Sleep in children with attention-deficit hyperactivity disorder: A meta-analysis of polysomnographic studies

doi:10.1016/j.smrv.2006.03.004

Sleep Medicine Reviews

Volume 10, Issue 6, December 2006, Pages 381-398

https://doi.org/10.1016/j.smrv.2006.03.004 Get rights and content

Summary

The links between sleep and attention-deficit hyperactivity disorder (ADHD) have been a topic for intense ongoing research and clinical interest. Previous narrative literature reviews conveyed a consensus that parents of children with ADHD are more likely to report sleep problems in their children in comparison to parents of control children. However, when objective measures are considered the results appear to be more complex and inconsistent. This review is based on a meta-analysis of relevant polysomnographic studies. We assessed measures related to sleep architecture, breathing disorders, and periodic limb movements in sleep (PLMS), and the role of potential moderators such as age, gender, and other methodological factors. The meta-analysis revealed only one significant combined effect that indicates that children with ADHD are more likely than controls to suffer from PLMS. Factors such as age, gender, inclusion of adaptation night, and comorbidity appear to play a moderating role in the associations between sleep characteristics and ADHD. To provide new insight regarding the links between sleep and ADHD research in this field should adopt new strict guidelines and consider the role of multiple pertinent moderating factors.

Introduction

The associations between sleep and attention-deficit hyperactivity disorders (ADHD) have been a focus for clinical and empirical efforts over the last two decades. A number of narrative literature reviews addressed this issue in recent years.1, 2, 3, 4, 5 These reviews conveyed the conclusion that the basic question of whether children diagnosed with ADHD have unique sleep characteristics is far from being resolved. For instance, a recent study concluded that sleep of children with ADHD is not distinct from normal sleep,⁶ leading to a strong rebuttal.⁷ To shed more light on this issue we performed a meta-analysis on the available polysomnographic studies of children with ADHD.

Section snippets

Difficulties in defining and diagnosing ADHD

The definition and diagnostic criteria of ADHD has evolved over the last few decades. Currently, the diagnosis of ADHD relates to three major domains of difficulty: attention problems, impulsivity, and hyperactivity. Subtypes of ADHD diagnosis have been identified according to the dominant areas of difficulty: a predominantly hyperactive–impulsive type, a predominantly inattentive type, and a combined type.⁸ The specific symptoms associated with each domain and type are listed in the Diagnostic

ADHD and sleep

Studies assessing the links between sleep and ADHD could be broadly characterized by a number of factors: (a) sleep assessment method (e.g., self or parental reports, polysomnography, actigraphy); (b) specific sleep-related domain (e.g., sleep architecture; sleep disordered breathing, PLMS or PLMD); (c) comparison method (e.g., comparing sleep in children with and without a diagnosis of ADHD; comparing ADHD symptoms or diagnosis in children with and without sleep problems; or correlative

Literature base

Studies were collected through a computerized search of the PsycInfo, PubMed and ISI Web of Science databases using the key words “ADHD” or “Attention deficit and hyperactivity disorder”, “hyperactivity” or “attention deficit” intersected with PSG, or polysomnography, or EEG and intersected with Sleep. Additionally, these databases were searched with the names of researchers in the field to see whether there were additional relevant papers from these authors. The references of all obtained

Results

Table 3 provides a detailed description of the results of the overall effect sizes as well as all tests of moderators for each PSG measure. A minimum of 3 studies per condition was set for moderator analyses. For each analysis, number of studies (k), number of participants in each group (n), effect size (d), 95% confidence interval, and p value are reported. In the text below, we address only the significant findings. We describe first the only significant global effect with regard to PLMS, and

Conclusions

Our study is the first meta-analysis on sleep in children with ADHD that include evaluation of major potential moderating factors. Before addressing the specific findings, the limitations of this meta-analysis should be highlighted. The power of our meta-analysis was limited by the small number of studies that met our inclusion criteria. This limited number of studies results from the small number of PSG studies in children in general and from the fact that some studies in the field have basic

Acknowledgment

The authors are thankful to Ornit Arbel for her help in preparing this manuscript.

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Consumption of a high-fat diet (HFD) has been associated with reduced wakefulness and various behavioral deficits, including anxiety, depression, and anhedonia. The dopaminergic system, which plays a crucial role in sleep and ADHD, is known to be vulnerable to chronic HFD. However, the association between HFD-induced behavioral and molecular changes remains unclear. Therefore, we investigated the effects of a HFD on the dopaminergic system and its association with behavioral deficits in male mice. The mice were divided into normal diet and HFD groups and were analyzed for sleep patterns, behavior tests, and transcription levels of dopamine-related genes in the brain. The HFD group showed decreased wakefulness, increased REM sleep with fragmented patterns, decreased time spent in the center zone of the open field test, shorter immobile time in the tail suspension test, impaired visuospatial memory, and reduced sucrose preference. Additionally, the HFD group had decreased mRNA levels of D1R, COMT, and DAT in the nucleus accumbens, which negatively correlated with REM sleep proportion and REM sleep bout count. The results suggest that HFD-induced behavioral deficits were resemblance to ADHD-like behavioral phenotypes and disturbs REM sleep by dysregulating the dopaminergic system.
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CLINICAL REVIEWSleep in children with attention-deficit hyperactivity disorder: A meta-analysis of polysomnographic studies

Summary

Introduction

Section snippets

Difficulties in defining and diagnosing ADHD

ADHD and sleep

Literature base

Results

Conclusions

Acknowledgment

Sleep Med Rev

J Am Acad Child Adolesc Psychiatry

Biol Psychiatry

Lancet

Lancet

Child Adolesc Psychiatr Clini North Am

Child Adolesc Psychiatr Clin North Am

Chest

J Am Acad Child Adolesc Psychiatry

Clin Neurophysiol

J Pediatr

Pediatr Clin North Am

The ADHD and sleep conundrum: a review

J Dev Behav Pediatr

Sleep-related disorders in ADHD: a review

Clin Pediatr

Dyssomnia in children diagnosed with attention deficit hyperactivity disorder: a critical review

Aust N Z J Psychiatry

Patients with attention-deficit/hyperactivity disorder without observed apneic episodes in sleep or daytime sleepiness have normal sleep on polysomnography

Sleep

Diagnostic and statistical manual of mental disorders

International Statistical Classification of Diseases and Related Health Problems (ICD-10)

International consensus statement on ADHD. January 2002

Clin Child Fam Psychol Rev

A critique of the international consensus statement on ADHD

Clin Child Fam Psychol Rev

National Institutes of Health Consensus Development Conference Statement: diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD)

J Am Acad Child Adolesc Psychiatry

The epidemiology of attention-deficit/hyperactivity disorder(ADHD): a public health view

Ment Retardat Dev Disabil Res Rev

Attention-deficit/hyperactivity disorder among adolescents: a review of the diagnosis, treatment, and clinical implications

Pediatrics

Influence of gender on attention deficit hyperactivity disorder in children referred to a psychiatric clinic

Am J Psychiatry

Effects of dextroamphetamine sulfate on EEG sleep patterns of hyperactive children

Arch Gen Psychiatry

Sleep amphetamine effects in MBDS and normal subjects

Arch Gen Psychiatry

A controlled study of all-night sleep in overactive imbecile children

Am J Ment Defic

Periodic limb movement disorder of sleep in children

J Sleep Res

Hypnopolygraphic alterations in Attention Deficit Disorder (ADD) children

Int J Neurosci

CLINICAL REVIEW
Sleep in children with attention-deficit hyperactivity disorder: A meta-analysis of polysomnographic studies