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



The setting for implementation of the pilot quality improvement project was a specialty ADHD clinic, located within a privately owned primary care practice in Raleigh, NC. The practice cares for pediatric patients from birth through 21 years of age, and 55% of patients have Medicaid as their primary insurance. The clinic implementation site was staffed with one pediatrician; one nurse practitioner, board-certified in pediatrics and pediatric mental health; one master's-prepared educational consultant; three specialty-trained medical assistants; and a receptionist.


After institutional review board approval, the 20-week project was conducted from July 6, 2015, through November 20, 2015. English-speaking patients, ages 5 through 11 years, with a diagnosis of ADHD who met the Diagnostics and Statistics Manual of Mental Health Disorders, 5th edition criteria were eligible to participate in the project (American Psychiatric Association, 2013). Inclusion criteria for the sleep intervention required a diagnosis of ADHD/attention deficit disorder and a score of 42 or greater on the sleep assessment tool. Exclusion criteria included a diagnosis or clinical presentation indicative of obstructive sleep apnea, changes in ADHD medications during the 6-week implementation, and use of a pharmaceutical or complementary sleep aid medication, such as clonidine or melatonin.

Assessments and Guidelines

The CSHQ, developed by Dr. Judith Owens, was used to assess sleep in children who met the inclusion criteria and agreed to participate. A sleep disturbance score of 42 or greater indicated a pediatric sleep disorder. A randomized controlled trial involving 75 children, 26 with ADHD and 46 healthy control volunteers, showed that the CSHQ reliably evaluated sleep and correlated with parental report and polysomnography (Gruber et al., 2012). Researchers report that children with ADHD, who experience shorter duration of sleep, have high scores on the CSHQ (Gruber et al., 2009). The CSHQ sensitivity and specificity were .80 and .72, respectively (Owens, Spirito, & McGuinn, 2000).

The prescriptive sleep hygiene routine interventions were based on the "Clinical Practice Guideline on Sleep Disorders in Childhood and Adolescent Primary Care" (Blasco et al., 2011). The age-specific interventions included consistent bedtime and awakening schedule; daily physical activity and spending some time outdoors every day; consistent presleep routine; elimination of naps; avoiding heavy meals, caffeine, and physical exertion before bed; avoiding screen time at least 2 hours before bed; and removing TV, computers, and mobile phones from the bedroom (Blasco et al., 2011). A copy of the prescriptive sleep hygiene routine is included in Box 1.


Parents or caregivers of identified patients with ADHD attending the clinic were invited to participate in the study using a standardized script. Once verbal agreement was obtained, the parent/caregiver was provided the CSHQ and the Vanderbilt screening tools with standardized instructions for completion from the medical assistant. The CSHQ and Vanderbilt were completed by the parent/caregiver and scored before the patient was seen by the provider. The physician or nurse practitioner reviewed the patient's chart and completed an interview with the parent/caregiver and child to determine if study inclusion and exclusion criteria were present. Children scoring 42 or greater on the CSHQ and not meeting exclusion criteria received the sleep hygiene intervention. The intervention consisted of (a) the parent/caregiver and child viewing a 6-minute, standardized sleep hygiene video (Box 2) created by the nurse practitioner and available in the clinical setting, (b) an opportunity to discuss the video and key aspects of the sleep hygiene routine with the provider before completion of the clinic visit, (c) development of a patient-specific sleep hygiene routine that was embedded in the electronic health record for documentation, (d) provision of a written copy of the patient-specific sleep hygiene routine, and (e) a planned 6-week follow-up visit to evaluate sleep and ADHD symptoms. At the 6-week follow-up visit, the CSHQ and Vanderbilt survey were readministered, and a parent satisfaction survey was completed. After completion of the pilot study, the CSHQ and Vanderbilt scores were analyzed using a paired t test.