Sleep disorders in patients with ADHD: impact and management challenges

Figures & data

Table 1 Summary of studies reviewed

Author and year	Sample	Study design	Diagnoses	Measures	Sleep differences	Daytime impairments			Conclusions
						Cognitive	Emotional	Physical
Table 1.1 OSA and sleep-disordered breathing
Smith et al (2017)^Citation67	631 children Sex: 347 males, 284 females Age (mean ± SD), years: 6.94±1.30	Cross-sectional	ADHD: CPRS-R, CBCL OSA/SDB: PSG	Sleep: PSG Attention: CPRS-R, CBCL Cognitive: NEPSY, NEPSY-II Intelligence: DAS	N/A	Snorers vs nonsnorers: more ADHD symptoms. Higher AHI was associated with less hyperactivity and inattention symptoms. Increased snoring, but not AHI, was associated with worse performance on cognitive tests.	Snorers vs nonsnorers: more internalizing and externalizing problems.	N/A	Snoring, but not AHI, was associated with more daytime dysfunction in attention, cognition, and psychological aspects.
Kim et al (2018)^Citation68	170 children with AT, 150 healthy controls Sex: 182 males, 135 females Age (mean ± SD), years: OSA/SDB: 7.7±1.5; controls: 7.6±1.5	Prospective cohort intervention: AT	ADHD: SDQ OSA/SDB: PSG, SRBD	Sleep: PSG, SRBD Attention: SDQ Socioemotional: CDI SCARED Physical: BMI	AT improved SDB symptoms	AT reduced hyperactivity and inattention symptoms. This improvement was reduced in older children (vs younger) and obese children (vs normal weight).	AT reduced symptoms of anxiety and depression.	AT increased odds of being overweight.	AT improved symptoms of SDB and daytime symptoms of ADHD, depression, and anxiety. Young children with normal weight had better improvement.
Wu et al (2017)^Citation80	437 children with OSA Sex: 298 males, 139 females Age (mean ± SD), years: 5.71±1.45	Retrospective cohort	ADHD: DSM-IV criteria OSA/SDB: PSG	Sleep: OSA-18 Socioemotional: OSA-18 Physical: OSA-18	OSA + ADHD vs OSA: more sleep disturbances, higher AHI, and lower oxygen saturation.	OSA + ADHD vs OSA: more daytime problems.	OSA + ADHD vs OSA: greater emotional distress and caretaker concern.	OSA + ADHD vs OSA: more physical suffering	OSA with comorbid ADHD had worse daytime functioning across cognitive, emotional, and physical outcomes compared with OSA without ADHD.
Smith et al (2016)^Citation69	1,022 children Sex: 562 males, 460 females Age (mean ± SD), years: 6.86±0.89	Cross-sectional	ADHD: CPRS-R, CBCL OSA/SDB: PSG Parental report	Sleep: PSG Attention CPRS-R, CBCL	N/A	Snorers with normal AHI vs nonsnorers with normal AHI: worse CPRS-R. Snorers with normal AHI vs nonsnorers with normal AHI, mild AHI, severe AHI: higher hyperactivity and ADHD scores on the CBCL.	Snorer with normal AHI vs nonsnorers with normal AHI: worse internalizing.	N/A	Snoring with a normal AHI is associated with worse daytime functioning for ADHD and internalizing than either snorers with abnormal AHI or nonsnorers with normal AHI.
Smith et al (2017)^Citation67	1,116 children Sex: 598 males, 518 females Age (mean ± SD), years: 6.84±0.86	Cross-sectional	ADHD: CPRS-R OSA/SDB: PSG	Sleep: PSG Attention CPRS-R, CBCL, NEPSY, NEPSY-II	N/A	SDB is associated with behavioral problems. SDB was not directly associated with cognitive problems. However, behavioral problems were an indirect mediator of the association between SDB and cognitive problems.	N/A	N/A	SDB is associated with more behavioral problems, which may lead to cognitive problems.
Villa et al (2016)^Citation71	76 children with suspected OSA Sex: 44 males, 32 females Age (mean ± SD), years: 4.95±1.75	Open-label trial intervention: AT, RME, or medical therapy	ADHD: DSM-IV criteria OSA/SDB: PSG Medical history	Sleep: PSG Attention: unspecified DSM-IV symptom checklist	AHI improved after AT and RME. Mean O2 saturation improved in AT group.	AT improved ADHD symptoms.	N/A	N/A	AT was better at improving symptoms of ADHD than RME or medical therapy.
Zhu et al (2014)^Citation72	51 children with OSA Sex: 35 males, 16 females Age (mean ± SD), years: 7.68±2.15	Open-label trial intervention: AT	ADHD: IVA-CPT OSA/SDB: PSG	Sleep: PSG Attention: IVA-CPT	AHI and mean O2 saturation improved between baseline and 3 months follow-up, as well as between 3 and 6 months follow-up. Those with severe OSA had worse parameters at baseline, but at 6 months follow-up there were no differences based on initial severity.	IVA-CPT scores improved from baseline to 3 months follow-up, as well as from 3 to 6 months follow-up. Severity of OSAHS was associated with worse Full Attention Quotient scores, but not Hyperactivity or Full Scale Response Control Quotient.	N/A	N/A	AT improved performance on a cognitive test of attention. Performance continued to improve until at least 6 months follow-up.
Vitelli et al (2015)^Citation73	36 children with OSA, 38 children with OSA + obesity, 58 controls Sex: 77 males, 57 females Age (mean ± SD), years: OSA: 8.29±2.04; OSA + obesity: 8.73±1.69; controls: 8.89±1.62	Case–control	ADHD: ADHD-RS OSA/SDB: PSG	Sleep: PSG Attention: ADHD- RS Physical: BMI	N/A	OSA + Obesity vs OSA: more symptoms of ADHD.	N/A	N/A	In children with OSA, obesity is associated with greater symptoms of ADHD (vs normal weight).
Oğuztürk et al (2013)^Citation74	81 treatment-naïve adults with OSA, 32 controls Sex: 89 males, 27 females Age (mean ± SD), years: OSA: 48.1±8.9; controls: 44.1±13.2	Case–control	ADHD: ASRS OSA/SDB: PSG	Sleep: PSG Sleepiness: ESS Attention ASRS Socioemotional: HADS Physical: SF-36	OSA + ADHD vs OSA: higher sleepiness, no PSG differences.	OSA vs controls: no differences in ADHD prevalence.	OSA + ADHD vs OSA: more anxiety and depression symptoms.	OSA + ADHD vs OSA: lower physical health quality of life, no difference in BMI	OSA with comorbid ADHD has worse emotional and physical outcomes than OSA without ADHD.
Perfect et al (2013)^Citation75	263 children Sex: 123 males, 140 females Age (mean ± SD), years: 13.22±1.70	Prospective cohort	ADHD: medical history OSA/SDB: PSG Parent-reported snoring	Sleep: PSG SHQ Attention: BASC-2 Socioemotional: ABAS-II School problems parent report	N/A	Persistent SDB vs never SDB: no significant differences in ADHD diagnosis, greater hyperactivity, and lower school grades.	Persistent SDB vs never SDB: impaired social and communication skills.	N/A	Presence of current SDB and persistence of SDB are associated with increased hyperactivity symptoms, impaired social skills, and lower school grades.
Ekici et al (2013)^Citation76	90 adult snorers or with OSA Sex: 67 males, 23 females Age (mean ± SD), years: 44.23±10.23	Cross-sectional	ADHD: ASRS OSA/SDB: PSG	Sleep: PSG Attention: ASRS	N/A	Snoring vs OSA: no difference in ADHD symptoms.	N/A	N/A	No difference was found in cognitive outcomes between snorers and OSA adults.
Amiri et al (2015)^Citation78	53 post-AT children with untreated ADHD Sex: 28 males, 25 females Age (mean ± SD), years: 6.89±2.06	Prospective cohort intervention: AT	ADHD: K-SADS-PL OSA/SDB: direct observation of tonsils and medical history	Attention: CPRS-R	N/A	AT improved ADHD symptoms between baseline and 3 months follow-up, as well as between 3 months follow-up and 6 months follow-up.	N/A	N/A	AT improved symptoms of ADHD and symptoms continue to improve at least until 6 months after surgery.
Table 1.2 RLS and periodic limb movement disorder
Roy et al (2018)^Citation86	1,632 adults Sex: 757 males, 875 females Age (mean ± SD), years: 43.2±12.7	Cross-sectional	ADHD: ADHD-RS RLS: IRLSSG criteria	Sleep: JSS Attention: ADHD- RS, WURS-K	Adult ADHD is associated with increased odds of presenter RLS, OR = 4.73. After controlling for sleep disturbances, this association was no longer significant, which suggests that sleep disturbances may partially mediate the relationship between ADHD and RLS.	RLS vs non-RLS: prevalence of ADHD is 17.3% vs 4.2%.	N/A	N/A	The prevalence of RLS is higher in adults with ADHD.
Um et al (2016)^Citation82	28 children with ADHD Sex: 22 males, 6 females Age (mean ± SD), years: male: 8.95±2.26; female: 9.17±2.04	Cross-sectional	ADHD: DSM-IV-TR criteria PLMD: PSG	Sleep: PSG Attention: CGI-P Cognitive: MFFT- KC Intelligence: K-WISC-III	Limb movement index: 11.64±3.90. Limb movement index with arousal: 6.74±2.33. Periodic limb movement: 0.30±1.57. Periodic limb movement with arousal: 0.05±0.25.	Higher limb movement index with arousal was associated with worse verbal IQ and number of correct answers in the MFFT-KC.	N/A	N/A	In children with ADHD, more symptoms of PLMD are associated with reduced performance on intelligence and cognitive tests.
Ghorayeb et al (2017)^Citation87	105 adults with RLS Sex: 43 males, 62 females Age (mean ± SD), years: 41.75±19.2	Cross-sectional	ADHD: ASRS RLS: IRLSSG	RLS: serum ferritin and iron. Attention: ASRS Socioemotional: MOCI	RLS + ADHD vs RLS: no difference in serum ferritin and iron levels.	27.6% of patients with RLS have comorbid ADHD.	RLS + ADHD vs RLS: prevalence of OCD is 7.62% for both groups.	N/A	ADHD is highly comorbid with RLS. OCD comorbidity may also be higher in those with RLS.
Ferri et al (2013)^Citation83	18 children with ADHD, 17 health controls Sex: 20 males, 15 females Age (mean ± SD), years: ADHD: 8.9± 1.35; control: 9.4±2.0	Double-blind, placebo-controlled randomized clinical trial Intervention: 25 mg/100 mg of carbidopa and levodopa, increased up to 250– 600 mg of levodopa vs placebo for the ADHD group	ADHD: DISC-IV RLS: PSG	Sleep: PSG	ADHD vs control: higher PLMD index and lower periodicity of leg movements. No changes with treatment in periodicity of movement.	N/A	N/A	N/A	Children with ADHD had more PLMD symptoms than controls. Treatment with levodopa and carbidopa did not change RLS symptoms.
Akinci et al (2015)^Citation84	28 children with ADHD and 15 healthy controls Sex: 29 males, 14 females Age (median [age range]), years: ADHD: 10 (9–13); control: 10 (8–12)	Case–control	ADHD: K-SADS RLS: PSG	Sleep: PSG, PSQI Sleepiness: ESS	ADHD vs control: PLMI was higher. No differences in subjective perception of RLS.	N/A	N/A	N/A	RLS is greater in children with ADHD than in healthy children.
Garbazza et al (2018)^Citation85	15 ADHD adults without RLS/ PLMD and 18 healthy controls Sex: 14 males, 19 females Age (mean ± SD), years: ADHD: 33.9 ±7.9; controls: 35.8±7.5	Case–control	ADHD: DSM-IV criteria RLS: RLDI	Sleep: PSG	ADHD vs control: longer sleep latency, longer duration of periodic leg movements during sleep, and higher PLMS index in REM sleep.	N/A	N/A	N/A	Adults with ADHD but without RLS/ PLMD present, greater subthreshold PLMD symptoms than healthy controls.
Table 1.3 Circadian rhythm sleep disorders
Bijlenga et al (2013)^Citation91	12 medication naïve adults with ADHD and DSPS, 12 healthy controls Sex: 12 males, 12 females Age (M±SD), years: ADHD + DSPS: 32.5±9.9; control: 32.4±10.8	Case–control	ADHD: DIVA 2.0 DSPS: inability to fall asleep at preferred time before 23:30 in the past 6 months	Sleep: MCTQ, SHQ, actigraphy Circadian rhythms: DLMO, CBT, actigraphy	Sleep: ADHD + DSPS vs controls: midpoint of sleep was 1:52 hours later, bed time was 2:23 hours later, sleep start time was 2:20 hours later, sleep duration was 1:08 hours shorter on work days, sleep hygiene was worse, sleep efficiency was better by 4.5 percentage points. Circadian rhythms: ADHD + DPSPvs controls: DLMO onset occurred 1:23 hours later; 24-hour activity parameters were delayed. CBT anddistal skin temperature were lower, while proximal skin temperature was higher.	N/A	N/A	N/A	Circadian rhythms of melatonin and activity were delayed in participants with ADHD and DSPS.
Durmuş et al (2017)^Citation92	52 children with ADHD, 52 healthy controls Sex: 82 males, 22 females Age (M±SD), years: ADHD: 9.24±1.94; control: 9.20±1.20	Case–control	ADHD: K-SADS-PL Sleep: None	Sleep: CHSQ Chronotype: CCTQ Attention: CPRS, CTRS, DSM-IV symptom checklist. Intelligence: WISC-R	ADHD vs control: more eveningness and worse sleep hygiene. In the ADHD group, eveningness was associated with the following subscales in the CSHQ: resistance to sleep, respiratory problems, daytime sleepiness, and total score. I n the control group, eveningness was only associated with daytime sleepiness.	In the ADHD group, somatic symptoms in the CPRS were associated with eveningness. ADHD vs control: lower WISC-R scores.	N/A	N/A	Children with ADHD had greater eveningness, which was associated with worse sleep hygiene. Eveningness was associated with worse daytime somatic symptoms of ADHD.
Snitselaar et al (2013)^Citation90	10 adults with ADHD Sex: 8 males, 2 females Age (mean ± SD), years: 33.2±7.6	Open-label trial Treatment: MPH	ADHD: DSM-IV criteria Sleep: None	Chronotype: MCTQ, DLMO Attention: ADHD- RS	Circadian rhythms: MPH increased melatonin levels but did not change the timing of DLMO.	Morningness was associated with greater reduction of symptoms after MPH treatment.	N/A		Patients with a morning type may have more improvement in ADHD symptoms than those with the evening type.
Büber et al (2016)^Citation88	27 children and adolescents with ADHD and 28 healthy controls. Sex: 44 males, 11 females Age (mean ± SD), years: ADHD: 9.37±2.69; control: 10.50±2.71	Case–control	ADHD: K-SADS-PL Sleep: None	Chronotype: urinary 6-OH MS Attention CPRS	Circadian rhythms: ADHD vs control: higher levels of daytime, nighttime, and 24-hour melatonin.	Levels of 6-OH MS were not associated with symptom severity.	N/A	N/A	While melatonin levels are associated with the presence of ADHD, no evidence suggests thatit was associated with daytime symptom severity or subtype.
Bron et al (2016)^Citation40	2,090 adults Sex: 696 males, 1,394 females Age (mean ± SD), years: lifetime depression or anxiety + ADHD: 47.6±11.3; lifetime depression or anxiety: 44.6 ±12.8; controls: 44.0±14.6	Cross-sectional	ADHD: CAARS DSPS: MCTQ	Chronotype: MCTQ Attention: CAARS Socioemotional: CIDI Physical: BMI	Lifetime depression or anxiety + ADHD vs controls or lifetime depression or anxiety: shorter sleep duration (OR=2.8). Lifetime depression or anxiety + ADHD vs lifetime depression or anxiety: higher prevalence of late chronotype (OR = 2.6) and DSPS (OR = 2.4). For every SD increase of inattentive symptoms or ADHD symptoms index, OR for DSPS and extreme evening chronotype increased by 1.3.	N/A	N/A	No differences in BMI between groups.	ADHD symptoms, specifically inattentive symptoms, are associated with extreme evening chronotype in the presence of lifetime depression and anxiety.
Bumb et al (2016)^Citation95	74 adults with ADHD, 86 healthy controls. Sex: 82 males, 78 females Age (mean ± SD), years: ADHD: 32.7 ±8.1; control: 23.1±2.6	Case–control	ADHD: ADHD-DC Sleep: none	Chronotype: MEQ Attention: ADHD- DC, WURS-K Intelligence: MWT-B	N/A	ADHD vs controls: greater eveningness. Eveningness was associated with greater ADHD symptoms.	N/A	N/A	Eveningness is associated with more symptoms of ADHD.
Molina-Carballo et al (2013)^Citation89	136 children with ADHD group, 42 healthy controls. Sex: 136 males, 42 females Age (mean ± SD), years: 9.70±2.55	Quasiexperimental open-label trial Intervention: extended release MPH	ADHD: DSM-IV or ICD-9 criteria Sleep: none	Sleep: sleep diary Attention: EDAH Chronotype: urinary 6-OH MS Serum melatonin Socioemotional: CDISerum serotonin	Circadian rhythms: MPH treatment reduced urinary 6-OH MS excretion and lowered morning melatonin in ADHD patients.	ADHD symptoms improve after MPH treatment.	CDI improves after MPH treatment. Serotonin was lower in ADHD patients in the morning comparedwith controls; serotonin was not affected by MPH.	N/A	Stimulant treatment of ADHD reduces melatonin levels, which may have an impact on DSPS or chronotype.
Table 1.4 Insomnia
Vélez-Galarraga et al (2016)^Citation99	126 children with ADHD, 1,036 controls Sex: 504 males, 658 females Age (mean ± SD), years: ADHD: 11.25±3.25; controls: 10.83±3.75	Case–control	ADHD: K-SADS- PL, DSM-IV criteria Insomnia: PSG	Sleep: PSG Attention: ADHD- RS, CPT	ADHD vs controls: greater bedtime resistance, difficulty falling asleep, and sleep onset latencies longer than 30 minutes than controls. No differences in insomnia prevalence.	In children with ADHD: ADHD-RS ≥24 vs ADHD <24: higher prevalence of insomnia. Higher omission errors on the CPT were associated with shorter sleep duration.	N/A	N/A	In children with ADHD, more symptoms of ADHD were associated with a higher prevalence of insomnia, and more inattentive errors on the CPT were associated with shorter sleep duration.
Yoon et al (2013)^Citation101	126 adults with ADHD Sex: 93 males, 33 females Age (mean ± SD), years: 38.1±10.4	Cross-sectional	ADHD: CAARS- S:L, ASRS, SCID-I, TCI Insomnia: PSQI	Sleep: PSQI Sleepiness: ESS, FSS Attention: CAARS- S:L, ASRS	Initial insomnia was the most common subjective complaint in adults with ADHD. ADHD- I vs ADHD-C: no differences in proportion of insomnia or sleepiness; greater PSQI scores and fatigue.	N/A	N/A	N/A	ADHD-I was associated with greater daytime fatigue and greater sleep disturbance.
Moreau et al (2014)^Citation97	41 children with ADHD, 41 controls Sex: 24 males, 17 females Age (mean ± SD), years: ADHD: 9.74 ±1.69; controls: 9.57±1.62	Case–control	ADHD: CPRS-R, CTRS-R, K-SADS- PL Insomnia: ISI-C	Sleep: Actigraphy, CSHQ, ISI-C Attention: CPRS, CTRS, CBCL Socioemotional: CBCL	Children with ADHD vs controls: increased sleep onset latency and night awakenings, higher insomnia severity, shorter actigraphic sleep time, longer sleep onset latency, lower sleep efficiency, and greater variability of sleep onset latency. Having a comorbid psychiatric disorder (in addition to ADHD) worsened these measures. Stimulant medication usewas not associated with any differences in sleep.	N/A	N/A	N/A	Presence of ADHD is associated with increased sleep problems and insomnia severity.
Corkum et al (2016)^Citation98	22 children with ADHD and 39 typically developing with behavioral insomnia Sex: 28 males, 33 females Age (mean ± SD), years: 9.11±1.96	Randomized controlled trial Intervention: “Better Nights/Better Days” distance sleep intervention or waitlist control	ADHD: K-SADS-PL Insomnia: DSM-IV criteria	Sleep: CHSQ Actigraphy Sleep evaluation questionnaire Attention: CBCL Socioemotional: CBCL	Sleep intervention improved objective and subjective sleep onset latency, subjective sleep duration, bedtime resistance, and total sleep disturbance (vs no changes in waitlist control). This improvement was maintained at 6-month follow-up.	Sleep intervention improved CBCL scores, which includes attention problems. Improvement increased at 6-month follow-up.	Sleep intervention improved CBCL internalizing and externalizing scores. This improvement increasedat 6-month follow-up.	N/A	Better nights/better days was effective in improving sleep and daytime functioning in children with insomnia that are either typically developing or with ADHD.
Brevik et al (2017)^Citation47	268 adults with ADHD, 202 controls Sex: 184 males, 286 females Age (mean ± SD), years: ADHD: 38.1±11.4; controls: 36.5±8.0	Case–control	ADHD: ASRS Insomnia: BIS	Sleep: BISvAttention: ASRS	ADHD vs controls: 67% vs 29% insomnia prevalence. ADHD-C vs ADHD-I: higher prevalence of insomnia. Stimulant treatment vs no treatment: lower insomnia severity.	Insomnia severity was strongly correlated with inattentive symptom severity.	N/A	N/A	Insomnia is more prevalent in adults with ADHD, specifically in ADHD-C. Inattentive symptoms are correlated with insomnia severity.
Table 1.5 Narcolepsy
Ito et al (2018)^Citation57	77 adolescent and adult outpatients with narcolepsy type 2 or hypersomnia. Sex: 48 males, 29 females Age (M±SD), years: narcolepsy type 2: 25.7±5.8; narcolepsy type 2 + ADHD: 23.0±7.0	Cross-sectional	ADHD: DSM-IV criteria Narcolepsy type 2: self-reported symptoms and MSLT	Sleep: PSG Sleepiness: MSLT	Sleep: shorter stage N1, longer stage N3 in narcolepsy + ADHD compared with those with only narcolepsy Sleepiness: narcolepsy + ADHD shorter REM sleep latencieson MSLT than those with only narcolepsy.	N/A	N/A	N/A	Narcolepsy type 2 + ADHD vs narcolepsy: greater daytime sleepiness.
Lecendreux et al (2015)^Citation106	188 children with narcolepsy. 67 healthy controls. Sex: 85 males, 90 females Age (median [range]), years: narcolepsy type 1: 14.0 (6.6–17.8); narcolepsy type 2: 10.3 (5.9–17.4); controls: 14.8 (7.0–17.9)	Case–control	ADHD: ADHD-RS Narcolepsy: ICSD-2 criteria, PSG, MSLT, CSF hypocretin-1 levels	Sleep: ISI Sleepiness: PDSS Attention: ADHD- RS Socioemotional: CDI	In children with narcolepsy, ADHD symptoms were associated with longer sleep onset latencies.	Narcolepsy vs controls: more ADHD symptoms. Insomnia and fatigue were associated with increased inattention.	Narcolepsy + ADHD vs narcolepsy: significantly more depressive symptoms and lower quality of life.	N/A	Narcolepsy vs controls: more symptoms of ADHD. More ADHD symptoms are associated with more depressive symptoms.
Filardi et al (2017)^Citation108	21 adults with narcolepsy type 1, 15 adults with narcolepsy type 2, and 22 healthy controls Sex: 26 males, 32 females Age (M±SD), years: narcolepsy type 1: 36±12; narcolepsy type 2: 36±13; controls: 35±12	Cross-sectional	ADHD: ASRS Narcolepsy: ICSD-3 criteria	Sleep: narcolepsy: PSG; controls: actigraphy. Sleepiness: ESS MSLT Attention ASRS; ANT Socioemotional: BDI; STAI; OCIr Physical: BMI.	In narcolepsy type 1, impaired attention was associated with greater sleepiness.	Narcolepsy vs controls: more inattentive and slower reaction times. Narcolepsy type 1 vs narcolepsy type 2 and controls: more hyperactive and worse alerting scores.	In narcolepsy type 1, higher ADHD symptoms were associated with higher depression scores.	Narcolepsy type 1 vs narcolepsy type 2 and controls: higher BMI	Narcolepsy vs controls: greater ADHD symptoms. ADHD symptoms in narcolepsy were associated with more depressive symptoms.
Rocca et al (2016)^Citation104	29 children with narcolepsy type 1, 39 controls. Sex: 36 males, 32 females Age (M±SD), years: narcolepsy type 1: 11.52± 2.89; control: 11.21±3.44	Case–control	ADHD: CBCL Narcolepsy: previous diagnosis by psychiatrist (criteria not specified)	Sleep: PSG Attention CBCL Quality of life: PedsQL	Total sleep time of 489±72 minutes in the narcolepsy group. Total sleep time was not reported in the control group.	Narcolepsy type 1 was associated with higher attention problems and ADHD scores. Treatment with sodium oxybate, but not with modafinil, was associated with improved attention and ADHD scores.	In participants with narcolepsy type 1, ADHD symptoms were associated with worse school functioning and higher psychosocial health.	In the narcolepsy type 1 group, there were no significant associations between ADHD symptoms and physical health.	Narcolepsy vs controls: more ADHD symptoms. ADHD symptoms in narcolepsy are associated with worse school and psychosocial health. Sodium oxybate treatment of narcolepsy is associated with reduced daytime impairment.
Zamarian et al (2015)^Citation107	51 narcolepsy. 35 healthy controls. Sex: 46 males, 40 females Age (M±SD), years: narcolepsy type: 38.94±14.15. Control: 39.86±13.96	Cross-sectional	ADHD: None Narcolepsy: ICSD-2	Sleepiness: SSS Attention Questionnaire on perceived deficits of attention, digit span, backward digit span, D2 attention test, RWT, IED, SOC, go/no go, auditory verbal learning test Socioemotional: HADS	Sleepiness increased with testing in the narcolepsy group but not in the control group.	Narcolepsy vs control: greater subjective deficits of attention, worse selective attention, reduced verbal fluency, and fewer participants reached the go ceiling in the go/no go task. Subjective deficit of attention was associated with sleepiness and depression.	Narcolepsy vs control: greater depression.	N/A	Narcolepsy was associated with worse deficits of attention.
Table 1.6 Various sleep disorders
Miano et al (2016)^Citation81	15 children with ADHD Sex: 13 males, 2 females Age (mean ± SD), years: 10.6±2.2	Cross-sectional	ADHD: K-SADS-PL ADHD-RS Narcolepsy: ICSD-3 MSLT PLMD: PSG	Sleep: actigraphy CSHQ Video PSG Sleepiness: MSLT PDSS	26.6% of children with ADHD had suspected narcolepsy 40% of children with ADHD had PLMD	N/A	N/A	N/A	Children with ADHD may have a high prevalence of narcolepsy and PLMD.
Vogel et al (2017)^Citation79	942 adults Sex: 256 males, 686 females Age (mean ± SD), years: 48.5±14.2	Cross-sectional	ADHD: ASRS Sleep disorders: DSISD	Sleep: DSISD, SNS, ISI, Berlin questionnaire for OSA Chronotype: MCTQ Attention ASRS	CRSD: the OR reporting an extreme evening type was 1.27 and 1.42 for overall ADHD and inattentive symptoms, respectively, for each increase in ADHD symptom severity. Insomnia: odds of having insomnia were significantly higher if ADHD was present. The OR of presenting insomnia was 1.67 if there were hyperactivity symptoms with an OR of 1.67. Severe symptoms vs none or mild: OR of 1.54, 2.42, and 1.55 for initial, middle, and terminal insomnia, respectively.	ADHD symptom severity classified as none, medium, and severe. Narcolepsy: ADHD symptom severity was not associated with narcolepsy. PLMD: PLMD was associated with severe overall ADHD and hyperactive symptoms. OSA vs non-OSA: OR of 1.22 for ADHD symptoms overall, 1.17 for inattention symptoms, 1.39 for hyperactivity symptoms, and 1.50 for severe overall ADHD symptoms.	N/A	N/A	ADHD symptoms are associated with PLMD, extreme evening chronotype, and insomnia. Inattentive symptoms were associated with OSA and extreme evening chronotype. Hyperactivity symptoms were associated with PLMD and insomnia.
Hysing et al (2016)^Citation94	9846 adolescents Sex: 4,594 males, 5,252 females Age (mean), years: 17. SD not reported	Cross-sectional	ADHD: ASRS DSPS: ICSD-R Insomnia:Lichstein’s criteria (2003)	Sleep: self-report ADHD: ASRS Socioemotional: SMFQ	Severe ADHD symptoms vs mild ADHD symptoms: 7.6% vs 2.8% prevalence of DSPS. 33.0% vs 11.4% prevalence of insomnia. They also had later bed times, wake up times, shorter sleep duration, and lower sleep efficiency on both weekdays and weekends.	Shorter sleep was associated with worse ASRS scores. This effect was stronger for inattentive symptoms than hyperactive symptoms.	N/A	N/A	ADHD symptoms are associated with greater prevalence of DSPS and insomnia. More symptoms are associated with shorter sleep, especially with inattentive symptoms.
Grünwald and Schlarb (2017)^Citation100	72 children with ADHD or subthreshold ADHD Sex: 57 males, 15 females Age (mean ± SD), years: 8.61±1.65	Cross-sectional	ADHD: DSM-5 criteria Sleep: CSHQ Socioemotional: KINDL Physical: KINDL	Sleep: CSHQ Attention FBB-HKS	ADHD-H vs ADHD-I: greater insomnia severity	SDB: higher SDB symptoms are associated with higher total ADHD symptoms. This association is stronger for hyperactivity, followed by impulsivity. SDB and inattentive symptoms were not correlated.	ADHD vs normative data: worse psychological well-being, self- esteem, friends and family quality of life, and daily/school functioning.	ADHD vs normative data: worse physical well-being	ADHD was associated with more SDB symptoms. Hyperactive symptoms were more strongly associated with SDB and insomnia than inattentive symptoms. ADHD was associated with worse socioemotional and physical well-being.
Bjorvatn et al (2017)^Citation77	268 adults with ADHD, 202 controls Sex: 183 males, 287 females Age (mean), years: ADHD: 38.1; controls: 36.5. SD not reported.	Cross-sectional	ADHD: DSM-IV criteria Sleep: GSAQ	Sleep: GSAQ	ADHD vs controls: more likely to report any sleep problems, loud snoring, breathing pauses during sleep, cataplexy, short sleep duration, daytime sleepiness, use of hypnotics, extreme evening types, restless legs, or periodic limb movements. Treated ADHD vs untreated ADHD: less likely to report sleep problems, cataplexy, and restless legs. ADHD-C and ADHD-H vs ADHD-I: more likely to report restless legs.	N/A	N/A	N/A	ADHD is associated with greater reporting of symptoms of narcolepsy, CRSD, RLS/PLMD, OSA/ SDB, and insomnia. Treatment of ADHD is associated with better sleep and less symptoms of narcolepsy and RLS. Hyperactive symptoms of ADHD are associated with RLS.
van der Heijden et al (2018)^Citation93	358 children Sex: 212 males, 146 females Age (mean ± SD), years: 9.02±2.06	Cross-sectional	ADHD: DSM-IV criteria Sleep: none	Sleep: CSHS, SDSC Chronotype: CCTQ	Insomnia: ADHD vs controls: shorter sleep duration and longer sleep onset latencies. DSPS: no differences in chronotype between ADHD, ASD, and healthy children. Eveningness predicted sleep problems in all three groups.	N/A	N/A	N/A	Children with ADHD have shorter sleep duration and longer sleep latency.

Abbreviations: 6-OH MS, 6-hydroxymelatoninsulfate; ABAS-II, Adaptive Behavior Assessment System, second edition; ADHD, attention-deficit/hyperactivity disorder; ADHD-C, ADHD combined subtype; ADHD-DC, ADHD Diagnostic Checklist; ADHD-I, ADHD inattentive subtype; ADHD-RS, ADHD Rating Scale; AHI, Apnea-Hypoapnea Index; ANT, Attention Network Task; ASD, autism spectrum disorder; ASRS, ADHD Self-Report Scale; AT, adenotonsillectomy; BASC-2: Behavior Assessment for Children, second children; BDI, Beck Depression Inventory; BIS, behavioral inhibition system; BMI, body mass index; CAARS, Conners’ Adult ADHD Rating; CAARS-S:L, Conners’ Adult ADHD Rating Scales – Self-report, Long version; CBCL, Child Behavior Checklist; CBT, core body temperature; CCTQ, Children’s Chronotype Questionnaire; CDI, Children’s Depression Inventory; CGI-P, Conner’s Global Index, parent version; CHSQ, Children’s Sleep Habits Questionnaire; CIDI, Composite International Diagnostic Interview; CPRS, Conner’s Parent Rating Scale; CPRS-R, Conner’s Parent Rating Scale, revised; CPT, Continuous Performance Test; CRSD, circadian rhythm sleep disorder; CSF, cerebrospinal fluid; CSHQ, Children Sleep Habits Questionnaire; CSHS, Children Sleep Hygiene Scale; CTRS, Conner’s Teacher Rating Scale; DAS, Differential Ability Scale; DISC-IV, Diagnostic Interview Schedule for Children; DIVA 2.0, Diagnostic Interview for ADHD in Adults; DLMO, dim light melatonin onset; DSISD, Duke Diagnostic Interview for Sleep Disorders; DSM-IV, Diagnostic and Statistical Manual, fourth edition; DSM-IV-TR, Diagnostic and Statistical Manual, fourth edition, text revision; DSPS, delayed sleep phase syndrome; EDAH, evaluation of deficit of attention and hyperactivity; ESS, Epworth Sleepiness Scale; FBB-HKS, Symptom Checklist for Attention Deficit Hyperactivity Disorders; FSS, Fatigue Severity Scale; GSAQ, Global Sleep Assessment Questionnaire; HADS, Hospital Anxiety and Depression Scale; ICD-9, International Classification of Diseases, ninth revision; ICSD-2, International Classification of Sleep Disorders, second edition; ICSD-3, International Classification of Sleep Disorders, third edition; IED, intra-/extradimensional set shift; IRLSSG, International Restless Leg Syndrome Study Group; IQ, intelligence quotient; ISI: Insomnia Severity Scale; ISI-C, Insomnia Severity Index for Children; IVA-CPT, Integrated Visual and Auditory Continuous Performance Test; JSS, Jenkins Sleep Scale; KINDL, Questionnaire for Measuring Health-related Quality of Life in Children and Adolescents; K-SADS, Kiddie Schedule for Affective Disorders and Schizophrenia; K-SADS-PL, Kiddie Schedule for Affective Disorders and Schizophrenia, present and lifetime version; K-WISC-III, Korean Wechsler Intelligence Scale for Children, third edition; MCTQ, Munich Chronotype Questionnaire; MEQ, Morningness-Eveningness Questionnaire; MFFT-KC, Matching Familiar Figure Test for Korean Children; MOCI, Maudsley Obsessive Compulsive Index; MPH, methylphenidate; MSLT, multiple sleep latency test; MWT-B, multiple choice vocabulary test; NEPSY, A Developmental Neuropsychological Assessment; OCD, obsessive-compulsive disorder; OCIr, Obsessive-Compulsive Index-revised; OSA, obstructive sleep apnea; OSA-18, Obstructive Sleep Apnea-18; OSAHS, obstructive sleep apnea hypopnea syndrome; PDSS, Pediatric Daytime Sleepiness Scale; PedsQL, Pediatric Quality of Life Inventory; PLMD, periodic limb movement disorder; PLMI, periodic limb movement index; PLMS, periodic limb movement syndrome; PSG, polysomnography; PSQI, Pittsburgh Sleep Quality Index; REM, rapid eye movement; RLDI, Restless Leg Diagnosis Index; RLS, Restless Leg Syndrome; RME, rapid maxillary expansion; RWT, Regensburger Wortflussigkeits-Test; SCARED, screen for child anxiety related disorders; SCID-I, Structured Clinical Interview for DSM-IV Axis I Disorders; SDB, sleep-disordered breathing; SDQ, Strengths and Difficulties Questionnaire; SDSC, Sleep Disturbance Scale for Children; SF-36, Short form (36) Health Survey; SHQ, Sleep Health Questionnaire; SMFQ, Moods and Feelings Questionnaire; SNS, Swiss Narcolepsy Scale; SOC, Stockings of Cambridge; SRBD, Sleep Related Breathing Disorders questionnaire; SSS, Stanford Sleepiness Scale; STAI, State-Trait Anxiety Index; TCI, Temperament and Character Inventory; WISC-R, Wechsler Intelligence Scale for Children, revised; WURS-K, Wender-Utah Rating Scale, short form.

SmithDLGozalDHunterSJKheirandish-GozalLFrequency of snoring, rather than apnea-hypopnea index, predicts both cognitive and behavioral problems in young childrenSleep Med20173417017828522088

 PubMed Web of Science ®Google Scholar

KimJYLeeCHKimH-MBehavioral consequences of children with sleep-disordered breathing after adenotonsillectomyWorld J Pediatr2018141576529464577

 PubMed Web of Science ®Google Scholar

WuJGuMChenSFactors related to pediatric obstructive sleep apnea-hypopnea syndrome in children with attention deficit hyperactivity disorder in different age groupsMedicine20179642e828129049225

 PubMed Web of Science ®Google Scholar

SmithDLGozalDHunterSJPhilbyMFKaylegianJKheirandish-GozalLImpact of sleep disordered breathing on behaviour among elementary school-aged children: a cross-sectional analysis of a large community-based sampleEur Respir J20164861631163927587553

 PubMed Web of Science ®Google Scholar

VillaMPSujanskaAVitelliOUse of the sleep clinical record in the follow-up of children with obstructive sleep apnea (OSA) after treatmentSleep Breath201620132132926564170

 PubMed Web of Science ®Google Scholar

ZhuJFangYChenXThe impacts of obstructive sleep apnea hypopnea syndrome severity and surgery intervention on psychological and behavioral abnormalities and postoperative recovery in pediatric patientsMed Sci Monit2014201474148025141885

 PubMed Web of Science ®Google Scholar

VitelliOTabarriniAMianoSImpact of obesity on cognitive outcome in children with sleep-disordered breathingSleep Med201516562563025862118

 PubMed Web of Science ®Google Scholar

OğuztürkÖEkiciMÇimenDEkiciASenturkEAttention deficit/hyperactivity disorder in adults with sleep apneaJ Clin Psychol Med Settings201320223423923179074

 PubMed Web of Science ®Google Scholar

PerfectMMArchboldKGoodwinJLLevine-DonnersteinDQuanSFRisk of behavioral and adaptive functioning difficulties in youth with previous and current sleep disordered breathingSleep201336451752523543901

 PubMed Web of Science ®Google Scholar

EkiciAEkiciMOğuztürkOKaraboğaIÇimenDSenturkEPersonality profiles in patients with obstructive sleep apneaSleep Breath201317130531022447173

 PubMed Web of Science ®Google Scholar

AmiriSAbdollahifakhimSLotfiABayazianGSohrabpourMHemmatjooTEffect of adenotonsillectomy on ADHD symptoms of children with adenotonsillar hypertrophy and sleep disordered breathingInt J Pediatr Otorhinolaryngol20157981213121726066853

 PubMed Web of Science ®Google Scholar

RoyMde ZwaanMTuinIPhilipsenABrählerEMüllerAAssociation between restless legs syndrome and adult ADHD in a German community-based sampleJ Atten Disord201822330030825555628

 PubMed Web of Science ®Google Scholar

UmYHJeongJHHongSCAssociation between sleep parameters and cognitive function in drug-naïve children with attention-deficit hyperactivity disorder: a polysomnographic studySleep Med20162116517026922621

 PubMed Web of Science ®Google Scholar

GhorayebIGamasAMazurieZMayoWAttention-deficit hyperactivity and obsessive-compulsive symptoms in adult patients with primary restless legs syndrome: different phenotypes of the same disease?Behav Sleep Med201732818

 Google Scholar

FerriRBruniONovelliLPicchiettiMAPicchiettiDLTime structure of leg movement activity during sleep in attention-deficit/hyperactivity disorder and effects of levodopaSleep Med201314435936623415543

 PubMed Web of Science ®Google Scholar

AkinciGOzturaIHizSSleep structure in children with attention-deficit/hyperactivity disorderJ Child Neurol201530111520152525713005

 PubMed Web of Science ®Google Scholar

GarbazzaCSauterCPaulJLeg movement activity during sleep in adults with attention-deficit/hyperactivity disorderFront Psychiatry2018917929780335

 PubMed Web of Science ®Google Scholar

BijlengaDvan SomerenEJGruberRBody temperature, activity and melatonin profiles in adults with attention-deficit/hyperactivity disorder and delayed sleep: a case-control studyJ Sleep Res201322660761623952346

 PubMed Web of Science ®Google Scholar

Durmus¸FBArmanARAyazABChronotype and its relationship with sleep disorders in children with attention deficit hyperactivity disorderChronobiol Int201734788689428574288

 PubMed Web of Science ®Google Scholar

SnitselaarMASmitsMGvan der HeijdenKBSmitASpijkerJInfluence of methylphenidate on circadian rhythmicity and sleep in adult attention-deficit/hyperactivity disorderSleep Biol Rhythms2013114282285

 Web of Science ®Google Scholar

BüberAÇakalozBIs¸ıldarYIncreased urinary 6-hydroxymelatoninsulfate levels in attention deficit hyperactivity disorder diagnosed children and adolescentNeurosci Lett201661719520026879834

 PubMed Web of Science ®Google Scholar

BronTIBijlengaDKooijJJAttention-deficit hyperactivity disorder symptoms add risk to circadian rhythm sleep problems in depression and anxietyJ Affect Disord2016200748127128360

 PubMed Web of Science ®Google Scholar

BumbJMMierDNoelteIAssociations of pineal volume, chronotype and symptom severity in adults with attention deficit hyperactivity disorder and healthy controlsEur Neuropsychopharmacol20162671119112627150337

 PubMed Web of Science ®Google Scholar

Molina-CarballoANaranjo-GómezAUberosJMethylphenidate effects on blood serotonin and melatonin levels may help to synchronise biological rhythms in children with ADHDJ Psychiatr Res201347337738323088865

 PubMed Web of Science ®Google Scholar

Vélez-GalarragaRGuillén-GrimaFCrespo-EguílazNSánchez-CarpinteroRPrevalence of sleep disorders and their relationship with core symptoms of inattention and hyperactivity in children with attention-deficit/hyperactivity disorderEur J Paediatr Neurol201620692593727461837

 PubMed Web of Science ®Google Scholar

YoonSYJainURShapiroCMSleep and daytime function in adults with attention-deficit/hyperactivity disorder: subtype differencesSleep Med201314764865523643650

 PubMed Web of Science ®Google Scholar

MoreauVRouleauNMorinCMSleep of children with attention deficit hyperactivity disorder: actigraphic and parental reportsBehav Sleep Med2014121698323473239

 PubMed Web of Science ®Google Scholar

CorkumPLingley-PottiePDavidsonFBetter nights/better days-distance intervention for insomnia in school-aged children with/without ADHD: a randomized controlled trialJ Pediatr Psychol201641670171327189687

 PubMed Web of Science ®Google Scholar

BrevikEJLundervoldAJHalmøyAPrevalence and clinical correlates of insomnia in adults with attention-deficit hyperactivity disorderActa Psychiatr Scand2017136222022728547881

 PubMed Web of Science ®Google Scholar

ItoWHondaMUenoTKatoNHypersomnia with ADHD: a possible subtype of narcolepsy type 2Sleep Biol Rhythms2018162205210

 Web of Science ®Google Scholar

LecendreuxMLavaultSLopezRAttention-deficit/hyperactivity disorder (ADHD) symptoms in pediatric narcolepsy: a cross-sectional studySleep20153881285129526118560

 PubMed Web of Science ®Google Scholar

FilardiMPizzaFTonettiLAntelmiENataleVPlazziGAttention impairments and ADHD symptoms in adult narcoleptic patients with and without hypocretin deficiencyPLoS One2017128e018208528763482

 PubMed Web of Science ®Google Scholar

RoccaFLFinottiEPizzaFPsychosocial profile and quality of life in children with type 1 narcolepsy: a case-control studySleep20163971389139827166243

 PubMed Web of Science ®Google Scholar

ZamarianLHöglBDelazerMSubjective deficits of attention, cognition and depression in patients with narcolepsySleep Med2015161455125434299

 PubMed Web of Science ®Google Scholar

MianoSEspositoMFoderaroGRamelliGPPezzoliVManconiMSleep-related disorders in children with attention-deficit hyperactivity disorder: preliminary results of a full sleep assessment studyCNS Neurosci Ther2016221190691427255788

 PubMed Web of Science ®Google Scholar

VogelSWNBijlengaDBenjaminsJSBeekmanATFKooijJJSvan SomerenEJWAttention deficit hyperactivity disorder symptom severity and sleep problems in adult participants of the Netherlands sleep registrySleep Med2017409410229221785

 PubMed Web of Science ®Google Scholar

HysingMLundervoldAJPosserudMBSivertsenBAssociation between sleep problems and symptoms of attention deficit hyperactivity disorder in adolescence: results from a large population-based studyBehav Sleep Med201614555056426503122

 PubMed Web of Science ®Google Scholar

GrünwaldJSchlarbAARelationship between subtypes and symptoms of ADHD, insomnia, and nightmares in connection with quality of life in childrenNeuropsychiatr Dis Treat2017132341235028919767

 PubMed Web of Science ®Google Scholar

BjorvatnBBrevikEJLundervoldAJAdults with attention deficit hyperactivity disorder report high symptom levels of troubled sleep, restless legs, and cataplexyFront Psychol201781621162128979226

 PubMed Web of Science ®Google Scholar

van der HeijdenKBStoffelsenRJPopmaASwaabHSleepSHSleep, chronotype, and sleep hygiene in children with attention-deficit/hyperactivity disorder, autism spectrum disorder, and controlsEur Child Adolesc Psychiatry20182719911128689312

 PubMed Web of Science ®Google Scholar