Friday 20 February 2015

Behavioural sleep intervention for ADHD?

I was really quite interested to read about the study from Harriet Hiscock and colleagues [1] (open-access) suggesting that: "A brief behavioural sleep intervention modestly improves the severity of ADHD [attention deficit hyperactivity disorder] symptoms in a community sample of children with ADHD." I had heard that these results would be forthcoming based on the publication of the study trial protocol [2] a few years back, alongside the trial entry listed in the ISRCTN registry (see here). There is also the promise of more to come from this group [3].

The Hiscock paper is open-access but a few pointers might be useful:

  • Based on the idea that sleep issues have been reported in quite a large proportion of those diagnosed with ADHD [4], authors set about testing the idea that consultations with specialists on managing sleep issues might impact on said problems and "might have lasting benefits not only on sleep but on the ADHD itself."
  • Participants were randomly assigned to sleep intervention or usual clinical care for such matters. As with these kinds of trials and the various issues of attrition (drop-outs) and loss at follow-up, although 122 children were initially allocated to each group, a mix of sample sizes were available at the 3 month and 6 month follow-up periods. Statistical analysis of the results was made on the basis of intention to treat.
  • Various outcomes were measured during the study. The ADHD rating scale IV was the primary outcome for ADHD symptoms (something I have a little experience of in my own research). Various sleep related issues were also monitored including actigraphy to measure movement "and used to differentiate between sleep and wake times."
  • Results: "The families reported greater improvements in their children’s ADHD symptoms, sleep, behaviour, health related quality of life, and daily functioning, and teachers reported improved behaviour" as a function of the sleep intervention. The effects for parents were also noticeable insofar as "intervention parents reported fewer days late for work as a result of their child’s behaviour than control parents."
  • The more objective actigraphy results also suggested: "an improved sleep duration of around 70 minutes a week in the intervention group" bearing in mind researchers reporting a few 'practical issues' with this method.
  • Accepting a few limitations associated with their study methods, authors highlight the positive effects of the intervention and how: "These benefits occur over and above the effects of stimulant medications." Further: "Effects are comparable to those seen with intensive behavioural interventions targeting ADHD symptoms, more wide reaching than those reported in studies of melatonin, and importantly seem to be sustained over six months." Not bad at all.

Of course further research is implied from such results to "determine whether these benefits can be replicated when the sleep intervention is implemented by community based clinicians in a rigorous effectiveness trial." Translational medicine I think its called. But there is little doubt that there is much more to see when it comes to the presentation of ADHD and the very valuable resource called sleep.

Just before I leave you, the paper from Papadopoulos and colleagues [5] potentially also indicates how the Hiscock results might translate into improvements for those with autism also diagnosed with ADHD (see here). Based on an analysis of a "subsample of children with ADHD-ASD [autism spectrum disorder]... participating in the Sleeping Sound With ADHD study" (the Hiscock study) authors reported that those in receipt of the behavioural sleep intervention "had large improvements in sleep problems and moderate improvements in child behavioral functioning 3 and 6 months post-randomization."

Further food for thought perhaps, added to what is already known about sleep and [some] autism (see here). Oh, and remember, screen time whilst useful, might also impact on sleep time as we are perhaps already seeing...

So: Primal Scream - Kill All Hippies ('though not literally I might add).


[1] Hiscock H. et al. Impact of a behavioural sleep intervention on symptoms and sleep in children with attention deficit hyperactivity disorder, and parental mental health: randomised controlled trial. BMJ. 2015 Jan 20;350:h68.

[2] Sciberras E. et al. Study protocol: the sleeping sound with attention-deficit/hyperactivity disorder project. BMC Pediatr. 2010 Dec 30;10:101.

[3] Lycett K. et al. Behavioural sleep problems in children with attention-deficit/hyperactivity disorder (ADHD): protocol for a prospective cohort study. BMJ Open. 2014 Feb 12;4(2):e004070.

[4] Silvestri R. et al. Sleep disorders in children with Attention-Deficit/Hyperactivity Disorder (ADHD) recorded overnight by video-polysomnography. Sleep Med. 2009 Dec;10(10):1132-8. 

[5] Papadopoulos N. et al. The Efficacy of a Brief Behavioral Sleep Intervention in School-Aged Children With ADHD and Comorbid Autism Spectrum Disorder. J Atten Disord. 2015 Feb 2. pii: 1087054714568565.

---------- Hiscock H, Sciberras E, Mensah F, Gerner B, Efron D, Khano S, & Oberklaid F (2015). Impact of a behavioural sleep intervention on symptoms and sleep in children with attention deficit hyperactivity disorder, and parental mental health: randomised controlled trial. BMJ (Clinical research ed.), 350 PMID: 25646809

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