Sleep habits, parasomnias and associated behaviors in school children with Attention Deficit Hyperactivity Disorder (ADHD)

Abstract

Considerable clinical data support an association between sleep problems and attention deficit hyperactivity disorder (ADHD). We aimed to investigate the sleep habits, associated parasomnias and behavioral symptoms in primary school children with ADHD. Forty primary school children with a clinical diagnosis of ADHD and 40 age-sex-matched healthy community controls were recruited. The Children's Sleep Habits Questionnaire providing information regarding sleep habits and nighttime and daytime symptoms was used. About 22% of children with ADHD (versus 2.9% of the controls) needed their parents to accompany them while going to sleep (p: 0.008). Transitional objects were needed by 8.1% of ADHD children in contrast to 2.9% of controls. Nightmares, overactivity during sleep, habitual snoring, and bed-wetting were significantly higher in the ADHD group. ADHD children needed significantly more time to go to sleep on school days (p < 0.02). Children undergoing evaluation for ADHD should be routinely screened for sleep disturbances.

Full text

Sleep habits, parasomnias and associated behaviors in school
children with Attention Deficit Hyperactivity Disorder
(ADHD)
Ayşe Rodopman-Arman¹, Neşe Perdahlı-Fiş¹, Özalp Ekinci², Meral Berkem¹
¹Department of Child and Adolescent Psychiatry, Marmara University Faculty of Medicine, İstanbul, and ²Antakya
Children’s Hospital, Antakya, Turkey
SUMMARY: Rodopman-Arman A, Perdahlı-Fiş N, Ekinci Ö, Berkem M. Sleep
habits, parasomnias and associated behaviors in school children with Attention
Deficit Hyperactivity Disorder (ADHD). Turk J Pediatr 2011; 53: 397-403.
Considerable clinical data support an association between sleep problems and
Attention Deficit Hyperactivity Disorder (ADHD). We aimed to investigate the
sleep habits, associated parasomnias and behavioral symptoms in primary school
children with ADHD. Forty primary school children with a clinical diagnosis
of ADHD and 40 age-sex-matched healthy community controls were recruited.
The Children’s Sleep Habits Questionnaire providing information regarding
sleep habits and nighttime and daytime symptoms was used. About 22% of
children with ADHD (versus 2.9% of the controls) needed their parents to
accompany them while going to sleep (p: 0.008). Transitional objects were
needed by 8.1% of ADHD children in contrast to 2.9% of controls. Nightmares,
overactivity during sleep, habitual snoring, and bed-wetting were significantly
higher in the ADHD group. ADHD children needed significantly more time
to go to sleep on school days (p<0.02). Children undergoing evaluation for
ADHD should be routinely screened for sleep disturbances.
Key words: sleep habits, Attention Deficit Hyperactivity Disorder, parasomnia, school
children, behavior.
Sleep-related problems are frequently
encountered in many of the developmental
psychopathologies. Attention Deficit
Hyperactivity Disorder (ADHD) is the
mo st f re qu en tl y d ia gn os ed p ed ia tr ic
neurodevelopmental disorder, with a
prevalence of 3–12%1,2. In some situations,
unrecognized medical conditions underlie
the problematic externalizing behaviors,
including sleep disorders3,4. Considerable
clinical as well as empirical data support
an association between sleep problems and
ADHD in children5-7. Particularly, difficulties in
initiating and maintaining sleep are frequently
reported in children with ADHD4,5. However,
the relationship between ADHD and sleep
problems seems to be complex and bidirectional
in recent studies3,8,9. Basic sleep habits include
environmental, scheduling (e.g., regular bedtime
and wake-up schedule), sleep practice (e.g.,
bedtime routine, presence of a family member
or an object while sleeping), and physiologic
factors that promote optimal sleep10. Studies
have suggested that implementation of good
sleep habits alone may be adequate for a
successful management of sleep initiation
problems in children with ADHD11,12.
Parents of those with ADHD and children
with ADHD report sleep difficulties more
frequently than healthy children and their
parents in most studies4,6,10,12. In contrast,
sleep hygiene in association with parasomnias
and behavioral parameters have not been
mentioned very often in school children with
ADHD. We aimed to investigate the sleep
habits, associated parasomnias, and behavioral
symptoms in primary school children with
ADHD and community control subjects.
Material and Methods
The study sample consisted of 40 primary
school children with a clinical diagnosis of
ADHD who admitted to the Child Psychiatry
The Turkish Journal of Pediatrics 2011; 53: 397-403 Original

Clinic in a university hospital, and 40 age-
sex-matched healthy community controls. The
patients were randomly recruited from a large
pool of ADHD outpatients, which represented
approximately 30% of the 1500 new outpatient
admissions per year. The study interval was six
months. Approvals by the Regional Director
of Education, which serves as the Institute
of Human Subject Protection Committee
for the schools in İstanbul, as well as by
the Institutional Review Board of Marmara
University Medical School were obtained
prior to the case-control study. Children with
combined type of ADHD were diagnosed with
Kiddie–Schedule for Affective Disorders and
Schizophrenia (SADS)-Present and Lifetime
version (KSADS-PL)13, a semi-structured
clinical schedule, Turkish version14. Only the
threshold conditions of KSADS-PL were taken
into consideration for the comorbidity. Children
who had an Intelligence Quotient (IQ) below
70 and who suffered from major sensorimotor
disabilities (such as blindness, deafness and
cerebral palsy), psychosis or autism were
excluded from the study. Wechsler Intelligence
Scale for Children Revised (WISC-R)15 was
administered to children for evaluating the IQ
levels using the Turkish adaptation made by
Savaşır and Şahin16. The diagnosis of learning
disorder was given if there was a discordance
between the WISC-R subscales and if the
patient’s academic problems well-matched the
Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV) criteria for learning
disorder. Additionally, subjects with ADHD who
were on pharmacotherapy and subjects with
comorbid anxiety/depressive disorders were
also excluded to avoid the over-interpretation
of sleep disorders. The community subjects
having T scores <+2SD by Conners’ Parent
Scales were randomly recruited from a larger
pool of a prior study group17.
In this case-control study, we utilized a
semi-structured parental sleep questionnaire,
the Children’s Sleep Habits Questionnaire
(CSHQ), designed by Owens et al.18, which was
formulated according to the former guidelines
of Carroll 19 and Brouillette et al.20. The validity
and the reliability of Turkish version of the
CSHQ were studied in 1749 elementary school
children21. The Cronbach alpha coefficient was
determined as 0.78. The test-retest correlation
coefficient was 0.81. There were statistically
significant relationships between all behavioral
and emotional parameters and the presence of
sleep problems. The CSHQ, which is a parent
proxy-report, is a valid and reliable instrument
for assessing sleep habits and screening for
possible sleep problems in Turkish children.
An envelope containing the questionnaire
and a personally addressed letter asking for
parental consent were given. The questionnaire
was completed by the parents. It provided
information regarding sleep habits, nighttime
symptoms (total sleep time, sleep latency,
habitual snoring, restless sleep, sleep arousals,
nocturnal enuresis, night terrors, nightmares,
somnambulism, sleep talking, and bruxism)
and daytime symptoms (sleepiness in different
situations), and learning disabilities of children.
Parents reported the behavioral measures
on a 4-point Likert scale as: 0 (never), 1
(occasionally), 2 (often), and 3 (always).
Parameters were considered positive if they
were reported by parents on the parental
questionnaire as either ‘often’ or ‘always’ on
a 4-point Likert scale. Similarly, the answer to
the question of ‘What do you think about your
child’s academic performance?’ was scored from
‘failure (0)’ to ‘successful (3)’ on a 4-point
scale. Sleepiness score was maintained by the
mean score of the sum of ‘often’ or ‘always’
answers to the questions such as ‘Does your
child feel sleepy in different conditions such as
in public places, while watching TV, or while
playing with friends?”.
Data Analysis
Statistical analysis was done using a statistical
software package (Version 11.0 for Windows;
SPSS, Chicago, IL). Comparisons between two
groups were done using independent t-tests
for continuous variables. The prevalence of
symptoms in study groups was compared by
Pearson chi-square analysis. One-way ANOVA
was applied for the nominal values. Bonferroni
corrections were applied to control for multiple
comparisons. Data were summarized with
means and SD unless otherwise indicated, and
the level of significance was set at p<0.05.
Results
All of the ADHD patients were of combined
type, and they were medication-free. There
398 Rodopman-Arman A, et al The Turkish Journal of Pediatrics • July-August 2011

were 11 ADHD children with comorbidity
(ADHD-C) apart from depression and anxiety
(5 were additionally diagnosed as learning
disability, 3 as oppositional defiant disorder
(ODD), 2 as enuresis nocturna, and 1 as
chronic tic disorder). Table I outlines the
demographic characteristics of the subjects.
The gender distribution and the age range were
similar between the two groups. The ADHD
group was composed of 32 boys and 8 girls
and the healthy control group was composed
of 30 boys and 10 girls. The mean age was
9.1±1.5 years (age range: 7-13 years) for the
ADHD group and 9.3±1.3 years (age range:
7.1-13.2 years) for the healthy controls. The
groups in our study did not differ with regard
to sociodemographic variables (Table I).
Characteristics of sleep habits are presented
in Table II. Children with ADHD, combined
type only (52.3%) and the ADHD-C group
(63.7%) were found to be less likely to sleep
alone than healthy controls (88.6%) (p: 0.03).
The percentage of children who needed their
parents to remain by their side during sleep
onset was 22.7% in ADHD, combined type only,
and 18.1% in the ADHD-C group vs. 2.9% in
controls (p: 0.008). Transitional objects were
needed by 8.1% of ADHD children in contrast
to 2.9% of controls (Table II).
Table III shows the time of sleep onset and
sleep latency in the study groups. The sleep
latencies of children with ADHD during
the weekdays (21.6±22 vs. 15.8±12.8 (in
minutes± SD), p: 0.03) and on weekends
(21.6±19.1 versus 14.9±11.7 (in minutes±
SD), p: 0.001) were longer than in the normal
controls (Table III).
As shown in Table IV, there were significant
differences in the rates of nighttime symptoms
between children with ADHD and normal
controls. The rates of nightmares (p: 0.001),
nocturnal enuresis (p: 0.001), habitual snoring
(p: 0.007), and restless sleep (p: 0.02) were
higher in children with ADHD (Table IV).
The prevalences of daytime symptoms in
ADHD children and normal controls are
shown in Table V. Daytime sleepiness score
was considerably higher in the ADHD group
(p<0.001). Compared with normal controls,
children with ADHD had significantly higher
scores in learning disability (38.8% vs. 11.1%;
p: 0.01) and lower academic performance (5.9%
and 1.8% of the subjects, respectively, failed
in school; p: 0.02) (Table V).
Discussion
In our study, school children with ADHD had
significantly higher sleep-related problems
regarding sleep habits such as bedtime
resistance, sleep latency and parasomnias as well
as daytime behavioral parameters, i.e. increased
sleepiness, when compared to controls. These
results were compatible with the previous
literature indicating that both disturbances in
† Manual worker indicates those with a position that requires handwork (i.e. cleaning services, textile industry, tailor
assistance, etc.). They may or may not be governmentally insured.
‡ State officer indicates those with high school or university education, usually engaged in office work, and who have
governmental health insurance (i.e. nurse, doctor, lawyer, teacher, etc.).
ADHD
(n= 44) Controls
(n= 40) P value
Mean age (y; range) 9.1 ± 1.5 (7.2- 13.5) 9.3 ± 1.3 (7.1- 13.2) 0.24
Male gender 32 (80%) 30 (75%) 0.36
Maternal educational status
Primary school 18 (45%) 19 (47.5%)
0.08
Junior high (middle) school 13 (32.5%) 14 (35%)
High school 7 (17.5%) 6 (15%)
College or higher 2 (5%) 1 (2.5%)
Maternal labor status
Housewife (not working) 32 (80%) 31 (77.5%)
0.09
State officer ‡4 (10%) 5 (12.5%)
Manual worker † 3 (7.5%) 2 (5 %)
Other 1 (2.5%) 2 (5%)
Table I. Demographic Characteristics of 44 Children with ADHD and 40 Control Subjects
Volume 53 • Number 4 Sleep Habits in ADHD 399

sleep4 and related daytime problems 9,11,12 were
frequently reported by the parents of children
with ADHD. Sleep problems were reported in
about 25-50% of children and adolescents who
had ADHD7,12,22, which might further worsen
the ADHD symptomatology23,24.
In the present study, daytime sleepiness,
learning disabilities and failure at school
were significantly higher in the ADHD group.
According to a review of related literature
by Cortese et al.8, although no significant
alterations in sleep macro-architecture were
found compared with controls, children with
ADHD had significantly higher daytime
sleepiness and were more restless during sleep
in this study. In a child with ADHD, sleep
disturbances such as parasomnias may result in
sleep fragmentation, which may consequently
lead to excessive daytime fatigue25,26. This
may interfere with several aspects of daytime
functioning, such as attention and learning,
which are crucial for good performance at
school4,27,28.
Similar to the findings of Hvolby et al.26,
difficulties relating to bedtime and sleep
settlement were significantly more frequent in
both the ADHD-combined only group and the
ADHD-C group than in the controls in our
study. Children with ADHD showed prolonged
sleep onset, but there was no difference
regarding the total sleep time per night on
weekdays versus weekends.
In many of the subjective studies based on
parental reports25-30, children with ADHD
had significantly higher bedtime resistance,
more sleep-onset difficulties, sleep disordered
breathing31,32, and daytime sleepiness compared
with the controls.
There might be several explanations for increased
bedtime resistance. First, it is possible that the
increased resistance to sleep encountered in
these children may reflect problematic parent-
child interaction, i.e. the significant need for
parents and/or transitional objects nearby
during sleep settlement, which is quite common
in ADHD33. Second, most of the families of
children with ADHD have inappropriate sleep
habits, including environmental, scheduling and
sleep practice4,7,34, which may also contribute
to the problems with sleep initiation and sleep
maintenance.
Our results are compatible with the previous
literature and showed that school children
with ADHD have significantly higher sleep-
related problems. Previous literature indicates
that both the sleep disorder symptoms4 and
related daytime problems9, 11,12 are frequently
reported by parents in ADHD. In correlation
with the literature, our results revealed that
ADHD-
combined only
(n=33)
ADHD with
comorbidity
(n=11)
Controls
(n=40) P value
The mode of sleep settlement, %
Alone 52.3 63.7 88.6 0.03
With the help of mother/father 22.7 18.1 2.9 0.008
With transitional objects 8.1 9.1 2.9 0.03
In the living room with others/while watching TV 2.7 - 3.8 0.14
Other 8.7 9.1 9.3 0.87
Table II. Characteristics of Sleep Habits in the Study Groups
ADHD Controls P value
Total sleep time, min±SD
Weekdays 596.2±67.7 595±74.7 0.2
Weekend 601±96.7 616.8±65.7 0.6
Sleep latency, min±SD
Weekdays 21.6±22 15.8 ± 12.8 0.03
Weekend 21.6±19.1 14.9±11.7 0.001
Table III. Time of Sleep Onset and Sleep Latency in Study Groups
400 Rodopman-Arman A, et al The Turkish Journal of Pediatrics • July-August 2011

children with ADHD had higher scores in
various domains of sleep problems and related
functioning.
When limitations are taken into consideration,
our study mainly relied on subjective
measures of parental reports rather than
objectively collected sleep measures such as
polysomnography. On the other hand, extensive
clinical evaluation of ADHD children was made
by KSADS-PL. A considerably lower incidence
of ODD comorbidity in our study group might
be explained due to exclusion of subthreshold
conditions in KSADS-PL. Additionally, we
excluded the ADHD children with comorbid
anxiety/depressive disorders to avoid the over-
interpretation of sleep disorders. That might
also result in a further decrease in the rate of
ODD comorbidity, which is commonly seen in
depressive ADHD cases35. We also excluded
the patients with psychiatric comorbidity and
those who were on medications in order to
minimize their possible confounding effects
on sleep and behavioral variables.
In conclusion, children undergoing evaluation
for ADHD should be screened routinely for
sleep disturbances. This screening may include
the evaluation of psychotropic medication
use, comorbid psychiatric conditions, circadian
rhythm disorders, sleep hygiene problems, and
Nighttime symptoms, % ADHD Controls P value
Sleep awakenings, % 3.8 2.3 0.1
Restless sleep, % 23.1 13.9 0.02*
Nocturnal enuresis, % 15.1 3.3 0.001*
Habitual snoring,% 19.3 7.2 0.007*
Nightmares,% 32 5.2 0.001*
Excessive vocalizations during sleep, % 52 22.2 0.07
Bruxism, % 43.1 17.1 0.1
Table IV. The Prevalence of Nighttime Symptoms in ADHD and Control Groups
*Significant results where Bonferroni procedure is applied. Significance levels were set after the Bonferroni procedure.
parental reactions4,8,11. Children undergoing
evaluation for ADHD should be screened
routinely for sleep disturbances and would
benefit from an assessment regarding the
sleep profiles. Behavioral and time-based
regulations on sleep may have positive effects
on the daytime symptom profile of children
with ADHD.
Acknowledgements
This study was supported by Marmara University
Scientific Research Projects Commission
(Project number: SAG-D-08410-0072). The
authors thank all students, parents and teachers
for their participation in this study, and the
Regional Director of Education of İstanbul,
who made this study possible by approving
the process.
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