INTRODUCTION
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD),
CHARACTERIZED BY INATTENTION, HYPERACTIVITY,
AND IMPULSIVITY, IS A COMMON neuropsychiatric disorder
worldwide among children and adolescents,1 with a prevalence
in the range of 5% to 10% in Western countries2 and 7.5% in Taiwan.3 It has been suggested that many people with ADHD, as high
as 60% in some studies, continue to have clinically significant
symptoms of ADHD when they become adults.4,5 Consistent with
this suggestion, a recent national survey of adults in the United
States found that 4.4% met the criteria for current adult ADHD.6 A
companion report from this study documented substantial impairDisclosure Statement
This was not an industry supported study. Dr. Gau has participated in research supported by Lilly Corporation and by Janssen-Cilag Taiwan as the
principal investigator. All investigator fees were put into research grants for
other studies. Dr. Kessler receives research grant support from Eli Lilly and
Company and Bristol-Myers Squibb. He consults with GlaxoSmithKline, Galt
Associates, and Pzer. His participation in this report consisted of help in
revising the manuscript. This work was carried out without nancial remuneration and was independent of any research or consultation in which he
is involved. Drs. Tseng, Wu, Chiu, Yeh, and Hwu have indicated no nancial
conicts of interest.
Submitted for publication June 21, 2006
Accepted for publication October 13, 2006
Address correspondence to: Susan Shur-Fen Gau, Department of Psychiatry, National Taiwan University Hospital & College of Medicine, No. 7, ChungShan South Road, Taipei 10002, Taiwan; Tel: 886 2 23123456 ext. 6802;
Fax: 886 2 23812408; E-mail: gaushufe@ntu.edu.tw
SLEEP, Vol. 30, No. 2, 2007
195
and PLM, there has been no consistent evidence either of a relationship between sleep problems in general and symptoms of
ADHD or of a clear causal direction of this relationship in cases
in which the relationship has been found to exist. A complicating
factor here is that, similar to the studies in children and adolescents,19 the findings from subjective reports are dissociated with
those from objective measures, indicating an increased likelihood
of a misinterpretation of sleep quality and problems in adults with
ADHD.26
Although the studies mentioned above have clearly documented
associations of inattention and hyperactivity with sleep problems,
particularly OSA and PLM, there has been a dearth of adequate
data delineating the associations of ADHD with other sleep problems among adults. Studies based on parental reports have almost
universally reported a high frequency of diverse sleep problems
in children with ADHD.14,17,19,27-29 However, it is not clear whether
similar specifications exist in the adult population. In view of
this, and given the considerable public health importance of adult
ADHD, we conducted a survey study of 2284 young adults to
examine whether the associations of ADHD symptoms with sleep
problems are similar to those found among children.
METHODS
Participants and Procedures
The Institutional Review Board of National Taiwan University
Hospital approved this study prior to implementation. A letter
describing the purposes and procedures of the study was mailed
to those who were accepted by the National Taiwan University
as first-year college students in July 2004. All students were informed that participation in the survey was completely voluntary,
and the confidentiality was assured in the letter. Of the 3756 firstyear students, 2284 (60.8%, 1156 men and 1128 women) consented to participate and completed the self-administered questionnaire survey in the first week of fall semester in conjunction with
a routine physical examination. There was no information about
the proportion of eligible subjects who received the mailings. The
trained school counselors provided clear instructions on self-administration prior to the questionnaire being filled out. Trained
research assistants then checked the completed questionnaires immediately to minimize missing data.
Instruments
Data Analysis
196
Men n = 1156
19.4 2.9
Women n = 1128
19.2 2.6
Total N = 2284
19.3 2.7
Sex differences
F1,2278 = 2.11, p = .147
643 (55.8)
606 (53.9)
1249 (54.9)
12 = 0.83, p = .362
328 (29.4)
789 (70.6)
319 (18.0)
780 (82.0)
647 (29.2)
1569 (70.8)
12 = 0.03, p = .861
485 (43.3)
634 (56.7)
473 (42.9)
629 (57.1)
958 (43.1)
1263 (56.9)
12 = 0.04, p = .842
260 (22.5)
614 (53.1)
282 (24.4)
248 (22.0)
661 (58.6)
219 (19.4)
508 (22.3)
1275 (55.8)
501 (21.9)
22 = 9.59, p = .008
80 (6.9)
507 (43.9)
569 (49.2)
72 (6.4)
501 (44.4)
555 (49.2)
152 (6.7)
1008 (44.1)
1124 (49.2)
22 = 0.29, p = .866
1056 (91.8)
94 (8.2)
1026 (91.1)
100 (8.9)
2082 (91.5)
194 (8.5)
12 = 0.36, p = .546
110 (9.5)
518 (44.9)
106 (9.2)
419 (36.4)
13.5 5.2
9.3 5.1
84 (7.5)
544 (48.4)
168 (14.9)
329 (29.2)
13.0 4.7
8.5 4.7
194 (8.5)
1062 (46.7)
274 (12.0)
748 (32.8)
13.2 4.9
8.9 4.9
Data are presented as number (%), except age and inattention and hyperactivity sum scores, which are presented as mean SD.
a
The job classication was based on the criteria of occupation category of Executive Yuan, Taiwan,35 which was modied from the Standard International Occupational Prestige Scale.36
ASRS score. The nonlinear multilevel model was used to examine the rates of sleep-related problems across different comparison groups and to test the random-intercept effect. If the p value
of the t statistic of the random-intercept effect was less than .05,
indicating that the random intercept was not equal to 0, we used
the nonlinear mixed model to conduct the logistic regression and
to compute the odds ratios and 95% confidence intervals for the
odds ratios. Otherwise, the logistic-regression model was used.
These statistical models were controlled for participants age, sex,
body mass index, residential area, and parental marital status to
decrease potential confounding effects from these variables.
RESULTS
ADHD or probable ADHD associated with inattention was associated with significantly longer required sleep time to maintain
normal daytime function and greater difference between required
sleep and self-estimated nocturnal sleep duration than their counterparts but not with actual self-estimated sleep duration (Table
2). ADHD associated with hyperactivity-impulsivity, in contrast,
was not significantly related to any of the sleep measures.
Demographics
197
1.11 (1.16)
0.80 (1.03)c
Lifetime
3.31 (2.33)
2.64 (2.16)d
3.62 (2.06)
Group
Difference
F2,2270 = 0.78,
p = .457
F2,2275 = 4.16,
p = .016
F2,2269 = 3.30,
p = .037
HyperactivityImpulsivity of ASRS
ADHD Probable ADHD non-ADHD
n = 16
n = 130
n = 2138
7 h 15 min
7 h 06 min
7 h 14 min
(80)
(68)
(63)
7 h 34 min
7 h 24 min
7 h 30 min
(69)
(81)
(67)
19 (75)
17 (90)
16 (72)
1.23 (1.16)
0.81 (1.04)e
3.45 (2.22)
2.67 (2.18)f
Group
Difference
F2,2270 = 0.98,
p = .377
F2,2275 = .60,
p = 0.550
F2,2271 = 0.02,
p = .985
F2,2279 = 14.41,
p < .001
F2,2279 = 14.78,
p < .001
Data are presented as mean (SD). ADHD refers to attention-decit/hyperactivity disorder; ASRS, Adult Self-Report Scale
*Difference between self-perceived need of sleep time to maintain normal daytime function and actual self-estimated total sleep time.
Highly likely ADHD.
a
Probable ADHD > non-ADHD
b
Probable ADHD > non-ADHD
c
ADHD > probable ADHD, ADHD > non-ADHD, Probable ADHD > non-ADHD
d
ADHD > non-ADHD, Probable ADHD > non-ADHD
e
ADHD > probable ADHD, ADHD > non-ADHD, Probable ADHD > non-ADHD
f
ADHD > non-ADHD, Probable ADHD > non-ADHD.
198
Current
Early insomnia
Middle insomnia
Sleep terror
Sleepwalking
Sleep talking
Nightmare
Bruxism
Snoring
Lifetime
Early insomnia
Middle insomnia
Sleep terror
Sleepwalking
Sleep talking
Nightmare
Bruxism
Snoring
Inattention
ADHD* Probable NonADHD vs
ADHD ADHD
non-ADHD
Hyperactivity-Impulsivity
Probable ADHD* Probable NonADHD vs
ADHD vs
ADHD
ADHD non-ADHD
non-ADHD
OR (95% CI) n = 16 n = 130 n = 2138 OR (95% CI)
%
%
%
Probable
ADHD vs
non-ADHD
OR (95% CI)
n = 53
%
n = 486
%
n = 1745
%
OR (95% CI)
45.3
28.3
0.0
0.0
18.9
28.3
11.3
22.6
33.5
14.4
2.5
0.6
12.6
22.4
7.8
17.5
26.7
9.7
1.0
0.1
8.5
15.0
5.9
12.9
56.3
25.0
6.3
0.0
18.8
31.3
12.5
43.8
43.1
16.2
3.9
0.8
9.2
21.5
6.2
20.0
27.5
10.8
1.1
0.2
9.6
16.5
6.4
13.5
84.9
66.0
26.4
11.3
43.4
58.5
28.3
43.4
73.7
52.9
21.4
17.7
43.4
53.9
28.4
39.5
64.8
41.0
13.1
12.3
35.0
43.9
22.5
32.2
3.1
2.8
2.4
0.9
1.4
1.8
1.4
1.6
1.5
1.6
1.8
1.5
1.4
1.5
1.4
1.4
93.8
75.0
31.3
18.8
62.5
87.5
43.8
68.8
76.9
56.2
25.4
19.2
41.5
56.9
33.1
47.7
66.3
43.1
14.5
13.1
36.5
45.4
23.2
32.9
2.2
2.5
2.4
1.8
2.0
2.4
2.3
2.3
1.7
1.7
2.0
1.6
1.2
1.6
1.6
1.9
(1.5, 6.6)b
(1.6, 5.0)c
(1.3, 4.5)b
(0.4, 2.2)
(0.8, 2.5)
(1.0, 3.2)a
(0.7, 2.5)
(0.9, 2.8)
(1.2, 1.9)c
(1.3, 2.0)d
(1.4, 2.3)d
(1.2, 2.0)b
(1.2, 1.8)c
(1.2, 1.8)d
(1.1, 1.7)b
(1.1, 1.7)b
(1.3, 4.0)b
(1.5, 4.0)c
(1.5, 4.1)c
(1.0, 3.2)a
(1.3, 3.2)b
(1.5, 3.9)c
(1.4, 3.7)c
(1.4, 3.7)c
(1.1, 2.6)a
(1.2, 2.4)b
(1.3, 3.1)c
(1.0, 2.5)a
(0.9, 1.8)
(1.1, 2.3)a
(1.1, 2.4)a
(1.3, 2.7)c
Inattention
Men vs Women
Current
Early insomnia
Middle insomnia
Nightmare
Snoring
Lifetime
Middle insomnia
Sleep terrors
Sleep talking
Nightmare
Nocturnal sleep
obtained, h
Sleep need
0.49
F
p
statistic Value
5.81
.016
HyperactivityImpulsivity
F
p
statistic Value
0.74 12.75 < .001
1.00
0.94
0.98
18.36
11.12
10.91
< .001
< .001
< .001
1.14 24.40
0.82 5.53
1.22 17.56
0.99
0.71
19.76
5.38
0.57 6.32
0.73 10.68
-0.23 5.86
0.34
14.36
< .001
< .001
.019
< .001
.004
.012
.001
.016
= parameter estimate.
199
Implications
Combining findings from several lines of work, including
our prior study on children and adolescents41 and this study, we
should know that although individuals with ADHD may not increase the risk for some sleep problems; individuals with sleep
problems may manifest varied degree of symptoms similar to the
core symptoms of ADHD. Without detailed and comprehensive
assessments, these individuals with sleep problems could easily
be misdiagnosed with ADHD, particularly for those adults who
did not have information about a childhood history of ADHD.42
It is particularly important for those subjects in this study who
had symptoms of mild inattention and hyperactivity to have a
complete assessment of sleep-related problems and vice versa,
given that these problematic behaviors that mimic symptoms of
ADHD may also result in adverse outcomes such as academic
failure43 or low work achievements,24,44 injuries and motor vehicle
crashes,29 and substance abuse.45 Therefore, for individuals with
ADHD-like symptoms and sleep problems, psycho-education of
sleep hygiene and behavior modification should be provided first
to prevent daytime inattention, irritability, and sleepiness in order
not to influence their school or occupational performance. If a
behavioral approach does not work, medication and other treatment for sleep problems should be the next step if the diagnosis of
ADHD cannot be confirmed. For individuals with severe symptoms of ADHD and sleep problems, a complete assessment for
the diagnosis of ADHD and sleep problems should be performed
first before initiation of medication for treating ADHD in addition
to treatment for sleep problems. Further study employing adults
with a diagnosis of ADHD are needed to determine the relationship between diagnoses of ADHD and sleep problems, and prospective cohort studies aiming at demonstrating a cause-and-effect relationship of sleep problems and ADHD-related symptoms
are crucial and merit being done.
ACKNOWLEDGMENT
This work was supported by grants from the National Taiwan
University Hospital (NTUH92-S07) and National Health Research Institute (NHRI-EX94-9407PC), Taiwan.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
200
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
2001;55:97-103.
29. Owens JA. The ADHD and sleep conundrum: a review. J Dev Behav Pediatr 2005;26:312-22.
30. Gau SF. Neuroticism and sleep-related problems in adolescence.
Sleep 2000;23:495-502.
31. Gau SF, Soong WT. The transition of sleep-wake patterns in early
adolescence. Sleep 2003;26:449-54.
32. Gau SS, Soong WT, Merikangas KR. Correlates of sleep-wake
patterns among children and young adolescents in Taiwan. Sleep
2004;27:512-9.
33. Shang CY, Gau SS, Soong WT. Association between childhood
sleep problems and perinatal factors, parental mental distress and
behavioral problems. J Sleep Res 2006;15:63-73.
34. Singer JD. Using SAS PROC MIXED to fit multilevel models, hierarchical models, and individual growth models. J Educ Behav Stat
1998;23:323-55.
35. Cheng TA. A community study of minor psychiatric morbidity in
Taiwan. Psychol Med 1988;18: 953-68.
36. Treiman, D. Standard International Occupational Prestige Scale. In:
Occupational Prestige in Comparative Perspective. New York: Academic Press, 1977:235-60.
37. Lecendreux M, Konofal E, Bouvard M, Falissard B, Mouren-Simeoni MC. Sleep and alertness in children with ADHD. J Child Psychol Psychiatry 2000;41:803-12.
38. Weiss MD, Weiss JR. A guide to the treatment of adults with ADHD.
J Clin Psychiatry 2004;3:27-37.
39. Wolfson AR, Carskadon MA. Sleep schedules and daytime functioning in adolescents. Child Dev 1998;69:875-87.
40. Gau SS. Prevalence of sleep problems and their association with
inattention/hyperactivity among children aged 6-15 in Taiwan. J
Sleep Res 2006;15:403-14.
41. Montano B. Diagnosis and treatment of ADHD in adults in primary
care. J Clin Psychiatry 2004;65:18-21.
42. Gozal D, Pope DW, Jr. Snoring during early childhood and academic performance at ages thirteen to fourteen years. Pediatrics
2001;107:1394-9.
43. Biederman J, Faraone SV, Spencer T, et al. Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults
with attention deficit hyperactivity disorder. Am J Psychiatry
1993;150:1792-8.
44. Barkley RA, Murphy KR, Dupaul GI, Bush T. Driving in young
adults with attention deficit hyperactivity disorder: knowledge, performance, adverse outcomes, and the role of executive functioning.
J Int Neuropsychol Soc 2002;8:655-72.
45. Wilens TE. Impact of ADHD and its treatment on substance abuse
in adults. J Clin Psychiatry 2004;65:38-45.
201