Child and Family Impacts of Sleep Problems in Children and Adolescents With ADHD

CHAPTER 7

Child and Family Impacts of Sleep Problems in Children and Adolescents With ADHD Nardia Jane Zendarski1 and Melissa Mulraney1,2 1

Centre for Community Child Health, Murdoch Children’s Research Institute, Parkville, VIC, Australia Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia

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7.1 INTRODUCTION Sleep problems affect many school-age children with attention deficit hyperactivity disorder (ADHD) and sleep problems impact negatively on a child’s daytime functioning, particularly in relation to their cognitive functioning, emotional control, and the impact on their families. Together, sleep and time spent at school comprise the majority of children’s lives and both are imperative for healthy development and learning. It is likely that sleep and school functioning are intertwined and that problems in either domain negatively impact upon the other. More than 50% of children with ADHD experience sleep problems, a rate that is much more common than in typically developing children (Cortese, Faraone, Konofal, & Lecendreux, 2009). One study of Australian school children aged 6 8 years found children with ADHD were three times more likely (Odds Ratio (OR): 3.1; 95% confidence interval (CI): 1.4, 6.8; p , .01) to have moderate/severe sleep problems when compared to children without ADHD (Sciberras et al., 2016). Sleep problems can differ in severity and can be both transient and persistent over time, with persistent problems likely to have greater impact on functional outcomes (Lycett, Sciberras, Hiscock, & Mensah, 2016). Evidence suggests that sleep is problematic for children with ADHD regardless of age, sex, or ADHD presentation (Fisher et al., 2014; Sciberras et al., 2016). Treating sleep problems in children with ADHD has been linked to a decrease in ADHD symptom severity and behavioral problems (Hiscock et al., 2015).

Sleep and ADHD DOI: https://doi.org/10.1016/B978-0-12-814180-9.00007-7

Copyright © 2019 Elsevier Inc. All rights reserved.

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Common sleep problems in children and adolescents with ADHD include short sleep duration, trouble falling asleep (i.e., increased sleep latency) and maintaining sleep, difficulty waking, and daytime sleepiness (Becker, Pfiffner, Stein, Burns, & McBurnett, 2016; Sung, Hiscock, Sciberras, & Efron, 2008). Specific sleep disorders including sleep disordered breathing such as obstructive sleep apnea and snoring, insomnias, and sleep-related movement disorders (e.g., periodic limb movement disorder) are also more prevalent in children with ADHD compared to children without ADHD (Cortese, Konofal, Yateman, Mouren, & Lecendreux, 2006). Although there is a growing body of research examining the prevalence and nature of sleep difficulties in children and adolescents with ADHD, far less research has documented how sleep difficulties impact daily functioning, particularly in adolescents (Lunsford-Avery, Krystal, & Kollins, 2016). Current evidence obtained from studying sleep in typically developing children indicates that persistent moderate to severe sleep problems in children and adolescents can lead to educational, emotional, social, and family difficulties (Beebe, 2011). How these problems interact and overlap to affect a child’s performance at school is still not well-understood (Kirov & Brand, 2014; Stein, Weiss, & Hlavaty, 2012). This chapter focuses on the impact of children’s sleep problems, daytime sleepiness, and sleep disorders on cognition (e.g., memory), academic achievement (e.g., grades), social emotional functioning (e.g., mental health), and on family functioning for children and adolescents with ADHD. Factors that are likely to mediate or moderate the relationship between sleep problems and daytime functioning are examined, as is the bidirectional nature of the association between sleep and functioning. In this relatively new area of research, we draw on the small number of studies that have examined such associations in school-age children and adolescents (students) with ADHD, and where appropriate findings from the broader student population are discussed.

7.2 OVERVIEW OF SLEEP, ADHD AND IMPACTS ON DAILY FUNCTIONING It is well-established that children with ADHD experience impairments in cognition (Willcutt, Doyle, Nigg, Faraone, & Pennington, 2005), poorer academic achievement (Loe & Feldman, 2007; Zendarski,

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Sciberras, Mensah, & Hiscock, 2017a), poorer social emotional functioning (Hoza, 2007), and that they live in families characterized by higher levels of dysfunction including increased parent mental health difficulties (Sung et al., 2008; Theule, Wiener, Tannock, & Jenkins, 2013). Research also demonstrates that these areas of functioning are affected by disruptions to sleep in general population studies (Owens & Weiss, 2017; Sadeh, 2007). Given the high prevalence of sleep problems in children with ADHD and the fact that sleep problems have generally been linked to poorer functioning for children, it is plausible that sleep problems are contributing to poorer child and family functioning in children with ADHD. The following sections present a review of current literature that examines the association between sleep and: (1) cognition, (2) academic achievement, (3) social emotional functioning, and (4) family functioning, for students (aged 5 18 years) with ADHD. It is important to note that the reviewed studies include different definitions of sleep problems as characterized by parent-report of sleep difficulties on rating scales or more objective assessments including actigraphy and polysomnography. Insufficient or poor quality sleep can result in increased daytime sleepiness and fatigue, which in turn can impact on daily functioning (Owens, 2009, 2014). Thus, the review makes note of the method by which sleep was defined and assessed, and also gives consideration to the association between functioning and daytime sleepiness parameters.

7.2.1 Cognition ADHD is characterized by impairing levels of inattention, hyperactivity, and/or impulsivity symptoms, which make aspects of school life harder for children including learning in the classroom (Faraone et al., 2015). Students with ADHD often have trouble paying attention, staying on task, being organized and behaving appropriately in the classroom (Langberg, Dvorsky, Marshall, & Evans, 2013). Underlying these behaviors is the child’s executive functioning skills, which include attention, planning, working memory, processing, vigilance, and the ability to shift between tasks. ADHD has been consistently associated with moderate deficits in executive functioning (Willcutt et al., 2005). Insufficient sleep can increase daytime sleepiness, impairing a student’s ability to concentrate and attend to school work; memory, and task processing speed

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may also decline (Frenda & Fenn, 2016). However, it remains uncertain if sleep problems have an independent and cumulative impact on cognition over and above the impact of ADHD (Kirov & Brand, 2014). In the general population, sleep restriction studies have provided strong evidence that sleep plays an important role in cognitive functioning and that even moderate deprivation of 1 hour can impact attention, memory, and emotional control (Lim & Dinges, 2010). Reduced sleep over short periods in children can increase irritability and moodiness, as well as off-task behavior (Baum et al., 2014; Beebe, Field, Milller, Miller, & LeBlond, 2017; Gruber, Cassoff, Frenette, Wiebe, & Carrier, 2012). Alertness and vigilance seem to be most consistently affected by sleep deprivation, particularly in relation to less complex tasks. A meta-analysis examining the effects of sleep deprivation across a range of cognitive tasks (simple attention, complex attention, working memory, processing speed, short-term memory, and reasoning) found simple attention tasks are more susceptible to the effects of sleep deprivation than more complex tasks (Lim & Dinges, 2010). The cognitive declines associated with sleep deprivation were able to be reversed when normal sleep patterns were resumed. Less is known about the effects of sleep deprivation on school-age children with ADHD. A sleep restriction study in a small sample of school-age children (mean age 5 8.7, SD 5 1.3; age range 7 11 years) with ADHD (n 5 11) and without ADHD (n 5 32) found restricted sleep was associated with poorer sustained attention in both groups and decreased accuracy (rates of errors of omission) in children with ADHD compared to their baseline scores (Gruber et al., 2011). These findings show that reduced sleep is likely to result in a cognitive decline for all children but may be associated with a bigger decline in functioning for children with ADHD. Night-time sleep problems including insufficient and poor quality sleep have been linked to poorer cognitive functioning in school-age children in the broader population, including poor working memory (Steenari et al., 2003), reduced processing speed and inattention (Araújo & Almondes, 2014; Astill, Van der Heijden, Van Ijzendoorn, & Van Someren, 2012). However, only a small number of cross-sectional studies have examined the relation between sleep problems and aspects of cognitive functioning in school-age children with ADHD with mixed findings. For example, working memory deficits, as measured by a simple

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backwards digit span test, were associated with child reported total sleep problems in 5 13-year-old children with ADHD (N 5 189) (Sciberras, DePetro, Mensah, & Hiscock, 2015). In a clinical study of 37 male children with ADHD (age range 7 12 years), fragmented sleep and wake after sleep onset, evaluated by actigraphy, were associated with aspects of selective attention including greater error rates and lower response speeds (Lee et al., 2014). In contrast, a study in younger children (N 5 64; mean age 5.52; age range 4 7 years), with and without ADHD, found group differences in cognitive performance was best explained by symptoms of inattention. The authors concluded that ADHD symptoms rather than sleep may be the strongest contributor to problems with executive functioning (Schneider, Lam, & Mahone, 2016). A study comparing the performance of students aged 7 18 years with ADHD and no sleep problems (n 5 52), sleep problems only (n 5 36), and both sleep problems and ADHD (n 5 32) across a range of cognitive tests found that students with ADHD and sleep problems (defined by self-report of sleep problems) exhibited a distinct cognitive profile in comparison to the other two groups (Sawyer et al., 2009). Children with both ADHD and sleep problems were likely to have more difficulty maintaining concentration and focus on learning tasks in comparison to children with either sleep problems or ADHD only as these students were more easily distracted by external stimuli in comparison to the other groups. There was no evidence that sleep problems provided a cumulative effect on cognitive deficits associated with ADHD on inattention, impulsivity, working memory or processing speed. While these cross-sectional studies provide some insights into the relationship between sleep problems and cognition, it remains relatively unclear the extent to which sleep problems in school children with ADHD impact cognitive functions that are involved in every day learning over and above the impaired functioning that may result from ADHD alone. In addition, the large number of methodological differences between studies (e.g., actigraphy vs parent-reported sleep problems) make it difficult to consolidate results and to be conclusive about findings. However, they help to shape future research (Kirov & Brand, 2014) (see Chapter 14). Sleep also plays an important role in the integration and consolidation of memories including consolidation of new learning and information

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into stable long-term memories both declarative (knowledge and information) and procedural (skills) (Ashworth, Hill, Karmiloff-Smith, & Dimitriou, 2014). Disrupted and shortened sleep may impact on these important functions and there is preliminary evidence that there may be differences in the memory consolidation process between children with and without ADHD (see Chapter 11).

7.2.2 Academic Achievement Prior research indicates that most children with ADHD do worse on all indicators of academic achievement in comparison to non-ADHD peers. Academic achievement (or performance) is measured across a range of indicators including academic tests and teacher grades, grade point average (GPA) and parent and self-ratings of academic skills and competencies in academic domains (e.g., numeracy and literacy) (Langberg et al., 2013; Loe & Feldman, 2007; Zendarski et al., 2017a). Achievement at school may also be assessed on a range of non-academic outcomes including student behavior and student engagement. Indicators may include a student’s feelings of belonging and connectedness with school, as well as indicators such as absenteeism, lateness, and rates of suspension (Loe & Feldman, 2007; Zendarski, Sciberras, Mensah, & Hiscock, 2017b). While it is unequivocal that ADHD has a negative impact on academic achievement, somewhat less is known about the possible additional impact of sleep problems. In this section, the impact of broad sleep problems and daytime sleepiness are examined in relation to academic achievement in students with ADHD. Sleep restriction studies have demonstrated that inadequate sleep can impact on behavior and classroom functioning in typical student groups (Beebe, 2011). Sleep-deprived students look and feel sleepier during the day and fall asleep more easily than students not deprived of sleep. As discussed, there is some evidence that shortened sleep may compromise cognitive functioning by impeding alertness, attention, memory, and reasoning. More complex tasks such as planning and decision-making may be less sensitive to sleep deprivation (Alhola & Polo-Kantola, 2007; Beebe, 2011). For example, in one experimental study, 87 healthy adolescents (aged 10.0 16.9 years) underwent a 3-week sleep manipulation protocol using a cross-over randomized design (Beebe et al., 2017). Participants were randomized to either shortened sleep (6.5 hours in bed)

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or healthy sleep (10 hours in bed) across two 5-night periods. Classroom achievement tasks were measured in a simulated classroom each morning. On average, participants in the shortened sleep group slept 6.5 hours and those in the healthy sleep group slept 9.1 hours. Adolescents reported being sleepier and less attentive during the day when sleep was restricted and had lower scores on classroom tests in comparison to when they obtained healthy sleep, although effect sizes were modest (Beebe et al., 2017). Sleep restriction studies with academic function as an outcome, are yet to be replicated in ADHD samples and it remains unknown if shortened sleep induces significant daytime sleepiness and impaired classroom performance in students with ADHD. It is also not clear whether these findings in artificial classroom settings would be replicated in real life. While findings regarding the impact of sleep on academic achievement in the general student population have been mixed, a metaanalysis of 86 studies reported a weak positive relationship between sleep duration and academic achievement (r 5 .09, CI 0.06, 0.12) in typical school students aged 5 12 years (Astill et al., 2012). There is a paucity of research that explicitly examines the relationship between sleep and academic performance for children and adolescents with ADHD. The two studies in students with ADHD did not find evidence of a relationship between sleep duration and academic outcomes for adolescents with ADHD when taking into account ADHD symptoms (Langberg et al., 2013; Zendarski et al., 2017a). Langberg, Dvorsky, Becker, and Molitor (2014) investigated the relationship between academic achievement and sleep in 100 middle school students with ADHD (mean age 11.9 years). Results showed self-reported sleep duration was not significantly associated with academic outcomes including student GPA, homework problems or teacher-reported academic competency. Similarly, another recent study examining the academic achievement of 130 high school students (mean age 13.7 years) found no significant association between parent-reported sleep problems (none/mild versus moderate/severe) and standardized tests of literacy and numeracy (Zendarski et al., 2017a). Current research suggests that sleep may not be a strong contributor to academic difficulties experienced by students with ADHD, most likely because ADHD itself, as well as IQ and comorbid learning difficulties, are strongly associated with academic achievement (Loe & Feldman, 2007).

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Studies in the general student population suggest that daytime sleepiness may be a stronger predictor of academic achievement than sleep duration or quality (Dewald, Meijer, Oort, Kerkhof, & Bogels, 2010). Similarly, daytime sleepiness, unlike night-time sleep problems, has been associated with reduced academic achievement in middle school students with ADHD, including lower teacher-rated academic competence and homework completion (Langberg et al., 2013). Langberg et al. (2014) also examined the relationship between self-reported daytime sleepiness in college students with ADHD and academic performance 12 months later. Daytime sleepiness predicted failing grades, school adjustment problems and overall functional impairment, and consistent with previous findings, there was no association with GPA (Langberg et al., 2014). In younger children, the relationship between daytime sleepiness and academic achievement has been largely unexplored. It is likely that sleep also impacts on broader school functioning, which in turn influences academic success. For example, a caring and supportive relationship with a teacher can enhance student engagement and academic motivation (Sherman, Rasmussen, & Baydala, 2008), but increased behavioral problems and moodiness as a result of sleep problems and tiredness may jeopardize this. A recent study investigating the student teacher relationship for students with ADHD found that sleep problems were associated with more student teacher conflict, in particular, daytime sleepiness was associated with lower reported closeness between the student and teacher (Holdaway & Becker, 2018). A study of student engagement in 130 students in early adolescence with a diagnosis of ADHD found no evidence of a relationship between sleep problems and student attitudes to school (cognitive and emotional) or suspension rates (behavioral) (Zendarski et al., 2017b). However, this study did not measure daytime sleepiness and it may be that daytime sleepiness is a better indicator of school functioning than problems initiating and maintaining night-time sleep. For example, daytime sleepiness as rated by teachers has been associated with poorer teacher-reported emotional and behavioral functioning in primary schoolage students (n 5 257; age range 5 13 years) with ADHD (Lucas, Mulraney, & Sciberras, 2017). Lucas et al. (2017) found that daytime sleepiness, but not parent-reported sleep problems, was associated with classroom functioning difficulties.

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7.2.3 Social Emotional Functioning In this section, we consider the relationship between sleep and social emotional functioning in children with ADHD. The term “social emotional” functioning is purposefully broad and includes dimensional measures of social and emotional functioning (e.g., internalizing and externalizing symptoms), as well categorical measures including the presence or absence of a diagnostic disorder. The term is also used to capture general well-being including quality of life. It is well-recognized that sleep is central to healthy social emotional functioning and wellbeing in children. Sleep problems may contribute to the development of anxiety, depression, or externalizing behavioral problems (Alfano & Gamble, 2009; Kamphuis, Meerlo, Koolhaas, & Lancel, 2012), poor emotional control, problems with daily functioning and reduced quality of life (Kahn, Sheppes, & Sadeh, 2013; Sung et al., 2008). Sleep restriction studies show that there is a range of psychological consequences related to not getting enough sleep including increased internalizing and externalizing problems, as well as decreasing the ability of children to adapt and respond appropriately to challenging contexts. One study (Baum et al., 2014) examined the impact of sleep on mood in a sample of adolescents (N 5 40, age range 14 17 years). Adolescents were randomized to either a restricted sleep (6.5 hours in bed) or healthy sleep duration (10 hours in bed per night) over a school week (5 nights). Both parents and adolescents in the restricted sleep group reported more oppositional/irritable symptoms, as well as poorer emotional control in comparison to participants in the healthy sleep group. Many children with ADHD already have a range of comorbid behavioral difficulties including oppositional and defiant behavior and aggression, are more irritable and have poorer self-regulation and emotional control in comparison to same-aged children. Comorbid conditions are common ( . 60%) including both internalizing (i.e., anxiety and depression) and externalizing disorders (i.e., oppositional defiant disorder and conduct disorder), as well as other comorbidities including Autism Spectrum Disorders, learning disorders and sluggish cognitive tempo (Becker et al., 2016; Smalley et al., 2007; Spencer, 2006). Importantly, the specific type of comorbid issue may have different associations with various sleep problems. Becker, Cusick, Sidol, Epstein, and Tamm (2018) recently examined how anxiety, depressive, oppositional, inattentive, and hyperactive symptoms were differentially associated with

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a number of sleep problems in children with ADHD (n 5 181; age range 7 13 years). Anxiety was uniquely associated with greater bedtime resistance and sleep anxiety, depressive symptoms were associated with increased daytime sleepiness, both depressive and oppositional symptoms were associated with shorter sleep duration, and hyperactive symptoms were associated with increased night wakings and parasomnias. Only depressive symptoms were independently associated with total sleep problems. This highlights an important limitation in the field; the majority of studies have used an overall measure of sleep problems rather than examining whether specific sleep domains are associated with child functioning. A number of studies have examined the link between sleep problems and co-occurring internalizing and externalizing comorbidities in children with ADHD (Accardo et al., 2012; Becker, Langberg, & Evans, 2015b; Becker et al., 2016; Gregory & Sadeh, 2012; Lycett, Sciberras, Mensah, & Hiscock, 2015). Lycett et al. (2015) found that children with ADHD and either externalizing or internalizing comorbidities are twice as likely to experience moderate to severe sleep problems in comparison to children without these difficulties, and children with both comorbid conditions are three times as likely to experience sleep problems. However, specific internalizing and externalizing comorbidities have been inconsistently linked with sleep problems. For example, anxiety has been linked to increased sleep problems in children with ADHD (Accardo et al., 2012), while in another study sleep problems did not prospectively predict increases in anxiety (Becker et al., 2015b) in children with ADHD. In a sample of young adolescents (ages 10 14 years) diagnosed with ADHD, parent-reported sleep problems were associated with increases in depressive symptoms and externalizing symptoms 1 year later, even after accounting for baseline symptoms (Becker et al., 2015b). In a subsequent study examining sleep problems in relation to comorbidity in children (6 11 years) with ADHD inattentive presentation (ADHD-I), comorbid anxiety but not oppositional behavior or depression was associated with sleep problems (Becker et al., 2016). Most of the research investigating the association between sleep problems and externalizing or internalizing comorbidities in children with ADHD is cross-sectional or only investigates sleep problems over a relatively short period of time (i.e., 12 months). This limits our ability to draw conclusions about the causal pathways, direction of relationships and

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our understanding of the developmental course of sleep problems from childhood to adolescence in children with ADHD. It likely that the relationships are multifaceted and bidirectional and may be related in some part to overlapping neurodevelopmental processes (Dorris, Scott, Zuberi, Gibson, & Espie, 2008; Kahn et al., 2013; Moreau, Rouleau, & Morin, 2014). Two recent studies have sought to examine the bidirectional relationship between sleep and internalizing and externalizing symptoms in school-age children. One in typically developing children (Quach, Nguyen, Williams, & Sciberras, 2017) and the other in a clinical sample of school children diagnosed with ADHD (Mulraney, Giallo, Lycett, Mensah, & Sciberras, 2016). In both these studies, behavioral outcomes were measured on subscales of the Strengths and Difficulties Questionnaire (SDQ), a well-validated screening measure for child and adolescent problem behaviors (Goodman, 2001). Both studies examined internalizing (i.e., emotional problems) and externalizing symptoms (i.e., conduct problems) on SDQ subscales. Understanding the nature of these interrelationships is important to help determine when to intervene and what areas to target. Quach et al. (2017) examined sleep and behavioral problems in a nationally representative sample of Australian children (N 5 4983; 79% retention) followed biennially from kindergarten (4 5 years) to early adolescence (12 13 years). Sleep problems in early childhood predicted later behavioral problems on both internalizing and externalizing dimensions and externalizing, but not internalizing, symptoms predicted later sleep problems. Findings suggest that treating sleep problems in the early school years may decrease later internalizing and externalizing problems, and interventions focused on decreasing externalizing symptoms will likely improve sleep. Mulraney et al. (2016) examined this same bidirectional relationship in school-age children aged 5 13 years with ADHD (N 5 270) across 3-time points over a 12-month period. There was a reciprocal, though weak, relationship between sleep problems and internalizing symptoms, and no evidence of a reciprocal relationship between externalizing symptoms and sleep problems. It is likely that the inconsistent findings are related to different methodology. Mulraney et al. only followed their ADHD sample for 12 months. Further, Quach et al. examined a large nationally representative sample of children whilst Mulraney et al. followed a clinical sample of children with ADHD.

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Irritable behavior including anger and temper outbursts (irritability) is commonly seen in children and adolescents with ADHD in comparison to typically developing children, and irritability is a risk factor for depression in later adolescence (Ivanenko & Johnson, 2008). Parent-reported irritability in a group of teens with ADHD (n 5 140; mean age 5 13.8, SD 5 1.2; 89% boys) has been associated with sleep problems, as well as poorer emotional and behavioral functioning in early adolescence (Mulraney, Zendarski, Mensah, Hiscock, & Sciberras, 2017). A longitudinal study examining the relation between behavioral sleep problems across 4-time points from birth to 7 years and irritability in children (8 9 years) with ADHD (n 5 112) found sleep problems were associated with increased regulation difficulties (Williams & Sciberras, 2016). Interestingly, this study also found evidence of bidirectional relations between sleep problems and self-regulation over this period. In general, persistent irritable mood, as well as disrupted sleep in adolescents increases the risk of developing a mood disorder. Extreme irritability, anger and frequent temper outbursts in childhood are now classified as disruptive mood dysregulation disorder (DMDD) under the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) (American Psychiatric Association, 2013). Sleep deprivation has been associated with lower regulatory control, however, the extent to which sleep deprivation impacts children that already have impaired emotional regulation has received little attention. Sleep problems are more common in children with DMDD but do not seem to independently contribute to DMDD symptoms to the same extent as behavioral problems (e.g., oppositional behavior) (Waxmonsky et al., 2017). Becker, Langberg, and Byars (2015a) proposed that sleep problems, anxiety, depression, and poor emotional regulation have cascading effects on each other. In children and adolescents with ADHD where these problems are pervasive, experts hypothesize that there is a complex interconnection between these processes that is only beginning to be understood. A few studies have examined the association between sleep problems in children with ADHD and child wellbeing, including child quality of life (Lycett et al., 2016; Sung et al., 2008; Yürümez & Kılıç, 2013). For example, Sung et al. (2008) found daily sleep problems in children with ADHD were associated with poor child daily functioning and school attendance. Further, Lycett et al. (2016) found transient or persistent parent-reported sleep problems in children (5 13 years) with ADHD,

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over a 12-month period, were associated with a lower child quality of life. In contrast, in a small sample of children with ADHD (n 5 46) there was no difference in parent-reported quality of life between children with ADHD with and without parent-reported sleep problems (Yürümez & Kılıç, 2013). Child reported quality of life, however, was poorer in children with sleep problems than in children without sleep problems, highlighting the importance of collecting information from multiple informants.

7.2.4 Family Functioning Family environments play a pivotal role in child development and family plays an important role in shaping young people’s behaviors, beliefs, and values. In relation to sleep, parent attitudes toward sleep and sleep behaviors, as well as attitudes towards child sleep are likely to influence child sleep habits (Meltzer & Montgomery-Downs, 2011). The reverse is also true, where child sleep problems can impact on parent depression, family function and marital conflict (El-Sheikh, Buckhalt, Mize, & Acebo, 2006). Family socioeconomic disadvantage has also been associated with increased sleep problems in school-age children. A recent review examining the interconnection between child sleep and aspects of family functioning in community samples of children found children’s sleep problems can disrupt family functioning and parent sleep leading to increased parent stress, higher marital conflict and less family cohesion. Sleep is not only a predictor of poor family functioning, but poor family functioning may also have reciprocal effects on child sleep habits (El-Sheikh & Kelly, 2017). Parenting a child with ADHD is often associated with more parenting stress in comparison to parenting typically developing children (Craig et al., 2016). Parenting stress has been associated with ADHD symptom severity, parenting children with more challenging behaviors, and higher parental conflict (Theule et al., 2013). Parenting children with sleep problems may also contribute to increased parent stress (Meltzer & Montgomery-Downs, 2011), and this finding has been replicated for children with ADHD (Sung et al., 2008). Sung et al. (2008) highlighted for the first time that sleep problems in children with ADHD (mean age 11.7, age range 5 18 years) were associated with poor family outcomes in comparison to children with ADHD and no sleep problems. Poorer

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caregiver mental health and work attendance and poorer family quality of life were observed in families of children with moderate to severe behavioral sleep problems. Similarly, Lycett et al. (2016) found both transient and persistent sleep problems in children with ADHD were associated with poorer family quality of life and reduced family wellbeing including poorer parent mental health and increased primary-caregiver work difficulties (i.e., arriving late). Overall, these findings suggest that moderate to severe sleep problems in children with ADHD can increase caregiver burden and reduce quality of life for families of children with ADHD. Parenting also plays a key role in shaping a child’s sleep habits (El-Sheikh & Kelly, 2017). In a sample of school-age children with ADHD (n 5 361), consistent parenting and good sleep hygiene have been associated with fewer behavioral sleep problems (Sciberras, Song, Mulraney, Schuster, & Hiscock, 2017). Specifically, this study found consistent parenting was associated with decreased bedtime resistance and sleep anxiety, while poor sleep hygiene was associated with increased bedtime resistance, shorter sleep duration, and daytime sleepiness. Establishing consistent bedtime routines may help prevent child sleep difficulties especially relating to bedtime resistance (Noble, O’Laughlin, & Brubaker, 2011). In addition, parental monitoring and rules (i.e., established bedtimes) have been associated with lower adolescent psychological distress and greater sleep efficiency in typically developing adolescents, suggesting good family functioning may play a protective role in regard to adolescent sleep (Bernert, Merrill, Braithwaite, Van Orden, & Joiner, 2007). Poor family supervision and monitoring during early adolescence in students with ADHD have also been associated with lower student engagement (Zendarski et al., 2017b) and poor reading achievement in Australian high school students with ADHD (Zendarski et al., 2017a). Evidence suggests that because ADHD tends to cluster in families (genetic link), children with ADHD are more likely to have parents who also exhibit symptoms such as disorganization and inattentiveness. This likely influences parenting practices and family functioning and consequently impacts upon the family’s ability to set consistent limits around sleep. For example, there is a relationship between high levels of ADHD symptoms in mothers and poor parenting behaviors including less involved parenting, lower positive parenting, and inconsistent use of discipline (Chronis-Tuscano et al., 2011).

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7.3 CONCLUSIONS AND FUTURE DIRECTIONS In recent years, we have made significant advances in our understanding of how sleep problems impact on the functioning of children with ADHD. It is clear that sleep problems are associated with poorer child quality of life and family functioning and likely contribute to the development and maintenance of social emotional difficulties. However, there is still much that we do not know and a number of key methodological limitations across the literature make it difficult to draw firm conclusions. The majority of research in this area has been cross-sectional, making directionality and causal contributions unknown. It is highly likely that a number of the factors discussed in this chapter interact with each other. For example, Lunsford-Avery et al. (2016) posit that the association between sleep and cognition may be bidirectional whereby poor sleep impacts on cognition through its impact on brain plasticity, and neurocognitive deficits may lead to poor sleep habits due to increasing environmental demands restricting sleep (e.g., more time required to complete homework). Research that has examined how sleep and functioning interact over time has typically focused on one or two factors such as the bidirectional associations between sleep problems and internalizing/externalizing symptoms (Mulraney et al., 2016; Quach et al., 2017). It will be important for future research to adopt a biopsychosocial framework to examine how biological, psychosocial, and contextual factors interact across development to influence both sleep and functioning in children with ADHD. Preliminary evidence suggests that aspects of functioning may be differentially associated with particular types of sleep problems (e.g., hyperactive symptoms with parasomnias, anxiety with bedtime resistance) (Becker et al., 2018). Yet, most research in this area has examined the relation between sleep duration or a general measure of sleep problems and functioning. A key area for future research is to investigate in depth the relation between different aspects of sleep problems and functioning, of particular interest, would be how daytime sleepiness is related to cognitive and academic functioning. A number of key factors have not been considered in the literature to date. Girls with ADHD experience more sleep problems than boys (Becker et al., 2018). However, many studies have only included boys, and those that do include girls typically have small numbers of girls and

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have not examined if sex moderates the relations between sleep and functioning. The role medication plays in the association between sleep problems and functioning is largely unknown. Given that the mainstay of ADHD treatment is stimulant medication, it may be that medication somewhat ameliorates the impact of sleep problems, particularly at school. Sleep is critical to healthy child development, emotional and cognitive functioning and is often compromised in children and adolescents with ADHD. It is encouraging that there has recently been substantial interest in examining the impact of sleep on functioning in school-aged children with ADHD. Nevertheless, our understanding of how sleep impacts functioning in students with ADHD remains very limited. There is a need for longitudinal studies that cover childhood and adolescence and use a multimethod design to examine the emergence and consequences of sleep problems. Monitoring and treating sleep problems in school-age children with ADHD across their school lives is important and is likely to improve child and family outcomes (see Chapter 9). Research addressing the key knowledge gaps and methodological limitations identified in this chapter will be important for informing prevention and intervention efforts best-suited to address sleep in students with ADHD.

CONFLICT OF INTEREST All authors report no conflict of interest in relation to this manuscript.

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