Examining bidirectional associations between sleep and behavior among children with attention-deficit/hyperactivity disorder

Craig A Sidol; Stephen P Becker; James L Peugh; James D Lynch; Heather A Ciesielski; Allison K Zoromski; Jeffery N Epstein

doi:10.1002/jcv2.12157

Examining bidirectional associations between sleep and behavior among children with attention-deficit/hyperactivity disorder

JCPP Adv. 2023 Mar 20;3(2):e12157. doi: 10.1002/jcv2.12157. eCollection 2023 Jun.

Authors

Craig A Sidol^{1

2}, Stephen P Becker^{1

3}, James L Peugh^{1

3}, James D Lynch², Heather A Ciesielski^{1

3}, Allison K Zoromski^{1

3}, Jeffery N Epstein^{1

2

3}

Affiliations

¹ Division of Behavioral Medicine and Clinical Psychology Cincinnati Children's Hospital Medical Center Cincinnati Ohio USA.
² Department of Psychology University of Cincinnati Cincinnati Ohio USA.
³ Department of Pediatrics University of Cincinnati College of Medicine Cincinnati Ohio USA.

Abstract

Background: Children with attention-deficit/hyperactivity disorder (ADHD) have more sleep problems than their peers which contribute to behavioral and functional impairments. This study examines the bidirectional relationship between nightly sleep (i.e., total sleep time and sleep efficiency) and daily behavior of children with ADHD.

Method: Forty-three children (ages 6-13 [mean = 9.05, 54% male, 77% medicated]) participated in a 2-week study during an ADHD Summer Treatment Program (STP). Sleep was measured with actigraphy. Behavior was assessed using STP clinical data and daily parent and counselor ratings of ADHD symptoms, oppositional defiant disorder behaviors, and emotion regulation (e.g., difficulty regulating emotional disposition and controlling emotions). We hypothesized that healthier night's sleep measured by actigraphy (i.e., sleep efficiency and total sleep time [TST]) would relate to less ADHD symptoms, less emotional dysregulation, and better academic performance the next day. Additionally, we hypothesized that less ADHD symptoms, less emotional dysregulation, and greater academic performance would relate to healthier sleep that night.

Results: Higher nightly sleep efficiency was related to improved parent-ratings of ADHD the next day (R ² = 0.04, p = 0.04) and improved parent-ratings of ADHD during the day lead to higher sleep efficiency that night (R ² = 0.002, p = 0.02). Higher rates of daily assignment completion were related to higher sleep efficiency at night (R ² = 0.035, p = 0.03). TST was not related to any behavioral outcomes.

Conclusion: Sleep efficiency may be more relevant than TST to behavioral performance the next day. Additionally, a bidirectional relationship exists between sleep efficiency and parent ratings of ADHD. Findings highlight the importance of assessing for manifestations of poor sleep efficiency, waking minutes, and wakings after sleep onset when diagnosing and treating ADHD.

Keywords: ADHD; intraindividual variability; sleep efficiency; summer treatment program; total sleep time.