Instability of Sleep Patterns in Children With Attention-Deficit/Hyperactivity Disorder

doi:10.1097/00004583-200004000-00019

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 39, Issue 4, April 2000, Pages 495-501

https://doi.org/10.1097/00004583-200004000-00019 Get rights and content

ABSTRACT

Objective

To compare the stability of the sleep-wake system of children with attention-deficit/hyperactivity disorder (ADHD) and controls by objective and subjective measures.

Method

Thirty-eight school-age boys with diagnosed ADHD and 64 control school-age boys were examined using actigraphic monitoring and sleep diaries, over 5 consecutive nights.

Results

Increased instability in sleep onset, sleep duration, and true sleep were found in the ADHD group compared with the control group. Discriminant analysis revealed that children's classification (ADHD versus control) could be significantly predicted on the basis of their sleep measures.

Conclusions

The findings support the hypothesis that instability of the sleep-wake system is a characteristic of children with ADHD. Given the potential negative effects of disturbed or unstable sleep on daytime functioning, it is recommended that a thorough sleep assessment be conducted when a sleep disturbance is suspected or when symptoms associated with daytime sleepiness or decreased arousal level are present.

Section snippets

Subjects

Participants were 38 boys (age range: 6-14 years; mean = 9.6, SD = 2.7) who met the DSM-IV (American Psychiatric Association, 1994) criteria for ADHD by ratings of their teachers and at least one parent and 64 boys (age range: 7.5-11.5; mean = 9.4, SD = 1.7) from a normative sample. The children in both groups were recruited from the same school district (many of them shared classes) with very homogenous psychosocial characteristics and cultural background.

The diagnosis of ADHD was based on

Averaged Actigraphic Sleep Measures

No significant differences between the groups were found on the MANCOVA using the averaged measures of sleep as the dependent variables (F = 0.49; not significant [NS]) (Table 1).

Night-to-Night Variability of Actigraphic Sleep Measures

The MANCOVA using the standard deviation of the sleep measures revealed significant group differences (F = 4.87; p < .0001). Results of the separate ANCOVAs for each sleep measure revealed significant group differences on the duration of sleep, true sleep, and sleep onset time, indicating an increased instability of

DISCUSSION

The purpose of the current study was to compare sleep patterns of children with ADHD and non-ADHD controls. To the best of our knowledge, this is the largest study using objective measures of sleep and the only study addressing the issue of night-to-night variability.

A comparison of the stability of the children's sleep over 5 consecutive nights revealed increased variability of the sleep measures, reflecting instability of the sleep-wake system in the ADHD group compared with controls.

REFERENCES (51)

W Carey
Night waking and temperament in infancy
J Pediatr
(1974)
P Corkum et al.
Sleep disturbances in children with attention-deficit/hyperactivity disorder
J Am Acad Child Adolesc Psychiatry
(1998)
LE Halpern et al.
Infant sleep-wake characteristics: relation to neurological status and the prediction of developmental outcome
Dev Rev
(1995)
AH Parmelee et al.
Development of states in infants
EB Thoman
Sleeping and waking states in infants: a functional perspective
Neurosci Biobehav Rev
(1990)
WD Tynan
Behavioral stability predicts morbidity and mortality in infants from a neonatal intensive care unit
Infant Behav Dev
(1986)
WA Weinberg et al.
Primary disorder of vigilance: a novel explanation of inattentiveness, daydreaming, boredom, restlessness and sleepiness
J Pediatr
(1990)
C Acebo et al.
Estimating sleep patterns with activity monitoring in children and adolescents: how many nights are necessary for reliable measures?
Sleep
(1999)
TM Achenbach
Integrative Guide for the 1991 CBCL14–18, YSR, and TRF Profiles
(1991)
TM Achenbach et al.
Manual for the Child Behavior Checklist and Revised Child Behavior Profile
(1983)

American Psychiatric Association

Diagnostic and Statistical Manual of Mental Disorders

(1980)

American Psychiatric Association

Diagnostic and Statistical Manual of Mental Disorders

(1994)

TF Anders et al.

Sleep habits of children and the identification of pathologically sleepy children

Child Psychiatry Hum Dev

(1978)

H Babkoff et al.

Monotonic and rhythmic influences: a challenge for sleep deprivation research

Psychol Bull

(1991)

MH Bonnet

Effect of sleep disruption on sleep, performance, and mood

Sleep

(1985)

K Busby et al.

Sleep patterns in hyperkinetic and normal children

Sleep

(1981)

RD Chervin et al.

Symptoms of sleep disorders, inattention, and hyperactivity in children

Sleep

(1997)

RE Dahl

The regulation of sleep and arousal: development and psychopathology

Dev Psychopathol

(1996)

RE Dahl et al.

The role of sleep disturbances in attention deficit disorder symptoms: a case study

J Pediatr Psychol

(1991)

VI Douglas et al.

Toward a clearer definition of the attentional deficit of hyperactive children

C Goyette et al.

Normative data on the Revised Conners Parent and Teacher Rating Scales

J Abnorm Child Psychol

(1978)

L Greenhill et al.

Sleep architecture and REM sleep measures in prepubertal children with attention deficit disorder with hyperactivity

Sleep

(1983)

R Gruber et al.

Sleep of school-aged children: objective and subjective measures

J Sleep Res

(1997)

C Guilleminault et al.

Children and nocturnal snoring: evaluation of the effects of sleep related respiratory resistive load and daytime functioning

Eur J Pediatr

(1982)

S Jenkins et al.

Behavior problems in preschool children

J Child Psychol Psychiatry

(1980)

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: This study was supported by the Israel Ministry of Education and by Woolf and Helene Marmot.

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ARTICLESInstability of Sleep Patterns in Children With Attention-Deficit/Hyperactivity Disorder

ABSTRACT

Objective

Method

Results

Conclusions

Section snippets

Subjects

Averaged Actigraphic Sleep Measures

Night-to-Night Variability of Actigraphic Sleep Measures

DISCUSSION

J Pediatr

J Am Acad Child Adolesc Psychiatry

Dev Rev

Neurosci Biobehav Rev

Infant Behav Dev

J Pediatr

Estimating sleep patterns with activity monitoring in children and adolescents: how many nights are necessary for reliable measures?

Sleep

Integrative Guide for the 1991 CBCL14–18, YSR, and TRF Profiles

Manual for the Child Behavior Checklist and Revised Child Behavior Profile

Diagnostic and Statistical Manual of Mental Disorders

Diagnostic and Statistical Manual of Mental Disorders

Sleep habits of children and the identification of pathologically sleepy children

Child Psychiatry Hum Dev

Monotonic and rhythmic influences: a challenge for sleep deprivation research

Psychol Bull

Effect of sleep disruption on sleep, performance, and mood

Sleep

Sleep patterns in hyperkinetic and normal children

Sleep

Symptoms of sleep disorders, inattention, and hyperactivity in children

Sleep

The regulation of sleep and arousal: development and psychopathology

Dev Psychopathol

The role of sleep disturbances in attention deficit disorder symptoms: a case study

J Pediatr Psychol

Toward a clearer definition of the attentional deficit of hyperactive children

Normative data on the Revised Conners Parent and Teacher Rating Scales

J Abnorm Child Psychol

Sleep architecture and REM sleep measures in prepubertal children with attention deficit disorder with hyperactivity

Sleep

Sleep of school-aged children: objective and subjective measures

J Sleep Res

Children and nocturnal snoring: evaluation of the effects of sleep related respiratory resistive load and daytime functioning

Eur J Pediatr

Behavior problems in preschool children

J Child Psychol Psychiatry

ARTICLES
Instability of Sleep Patterns in Children With Attention-Deficit/Hyperactivity Disorder