Behavioral and combined behavioral and pharmacological interventions were investigated for their potential to help improve sleep outcomes in children with attention-deficit/hyperactivity disorder (ADHD).
Behavioral sleep interventions might improve sleep disturbances for children with attention-deficit/hyperactivity disorder (ADHD), shows a review in Sleep Medicine. In terms of behavioral sleep interventions only for children with ADHD, moderate certainty of the evidence was seen, in particular, for children aged 5 to 13 years.
Melatonin usage in conjunction with one behavioral intervention produced a moderate effect size with low certainty of evidence for total sleep time (TST). These outcomes demonstrate that one pharmacological intervention with melatonin, compared with placebo, and a nonpharmacological intervention with sleep hygiene practices and standardized behavioral strategies, vs standard care, affect sleep quantity and quality for children with ADHD, even without certain results.
It is known that disturbances in sleep might exacerbate symptoms of ADHD in children with this condition, so the researchers conducted a systematic literature review to see what might address these disturbances. The review was designed to synthesize and report evidence on sleep intervention effectivity in increasing sleep, quality of life (QOL), and symptoms in children with ADHD.
In the review, studies published from 2005 and onward detailing controlled trials with a minimum of 20 children aged 6 to 18 years were used. Out of 7710 records identified, 4808 abstracts were screened, 99 papers were fulltext-screened, and 8 papers from 5 studies including behavioral sleep interventions and melatonin and eszopiclone (pharmacological interventions), were used. Two pharmacological studies and 2 nonpharmacological studies met inclusion criteria.
Two of the studies involved parent information and nonpharmacological, parental-directed comprehensive intervention results compared with usual clinical care. Follow-up periods ranged from 4 weeks to 6 months. Out of 7 outcomes from the studies, 6 possessed effect sizes that were small to moderate with low certainty of the evidence, deeming them inconclusive.
The remaining outcome, sleep disturbances, had a moderate effect size of –0.49 standardized mean differences (95% CI, –0.65 to –0.33), with a moderate certainty of evidence for the behavioral interventions for children 5 to 13 years old with ADHD. These results reflect the conclusions of previous studies.
The sleep disturbances outcome illustrates that tailored sleep behavior interventions look to be a fair choice of treatment for children with ADHD and comorbid sleep problems.
TST effect size was reported to go over 30 minutes after a 4-week follow-up for children using melatonin and about 15 minutes at the 3-month follow-up after a behavioral intervention. This result is considered a moderate effect with low evidence based on previous research illustrating that improvement in TST rarely goes over 30 minutes in sleep interventions but will probably increase over time.
Melatonin improved sleep outcomes but not QOL or ADHD functioning, and eszopiclone showed no effect on included sleep outcomes. Since the eszopiclone study was the only one that included children aged 6 to 11 and 12 to 17 years, the effectiveness of sleep interventions on adolescents cannot be reported. At the 6-month follow-up period, sustained results for QOL and ADHD behavior weren’t shown.
Results discovered through this review might be used by treatment providers to guide sleep intervention measures for children with ADHD of certain age groups. The authors also noted that economic decision makers should consider the implications of the interventions they choose, and that highly effective interventions might be too costly.
They emphasized, too, the importance of longer follow-up periods, and consensus on a core outcome set in future intervention studies addressing sleep among children. For health care professionals, they highlight that pharmacological and behavioral sleep intervention treatments for children with ADHD have a weak evidence base and need further research.
One limitation to generalizability of their findings is that the strict methodology used in this study means that few studies are included, which may have negatively influenced evidence certainty, but they assure that the aforementioned methodology imposes scientific rigor in the results. Another limitation was that the researchers drew conclusions from randomized controlled trials with different timeframes (4 weeks to 6 months).
Overall, the study researchers determined, their findings illustrate that behavioral sleep interventions and behavioral sleep interventions with pharmacological assistance (melatonin) can have an impact on sleep quantity and quality for children with ADHD, despite uncertainty.
Larsson I, Aili K, Lönn M, et al. Sleep interventions for children with attention deficit hyperactivity disorder (ADHD): a systematic literature review. Sleep Med. 2022;102:64-75. doi:10.1016/j.sleep.2022.12.021