An Open-Label Pilot Trial of a Brief,Parent-Based Sleep Intervention in Children With ADHD

Abstract

Objective:

To assess the effects of a brief parent-based behavioral sleep intervention in children with ADHD.

Methods:

Families with a child with ADHD and parent-reported sleep problems received a brief parent-based sleep intervention, which involved two one-to-one consultation sessions and one telephone follow-up with the parent/caregiver. Child’s sleep and clinical symptoms, and parental sleep and daytime functioning were assessed at baseline, 2-week post-intervention, and 3-month follow-up.

Results:

Sixty eligible families (mean age of the child: 9.4 ± 1.5 years; boys: 75%) were recruited, and 43 (72%) completed the whole intervention. The intervention resulted in significant improvements in the child’s sleep, clinical symptoms, and parental sleep and parenting stress, and these improvements were generally maintained at 3-month follow-up.

Conclusion:

The findings supported the promising effects of a brief parent-based sleep intervention on improving sleep and clinical symptoms in children with ADHD and parental sleep and parenting stress. Further randomized clinical trials with long-term follow-up are needed to test the robustness of the effectiveness of the intervention.

Keywords

ADHD sleep insomnia behavioral intervention daytime·behaviur children

Introduction

ADHD is a common neurodevelopmental disorder with childhood onset, affecting approximately 5% to 10% of school-aged children worldwide (Scahill & Schwab-Stone, 2000). It is characterized by the impairments associated with inattention, hyperactivity, and impulsivity. (Posner, Polanczyk, & Sonuga-Barke, 2020; Ros & Graziano, 2018). ADHD is associated with high rates of psychiatric comorbidities, such as sleep disorders, conduct disorder, and mood disorders (Accardo et al., 2012).

Insomnia, characterized by bedtime resistance, sleep onset delay, and frequent nocturnal awakenings, is the most common sleep problem in children with ADHD (P. P. Corkum, Davidson, Tan-MacNeill, & Weiss, 2014). It was reported that approximately 71% of children with ADHD had insomnia symptoms (Sung, Hiscock, Sciberras, & Efron, 2008), which is much higher than that of reported in typically developing children (20%–30%; Calhoun, Fernandez-Mendoza, Vgontzas, Liao, & Bixler, 2014). Insomnia, if left untreated, is not only associated with increased ADHD severity, but also linked to an increased risk for internalizing and externalizing behavior problems, and poorer treatment response in children with ADHD (Craig, Weiss, Hudec, & Gibbins, 2020; X. Li et al., 2022; Virring, Lambek, Jennum, Moller, & Thomsen, 2017).

In addition to the negative impacts on the child, sleep problems in children with ADHD also have significant negative effects on parents’ own sleep, mental health, and parenting stress. A systematic review showed that parents of children with neurodevelopmental disabilities, including ADHD, reported poorer subjective sleep quality in comparison to the parents of typically developing children (Micsinszki, Ballantyne, Cleverley, Green, & Stremler, 2018). Parents of children with ADHD also experienced higher rates of depression than parents of children without ADHD (Martin, Papadopoulos, Rinehart, & Sciberras, 2021). Sung et al. (2008) found that parents with a child with ADHD and comorbid sleep problems were 2.7 times more likely to be clinically depressed, stressed, or anxious, as compared to those parents with a child with ADHD who does not have sleep problems. Moreover, previous research has suggested that sleep problems in children with neurodevelopmental disorders (e.g., autism spectrum disorder) were associated with increased parenting stress (Martin, Papadopoulos, Chellew, Rinehart, & Sciberras, 2019).

Given that sleep problems, especially insomnia, are prevalent and may lead to a constellation of daytime functioning impairments in children with ADHD and their parents, there is a need to consider targeted intervention to manage sleep problems in this vulnerable group. In this regard, there has been some, albeit limited, research to examine the effects of sleep-focused interventions in children with ADHD. Some promising results have been reported to support the effectiveness of behavioral sleep intervention in alleviating sleep problems and reducing insomnia symptoms, such as sleep onset delay and night wakings in children with ADHD (P. Corkum et al., 2016; Hiscock et al., 2019; Hiscock et al., 2015; Keshavarzi et al., 2014; Sciberras et al., 2020). Nevertheless, despite the positive effects of behavioral sleep intervention on improving sleep for children with ADHD, its effects on the child’s daytime behaviors and functioning remained inconclusive. Whilst some studies have shown the benefits of behavioral sleep intervention on improving daytime symptoms, such as inattentiveness, hyperactivity, and internalizing and externalizing symptoms, in children with ADHD (P. Corkum et al., 2016; Hiscock et al., 2015; Keshavarzi et al., 2014; Sciberras et al., 2020), others failed to find any significant improvement in ADHD symptoms, behavior, or quality of life, after the behavioral sleep intervention delivered by pediatricians or psychologists in the community settings (Hiscock et al., 2019). Furthermore, despite the evidence showing the negative impacts of sleep problems on parents’ own sleep, mental health, and parenting stress, there has been a lack of study that examined whether interventions for sleep problems in children with ADHD could also improve parent-related outcomes.

Therefore, the current study aimed to examine the effects of a brief parent-based behavioral sleep intervention on sleep and clinical symptoms in children with ADHD and parent-reported sleep problems, as well as parental sleep, mental health, and parenting stress. We hypothesized that (1) after receiving a brief parent-based behavioral sleep intervention, children with ADHD and sleep problems would show improvements on sleep and clinical symptoms at post-intervention and 3-month follow-up; and (2) parents of children with ADHD and sleep problems would show improvements on their own sleep, mental health, and parenting stress at post-intervention and 3-month follow-up.

Methods

Study Participants and Procedure

Potential families with a child with a diagnosis of ADHD were recruited between December 2016 to December 2019 from one of the following sources: 1. Families with a child with ADHD were referred by their attending psychiatrists at the child psychiatric clinic of a local hospital in Hong Kong; 2. Invitation letters were sent to the special educational needs coordinators (SENCOs) of 112 local primary schools. The SENCOs were invited to help to distribute the research flyers to children with ADHD individually; 3. Research posters were sent out to self-help groups of parents of children with ADHD to reach out to potential families. Ethical approval was obtained from the Human Research Ethics Committee (Reference no: EA1903023) at the University of Hong Kong and the Joint Chinese University of Hong Kong-New Territories East Cluster Clinical Research Ethics Committee (Reference no: 2016.549).

Potentially interested parents were initially contacted via phone to undergo a brief assessment to ascertain the presence and severity of sleep problems of their child. Parents were asked in the phone screening interview whether their child had experienced sleep problems, including “difficulty initiating sleep, resisting going to bed, difficulty maintaining sleep, or early morning awakening” in the past 4 weeks (Sung et al., 2008). If affirmative, they were further asked to rate their subjective impression of the overall severity of the child’s sleep problem as mild, moderate, and severe (X. Li et al., 2022). Families that reported their child had moderate to severe sleep problems were subsequently invited to attend a face-to-face clinical interview to ascertain the eligibility. Inclusion criteria included: (1) children aged between 6 and 12 years; (2) having a diagnosis of ADHD (any subtype) as confirmed by the Diagnostic Interview Schedule for Children—Version-IV (DISC-IV); and (3) with parent-reported moderate to severe sleep problem. Exclusion criteria included: (1) having a serious medical condition (e.g., severe cerebral palsy) or intellectual disability; (2) having a neurological and/or medical condition that could potentially have an effect on the child’s sleep (e.g., epilepsy, endocrine disorders, and traumatic injury); (3) having a clinical diagnosis of sleep disorders other than insomnia (e.g., sleep-disordered breathing, restless legs syndrome/periodic limb movements, and circadian rhythm sleep-wake disorders), that may potentially lead to a disruption in sleep continuity and quality. To further exclude those children with possible sleep apnea, we also excluded those children who scored frequently (five to seven times/week) on item 29 (Stops breathing whilst sleeping) and item 30 (Snorts and gasps during sleep) in Children’s Sleep Habits Questionnaire (CSHQ); (4) having been receiving specialized help for the child’s sleep problem from a psychologist or in a specialist sleep clinic; and (5) impaired vision or hearing deficit. For those eligible families, parents were asked to complete a battery of questionnaires to assess the family’s demographics, the child’s health conditions, sleep characteristics, ADHD symptoms, emotional and behavioral symptoms, and daytime functioning, as well as parental sleep, mental health, and parenting stress. Children and their parents were also asked to wear a wrist actigraphy (Actiwatch Spectrum PRO, Philips—Respironics) to objectively measure their sleep at home for seven consecutive days at each assessment timepoint, whilst parents were asked to complete a sleep diary for themselves as well as for their children. All the study participants were assessed at baseline, at 2-week post-intervention, and at 3-month follow-up. Families were asked to provide their feedback on their perceived usefulness of the intervention at the post-intervention assessment by responding to 13 closed-ended questions and 3 open-ended questions.

Intervention

The interventions were provided by three trained therapists (master’s level clinical psychology trainees: FLF Lau, WV Chiu, CKD Wong) supervised by a qualified clinical psychologist with extensive training in behavioral sleep medicine (SX Li). The intervention program consisted of two face-to-face individual consultation sessions and one brief follow-up telephone consultation with a therapist. The individual consultations were held 2 weeks apart while the telephone follow-up was arranged 2 weeks after the second face-to-face consultation session. All the intervention consultation sessions were attended by a parent/caregiver of the targeted child.

The first session was held for approximately 1.5 hours. It was focused on a thorough assessment of the child’s sleep problems, followed by providing sleep-related psychoeducation to the parents. Parents were taught about sleep hygiene and behavioral strategies (e.g., bedtime fading) to manage insomnia symptoms in children with ADHD. For example, for children with limit-setting problems, their parents were suggested to enforce extinction and reinforcement schedule, such that they should ignore the children’s protests and reward their compliance on bedtime routines. For children with difficulties in falling asleep without parental presence, their parents were suggested to gradually eliminate their presence in the children’s bedroom over 2 weeks (i.e., stimulus fading). Parents were suggested to apply the discussed strategies after the session. A pamphlet containing the psychoeducation materials and a variety of behavioral strategies to address sleep problems was given to the parents after the session. Parents were also asked to complete a sleep diary to monitor their child’s sleep patterns in the subsequent 2 weeks. The second consultation session lasted about 45 minutes, with a focus on reviewing the treatment progress (e.g., review of sleep diary), clarifying the discussed strategies, problem-solving the issues encountered when implementing the strategies at home, and reinforcing the gains and changes. A brief telephone consultation session (about 15 minutes) for further troubleshooting and follow-up was held 2 weeks after the second consultation. The treatment sessions were video-taped and were randomly reviewed by SX Li, and the therapist met for supervision regularly to ensure the treatment fidelity.

Measurements

Child-Related Measurements

Sleep-Related Measures

The Chinese version of Children’s Sleep Habits Questionnaire (CSHQ)—parent-report is a validated 33-item parent-report measure of difficulties initiating and maintaining sleep over the past week in children aged 4 to 12 years (Cronbach’s alpha = .73; S. H. Li et al., 2007). Items are rated on a three-point scale from “rarely” to “usually.” The total sleep disturbance score ranges from 33 to 99. For the current study, three subscales were used to measure the severity of insomnia symptoms in this age group: bedtime resistance (six items; score range: 6–18), sleep onset delay (one item; score range: 1–3), and night wakings (three items; score range: 3–9).

Measure of ADHD Symptoms

Strengths and Weaknesses of ADHD symptoms and normal-behavior (SWAN)—parent report is an 18-item questionnaire to assess the severity of ADHD symptoms. SWAN has been validated locally for use in Chinese children in Hong Kong (Cronbach’s alpha = .90) (Lai et al., 2013). Parents were asked to compare their child’s inattention and hyperactivity behaviors with children of the same age using a 7-point scale. Scores range from −3 (far better than peers) to +3 (far worse than peers), with 0 denoting average behavior. Items were averaged for a total score. Higher scores represent more severe ADHD behaviors.

Measures of Emotional and Behavioral Symptoms

Child Behavior Checklist (CBCL) was used to assess behavioral and emotional symptoms in each child. It is a validated 118-item parent-report measure to assess externalizing and internalizing symptoms in children (Achenbach, 2001). The validated Chinese version was used (Cronbach’s alpha = .83; Leung et al., 2006). Age- and sex-standardized T scores for total, externalizing, and internalizing symptoms were calculated.

Measures of Daytime Sleepiness and Quality of Life

The validated Chinese version of the Pediatric Daytime Sleepiness Scale (PDSS) was used to measure the child’s daytime sleepiness (Cronbach’s alpha = .80; Yang et al., 2010). The PDSS has eight items, and the total scores range from 0 to 32, with higher scores indicating greater daytime sleepiness.

Pediatric Quality of Life Inventory 4.0 (PedsQL) is a validated 23-item measure of quality of life for children aged 2 to 18 years, with a good internal consistency of 0.86 (Varni et al., 2003). Each item is rated on a 5-point Likert scale from “never” to “almost always” based on the behavior of child in the past month. The scores are transformed on a scale from 0 to 100, with a higher score indicating better quality of life.

Parent-Related Measurements

Sleep-Related Measures

Pittsburgh Sleep Quality Index (PSQI) was used to measure parental subjective sleep quality. PSQI is a validated 19-item measure used to assess sleep habits, quality, and quantity. PSQI total score ranges from 0 to 21, and a higher score reflects worse sleep quality. The validated Chinese version was used (Tsai et al., 2005).

Insomnia Severity Index (ISI) was used to measure insomnia symptoms. It is a 7-item questionnaire validated to measure the severity of insomnia and has been shown to be sensitive to treatment-related changes (Morin et al., 2011). Items are rated on a 5-point scale from “not at all” to “extremely.” The total score ranges from 0 to 28, and a higher score indicates more severe insomnia symptoms.

Mental Health Measures

Depression Anxiety Stress Scales—21 item (DASS-21) is a validated 21-item measure of adult mental health (Cronbach’s alpha = .95), with specific subscales on depression, anxiety, and stress (Lovibond & Lovibond, 1995). Items are rated on a 4-point scale from “not at all” to “most of the time,” with higher scores representing greater difficulties. The validated Chinese version was used (Moussa et al., 2016).

Measure of Parenting Stress

Parental Stress Index—Short Form (PSI-SF) is a validated 36-item measure designed to assess parenting distress, parent-child dysfunctional interaction, and difficult child (Cronbach’s alpha = .81; Abidin et al., 2006). Higher scores indicate higher parenting stress. The validated Chinese version was used (Yeh et al., 2001).

Objective Measure of Sleep (Child and Parent)

Actigraphy was used to objectively measure night-time sleep of both children with ADHD and their parents. They were instructed to wear actigraphy on their non-dominant hand continuously for seven consecutive days. They were also instructed to press the event marker button on the device when going to bed at night and waking up in the morning, as well as when they took off the device (e.g., taking shower or swimming). Parents of children with ADHD were instructed to complete a sleep diary every morning over 7 days for both their children and themselves. The sleep diary collected one’s sleep related information, such as time to bed, sleep latency, wake after sleep onset, wake time, the time out of bed, the times and reasons for taking off the device and medication use where applicable.

Actigraph was configured to record in 1-minute epochs. Actigraphic data were analyzed using Actiware software version 6.0.9 (Philips Respironics, Murrysville, USA), which uses a validated algorithm to score each epoch as either wake or sleep (Weiss et al., 2010). Rest intervals (i.e., time in bed) were manually set following a standardized actigraphy scoring protocol (Patel et al., 2015) using the inputs in the following order of importance: (1) event marker, (2) sleep diary, (3) white light intensity, (4) activity level. Sleep parameters generated for the analysis in this study included time in bed (TIB), total sleep time (TST), sleep onset latency (SOL), sleep efficiency (SE), wake after sleep onset (WASO), and the number of awakenings. SE was derived as follows: SE = (TST/TIB) × 100%. The number of awakenings was determined as the number of times children were awake (for 1 or more minutes) after sleep onset. Children and parents with at least 5 days of complete actigraphic data were included in the analysis (Acebo et al., 1999).

Feedback Form

A feedback form with 13 closed-ended questions and 3 open-ended questions was specifically designed to evaluate the program. Items 1 to 4 on sleep-specific outcomes were rated on a scale from 1 (strongly agree) to 5 (strongly disagree). Items 5 to 7 on intervention design were rated on a scale from 1 to 5, with 1 representing “too much/long,” 3 representing “just right,” and 5 representing “too little/short.” Items 8 to 13 on intervention content, parent’s own participation level and satisfaction with the program were rated on a scale from 1 (strongly agree) to 5 (strongly disagree). The three open-ended questions included: “What did you find most helpful about the program?” “What was least helpful about the program?” “Do you have any other suggestions or comments?”

Statistical Analysis

Descriptive analyses were conducted to examine the socio-demographic characteristics of the families that received the intervention. Chi-square analysis and independent Student’s t-test were used to compare baseline characteristics between the families who completed the intervention and those dropouts. Linear mixed models for repeated measures, with compound as the covariance structure, were used to evaluate the treatment effect on the outcome variables, with time (baseline, 2-week post-intervention, and 3-month follow-up) as the fixed effect. These models produced an unbiased estimation of the intervention effect, assuming that data were missing at random using maximum-likelihood methods. Cohen’s d was used to calculate the effect size. A Cohen’s d value of 0.2 to 0.5, 0.5 to 0.8, and 0.8 or higher were considered as small effect, medium effect, and large effect, respectively. All the statistical tests were based on a .05 level of significance. All the statistical analyses were performed using Statistical Package System Software (SPSS) Version 24.0.

Results

Participants

A total of 75 families that met the study criteria were recruited into this study. Figure 1 shows the flowchart of the study. Fifteen participants dropped out after the baseline assessment due to various reasons (e.g., being too busy to attend the treatment sessions due to other commitments, changed mind/no longer interested in the program). A total of 60 families received the intervention, in which 43 (72%) completed the whole intervention program (two face-to-face consultation sessions + one telephone follow-up consultation). Of 43 families who completed the intervention, 38 completed the 2-week post-intervention follow-up assessment, and 27 completed the 3-month follow-up assessment. Baseline characteristics of the sample are presented in Table 1. The child sample was predominantly boys (75%) with a mean age of 9.4 ± 1.5 years. The majority of the caregivers who attended the intervention session were mothers (91.7%). There were no significant differences in child’s age, sex, baseline CSHQ total sleep disturbance score, use of medication for ADHD, and comorbidities, as well as attendees’ education level and employment status, between the families who completed the intervention and those who did not (Table 2, all ps > .05).

Figure 1.

Flowchart of the study.

Table 1.

Socio-demographic Characteristics of the Families That Received the Intervention.

Characteristics	N = 60
Index child
Boys, n (%)	45 (75)
Age, years (mean ± SD)	9.4 ± 1.5
CSHQ total sleep disturbance score (mean ± SD)	58.24 ± 8.32
Medication, n (%)	26 (43.4)
None	34 (56.7)
Ritalin or Ritalin LA (Novartis Pharmaceuticals, Basel, Switzerland)	18 (30)
Concerta (Janssen Pharmaceuticals, Schaffhausen, Switzerland)	12 (20)
Strattera (Eli Lilly Pharmaceuticals, Indianapolis, USA)	9 (15)
Other neuropsychiatric comorbidities, n (%)
None	57 (95)
Autism spectrum disorder	3 (5)
Family background
Maternal characteristics
Age, years (mean ± SD)	40.02 ± 5.75
Maternal education level, secondary school, or below, n (%)	25 (41.7)
Employed, n (%)	29 (48.3)
Paternal characteristics
Age, years (mean ± SD)	44.7 ± 6.3
Paternal education level, secondary school, or below, n (%)	25 (41.7)
Employed, n (%)	45 (75)
Household monthly income, HKD$30,000 or below, n (%)	22 (36.7)
Caregiver who attended the treatment session, mother, n (%)	55 (91.7)

Abbreviations: CSHQ = The Children’s Sleep Habits Questionnaire; SD = standard deviation. US$1 = HKD$7.8.

Table 2.

Comparisons of the Families Who Completed the Intervention and Those Dropouts.

Characteristics	Completers (N = 43)	Dropouts (N = 17)	t or χ²	p Value
Index child
Boys, n (%)	31 (72.1)	14 (82.4)	0.684	.408
Age, years (mean ± SD)	9.35 ± 1.56	9.53 ± 1.47	−0.412	.682
CSHQ total sleep disturbance score (mean ± SD)	57.76 ± 8.48	59.92 ± 7.86	0.057	.434
Medication, n (%)	18 (41.86)	8 (47.06)	0.134	.714
None	25 (58.14)	9 (52.94)	0.134	.714
Ritalin or Ritalin LA (Novartis Pharmaceuticals, Basel, Switzerland)	14 (32.56)	4 (23.53)	0.472	.491
Concerta (Janssen Pharmaceuticals, Schaffhausen, Switzerland)	7 (16.28)	5 (29.41)	1.313	.252
Strattera (Eli Lilly Pharmaceuticals, Indianapolis, USA)	7 (16.28)	2 (11.76)	0.194	.659
Comorbidity, n (%)^a	2 (4.6)	1 (5.9)	0.038	.843
Family background
Maternal characteristics
Age, years (mean ± SD)	40.14 ± 5.87	39.64 ± 5.54	0.25	.803
Maternal education level, secondary school, or below, n (%)	20 (52.6)	5 (55.6)	0.025	.874
Employed, n (%)	20 (46.5)	9 (52.9)	0.202	.653
Paternal characteristics
Age, years (mean ± SD)	44.94 ± 5.99	43.91 ± 7.48	0.47	.64
Paternal education level, secondary school, or below, n (%)	18 (50)	7 (77.8)	2.25	.134
Employed, n (%)	34 (97.1)	11 (100)	0.321	.571
Household monthly income, HKD30,000 or below, n (%)	18 (50)	4 (36.4)	0.629	.428
Caregiver who attended the treatment session, mother, n (%)	40 (93)	15 (88.2)	0.366	.545

Abbreviations. CSHQ = The Children’s Sleep Habits Questionnaire; SD = standard deviation. US$1 = HKD$7.8.

Comorbidity included the diagnosis of autism spectrum disorder.

Treatment Effects on the Child’s Sleep

As shown in Table 3 and Supplemental Table 1, there was a significant change in CSHQ total sleep disturbance score (p = .001), where CSHQ total sleep disturbance score was significantly reduced from baseline to post-intervention assessment (Cohen’s d = −0.677, p = .001) and 3-month follow-up assessment (Cohen’s d = −0.665, p = .001), whilst there was no significant difference between post-intervention and 3-month follow-up (p = .815). In terms of the three CSHQ subscales specifically measuring insomnia symptoms, CSHQ sleep onset delay was significantly decreased at post-intervention (Cohen’s d = −0.557, p = .008) and 3-month follow-up (Cohen’s d = −0.473, p = .027) as compared to baseline. CSHQ night wakings was significantly decreased at 3-month follow-up (Cohen’s d = −0.473, p = .027) as compared to baseline. No significant changes were found in CSHQ bedtime resistance at post-intervention (p = .35) and 3-month follow-up (p = .31) compared to baseline.

Table 3.

Changes of the Child’s Sleep and Daytime Behaviors.

	Baseline	Post-intervention	Post-3 month follow-up	F	p-value
	Mean ± SD	Mean ± SD	Mean ± SD	F	p-value
Sleep symptoms
CSHQ total sleep disturbance score	56.21 ± 8.05	51.11 ± 6.8	51 ± 7.67	8.573	<.001***
CSHQ bedtime resistance	9.68 ± 3.29	9.16 ± 2.34	9.04 ± 2.98	0.615	.546
CSHQ sleep onset delay	2.25 ± 0.78	1.84 ± 0.68	1.89 ± 0.75	4.509	.014*
CSHQ night wakings	4.19 ± 1.14	3.92 ± 1.12	3.7 ± 1.14	2.333	.11
Sleep diary measures
TIB, hours	9.13 ± 0.68	9.04 ± 0.81	8.98 ± 0.56	0.358	.703
TST, hours	8.12 ± 0.82	7.92 ± 0.79	8.53 ± 1.22	9.812	.005**
SOL, minute	29.73 ± 12.91	22 ± 15.22	19.9 ± 11.23	2.892	.094^
SE, %	88.24 ± 4.62	89.09 ± 5.84	91.82 ± 3.91	7.273	.007**
WASO, minute	4.7 ± 6.75	3.06 ± 4.46	2.89 ± 3.92	1.247	.334
#Awakenings, N	0.6 ± 0.59	1.05 ± 1.35	0.61 ± 0.62	0.822	.465
Actigraphy sleep measures
TIB, hours	9.12 ± 0.77	8.76 ± 0.95	8.64 ± 0.61	4.255	.024*
TST, hours	7.46 ± 0.60	7.2 ± 0.88	7.21 ± 0.67	0.431	.656
SOL, minute	25.19 ± 14.45	16.19 ± 11.33	12.01 ± 9.69	12.088	<.001***
SE, %	82.06 ± 4.51	83.05 ± 5.86	86.47 ± 5.45	7.891	.002**
WASO, minute	57.65 ± 18.44	58.14 ± 19.53	48.14 ± 25.65	1.83	.184
#Awakenings, N	33.6 ± 10.51	31.91 ± 8.42	29.39 ± 11.57	0.344	.712
ADHD symptoms
SWAN total score	1.24 ± 0.86	0.98 ± 0.84	0.86 ± 0.85	3.364	.046*
SWAN inattention	1.39 ± 0.9	1.11 ± 0.83	1.17 ± 0.79	2.152	.131
SWAN hyperactivity	1.1 ± 0.98	0.85 ± 0.95	0.79 ± 1.02	4.188	.024*
Emotional and behavioral symptoms
CBCL total score	62.5 ± 9.52	58.63 ± 9.94	60.15 ± 11.86	6.625	.004**
CBCL internalizing symptoms	58.56 ± 10.64	56.97 ± 9.52	57.56 ± 13.76	0.987	.383
CBCL externalizing symptoms	60.9 ± 10.14	57.68 ± 10.29	56.85 ± 9.93	4.016	.028*
Daytime sleepiness
PDSS score	19.18 ± 4.57	17.87 ± 4.9	19 ± 5.36	2.129	.138
Quality of life
PedsQL total score	65.76 ± 15.02	67.63 ± 14.97	65.59 ± 11.27	0.171	.844

Abbreviations: # Awakenings = number of awakenings; CBCL = Child Behavior Checklist; CSHQ = The Children’s Sleep Habits Questionnaire; PDSS = Pediatric Daytime Sleepiness Scale; PedsQL = the Pediatric Quality of Life Inventory; SD = standard deviation; SE = sleep efficiency; SOL = sleep onset latency; SWAN = strengths and weaknesses of ADHD symptoms and normal behavior; TIB = time in bed; TST = total sleep time; WASO = wake after sleep onset.

***

p < .001. **p < .01. *p < .05. ^p < .1.

Child’s sleep diary showed that there were significant changes in TST (p = .005) and SE (p = .007), as well as a marginally significant change in SOL (p = .094), as shown in Table 3. Specifically, as shown in Supplemental Table 1, TST was increased from baseline to 3-month follow-up with a marginal significance (Cohen’s d = 0.441, p = .057), and significantly increased from post-intervention assessment to 3-month follow-up (Cohen’s d = 0.635, p = .01). SOL was decreased from baseline to post-intervention assessment with a marginal significance (Cohen’s d = −0.568, p = .093), and significantly reduced from baseline to 3-month follow-up (Cohen’s d = −0.799, p = .032). SE was significantly increased from baseline to 3-month follow-up (Cohen’s d = 0.818, p = .003).

In terms of the actigraphy-based sleep outcome, as shown in Table 3, there were significant changes in the child’s TIB (p = .024), SOL (p < .001), and SE (p = .002). Post-hoc pairwise comparisons (see Supplemental Table 1) showed a significant decrease in TIB from baseline to 3-month follow-up (Cohen’s d = −0.666, p = .009). SOL was significantly decreased from baseline to post-intervention (Cohen’s d = −0.68, p = .004) and 3-month follow-up (Cohen’s d = −1.001, p < .001), whilst there was no significant difference between post-intervention and 3-month follow-up (p = .169). SE was significantly increased at 3-month follow-up (Cohen’s d = 0.937, p = .001) and post-intervention assessment (Cohen’s d = 0.613, p = .023) compared with baseline. WASO was decreased at 3-month follow-up compared to post-intervention at a marginal significance (Cohen’s d = −0.462, p = .076).

Treatment Effects on the Child’s Clinical Symptoms and Daytime Functioning

As shown in Table 3, there were significant changes in SWAN total score (p = .046) and SWAN hyperactivity score (p = .024). Specifically, as shown in Supplemental Table 1, SWAN total score was decreased from baseline to post-intervention, although this difference was of marginal significance (Cohen’s d = −0.309, p = .067). The SWAN total score was significantly decreased at 3-month follow-up compared to baseline (Cohen’s d = −0.45, p = .013). Whilst there was no significant difference in the SWAN hyperactivity score between baseline and post-intervention (p = .169), the SWAN hyperactivity score decreased significantly at 3-month follow-up compared to baseline (Cohen’s d = −0.317, p = .008), and decreased at 3-month follow-up compared to post-intervention (Cohen’s d = −0.063, p = .063) at a marginal significance. The SWAN inattention score was also decreased from baseline to post-intervention (Cohen’s d = −0.324, p = .05) and from baseline to 3-month follow-up (Cohen’s d = −0.256, p = .071), albeit at a marginal significance.

As shown in Table 3 and Supplemental Table 1, there was a significant change in the CBCL total score (p = .004). Post-hoc pairwise comparisons showed that the CBCL total score was significantly decreased at post-intervention (Cohen’s d = −0.405, p = .008) and 3-month follow-up (Cohen’s d = −0.234, p = .004) as compared to baseline. Significant changes were also found in CBCL externalizing symptoms (p = .028). Specifically, CBCL externalizing symptoms were significantly decreased at post-intervention (Cohen’s d = −0.32, p = .043) and 3-month follow-up (Cohen’s d = −0.407, p = .011) compared to baseline.

As shown in Table 3 and Supplemental Table 1, PDSS score was decreased at post-intervention compared to baseline at a marginal significance (Cohen’s d = −0.283, p = .05). There was no significant change in the PedsQL total score after the intervention (p = .844).

Treatment Effects on Parental Sleep

As shown in Table 4 and Supplemental Table 2, the PSQI total score was decreased from baseline to post-intervention (Cohen’s d = −0.332, p = .04) but such an improvement was not able to sustain at 3-month follow-up. There was a significant change in insomnia severity (as measured by ISI, p = .005), where ISI was significantly decreased from baseline to post-intervention assessment (Cohen’s d = −0.266, p = .002).

Table 4.

Changes of Parental Sleep, Mental Health, and Parenting Stress.

	Baseline	Post-intervention	Post-3 month follow-up	F	p Value
	Mean ± SD	Mean ±	Mean ±	F	p Value
Sleep quality
PSQI total score	7.94 ± 3.88	6.75 ± 3.14	7.08 ± 2.12	2.318	.115
Insomnia symptoms
ISI	11.21 ± 5.64	9.7 ± 5.96	10.28 ± 5.46	6.334	.005**
Sleep diary measures
TIB, hours	7.58 ± 1.01	8.94 ± 0.99	7.27 ± 1.07	19.905	<.001***
TST, hours	6.26 ± 1.27	7.55 ± 1.31	6.41 ± 1.04	8.435	.013*
SOL, minute	24.6 ± 18.43	21.88 ± 15.27	14.54 ± 9.04	3.976	.047*
SE, %	82.99 ± 11.82	89.73 ± 4.47	90.08 ± 4.98	11.374	.002**
WASO, minute	15.5 ± 18.78	17.89 ± 57.18	10.79 ± 16.2	2.612	.135
#Awakenings, N	1.26 ± 1.15	0.98 ± 1.38	0.85 ± 0.62	0.892	.43
Actigraphy sleep measures
TIB, hours	7.31 ± 0.95	7.67 ± 1.08	7.09 ± 1.57	1.504	.242
TST, hours	6.11 ± 0.81	6.45 ± 0.98	6.09 ± 1.34	1.545	.237
SOL, minute	9.93 ± 8.52	13.18 ± 11.46	14.64 ± 11	1.975	.162
SE, %	84.36 ± 5.55	84.16 ± 4.96	82.89 ± 5.37	0.216	.807
WASO, minute	46.87 ± 17.56	49.92 ± 20.2	45.93 ± 15.09	0.201	.819
#Awakenings, N	31 ± 10.9	28.23 ± 11.03	25.42 ± 6.89	1.99	.158
Mental health
DASS total score	37.31 ± 28.86	33.60 ± 25.27	36.10 ± 19.28	0.556	.579
DASS depression score	12.10 ± 11.23	10.59 ± 9.61	11.25 ± 6.94	0.562	.576
DASS anxiety score	9.00 ± 9.53	7.76 ± 7.94	9.00 ± 6.39	1.156	.33
DASS stress score	16.28 ± 10.11	15.17 ± 9.08	16.18 ± 7.28	0.423	.659
Parenting stress
PSI-SF total score	117.92 ± 19.87	111.21 ± 15.71	112.93 ± 11.24	4.631	.016*
PSI parental distress	40.72 ± 8.41	36.86 ± 7.38	37.25 ± 5.44	8.608	.001**
PSI parent-child dysfunctional interaction	34.59 ± 6.59	34.45 ± 5.13	35.58 ± 3.40	1.558	.224
PSI difficult child	42.57 ± 8.47	39.90 ± 6.27	39.88 ± 5.95	4.774	.015*

Abbreviations: # Awakenings = number of awakenings; DASS = Depression Anxiety Stress Scales; ISI = Insomnia Severity Index; PSI-SF = Parental Stress Index—Short Form; PSQI, Pittsburgh Sleep Quality Index; SD, Standard deviation; SE, sleep efficiency; SOL, Sleep onset latency; TIB, Time in bed; TST, Total sleep time; WASO, Wake after sleep onset.

***

p < .001. **p < .01. *p < .05.

Parental sleep diaries showed significant changes in TIB, TST, SOL, and SE (all ps < .05, see Table 4). Specifically, as shown in Supplemental Table 2, TIB and TST increased from baseline to post-intervention (TIB: Cohen’s d = 1.373, p < .001; TST: Cohen’s d = 1.017, p = .007), and decreased from post-intervention to 3-month follow-up (TIB: Cohen’s d = −1.669, p < .001; TST: Cohen’s d = −0.961, p = .015). There was a significant change in SOL (p = .047), where SOL was significantly reduced from baseline to 3-month follow-up (Cohen’s d = −0.62, p = .028). A significant change was also found in SE (p = .002). Specifically, SE increased significantly at post-intervention (Cohen’s d = 0.694, p = 0.001) and 3-month follow-up (Cohen’s d = 0.688, p = .005) compared to baseline. Nonetheless, there were no significant changes in parental sleep as measured by actigraphy (all ps > .05).

Treatment Effects on Parental Mental Health and Parenting Stress

As shown in Table 4 and Supplemental Table 2, there were no significant changes in parental DASS total and subscale scores after the intervention (all ps > .05). There were significant changes in PSI-SF total score (p = .016), PSI parental distress (p = .001), and PSI difficult child (p = .015). Specifically, PSI-SF total score decreased from baseline to post-intervention (Cohen’s d = −0.368, p = .006) and from baseline to 3-month follow-up (Cohen’s d = −0.281, p = 0.02). PSI parental distress subscale score decreased from baseline to post-intervention (Cohen’s d = −0.485, p = .001) and from baseline to 3-month follow-up (Cohen’s d = −0.455, p = 0.002). PSI difficult child subscale score decreased from baseline to post-intervention (Cohen’s d = −0.349, p = .007) and from baseline to 3-month follow-up (Cohen’s d = −0.346, p = .023).

Parental Feedback About the Intervention

Descriptive statistics presented in Supplemental Table 3 indicated that families generally showed satisfaction on the program with positive feedback and high ratings.

Discussion

The present study examined the effects of a brief parent-based sleep intervention on sleep, clinical symptoms, and daytime functioning in children with ADHD and sleep problems, as well as their parent’s sleep, mental health, and parenting stress. The findings of the present study supported the beneficial effects of the intervention in improving the child’s sleep, especially sleep onset delay, and the improvements were maintained at 3 months after the intervention. In addition, the child’s objective sleep outcomes including sleep onset latency and sleep efficiency, as measured by actigraphy, were found to be improved 3 months after the intervention. In terms of the clinical symptoms, externalizing symptoms were improved following the intervention, and ADHD symptoms, especially hyperactivity, were improved 3 months after the intervention. As for parents, parental sleep quality and insomnia symptoms by self-report were both improved following the intervention, but these improvements did not seem to be able to sustain at 3-month follow-up. Parental sleep efficiency as measured by sleep diary was found to be significantly improved following the intervention, and the treatment effect was maintained at 3-month follow-up. Parenting stress also improved after the intervention, yet there was no significant change in parental mental health.

Children’s Sleep

Our study found that a brief parent-based behavioral sleep intervention showed promise in improving sleep in children with ADHD and sleep problems. The improvement in sleep problems with medium effect size (as measured by CSHQ total sleep disturbance score) were observed at post-intervention (Cohen’s d = −0.677) and 3-month follow-up (Cohen’s d = −0.665). The effect size at post-intervention was comparable to that reported in a recent meta-analysis of behavioral sleep interventions (Hedges’ g = −0.73, 95% CI [−0.62, −0.41]) (Malkani et al., 2022). In addition, our study expanded previous research by specifically looking into the effects of the behavioral sleep intervention on the severity of insomnia symptoms in children with ADHD, including bedtime resistance, sleep onset delay, and night waking. In particular, our results showed that the intervention improved parent-reported sleep onset delay in children with ADHD, and the treatment effects were maintained at 3-month follow-up. Moreover, the intervention led to the improvement of objectively measured sleep outcomes in the child, including sleep onset latency and sleep efficiency at 3 months after the intervention, which aligned with the parental reported improvements in sleep symptoms. The results of our study were consistent with the findings reported by a previous study (P. Corkum et al., 2016), which implemented a manualized behavioral intervention to address sleep problems in a group of 61 children with and without ADHD. Their findings indicated a significant reduction in sleep onset latency (SOL) at the 6-month follow-up compared to the pre-treatment period within the intervention group.

Our results showed that both subjective and objective total sleep time in children appeared to decrease at post-intervention. The treatment strategies implemented in the intervention may potentially explain such an observation. For example, bedtime fading, which is a behavioral strategy aiming at improving sleep onset and reducing bedtime struggle by temporarily delaying the child’s bedtime to better align with his/her natural sleep onset. During the initial stage of implementing bedtime fading, it is possible to observe a temporary decrease in total sleep time as the children adapt to the new schedule of delayed bedtime whilst maintaining their usual rise time consistently. Notably, at the post-3-month follow-up, we observed a significant increase in subjective total sleep time, which was expected as part of the treatment effect over time because the parents learned the strategy of gradually adjusting and advancing their child’s bedtime when needed once the child no longer struggled to fall asleep or the child’s bedtime struggle/resistance was improved. On the other hand, objective total sleep time did not show a significant increase after the intervention and at 3-month follow-up. It was possible that treatment effects on the objective outcomes might take time to consolidate and longer-term follow-up (e.g., 6-month or 1-year) would be needed. Future interventional studies that incorporate objective sleep measures with long-term follow-up would help to further delineate the effects of the treatment on sleep related outcomes in children with ADHD.

Children’s ADHD Symptoms and Daytime Functioning

Our study supported that behavioral sleep intervention could improve not only night-time symptoms but also daytime ADHD symptoms (as measured by SWAN) and behaviors (as measured by CBCL), particularly hyperactivity problems and externalizing behaviors in children with ADHD and sleep problems. Similarly, Hiscock et al. (2015) found that a brief behavioral sleep intervention was effective in improving sleep problems and ADHD symptoms in children with ADHD. In another randomized controlled trial of a sleep intervention program for parents of school-aged children with and without ADHD, not only sleep problems but also internalizing and externalizing symptoms were found to improve after the intervention and at 6-month follow-up (P. Corkum et al., 2016). Taken together, these findings provided some evidence to support the hypothesis that daytime symptoms and behavioral problems could be ameliorated in children with ADHD via improving their sleep.

Parental Impacts

The intervention also led to significant improvements in the parental subjective sleep quality, insomnia symptoms, and sleep diary-assessed sleep efficiency, as well as parenting stress. This study added to the current literature by showing that parental sleep and functioning could also be significantly improved along with the improvement in their child’s sleep following a brief behavioral intervention targeting the child’s sleep problem. These findings were in line with previous research showing that increased parental sleep knowledge was associated with longer child sleep duration and reduced parental sleep disturbance (Halstead et al., 2021). The behavioral sleep intervention delivered in our study included the components to enhance parental understanding of sleep science via sleep-related psychoeducation, promote good sleep hygiene practices, and provide specific strategies to improve sleep (e.g., maintaining a consistent sleep schedule and a consistent bedtime routine). These elements, albeit focusing on the child, could potentially facilitate parental understanding of their own sleep issues thereby improving their own sleep practices. It is important to note that the improvements of some aspects of parental sleep (e.g., sleep quality) were not sustained at the 3-month follow-up. One possible reason might be related to the nature of the intervention, which was primarily focused on the childhood sleep problems and did not specifically address some of the factors (e.g., dysfunctional belief about sleep) that could potentially perpetuate adult insomnia. It was also possible that parental sleep problems could be influenced by some other psychosocial factors, such as stress, anxiety, and depression, which were not directly targeted by the intervention. In this regard, the pattern of changes in parental mental health, albeit not statistically significant, also aligned with the findings on parental sleep, as evidenced by a decrease in the DASS subscale (depression, anxiety, and stress) scores at post-intervention, followed by a rebound at post-3-month follow-up. Parents with a child with ADHD often face increased challenges and parenting demands in their daily life and may experience mental health problems themselves (Margari et al., 2013), which could significantly impact their sleep. As the current intervention was mainly sleep focused, future interventions may consider incorporating additional strategies to support parenting and increase parenting efficacy in implementing learned strategies.

Strengths and Limitations

There were several strengths of the present study. We applied a rigorous screening procedure to ascertain participants’ eligibility for the intervention program. For example, the ADHD diagnosis was stringently assessed and confirmed by a validated structured interview (DISC-IV). Moreover, validated subjective and objective measures such as CSHQ, SWAN, CBCL, and actigraphy were used to examine the treatment outcomes. Several limitations should be considered when interpreting the findings. First, our study utilized a single-arm, unblinded trial design. The lack of a control group made it difficult to fully ascertain whether the observed changes in symptoms and sleep outcomes were solely due to the intervention or as a result of the natural fluctuation or spontaneous improvement of the symptoms over time. Additionally, the lack of blinding in the trial could potentially introduce biases in the assessment of outcomes. Further randomized controlled trials are warranted to test the robustness of the effectiveness of this intervention. Secondly, although 72% of the participants (43/60) completed the intervention, the follow-up rate at 3-month follow-up was modest (45%). Lost to follow-up could potentially bias the outcome evaluation, making it difficult to have an unbiased estimate of the long-term treatment effects. Third, due to the small sample size of children with any other neuropsychiatric comorbidity, we did not conduct subgroup analyses based on the presence of co-occurring diagnoses. Future studies may consider including larger and more diverse samples of children with various comorbidities to examine the potential influence of comorbidity on the effectiveness of the intervention.

Implications

Our study added to the existing literature by showing that a brief parental-based behavioral sleep intervention could significantly improve not only nighttime sleep symptoms but also daytime behaviors in children with ADHD. In addition, this intervention was found to benefit not only the child but also the parents themselves with improved parental sleep and parenting stress. Furthermore, the intervention was well-received by parents with a high level of satisfaction. This pilot trial could also offer valuable insights for future RCTs in terms of selecting suitable outcome measures. By identifying the measures that are most responsive to change, our study laid the groundwork for designing more rigorous trials in future.

Conclusions

The current study showed that a brief parent-based behavioral intervention could be a promising approach in managing sleep and clinical symptoms in children with ADHD and sleep problems, as well as improving parental sleep and parenting stress. The findings highlighted the importance of addressing sleep difficulties to optimize the clinical outcomes in children with ADHD.

Supplemental Material

sj-docx-1-jad-10.1177_10870547241233731 – Supplemental material for An Open-Label Pilot Trial of a Brief, Parent-Based Sleep Intervention in Children With ADHD

Supplemental material, sj-docx-1-jad-10.1177_10870547241233731 for An Open-Label Pilot Trial of a Brief, Parent-Based Sleep Intervention in Children With ADHD by Xiao Li, Fanny Lok Fan Lau, Waiyan Vivian Chiu, Ching Kwong Dino Wong, Albert Martin Li, Yun Kwok Wing, Yee Ching Kelly Lai, Ka Sin Caroline Shea and Shirley Xin Li in Journal of Attention Disorders

Footnotes

Author Contributions

All the authors made substantial contributions to the work leading to this article. Dr. X Li managed the data, conducted the statistical analyses, drafted the initial manuscript, and made critical revisions to the manuscript. Dr. Shirley X. Li conceptualized the study, provided supervision of the implementation of the study, drafted the initial manuscript, and made critical revisions to the manuscript. Ms. Lau, Ms. Chiu, and Mr. Wong conceptualized the study, delivered the intervention, conducted data collection, and managed the data. Prof. Albert M. Li, Prof. Wing, Dr. Lai, and Dr. Shea conceptualized the study and critically reviewed the manuscript.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by Health Care and Promotion Fund (Project No.: 30160604) Food and Health Bureau, Hong Kong. The funding body had no role in the study design, data collection, data analysis, data interpretation, the writing of the manuscript, or the decision to submit the paper for publication. The funding was awarded to Dr. Shirley X. Li.

ORCID iD

Shirley Xin Li

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Xiao Li is a post-doctoral research fellow at the University of Hong Kong. Her research is focused on insomnia, ADHD, and mental health.

Fanny Lok Fan Lau is a clinical psychology doctoral student at the University of Hong Kong, with research interests focusing on sleep disturbance in ADHD and ASD.

Waiyan Vivian Chiu is a clinical psychology doctoral student at the University of Hong Kong, with research interests focusing on sleep disturbance in ADHD.

Ching Kwong Dino Wong is a clinical psychology doctoral student at the Hong Kong University, with research interests focusing on sleep disturbance in ADHD.

Albert Martin Li is a Professor and Chairman at Department of Paediatrics at the Chinese University of Hong Kong. He is also the vice-president of the Asia Pacific Paediatric Sleep Alliance. His research is focused on pediatric respiratory and sleep medicine.

Yun Kwok Wing is a professor and Chairman at Department of Psychiatry at the Chinese University of Hong Kong. His research areas of interest include sleep medicine, epidemiology and clinical psychiatry, and neuropsychiatry and transcultural psychopharmacology.

Yee Ching Kelly Lai is a clinical associate professor (Honorary) at Department of Psychiatry at The Chinese University of Hong Kong, specializing in child and adolescent psychiatry.

Ka Sin Caroline Shea is a clinical assistant professor (Honorary) at Department of Psychiatry of The Chinese University of Hong Kong, specializing in child and adolescent psychiatry.

Shirley Xin Li is an associate professor at Department of Psychology and a principal investigator in the State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong. Her main research interests are centered on sleep and sleep disorders, with a particular emphasis on the interplay between sleep and circadian disturbances and psychopathology. She is particularly interested in uncovering the processes that contribute to the cause and maintenance of sleep problems, such as insomnia, and their impacts in young people, and in delineating how sleep and circadian disturbances are linked to the clinical course of neuropsychiatric disorders.

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