Original Article ISSN: 1110-5925

Sleep Characteristics in Egyptian Children with Attention Deficit-Hyperactivity

Disorder

Mohammed Abd El-Hay, Adel Badawy and Hosam El Sawy

Assistant Professor of Neuropsychiatry, Faculty of Medicine, Tanta University

ABSTRACT
Introduction: Sleep problems have been clinically reported in an estimated 25% to 50% of children and adolescents
with attention deficit hyperactive disorder (ADHD).
Aim of the Study: To assess subjective and objective sleep disturbances in an Egyptian sample of children who have
ADHD.
Subjects and Methods: Twenty five medication-free children with a clinical diagnosis of ADHD (21 boys and 4 girls; age
range 5-12 years) were compared with 20 healthy matched controls. All 25 children with ADHD and
controls underwent a semi-structured psychiatric interview (Kiddie-SADS) and a behavior assessment
by Conners Teacher Rating Scale (CTRS), Conner’s Parents Rating Scale (CPRS) and Swanson,
Nolan and Pelham Rating Scale (SNAP-IV). The demographic, clinical and psychiatric information
of all children were collected from the histories reported by the parents. Patients and control were
administered a sleep questionnaire before undergoing nocturnal video-polysemnography (PSG).
Results: Parents reported a wide range of frequently occurring sleep disturbances in their children. Objective
sleep measures revealed increase of rapid eye movement (REM) sleep latency and a decrease of
REM sleep percentage and decreased duration of sleep in children diagnosed with ADHD (p<0.01).
No significant correlations between objective sleep measures and clinical symptoms were found.
Conclusion: ADHD is associated with specific sleep alterations. These results stress the need for clinicians to
routinely screen for the presence of sleep disorders and found to future evidence-based guidelines
on the management of sleep disturbances in children with ADHD.

Key words: Sleep, polysemnography, attention deficit hyperactive disorder, hyperkinetic child.
Current Psychiatry; Vol. 17, No. 3, 2010: 1-6

INTRODUCTION

Attention deficit/hyperactivity disorder (ADHD) is one Studies assessing subjective sleep disturbances consistently
of the most prevalent conditions in child psychiatry, revealed more problems with falling asleep along with
estimated to affect 3% - 5% of school-aged children1,2. longer sleep latencies, more bedtime strug­gles, nocturnal
ADHD is characterized by a persistent pattern of inattention, awakenings, restless sleep, daytime sleepiness and a higher
hyperactivity-impulsivity, or both. Onset before the age rate of enuresis compared to control children with­out ADHD,
of 7 and impaired functioning in two or more settings are indicating an approximately 5 fold increase in the rate of
essential for the diagnosis3. Symptoms of ADHD may persist sleep problems in children with ADHD6,8.
into adulthood in about two thirds of patients4,5.
Polysomnographic (PSG) studies looking at measures of
Sleep disruption has been reported in patients with ADHD, sleep architecture have failed to find consistently significant
it is present in about 25% - 50% of children and adolescents differences between children with ADHD and controls9.
with ADHD. Rest­less and disturbed sleep was initially Some studies found no differences in PSG measures between
included in the DSM di­agnostic criteria for ADHD, but was children with ADHD and controls10, whereas other studies
later excluded as being a nonspecific symptom6. However, have yielded varied and often contradictory findings, such as
the links between sleep disturbances and ADHD have been a signifi­cant decreases in REM sleep7,11, significant increases
topic of ongoing research and clinical inter­est, because sleep in REM sleep12 and significant decrease in REM latency13 in
difficulties in children with ADHD present a considerable ADHD children versus controls. Also, other investigations
challenge for parents and for clinicians and may increase of objective sleep parameters have quite consistently shown
daytime ADHD symptoms7. reduced REM sleep, more nocturnal movements, increased
frequency of periodic limb movements (PLMS) and PLMS-

Personal non-commercial use only. Current Psychiatry Copyright © 2010. All rights reserved.
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Current Psychiatry
Vol. 17, No. 3, July. 2010

associated arousal as well as elevated daytime somnolence in Subjective sleep assessment: All children and their parents
children with ADHD when compared to controls10,13. underwent a detailed structured interview about their sleep
habits and sleep related symptoms. The children’s sleep
THE AIM OF THE STUDY habits questionnaire (CSHQ)18 was used for assessment of
sleep characters of the studied population. It included the
Was to assess subjective and objective sleep disturbances in following categories:-
an Egyptian sample of children with ADHD.
1. Bed time resistance (goes to bed at same time, falls
SUBJECTS AND METHODS asleep in own bed, falls asleep in other’s bed, needs
parent in room to sleep, struggles at bedtime and afraid
Thirty The present study was carried out at Neuropsychiatry of sleeping alone).
Department, Tanta University Hospital and the
Neuropsychiatry and Neurosurgery center of Tanta University, 2. Sleep onset delay (Falls asleep in 20 minutes).
Egypt from June 2007 to February 2009. The patients group
included 25 children (21 males and 4 females) with ADHD 3. Sleep duration (sleeps too little, sleeps the right amount,
(diagnosed according to DSM-IV (American Psychiatric sleeps same amount each day).
Association 2000)); all of them were non-medicated; their
mean age was 9.08±2.04 years. The control group included 4. Sleep anxiety (needs parent in room to sleep, afraid of
20 healthy children (18 males and 2 females) and their mean sleeping in the dark, afraid of sleeping alone, trouble
age was 10 ±1.62 years. sleeping away).

Both groups were matched as regards age and sex (Table 3), 5. Night waking (moves to other’s bed in night, awakes
with no significant difference between the 2 group as regards once during night and awakes more than once).
both age and sex (p>0.05). The study was explained to the
children and their parents and written consents were obtained 6. Parasomnias (include the following items: wets the
from parents of those children. bed at night, talks during sleep, restless and moves a
lot, sleepwalks, grinds teeth during sleep, awakens
Exclusion criteria for both groups included primary sleep screaming, sweating, alarmed by scary dream).
disorders (e.g. obstructive sleep apnea, restless leg syndrome),
other major psychiatric disorders (e.g. depression, bipolar 7. Sleep disordered breathing (snores loudly, stops
disorders, schizophrenia, or anxiety disorders, substance breathing, snorts and gasps) and day time sleepiness.
abuse disorders), axis II diagnosis (mental subnormality),
pervasive developmental disorders, use of psychotropic Polysomnographic study: All children were recorded
medication or any drugs that can affect CNS one month during nocturnal sleep for a minimum of one night by means
before the start of the study. of video-PSG.

Patients with ADHD were subjected to clinical assessment Basic polygraphic parameters for clinical polysomnographic
of their ADHD symptoms by using a semi-structured evaluation were obtained. Polysomnography encompassed
psychiatric interview (Kiddie-SADS)14,15 and a behavioral EEG (C3-A2, C4-A1), horizontal and vertical eye movements,
assessment by Conners Teacher Rating Scale (CTRS), submental and leg electromyogram (left and right anterior
Conners Parents Rating Scale (CPRS)16 and Swanson, Nolan tibial muscles) and electrocardiogram. Respiration (oral and
and Pelham Rating Scale (SNAP-IV)17. Conners Rating nasal air flow, thoracoabdominal respiratory movements and
Scales (CPRS and CTRS) were completed as the first stage oxygen saturation) was recorded. All sleep recordings were
of the initial assessment by parents and teachers. On the scored in 30-sec epochs, according to Rechtschaffen and
basis of the informant’s descriptions, the interviewer rated Kales criteria19.
the frequency and severity of the child’s behaviors on 4 point
scales (0–3). Parents were subsequently asked to rate child Nine polysomnographic parameters were included in our
behavior using the SNAP-IV Rating Scales (short form)17. analysis; sleep-onset latency (time in minutes from getting
The SNAP-IV provides measures on 3 separate subscales: into bed to polysomnoghraphically defined sleep onset),
total sleep duration (time in minutes from sleep onset to
1. Inattention (time spent on a single activity). final morning awakening of all epochs scored as sleep, i.e.,
2. Activity Level (rating of restlessness, fidgetiness and excluding total duration of all epochs scored as wake), sleep
activity level in structured situations such as meals and efficiency (total sleep time/time in bed×100), REM latency
car trips). in minutes (time between sleep onset and first epoch of REM
3. Defiance/antisocial behavior (items concerning temper sleep), REM percentage, percentage of stage 1, percentage
tantrums, lying, stealing, defiance, disobedience, truancy of stage 2, percentage of slow-wave sleep (SWS) and the
and destructiveness). The results of clinical evaluation and apnea-hypopnea index (it is calculated by dividing the
the scores of the used scales were presented in table (1). number of apneas and hypopneas by the number of hours
of sleep).

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 Sleep Characteristics in Egyptian Children with Attention Deficit-Hyperactivity Disorder
Mohammed Abd El-Hay et al.

Statistical Analysis: Table 2: Subjective sleep variables of the studied groups .

ADHD Control
The collected data was statistically analyzed using Minitab group group
15 software statistical computer package. The mean and Number (%) Number (%)
standard deviation was used for presentation of quantitative
1. Bedtime Resistance 6 (24%) 5 (25%) 0.9
data. The student (t) test was used for comparison between
2 means. For qualitative data the number and percent 2. Sleep Onset Delay 10 (40%) 2 (10%) 0.02*
distribution was calculated and Chi square and Fisher exact 3. Sleep Duration
12 (48%) 1 (5%) 0.002*
tests were used for comparison between studied groups. The Sleeps too little
5% level of significance was adopted for interpretation of 4. Sleep Anxiety 1 (4%) 1(5%)
tests of significance.
5. Night Waking 3 (12%) - 0.11
RESULTS 6. Parasomnias
0.22
Wets the bed at night 6 (24%) 2 (10%)
The demographic data and clinical characteristics of the ADHD
Talks during sleep 8 (32%) 2 (10%) 0.8
patients were presented in table (1). According to DSM-IV,
clinical types of studied ADHD patients were hyperactive/ Restless and moves a lot
impulsive type (68%), mixed inattention and hyperactive/ 15(60%) 3 (15%) 0.002*
Sleepwalks
impulsive (20%) and 12% with only inattention.
Grinds teeth during
11 (44%) 3 (15%) 0.03*
sleep
Table 1: Demographic and clinical data of the studied ADHD Awakens screaming,
patients. sweating and alarmed 7(28%) 6 (30%) 0.7
by scary dream
Age (Mean ± SD) 9.08±2.04
7. Sleep Disordered
- -
Sex (Males/Females) 21/4 Breathing

8. Daytime Sleepiness - 1 (5%)

DSM-IV ADHD subtype n (%)
1- Hyperactive/impulsive 17 (68%) Total number of persons
15 (60%) 6 (30%) 0.04*
2- Inattentive 3 (12%) with sleep complaints
3- Mixed 5 (20%)
Polysomnographic results:
Conners parents rating scale 47.68±8.75

Conners teachers rating scale 43.36±9.23 ADHD children show significantly longer sleep onset latency,
decreased sleep duration and efficiency than control group.
SNAP-inattention 2.08±0.620 Also, they had significantly decreased percentage of REM
sleep and longer REM latency than the normal children. There
SNAP-hyperactivity-combined 1.63±0.64
was no significant difference between the 2 groups as regards
SNAP-oppositional 1.640± 0.68 other polysomnographic parameters. No significant correlations
between objective sleep measures and clinical symptoms were
Subjective evaluation of sleep revealed that all children with found (table 3).
ADHD had more frequently abnormal sleep parameters
(Table 2). Sixty percent of the ADHD patients had one or The ADHD patients had longer sleep latency (27.88±6.64min.)
more sleep complaints, while 30% of the control group had Than the control group and the difference between the 2 groups
sleep complaints and the difference between the 2 groups was was statistically significant (p=0.03). They had significantly
significant (p=0.04). Parents of ADHD patients significantly (p=0.04) shorter duration of the total sleep time (459.3±98.9
reported that their children had a delay in sleep onset and min.) Than control group (508±55.8).
time to go to bed (40%) and this was present in only 10% of
the control group, the difference between the 2 groups was The ADHD patients had a longer REM latency (94.4±17min.)
statistically significant (p=0.02). Also, parents of ADHD Than the control group (84.7±17.9) but the difference between
patients reported that their children (48%) sleep for shorter both groups was non significant (p=0.07). The percentage of
duration than the control (5%), the difference between the 2 REM sleep in patients of ADHD (16.20±3.20) was significantly
groups was significant (p=0.002). Most of the ADHD patient less than the control group (20.35±5.07), the difference between
(60%) show motor restlessness during sleep and only 15% of the 2 groups was significant (p=0.03).
the control show motor restlessness and the difference between
the 2 groups was significant (p=0.002). The difference between While, the ADHD patients frequently awake during sleep
the 2 groups was also significant as regards bruxism. There was (number of awakening=20.20±7.3), the control group awake
no significant difference between the 2 groups as regards other for only 14.10±3.60 and the difference between both groups
items of the questionnaire (table 2). was significant (0.001).

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Current Psychiatry
Vol. 17, No. 3, July. 2010

The respiratory function of ADHD patients was not significantly common in delayed sleep phase syndrome. It may be that
different from the control group. There was no correlation hyperactivity at night in ADHD causes a delayed sleep onset
between the type of ADHD and the results of both subject and characteristic of Delayed Sleep Phase Syndrome, but that the
objective assessment of sleep. sleep disruption from a delayed sleep onset is not enough to
Table 3: Polysomnogaphic data of the studied patients and cause daytime inattention and hyperactivity characteristic of
control subjects. ADHD. The endogenous circadian pacemaker was suggested
ADHD Control t p
to be fixed at a later phase than the desired sleep-wake
schedule in children with ADHD and sleep-onset insomnia.
Age 9.08±2.04 10±1.62 0,099

Sex (male/female) 21/4 18/2 0.56

The shorter duration of sleep among patients with ADHD
than the control (49 minutes shorter), is going with other
Sleep latency studies24. Also disrupted and short sleep can affect daytime
27.88±6.64 23.30±6.94 2.24 0.03*
(min) learning and attention in childhood and can lead to ADHD-
Total sleep time like symptoms25. It has been suggested that disrupted sleep
459.3±98.9 508±55.8 2.08 0.04* architecture can cause executive dysfunction, impaired
(min)
Sleep efficiency
vigilance, depression, anxiety and hyperactivity26,27. These
95±3.56 96±3.73 0.91 0.37 findings collectively suggest that the impact of decreased
(%)
Stage I (%) 10.32±2.06 11±3.70 0.74 0.47
sleep duration on neuropsychological functioning in children
with ADHD should be investigated further.
Stage II (%) 55.76±4.92 56.95±4.61 0.84 0.41
Slow wave sleep
7.68±1.89 7.90±2 0.83 0.71
The ADHD patients of the present study had significantly
(%) decreased percentage of REM sleep (16.20±3.20) than the
REM latency
94.4±17 84.7±17.9 1.48 0.07 control (20.35±5.07). The REM latency of the patients
(min.) was longer than that of the control but the difference was
not significant. These findings are in agreement with
REM sleep (%) 16.20±3.20 20.35±5.07 3.19 0.03*
other studies documenting REM sleep abnormalities in
Number of
20.20±7.3 14.10±3.60 3.73 0.001*
ADHD children28-31. These findings may suggest that
awakening ADHD children suffer from an intrinsic sleep problem that
Apnea-hypopnea
5.48±6.18 5.50±5.72 0.19 0.82
could be related to the underlying pathophysiology of the
index disorder. REM sleep has been associated with increased
brain-derived neurotrophic factor (BDNF) levels in the
DISCUSSION dorsal hippocampus32,33. BDNF has been suggested to play
a role in the pathogenesis of ADHD and two family-based
In the present study parents of unmedicated ADHD parents association studies demonstrated an association of BDNF
reported that 60% of their children had one or more sleep polymorphisms with ADHD34,35. The catecholamine systems
problems, significantly higher than that of the control group. was also implicated in both the pathophysiology of ADHD
This finding supports results of previous studies showing and the regulation of sleep and arousal. Variety of anatomical,
increased parental ratings of sleep problems among ADHD animal and clinical studies have indicated that dopamine
children compared to children in the control group. Owens et signaling acts not only to stimulate arousal and attention, but
al, reported quite similar results. In the present study; there is also involved in both the regulation of overall sleep and
was no increase in the day time sleepiness20,21. This was in in mechanisms specifically related to REM sleep36,37. Thus,
agreement with decreased daytime sleepiness in ADHD there appears to be a relationship between the mechanisms
children with co-morbid sleep disorders reported before10,22. underlying the pathophysiology of ADHD and the regulation
of REM sleep.
In contrast with this study excessive day time sleepiness in a
group of ADHD children was reported13,20. CONCLUSION

The polysomnographic finding of the present study The present study revealed an association between some
demonstrated that nonmedicated ADHD children had sleep parameters and ADHD. The ADHD patients had
significantly longer sleep latency, shorter total sleep time significantly delayed sleep onset and decreased sleep
than the control group. The polysomnographic results are duration. Also, they had significantly decreased REM sleep
going with some subjective findings in the present study. and increased number of awakenings.
Sleep onset delay is significantly present in more ADHD
patients, who had also significantly longer sleep latency Recommendations
(27.88±6.64min.) Than control (23.30±6.94min.). This
is in agreement with Gruber et al.23. ADHD seems to be The present study was limited by its small sample size, so,
characterized, in some cases, by a sleep onset insomnia it is recommended to replicate it with more patients to study
characteristic of delayed sleep phase syndrome. On the other the effect of ADHD medication on both clinical ADHD
hand, the reverse relationship does not seem to hold, as a symptoms and sleep parameters as this may help in our
preliminary study suggests that ADHD symptoms are not understanding of the relationship between the two conditions.
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 Sleep Characteristics in Egyptian Children with Attention Deficit-Hyperactivity Disorder
Mohammed Abd El-Hay et al.

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