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ADHD, Sleep Problems, and Bed Sharing:
Future Considerations
Tracy G. Cassels a
a Department of Psychology, University of British Columbia,
Vancouver, Canada
Version of record first published: 26 Dec 2012.
To cite this article: Tracy G. Cassels (2013): ADHD, Sleep Problems, and Bed Sharing: Future
Considerations, The American Journal of Family Therapy, 41:1, 13-25
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The American Journal of Family Therapy, 41:13–25, 2013
Copyright © Taylor & Francis Group, LLC
ISSN: 0192-6187 print / 1521-0383 online
DOI: 10.1080/01926187.2012.661653
ADHD, Sleep Problems, and Bed Sharing:
Future Considerations
TRACY G. CASSELS
Department of Psychology, University of British Columbia, Vancouver, Canada
Attention Deficit/Hyperactivity Disorder (ADHD) is one of the most
common childhood disorders (American Psychiatric Association,
2000); however, recent research suggests that there is a potential
for faux-ADHD diagnoses (Pressman & Imber, 2011) which may be
due to externalizing problems with a different etiology. One etiology
that has received attention is sleep-related behaviors, in so far as
they have been correlated with behavioral problems (Presman &
Imber, 2011; and see Thunstr¨
om, 2002 for research on severe infant
sleep problems predicting later ADHD diagnoses). This paper adds to
the research in suggesting further factors that should be considered
by researchers and clinicians.
A recently published study introducing the concept of Faux Attention
Deficit/Hyperactivity Disorder (ADHD) (Pressman & Imber, 2011) opened
the doors to understanding how family bedtime routines may impact the
diagnosis of ADHD. The current article explores ways in which to build on
this research and to highlight factors clinicians and parents should be aware
of when faced with a child displaying disruptive behaviors. Of particular
interest are bringing into play socio-economic status (SES) and cultural fac-
tors, as well as the consideration of the impact of intentional vs. reactive
bed sharing in the understanding of the effect of family bedtime routines on
daytime behavior of children.
ADHD is a disorder characterized by “a persistent pattern of inattention
and/or hyperactivity-impulsivity” (American Psychiatric Association, 2000,
The preparation of this article was supported by a fellowship to the author by the Social
Sciences and Humanities Research Council of Canada. The author would like to thank the
reviewers of this article for their helpful and insightful comments. She would also like to
thank Drs. Pressman and Imber for their work which served as the catalyst for this article.
Address correspondence to Tracy G. Cassels, Department of Psychology, University of
British Columbia, 2136 West Mall, Vancouver, BC V5Y 1T6, Canada. E-mail: tracy@psych.
ubc.ca
13
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14 T. G. Cassels
p. 85). Specific examples of inattention include being easily distracted and
forgetful in daily activities; specific examples of hyperactivity and impulsivity
include fidgeting with hands or feet and interrupting or intruding on others
(APA, 2000, p. 92). Sleep disorders or dysfunction have frequently been
implicated in ADHD for both children and adults. The prevalence of sleep
dysfunction in ADHD has been well documented (for a review, see Cohen-
Zion & Ancoli-Israel, 2004), with research on various treatments showing
improvement in both sleep patterns and externalizing behaviors (Yehuda,
Rabinovitz-Shenkar, & Carasso, 2011; Youssef, Ege, Angly, Strauss, & Marx,
2011). This research presupposes that the diagnosis of ADHD is valid and
that sleep dysfunction is either a product of the ADHD or simply comorbid
with it. However, Pressman and Imber’s (2011) research suggests that this
may not always be the case. For example, research into the prevalence
of ADHD in childhood consistently suggests a rate of 5–6% (e.g., Faraone,
Sergeant, Gillberg, & Biederman, 2003; Neuman et al., 2005), yet in Pressman
and Imber’s (2011) study, 25% of parents reported being told by their doctor
that their child should be taking medication for their behavior ‘often’ or
‘usually/always’. A five-fold increase in drug recommendations for children
implies that doctors and clinicians are not considering all possibilities before
administering a diagnosis of ADHD.
The correlates of sleep problems include similar behaviors to those
found in ADHD, making false diagnoses not only possible but probable. It
has been well documented that a lack of enough sleep can manifest in vari-
ous behavioral problems in childhood (e.g., Kataria, Swanson, & Trevathan,
1987; Zuckerman, Stevenson, & Bailey, 1987). For example, Zuckerman and
colleagues (1987) found that sleep problems at 3 years of age were cor-
related with both tantrums and behavior management problems and with
sleep problems at 8 months, suggesting an early etiology for sleep prob-
lems in childhood. This long-term, persistent pattern of behavioral problems
may lead clinicians to believe that the behaviors are not related to sleep
disturbances and thus label the symptoms as those of ADHD as opposed
to sleep-related. While there has been a fair amount of research into sleep
disturbances and their associated problems, virtually none of the research
has examined what causes sleep disturbances in childhood. And yet, if clin-
icians are to treat children displaying with behavioral problems, identifying
the behaviors as sleep-related and understanding the etiology of their sleep
problems is paramount.
In this vein Drs. Pressman and Imber (2011) took the much-needed
step in examining bedtime routines and their role in daytime behavioral
problems and the possibility of faux-ADHD diagnoses in children aged 2
to 13. They found strong relationships between both the presence of bed
sharing and the lack of a set bed time and various externalizing behaviors and
the potential for faux-ADHD diagnoses. Notably, both bed sharing and not
having a set bedtime have been suggested as being related to sleep disorders
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ADHD and Sleep Problems 15
in children by other researchers (Kataria et al., 1986; Lozoff, Askew, & Wolf,
1996; Lozoff, Wolf, & Davis, 1984; Madansky & Edelbrock, 1990; Mindell,
Kuhn, Lewin, Meltzer, & Sadeh, 2006; Mindell, Telofski, Wiegand, & Kurtz,
2009). Given the previously outlined relationship between sleep disorders
and behavioral problems, it is logical to believe these factors may result in
faux-ADHD diagnoses; however, this would be ill-advised as it ignores a
fuller picture that is necessary to make accurate diagnoses and treatment
recommendations. Pressman and Imber’s findings have paved the way for
researchers to consider other factors in the intricate web of relationships
between ADHD, sleep disorders, daytime behavior, and bed sharing and I
hope to highlight some of these factors that should be considered going
forward.
FACTORS IN RELATIONSHIP BETWEEN ADHD
AND SLEEP DISORDERS
Child’s Age
Many studies looking at the diagnosis of ADHD and the behaviors associ-
ated with it include broad age-ranges (e.g., Pressman & Imber, 2011; Owens
et al., 2009); however, it is questionable as to whether parents and clinicians
alike are aware of or considerate of the normative externalizing behaviors
that can be expected across development. The reasons for these external-
izing behaviors, their manifestation, and their frequency are expected to be
qualitatively different across development and this may temper the relation-
ship to ADHD. For example, in reviewing how we conceptualize problem
behaviors in young children, Keenan and Wakschlag (2002) found that dis-
ruptive behaviors in preschool-aged children are not only expected, but quite
normative in most cases. While some behaviors persist to become clinically-
relevant, the vast majority do not. In another study on the frequency and
severity of behavioral disorders in preschool children, Crowther and col-
leagues (1981) reported that a substantial proportion of normative children
aged 2 to 5 displayed certain externalizing behaviors with a high degree of
severity. As children age, however, these externalizing behaviors decrease in
frequency (e.g., Bongers, Koot, van der Ende, & Verhulst, 2004; Fischer, Rolf,
Hasazi, & Cummings, 1984), but can increase in severity (for a review, see
Loeber & Hay, 1997), suggesting that some children may present with myriad
problem behaviors, but none which will persist to become severe. Thus the
question of when a diagnosis of ADHD is appropriate becomes paramount.
While there are many children, and even some quite young children, who
will clearly fit the criteria for ADHD, research into the remission of symp-
toms suggests a natural decline of these problematic behaviors over time.
Biederman and colleagues (2000) examined age-related declines in ADHD
syndromes and symptoms in 128 boys from under 6 years of age through
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16 T. G. Cassels
20 years of age. By 20 years of age, there was a 60% decline in ADHD
syndromes, meaning 60% of individuals diagnosed prior to that age were
found to no longer qualify for an ADHD diagnosis. Importantly, there was
a near-linear relationship between age and ADHD syndromatic remission.
One interpretation is that the syndrome of ADHD is transient, but another is
that clinicians are providing a diagnosis of behavior in young children, the
etiology of which may be unrelated to ADHD.
In addition to the effects on possible ADHD diagnoses, age should
also be taken into account when considering bedtime behaviors and sleep
problems. With respect to sleep problems, dominant Western views are
that infants and young children should be sleeping through the night with
many researchers suggesting that anything other than that is problematic
(e.g., France & Hudson, 1993; Thiedke, 2001). However, the interpretation
of problematic sleep patterns is not so simple. Amongst other cultures and
even within some subcultures of the United States, night time waking is con-
sidered normal for infants and younger children (Keller & Goldberg, 2004;
Lozoff et al., 1984, 1996) and thus the behavior itself is not seen as being
symptomatic of sleep dysfunction, but simply part of a normal child’s night-
time behavior. Notably some research suggests that there are no negative
effects on certain child and maternal outcomes based on whether or not a
child was sleeping through the night by age one (Germo, Goldberg, & Keller,
2009). This highlights the need for greater exploration into the individual cir-
cumstances surrounding sleep dysfunction in young children as opposed to
the set criteria of sleeping through the night or not. With respect to bed-
time routines and sleeping arrangements, research suggests that as children
age, the proportion of children co-sleeping or bed sharing decreases (e.g.,
Madansky & Edelbrock, 1990; Welles-Nystrom, 2005). In younger children,
the relationship to daytime externalizing behaviors may simply be a spurious
relationship due to the presence of two age-normative behaviors; therefore,
bed sharing may not offer much in the way of decreasing unwanted daytime
behaviors or helping sleep problems for that age group.
Child’s Socio-Economic Status
While the role of the researcher is to isolate a construct from external effects
in order to examine it and the role of the clinician is to tease apart the symp-
toms from the person, there are certain cases in which the personal variables
must be considered as being vital to the symptoms. Socio-economic status
(SES) is one of these cases. There is myriad research suggesting that the fam-
ily environment has a large effect on children’s behavior and SES is consis-
tently labeled a culprit in contributing to and exacerbating the externalizing
problems of ADHD (Counts et al., 2005; Pressman et al., 2006; Schneider &
Eisenberg, 2006). Counts and colleagues (2005) examined how familial risk
factors—including SES, marital conflict, and stressful life events—affected
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ADHD and Sleep Problems 17
children’s ADHD symptoms in children aged 7 to 13. They found that SES
was uniquely related to conduct disorder symptomology, with lower SES
correlating with a greater number of conduct disorder symptoms. Pressman
and colleagues (2006) found that the family environment was also signif-
icantly associated with ADHD impairment for children aged 5 to 18. In a
larger and more systematic analysis, Schneider and Eisenberg (2006) utilized
the Early Childhood Longitudinal Survey-Kindergarten Cohort data to look at
what factors were the greatest predictors in ADHD diagnoses. With a sample
of nearly 10,000 children, one of the most significant predictors was SES;
specifically, low-SES predicted an increased risk and high SES predicted a
decreased risk of being diagnosed with ADHD.
In addition to the links between SES and ADHD externalizing behaviors,
SES has been linked to externalizing behaviors more generally. For example,
Kalff and colleagues (2001) found that child behavior problems were more
likely in children aged 5 to 7 of low-SES households or who lived in lower
SES neighborhoods. In a similar study, neighborhood-level SES was found
to predict total, internalizing, and externalizing problems in a sample of
children aged 10-14 years (Schneiders et al., 2003). Achenbach and Edelbrock
(1981) compared 1,300 referred children aged 4 through 16 with 1,300 non-
referred children using the Child Behavior Checklist and found that low-SES
children showed greater behavioral problems and lower social competency.
Given this link between SES and behavioral problems, it is worth questioning
whether the behavioral problems displayed by some children in lower SES
households and neighborhoods is really a product of their environment and
providing an ADHD diagnosis is simply the easiest way in which to deal
with the problem.
SES also has been found to relate to bed sharing and sleep problems,
making it even more important to consider when examining the potential
for sleep-related factors to influence externalizing behavior. First, parents in
lower SES groups are more likely to bed share, not just between parent and
child, but between siblings as well (e.g., Hauck, Signore, Fein, & Raju, 2008;
Horsley et al., 2007). While financial constraints may be part of the reason
for this practice—after all, owning a home with multiple bedrooms and
beds is no cheap endeavor—there may also be cultural factors at play. The
majority of cultures in the United States that practice bed sharing regularly are
typically those that also fall into lower SES categories (e.g., African-America,
Hispanic) (e.g., Lozoff et al., 1984). It is possible that findings of bed sharing
contributing to behavioral problems are really an example of a third variable
problem with SES affecting both bed sharing rates and externalizing behavior.
It is possible that SES affects bed sharing rates which then affect externalizing
behaviors, however, cultural considerations (which will be discussed in the
next section) make this possibility less likely. Furthermore, it is difficult to
disentangle the effects of SES from culture in the United States as they are so
intertwined, and thus consideration of SES may end up being consideration
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18 T. G. Cassels
of cultural factors independent of SES. Second, recent longitudinal research
in the United States suggests a relationship between SES and both sleep
problems and behavioral outcomes in children in both grades three and five
(El-Sheikh, Kelly, Buckhalt, & Hinnant, 2010). In this study, children from
low-SES homes were found to be at higher risk for sleep problems than
children from higher-SES homes. Furthermore, sleep problems and SES were
predictive of externalizing behaviors in the group at both time points (grades
three and five). These findings were complimentary to those presented earlier
by the same group of researchers, which found low-SES children were more
likely to sleep less and report greater sleep problems than high-SES children
independent of ethnicity or culture (El-Sheikh et al., 2007).
Cultural Considerations
The most common concern with respect to culture and ADHD is the cross-
cultural validity of ADHD, with debate surrounding how best to conceptu-
alize ADHD—cultural construct or neurobiological disorder (Ali, 1996; An-
derson, 1996). However, more recent cross-cultural data (Rohde et al., 2005)
and reviews of the existent data (Faraone et al., 2003; Polanczyk et al., 2007)
should put that notion to rest as the rate of 5–6% remains relatively stable
worldwide. However, there is a cultural consideration that has received less
attention and yet is worthy of future research—the predominantly ethnic di-
vide in the diagnosis of ADHD in the United States. Within the United States,
being Caucasian is a strong predictor of being diagnosed with ADHD. In a
national sample of nearly 10,000 children, the rate of diagnosis was 5.44%, in
line with the known worldwide rates, but over 80% of those diagnosed were
Caucasian children (Schneider & Eisenberg, 2006), suggesting either that the
ADHD syndrome is somehow uniquely targeting these individuals, which
seems unlikely given the neurobiological explanations typically associated
with ADHD (see Ali, 1996), or there is another factor at play that has yet
to be identified. Pulling from the research on sleep problems and culture
(e.g., Ball, Hooker, & Kelly, 1999; Keller & Goldberg, 2004; Lozoff et al.,
1984, 1996), it is possible that there are cultural differences in the types of
behaviors expected of children at certain ages and that the failure to meet
these expectations is sending some parents to clinicians for diagnoses and
treatments.
Sleeping arrangements and parental acceptance of children’s external-
izing behaviors are also subject to cultural influences. For example, some
research has suggested that frequent co-sleeping or bed sharing is associ-
ated with sleep problems (e.g., Madansky and Edelbrock, 1990) and that
sleep problems are related to behavioral problems (e.g., Kataria et al., 1987).
As such, it would be easy for clinicians to suggest that parents do not bed
share in hopes of reducing sleep—and therefore behavioral—problems, but
such a move would ignore the wealth of cultural research into bed sharing
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ADHD and Sleep Problems 19
that contradicts such an automatic suggestion. Notably, other cultures with
high bed sharing rates in both infancy and childhood do not have the behav-
ioral problems found in North America (e.g., Kataria et al., 1986; Madansky &
Edelbrock, 1990). In Sweden, the practice of bed sharing is incredibly com-
mon, with one estimate putting over half of children still bed sharing at least
part of the time at 4–5 years of age (Welles-Nystrom, 2005), and yet Swedish
children present with much lower rates of emotional and behavioral prob-
lems than their Western counterparts (Larsson & Frisk, 1999). Importantly
though, the relationship between sleep problems and behavioral difficulties
exists in Swedish culture, but bed sharing is not one of the features leading
to sleep problems (Smedje, Broman, & Hetta, 2001). Similar findings exist
for Japan, which boasts some of the highest rates of bed sharing across de-
veloped nations (Owens, 2004), but which also boasts some of the lowest
rates of emotional and behavioral problems (Matsuura et al., 1989).
In addition to the failure to find these relationships in other cultures,
within North America the effects of bed sharing and sleep problems de-
pend upon culture. Betsy Lozoff and colleagues (1984; 1996) examined co-
sleeping habits in American families and found significant differences based
on culture. First, they found the incidence of co-sleeping is much higher in
African-American families (70%) than Caucasian families (35%) (Lozoff et al.,
1984). Second, only in Caucasian families was co-sleeping related to disrup-
tive sleep (Lozoff et al., 1984), and even this was moderated by SES, with
low-SES Caucasian families and high-SES African-American families reporting
problems with co-sleeping (Lozoff et al., 1996). It is unclear if the behaviors
between groups are different or if the differences are due to parental inter-
pretation of the behavior. In line with this second possibility, research on
bed sharing and sleep disturbances in early childhood in the United States
found that while parents of bed sharing children reported greater tempera-
mental problems, the children’s teachers ratings made no such predictions
(Hayes, Parker, Sallinen, & Davare, 2001), suggesting differences in parental
interpretation of behaviors. These findings by Hayes and colleagues (2001)
suggest that it is the parental interpretation of their child’s behavior that may
influence the diagnosis of ADHD, for if parents do not perceive a problem,
they will not seek treatment. Thus identifying cultural norms for particu-
lar behaviors, both sleep-related and with respect to daytime behaviors, is
paramount.
Reactive Versus Intentional Bed Sharing
Several studies have suggested sleep disorders or problems associated with
bed sharing in childhood (e.g., Madansky & Edelbrock, 1990), but as pre-
viously mentioned in the Culture section, results of various studies do not
support this link in different cultures (e.g., Smedje et al., 2001). One fac-
tor that may explain some of these differences is the distinction between
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20 T. G. Cassels
different types of bed sharing a family is engaging in, namely the distinction
between reactive and intentional bed sharing. Reactive bed sharing refers to
bed sharing in which the parent starts to bring the child to bed after the
age of one and typically in response to bad sleeping patterns by the child.
Intentional bed sharing refers to parents who intended to bed share and did
so from early infancy onward. In both Swedish and Japanese cultures bed
sharing is common from birth onward, meaning it fits into the intentional bed
sharing framework, and this may be (part of) the reason why bed sharing is
not implicated in sleep or behavioral problems.
A similar argument can be made for North America as children who
reactively bed share have been found to have markedly different outcomes
than intentional bed sharers, both behaviorally and with respect to sleep
patterns. For example, Keller and Goldberg (2004) found that early bed
sharers were more likely to be self-reliant and socially independent relative
to reactive bed sharers and solitary sleepers. Reactive bed sharers, on the
other hand, were more likely to display sleep problems—typically night
wakings—that were deemed to be disruptive to the family unit, and were
found to be less socially independent than the other groups. Other research
also supports the relationship between intentional bed sharing and positive
child outcomes (Abel et al., 2001) while reactive bed sharing continues to
be associated with various childhood problems (e.g., Simard et al., 2008).
Much of the aforementioned work on bed sharing and behavioral problems
has failed to consider the context in which bed sharing is occurring. In
the case of reactive bed sharers, which may be a large portion of North
American families because of the lower base rates of this behavior, bed
sharing may be a symptom of sleep problems rather than a cause. As Keller
and Goldberg (2004) noted, reactive bed sharers may have turned to bed
sharing in hopes of reducing the incidences of nighttime problem behavior,
thus the negative sleep patterns were already in place when bed sharing
began.
Importantly, in cases where intentional bed sharing occurs, changing the
sleeping arrangement may have little to no impact on externalizing behavior.
In one longitudinal study of sleeping arrangements and sleep problems, bed
sharing and night-wakings during early infancy were not predictive of bed
sharing and night-wakings in childhood (Jenni et al., 2005). Furthermore,
in an 18-year longitudinal study on bed sharing, bed sharing in infancy
and early childhood was unrelated to any sleep disorder, pathologies, or
problematic behaviors at age 6 and at age 18 (Okami, Weisner, & Olmstead,
2002). Therefore, any attempt by clinicians to treat behavioral problems via
a change in sleeping arrangements must be cognizant of the reasons behind
the sleeping arrangement, the cultural considerations, and whether there
is a likelihood that that arrangement will help modify both sleeping and
externalizing behaviors.
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ADHD and Sleep Problems 21
Implications for Pressman and Imber’s Findings
The research on bed sharing, sleep problems, ADHD, and externalizing
behaviors is complicated with little direct study of the interconnections be-
tween the constructs. Pressman and Imber (2011), in taking that first step,
have put their research as one of the first models for other researchers to
build from. They have rightfully pointed out areas—bedtime routines and
bed sharing—deserving of inquiry in relationship to daytime behaviors and
faux-ADHD diagnoses. Indeed, research into bedtime routines has supported
the idea that a set bedtime with routine can help eliminate sleep problems in
young children (Mindell, Telofski, Wiegand, & Kurtz, 2009) which may help
reduce externalizing problems as well. However, more research is necessary
in order to fully understand the implications of and possible reasons behind
faux-ADHD.
Recommendations for Treatment
Given the apparent surge in pharmaceutical recommendations (typically cou-
pled with an ADHD diagnosis) to children (Pressman & Imber, 2011), it
seems prudent that clinicians and researchers work to discover other possi-
ble etiologies for these problematic behaviors. When presented with a child
whose symptomology may indicate a possible ADHD diagnosis, the clinician
should first consider the age of the patient and whether or not the behavior is
age-appropriate. This is particularly important when considering the types of
behavior used to diagnose ADHD as many of them (e.g., fidgeting) are very
common in younger children when put in situations where they are asked to
keep still for long period of time (e.g., preschool or school). Simply because
a parent finds behavior problematic does not make it a disorder, and yet
some diagnostic measures (for both sleep problems and ADHD symptoms)
rely solely on the parent (or teacher) report of behaviors as problematic.
Utilizing a more stringent, objective criterion which involves comparisons to
known base rates of behaviors in the diagnosis of any disorder is strongly rec-
ommended. Adjusting parental expectations may be another way to decrease
the rates of faux-ADHD, particularly amongst Caucasian families where the
rates of diagnosis are abnormally high. Second, family variables need to be
taken into account. A child does not exist in a vacuum and neither does
his or her behavior. A family’s cultural practices, economic circumstances,
and environment will all play a role in how that child behaves. All treatment
recommendations must consider whether or not the behavior being targeted
is culturally important and thus less susceptible to change. Additionally, be-
ing open to not asking a family to change a certain cultural behavior can
help the overall therapeutic relationship which may make the family more
willing to attempt other forms of treatment (or even the initial treatment with
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22 T. G. Cassels
time). Finally, clinicians should be aware of the very important nuances that
can exist within a particular behavior. Using bed sharing as an example,
the different outcomes associated with intentional versus reactive bed shar-
ing highlight the need to inquire about when bed sharing began and under
what circumstances. If it began at birth and has been intentionally continued,
it is likely that changing that sleeping arrangement would have little effect on
sleep problems. Taking these recommendations and combining them with
the knowledge imparted by Pressman and Imber (2011) on the possibility
of faux-ADHD diagnoses should help reduce the risk of overmedicating and
overdiagnosing children.
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