A conversation about the cycle of ADHD and sleep problems in children, with Alison Pritchard, Ph.D.

In this conversation, Alison Pritchard, Ph.D., explains how ADHD and sleep problems can form a cycle in children and shares findings from ‘What Matters to Caregivers of Youth With ADHD: Defining the Minimum Clinically Important Difference for Sleep Treatment.’ Pritchard, a child clinical psychologist and co-director of the Center for Neuropsychological and Psychological Assessment at Kennedy Krieger Institute in Baltimore and an associate professor of psychiatry and behavioral sciences at Johns Hopkins University School of Medicine, was the lead author.

The results of this preliminary survey were published recently in the Journal of Attention Disorders.

In this Managed Healthcare Executive interview, Pritchard stresses the role of caregiver buy-in, the need for clinicians to pinpoint whether a child struggles with falling asleep, staying asleep, waking, or restlessness, and practical steps such as consistent bedtime routines and removing screens from the bedroom.

This conversation has been edited for length and clarity.

MHE: Can you begin by giving an overview of the study?

Pritchard: This was a survey study that we did here at the Kennedy Krieger Institute in Baltimore, Maryland, at a children's rehabilitation hospital. We wanted to get a sense of what was important for caregivers of kids who have ADHD and sleep problems. This research took place in an outpatient department, where kids are coming for psychological or neuropsychological evaluation. So we asked 100 caregivers to complete a questionnaire while they were sitting in our waiting area, and about half of our participants in this study had commercial insurance, with the other half using medical assistance, because we wanted to see whether there were differences in parent perspectives based on income level.

There were no differences in severity of symptoms for ADHD or sleep problems based on income level. We saw no differences in what was most important to parents or what symptoms they cared the most about treating, and we didn't see any differences in how much improvement they would need to see before they considered the symptoms were improved.

On average, parents are prioritizing improvement in the ADHD symptoms over improvement in the sleep problems and maybe not realizing how much the sleep problems could be playing into the ADHD symptoms.

Another big takeaway was that what parents feel is necessary in terms of the magnitude of improvement that they would see if they participated in a treatment is that they want to see very large improvements in sleep or in functioning. The average improvement that they would want to see in how long it takes their child to fall asleep at night is 30 minutes.

With the best treatments we have, the fastest you're likely to see is 20 minutes, on average. It's a similar story with ADHD symptoms. Parents want to see a reduction in half of the child's symptoms, and we know even with stimulant medications like Ritalin or Adderall, which tend to be very effective, we don't see symptoms being halved. What parents expect out of treatment and what we're able to deliver as treatment providers are different. As providers, we need to make sure that parents and caregivers know what to expect going into the treatment.

MHE: How can ADHD affect sleep?

Pritchard: Unfortunately, ADHD and sleep often fall into a vicious cycle. Sometimes having ADHD makes it harder for kids to fall asleep and stay asleep. Many kids with ADHD report having trouble turning their brains off, and a lot of kids who have trouble sleeping are groggy in the morning and have a difficult time waking up to go to school.

MHE: Why is a caregiver’s input so important when it comes to treating their child's ADHD?

Pritchard: When you treat a child, the parent is usually a big part of that treatment, especially when it comes to sleep and ADHD, especially for younger children. Parents are establishing bedtime routines. Parents are determining schedules and whether they want to allow screens in the bedroom at night. So, if you don't have parent buy-in for treatment, it’s difficult to implement the treatment.

One of the main findings of this study was that what parents want out of treatment varies tremendously from one parent to the next. If I were to take one conclusion from the study that I would want clinicians and caregivers to know, it's that the treatment provider needs to talk to the family specifically about what the sleep problems are. They can't just say, ‘Oh, okay, there are sleep problems. We're going to do X treatment.’ We need to know whether it's trouble falling asleep, staying asleep, waking up in the morning or restlessness during sleep, because that's going to help us pinpoint which treatment to use and help us as providers manage parents' expectations about the kind of improvement they are or aren't likely to see.

MHE: Do you expect this gap to close as more treatments become available?

Pritchard: I hope so. I do think over the last 10 years there has been a substantial increase in interest in sleep and a better understanding of the importance of sleep across the board, but especially for kids with ADHD. So, we do see a lot of new treatments or improvements to existing treatments that are coming out rapidly at this point. I do hope that many of those will result in some sort of greater symptom improvement.

MHE: What are some ways sleep can be improved in children with ADHD?

Pritchard: Number one is having a schedule and sticking to it. As in many areas of life for kids with ADHD, having structure can be helpful. And so, having a well-structured, kind of bedtime routine that you do the same way, at the same time, every night. I also always recommend that families remove phones, TVs, and video games from the bedroom at night. If you have a child waking up in the middle of the night and having trouble falling back asleep, it can be helpful to work with a therapist to figure out how best to address that. It may be as simple as being afraid of the dark.

MHE: What’s next for this study?

Pritchard: This was a preliminary study. We applied for funding to the Patient-Centered Outcomes Research Institute. For the study that we are proposing, we're interested in comparing behavioral sleep treatment with a therapist versus melatonin.