleep cognitive arousal, self-reported pre-sleep somatic arousal is a rather elusive construct for which little validity has been provided. Thus, the clinical significance of somatic symptoms during the pre-sleep period remains unknown. Participants: 248 patients (45.0 ± 16.7 years old, 65.3% female) with a diagnosis of chronic insomnia disorder, out of 388 consecutive patients evaluated at the Behavioral Sleep Medicine (BSM) program of Penn State Hershey Sleep Research & Treatment Center. Methods: Participants completed the Pre-sleep Arousal Scale assessing cognitive (PSAS-C) and somatic (PSAS-S) arousal as well as the Insomnia Severity Index (ISI), Ford Insomnia Response to Stress Test (FIRST), Arousal Predisposition Scale (APS), and Depression Anxiety Stress Scale (DASS). Multivariable stepwise regression assessed which clinical factors were independently associated with greater PSAS-C and PSAS-S scores. Receiver operating characteristic analysis determined the predictive value for identifying sleep reactivity (FIRST≥18) and clinical anxiety (DASS-A ≥ 10) and clinically useful cutoff scores. Results: The strongest correlates of PSAS-S were DASS-A (ß = 0.64) and chronic pain (ß = 0.11), while those of PSAS-C were FIRST (ß = 0.29) and a history of stroke (ß = 0.10). A PSAS-S score of 14.8 (AUC = 0.87, 95%CI = 0.83-0.91) and a PSAS-C score of 24.5 (AUC = 0.82, 95%CI = 0.76-0.88) showed the best balance in specificity and sensitivity to identify clinical anxiety and sleep reactivity, respectively. Conclusions: Self-reported pre-sleep somatic symptoms are a marker of comorbid anxiety and, potentially chronic pain, impacting nighttime sleep. The optimal cutoff scores of 14 and 20 proposed herein can help clinicians with case formulation, with tailoring BSM treatments and their targets.

Am I (hyper)aroused or anxious? Clinical significance of pre-sleep somatic arousal in young adults.

Self-reported somatic arousal remains a challenging clinical construct, particularly because only a subset of patients report symptoms such as racing heart, palpitations or increased body temperature interfering with their sleep. It is unclear whether self-reported somatic arousal is a marker of hyperarousal or co-morbid clinical anxiety in individuals with insomnia. Participants included 196 young adults aged 20.2 ±â€…1.0 years old who were predominantly females (75%). About 39% of the sample reported subthreshold insomnia, and about 8% reported clinically significant insomnia, based on their Insomnia Severity Index. Participants completed the Pre-Sleep Arousal Scale, Beck Anxiety Inventory, Beck Depression Inventory, Arousal Predisposition Scale, and Ford Insomnia Response to Stress Test. Multivariable stepwise regression assessed which factors were independently associated with pre-sleep cognitive (Pre-Sleep Arousal Scale-Cognitive) and somatic (Pre-Sleep Arousal Scale-Somatic) arousal. Receiver-operating characteristic analysis assessed the predictive value to identify clinically significant anxiety (Beck Anxiety Inventory ≥ 20), insomnia (Insomnia Severity Index ≥ 15) and arousability (Arousal Predisposition Scale ≥ 32). Beck Anxiety Inventory (ß = 0.42) was the best single correlate of Pre-Sleep Arousal Scale-Somatic, while Insomnia Severity Index (ß = 0.33) was of Pre-Sleep Arousal Scale-Cognitive. A Pre-Sleep Arousal Scale-Somatic score of 12 or more identified those with clinically significant anxiety with 65% specificity and 65% sensitivity, while a cut-off score of 14 increased its sensitivity (86%). Self-reported pre-sleep somatic arousal may be an index of co-morbid clinical anxiety in individuals with insomnia. These findings aid clinicians with assessment and treatment, particularly in the absence of clinical guidelines indicating when somatically focused relaxation techniques should be included as part of multicomponent cognitive behavioural treatment of insomnia.

A Survey of Practicing Sleep Coaches.

BACKGROUND: Sleep coaches are individuals of various backgrounds who offer services to families struggling with behavioral childhood sleep problems. We conducted a survey of coaches to further elucidate scope of practice, practice patterns, geographic distribution, education, training, and beliefs regarding qualification requirements. METHODS: A Web-based survey was completed by 142 individuals who identified as a sleep coach. RESULTS: Coaches were distributed across 17 countries and 5 continents. Overall, 65% of coaches served clients in countries beyond their home country. Within the United States, coaches were generally located in more affluent and well-educated zip codes near large metropolitan centers, 91% served clients beyond their home state, and 56% served clients internationally. Educational background varied across coaches (12% high school degree, 51% bachelor's degree, 32% master's degree, 2% doctoral degree, 1.5% JD degree). Few coaches (20%) were or had been licensed health care providers or carried malpractice insurance (38%). Coaches usually provided services for children < 4 months of age to about 6 years of age, and were much less likely to provide services for children with comorbid neurodevelopmental (32%) or significant medical disorders (19%). Coaches reported an average of 3 new and 6 total clients per week and working 20 hr per week on average. Most coaches (76%) felt that a formal sleep coach training program was the most important qualification for practice. CONCLUSIONS: These results highlight a diversity of background, training, and geographical distribution of sleep coaches, and may help inform discussions regarding guidelines for training and credentialing of sleep coaches.

Parental Concerns About Infant and Toddler Sleep Assessed by a Mobile App.

The aim of this study was to assess the primary concerns of parents/caregivers regarding their young child's sleep. A total of 1,287 consecutive sleep-related questions were analyzed from submissions to an Ask the Expert section of a publicly available iPhone-based application for sleep in young children. Questions regarding infants were most likely to be submitted (53.9%), followed by newborns (23.76%) and toddlers (17.8%), with an average age of 10.94 months. The primary concerns regarded night wakings, sleep schedules, and bedtime problems, accounting for almost 85% of all questions. Results align with common concerns noted in epidemiological studies. Understanding the types of concerns for which parents seek advice is beneficial in the continued development of resources for caregivers.

Natural history of insomnia symptoms in the transition from childhood to adolescence: population rates, health disparities, and risk factors.

STUDY OBJECTIVES: To determine the sociodemographic, behavioral, and clinical risk factors associated with the persistence, remission, and incidence of insomnia symptoms in the transition from childhood to adolescence. METHODS: The Penn State Child Cohort is a random, population-based sample of 700 children (5-12 years at baseline), of whom 421 were followed-up as adolescents (12-23 years at follow-up). Subjects underwent polysomnography, clinical history, physical exam, and parent- and self-reported scales at baseline and follow-up. Insomnia symptoms were defined as a parent- or self-report of difficulty falling and/or staying asleep. RESULTS: The 421 subjects with baseline (Mage = 8.8 years) and follow-up (Mage = 17 years) data were 53.9% male and 21.9% racial/ethnic minorities. The persistence of childhood insomnia symptoms (CIS) was 56% (95% CI = 46.5-65.4), with only 30.3% (95% CI = 21.5-39.0) fully remitting. The incidence of adolescent insomnia symptoms was 31.1% (95% CI = 25.9-36.3). Female sex, racial/ethnic minority, and low socioeconomic status as well as psychiatric/behavioral or neurological disorders, obesity, smoking, and evening chronotype were associated with a higher persistence or incidence of insomnia symptoms. CONCLUSIONS: CIS are highly persistent, with full remission occurring in only a third of children in the transition to adolescence. Sex-, racial/ethnic-, and socioeconomic-related disparities in insomnia occur as early as childhood, while different mental/physical health and lifestyle/circadian risk factors play a key role in the chronicity of CIS versus their incidence in adolescence. CIS should not be expected to developmentally remit and should become a focus of integrated pediatric/behavioral health strategies.

The Hypersomnia Severity Index: reliability, construct, and criterion validity in a clinical sample of patients with sleep disorders.

STUDY OBJECTIVES: The Hypersomnia Severity Index (HSI) was designed to assess the severity and impairment of hypersomnolence and has been validated in persons with psychiatric disorders. Little is known about its psychometric properties in clinical samples of patients with sleep disorders. METHODS: One hundred fifty-eight patients (aged 44.1 ± 16.4 years, 29.1% male, 19.6% racial/ethnic minority) evaluated at the Behavioral Sleep Medicine program of the Penn State Health Sleep Research and Treatment Center completed the HSI and other patient-reported outcomes. We examined the HSI's reliability and factorial, construct, and criterion validity. RESULTS: The HSI showed satisfactory internal consistency (α = 0.79). A 2-factor structure, reflecting symptoms (HSI-S) and impairment, explained 56.2% of the variance. Convergent validity with the Epworth Sleepiness Scale was optimal (r = .65) but greater for HSI-S (r = .69) than for impairment (r = .39). Divergent validity was optimal for HSI-S against unrelated measures of sleep effort, reactivity, and incompatible behaviors (r ≤ .02). Construct validity showed higher scores in patients with central disorders of hypersomnolence and lower scores in patients with chronic insomnia disorder compared to those with other sleep disorders; however, these divergent scores were primarily driven by HSI-S rather than impairment. Criterion validity showed that an HSI-S cutoff score ≥ 8 provided the best balance in sensitivity/specificity (0.82/0.78) to identify central disorders of hypersomnolence (area under the curve, 0.85). CONCLUSIONS: The HSI shows satisfactory indices of reliability and validity in a clinical patient sample. Its construct and criterion validity are supported by its divergent association with other patient-reported outcomes and central disorders of hypersomnolence vs chronic insomnia disorder diagnoses and the adequate sensitivity/specificity of its HSI-S cutoff score to reliably identify central disorders of hypersomnolence. CITATION: Fernandez-Mendoza J, Puzino K, Amatrudo G, et al. The Hypersomnia Severity Index: reliability, construct, and criterion validity in a clinical sample with sleep disorders. J Clin Sleep Med. 2021;17(11):2249-2256.

Arousability as a trait predisposition to insomnia: multidimensional structure and clinical utility of the Spanish and English versions of the Arousal Predisposition Scale.

OBJECTIVES: Traits related to a hyper-reactive arousal system (arousability) and weakened sleep system (sleep reactivity) are considered predisposing factors for insomnia of potential clinical utility. However, research examining the psychometric properties (ie, reliability and validity) of the Arousal Predisposition Scale (APS) and its clinical utility (ie, cut-off scores) among population-based and clinical samples is very limited. METHODS: A total of 500 adults (41.8% female, 39.1 ± 15.9 years) from the general population in Spain and 217 adults (64.5% female, 46.0 ± 16.1 years) from a clinical sample in the United States completed the APS, as well as measures of sleep reactivity, insomnia severity, anxiety, depression, and stress. Structural equation modeling was used to conduct confirmatory factor analysis (CFA) of the APS. Correlation and receiver operating characteristic (ROC) analyses were used to determine convergent and predictive validity of the APS and its factors. RESULTS: The CFAs supported two dimensions of emotional reactivity (APS-ER, 9 items) and trait anxiety (APS-TA, 3 items) in both independent samples. APS-ER was associated with sleep reactivity and performed better than APS-TA when predicting clinically significant sleep reactivity and similarly when predicting clinically significant insomnia severity. CONCLUSIONS: Our findings support the specificity of emotional reactivity and sleep reactivity as trait predispositions to insomnia, while trait anxiety is a predisposing factor for the comorbidity of insomnia with state anxiety rather than a specific diathesis for insomnia. These data provide further support for the diathesis-stress model of insomnia and, as a transdiagnostic process, its potential etiological link with psychopathology.

Insomnia with objective short sleep duration is associated with cognitive impairment: a first look at cardiometabolic contributors to brain health.

STUDY OBJECTIVES: Insomnia with objective short sleep duration has been previously associated with adverse cardiometabolic health outcomes as well as poorer cognitive performance in otherwise noncognitively impaired adults. However, studies demonstrating an increased prevalence of cognitive impairment (CI) in this insomnia phenotype are lacking. METHODS: We analyzed data from Penn State Adult Cohort (N = 1,524; 48.9 ± 13.4 years; 53.4% women). Self-reported sleep difficulty was defined as normal sleep (n = 899), poor sleep (n = 453), and chronic insomnia (n = 172). Objective short sleep duration was defined as less than 6-h of sleep, based on in-lab, 8-h polysomnography. CI (n = 155) and possible vascular cognitive impairment (pVCI, n = 122) were ascertained using a comprehensive neuropsychological battery. Analyses adjusted for age, sex, race, education, body mass index, apnea/hypopnea index, smoking, alcohol, psychoactive medication, and mental and physical health problems. RESULTS: Participants who reported poor sleep or chronic insomnia and slept objectively less than 6 hours were associated with a 2-fold increased odds of CI (OR = 2.06, 95% confidence limits [CL] = 1.15-3.66 and OR = 2.18, 95% CL = 1.07-4.47, respectively) and of pVCI (OR = 1.94, 95% CL = 1.01-3.75 and OR = 2.33, 95% CL = 1.07-5.06, respectively). Participants who reported poor sleep or chronic insomnia and slept objectively more than 6 hours were not associated with increased odds of either CI (OR = 0.72, 95% CL = 0.30-1.76 and OR = 0.75, 95% CL = 0.21-2.71, respectively) or pVCI (OR = 1.08, 95% CL = 0.42-2.74 and OR = 0.76, 95% CL = 0.16-3.57, respectively). CONCLUSIONS: Insomnia with objective short sleep duration is associated with an increased prevalence of CI, particularly as it relates to cardiometabolic health (i.e. pVCI). These data further support that this insomnia phenotype may be a more biologically severe form of the disorder associated with cardiovascular, cerebrovascular, and neurocognitive morbidity.

Effects of trazodone versus cognitive behavioral therapy in the insomnia with short sleep duration phenotype: a preliminary study.

STUDY OBJECTIVES: The insomnia with objective short sleep duration phenotype is associated with increased risk for adverse health outcomes, physiological hyperarousal, and a blunted response to cognitive behavioral therapy for insomnia (CBT-I). Whether insomnia with objective short sleep duration responds better to pharmacological treatment compared to CBT-I has not been examined. METHODS: Participants included 15 patients with chronic insomnia (86.7% female), aged 45.3 ± 8.1 years. Eight patients were randomized to CBT-I and 7 to trazodone. Patients were examined with 2 weeks of actigraphy, salivary cortisol, and the insomnia severity index at 3 time points (pretreatment, 3-month posttreatment, and 6-month follow-up). Mixed between-within-subjects analysis of variance and univariate analysis of covariance were conducted to assess the impact of trazodone and CBT-I on patients' total sleep time, salivary cortisol, and insomnia severity index scores across the 3 time points. RESULTS: Trazodone, but not CBT-I, significantly lengthened total sleep time (when measured with actigraphy) both at posttreatment (51.01 minutes vs -11.73 minutes; P = .051; Cohen's d = 1.383) and at follow-up (50.35 minutes vs -7.56 minutes; P = .012; Cohen's d = 1.725), respectively. In addition, trazodone, but not CBT-I, showed a clinically meaningful decrease in salivary cortisol from pretreatment to posttreatment (-36.07% vs -11.70%; Cohen's d = 0.793) and from pretreatment to follow-up (-21.37% vs -5.79%; Cohen's d = 0.284), respectively. Finally, there were no differences on insomnia severity index scores between the trazodone and the CBT-I groups. CONCLUSIONS: The current preliminary, open-label, randomized trial suggests that trazodone, but not CBT-I, significantly improves objective sleep duration and reduces hypothalamic-pituitary-adrenal axis activation, suggesting a differential treatment response in the insomnia with objective short sleep duration phenotype. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Study of Trazodone & Cognitive Behavioral Therapy to Treat Insomnia; URL: https://clinicaltrials.gov/ct2/show/NCT01348542; Identifier: NCT01348542.

High school teacher ratings of academic, social, and behavioral difficulties: Factor structure and normative data for the School Functioning Scale.

Because academic, behavioral, and social difficulties are highly prevalent among U.S. high school students, teacher report is a critical component of comprehensive screening and assessment of adolescents. Currently available teacher questionnaires have limited utility in high school settings because of time demands and lesser opportunity to observe a wide variety of student behaviors relative to elementary school teachers. The School Functioning Scale (SFS) is a 9-item measure designed to efficiently obtain teacher perceptions of specific indicators of student performance across academic, behavior, and social functioning. Online SFS ratings were collected for 799 9th through 12th grade high school students (50% female) from 400 teachers (63.7% female). Teachers also reported each student's subject grades and percentage of assignments completed within the past month. Exploratory and confirmatory factor analyses indicated a general factor and three-factor structure for the SFS: academic, behavior, and social factors. The general factor demonstrated adequate levels of internal consistency and evidence of convergent validity. Findings regarding the group factors less robust. The factor structure was consistent across age, gender, and ethnicity groups. Normative data along with suggested cut-points for screening and assessment purposes are provided. Findings support the potential use of SFS teacher ratings for multimethod assessment and, possibly, screening and treatment evaluation. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Impact of Study Skills and Parent Education on First-Year GPA Among College Students With and Without ADHD: A Moderated Mediation Model.

OBJECTIVE: To test if the relationship between ADHD and academic achievement is mediated by service utilization and/or study skills, and if these mediation effects are moderated by parental education level. METHOD: A bootstrapping method within structural equation modeling was used with data from 355 first year college students meeting strict criteria for ADHD or clearly without ADHD to test the mediation and moderation effects. RESULTS: Study skills, but not service utilization, significantly mediated the relationship between ADHD status and GPA; however, this relationship was not significant among students with at least one parent holding a master's degree or higher. CONCLUSION: Among first year college students study skills may be a more salient predictor of educational outcomes relative to ADHD status. Additional research into support services for college students with ADHD is needed, however, results suggest interventions targeting study skills may hold particular promise for these students.

Investigating reasons for CPAP adherence in adolescents: a qualitative approach.

STUDY OBJECTIVES: Adolescents with obstructive sleep apnea syndrome (OSAS) represent an important but understudied subgroup of long-term continuous positive airway pressure (CPAP) users. The purpose of this qualitative study was to identify factors related to adherence from the perspective of adolescents and their caregivers. METHODS: Individual open-ended, semi-structured interviews were conducted with adolescents (n = 21) and caregivers (n = 20). Objective adherence data from the adolescents' CPAP machines during the previous month was obtained. Adolescents with different adherence levels and their caregivers were asked their views on CPAP. Using a modified grounded theory approach, we identified themes and developed theories that explained the adolescents' adherence patterns. RESULTS: Adolescent participants (n = 21) were aged 12-18 years, predominantly male (n = 15), African American (n = 16), users of CPAP for at least one month. Caregivers were mainly mothers (n = 17). Seven adolescents had high use (mean use 381 ± 80 min per night), 7 had low use (mean use 30 ± 24 min per night), and 7 had no use during the month prior to being interviewed. Degree of structure in the home, social reactions, mode of communication among family members, and perception of benefits were issues that played a role in CPAP adherence. CONCLUSIONS: Understanding the adolescent and family experience of using CPAP may be key to increasing adolescent CPAP adherence. As a result of our findings, we speculate that health education, peer support groups, and developmentally appropriate individualized support strategies may be important in promoting adherence. Future studies should examine these theories of CPAP adherence.