Sleep treatment may help teens with ADHD who have co-occurring sleep problems

Teens with ADHD have more frequent sleeps problems than their peers, including delayed sleep onset, reduced sleep duration and quality, and increased daytime sleepiness.

These sleep problems are associated with, and may directly contribute to, impairment at school and elsewhere. Despite this, there has been no prior research that examines whether sleep intervention may help teens with ADHD.

The study summarized below provides the first examination of this. Fourteen 13-17 year olds -7 males and 7 females with both ADHD and documented sleep difficulties participated in a 6-session cognitive-behavioral based treatment that targeted a variety of sleep issues.

Intervention

The 6-session sleep intervention was called the Transdiagnostic Sleep and Circadian Intervention for Youth, TranS-C. Sessions were conducted individually for 50 minutes on a weekly or biweekly basis.

A range of issues related to improving sleep were addressed in the intervention. Cross-cutting themes addressed in each session included developing treatment targets and providing a rational for treatment, educating youth about sleep and sleep cycles, enhancing motivation to modify sleep-related behavior, and setting realistic, achievable, and measurable sleep goals.

There was also specific core content covered in different sessions; this content focused on:standardizing bed and wake up times across the week;developing skills to cope with a poor night’s sleep;correcting unhelpful beliefs about sleep, e.g., if I don’t get to sleep now, I won’t be able to function tomorrow; I need to try harder to fall asleep;relapse prevention and dealing with setbacks;
Finally, there were several optional modules, e.g., reducing anxiety about sleep and pre-sleep arousal, that were introduced on an as needed basis as determined by the clinician.

Measures

The primary outcome measures were parent, teen and teacher report of teens’ attentional and behavioral functioning. These ratings were collected before treatment began, when treatment ended, and at 3-month follow-up. While parents knew that their teen was receiving treatment, teachers were not informed and their ratings are less likely to be influenced by expectations of benefit.
Measures of changes in sleep behavior, sleep quality, and actual duration of sleep were also obtained.

Results Sleep outcomes

Prior to treatment, over 70% of teens were classified as Poor Sleepers based on their responses to a sleep quality measure; after the intervention, only 21% remained classified this way. At the 3-month follow-up, this had risen slightly to 28%. Parents’ reports of their child’s sleep quality and habits also showed significant improvement that remained evident at follow-up.

During the intervention, adolescents shifted their bedtime an average of 30 minutes earlier during the week. An objective measure of actual sleep time using a wrist-mounted actigraph (similar in function to a Fitbit) showed an average sleep increase of 35 minutes per night.

Behavioral and emotional outcomes

Immediately following treatment, parent, teen, and teacher reports showed showed significant declines in attention problems compared to ratings obtained before treatment began. These reductions were in the moderate to large range. For parents – but not teens and teachers – these reductions remained evident at the 3-month follow-up.

Parents and teachers, but not teens themselves, reported significant reductions in hyperactive symptoms that were present at the 3-month follow-up. Adolescents reported substantial reductions in their depressive and anxiety symptoms and parents reported significant reductions in adolescents’ internalizing problems that remained evident at follow-up.

Acceptability and satisfaction

Even if an intervention is helpful, it is unlikely to be of practical value if teens and parents don’t find it acceptable. In this case, all 14 teens reported that they were either satisfied or very satisfied with the sleep intervention, that it had been more helpful than they expected, and that they would recommend it to others. Parents responded similarly.

Summary and implications

This study provides initial evidence that a sleep intervention in teens with ADHD and sleep problems is beneficial. The 6-session intervention was feasible and acceptable to both adolescents and parents, and was linked to reduced attention problems based on reports from parents, adolescents, and teachers.

Adolescents also reported reductions in depressive and anxiety symptoms and that their sleep had improved. Based on an objective measure, the intervention contributed to adolescents going to bed 30 minutes earlier and getting just over 30 minutes additional sleep per night on average. This difference is large enough to be meaningful as prior research has shown that an increase of 30 minutes of sleep per night is linked to improved academic performance in children.

While prior research has shown that sleep interventions may help children with ADHD, this study adds to the literature by suggesting similar benefits occur in adolescents. Given that sleep problems are quite common in youth with ADHD – with over 40% having moderate to severe sleep difficulties – it seems essential for sleep issues to be considered when evaluation a child or teen for ADHD.

And, although results from this study should be confirmed with a larger sample in the context of a randomized-controlled trial, the findings suggest that when sleep challenges are present in teens with ADHD, direct efforts to address them may be an important component of an effective intervention. 

Copyright © 2021 by David Rabiner