Case Series

Abstract

Objective: To assess the effectiveness and feasibility of behavioral sleep intervention for medicated children with ADHD. Method: Six medicated children (five boys, one girl; aged 6-12 years) with ADHD participated in a 4-week sleep intervention program. The main behavioral strategies used were Faded Bedtime With Response Cost (FBRC) and positive reinforcement. Within a case-series design, objective measure (Sleep Disturbance Scale for Children [SDSC]) and subjective measure (sleep diaries) were used to record changes in children’s sleep. Results: For all six children, significant decrease was found in the severity of children’s sleep problems (based on SDSC data). Bedtime resistance and mean sleep onset latency were reduced following the 4-week intervention program according to sleep diaries data. Gains were generally maintained at the follow-up. Parents perceived the intervention as being helpful. Conclusion: Based on the initial data, this intervention shows promise as an effective and feasible treatment.

Keywords

ADHD children faded bedtime response cost positive reinforcement

Introduction

ADHD affects about 3% to 7% of school-aged children worldwide (American Psychiatric Association [APA], 2000). In Malaysia, clinicians’ report that children with ADHD form a large proportion of clinical cases indicated that in a sample of admissions to a child psychiatric unit, children diagnosed with ADHD formed 25% of the cases (Woo & Teoh, 2007). According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; APA, 2000), ADHD is characterized by developmentally inappropriate symptoms of inattention, hyperactivity, and/or impulsivity, with onset before the age of 7 years, impaired functioning in two or more settings (e.g., at school and at home), and places children at risk for poorer long-term functioning in social, academic, and family domains (e.g., educational problems, peer relationship difficulties).

Sleep problems are common among children. Studies done in Western countries have estimated that sleep problems range from 10% to 45% for school-age children, whereas for adolescents the studies have reported rates ranging from 10% to 13% (Mahendran, Subramaniam, Cai, & Chan, 2006). There are two broad categories of sleep problem in children: dyssomnias and parasomnias. Dyssomnias are sleep disorders that include problems falling asleep, remaining asleep, and/or excessive daytime sleepiness (Stores, 2001). Parasomnias are a category of sleep disorders in which behaviors intrude on ongoing sleep and are classified according to the stage of sleep in which they usually occur (Stores, 2001). Mahendran et al. (2006) stated that sleep problems in children can impair the child’s development and they are often closely related to mental health problems.

The presence of sleep problems in children with ADHD has long been studied. The first scientific report of sleep problems in children with ADHD was published in 1971 by Small, Hibi, and Feinberg. The link between ADHD and sleep disturbances has also been evidenced by the addition of sleep problems as one of the ADHD diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM-III; APA, 1980; Cohen-Zion & Ancoli-Israel, 2004). Corkum, Moldofsky, Hogg-Johnson, Humphries, and Tannock (1999) reported that 25% to 50% of children and adolescents with ADHD had sleep problems. Besides, in a 6-month survey to estimate the prevalence of sleep problems in children and adolescents attending psychiatric services in Singapore, the researchers found that the highest prevalence of sleep problems was reported in children diagnosed with ADHD in which 77.3% of them suffered from any one sleep problem (Mahendran et al., 2006).

In addition, population-based surveys have also revealed a strong association between sleep problems and behavioral and emotional symptoms in children (Carvalho Bos et al., 2009). In a 2006 survey of 239 school-aged ADHD children, the investigators found that moderate or severe sleep problems were associated with poorer child psychosocial quality of life, child daily functioning, caregiver mental health, and family functioning. Children with moderate or severe sleep problems were also more likely to miss or be late for school, and their caregivers were more likely to be late for work when compared with children with no sleep problems (Sung, Hiscock, Sciberras, & Efron, 2008).

Researchers have found that when parents seek treatment for their child’s sleep problem, they tend to look more favorably on behavioral intervention rather than medically prescribed treatments (Wiggs & Stores, 1998). In addition, sleep expert do not encourage the use of sedative medication for the treatment of sleep disturbances in children as these medications may cause significant side effects and their long-term usefulness has yet to be demonstrated empirically (Wiggs & Stores, 2001). For example, research findings have indicated that antihistamines result in short-term improvements in children’s sleep; however, these improvements appear to be temporary and do not seem to increase the likelihood of a child sleeping through the night (Richman, Douglas, Hunt, Lansdown, & Levere, 1985).

The efficacy of behavioral sleep interventions has been demonstrated in the general population. However, no controlled trials of behavioral sleep interventions have been reported in children with ADHD. Only three studies (Mullane & Corkum, 2006; Piazza, Fisher, Roane, & Hilker, 1999) evaluated the effectiveness of a behavioral sleep intervention for sleep problems in unmedicated children with ADHD and it showed improvement in sleep for the participating children. Besides, behavioral sleep trials in children with challenging behaviors such as learning disabilities and autism suggest that behavioral sleep interventions can be effective (Kodak & Piazza, 2008).

In addition, a pilot randomized controlled trial study comparing a brief and extended sleep program in ADHD children with or without stimulant medications (Sciberras, Fulton, Efron, Oberklaid, & Hiscock, 2011) revealed that both brief and extended sleep programs were found to be feasible to deliver and acceptable to caregivers. Both programs resulted in a reduction in child sleep problems at 5 months post-randomization. Compared with the brief program, the extended program showed additional benefits of improved child psychosocial quality of life, child daily functioning, and parental anxiety.

Most of the studies are done using unmedicated children with ADHD as their participants; however, none of the studies examine the effectiveness of behavioral sleep intervention for children with ADHD who were also taking stimulant medication. Although research to date on the relationship between methylphenidate and sleep disturbances in children with ADHD remains somewhat unclear (Cohen-Zion & Ancoli-Israel, 2004), Schwartz and colleagues (2004) found that children with ADHD had significantly longer sleep onset latencies and shorter sleep durations when being treated with methylphenidate. Therefore, the present study aimed to determine the effectiveness of behavioral sleep intervention for medicated children with ADHD.

Method

Participants

Children diagnosed with ADHD between 6 and 12 years old were recruited to participate in the present research study while attending occupational therapy program at Department of Occupational Therapy of Hospital Pakar Sultanah Fatimah (HPSF), Muar Johor, Malaysia. ADHD diagnosis was made according to the DSM-IV-TR (APA, 2000). Sleep problems were diagnosed for the purpose of this study according to the information derived from parent interviews and the Sleep Disturbance Scale for Children (SDSC). In addition to employing these diagnostic criteria, the researcher also used the criteria described by Mindell and Durand (1993). Their criteria were as follows: (a) The child demonstrated the primary sleep concern a minimum of three nights per week and (b) the sleep problems were persistent (i.e., a minimum duration of 4 weeks). Besides, the children were also eligible if they were taking stimulant medication, attending school, and were providing parental authorization to participate in the intervention program. This age group was selected to ensure that the children would be young enough to require direct parental involvement in their bedtime routines and sleep habits.

Nine potential children were screened; three were ineligible (two not taking medication, one no sleep problems). Thus, six children (five boys, one girl) were participated. The children included an 8-year 4-month-old Malay boy (MF), 9-year 4-month-old Malay boy (MS), 9-year 8-month-old Chinese boy (AM), 6-year 10-month-old Malay girl (AS), 7-year 3-month-old Malay boy (AF), and 7-year 8-month-old Malay boy (MA). All the children were taking stimulant medication. Specifically, MF, AM, AS, and MA were taking 10 mg tablet Ritalin twice per day while MS and AF were taking 27 mg tablet Concerta (Concerta: Frequently Asked Questions About ADHD Medications, www.additudemag.com) once per day. The primary sleep problems in the children were primary insomnia and bedtime resistance. MF, AM, and AS demonstrated difficulty initiating and falling asleep. According to the parental report, it took about 1 hr for MF, 45 min for AM, and 35 min for AS to fall asleep in most nights. MS, AF, and MA were advised to perform bedtime resistances such as reluctant to go to bed and leaving bed repeatedly to avoid sleep disturbance. All the children were attending primary school during the duration of intervention except for AS who was attending preschool. In four cases, both parents were reportedly involved in implementing the intervention, but mothers took all telephone calls from the researcher for AF, AS, MA, and AM whereas in other cases, the father took all the telephone calls (MF and MS).

Materials

Demographic Questionnaire

Demographic questionnaire is a questionnaire designed to obtain information about family composition and the child’s medical history. This questionnaire was given during initial meeting, prior the implementation of the sleep intervention.

Behavioral Sleep Treatment

Parents learned about Faded Bedtime With Response Cost (FBRC) and positive reinforcement protocol and they were given written material about the sleep intervention.

SDSC

The SDSC is a 26-item parent-administrated questionnaire to examine childhood sleep problems on a 6-point Likert-type scale. SDSC have been found to have satisfactory internal consistency, to have adequate test–retest reliability, and to be a valid measure of discrimination between controls and clinical groups (Bruni et al., 1996).

Sleep Diary

The data collected from the sleep diary (Mullane & Corkum, 2006) provide both quantitative (i.e., time child went to bed, time child woke up, number of times the child called out to his or her parents, etc.) and qualitative (i.e., parents were asked to note any factors that affected sleep) information concerning the child’s sleep. Sleep diaries have been found to demonstrate reasonable validity, high internal consistency, and good agreement with actigraphic measures of children’s sleep (Wiggs & Stores, 1995).

Intervention Satisfaction Questionnaire (ISQ)

The ISQ is a questionnaire developed to measure parental perceptions of the effectiveness of the behavioral sleep intervention. The data obtained provided both qualitative and quantitative information in regard to the sleep intervention and were given to the parents to complete at the end of the program.

Procedures

Prior of this research study, ethical approval was obtained from the ethical committee of Faculty of Health Science, Universiti Teknologi MARA. Then, consent letter was sent to the Occupational Therapy Head of Department of HPSF. The program began with a meeting between the researcher and the child’s parents to obtain informed consent and discuss the particulars of the program. During the meeting, the parents were given a written material about behavioral sleep intervention. The parents were taught how to use the sleep diary. The sleep diary data were collected each day for the duration of the program, and the questionnaire (e.g., SDSC) was completed at the end of each week for the duration of the program. ISQ was completed at the end of the program.

Baseline

During a 1-week baseline period, the parents were given no instruction on how to manage their child’s sleep problems and they were asked not to change their way of responding to their child’s sleep difficulties. All measures such as sleep diary and SDSC were collected during this baseline period. After the 1-week baseline period had ended, the behavioral sleep program began.

Treatment

During 4 weeks treatment period, parents were asked to apply behavior sleep intervention they had learned. The first step in intervention was using baseline data to determine a bedtime at which rapid sleep onset (measure in minutes from the time parent indicate “lights out” on sleep diary to the time child reported to fall asleep) is highly probable. Initial bedtime was determined by calculating the average sleep onset time during baseline and then adding 15 min. The child was not allowed to go to bed or fall asleep prior to this time. Fading involved adjusting the child’s bedtime by 15 min each night based on latency to sleep onset for the previous night. If the child falls asleep within 15 min of bedtime, the bedtime was then made 15 min earlier on the next night. However, if the child does not fall asleep within 15 min of bedtime, the bedtime was made 15 min later on the subsequent night. This process was repeated until the child was consistently falling asleep within 15 min of his or her target bedtime.

The response cost component involved removing the child from bed and keeping him or her awake for 15 min if sleep is not initiated within 15 min of bedtime. At the end of 15 min, the child was returned to bed and the same procedure was repeated until he or she fell asleep within 15 min of going to bed.

Positive reinforcement component was used to increase adaptive bedtime behavior (e.g., going to sleep at bedtime) and to decrease maladaptive bedtime behavior (e.g., resisting bedtime). In this approach, the child was able to earn “token” each morning for meeting the expectation of the program. In addition, each day at an agreed upon time that was convenient for the family, the researcher called the parents to discuss and to answer any questions that the parents may have.

Follow-Up

During the 1-week post-intervention, the parents continued to implement the behavioral intervention, as well as to complete sleep diary and questionnaire. After the follow-up had concluded, the researcher met with the parents to have them complete ISQ as well as to pick up final measures (sleep diary and SDSC). Parents were also reminded on how to fade the behavioral program.

Results

As this study used a case-series design, data from all sources were compiled and graphed for each child individually. For the children who completed more than 1 week of baseline, the baseline data described below are reported as mean values across weeks.

SDSC

The SDSC data were collected weekly and then the corresponding T-score was used to summarize the data. The corresponding T-score within one standard deviation of the mean was considered normal (e.g., T-score between 40 and 60). During baseline, parents reported that the children demonstrated problems in areas of initiating and maintaining sleep. However, the improvement was reported after the FBRC and positive reinforcement were implemented. Specifically, from baseline to the final week of intervention, MF’s T-score on the SDSC decreased from 71 to 55, MS’s from 78 to 60, AM’s from 67 to 56, AF’s from 66 to 54, AS’s from 72 to 66, and MA’s from 80 to 58. These results suggest that the child’s sleep problem in areas of initiating and maintaining was normalized after the FBRC and positive reinforcement procedures were implemented.

Sleep Diary

As seen in Figure 1, MF’s mean sleep latency was recorded to be 41 min at baseline, which indicated that it took about 41 min for MF to fall asleep after the light was switched off. During Treatment Weeks 1 to 4, MF’s mean sleep latency was recorded to be 38, 30, 18, and 12 min, respectively. After the FBRC and positive reinforcement procedures were implemented, the mother reported a reduction in MF’s sleep latency. However, his mean sleep latency was slightly increased during the follow-up week (14 min).

Figure 1.

MF’s mean sleep onset latency in minutes, mean sleep duration in minutes, and mean bedtime resistance.

The mean data for baseline week indicated that MF was asleep for 551 min. During Treatment Weeks 1 to 4, MF was reported to be asleep for 514, 520, 530, and 525 min, respectively. The data showed that there was slight variation in MF’s average weekly sleep duration throughout the treatment week. Contrary to the expectation that behavioral sleep treatment increased the child’s sleep duration, MF’s mean sleep duration was, however, further decreased to 471 min during follow-up week, which suggested that he was asleep less than during the treatment weeks.

Episode of bedtime resistance was defined as the child calling out to parents and/or left bedroom prior to falling asleep and/or reluctant to go to bed. Blader, Koplewicz, Abikoff, and Foley (1997) defined bedtime resistance as problematic if it is difficult to get a child to bed more than three nights per week. Baseline data as reported by mother in sleep diary indicated that MF was calling out and reluctant to go to bed, which indicated problems with bedtime resistance (baseline = 7 nights, mean bedtime resistance = 3.24). As seen in Figure 1, MF demonstrated significant bedtime resistance during Treatment Weeks 1 to 3 (Week 1 = 7 nights, mean bedtime resistance = 3.36; Week 2 = 6 nights, mean bedtime resistance = 1.86; and Week 3 = 5 nights, mean bedtime resistance = 1.26). However, bedtime resistance was reduced to normal level for the remaining weeks (Week 4 = 3 nights, mean bedtime resistance = 0.57 and follow-up week = 2 nights, mean bedtime resistance = 0.43).

As seen in Figure 2, MS’s mean sleep latency was recorded to be 24 min at baseline, which indicated that it took MS an average of 24 min from the time it was light out to the time he fell asleep. During Treatment Week 1 to follow-up week, MS’s mean sleep latency was recorded to be 15, 11, 13, 9, and 5 min, respectively. Even though there was a slight increase in MS’s mean sleep latency during Treatment Week 3, his mean sleep latency was constantly declined at Treatment Week 4 and follow-up week after FBRC and positive reinforcement procedures were implemented.

Figure 2.

MS’s mean sleep onset latency in minutes, mean sleep duration in minutes, and mean bedtime resistance.

The mean data for baseline week indicated that MS was asleep for 399 min. During Treatment Weeks 1 to 2, there was a slight decrease in MS’s mean sleep duration. MS was reported to be asleep for 395 min for Week 1 and 391 min for Week 2. The most noteworthy changes were seen in his mean sleep duration during Treatment Week 3 through follow-up week. As reported by parents in sleep diary, MS was asleep for 421, 455, and 460 min, respectively.

MF also demonstrated significant bedtime resistance during baseline week through Treatment Week 2 (baseline = 7 nights, mean bedtime resistance = 1.53; Week 1 = 7 nights, mean bedtime resistance = 2.00; and Week 2 = 6 nights, mean bedtime resistance = 1.87). However, his bedtime resistance further decreased for the remaining weeks (Week 3 = 3 nights, mean bedtime resistance = 0.90; Week 4 = 2 nights, mean bedtime resistance = 0.50; and follow-up week = 3 nights, mean bedtime resistance = 0.41).

According to sleep diary data, AM’s mean sleep latency was recorded to be 45, 28, 8, 10, and 6 min from baseline week through Treatment Week 4, respectively. The result indicated that the behavioral sleep treatment substantially reduced AM’s sleep latency from that which was observed during the baseline week, according to sleep diary data. However, his mean sleep latency was slightly increased during the follow-up week (mean sleep latency = 19 min).

As depicted in Figure 3, the data suggested that AM’s mean sleep duration was increased from baseline, then slightly decreased during Treatment Week 2, and remained relatively increased until Treatment Week 4. Specifically, during baseline week through Treatment Week 4, AM was reported to be asleep for 485, 504, 448, 519, and 552 min, respectively. However, there was a dramatic decline in AM’s mean sleep duration during follow-up week (mean sleep duration = 492 min).

Figure 3.

AM’s mean sleep onset latency in minutes, mean sleep duration in minutes, and mean bedtime resistance.

AM demonstrated not much problems in bedtime resistance. Specifically, from baseline week through 1st week of treatment, AM’s bedtime resistance was three nights (mean bedtime resistance = 0.57) and four nights (mean bedtime resistance = 0.71), respectively. His bedtime resistance remained constant during Treatment Weeks 2 to 4 (Weeks 2, 3, and 4 = 3 nights, mean bedtime resistance = 0.43). However, follow-up data as reported by mother in sleep diary indicated that AM was calling out and reluctant to go to bed, which suggested problems with bedtime resistance (baseline = 4 nights, mean bedtime resistance = 0.53).

Reduction in AS’s sleep latency was reported by her mother after FBRC and positive reinforcement procedures were implemented. During Treatment Weeks 1 to 2, AS’s mean sleep latency was reduced from 35 min at baseline to 24 and 16 min, respectively. However, there was a slight increase in her sleep latency during Treatment Week 3 (mean sleep latency = 20 min), then continued to decrease during Treatment Week 4 and follow-up week (18 and 13 min, respectively).

As seen in Figure 4, the mean data indicated that AS was asleep for 452 min during baseline week. AS was reported to be asleep for 432, 451, 474, 465, and 508 min during Treatment Week 1 through follow-up week, respectively. The data showed that there was a slight variation in AS’s average weekly sleep duration throughout the end of treatment program. However, the results indicate that behavioral sleep treatment substantially increased AS’s sleep duration from that which was observed during the baseline week.

Figure 4.

AS’s mean sleep onset latency in minutes, mean sleep duration in minutes, and mean bedtime resistance.

Baseline data as reported by mother in sleep diary indicated that AS was calling out and reluctant to go to bed, which indicated problems with bedtime resistance (baseline = 5 nights, mean bedtime resistance = 1.45). As seen in Figure 4, AS demonstrated significant bedtime resistance during Treatment Week 1 (Week 1 = 5 nights, mean bedtime resistance = 1.86). However, her bedtime resistance was reduced to normal levels for the remaining weeks. Specifically, her bedtime resistance was three nights during Treatment Week 2 (mean bedtime resistance = 1.43), three nights during Treatment Week 3 (mean bedtime resistance = 1.14), three nights during Treatment Week 4 (mean bedtime resistance = 0.71), and two nights during follow-up week (mean bedtime resistance = 0.65). These data indicate that the behavioral sleep treatment reduced AS’s bedtime resistance.

As seen in Figure 5, the data suggested that AF had not much problems in initiating a sleep. Improvement in AF’s mean sleep latency can be seen during Treatment Weeks 1 to 3. During Treatment Weeks 1 to 3, AF’s mean sleep latency was recorded to be 10, 10, and 6 min, respectively. However, his mean sleep latency was slightly increased during Treatment Week 4 but then decreased during follow-up week. Specifically, during Treatment Week 4, his mean sleep latency was 13 and 11 min during follow-up week.

Figure 5.

AF’s mean sleep onset latency in minutes, mean sleep duration in minutes, and mean bedtime resistance.

The mean for sleep duration data indicated that AF was asleep for 598 min during baseline week. During Treatment Week 1, there was a distinct decline in his mean sleep duration (500 min) when compared with baseline week. However, his sleep duration further increased during Treatment Week 3 (620 min) and then declined during the remaining week. Specifically, from Treatment Week 3 through follow-up week, AF was reported to be asleep for 457, 480, and 500 min, respectively.

In addition, AF demonstrated significant bedtime resistance during baseline week through Treatment Week 2 (baseline = 7 nights, mean bedtime resistance = 5.14; Week 1 = 7 nights, mean bedtime resistance = 4.86; and Week 2 = 7 nights, mean bedtime resistance = 4.57). However, his bedtime resistance was reduced to normal level during Treatment Week 3 (3 nights, mean bedtime resistance = 3.50). As seen in Figure 5, his bedtime resistance turns to increase for the remaining weeks—specifically, five nights during Treatment Week 4 (mean bedtime resistance = 4.86) and four nights during follow-up week (mean bedtime resistance = 5.70).

According to sleep diary data, MA’s mean sleep latency was recorded to be 25 min at baseline, which indicated that it took about 25 min for MA to fall asleep after the light was switched off. The data showed that there was a slight variation in MA’s average weekly sleep latency throughout the treatment week. During Treatment Weeks 1 to 4, MA’s mean sleep latency was recorded to be 12, 14, 9, and 15 min, respectively. As seen in Figure 6, MA’s mean sleep latency during follow-up week (8 min) was less than during baseline week.

Figure 6.

MA’s mean sleep onset latency in minutes, mean sleep duration in minutes, and mean bedtime resistance.

As depicted in Figure 6, the mean sleep duration data for baseline week indicated that MA was asleep for 531 min. During Treatment Week 1, there was a slight decrease in MA’s sleep duration as compared with baseline week. However, from Treatment Weeks 2 to 4, his mean sleep duration was fairly constant (505, 496, and 499 min, respectively). Interestingly, his sleep duration was increased during follow-up week (mean sleep duration = 560 min), which suggested that behavioral sleep treatment was successfully increased MA’s mean sleep duration.

MA demonstrated significant problems in bedtime resistance. Data from sleep diary indicated that MA’s bedtime resistance was reduced from baseline week to Treatment Week 4. Specifically, from baseline week through Treatment Week 4, MA’s bedtime resistance was seven nights (mean bedtime resistance = 4.71), seven nights (mean bedtime resistance = 3.86), six nights (mean bedtime resistance = 2.00), four nights (mean bedtime resistance = 1.26), and three nights (mean bedtime resistance = 0.71), respectively. However, follow-up data indicated that MA bedtime resistance was increased than during treatment program (follow-up = 5 nights, mean bedtime resistance = 1.40).

Treatment Feasibility

The parents and the children who involved in the present study successfully fulfilled their roles and responsibilities, suggesting that the program was a feasible intervention for childhood sleep problems. Generally, the parents successfully implemented the strategies with support from the researcher.

The parents were asked to complete the ISQ to provide their feedback on the strength and/or weakness of the program. Parents perceived the intervention to be effective for addressing their child’s sleep problem (M rating = 3.50). They also perceived the information from the sleep diary and the daily telephone call from the researcher as helpful for understanding their children’s sleep problems (M ratings = 3.67 and 4.00, respectively). Besides, when asked what works best for the parents and child, four of the parents responded that response cost procedures were most important while two parents responded that positive reinforcement was most important. All parents stated that they would definitely recommend the program to others.

Discussion

This study aimed to examine the effectiveness of behavioral sleep intervention program tailored for six medicated children with ADHD using a case-series design. Based on the case-series data, it was suggested that this treatment program shows promise as a means of treating a number of common sleep problems in ADHD children (Mullane & Corkum, 2006; Piazza & Fisher, 1991).

Impact on Sleep/Effectiveness

Results indicated reductions in the severity of the six children’s dyssomnia (as measured by the SDSC) and reduction in bedtime resistance for all children at the end of 4-week intervention. As seen in Figures 1 to 4, there was a slight increase in the children bedtime resistance during Treatment Week 1. According to parental report, the positive reinforcement strategy reduced maladaptive bedtime behaviors (e.g., bedtime resistance); however, finding an effective reward was a challenge to the parents. Most of the parents were unsure about the best reward to be given to their child during the 1st week of treatment program. Therefore, it is possible to explain why there was an increase in children’s bedtime resistance at an early implementation of treatment program.

Although a previous study reported that bedtime resistance can be treated using behavioral intervention, the behavioral strategy used was different with this present study. Mullane and Corkum (2006) used systematic ignoring (SI) procedure in which the parents were instructed to gradually and systematically increase the time before responding to their child’s concern over an extended period of time, whereas the present study used token system to reduce bedtime resistance. SI procedure was not used because many parents find it challenging to ignore their child for a long period of time, which is required for this procedure to be effective. This approach was consistent with the existing literature, which indicates that different types of sleep disturbance are best treated by different behavioral strategies (Kuhn & Elliott, 2003).

The review of the literature yielded one study in which researchers used a bedtime fading procedure (Piazza & Fisher, 1991). In theory, delaying a child’s bedtime regulates sleep problems by increasing the probability of a short latency to sleep onset. To enhance the effectiveness of faded bedtime procedure, Piazza and Fisher (1991) added a response cost to the bedtime fading procedures, where the researchers assume that adding the response cost would result in more rapid fading of bedtime. The fading procedure is hypothesized gradually, and increase the child’s duration of sleep by gradually moving his or her bedtime earlier. For all six participants, mean sleep onset latency decreased following the intervention according to sleep diary. These improvements were relatively small but were maintained at follow-up for four children (MS, AS, MA, and AF). As seen in Figures 3, 5, and 6, the variability in night-by-night sleep onset latency appeared higher in three children (AM, MA, and AF) during the end of treatment and follow-up week than during the baseline week. These patterns may indicate that for these children, prolonged sleep latency is the natural state. The variability at the end of treatment and follow-up may reflect families’ effort to implement the treatment strategies they learned to adjust this natural state.

Norm for sleep duration indicates that a 7-year-old child should sleep approximately 10 hr 30 min per night (Ferber, 1985). Although the children’s sleep duration do not meet the recommended guideline of 10 hr 30 min, an interesting finding within this study was that sleep duration did increase over the 4 weeks of intervention for AS, AM, and MS (see Figures 2-4), but it had decreased for AF, MA, and MF. This finding was contrary with a previous study, which reported that FBRC procedures were unsuccessfully to increase sleep duration in three unmedicated children with ADHD (Mullane & Corkum, 2006). This suggested that behavioral sleep intervention was also effective for children with ADHD who are being treated with stimulant medication. However, it warrants further study as improvement was not seen in all the children and it may suggest that some of the benefits of this intervention may not be realized until a longer period of time has elapsed.

Treatment Feasibility

Implementing behavioral strategies for childhood sleep problem is challenging for all families; however, a number of obstacles are specific to medicated children with ADHD. Finding effective rewards for the positive reinforcement component of the program was a challenge. One modification was that stickers earned for positive sleep behaviors were cashed in more quickly than previous study (Mullane & Corkum, 2006) to maintain motivation. Besides, calling the parents daily at a time that was convenient for them provides a greater opportunity for their participation because they did not have to travel. More frequent calls to the family may offer the support necessary to ensure that the intervention was implemented accurately. However, as there were two families that had a very busy family schedule (AS and MA), daily telephone call was rescheduled into once per week during baseline and once every couple of days during 4-week intervention program. By offering this flexibility, the family still had an opportunity to participate and discuss without too much interference with the family daily lives.

Conclusion

The present study provides evidence for the effectiveness and feasibility of FBRC and positive reinforcement procedures in improving different sleep problems in medicated children with ADHD. Some implications for service providers have emerged from these findings. In fact, some children may benefit from FBRC and positive reinforcement procedures, so it is imperative that occupational therapy practitioners consider using this type of sleep intervention when working with children who are referred for sleep remediation in the hospital setting. Besides, occupational therapy practitioners can also use the information obtained when providing sleep consultation to the parents.

Despite these generally promising results, further research must address a number of limitations inherent within a case-series design (e.g., no control group). Without a control group, the researcher cannot disprove that the positive changes documented in this study are the result of factors other than sleep intervention. It is possible that changes in the child’s daytime activities could have been a confounding variable. With regard to the present study, it should be noted that the sleep intervention begin during school holiday and Treatment Week 1, the children begin attending primary school.

Most important, result of this study was derived mostly from subjective measure based on parents’ report on their child sleep. Research reported that parental report of some aspect of children’s sleep may be inconsistent with objective measures (Sadeh, 1994, 1996), so it will be important for further research to include objective and subjective measures of sleep whenever possible to determine the effectiveness of FBRC with positive reinforcement procedures in treating sleep problem in medicated children with ADHD.

Another limitation is that the result of this study may not be generalizable to a wider population of children with ADHD from such a small sample. Further research is needed to determine whether older and/or younger medicated children with ADHD might benefit from such an intervention program. A fourth limitation is that the program was designed for 4 weeks. Although the length of treatment did not appear to have any effect on outcome, it may suggest that some of the benefits of this intervention may not be realized until a longer period of time has elapsed.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Jayachandran Vetrayan, MOT (Neuroscience), Msc (Psychology), is a lecturer at the Department of Occupational Therapy, Faculty of Health Science, Universiti Teknologi MARA (UiTM), Puncak Alam Campus, Malaysia.

Suhana Othman, BOT, is an occupational therapist at the Department of Occupational Therapy, Faculty of Health Science, Universiti Teknologi MARA, Puncak Alam Campus, Malaysia.

Smily Jesu Priya Victor Paulraj, MOT (Neuroscience), is a lecturer at the Department of Occupational Therapy, Faculty of Health science, Universiti Teknologi MARA (UiTM), Puncak Alam Campus, Malaysia.

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