An Intervention to Promote Sleep and Reduce ADHD Symptoms

Katherine H. Peppers, DNP, CPNP, CPMHS, RN; Shelly Eisbach, PhD, RN, PMHNP; Sarah Atkins, MD, MPH; James M. Poole, MD, FAAP; Anne Derouin, DNP, CPNP, RN


J Pediatr Health Care. 2016;30(6):e43-e48. 

In This Article

Literature Review

The primary sleep disorder symptoms seen in children with ADHD are bedtime resistance, latency of sleep onset, decreased duration of sleep, increased number of overnight awakenings, and daytime somnolence (Cortese et al., 2013; Yoon, Jain, & Shapiro, 2011). Bedtime resistance or "difficulty falling asleep" is the most common symptom reported by children affected with ADHD and/or their parents (Cortese et. al, 2013, p. 785). Case–control studies of children with ADHD not receiving medication show that latency of sleep onset duration is double in children with ADHD and that sleep duration was decreased by nearly 10% compared with healthy matched controls (Cortese, Faraone, Konofal, & Lecendreux, 2009; Van Der Heijden, Smits, & Gunning, 2006). Persistent, untreated sleep disorders led to increased daytime behavioral symptoms and decreased daily functioning among children with ADHD, including decreased quality of life for both the child and the family (Sung, Hiscock, Sciberras, & Efron, 2008).

Further compounding the issue of sleep onset latency is stimulant use among children with ADHD. Children with ADHD receiving methylphenidate, a commonly used medication, experience an additional 20-minute delay in sleep onset and shortened sleep duration of 1 to 2 hours compared with their nonmedicated peers (Galland, Tripp, & Taylor, 2010). Among children with ADHD, prolonged sleep latency onset, decreased duration of sleep, and frequent overnight awakenings correlate with increased behavior difficulties and poorer scores on standardized ADHD rating scales, such as the Vanderbilt Assessment Scale–Parent Form (Biggs, Lushington, Van Der Huevel, Martin, & Kennedy, 2011).

Behavioral interventions are the first-line treatment for sleep disorders in children with ADHD (Cortese et al., 2013). A randomized controlled trial of 244 children with ADHD, ages 5 through 12 years, who were receiving stimulant medication found that provider instruction of sleep hygiene routine, combined with behavior modification techniques, yielded a sustained improvement in ADHD symptoms, sleep duration, and quality of life (Hiscock et al., 2015). The sleep hygiene routine also showed improvements in the quality of life and daily functioning in children with ADHD (Hiscock et al., 2015; Sciberras, Fulton, Efron, Okerlaid, & Hiscock, 2011).

The Hiscock et al. (2015) randomized controlled trial guided the development of this quality improvement project, which evaluated the effect of implementing a provider-instructed sleep hygiene routine for children with ADHD being treated with stimulant medication. We believed that implementation of a validated sleep assessment tool among children with ADHD and the provision of a provider-instructed sleep hygiene routine for those with disordered sleep would result in better sleep quality, as evidenced by decreased scores on the Child Sleep Habits Questionnaire (CSHQ) and the Vanderbilt ADHD symptom checklist.