Katherine H. Peppers, DNP, CPNP, CPMHS, RN; Shelly Eisbach, PhD, RN, PMHNP; Sarah Atkins, MD, MPH; James M. Poole, MD, FAAP; Anne Derouin, DNP, CPNP, RN
J Pediatr Health Care. 2016;30(6):e43-e48.
Abstract and Introduction
Objective: To determine the effect of a sleep hygiene education module and prescriptive sleep routine for children ages 5 through 11 years with attention deficit hyperactivity disorder (ADHD).
Methods: The 20-week pilot project used a pre–/posttest design to assess sleep and ADHD symptoms. The Child Sleep Habits Questionnaire (CHSQ) and Vanderbilt Assessment Scale–Parent Form survey were provided to assess sleep and ADHD behaviors of participants at baseline and 6 weeks after implementation of the sleep hygiene routine. Fifty-three children participated in the project. Of these, 23 scored 42 or greater on the CHSQ, indicating a sleep disorder, and received the intervention.
Results: The CHSQ and Vanderbilt scores indicated a significant improvement in sleep quality and reduction in ADHD symptoms after implementation of the sleep hygiene routine (CHSQ: p < .001, d = .928; Vanderbilt Questions 1–9: p < .001, d = .473; Vanderbilt Questions 10–18: p = .004; d = .329).
Conclusion: A provider-instructed sleep hygiene routine in children with ADHD improves sleep quality and reduces ADHD symptoms.
Attention deficit hyperactivity disorder (ADHD) is a complex neurobehavioral disorder characterized by inattention, hyperactivity, impulsivity, emotional dysregulation, and impaired learning (American Psychiatric Association, 2013). It is the most common mental health disorder among children and adolescents in the United States, affecting 6.4 million youth (11%) annually (Centers for Disease Control and Prevention, 2014). Symptoms of ADHD are often persistent and age inappropriate, and they affect multiple domains of a child’s life. Children and adolescents with ADHD are at increased risk for academic failure, mental illness comorbidity, low self-esteem, risk-taking behaviors, and delinquency (Sonuga-Barke et al., 2013). Sixty percent of affected children and adolescents will have lifelong ADHD (Centers for Disease Control and Prevention, 2014).
Sleep is foundational to a child’s physical, mental, and social growth and development (Mindell et al., 2011). The prevalence of sleep disorders is 25% to 40% among healthy children but increases to 70% to 90% among those with mental health issues, such as ADHD (Mindell, Meltzer, Carskadon, & Chervin, 2009). Disordered sleep is associated with reduced cognitive function, inattention, problematic behavior, progressive psychopathology, and attenuated emotional regulation (Matricciani, Olds, & Petkov, 2012). These behaviors often mirror the symptoms of ADHD; therefore, it is imperative to assess sleep before diagnosing ADHD (Cortese et al., 2013).
The primary sleep disorder symptoms seen in children with ADHD are bedtime resistance, latency of sleep onset, decreased duration of sleep, increased number of overnight awakenings, and daytime somnolence (Cortese et al., 2013; Yoon, Jain, & Shapiro, 2011). Bedtime resistance or “difficulty falling asleep” is the most common symptom reported by children affected with ADHD and/or their parents (Cortese et. al, 2013, p. 785). Case–control studies of children with ADHD not receiving medication show that latency of sleep onset duration is double in children with ADHD and that sleep duration was decreased by nearly 10% compared with healthy matched controls (Cortese, Faraone, Konofal, & Lecendreux, 2009; Van Der Heijden, Smits, & Gunning, 2006). Persistent, untreated sleep disorders led to increased daytime behavioral symptoms and decreased daily functioning among children with ADHD, including decreased quality of life for both the child and the family (Sung, Hiscock, Sciberras, & Efron, 2008).
Further compounding the issue of sleep onset latency is stimulant use among children with ADHD. Children with ADHD receiving methylphenidate, a commonly used medication, experience an additional 20-minute delay in sleep onset and shortened sleep duration of 1 to 2 hours compared with their nonmedicated peers (Galland, Tripp, & Taylor, 2010). Among children with ADHD, prolonged sleep latency onset, decreased duration of sleep, and frequent overnight awakenings correlate with increased behavior difficulties and poorer scores on standardized ADHD rating scales, such as the Vanderbilt Assessment Scale–Parent Form (Biggs, Lushington, Van Der Huevel, Martin, & Kennedy, 2011).
Behavioral interventions are the first-line treatment for sleep disorders in children with ADHD (Cortese et al., 2013). A randomized controlled trial of 244 children with ADHD, ages 5 through 12 years, who were receiving stimulant medication found that provider instruction of sleep hygiene routine, combined with behavior modification techniques, yielded a sustained improvement in ADHD symptoms, sleep duration, and quality of life (Hiscock et al., 2015). The sleep hygiene routine also showed improvements in the quality of life and daily functioning in children with ADHD (Hiscock et al., 2015; Sciberras, Fulton, Efron, Okerlaid, & Hiscock, 2011).
The Hiscock et al. (2015) randomized controlled trial guided the development of this quality improvement project, which evaluated the effect of implementing a provider-instructed sleep hygiene routine for children with ADHD being treated with stimulant medication. We believed that implementation of a validated sleep assessment tool among children with ADHD and the provision of a provider-instructed sleep hygiene routine for those with disordered sleep would result in better sleep quality, as evidenced by decreased scores on the Child Sleep Habits Questionnaire (CSHQ) and the Vanderbilt ADHD symptom checklist.
The setting for implementation of the pilot quality improvement project was a specialty ADHD clinic, located within a privately owned primary care practice in Raleigh, NC. The practice cares for pediatric patients from birth through 21 years of age, and 55% of patients have Medicaid as their primary insurance. The clinic implementation site was staffed with one pediatrician; one nurse practitioner, board-certified in pediatrics and pediatric mental health; one master’s-prepared educational consultant; three specialty-trained medical assistants; and a receptionist.
After institutional review board approval, the 20-week project was conducted from July 6, 2015, through November 20, 2015. English-speaking patients, ages 5 through 11 years, with a diagnosis of ADHD who met the Diagnostics and Statistics Manual of Mental Health Disorders, 5th edition criteria were eligible to participate in the project (American Psychiatric Association, 2013). Inclusion criteria for the sleep intervention required a diagnosis of ADHD/attention deficit disorder and a score of 42 or greater on the sleep assessment tool. Exclusion criteria included a diagnosis or clinical presentation indicative of obstructive sleep apnea, changes in ADHD medications during the 6-week implementation, and use of a pharmaceutical or complementary sleep aid medication, such as clonidine or melatonin.
Assessments and Guidelines
The CSHQ, developed by Dr. Judith Owens, was used to assess sleep in children who met the inclusion criteria and agreed to participate. A sleep disturbance score of 42 or greater indicated a pediatric sleep disorder. A randomized controlled trial involving 75 children, 26 with ADHD and 46 healthy control volunteers, showed that the CSHQ reliably evaluated sleep and correlated with parental report and polysomnography (Gruber et al., 2012). Researchers report that children with ADHD, who experience shorter duration of sleep, have high scores on the CSHQ (Gruber et al., 2009). The CSHQ sensitivity and specificity were .80 and .72, respectively (Owens, Spirito, & McGuinn, 2000).
The prescriptive sleep hygiene routine interventions were based on the “Clinical Practice Guideline on Sleep Disorders in Childhood and Adolescent Primary Care” (Blasco et al., 2011). The age-specific interventions included consistent bedtime and awakening schedule; daily physical activity and spending some time outdoors every day; consistent presleep routine; elimination of naps; avoiding heavy meals, caffeine, and physical exertion before bed; avoiding screen time at least 2 hours before bed; and removing TV, computers, and mobile phones from the bedroom (Blasco et al., 2011). A copy of the prescriptive sleep hygiene routine is included in Box 1.
Parents or caregivers of identified patients with ADHD attending the clinic were invited to participate in the study using a standardized script. Once verbal agreement was obtained, the parent/caregiver was provided the CSHQ and the Vanderbilt screening tools with standardized instructions for completion from the medical assistant. The CSHQ and Vanderbilt were completed by the parent/caregiver and scored before the patient was seen by the provider. The physician or nurse practitioner reviewed the patient’s chart and completed an interview with the parent/caregiver and child to determine if study inclusion and exclusion criteria were present. Children scoring 42 or greater on the CSHQ and not meeting exclusion criteria received the sleep hygiene intervention. The intervention consisted of (a) the parent/caregiver and child viewing a 6-minute, standardized sleep hygiene video (Box 2) created by the nurse practitioner and available in the clinical setting, (b) an opportunity to discuss the video and key aspects of the sleep hygiene routine with the provider before completion of the clinic visit, (c) development of a patient-specific sleep hygiene routine that was embedded in the electronic health record for documentation, (d) provision of a written copy of the patient-specific sleep hygiene routine, and (e) a planned 6-week follow-up visit to evaluate sleep and ADHD symptoms. At the 6-week follow-up visit, the CSHQ and Vanderbilt survey were readministered, and a parent satisfaction survey was completed. After completion of the pilot study, the CSHQ and Vanderbilt scores were analyzed using a paired t test.
A total of 161 patients met inclusion criteria and were invited to participate. Of those patients, 53 enrolled and completed the innovation; 49 caregivers of identified patients declined participation in the study. (Table 1 provides a summary of the reasons for declination.) More than half of the patients identified for study were eliminated because of attrition or medication changes. Four patients were referred for polysomnography because of concerns regarding obstructive sleep apnea. (Table 2provides a summary the sample and patient disposition.) Of the 53 patients, 30 scored 41 or less on the CSHQ. The remaining 23 scored 42 or greater on the CSHQ and received the sleep hygiene intervention. Baseline characteristics for the intervention group are provided in Table 3. The numbers of male and female study participants were nearly equal. Most received methylphenidate medication, and 61% (n = 14) used Medicaid as their primary insurance. Primary comorbid diagnoses for the intervention group included anxiety, oppositional defiant disorder, learning disability, and mood disorder. Nearly half of the children in the intervention group reported multiple “home” settings for sleep. The mean daily screen time duration for the intervention group was 3 hours; most did not have a television in their bedroom. (Table 4provides a summary of the data listed above).
The baseline mean CSHQ score ± standard deviation was 50.13 ± 7.16. The post-CSHQ score decreased to a mean ± standard deviation of 43.74 ± 6.49 after the 6-week intervention. The decreased CSHQ score indicated a significant improvement in sleep quality after implementation of the sleep hygiene routine and a large effect size (p < .001; Cohen d = .928). The mean ± standard deviation Parent Vanderbilt score on Questions 1 through 9 was 11.39 ± 7.75 at baseline and 7.52 ± 8.41 after the intervention. The initial mean ± standard deviation Parent Vanderbilt score on Questions 10 through 18 was 9.30 ± 9.08 at baseline and 6.39 ± 8.51 after the intervention. The Parent Vanderbilt scores decreased appreciably after implementation of the 6-week sleep hygiene routine, indicating a significant decrease in ADHD behaviors (Questions 1–9: p < .001, Cohen d = .473; Questions 10–18: p = .004, Cohen d = .329). Table 5 and Table 6 summarize statistical calculations. All caregivers (N = 53) completed the Patient Satisfaction Likert Survey; 87% of the responses were positive.
Study participants receiving sleep hygiene interventions had a significant reduction in ADHD symptoms and a significant improvement in sleep quality. The results substantiate the benefits of assessing sleep and instructing parents on clinical guideline-based behavior interventions incorporated into a sleep hygiene routine. The intervention was cost effective, conducive to a busy clinical setting, and easily tailored for use in pediatric primary care. The project showed the ease of assessing and treating sleep difficulties among children with ADHD and established documentation of interventions in the electronic medical record, to facilitate sharing with treatment team members and caregivers. The associated cost of assessing and treating sleep difficulties equated to provider and staff time; provider time totaled an additional 10 minutes/visit, and staff time totaled an additional 5 minutes/visit. Standardized sleep assessment and the provision of the prescriptive sleep hygiene routine occurred during routine office visits.
Strengths of the study included careful exclusion criteria for patients with medication changes, pharmaceutical and alternative sleep aids, and symptoms of obstructive sleep apnea. Additional strengths were modeling implementation of the clinical practice guideline, embedding the sleep hygiene routine in the electronic medical record, instructing a patient-specific sleep hygiene routine, and use of a brief standardized video. Each of the features shows the ease of replication of this project in other pediatric clinics. Although the overall sample size was acceptable (N = 53), convenience sampling was used to obtain the participants, and the innovation group had only 23 participants, limiting the generalizability.
We were surprised by the significant number of caregivers who declined to participate in this intervention. Most parents/caregivers who declined cited lack of time or their inability to implement the sleep hygiene routine in their home. As providers, we need to acknowledge how time requested for study participation, whether real or perceived by families, affects their willingness to participate in a collaboratively developed, individualized treatment plan. As the sleep hygiene innovation evolves in our clinical settings, we will consider providing sleep assessment surveys via electronic mail or before the follow-up visit, to decrease in-office time requirements and improve participation. We will also offer the sleep intervention to all children with ADHD who score 42 or greater on the CHSQ in an effort to improve sleep hygiene and reduce the effects of disordered sleep.
Children with ADHD benefit from standardized sleep assessments. Those with sleep disorders show both a significant improvement in sleep quality and a significant reduction in ADHD symptoms when provided with a patient-specific sleep hygiene routine and follow-up. Our outcomes align with the current literature and further validate the recommendation for behavior modification as the first-line treatment for sleep difficulties in children with ADHD. Future research will involve implementing this project across our remaining clinic sites, developing the standardized video in the Spanish language, and using technology to promote the continuation of the clinical practice change.