Study Reviewed: Peppers K et al. An intervention to promote sleep and reduce ADHD symptoms. Journal of Pediatric Healthcare 2016;30(6):43–48.

Study Type: Open, uncontrolled clinical trial

We know that kids with ADHD often have sleep issues, and that the stimulants we use to treat them can cause insomnia. What would happen if we focused our treatment on the insomnia portion of ADHD? Presumably kids would sleep better, but would their ADHD symptoms also improve?

The authors of this new study based this pilot project on an earlier randomized controlled trial of a sleep intervention with 244 Australian children (Hiscock H et al, BMJ 2015;350:h68. doi:10.1136/bmj.h68). In that study, children with ADHD were randomly assigned to either a brief intervention to improve sleep or a control condition. Those in the intervention group were seen twice by a clinician, who evaluated the sleep problem and provided tips on sleep hygiene. Clinicians recommended a regular bedtime routine, avoidance of caffeine after 3 pm, and no screen media in the bedroom. Children in the intervention group showed significant improvements in ADHD symptoms and sleep quality.

The goal of the current 20-week project was to see whether a similar intervention delivered by video and not requiring highly trained clinicians would also be successful. Twenty-three children, between 5 and 11 years of age, with both ADHD and sleep problems as assessed by the Children’s Sleep Habits Questionnaire (CSHQ), were enrolled in an open, non-controlled trial. In this intervention, children and parents watched a single 6-minute video, which described good sleep hygiene practices like those in the Hiscock intervention described above. After the video, the provider gave the parents a written sleep hygiene plan. Six weeks after the intervention, the children were assessed again.

Results
After 6 weeks, the children showed significant improvement in both ADHD and sleep symptoms. Improvement on the Parent Visual Analogue Scale was significant on questions 1–9 dealing with inattention (p <. 001) and questions 10–18 dealing with hyperactivity (p < .004). The scores on the CSHQ showed ­significant improvement from baseline to the 6-week ­re-assessment (p < .001).

CCPR’s Take
This study implies that a very brief and easy-to-administer sleep intervention may lead to improvement in both ADHD and insomnia symptoms in children. The study was limited by the lack of a control group, so it’s possible that these improvements were the result of placebo factors having little to do with the intervention. In addition, there was no teacher rating of ADHD symptoms, decreasing our confidence that the improvement in those symptoms was robust enough to be apparent in school as well as at home. The original study by Hiscock et al from 2015 is more compelling: There were a larger number of participants, and it was a randomized controlled trial.

Practice Implications
When you evaluate patients for ADHD, make sure to diligently ask about sleep issues, and take some extra time to talk about sleep hygiene, including providing parents with a sleep hygiene handout. This may pay dividends for improving sleep and ADHD symptoms.