Associations of sleep disturbance with ADHD: implications for treatment
Open accessAbstract
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.
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Written from the paper’s full text.
TL;DR
This review synthesizes evidence that ADHD is commonly associated with sleep disturbances and specific sleep disorders, with complex bidirectional relationships involving medications and psychiatric comorbidities. It proposes a four-scenario conceptual model and emphasizes assessing sleep before ADHD pharmacotherapy, with healthy sleep practices as first-line management.
Key findings
- Sleep disturbances are reported in 25–55% of individuals with ADHD; in an Australian study, 62% of children with ADHD had moderate or severe sleep problems and 22% took sleep medications during a 1-week observation period.
- Meta-analytic and objective findings are most concordant for apnea/hypopnea and periodic limb movements in sleep or nocturnal motor activity on polysomnography; actigraphy showed longer mean sleep onset latency and shorter true sleep time; subjective meta-analysis found the largest impairment for bedtime resistance, followed by difficulty with morning awakenings, sleep onset difficulties, sleep-disordered breathing, night awakenings, and daytime sleepiness.
- Sleep disorder overlap is substantial: obstructive sleep apnea prevalence is 25–30% in patients with ADHD versus about 3% in the general population; up to 44% of children with ADHD have restless legs syndrome symptoms and 26% of children with RLS have ADHD symptoms, while 2% of typically developing children and adolescents aged 8–17 years meet RLS diagnostic criteria.
- Stimulants can disrupt sleep but may paradoxically calm some patients; insomnia treatment-emergent adverse event rates include OROS-MPH 13.4% vs placebo 7.3% (Medori et al.) and 13% vs 1% (Newcorn et al.), LDX 18.8% vs 2.8% (Biederman et al.), and atomoxetine somnolence 15–17%; sleep hygiene reduced sleep onset delay to below 60 min in about 20% of patients, with an overall effect size of 0.67.
Methods
- Narrative review of published studies comparing sleep in individuals with ADHD with typically developing controls, including polysomnographic, actigraphic, multiple sleep latency test, and subjective studies, plus literature on sleep disorders, ADHD medications, and clinical guidelines.
- Presents a conceptual model of four hypothetical modes of interaction: ADHD causes sleep problems; sleep problems cause or mimic ADHD; ADHD and sleep problems interact reciprocally with possible comorbidity; and ADHD and sleep problems share a common underlying neurological etiology.
- No new primary data or formal meta-analysis are reported; the synthesis is qualitative.
Limitations
- The paper states that polysomnographic studies are generally small (typically 20–30 participants per arm) and that larger-scale, multicenter studies are needed; age, gender, comorbidities, ADHD diagnostic criteria, subtype, and inclusion of an adaptation night are not controlled in many studies.
- The paper states there is no convincing demonstration that pharmacological or non-pharmacological intervention to improve sleep actually leads to improved ADHD symptoms or reduced functional impairment, and calls for research on sleep phenotypes and mechanisms.
- Evident from the text: as a narrative review, it does not describe a systematic search strategy, inclusion criteria, or formal risk-of-bias assessment; conclusions depend on the cited literature and author interpretation.
Model-written summary. Check it against the paper before relying on it.
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Claims the paper makes
0 of 122 cited sources checked · 0 supported · 0 flagged
- Premisecitation
Psychostimulant medications can paradoxically calm some patients with ADHD for sleep by alleviating their symptoms.
“but also ‘paradoxically’ calm some patients with ADHD for sleep by alleviating their symptoms.”
- Also stated in: § Pharmacotherapy with stimulants · hedged
“clinical experience also indicates that stimulants produce paradoxical effects (Bradley 1937), whereby alleviation of symptoms can calm patients and promote sleep (Jerome 2001; Kinsbourne 1973; Kooij et al. 2001; Kratochvil et al. 2005).”
Quote in the paperNot a substantial claim0 of 3 sources checked - Also stated in: § Pharmacotherapy with stimulants · hedged
- Interpretationcitation
Evidence from published studies comparing sleep in individuals with ADHD with typically developing controls is most concordant for increased sleep onset latency and shorter sleep time in actigraphic studies.
“increased sleep onset latency and shorter sleep time in actigraphic studies;”
Quote in the paperSubstantial claim - Premisenone given
ADHD is frequently coincident with sleep disorders (obstructive sleep apnea, peripheral limb movement disorder, restless legs syndrome and circadian-rhythm sleep disorders).
“ADHD is also frequently coincident with sleep disorders (obstructive sleep apnea, peripheral limb movement disorder, restless legs syndrome and circadian-rhythm sleep disorders).”
Quote in the paperSubstantial claim - Interpretationcitation
Evidence from published studies comparing sleep in individuals with ADHD with typically developing controls is most concordant for bedtime resistance, difficulty with morning awakenings, sleep onset difficulties, sleep-disordered breathing, night awakenings and daytime sleepiness in subjective studies.
“and bedtime resistance, difficulty with morning awakenings, sleep onset difficulties, sleep-disordered breathing, night awakenings and daytime sleepiness in subjective studies.”
Quote in the paperSubstantial claim - Premisecitation
ADHD is commonly associated with disordered or disturbed sleep.
“Attention-deficit/hyperactivity disorder (ADHD) is commonly associated with disordered or disturbed sleep.”
- Also stated in: § Introduction · plain
“the prevalence of sleep disturbances in individuals with ADHD is reported to be in the range 25–55 % (Corkum et al. 1998; Hodgkins et al. 2013; Owens 2005; Sung et al. 2008).”
Quote in the paperSubstantial claim0 of 3 sources checked - Also stated in: § Introduction · plain
- Premisecitation
Long-acting formulations may have insufficient duration of action, leading to symptom rebound at bedtime.
“Long-acting formulations may have insufficient duration of action, leading to symptom rebound at bedtime.”
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- Premisecitation
Psychostimulant medications are associated with disrupted or disturbed sleep in patients with ADHD.
“Psychostimulant medications are associated with disrupted or disturbed sleep”
Quote in the paperSubstantial claim0 of 3 sources checked - Premisecitation
The prevalence of sleep disturbances in individuals with ADHD is reported to be in the range 25-55%.
“the prevalence of sleep disturbances in individuals with ADHD is reported to be in the range 25–55 % (Corkum et al. 1998; Hodgkins et al. 2013; Owens 2005; Sung et al. 2008).”
Quote in the paperNot a substantial claim0 of 3 sources checked - Interpretationcitation
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.
“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;”
Quote in the paperSubstantial claim - Interpretationcitation
The available evidence from polysomnographic studies is most concordant for associations of ADHD with apnea/hypopnea and PLMS/nocturnal motor activity in children.
“In summary, the available evidence from polysomnographic studies is most concordant for associations of ADHD with apnea/hypopnea and PLMS/nocturnal motor activity in children (Cortese et al. 2006a; Spruyt and Gozal 2011).”
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- cites Spruyt and Gozal 2011
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A meta-analysis of 11 studies found a higher incidence of periodic limb movements in sleep (PLMS) in children with ADHD than in controls.
“In a meta-analysis of 11 studies, the only statistically significant polysomnographic finding was a higher incidence of periodic limb movements in sleep (PLMS) in children with ADHD than in controls (Sadeh et al. 2006).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Sadeh et al. 2006 source
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- Interpretationcitation
The reciprocal nature of the relationships between ADHD and sleep may reflect the functional and neuroanatomical overlap between brain regions involved in attention, arousal and sleep regulation.
“The reciprocal nature of the relationships between ADHD and sleep may reflect the functional and neuroanatomical overlap between brain regions involved in attention, arousal and sleep regulation (Owens et al. 2013; Owens 2008).”
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The most recent meta-analysis of subjective studies found that ADHD was associated with statistically significant greater impairments in six parent-reported subjective measures of sleep in children than in controls.
“The most recent meta-analysis of subjective studies found that ADHD was associated with statistically significant greater impairments in six parent-reported subjective measures of sleep in children than in controls (Cortese et al. 2009).”
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- Premisecitation
Sleep-disordered breathing (SDB) has been consistently associated with neurobehavioral and neurocognitive deficits, including inattentive or ADHD-like symptoms.
“SDB has been consistently associated with neurobehavioral and neurocognitive deficits, including inattentive or ADHD-like symptoms (Beebe 2006; Beebe et al. 2004; Chervin et al. 2002, 2012; Gottlieb et al. 2003; Lal et al. 2012; O’Brien 2009; Owens 2008; Rosen et al. 2004; Soylu et al. 2013; Suratt et al. 2011).”
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The effects of restricted, disordered or disturbed sleep can manifest as symptoms, behaviors or functional impairments that are remarkably similar to those of ADHD.
“The effects of restricted, disordered or disturbed sleep can manifest as symptoms, behaviors or functional impairments that are remarkably similar to those of ADHD (Beebe 2006; Gruber 2009; O’Brien 2009).”
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The largest standardized mean difference in subjective sleep measures was for bedtime resistance, followed by difficulty with morning awakenings, sleep onset difficulties, sleep-disordered breathing, night awakenings and daytime sleepiness.
“The largest standardized mean difference was observed for bedtime resistance, followed by difficulty with morning awakenings, sleep onset difficulties, sleep-disordered breathing, night awakenings and daytime sleepiness.”
Quote in the paperNot a substantial claim - Premisecitation
Three meta-analyses of polysomnographic studies found no significant alterations in REM sleep parameters in children with ADHD compared with controls.
“However, three meta-analyses of polysomnographic studies found no significant alterations in REM sleep parameters in children with ADHD compared with controls (Cortese et al. 2006a, 2009; Sadeh et al. 2006).”
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- cites Cortese et al. 2009
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- cites Sadeh et al. 2006 source
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- Premisenone given
Increased periodic limb movements in sleep (PLMS) in patients with ADHD compared with controls is a common finding in polysomnographic studies.
“As described previously, increased PLMS in patients with ADHD compared with controls is a common finding in polysomnographic studies.”
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The prevalence of obstructive sleep apnea (OSA) in patients with ADHD (25-30%) is higher than in the general population (about 3%).
“a recent systematic review indicated that the prevalence of OSA in patients with ADHD (25–30 %) is higher than in the general population (about 3 %) (Youssef et al. 2011).”
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- Interpretationcitation
There is evidence to suggest that ADHD may be associated with disturbances of the circadian rhythm.
“There is evidence to suggest that ADHD may be associated with disturbances of the circadian rhythm.”
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There is good evidence from cross-sectional studies for an association of ADHD with obesity.
“There is good evidence from cross-sectional studies for an association of ADHD with obesity: The prevalence of ADHD is higher than expected in people with obesity sampled at obesity clinics, and the body mass index of patients with ADHD is higher than average (Cortese et al. 2008a).”
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In children with diagnoses of ADHD and OSA, two prospective studies have demonstrated significant improvements in ADHD symptoms, including hyperactivity, following adenotonsillectomy.
“In children with diagnoses of ADHD and OSA, two prospective studies have demonstrated significant improvements in ADHD symptoms, including hyperactivity, following adenotonsillectomy (Chervin et al. 2006; Huang et al. 2007).”
Quote in the paperSubstantial claim0 of 2 sources checked - Premisecitation
A delayed pattern of melatonin secretion in children with ADHD compared with controls has been described.
“A delayed pattern of melatonin secretion in children with ADHD compared with controls has been described (Van der Heijden et al. 2005, 2007).”
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In a 33-year longitudinal study, 41.4% of adults who had combined-type ADHD as children were obese, compared with 21.6% of those without a childhood diagnosis of ADHD.
“in a 33-year longitudinal study, 41.4 % of adults who had combined-type ADHD as children were obese, compared with 21.6 % of those without a childhood diagnosis of ADHD (Cortese et al. 2013c).”
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- Premisecitation
In clinical trials using objective sleep measures, immediate-release methylphenidate has been reported to increase sleep onset latency and/or to decrease total sleep time in patients with ADHD.
“immediate-release methylphenidate has been reported to increase sleep onset latency and/or to decrease total sleep time in patients with ADHD (Boonstra et al. 2007; Galland et al. 2010; Greenhill et al. 1983; Sangal et al. 2006)”
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In clinical trials using objective sleep measures, immediate-release methylphenidate has been reported to leave sleep quality either unaffected or improved in patients with ADHD.
“with sleep quality either unaffected (Galland et al. 2010) or improved (Boonstra et al. 2007; Sobanski et al. 2008)”
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A recent meta-analysis of six actigraphic studies in children with ADHD reported statistically significant lower daytime activity, longer sleep onset latency, lower total sleep time and lower sleep efficiency with immediate-release methylphenidate treatment than with placebo.
“A recent meta-analysis of six actigraphic studies in children with ADHD reported statistically significant lower daytime activity, longer sleep onset latency, lower total sleep time and lower sleep efficiency with immediate-release methylphenidate treatment than with placebo (De Crescenzo et al. 2014).”
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- Premisecitation
LDX is the only stimulant prodrug.
“LDX is the only stimulant prodrug.”
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- Premisecitation
In a 2009 systematic review, the frequency of somnolence reported as a TEAE in placebo-controlled clinical trials of atomoxetine ranged from 15 to 17%.
“In a 2009 systematic review, the frequency of somnolence reported as a TEAE in placebo-controlled clinical trials of atomoxetine was reported to range from 15 to 17 % (Garnock-Jones and Keating 2009).”
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- Premisecitation
Lower frequencies of insomnia and higher frequencies of somnolence with atomoxetine than with long-acting stimulants have been reported as TEAEs in randomized, double-blind, parallel-group efficacy studies.
“Lower frequencies of insomnia and higher frequencies of somnolence with atomoxetine than with long-acting stimulants have been reported as TEAEs in randomized, double-blind, parallel-group efficacy studies (Dittmann et al. 2013; Newcorn et al. 2008).”
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After oral administration, rate-limiting enzymatic hydrolysis of LDX in the bloodstream releases the pharmacologically active d-amfetamine moiety from the lysine conjugate.
“After oral administration, rate-limiting enzymatic hydrolysis of LDX in the bloodstream releases the pharmacologically active d-amfetamine moiety from the lysine conjugate (Steer et al. 2012).”
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In contrast to stimulants, somnolence is the most common sleep-related adverse event associated with atomoxetine.
“In contrast to stimulants, somnolence is the most common sleep-related adverse event associated with atomoxetine (a noradrenaline reuptake inhibitor approved for treatment of ADHD).”
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- Interpretationcitation
An additional dose of a short-acting stimulant, or the use of a formulation with an increased duration of action, may prevent sleep disturbances resulting from worsening of hyperactivity or behavioral difficulties at bedtime.
“an additional dose of a short-acting stimulant, or the use of a formulation with an increased duration of action, may prevent sleep disturbances resulting from worsening of hyperactivity or behavioral difficulties at bedtime (Cortese et al. 2013a, b; Lecendreux et al. 2000).”
Quote in the paperSubstantial claim0 of 3 sources checked- cites Cortese et al. 2013a
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- cites Cortese et al. 2013b
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In a randomized study in children with ADHD, both OROS-MPH and another extended-release methylphenidate formulation led to statistically significant reductions in total sleep time 1-4 weeks after initiation of treatment, based on parental sleep diaries.
“Based on parental sleep diaries, both OROS-MPH and another extended-release methylphenidate formulation led to statistically significant reductions in total sleep time 1–4 weeks after initiation of treatment in a randomized study in children with ADHD (Lee et al. 2012).”
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In children with ADHD, sleep quality was rated as good or excellent by parents after 1 and 12 months of open-label OROS-MPH treatment.
“Sleep quality was also rated as good or excellent by parents after 1 and 12 months of open-label OROS-MPH treatment in children with ADHD (Wilens et al. 2003).”
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In a randomized, double-blind, placebo-controlled study, the majority of children in all three treatment groups (OROS-MPH, placebo or immediate-release methylphenidate three times daily) continued to have good or excellent sleep quality based on parent ratings at 2 and 4 weeks after initiation of treatment.
“In a randomized, double-blind, placebo-controlled study, the majority of children in all three treatment groups (OROS-MPH, placebo or immediate-release methylphenidate three times daily) continued to have good or excellent sleep quality based on parent ratings at 2 and 4 weeks after initiation of treatment (Wolraich et al. 2001).”
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- Premisecitation
LDX treatment is not associated with impairments in sleep quality or quantity in clinical trials using objective sleep measures in adults with ADHD and children with ADHD.
“LDX treatment was not associated with impairments in sleep quality or quantity in clinical trials using objective sleep measures in adults with ADHD (Adler et al. 2009a; Surman and Roth 2011) and children with ADHD (Giblin and Strobel 2011) (Fig. 2).”
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In an open-label polysomnographic study in children with ADHD, OROS-MPH treatment compared with pre-treatment baseline produced only statistically significant decrease in night-time awakenings and increase in percentage of stage 2 sleep.
“In an open-label polysomnographic study in children with ADHD, the only statistically significant effects of OROS-MPH treatment were a decrease in the number of night-time awakenings and an increase in the percentage of stage 2 sleep, compared with pre-treatment baseline (Kim et al. 2010).”
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Ball blankets are filled with loose balls to stimulate sensory receptors in the skin, muscles and joints, which transmit inhibitory signals to the central nervous system.
“Ball blankets (Fig. 3) are filled with loose balls to stimulate sensory receptors in the skin, muscles and joints, which transmit inhibitory signals to the central nervous system (Hvolby and Bilenberg 2011).”
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- Interpretationcitation
Assessment of sleep disturbance during evaluation for suspected ADHD and before initiation of pharmacotherapy enables any effects of the disorder on sleep to be distinguished from those of medication.
“This approach enables any effects of the disorder on sleep to be distinguished from those of medication (Cortese et al. 2013b).”
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There is some evidence that iron supplementation may be effective in relieving the symptoms of RLS in children.
“there is some evidence that iron supplementation may be effective in relieving the symptoms of RLS in children (Cortese et al. 2013a).”
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A pilot study indicated that a sleep program involving face-to-face and telephone contact with a specialist pediatrician or child psychiatrist improved children's sleep, quality of life and psychosocial functioning, based on parent reports after 5 months.
“A pilot study indicated that a sleep program involving face-to-face and telephone contact with a specialist pediatrician or child psychiatrist improved children’s sleep, quality of life and psychosocial functioning, based on parent reports after 5 months (Sciberras et al. 2011).”
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A subsequent subgroup analysis of the levodopa study failed to confirm the effect of levodopa on PLMS.
“However, a subsequent subgroup analysis of this study failed to confirm the effect of levodopa on PLMS (Ferri et al. 2013).”
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- Interpretationreasoning
The strongest evidence for a sleep disorder giving rise to ADHD or ADHD-like symptoms is the amelioration of such symptoms after surgical intervention to improve nocturnal breathing.
“The strongest evidence for a sleep disorder giving rise to ADHD or ADHD-like symptoms is the amelioration of such symptoms after surgical intervention to improve nocturnal breathing.”
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Two randomized, double-blind, placebo-controlled trials and a preliminary open-label study have indicated that melatonin treatment is effective in reducing sleep onset delay in children with ADHD.
“Two randomized, double-blind, placebo-controlled trials (Van der Heijden et al. 2007; Weiss et al. 2006) and a preliminary open-label study (Tjon Pian Gi et al. 2003) have indicated that melatonin treatment is effective in reducing sleep onset delay in children with ADHD (Cortese et al. 2013a).”
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No therapies have yet received regulatory approval for treating RLS in children.
“No therapies have yet received regulatory approval for treating RLS in children (Cortese et al. 2013a).”
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- Premisecitation
Dosing atomoxetine in the evening rather than in the morning reduces daytime somnolence.
“Dosing in the evening rather than in the morning has been found to reduce daytime somnolence with atomoxetine (Block et al. 2009).”
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- Premisecitation
Extended-release clonidine is associated with somnolence.
“Extended-release clonidine (another selective α2-adrenoceptor agonist) is also approved in North America with a similar indication (Childress and Sallee 2012) and is associated with somnolence (Cortese et al. 2013b).”
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- Premisecitation
Case reports indicate efficacy of behavioral programs in reducing the severity of dyssomnia in children with ADHD.
“Case reports also indicate efficacy of behavioral programs in reducing the severity of dyssomnia in children with ADHD (Mindell et al. 2006).”
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- Premisecitation
A small, randomized study of iron supplementation in children with ADHD detected a statistically significant reduction of ADHD symptoms.
“A small, randomized study of iron supplementation in children with ADHD detected a statistically significant reduction of ADHD symptoms (Konofal et al. 2008).”
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- Premisecitation
In a study of children with ADHD and initial insomnia receiving stimulants, implementing sleep hygiene reduced sleep onset delay to below 60 min in about 20% of patients, with an overall effect size of 0.67.
“In a study of children with ADHD and initial insomnia receiving stimulants, implementing sleep hygiene reduced sleep onset delay to below 60 min in about 20 % of patients, with an overall effect size of 0.67 (Weiss et al. 2006).”
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- Premisecitation
Sleep disturbances in ADHD can occur independently of psychiatric comorbidities, as demonstrated in studies employing psychiatric control groups.
“Sleep disturbances in ADHD can, however, occur independently of psychiatric comorbidities, as demonstrated in studies employing psychiatric control groups (Hvolby et al. 2008).”
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- Premisecitation
Somnolence is one of the most commonly reported TEAEs in clinical trials of extended-release guanfacine, either alone or when co-administered with a stimulant.
“Somnolence is one of the most commonly reported TEAEs in clinical trials of extended-release guanfacine (either alone or when co-administered with a stimulant) (Faraone et al. 2013).”
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- Interpretationreasoning
Conspicuously absent from the current literature is any convincing demonstration that pharmacological or non-pharmacological intervention to improve sleep actually leads to improved ADHD symptoms or reduced functional impairment associated with the disorder.
“Conspicuously absent from the current literature is any convincing demonstration that pharmacological or non-pharmacological intervention to improve sleep actually leads to improved ADHD symptoms or reduced functional impairment associated with the disorder.”
Quote in the paperSubstantial claim - Premisecitation
Intra-individual variability in neuropsychological tasks, rather than a constant level of impairment, is characteristic of ADHD.
“Intra-individual variability in neuropsychological tasks, rather than a constant level of impairment, is characteristic of ADHD (Spencer et al. 2009; Tamm et al. 2012)”
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A more rapid decrease in sleep duration compared with normative centiles at 3-5 years of age has been reported to be a significant predictor of subsequent ADHD.
“a more rapid decrease compared with normative centiles at 3–5 years of age has been reported to be a significant predictor of subsequent ADHD (Scott et al. 2013).”
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- Interpretationreasoning
Stimulant medications may disrupt or improve sleep in different patients, depending not only on the nature of the patient's illness, but also on the drug dose, class, formulation and duration of efficacy.
“Stimulant medications may disrupt or improve sleep in different patients, depending not only on the nature of the patient’s illness, but also on the drug dose, class, formulation and duration of efficacy.”
Quote in the paperSubstantial claim - Premisecitation
A similar picture of volatility and unpredictability is observed in sleep patterns in children with ADHD.
“and a similar picture of volatility and unpredictability is observed in sleep patterns in children with ADHD (Gruber and Sadeh 2004; Gruber et al. 2000; Lecendreux and Cortese 2007; Tsai and Huang 2010).”
Quote in the paperNot a substantial claim0 of 3 sources checked - Interpretationnone given
ADHD is commonly associated with specific sleep disorders and objectively or subjectively assessed sleep disturbances.
“ADHD is commonly associated with specific sleep disorders and objectively or subjectively assessed sleep disturbances.”
Quote in the paperNot a substantial claim
- Classified as probably not a substantial claim. 8
- May combine two claims. 28
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PremisecitationCurrent 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.
“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.”
Quote in the paperSubstantial claim0 of 3 sources checked- cites Graham et al. 2011
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- cites Wolraich et al. 2011 source
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- cites Cortese et al. 2013a
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PremisecitationIn a recent Australian study, 62% of children with ADHD had moderate or severe sleep problems and 22% took sleep medications during the 1-week observation period.
“In a recent Australian study, 62 % of children with ADHD had moderate or severe sleep problems and 22 % took sleep medications during the 1-week observation period (Efron et al. 2014).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Efron et al. 2014
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Interpretationnone givenADHD may cause sleep problems as an intrinsic feature of the disorder.
“ADHD may cause sleep problems as an intrinsic feature of the disorder;”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationProblems with sleep can lead to the development of ADHD or ADHD-like symptoms, potentially resulting in misdiagnosis.
“Problems with sleep can, however, also lead to the development of ADHD or ADHD-like symptoms, potentially resulting in misdiagnosis (Cortese et al. 2006b; Owens 2008).”
Quote in the paperSubstantial claim0 of 2 sources checked- cites Cortese et al. 2006b
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- cites Owens 2008 source
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May combine two claims.
PremisecitationA meta-analysis of four actigraphic studies reported statistically significantly longer mean sleep onset latency and shorter true sleep time in non-medicated children with ADHD than in typically developing controls.
“A meta-analysis of four actigraphic studies reported statistically significantly longer mean sleep onset latency and shorter true sleep time in non-medicated children with ADHD than in typically developing controls (Cortese et al. 2009).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Cortese et al. 2009
Not checked in the free run.
Probably not a substantial claim: may not pass S4 (based).
Interpretationnone givenADHD and sleep problems may share a common underlying neurological etiology.
“and ADHD and sleep problems may share a common underlying neurological etiology.”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationA subsequent meta-analysis found lower sleep efficiency, higher apnea-hypopnea index (AHI) and a larger number of sleep stage shifts per hour in children with ADHD than in controls.
“Statistically significant polysomnographic findings were lower sleep efficiency, higher apnea–hypopnea index (AHI) and a larger number of sleep stage shifts per hour in children with ADHD than in controls (Cortese et al. 2009).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Cortese et al. 2009
Not checked in the free run.
May combine two claims.
Interpretationnone givenSleep problems may cause or mimic ADHD.
“sleep problems may cause or mimic ADHD;”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationPolysomnography is considered the gold standard for the objective measurement of sleep.
“Polysomnography is considered the ‘gold standard’ for the objective measurement of sleep (Cortese et al. 2009; Owens 2008)”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites Cortese et al. 2009
Not checked in the free run.
- cites Owens 2008 source
Not checked in the free run.
May combine two claims.
Interpretationnone givenADHD and sleep problems may interact, with reciprocal causation and possible involvement of comorbidity.
“ADHD and sleep problems may interact, with reciprocal causation and possible involvement of comorbidity;”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationOther sleep problems reportedly associated with ADHD in children and/or adults include early and middle insomnia, nocturnal awakening, nocturnal activity, snoring, breathing difficulties, restless sleep, parasomnias, nightmares, daytime sleepiness, delayed sleep phase, short sleep time and anxiety around bedtime.
“Other sleep problems reportedly associated with ADHD in children and/or adults include early and middle insomnia, nocturnal awakening, nocturnal activity, snoring, breathing difficulties, restless sleep, parasomnias, nightmares, daytime sleepiness, delayed sleep phase, short sleep time and anxiety around bedtime (Hansen et al. 2013; Hvolby et al. 2008, 2009; Spruyt and Gozal 2011; Yoon et al. 2012”
Quote in the paperNot a substantial claim0 of 3 sources checked- cites Hansen et al. 2013
Not checked in the free run.
- cites Hvolby et al. 2008
Not checked in the free run.
- cites Spruyt and Gozal 2011
Not checked in the free run.
May combine two claims.
PremisecitationObesity is correlated with sleep-disordered breathing and other sleep disorders, short sleep duration and short time in bed.
“Obesity is, in turn, correlated with sleep-disordered breathing and other sleep disorders (Cortese et al. 2008b), short sleep duration (Taheri et al. 2004) and short time in bed (Hart et al. 2013).”
Quote in the paperNot a substantial claim0 of 3 sources checked- cites Cortese et al. 2008b
Not checked in the free run.
- cites Taheri et al. 2004 source
Not checked in the free run.
- cites Hart et al. 2013
Not checked in the free run.
May combine two claims.
PremisecitationChildren with ADHD have been reported to exhibit stronger circadian evening tendencies than controls, and scores on the child morning-evening preference scale were correlated with both parental and polysomnographic measures of sleep onset latency.
“Children with ADHD have also been reported to exhibit stronger circadian evening tendencies than controls, as assessed using the child morning-evening preference scale. Scores on this parent-rated instrument were correlated with both parental and polysomnographic measures of sleep onset latency (Gruber et al. 2012a).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Gruber et al. 2012a
Not checked in the free run.
May combine two claims.
PremisecitationUp to 44% of children with ADHD have symptoms of restless legs syndrome (RLS), and 26% of children with RLS have symptoms of ADHD.
“up to 44 % of children with ADHD have symptoms of RLS, and 26 % of children with RLS have symptoms of ADHD (Cortese et al. 2005; Owens 2008).”
Quote in the paperSubstantial claim0 of 2 sources checked- cites Cortese et al. 2005
Not checked in the free run.
- cites Owens 2008 source
Not checked in the free run.
May combine two claims.
InterpretationcitationThe effects of stimulants on sleep in patients with ADHD differ from patient to patient and reflect the underlying complexity of the links between ADHD and sleep disturbance.
“The effects of stimulants on sleep in patients with ADHD differ from patient to patient and reflect the underlying complexity of the links between ADHD and sleep disturbance (Graham et al. 2011).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Graham et al. 2011
Not checked in the free run.
May combine two claims.
PremisecitationIn a randomized, double-blind trial, atomoxetine was associated with a smaller increase in sleep onset latency, a lower frequency of insomnia, a higher frequency of somnolence, and smaller effects on subjective measures of sleep than methylphenidate taken three times daily.
“In a randomized, double-blind trial, atomoxetine was associated with a smaller increase in sleep onset latency, a lower frequency of insomnia, a higher frequency of somnolence and smaller effects on subjective measures of sleep than methylphenidate taken three times daily (Sangal et al. 2006).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Sangal et al. 2006
Not checked in the free run.
May combine two claims.
PremisecitationBoth amfetamine and methylphenidate are associated with treatment-emergent adverse events of insomnia in clinical studies.
“Both amfetamine and methylphenidate are associated with treatment-emergent adverse events (TEAEs) of insomnia in clinical studies (Efron et al. 1997; Stein et al. 2011).”
Quote in the paperSubstantial claim0 of 2 sources checked- cites Efron et al. 1997
Not checked in the free run.
- cites Stein et al. 2011
Not checked in the free run.
May combine two claims.
PremisecitationOROS-MPH and LDX are recently developed and widely used ADHD medications with daily durations of efficacy of at least 12 h post-dose.
“This section focuses on osmotic-release oral system methylphenidate (OROS-MPH) and lisdexamfetamine dimesylate (LDX), both of which are recently developed and widely used ADHD medications with daily durations of efficacy of at least 12 h post-dose (Coghill and Seth 2006; Lakhan and Kirchgessner 2012; Setyawan et al. 2013a, b; Steer et al. 2012).”
Quote in the paperNot a substantial claim0 of 3 sources checked- cites Coghill and Seth 2006
Not checked in the free run.
- cites Lakhan and Kirchgessner 2012
Not checked in the free run.
- cites Setyawan et al. 2013a, b
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationThe sympathomimetic action of stimulants promotes wakefulness in most people, underlying their use in the treatment of narcolepsy.
“The sympathomimetic action of stimulants promotes wakefulness in most people, underlying their use in the treatment of narcolepsy (Morgenthaler et al. 2007).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Morgenthaler et al. 2007
Not checked in the free run.
May combine two claims.
PremisecitationIn a study in children with ADHD, the use of ball blankets reduced sleep onset latency, the number of awakenings and intra-individual variability in sleep parameters.
“In a study in children with ADHD, the use of ball blankets was found to reduce sleep onset latency, the number of awakenings and intra-individual variability in sleep parameters (Hvolby and Bilenberg 2011).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Hvolby and Bilenberg 2011
Not checked in the free run.
May combine two claims.
PremisecitationIron deficiency has been implicated in the etiology of both RLS and ADHD, with potential links to alteration of dopamine transporter expression and the synthesis and catabolism of monoaminergic neurotransmitters.
“Iron deficiency has been implicated in the etiology of both RLS and ADHD, with potential links to alteration of dopamine transporter expression and the synthesis and catabolism of monoaminergic neurotransmitters (Allen and Earley 2007; Cortese et al. 2005, 2012).”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites Allen and Earley 2007 source
Not checked in the free run.
- cites Cortese et al. 2005, 2012
Not checked in the free run.
May combine two claims.
PremisecitationClinical studies of behavioral interventions to improve sleep in children with ADHD are limited and have not demonstrated any effect on ADHD symptoms.
“Clinical studies of behavioral interventions to improve sleep in children with ADHD are limited and have not demonstrated any effect on ADHD symptoms (Cortese et al. 2013a).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Cortese et al. 2013a
Not checked in the free run.
Classified as probably not a substantial claim.
PremisecitationBoth European and US guidelines recommend assessment of sleep disturbance during evaluation of an individual for suspected ADHD, and before initiation of pharmacotherapy.
“Both European and US guidelines recommend assessment of sleep disturbance during evaluation of an individual for suspected ADHD, and before initiation of pharmacotherapy (Graham et al. 2011; Wolraich et al. 2011).”
Quote in the paperSubstantial claim0 of 2 sources checked- cites Graham et al. 2011
Not checked in the free run.
- cites Wolraich et al. 2011 source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).
Interpretationnone givenAssociations between ADHD and sleep disorders and subjective or objective measures of sleep or sleep disturbance do not provide information on causation.
“Associations between ADHD and sleep disorders and subjective or objective measures of sleep or sleep disturbance do not provide information on causation.”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationIn a double-blind, placebo-controlled trial in 29 children with ADHD or ADHD and RLS/PLMS, levodopa treatment slightly improved PLMS and/or RLS symptoms, but did not affect other sleep parameters, ADHD symptoms or performance in neuropsychometric tests.
“In this study, levodopa treatment slightly improved PLMS and/or RLS symptoms, but did not affect other sleep parameters, ADHD symptoms or performance in neuropsychometric tests (England et al. 2011).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites England et al. 2011
Not checked in the free run.
May combine two claims.
PremisecitationHypnotic agents, including zolpidem, mirtazapine, trazodone and antihistamines, have been used off-label in clinical practice to treat insomnia in children with ADHD, and some have been evaluated in clinical trials, but their use does not form part of current clinical guidelines.
“Hypnotic agents, including zolpidem, mirtazapine, trazodone and antihistamines, have been used off-label in clinical practice to treat insomnia in children with ADHD (Kratochvil et al. 2005) and some have been evaluated in clinical trials (Cortese et al. 2013b), but their use does not form part of current clinical guidelines.”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites Kratochvil et al. 2005
Not checked in the free run.
- cites Cortese et al. 2013b
Not checked in the free run.
May combine two claims.
PremisecitationDaytime sleepiness has been reported to be associated with worsened internalizing symptoms in children with anxiety disorder, suggesting that poor sleep may negatively affect emotional regulation as well as attentional functioning.
“Furthermore, daytime sleepiness has been reported to be associated with worsened internalizing symptoms in children with anxiety disorder, suggesting that poor sleep may negatively affect emotional regulation as well as attentional functioning (Hansen et al. 2013).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Hansen et al. 2013
Not checked in the free run.
May combine two claims.
PremisecitationSuccessful treatment of OSA, RLS and delayed sleep-phase disorder can lead to improvements in ADHD symptoms, as borne out by case studies.
“That successful treatment of OSA, RLS and delayed sleep-phase disorder can lead to improvements in ADHD symptoms is borne out by case studies (Miano et al. 2013).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Miano et al. 2013
Not checked in the free run.
May combine two claims.
Interpretationnone givenBoth non-pharmacological and pharmacological interventions are available for improving sleep in patients with ADHD, and are applicable to sleep disturbance associated with ADHD medication and with the disorder itself.
“Both non-pharmacological and pharmacological interventions are available for improving sleep in patients with ADHD, and are applicable to sleep disturbance associated with ADHD medication and with the disorder itself.”
Quote in the paperSubstantial claimMay combine two claims.
PremisecitationIn an observational study in a population of children with ADHD, 63% of whom had moderate or severe sleep problems, 19% took clonidine and 9% took melatonin during the 1-week reporting period, and none took antihistamines, benzodiazepines or dopamine agonists.
“In observational study in a population of children with ADHD, 63 % of whom had moderate or severe sleep problems, 19 % took clonidine and 9 % took melatonin during the 1-week reporting period (none took antihistamines, benzodiazapenes or dopamine agonists) (Efron et al. 2014).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Efron et al. 2014
Not checked in the free run.
May combine two claims.
InterpretationcitationEffective management of sleep problems associated with ADHD and its treatment may not only alleviate sleep-related symptoms, but also improve quality of life in parents or carers of children with disruptive bedtime behavior or insomnia.
“Effective management of sleep problems associated with ADHD and its treatment may not only alleviate sleep-related symptoms, but also improve quality of life in parents or carers of children with disruptive bedtime behavior or insomnia.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S4 (based). May combine two claims.
Interpretationnone givenObesity and psychiatric comorbidities (e.g., anxiety and depression) can lead to sleep problems.
“Obesity and psychiatric comorbidities (e.g., anxiety and depression) can also lead to sleep problems”
Quote in the paperNot a substantial claimMay combine two claims.
InterpretationreasoningThe relationship between ADHD and sleep problems is complex and bidirectional, and is modulated by interactions with ADHD medications and by psychiatric comorbidities and associated medications.
“The relationship between ADHD and sleep problems is complex and bidirectional, and is modulated by interactions with ADHD medications and by psychiatric comorbidities and associated medications.”
Quote in the paperSubstantial claim- The authors state this as an assumption: ADHD can lead directly to problems with sleep.
- The authors state this as an assumption: Disturbed sleep can be responsible for daytime symptoms, behaviors and functional impairments that are characteristic of ADHD.
- The authors state this as an assumption: Sleep disturbances and ADHD can be coincident and may exacerbate each other in a feed-forward loop.
- The authors state this as an assumption: Common or overlapping neurobiological disease mechanisms can give rise to both ADHD and sleep disturbance.
The authors state this as an assumption.
ADHD can lead directly to problems with sleep.
“In one scenario, ADHD leads directly to problems with sleep (Fig. 4, left-hand panel).”
The authors state this as an assumption.
Disturbed sleep can be responsible for daytime symptoms, behaviors and functional impairments that are characteristic of ADHD.
“In a contrasting scenario, disturbed sleep is responsible for daytime symptoms, behaviors and functional impairments that are characteristic of ADHD (Fig. 4, right-hand panel).”
The authors state this as an assumption.
Sleep disturbances and ADHD can be coincident and may exacerbate each other in a feed-forward loop.
“In another scenario, sleep disturbances and ADHD are coincident, but may exacerbate each other in a feed-forward loop (Fig. 4, upper-middle panel).”
The authors state this as an assumption.
Common or overlapping neurobiological disease mechanisms can give rise to both ADHD and sleep disturbance.
“In a final scenario, common or overlapping neurobiological disease mechanisms are hypothesized to give rise to both ADHD and sleep disturbance (Fig. 4, lower-middle panel).”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
ADHD is associated with significant sleep disturbances in both adults and children.
“A common finding in ADHD in both adults and children is that there are significant sleep disturbances associated with the condition (Hvolby 2015).”
From A systematic review of circadian function, chronotype and chronotherapy in attention deficit hyperactivity disorder (2017) · cites this paper as Hvolby 2015
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Different prevalence figures for the same study
MinorThe paper gives 62% and 63% for children with moderate or severe sleep problems in the same cited study (Efron et al. 2014).
“In a recent Australian study, 62 % of children with ADHD had moderate or severe sleep problems and 22 % took sleep medications during the 1-week observation period (Efron et al. 2014).”
“In observational study in a population of children with ADHD, 63 % of whom had moderate or severe sleep problems, 19 % took clonidine and 9 % took melatonin during the 1-week reporting period (none took antihistamines, benzodiazapenes or dopamine agonists) (Efron et al. 2014).”
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“…of ADHD which are suggestive of a disturbance in arousal regulation include emotional dysregulation (Faraone et al., 2019), sleep disorders (Hvolby, 2015), dysregulation of the Hypothalamus-Pituitary-Adrenal (HPA) axis (Isaksson et al., 2012) and problems regulating appetite (Hanc and…”
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- Authors
- Hvolby, A.
- Corresponding author
- Hvolby, Allan
- ORCID
- Hvolby, Allan
- Venue
- ADHD Attention Deficit and Hyperactivity Disorders
- Published
- 2014-08-17
- Volume
- 7
- Issue
- 1
- Pages
- 1-18
- ISSN
- 1866-6116 (ISSN-L)
- 1866-6647
- PMC
- PMC4340974
- OpenAlex
- W2121891157
- Cited by
- 339
- References
- 190
- Citations by year
- 2026: 33 · 2025: 49 · 2024: 37 · 2023: 34 · 2022: 27 · 2021: 42 · 2020: 34 · 2019: 23 · 2018: 20 · 2017: 12 · 2016: 16 · 2015: 10 · 2014: 1 · 2013: 1
- FWCI
- 1.80
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- ADHD Attention Deficit and Hyperactivity Disorders (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- University of Southern Denmark Research Portal (University of Southern Denmark) (submittedVersion)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Attention Deficit Hyperactivity Disorder
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Health Sciences › Medicine › Physiology › Obstructive Sleep Apnea Research
- Keywords
- attention deficit hyperactivity disorder, sleep disorders, obstructive sleep apnea, restless legs syndrome, circadian rhythm sleep disorders, sleep latency, daytime sleepiness, nocturnal awakenings, bedtime resistance, psychiatric comorbidity, reciprocal causation
- MeSH terms
- Central Nervous System Stimulants, Attention Deficit Disorder with Hyperactivity, Humans, Movement Disorders, Restless Legs Syndrome, Comorbidity, Disease Management, Sleep Disorders, Circadian Rhythm, Sleep Apnea, Obstructive
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