Introduction

ADHD (Attention Deficit Hyperactivity Disorder) is a heterogenous, genetically

determined neurodevelopmental disorder that manifests itself through hiperactivity-
impulsivity, impaired executive functions (planning, organizing, working memory, selective
attention, flexibility) caused by dopamine and norepinephrine pathway dysfunctions in the
limbic system.
ADHD belongs to the child and adolescent psychiatric disorders that registered an
increase of incidence and prevalence over recent years.
The correlation between altered sleep patterns and ADHD is well known. Sleep
disorders have been reported in a high number of children with an ADHD diagnosis. It is also
known that chronic sleep deprivation leads to poor daytime performances and can therefore
cause ADHD-like symptoms and impaired cognitive assimilation. However, it is difficult to
assign which disorder is primary and which one is a secondary outcome of the the other.
Sleep habits and its characteristics are not always assessed in ADHD patients
despite the fact that research show important differences regarding sleep quality between
ADHD children and those with normal psychiatric development.
Psychiatric literature points that sleep disorders have been reported by 25 50 % of
the parents that had children with ADHD diagnosis, with an emphasis on trouble falling
asleep and difficultes in maintaining sleep.
Sleep habits are determined by patient specific factors and by the patients
interaction with the external environment. Sleep can also be considered as a process that is
modulated according to the developmental stage that varies in time.
In this context, sleep disorders are divided into behavioral and non-behavioral.
Behavioral sleep disorders include:
- Sleep on-set difficulties;
- Awakening difficulties;
- Sleep length irregularities difficulties;
- Altering of sleep-wake cycle;
Non-behavioral sleep disorders include:
- Insomnia and altering of circadian rhythm ;
- Parasomnias enuresis, bruxism, nightmare frequency, sleep terrors,
sleepwalking, sleep related eating disorders, confusional arousals;
- Sleep-Disordered Breathing;
- Periodic Limb Movement Syndrome
Objectives
 The aim of this study is to estimate the frequency of different sleep patterns that appear
in children diagnosed with ADHD in comparison with a control group of children aged
between 4 and 11 years old.
The participants were assigned into two groups: one that includes children aged between
4 and 11 years old diagnosed with ADHD according to DSM 5 criteria and a control group of
healthy children aged between 4 and 11 years old, that were recruited from kindergardens.
The frequency of sleep disorders was estimated in each group using the Albany Sleep
Problems Scale.
Objectives:
- Identifying sleep disorders frequency in children with ADHD diagnosis in
comparison to normally developed children;
- Presenting the different types of sleep disorders that were identified in ADHD
children in comparison to the control group;
- Presenting correlations between certain types of sleep disorders frequency in
ADHD children compared to the control group;

Method
 Group repartition
Our descriptive study runs between 01.04.2014 15.07.2014 and it includes 100
participants. 50 participants were evaluated at the Child And Adolescenct Psychiatry
Department of Prof. Dr. Alexandru Obregia Clinical Psychiatry Hospital. 50 other
participants were evaluated in different kindergardens over the same time period.
The sample is made of 2 groups (Group I children diagnosed with ADHD and
Group II as a control group):
- Group I includes 50 children patients from the Child And Adolescent
Psychiatry Department of Prof. Dr. Alexandru Obregia Clinical Psychiatry
Hospital, both male and female, having an ADHD diagnosis according to the
DSM V criteria.. The patients are aged between 4 and 11 years old. Data
collection was transversal, at the time of patients arrival at the clinic.
- Group II includes 50 normally developed children, both male and female, that
were evaluated at different kindergardens across Bucharest. Data collection was
transversal.

Inclusion criteria

For Group I:
- ADHD diagnosis;
- Lack of additional psychiatric diagnosis on Axis I or Axis II;
- The possibility of applying the Albany scale.

For Group II;

- Lack of a medical history that includes neurologic and psychiatric disorders;
- A history of normal development according to all age milestones;
- The possibility of applying the Albany scale.

Measures

Participants were evaluated using the Albany Sleep Problems

Scale. The aim is to identify the sleep disorders distribution differences
between the two groups by assessing the presence of altered sleep
patterns using the Albany Sleep Problems Scale in both groups. The Albany
questionnaire was filled in by the childrens parents in both groups.
Parents agreed and signed an informed consent regarding research
participation.

Albany Sleep Problems Scale

ASPS Albany Sleep Problems Scale is a questionnaire used

to assess the presence, type and severity of sleep disturbances.

The questionnaire is comprised of 46 questions and is

addressed to the parents. It can be applied by the medical staff ,
therapists or by parents.

Most questions are close-ended but the questionnaire also

includes open-ended questions that are meant to be answered according
to a specific situation.

The scales questions ask for detailed aspects concerning

sleep problems, aspects by which the questions can be grouped into
different categories or domains of interest that study different
characteristics pertaining sleep habits. The questions are grouped into the
following categories: (A) Sleeg hygiene, (B) Sleepwalking, (C) Sleepiness,
(D) Medication, (E) Sleep Habits, (F) Nightmares, (G) Sleep Terrors, (H)
Hypersomnia and narcolepsy, (I) Breathing, (J) Limb movement during
sleep, (K) Bedwetting, (L) Bruxism, (M) Sleep anxiety and depression, (N)
Daytime behavioral problems, (O) Other general medical conditions and
associated medication.

Questions 1-3, 5-12, 14, 17-19, 21, 23-27, 29-32, 34-36, 38-
41, have predetermined answers that are represented by a score ranging
between 0 and 4, corresponding to the specific impairment or behaviour
frequency that is evaluated through each question. Therefore 0 = never,
1= less than once in a week, 2 = once twice in a week, 3 = between
three and six times in a week, 4 = each night.
 Questions 4, 13, 28, 33, 37, 42, 43, 46 have Yes / No answers.
Questions 15, 16, 20, 22 have Yes / No / Non Applicable answers, while
questions 44 and 45 are open-ended questions.

The collected data was processed by grouping questions into

domains of interest to facilitate statistical analysis. Each domain registered
scores based on points that were collected through the most important
questions that evaluated a specific domain of interest. Therefore questions
3 8 were assigned to Group (A) Sleep routine and sleep hygiene ( 3
works or plays in bed often right up to the time he goes to bed; 4 sleeps
poorly in his or her own bed, but better away from it; 5 caffeine
consumption; 6 vigorous activity engagement in the hours before
bedtime; 7 resists going to bed; 8 takes more than 1 hour to fall asleep
but dies not resist.), questions 9, 10, 19 were assigned to Group (B)
Nighttime awakenings (9 awakens during the night but remains quiet and
in bed; 10 awakens durind the night and is disruptive; 19 wakes up in
the middle of the night upset.), question 12 was assigned to Group (C)
Sleepiness (often feels exhausted during the day because of lack of sleep),
questions 17, 18, were assigned to Group (D) Circadian rhythm
impairment (17 falls asleep early in the evening and awakens too early in
the morning; 18 difficulty fallins asleep until a very late hour and
difficulty awakening early in the morning), questions 23, 24 were assigned
to Group (E) Hypersomnia / Narcolepsy (23 experiences sleep attacks
falling asleep almost immediately and without warning during the day;
24 experiences excessive daytime sleepiness that is not due to an
inadequate amount of sleep), questions 25 28 were assigned to Group
(F) Respiratory problems (25 snores when asleep; 26 sometimes stops
breathing for a few seconds during sleep; 27 has trouble breathing; 28
is overweight), questions 31 and 32 were assigned to Group (G) Sleep
problems associated with limb movement (31 sheets and blankets in
extreme disarray in the morning when he or she wakes up; 32 wakes up
at night because of kicking legs), questions 37 41 were assigned to
Group (H) Sleep anxiety (37 sleeps well when it doesnt matter, such as
on weekends, but sleeps poorly when he or she must sleep well, such as
when a busy day at school is ahead; 38 often has feelings of
apprehension, anxiety, or dread when he or she is getting ready for bed;
39 worries in bed; 40 often has depressing thoughts, or do tomorrows
worries or plans buzz through his or her mind when he or she wants to go
to sleep; 41 has feelings of frustration when he or she cant sleep),
question 36 was assigned to Group (I) Bruxism (36 grinds his or her teeth
at night), question 35 was assigned to Group (J) Enuresis (35 wets the
bed).

Defining variables

The study contains two types of variables: quantitative

(continuous and discrete) and qualitative (nominal and ordinal).

Quantitative variables:

1. Age (years)

2. Sleep routine and sleep hygiene (points)

3. (B) Nighttime awakenings (points)

4. (C) Sleepiness (points)

5. (D) Circadian rhythm impairment (points)

6. (E) Hypersomnia / Narcolepsy (points)

7. (F) Respiratory problems (points)

 8. (G) Sleep problems associated with limb movement
(points0

9. (H) Sleep anxiety (points)

10. (I) Bruxism (points)

11. (J) Enuresis (points)

Qualitative variables:

1. Gender : M / F
2. Group I (ADHD) / Group II (Control group).
3. Age categories: 4-7 years old / 8-11 years old.
Data analysis:

The IBM SPSS Statistics software was used for the statistical analysis of the data
and for creating the database.
The following statistical tools were used for analysis:

Descriptive statistics:
- Mean, median, mode estimates of central tendency;
- The standard deviation estimate of dispersion;
- Skewness (lack of simmetry), Kurtosis (excess) measures of shape.

Graphic description:
- Box-plot graphs provide a better visualization of important distribution
elements.
- Cluster-bar charts, histograms, bar graphs, pie charts help with a better
visualization of information associated with the frequency of some variables.
Statistic tests:
T test (Student) - compares the means of two groups. It is commonly used with small
sample sizes, testing the difference between the samples when the variances of two normal
distributions are not known. When the t value and degrees of freedom are determined, the p-
value can be found using a table of values from Students t-distribution. If the calculated p-
value is below the threshold chosen for statistical significance (0.10, the 0.05 or 0.01 level),
then the null hypothesis is rejected in favor of the alternative hypothesis.
The Mann Whitney U Test is the non parametric equivalent of the T test
(Student), it does not require dispersion homogenity. It is used for comparing two groups with
a non-gaussian distribution or for comparing two ordinal variables.
Spearmans rank correlation coefficient it is the non-parametric equivalent of the
Pearson correlation coefficient, used for comparing the correlation level between two
quantitative variables with a non-gaussian distribution. The obtained value was compared
with the critical value corresponding to the degrees of freedom and to the statistical
significance level of p<0.05. The Spearmans rank correlation coefficient can have values
between +1 and -1. A value of +1 shows a perfect association between variables (the score
increse of a variable determines the score increase of the other) while a value of ) shows that
there is no association between the variables. A value of -1 corresponds to a negative
association (the score increase of one variable will cause the score decrease of the other).
Values between 0.10 0.29 correspond to a medium correlation while values between 0.50
1 suggest a strong correlation.

Results

Study results are organized into the following categories:

 - Descriptive statistics by groups
- Statistical analysis of data obtained through applying the Albany Scale and the
comparative analysis regarding sleep disorders between the two population
groups.

Descriptive statistics by groups

- Age descriptive statistics by groups : Group I ADHD (n=50) and Group II
Control Group (n=50).
According to the statistical analysis of age in Group I and according to the ADHD
Group histogram, the mean age of the ADHD group is of 7,24 years old, with a standard
deviation of 2,520.
Age distribution is multimodal, most frequent values corresponding to ages 4,5
years old and 11 years old.
According to the Group II histogram and to the statistical analysis of age in Group
II, the mean age of the control group is of 7,66 years old with a standard deviation of 1,944.
Age distribution is gaussian, as suggested by the small difference between the mean
value (7,66), the median value (8,00) and mode value (8). Also, the difference between the
mean and the double of the standard deviation does not register a negative value (7,66 2 x
1,944 = 3.772).
The age distribution curve is slightly asymmetrical to the left, as suggested by the
skewness of 0.400.

- Gender
The gender distribution in the two groups, shows that the ADHD group participants
are 70% male and 30% female. This result corresponds to the data found in the specialty
literature that points to the higher prevalence of ADHD in male patients. The control group
participants are 60% female and 40% male.

Statistical analysis of data obtained through applying the Albany Scale and the
comparative analysis regarding sleep disorders between the two groups.
Sleep problems associated with sleep routine and sleep hygiene
A significant difference in the frequency of sleep problems associated with sleep
routine and sleep hygiene between the two groups has been registered by applying the Mann-
Whitney U test (U value of 680.000, corresponding to a p value of 0.000). Thus there is a
significant difference in the distribution of sleep problems related to sleep routine and hygiene
between the ADHD group (n = 50, mean = 61.90) and the control group (n = 50, mean =
39.10).
The frequency variation of sleep problems related to sleep routine and hygiene was
also studied in relation to age categories, but no significant results were found in the ADHD
group (p=0.093). The Mann Whitney U test was applied to both groups to compare the
frequency of sleep hygiene related problems in relation to separate age categories (4-7 years
old and 8-11 years old).
A higher frequency of sleep problems related to sleep hygiene and routine was
found in children aged between 4 7 years old that were assigned to the control group (rs =
-0.515, p=0.000). By applying the Spearman correlation test, there was a strong negative
correlation between sleep hygiene and age category as variables.
A regular sleep routine has been reported less frequently in ADHD children than in
the control group.
Irregular sleep routines have been found in 48% of the children assigned to the
ADHD group (24 / 50, n = 50). 36 % of the ADHD children never had a regular sleep routine
(18 / 50, n = 50).
Most participants in the control group have a regular sleep routine. Only 8% of the
control group children have regular sleep / wake hours less than once a month ( 4 / 50, n =
50).
The frequency of bedtime resistance is of 30% in the ADHD group (15 / 50, n = 50),
occuring every night or at least three times in a week. The control group has no participant
resisting sleep with such a high frequency.

Nighttime awakenings
By apllying the Mann Whitney U test, no significant difference has been found
between the scores gathered from both groups concerning nighttime awakenings frequency (U
= 1081.00, p = 0.200).

Sleepiness
30% of the ADHD participants feel tired during daytime bacause of insufficient
sleep time. This occurs daily or at least once or twice in a week, compared to only 10% of the
controls that experienced sleepiness once or twice in a week.
 Circadian rhythm problems
No significant difference in score distribution was observed between the two groups
concerning circadian rhythm problems frequency (U = 1235.5, p = 0.918).
22% of the ADHD children register difficulties falling asleep and waking up at
least once or twice in a week (11 / 50, n = 50), while in the control group 10% of the control
participants reported these problems (6 / 50, n = 50).

Hypersomnia / Narcolepsy
By applying the Mann Whitney U Test, a significant difference in hypersomnia /
narcolepsy frequency was observed (U = 806.00, p = 0.000) between the ADHD group (n =
50; mean = 59.38) and the control group (n = 50; mean = 41.69), the ADHD group registering
a higher frequency.

Sleep disorders related to respiratory problems

Significant difference in distribution of sleep disorders related to respiratory
problems (U = 976.500, p = 0.046) was observed between the ADHD group (n = 50; mean =
55.97) and the control group (n = 50; mean = 45.03).
Most participants dont have sleep apnea, yet 12% of the children with ADHD
diagnosis reported sleep apnea at least once or twice in a week.
Snoring occurs in 40% of the ADHD participants more than once or twice in a
week (20 / 50, n = 50), while the control group has a snoring frequency of 8% (4 /50, n = 50).
The percentage of overweight participants is of 16% in the ADHD group (8 / 50, n
= 50), and of only 2% in the control group (1 / 50; n = 50).

Sleep problems associated with limb movement

No significant difference regarding the frequency of sleep problems associated
with limb movement was found between the two groups. The Mann Whitney Test was
applied, with a U coefficient of 1053.00 corresponding to a p value of 0.159, showing no
significant statistical difference.
The mean score value of sleep problems associated with limb movement was
higher in the ADHD group than in the control group. Also, the distribution of sleep problems
related to limb movements score was more variable in Group II (control group).
 16% of the ADHD children (n = 50, 13 / 50) always wake up in the morning
having the bed sheets in disarray, while the control group registers a frequency of 2% ( 2 / 50,
n = 50).
The frequency of limb movements that interrupt sleep is of 30% in the ADHD
group (15 / 50, n = 50), occuring at least once or twice in a week, while the frequency in the
control group is very low.
16% of the children diagnosed with ADHD in our study experience limb
restlessness while in supine position (8 / 50, n = 50), a sign that suggests the presence of the
restless legs syndrome. The frequency in the control group is of 2%.

Sleep anxiety
By applying the Mann Whitney U test, no significant difference in the
distribution of sleep anxiety frequency was found between the two groups (U = 1040.000, p =
0.124).
The sleep anxiety frequency distribution was almost equal when comparing the
ADHD group and the control group. A slightly higher median value of the anxiety sleep score
was observed in the control group, but this value is within the inferior value limits which
suggests a very low sleep anxiety frequency score in the control group.
Anxiety at bedtime hours was reported in 12% of the ADHD patients more than
once or twice in a week (6 / 50, n = 50).

Bruxism
By applying the Mann Whitney U test, a significant difference regarding the
frequency of bruxism has been observed between the two groups (U = 1000.500, p = 0.033).
Almost 18% of the ADHD patients taking part in the study grind their teeth while
sleeping at least once or twice in a week, while teeth grinding is significantly less present in
the control group.

Enuresis
A significant statistical difference in enuresis frequency was observed between
the two groups by using the Mann Whitney U test (U = 629.500, p = 0.000).
In the ADHD group, the enuresis frequency is almost 20%, (n = 50, 10 / 50)
occuring at least once or twice in a week and even every night while only one patient in the
control group was reported.
 Enuresis occurs less than once in a week with a frecuency of almost 32% in the
ADHD group (16 / 50, n = 50) while no such case has been reported in the control group.

Sleep problems frequency in both groups

In the ADHD group, 44% of the patients have sleep problems (22 / 50, n = 50),
while in the control group sleep problems were observed in 16% of the participants (8 / 50, n
= 50).

Discussion
Sleep problems frequency was studied by applying the Albany questionnaire. The presence of
different types of sleep problems was reported by the childrens parents from both the ADHD
group and from the control group.
A regulated sleep routine is less represented in the ADHD group than in the control group.
The ADHD children show an irregular sleep schedule that occurs in 48% of this group. 36%
of the participants in the ADHD group also never go to sleep or wake up at the same hours
while only 8% of the participants in the control group have a regular sleep/wake schedule less
than once in a week. It has also been observed that the bedtime resistance in the ADHD group
has a high frequency of 30%, occurring at least three six times in a week. This result
corresponds to the psychiatric literature that documents the high frequency of sleep time
resistance in ADHD children ().
No significant difference in the score distribution of nighttime awakenings was obtained
between the ADHD group and the control group.
In case of sleepiness, results show a higher degree of sleepiness during daytime due to lack of
sufficient sleep in the ADHD group than in the control group. This result also corresponds to
documented information found in the specialty literature.
No significant difference in the distribution of circadian rhythm impairments was found
between the ADHD group and the control group. A higher frequency of awakening and falling
asleep troubles was found in the ADHD patients than in the control group.
Hypersomnia / narcolepsy scores registered a significant distribution difference between the
two groups, with a higher hypersomnia / narcolepsy incidence in ADHD patients.
Respiratory sleep problems have a higher incidence in the ADHD group than in the control
group. Apnea has been reported by 12% of the parents corresponding to the ADHD children
group while the incidence was of 6% in the control group. Also, snoring occurs in 40% of the
children diagnosed with ADHD than in the control group where the incidence is of 8%. These
results are close to the documented information that snoring occurs in up to a third of ADHD
cases and in up to 10% of normal children. Most overweight participants are part of the
ADHD group 16%, while only 2% of the control children are overweight.
Concerning sleep problems related to limbs movements, no significant statistical difference
was observed in the score distribution between the two groups, but 26% of the ADHD
children wake up with sheets in disarray, a sign of limbs movements during sleep, while this
was reported in only 2% of the control children. Also, 30% of the ADHD subjects have been
reported as having limbs movements that interrupts sleep at least once or twice in a week,
while only 2% of the control subjects have been reported to show this behaviour. 16% of the
ADHD children show signs that suggest the presence of restless legs syndrome, while the
incidence in the control group is of 2%.
Sleep anxiety showed no significant difference in the distribution between the two groups.
However, almost 12% of the ADHD subjects have been reported as having sleep anxiety at
least once or twice in a week while no such case has been reported in the control group.
Bruxism is more frequent in ADHD patients (almost 18%) than in the control group where no
case was reported.
Enuresis is also more frequent in ADHD subjects (20% of the participants). Also, 32% of the
ADHD subjects grind their teeth less than once in a week while no such case was reported in
the control group.
Considering the initial aim of identifying the sleep problems incidence in ADHD children, the
results are close to those documented in other studies.() The ADHD group has a higher
incidence of sleep problems (44%) than in the control group where 16% of the participants
have been reported as having different types of sleep problems. These results are close to the
documented information found in the psychiatric literarure stating that sleep disturbances can
be found in up to 50% of the ADHD children while the incidence in normal children is up to
almost 23%.
Correlation tests were applied to reach our aim of presenting different correlations between
sleep disturbances incidence in ADHD children. Sleep routine and hygiene in ADHD children
is affected through an increase in nighttime awakenings frequency. A moderate positive
correlation has been observed between sleep routine and hygiene impairment and enuresis
incidence. Hypersomnia / narcolepsy incidence in ADHD children is correlated to the
frequency of sleep problems associated with limbs movements.
An unexpected correlation has been observed in ADHD children between respiratory sleep
problems and the incidence of sleep disturbances associated with limbs movements. Thus,
sleep disorders associated with limb movements are more frequent as the incidence of
respiratory sleep problems is higher. A mild positive correlation has been found in ADHD
patients between snoring and the sleep routine and hygiene impairment incidence. Snoring in
ADHD children also registered a moderate positive correlation with the incidence of enuresis.
In the control group, the frequency of nighttime awakenings has a strong correlation to the
increasing incidence of respiratory sleep problems. Also, nighttime awakening are caused by
the increase in incidence of sleep disturbances associated with limbs movements. Strong
positive correlations have been found between respiratory sleep problems and sleep disorders
associated with limb movements and sleep anxiety and depression. A mild positive correlation
has been observed between the increase in incidence of sleep problems associated with limbs
movements and sleep anxiety and depression.
Limitations
The results interpretation is conditioned by the following methodological limits : the small
number of participants; patients were not assigned to the different diagnostic subtypes of
ADHD; lack of paraclinical tests; the subjective aspect of the questionnaire that was filled by
parents.
Conclusions
Sleep problems incidence is higher in children diagnosed with ADHD. 44 % of the pediatric
patients in our study that had an ADHD diagnosis had been reported by parents as having
sleep disturbances while the incidence in normal children was of 16%. A higher incidence of
insomnia has been observed in ADHD children while parasomnias frequency was lower. The
most common sleep problems found in ADHD patients are those related to sleep routine and
hygiene impairment, respiratory sleep problems, those related to limbs movements during
sleep, difficulties in initiating sleep and difficulties waking up in the morning and the
presence of enuresis. The high incidence of sleep routine and hygiene impairment is
correlated to the increase in nighttime awakenings incidence and to the increase in enuresis
presence frequency.
Sleep problems related to limbs movements are more frequent as there is an increse in the
incidence of respiratory sleep problems and hypersomnia / narcolepsy.