Practice Tools for Screening and Monitoring Insomnia in Children and Adolescents with Autism Spectrum Disorder.

Between 50-80% of children with autism spectrum disorder (ASD) have insomnia, which adversely affects their mental and physical health. However, there is no consensus to-date on suitable tools for insomnia screening and monitoring in daily clinical practice. An expert panel of child neuropsychiatry and sleep specialists, with expertise in children with neurodevelopmental disabilities, recommends: (1) performing insomnia screening of all children with ASD; (2) considering discussion or referral to a sleep specialist when comorbid sleep disorders are suspected. The panel further developed structured, brief screening and monitoring tools to facilitate insomnia screening and management in daily practice, monitor treatment effectiveness and standardize and compare outcomes across clinical settings to improve care and well-being of children with ASD and their families.

The effect of the March 2020 COVID-19 lockdown on national psychiatric contacts in Denmark: An interrupted time series analysis.

The COVID-19 pandemic resulted in national lockdowns in several countries. Previous global epidemics led to an increase in the number of psychiatric patients presenting symptoms of anxiety or depression. Knowledge about the impact of early lockdown initiatives during the COVID-19 pandemic on the number of healthcare interactions is sparse. Contacts in this study include all recorded face-to-face (FTF) and virtual treatment interactions between patients and healthcare systems. AIM: To investigate both the impact of the Danish lockdown event on psychiatric patients' contact with the healthcare system, stratified by type of contact (FTF or virtual) and ICD-10 diagnosis, and how acute contacts were impacted in the five regions in Denmark. METHODS: An interrupted time series analysis was applied to determine the effect of the COVID-19 lockdown event on the number of contacts with psychiatric hospitals in Denmark, from February 25, 2019 to May 3, 2020. The analyses took a Box-Jenkins approach to fit an autoregressive integrated moving average (ARIMA) model. RESULTS: Virtual contacts replaced most FTF contacts during the lockdown. For most patient groups, the total number of contacts did not decrease significantly. However, for adult patients diagnosed with ICD-10 F 0-10, 10-19, and 60-69 and child and adolescent patients diagnosed with F 10-19, 70-79, and 80-89, the number of contacts decreased during lockdown. The number of acute contacts with the psychiatric system decreased significantly in all regions in Denmark during lockdown. DISCUSSION: The Danish healthcare system was forced to introduce innovative tele-psychiatry to mental health care during the lockdown. Disruption to service delivery was minimized because the resources were in place to sustain the transition from FTF to virtual contacts.

Pediatric prolonged-release melatonin for insomnia in children and adolescents with autism spectrum disorders.

Introduction: Insomnia is common among children and adolescents with Autism spectrum disorder (ASD). The first drug licensed for insomnia in this population, a pediatric-appropriate prolonged-release melatonin (PedPRM) formulation is described.Areas covered: Literature search on  PedPRM efficacy and safety profile in clinical trials, and a proposed decision-making algorithm to optimize outcome  in the treatment of insomnia in children and adolescents with ASD.Expert opinion: PedPRM treatment effectively improves sleep onset, duration and consolidation, and daytime externalizing behaviors in children and adolescents with ASD and subsequently caregivers' quality of life and satisfaction with their children's sleep. The coated, odorless and taste-free mini-tablets are well-accepted in this population who often have sensory hypersensitivity and problems swallowing standard tablet preparations. The most frequent long-term treatment-related adverse events were fatigue (6.3%), somnolence (6.3%), and mood swings (4.2%) with no evidence of delay in height, BMI, or pubertal development, or withdrawal effects. The starting dose is 2 mg once daily independent of age or weight, escalated to 5-10 mg/day if predefined treatment success criteria are unmet. Slow melatonin metabolizers (~10% of children), may require lower doses. Given its long-term efficacy, safety and acceptance, PedPRM may ameliorate long-term consequences of insomnia in this population.

Cumulative incidence and relative risk of sleep problems among children and adolescents with newly diagnosed neurodevelopmental disorders: A nationwide register-based study.

We estimated the absolute and relative risk of sleep problems in children and adolescents with newly diagnosed neurodevelopmental disorders. This was a population-based cohort study of individuals born in Denmark in 1993-2014 and followed in nationwide registers in 2011-2016. We estimated the 5-year cumulative incidence of sleep problems in incident cases of attention-deficit/hyperactivity disorder (ADHD; n = 12,844), autism spectrum disorder (ASD; n = 8,073), oppositional defiant disorder/conduct disorder (ODD/CD; n = 2,234) and epilepsy (n = 3,709). Hazard ratios (HRs) for sleep problems were estimated by Cox regression. The 5-year risk of sleep problems was highest in ADHD (29.2%; 95% CI, 28.4-30.1), ASD (24.2%; 95% CI, 23.1-25.3) and ODD/CD (27.1% 95% CI, 25.0%-29.2%) and lowest in epilepsy (11.3%; 95% CI, 10.2%-12.6%). For ADHD and ASD, sleep problems were more common in females than in males. Furthermore, sleep problems were predicted by high parental socioeconomic status and varied with the geographical region of residence, suggesting that different clinical practices exist across Denmark and that sleep problems may be more likely to go undetected in families of lower socioeconomic position. Compared with individuals without these disorders, the likelihood of sleep problems was increased in individuals with ADHD (HR, 33.81; 95% CI, 32.78-34.87), ASD (HR, 16.77; 95% CI, 16.15-17.41), ODD/CD (HR, 14.73; 95% CI, 13.88-15.64) and epilepsy (HR, 6.01; 95% CI, 5.67-6.37). After mutual adjustment for comorbidity, HRs were attenuated, especially in ASD, ODD/CD and epilepsy when adjusted for ADHD, suggesting that the increased risk of sleep problems in individuals with ASD, ODD/CD and epilepsy is driven largely by comorbid ADHD.

Vitamin D3 supplementation and treatment outcomes in patients with depression (D3-vit-dep).

OBJECTIVE: To examine whether vitamin D supplementation in patients with depression would result in a reduction in Hamilton D-17 depression score (primary outcome) at 3 and 6 months compared to controls and to explore the correlations between serum vitamin D and symptoms of depression, wellbeing, systolic blood pressure, and waist circumference. In this outpatient multicentre study conducted between 2010 and 2013, patients, 18-65 years old, diagnosed with mild to severe depression were randomly assigned to receive D supplementation 70 micrograms daily or placebo on top of standard treatment. Participants, care givers and those assessing the outcomes were blinded to group assignment. RESULTS: At baseline, 23 patients had a normal 25(OH)D level, 22 had insufficiency (< 25 nmol/L), and 17 had deficiency (25-50 nmol/L). No significant reduction in depression was seen after vitamin D supplementation compared to placebo at Hamilton (18.4-18.0; p = 0.73 at 12 weeks). Vitamin D supplementation did not provide a reduction in symptom score among patients with depression. Trial registration The trial was registered in the National Board of Health (EudraCT: 2011-002585-20) and in ClinicalTrials.Gov (NCT01390662).

Fever and infections in pregnancy and risk of attention deficit/hyperactivity disorder in the offspring.

BACKGROUND: Fever and infections are common events during pregnancy, and have been shown to be associated with neurodevelopmental impairment in the offspring. The evidence in relation to attention deficit/hyperactivity disorder (ADHD) is, however, nonexistent for fever and limited for infections. The aim of this study was therefore to investigate the impact of these exposures on the occurrence of ADHD in the offspring, considering gestational timing as well as intensity of exposure. METHODS: The study was conducted within the Danish National Birth Cohort, using data on 89,146 pregnancies enrolled during 1996-2002. Exposure to fever and infections were assessed prospectively in two computer-assisted telephone interviews during pregnancy and ADHD status in the child was determined using registry information from three nation-wide patient and prescription registers. Stratified Cox regressions were used to calculate adjusted hazard ratios of ADHD occurrence. RESULTS: The analyses revealed no overall association between maternal exposure to fever or infections and ADHD in the offspring [adjusted hazard ratio (aHR): 1.03, 95% confidence interval (CI): 0.93-1.13 and aHR: 1.01, 95% CI: 0.92-1.11]. When the exposures were considered during specific gestational periods, increased rates of ADHD were observed following fever in gestational weeks 9-12 (aHR: 1.33, 95% CI: 1.12-1.58), and genitourinary infections in weeks 33-36 (aHR: 1.60, 95% CI: 1.13-2.26). CONCLUSIONS: Although no overall adverse association between fever and infections in pregnancy and ADHD in the offspring was found, the analyses indicated that exposures during specific time windows of the pregnancy could be associated with increased ADHD occurrence.

The effect of daily small text message reminders for medicine compliance amongst young people connected with the outpatient department for child and adolescent psychiatry. A controlled and randomized investigation.

BACKGROUND: Many patients with psychiatric illnesses have difficulty maintaining medication over time. Many take their medicine irregularly and studies show that it is the most vulnerable patients who have the greatest problems adhering to treatment. Often only 50% are still under medical treatment after 6 months. AIM: In this study we investigated whether text message reminders could improve medicine compliance amongst vulnerable young people with psychiatric disorders who were being treated in the outpatient department for child and adolescent psychiatry and who either are under or were to commence medicinal treatment. METHODS: This study was conducted as a randomized controlled trial including all non-acute referrals to an outpatient department for adolescent psychiatry within a group aged 15-20 years starting medical treatment. The patients were followed until the end of their treatment, for a minimum of 3 months. To enhance medicine compliance, text messages were sent daily to one group. No message was sent to the other group. RESULTS: Compliance was not associated with text message intervention in any of the drug interventions. The effect size was calculated to 0.3013, which is low and therefore indicates a weak association between text message and compliance. The power in this study was calculated to 0.3539, which is also low and therefore the likelihood of finding significant association is low. CONCLUSION: This study does not show increased medicine compliance from the text message intervention group. The conclusion of this study is that it is essential that significant resources are spent preparing and testing a text message strategy.

Associations of sleep disturbance with ADHD: implications for treatment.

Attention-deficit/hyperactivity disorder (ADHD) is commonly associated with disordered or disturbed sleep. The relationships of ADHD with sleep problems, psychiatric comorbidities and medications are complex and multidirectional. Evidence from published studies comparing sleep in individuals with ADHD with typically developing controls is most concordant for associations of ADHD with: hypopnea/apnea and peripheral limb movements in sleep or nocturnal motricity in polysomnographic studies; increased sleep onset latency and shorter sleep time in actigraphic studies; and bedtime resistance, difficulty with morning awakenings, sleep onset difficulties, sleep-disordered breathing, night awakenings and daytime sleepiness in subjective studies. ADHD is also frequently coincident with sleep disorders (obstructive sleep apnea, peripheral limb movement disorder, restless legs syndrome and circadian-rhythm sleep disorders). Psychostimulant medications are associated with disrupted or disturbed sleep, but also 'paradoxically' calm some patients with ADHD for sleep by alleviating their symptoms. Long-acting formulations may have insufficient duration of action, leading to symptom rebound at bedtime. Current guidelines recommend assessment of sleep disturbance during evaluation of ADHD, and before initiation of pharmacotherapy, with healthy sleep practices the first-line option for addressing sleep problems. This review aims to provide a comprehensive overview of the relationships between ADHD and sleep, and presents a conceptual model of the modes of interaction: ADHD may cause sleep problems as an intrinsic feature of the disorder; sleep problems may cause or mimic ADHD; ADHD and sleep problems may interact, with reciprocal causation and possible involvement of comorbidity; and ADHD and sleep problems may share a common underlying neurological etiology.

Diet in the treatment of ADHD in children - a systematic review of the literature.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric conditions in childhood. Dietary changes have been suggested as a way of reducing ADHD symptoms. AIMS: To provide an overview of the evidence available on dietary interventions in children with ADHD, a systematic review was carried out of all dietary intervention studies in children with ADHD. METHODS: Relevant databases were searched in October 2011, with an update search in March 2013. The studies included describe diet interventions in children with ADHD or equivalent diagnoses measuring possible changes in core ADHD symptoms: inattention, hyperactivity and impulsivity. RESULTS: A total of 52 studies were identified, some investigating whether ADHD symptoms can improve by avoiding certain food elements (20 studies), and some whether certain food elements may reduce ADHD symptoms (32 studies). CONCLUSION: Elimination diets and fish oil supplementation seem to be the most promising dietary interventions for a reduction in ADHD symptoms in children. However, the studies on both treatments have shortcomings, and more thorough investigations will be necessary to decide whether they are recommendable as part of ADHD treatment.

Use of Ball Blanket in attention-deficit/hyperactivity disorder sleeping problems.

OBJECTIVES: Based on actigraphic surveillance, attention-deficit/hyperactivity disorder (ADHD) symptom rating and sleep diary, this study will evaluate the effect of Ball Blanket on sleep for a sample of 8-13-year-old children with ADHD. DESIGN: Case-control study. SETTING: A child and adolescent psychiatric department of a teaching hospital. PARTICIPANTS: 21 children aged 8-13 years with a diagnosis of ADHD and 21 healthy control subjects. INTERVENTION: Sleep was monitored by parent-completed sleep diaries and 28 nights of actigraphy. For 14 of those days, the child slept with a Ball Blanket. MAIN OUTCOME MEASURES: The sleep latency, number of awakenings and total length of sleep was measured, as was the possible influence on parent- and teacher-rated ADHD symptom load. RESULTS: The results of this study will show that the time it takes for a child to fall asleep is shortened when using a Ball Blanket. The time it takes to fall asleep when using the Ball Blanket is found to be at the same level as the healthy control subjects. Teacher rating of symptoms show an improvement in both activity levels and attention span of approximately 10% after using the Ball Blankets. CONCLUSIONS: The results of this study show that the use of Ball Blankets is a relevant and effective treatment method with regard to minimizing sleep onset latency. We find that the use of Ball Blankets for 14-days improves the time it takes to fall asleep, individual day-to-day variation and the number of awakenings to a level that compares with those found in the healthy control group. Furthermore, we find that the use of Ball Blankets significantly reduces the number of nights that the ADHD child spends more than 30 min falling asleep from 19% to 0%.

Parental rating of sleep in children with attention deficit/hyperactivity disorder.

OBJECTIVE: Sleep problems have often been associated with attention deficit/hyperactivity disorder (ADHD). Parents of those with ADHD and children with ADHD report sleep difficulties more frequently than healthy children and their parents. The primary objective of this paper is to describe sleep patterns and problems of 5 to 11-year-old children suffering from ADHD as described by parental reports and sleep questionnaires. METHOD: The study included 321 children aged 5-11 years (average age 8.4 years); 45 were diagnosed with ADHD, 64 had other psychiatric diagnoses, and 212 were healthy. One hundred and ninety-six of the test subjects were boys and 125 were girls. A semi-structured interview (Kiddie-SADS-PL) was used to DSM-IV diagnose ADHD and comorbidity in the clinical group. Sleep difficulties were rated using a structured sleep questionnaire (Children Sleep Behaviour Scale). RESULTS: Children diagnosed with ADHD had a significantly increased occurrence of sleep problems. Difficulties relating to bedtime and unsettled sleep were significantly more frequent in the ADHD group than in the other groups. Children with ADHD showed prolonged sleep onset latency, but no difference was shown regarding numbers of awakenings per night and total sleep time per night. Comorbid oppositional defiant disorder appeared not to have an added effect on problematic behaviour around bedtime. CONCLUSION: Parents of children with ADHD report that their children do not sleep properly more often than other parents. The ADHD group report problems with bedtime resistance, problems with sleep onset latency, unsettled sleep and nightmares more often than the control groups. It may therefore be relevant for clinicians to initiate a closer examination of those cases reporting sleep difficulties.

Actigraphic and parental reports of sleep difficulties in children with attention-deficit/hyperactivity disorder.

OBJECTIVES: To describe actigraphically detected and parent-reported sleep problems in nonmedicated children with attention-deficit/hyperactivity disorder (ADHD); to clarify whether or not comorbid oppositional defiant disorder contributes to sleep difficulties; and to compare objectively measured sleep with the parents' observations of sleep. DESIGN: Case-control study. SETTING: A child and adolescent psychiatric department of a teaching hospital. PARTICIPANTS: Two hundred six children aged 5 to 11 years, including 45 with a diagnosis of ADHD, 64 with a diagnosis of other psychiatric diagnoses (psychiatric control group), and 97 healthy control subjects (reference group). Intervention Sleep was monitored by parent-completed sleep diaries and 5 nights of actigraphy. We used a semistructured interview to diagnose psychiatric disorders according to Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria. MAIN OUTCOME MEASURES: Actigraphically measured sleep variables and parent-estimated sleep by diary. RESULTS: We found that children with ADHD have significantly longer sleep onset latency and a more irregular sleep pattern than the psychiatric control or healthy reference subjects. Average sleep onset latencies were 26.3 minutes in the ADHD group, 18.6 minutes in the psychiatric control group, and 13.5 minutes in the healthy reference group. There was no apparent relationship between sleep problems and comorbid oppositional defiant disorder. We found discrepancies between the objectively measured sleep variables and those reported by parents, who overestimated sleep onset latency. CONCLUSIONS: The results of this study allow us to conclude that some children with ADHD have impaired sleep that cannot be referred to comorbid oppositional defiant disorder. However, it is important to make an in-depth review of the sleep complaints, as the problem may be a product of the parents' perception rather than the child's actual experience.

[Sleep and sleep difficulties in Danish children aged 6-11 years]. / Søvn og søvnproblemer hos danske børn i alderen 6-11 år.

INTRODUCTION: Sleeping difficulties in children can affect learning and behaviour. Parental understanding of sleep can differ from what clinicians define as a sleep problem. It is therefore important to have information on sleep in Danish children in order to be able to advice parents on normal and deviant sleep. The purpose of this article is to describe the sleep in Danish healthy children. METHODS AND MATERIALS: We examined 211 healthy children aged 6-11 years, recruited in a public school. Their sleep was evaluated objectively with actigraphy. Sleep patterns and sleep problems were examined by means of a questionnaire completed by parents. The objective and subjective measurements were compared. RESULTS: The most frequently reported sleep problem was fear of falling asleep in the dark, which 19.4% reported. Unwillingness to go to bed was reported in 7.1% and 7.5% had difficulties falling asleep. Actigraphic-measured sleep onset latency was on average 13.5 minutes, while parents reported an average of 21.5 minutes. CONCLUSION: The results comply with other findings. As in other sleep studies we found that parents estimate the child's sleep to be poorer than it actually is, although the discrepancy is less than seen in clinical populations. Detailed sleep history, possibly in combination with a sleep diary, can usually identify sleep problems and might be the first step in an effective treatment. Furthermore, actigraphy can be an effective supplement in the unravelling of sleep difficulties.

[Sleeping disorders can imitate attention deficit/hyperactivity disorder]. / Søvnrytmeforstyrrelse kan ligne symptomer på opmaerksomhedsforstyrrelse.

Attention deficit/hyperactivity disorder (ADHD) is often associated with anxiety, depression, oppositional defiant disorder and sleeping difficulties. Sleeping disorders are reported in more than 50% of children with ADHD. On the other hand, symptoms of sleep disorder, inattention, hyperactivity and impulsiveness can imitate the symptoms of ADHD. We describe a 5(1/2)-year-old boy with symptoms of attention deficit and social withdrawal. His sleep was disturbed, with late sleep onset and frequent awakening during the night. After correction of his sleep pattern, the symptoms of attention deficit and social withdrawal disappeared.