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Delayed Circadian Rhythm in Adults with Attention-Deficit/Hyperactivity Disorder and Chronic Sleep-Onset Insomnia
Abstract
Previous studies suggest circadian rhythm disturbances in children with attention-deficit/hyperactivity disorder (ADHD) and sleep-onset insomnia (SOI). We investigate here sleep and rhythms in activity and melatonin in adults with ADHD.
Sleep logs and actigraphy data were collected during 1 week in 40 adults with ADHD, of whom 31 reported SOI. Salivary melatonin levels were assessed during 1 night. Sleep measures, circadian activity variables, and dim light melatonin onset were compared between groups of ADHD adults with and without SOI and with matched healthy control subjects.
Compared with control subjects, both groups of ADHD adults had longer sleep-onset latency and lower sleep efficiency. Adults with ADHD and SOI showed a delayed start and end of their sleep period and a delayed melatonin onset compared with adults with ADHD without SOI (p = .006; p = .023; p = .02) and compared with healthy control subjects (p = .014; p = .019; p = .000). Adults with ADHD and SOI also showed an attenuated 24-hour amplitude in their rest-activity pattern, in contrast to those without SOI, who showed a higher day-to-day stability.
These findings demonstrate diurnal rhythm deviations during everyday life in the majority of adults with ADHD that have SOI and suggest that potential benefits of rhythm-improving measures should be evaluated.
... This has important implications for both educational and occupational settings, where individuals with ADHD may struggle to perform at their best due to misaligned circadian timing [88,89]. Furthermore, subtype differences in the prevalence of sleep-onset insomnia have been indicated, with a decreased number of adults with the inattentive ADHD subtype displaying symptoms of sleep-onset insomnia compared to other subtypes [95]. Inattentive subtype patients not suffering from sleep-onset insomnia exhibited longer sleep duration and more stable sleep-wake rhythms compared to those with sleep-onset insomnia [96]. ...
... Inattentive subtype patients not suffering from sleep-onset insomnia exhibited longer sleep duration and more stable sleep-wake rhythms compared to those with sleep-onset insomnia [96]. This aligns with previous reports that inattentive subtypes of ADHD are sleepier during the day and sleep for longer durations at a time, with dysregulation of the melatonin rhythm potentially mediating these associations [95,97]. ...
... For example, Bijlenga et al. (2013) have recently postulated that the higher than expected prevalence of photophobia in ADHD may reflect a deficit in non-visual photic transmission associated with the circadian system, and that such a change could lead to the phase alterations observed in this conditions [98]. Circadian disturbance is further implicated in ADHD by findings that seasonal affective disorder (SAD), a form of depression intimately linked to circadian dysfunction [99], is significantly comorbid with this population [93,95,98,100]. For example, hormonal rhythms, including cortisol secretion, which follows a diurnal pattern, may be disrupted in ADHD [83,101]. ...
Background: Chronobiology has gained attention in the context of paediatric neurological and neuropsychiatric disorders, including migraine, epilepsy, autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), and post-traumatic stress disorder (PTSD). Disruptions in circadian rhythms are associated with key symptoms such as sleep disturbances, mood dysregulation, and cognitive impairments, suggesting a potential for chronobiology-based therapeutic approaches. Methods: This narrative review employs a systematic approach to identify relevant studies through searches of three major scientific databases, NCBI/PubMed, ScienceDirect, and Scopus, up to July 2024. We used a combination of broad and condition-specific keywords, such as “chronobiology”, “biorhythm”, “pediatric”, “epilepsy”, “ADHD”, and “ASD”, among others. Articles in English that focused on clinical features, treatments, or outcomes related to circadian rhythms in paediatric populations were included, while non-peer-reviewed articles and studies lacking original data were excluded. Rayyan software was used for article screening, removing duplicates, and facilitating consensus among independent reviewers. Results: A total of 87 studies were included in the analysis. Findings reveal a consistent pattern of circadian rhythm disruptions across the disorders examined. Specifically, dysregulation of melatonin and cortisol secretion is observed in children with ASD, ADHD, and PTSD, with altered circadian timing contributing to sleep disturbances and mood swings. Alterations in core clock genes (CLOCK, BMAL1, PER, and CRY) were also noted in children with epilepsy, which was linked to seizure frequency and timing. Chronotherapy approaches showed promise in managing these disruptions: melatonin supplementation improved sleep quality and reduced ADHD symptoms in some children, while light therapy proved effective in stabilizing sleep–wake cycles in ASD and ADHD patients. Additionally, behaviour-based interventions, such as the Early Start Denver Model, showed success in improving circadian alignment in children with ASD. Conclusions: This review highlights the significant role of circadian rhythm disruptions in paediatric neurological and neuropsychiatric disorders, with direct implications for treatment. Chronobiology-based interventions, such as melatonin therapy, light exposure, and individualized behavioural therapies, offer potential for improving symptomatology and overall functioning. The integration of chronotherapy into clinical practice could provide a paradigm shift from symptom management to more targeted, rhythm-based treatments. Future research should focus on understanding the molecular mechanisms behind circadian disruptions in these disorders and exploring personalized chronotherapeutic approaches tailored to individual circadian patterns.
... Up to 78% of adults with ADHD have a delayed biological rhythm, as measured by salivary melatonin (Van Veen et al., 2010). Melatonin is the main signaling molecule of the internal biological clock located in the brain. ...
... The majority of adults with ADHD have a delayed biological sleep-wake rhythm (Van Veen et al., 2010). ADHD and delayed, short sleep have been associated with obesity and diabetes. ...
Background: ADHD is highly comorbid with Delayed Sleep Phase Syndrome (DSPS). Both are associated with obesity and diabetes, which can be caused by long-term dysregulations of appetite and glucose metabolism. This study explores hormones involved in these processes and the effects of chronotherapeutic interventions in a small sample of adults with ADHD and DSPS. Methods: Exploratory, secondary analysis of data from the PhASE study, a three-armed randomized clinical trial, are presented, including 37 adults (18–53 years) with ADHD and DSPS receiving three weeks of 0.5 mg/day (1) placebo, (2) melatonin, or (3) melatonin plus 30 minutes of bright light therapy (BLT). Leptin (appetite-suppressing), ghrelin (appetite-stimulating), insulin, insulin-like growth factor-1 (IGF-1), and glucose were measured from blood collected at 08:00 hours. Salivary cortisol was collected during the first 30 minutes after awakening and self-reported appetite was assessed. Results: Baseline leptin and IGF-1 levels were higher than reference ranges, and ghrelin and cortisol levels were lower, while insulin and glucose were normal. Melatonin treatment decreased leptin and insulin. Other outcomes remained unchanged and melatonin + BLT had no effects. Conclusion: Due to the small sample size and exploratory nature of the study, results should be interpreted with caution. Overall, these results show no strong indications for dysregulation of appetite and glucose metabolism to suggest high risk of obesity and diabetes in this small sample of adults with ADHD and DSPS. However, baseline appetite was suppressed, likely because measurements took place in the early morning which could be considered the biological night for this study population. Melatonin treatment seemed to cause subtle changes in appetite-regulating hormones suggesting increased appetite. Chronotherapeutic treatment may affect appetite-regulating hormones by advancing the biological rhythm and/or altering eating behaviors, but this remains to be investigated in larger samples using detailed food diaries.
... By contrast, some studies conducted in autistic children (Goldman et al., 2014(Goldman et al., , 2017 reported normal overnight blood and salivary melatonin profiles and others melatonin half-life (>5 h) in 15 intellectually disabled children and adolescents with sleep onset insomnia, including seven autistic children. On the other hand, studies in ADHD have described a delayed melatonin onset with later chronotype, most reports concern adult subjects (Becker, 2020;Snitselaar et al., 2017;Van Der Heijden et al., 2005;Van Veen et al., 2010). Given all these reasons, the evidence for circadian dysfunction remains weak, and further research is required. ...
... In this study, we detected a subtle circadian phase advance among autistic participants, thus contrasting with the comparison group and those with co-occurring ADHD, as both groups showed more delayed phase markers of central sleep. ADHD is frequently associated with an evening chronotype, and eveningness is correlated with inattention and emotional difficulties (Kivelä et al., 2018;Van der Heijden et al., 2018;Van Veen et al., 2010). It is therefore plausible that ADHD can modify the autism chronotype, causing it to resemble more closely the chronotype shown by the comparison group. ...
Sleep problems are prevalent in autism spectrum disorder (ASD) and have a range of causes, including circadian rhythm misalignment. However, little is known about sleep in autistic children with co-occurring attention deficit hyperactivity disorder (ADHD). A cross-sectional descriptive and analytic study was conducted in 87 autistic children and adolescents (10.22 ± 3.36), 27 of whom had a diagnosis of ADHD, and 30 children with typical development (9.07 ± 2.75). An ambulatory circadian monitoring device was used to record wrist temperature (WT), motor activity, sleep, and light intensity. Higher WT values were detected in the comparison group, followed by autistic children and, ultimately, participants with co-occurring ADHD. In addition, atypical daily WT patterns were observed in autistic children, with slope flattening during afternoon and evening hours and an absent or subtle postprandial peak. Participants with co-occurring ADHD showed greater motor activity during sleep. Our findings, especially concerning WT rhythm, appear to support previous findings on the etiology of sleep problems in autism, as WT is closely connected to sleep-wakefulness. We found specific sleep patterns in autistic children depending on the presence of co-occurring ADHD, particularly regarding sleep maintenance, which may be an area of future research.
Lay abstract
Sleep problems are common in autism spectrum disorder (ASD) and different factors can contribute to its occurrence in this population. Misalignment of the biological clock (our circadian system) has been described as one possible explanation. While there is a body of research on sleep problems, relatively less is known about circadian functioning and the specific population of autistic children with co-occurring attention deficit hyperactivity disorder (ADHD). Using an ambulatory circadian monitoring (ACM) system, which resembles a common watch, we gathered sleep parameters and the different rhythms obtained from measuring motor activity, light exposure and distal temperature in 87 autistic children and adolescents, 27 of whom were diagnosed with co-occurring ADHD, and 30 neurotypical children and adolescents as a comparison group. Autistic children and, especially, those with co-occurring ADHD showed greater motor activity during sleep which would be worth studying in future projects which could better define this restless sleep. Of note, we observed an atypical pattern of wrist temperature, with higher values in neurotypical children, followed by autistic children and, ultimately, those with co-occurring ADHD. Temperature is one of the most valuable factors evaluated here as it is closely connected to sleep-wakefulness and the hormone melatonin. Its special pattern during day and nighttime would support the hypothesis of an atypical secretion of melatonin in autistic individuals which would also link with the higher presence of sleep problems in this neurodevelopmental condition.
... ADHD and sleep disorders are intimately intertwined in the majority of children and adults. The most common sleep disorder is a circadian rhythm sleep disorder, called delayed sleep phase syndrome (DSPS), which occurs in around 73-78% of ADHD cases [96,97]. Adults with ADHD typically become more active in the evening and have difficulty falling asleep at a desired bedtime. ...
... Sleep onset is often around 2-3 AM. DSPS is associated with a 1.5-hour delay in the onset of melatonin [96,98]. ADHD is also associated with other sleep disorders, such as insomnia in 43% of cases (hyperarousal, worrying or mental restlessness that impairs falling asleep or sleeping through), restless legs syndrome and periodic limb movement disorder in 30-40% (restless painful legs that prevent falling asleep or sleeping through), and sleep apnea in 30% (breathing stops which impairs sleep) [99][100][101][102][103][104]. ...
A comprehensive handbook covering current, controversial, and debated topics in psychiatric practice, aligned to the EPA Scientific Sections. All chapters been written by international experts active within their respective fields and they follow a structured template, covering updates relevant to clinical practice and research, current challenges, and future perspectives. This essential book features a wide range of topics in psychiatric research from child and adolescent psychiatry, epidemiology and social psychiatry to forensic psychiatry and neurodevelopmental disorders. It provides a unique global overview on different themes, from the recent dissemination in ordinary clinical practice of the ICD-11 to the innovations in addiction and consultation-liaison psychiatry. In addition, the book offers a multidisciplinary perspective on emerging hot topics including emergency psychiatry, ADHD in adulthood, and innovation in telemental health. An invaluable source of evidence-based information for trainees in psychiatry, psychiatrists, and mental health professionals.
... ADHD has been associated with increased sleep duration and increased daytime sleepiness. Furthermore, individuals with ADHD may be more likely to have an evening circadian preference and often take longer to fall asleep (4,5). Abnormal circadian rhythms of melatonin secretion have also been observed in ADHD patients (5). ...
... Furthermore, individuals with ADHD may be more likely to have an evening circadian preference and often take longer to fall asleep (4,5). Abnormal circadian rhythms of melatonin secretion have also been observed in ADHD patients (5). ...
Attention-deficit hyperactivity disorder (ADHD) is a highly heritable neurodevelopmental disorder that affects approximately 5.3% of children and approximately 2.5% of adults. There is an intimate relationship between ADHD and sleep disturbance. Specifically, individuals carry a mutation in the core circadian gene CRY1 (c. 1657 + 3A > C), which results in the deletion of exon 11 expression in the CRY1 protein (CRY1Δ11), causing them to exhibit typical ADHD symptoms. However, the underlying mechanism is still elusive. In this study, we demonstrate that Cry1Δ11 (c. 1717 + 3A > C) mice showed ADHD-like symptoms, including hyperactivity, impulsivity, and deficits in learning and memory. A hyperactive cAMP signaling pathway was found in the nucleus accumbens (NAc) of Cry1Δ11 mice. We further demonstrated that upregulated c-Fos was mainly localized in dopamine D1 receptor-expressing medium spiny neurons (DRD1-MSNs) in the NAc. Neuronal excitability of DRD1-MSNs in the NAc of Cry1Δ11 mice was significantly higher than that of WT controls. Mechanistically, the CRY1Δ11 protein, in contrast to the WT CRY1 protein, failed to interact with the Gαs protein and inhibit DRD1 signaling. Finally, the DRD1 antagonist SCH23390 normalized most ADHD-like symptoms in Cry1Δ11 mice. Thus, our results reveal hyperactive DRD1 signaling as an underlying mechanism and therapeutic target for ADHD induced by the highly prevalent CRY1Δ11 mutation.
... Reductions in sleep quality, delays in the circadian phase, and having an evening chronotype are consistently associated with ADHD in children and adults, and these alterations may be correlated with the severity of ADHD symptoms [47,49]. Specifically, ADHD is a condition with comorbid insomnia reported in >70% of children and adults, and a large proportion of patients with ADHD report emerging delays in sleep-wake rhythms, nocturnal rise in melatonin, and early morning rise in cortisol [47,50]. In addition, the high efficiency of chronotherapy approaches for the ADHD population strongly suggests that the circadian system may be an essential target for managing ADHD [49]. ...
... Loss of rhythmic host-microbiome interactions also disrupts the immune system [13] and consequently increases the risk of inflammatory and metabolic complications [50] commonly linked to mental health disorders [119]. Some studies have directly examined the circadian regulation of the immune response to gastrointestinal pathogens, which may impact mental health [120,121]. ...
Mental illness is alarmingly on the rise, and circadian disruptions linked to a modern lifestyle may largely explain this trend. Impaired circadian rhythms are associated with mental disorders. The evening chronotype, which is linked to circadian misalignment, is a risk factor for severe psychiatric symptoms and psychiatric metabolic comorbidities. Resynchronization of circadian rhythms commonly improves psychiatric symptoms. Furthermore, evidence indicates that preventing circadian misalignment may help reduce the risk of psychiatric disorders and the impact of neuro–immuno–metabolic disturbances in psychiatry. The gut microbiota exhibits diurnal rhythmicity, as largely governed by meal timing, which regulates the host’s circadian rhythms. Temporal circadian regulation of feeding has emerged as a promising chronotherapeutic strategy to prevent and/or help with the treatment of mental illnesses, largely through the modulation of gut microbiota. Here, we provide an overview of the link between circadian disruption and mental illness. We summarize the connection between gut microbiota and circadian rhythms, supporting the idea that gut microbiota modulation may aid in preventing circadian misalignment and in the resynchronization of disrupted circadian rhythms. We describe diurnal microbiome rhythmicity and its related factors, highlighting the role of meal timing. Lastly, we emphasize the necessity and rationale for further research to develop effective and safe microbiome and dietary strategies based on chrononutrition to combat mental illness.
... Here, normative circadian rhythms mean sleeping in accord to the nighttime and to current social norms and expectations. Unsurprisingly, non-restoring sleep and circadian rhythm disorders were associated with higher scores for aggressive behavior both among the general population [31,32] and in the forensic context [33]. ...
... Importantly, sleeping in accord with normative circadian rhythms was also associated with lower impulsivity, that is to say, with higher impulse control [29]. Unsurprisingly, non-restoring sleep and circadian rhythm disorders were associated with higher scores for aggressive behavior, both among the general population [31,32,[65][66][67][68][69] and in the forensic context [33]. Data from the participants assigned to Cluster 4 (Lo-Sleep-Lo-PA) confirmed this. ...
Background: From a psychological perspective, aggressive behavior, non-suicidal self-injury and suicidal behavior could be considered dysfunctional coping strategies. Poor sleep patterns may further increase such dysfunctional coping. In contrast, regular physical activity may have the power to counteract such dysfunctional coping. Given this background, the aim of the present study was to combine categories of circadian rhythms as a proxy of normative sleep patterns and categories of physical activity patterns, and to associate these categories with aggressive behavior, non-suicidal self-injury and suicidal behavior among a larger sample of adolescents and young adults, aged 15 to 34 years.
Method: A total of 2991 (55.6% females) individuals aged 15 to 34 years of the so-called Persian Cohort Study took part in the study. Participants completed self-rating questionnaires covering circadian-related sleep patterns, regular physical activity, sociodemographic information, and dimensions of aggression, non-suicidal self-injury, and suicidal behavior.
Results: In a first step, both sleep patterns (circadian rhythm disorder: yes vs. no) and physical activity patterns (high vs. low) were dichotomized. Next, participants were assigned to one of four prototypical clusters: No circadian sleep disorders and high physical activity (“Hi-Sleep-Hi-PA"); no circadian sleep disorders and low physical activity (“Hi-Sleep-Lo-PA"); circadian sleep disorders and high physical activity (“Lo-Sleep-Hi-PA"); circadian sleep disorders and low physical activity (“Lo-Sleep-Lo-PA"). Projecting these four clusters on dimensions of aggressive behavior, non-suicidal self-injury and suicidal behavior, the following findings were observed: Participants of the “Hi-Sleep-Hi-PA" reported the lowest scores for aggressive behavior, self-injury and suicidal behavior, compared to participants of the “Lo-Sleep-Lo-PA" cluster. No differences for aggressive behavior, self-injury and suicidal behavior were observed among participants of the “Hi-Sleep-Lo-PA" and the “Lo-Sleep-Hi-PA" clusters.
Conclusion: It appeared that the combination of favorable circadian sleep patterns and high physical activity patterns was associated with lower aggressive behavior, lower self-injury and suicidal behavior as proxies of favorable psychological functioning. In contrast, persons reporting high circadian sleep disorders and low physical activity patterns appeared to demand particular attention and counseling for both their life style issues (sleep and physical activity) and their dysfunctional coping strategies.
... Attention-deficit/hyperactivity disorder (ADHD) in adults is often concurrent with sleep disorders (Bijlenga et al., 2019). As many as 78% of adults with ADHD have a delayed circadian rhythm, as objectively marked by a delay in their dim-light melatonin onset (DLMO) measured in saliva (Van Veen et al., 2010). A delayed circadian rhythm often causes an inability to fall asleep or wake up at a desired time and may lead to a diagnosis of circadian rhythm sleep disorder-delayed sleep phase type (CRSD-DSPT), also termed delayed sleep phase syndrome (DSPS;American Psychiatric Association, 2013). ...
... Especially the accuracy of sleep onset latency would benefit from longer measurement and sleep logs, as it is difficult to distinguish between quiet wakefulness and sleep. Still, the currently reported onset latency of 19.74 min is comparable with ADHD populations in previous studies, which did include 7 days of monitoring and sleep logs (Boonstra et al., 2007;Kooij et al., 2001;Tonetti et al., 2017;Van Veen et al., 2010; for systematic review and meta-analysis see Díaz-Román et al., 2018). Third, sleep diary variables were not assessed before treatment, so only their development during 3-week treatment could be studied. ...
Delayed sleep phase syndrome (DSPS) is the most common sleep disturbance in adults with attention-deficit/hyperactivity disorder (ADHD). We previously showed that chronotherapy with melatonin effectively advanced the dim-light melatonin onset (DLMO), a biomarker for the internal circadian rhythm, by 1.5 h and reduced ADHD symptoms by 14%. Melatonin combined with bright light therapy (BLT) advanced the DLMO by 2 h, but did not affect ADHD symptoms. This article explores whether sleep times advanced along with DLMO, leading to longer sleep duration and better sleep in general, which might explain the working mechanism behind the reduction in ADHD symptoms after treatment with melatonin. This article presents exploratory secondary analysis on objective and self-reported sleep characteristics from a three-armed double-blind randomized placebo-controlled clinical trial (RCT), which included 49 adults (18-55 years) with ADHD and DSPS. Participants were randomized to receive sleep education and 3 weeks of (1) 0.5 mg/day placebo, (2) 0.5 mg/day melatonin, or (3) 0.5 mg/day melatonin plus 30 min of bright light therapy (BLT) between 0700 and 0800 h. Sleep was assessed at baseline, directly after treatment, and 2 weeks after the end of treatment. Objective measures were obtained by actigraphy, self-reported measures by various sleep questionnaires and a sleep diary. Melatonin with or without BLT did not advance sleep times, improve sleep in general, or strengthen wake-activity rhythms. So even though the DLMO had advanced, sleep timing did not follow. Adding extensive behavioral coaching to chronotherapy is necessary for advancing sleep times along with DLMO and to further alleviate ADHD symptoms.
... The core symptoms of ADHD-inattention, impulsivity, and motor hyperactivity-are very similar to those seen after sleep deprivation. Several studies have described a shorter average sleep duration in children with ADHD [10], chronic sleep-onset insomnia, and a diurnal preference toward eveningness was found in children and adults with ADHD [10][11][12][13]. However, the results remain inconsistent, even in studies using objective tools such as PSG and acitgraphy. ...
... The SCN is responsible for regulating the rhythmic secretion of various hormones such as cortisol and melatonin. Alterations of these secretions have been described in ADHD in children and adults, but with partially inconsistent results [13,[17][18][19]. ...
Attention deficit hyperactivity disorder (ADHD) is a very common disorder in children and adults. A connection with sleep disorders, and above all, disorders of the circadian rhythm are the subject of research and debate. The circadian system can be represented on different levels. There have been a variety of studies examining 24-h rhythms at the behavioral and endocrine level. At the molecular level, these rhythms are based on a series of feedback loops of core clock genes and proteins. In this paper, we compared the circadian rhythms at the behavioral, endocrine, and molecular levels between children with ADHD and age- and BMI-matched controls, complementing the previous data in adults. In a minimally invasive setting, sleep was assessed via a questionnaire, actigraphy was used to determine the motor activity and light exposure, saliva samples were taken to assess the 24-h profiles of cortisol and melatonin, and buccal mucosa swaps were taken to assess the expression of the clock genes BMAL1 and PER2. We found significant group differences in sleep onset and sleep duration, cortisol secretion profiles, and in the expression of both clock genes. Our data suggest that the analysis of circadian molecular rhythms may provide a new approach for diagnosing ADHD in children and adults.
... Curcumin also acts by inhibiting Cycloxygenase-2 (COX-2), Lipoxygenase (LOX), inducible Nitric Oxide Synthase (iNOS), arachidonic acid metabolites, cytokines (Interleukin (IL)), Nuclear Factor-kappa B (NF-κB) and Tumor Necrosis Factor-Alpha (TNF-α) [20] . Curcumin inhibits inflammation in acute pulmonary injury by a decline in the concentration of cytokines TNF-α, IL-1β, IL-6 and IL-17A [25] . However, diclofenac sodium has beneficial efficacy on various oxidative stress parameters such as Malondialdehyde (MDA), the indirect assessment of Nitric Oxide synthesis (NOx), Total Oxidative Status (TOS), total Thiols (SH), Total Antioxidant Capacity (TAC) and Oxidative Stability Index (OSI) but the combination of diclofenac sodium with curcumin nanoparticles showed a better effect on antioxidant parameters (TAC and SH) and pro-oxidant parameters (MDA, NOx, TOS and OSI) experimental acute inflammation due to its increased bioavailability [26] . ...
... A possible explanation for this result could be that individuals in the 35-49 age group are more likely to have stable jobs temperature on insomnia can be suggested. Sleep is influenced by skin and core body temperatures (Magnussen 1939;Van Den Heuvel et al. 1998;Van Veen et al. 2010). A decrease in core body temperature aids the onset of sleep (Barrett et al. 1993). ...
Insomnia is a growing health concern globally, with significant implications for public health. Most studies have primarily focused on the effects of nighttime temperatures on sleep problems. However, there is a lack of studies comparing nighttime temperatures with daytime temperatures, which are more closely related to daily life activities. This study aimed to explore a short–term association of nighttime and daytime ambient temperature with emergency department (ED) visits for insomnia in the capital city of South Korea. A time–stratified case–crossover design was employed using a conditional logistic regression model. A distributed lag non–linear model was utilized to explore potential non–linear and lag effects of ambient temperature on ED visits for insomnia. Odds ratio (OR) for temperature with maximum ED visits for insomnia (MaxIT) and that for temperature with minimum ED visits for insomnia (MinIT) were calculated and compared. We observed significant associations at high temperatures for both nighttime and daytime (nighttime: 25.0℃ (94.1%) [OR: 1.82, 95% CIs: 1.31–2.55], daytime: 30.6℃ (99.0%) [OR: 2.13, 95% CIs: 1.49–3.06]) compared to MinIT (-8.5℃ (2.7%) and − 8.4℃ (1.0%), respectively). Subgroup analyses found significant associations at high temperatures in females, individuals aged 35–49, and those without comorbidities, and during spring, fall, and winter, for both daytime and nighttime. Our findings provide insights for proactive public health strategies for managing insomnia during global temperature rise.
... However, children who reported sleep disorders presented with delayed DLMO and the delayed sleep phase [53]. Van Veen MM et al., and Bijlenga D et al. also point out the co-occurring sleep problem [54,55]. Patients with ADHD had significantly higher levels of total 24-h urinary excretion of 6-OH MS than controls. ...
... However, children who reported sleep disorders presented with delayed DLMO and the delayed sleep phase [53]. Van Veen MM et al., and Bijlenga D et al. also point out the co-occurring sleep problem [54,55]. Patients with ADHD had significantly higher levels of total 24-h urinary excretion of 6-OH MS than controls. ...
Autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) are neurodevelopmental disorders with disturbed melatonin secretion profile and sleep problems. The growing incidence of ASD and ADHD inspires scientists to research the underlying causes of these conditions. The authors focused on two fundamental aspects, the first one being the presentation of the role of melatonin in ASD and ADHD and the second of the influence of melatonin treatment on sleep disorders. The authors present the use of melatonin both in the context of causal and symptomatic treatment and discuss melatonin supplementation: Dosage patterns, effectiveness, and safety. Sleep disorders may have a different clinical picture, so the assessment of exogenous melatonin efficacy should also refer to a specific group of symptoms. The review draws attention to the wide range of doses of melatonin used in supplementation and the need to introduce unified standards especially in the group of pediatric patients.
... lifestyle, combined with the consumption of highly palatable or caloric food, that activate the dopamine-reward pathways and could be used as self-medication [27]. In addition, sleep problems encountered by individuals with ADHD, including disruptions in circadian rhythm and shortened sleep duration resulting from delayed onset of melatonin, have already been associated with the development of obesity [28,29]. ...
Purpose
Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition characterized by inattention, hyperactivity, and impulsivity. A positive association between ADHD and obesity has been observed, especially in adult samples. In this study, prevalence and correlates of self-reported symptoms indicative of a positive screening for ADHD were examined in patients seeking bariatric treatment.
Material and Methods
The study sample was composed of 260 adult patients with obesity referred for bariatric surgery to the Obesity Center of the Endocrinology Unit in Pisa University Hospital between January 2006 and November 2016 (BMI ≥ 30 kg/m²; mean ± standard deviation = 46.27 ± 7.45 kg/m²). ADHD symptoms were identified using ADHD Symptom Check‐List‐90‐R Screening Scale. Night-eating, binge-eating/purging behaviors, and temperamental and character traits were assessed in a subsample of 95 patients.
Results
Thirty participants had a positive screening for ADHD (11.5%, 95% CI = 7.9–16.1%). Patients with a positive screening showed significantly higher rates of anxiety disorders (40% vs. 16.5%, χ² = 7.97, p = 0.005) panic disorder (40% vs. 14.3%, χ² = 10.48, p = 0.001), and a higher severity of psychopathological symptoms and sleep disturbances than those without. In subsample analyses, ADHD symptoms severity was associated with more bulimic behaviors (r = 0.31–0.46), greater harm avoidance (r = 0.45–0.66), less self-directedness (r = − 0.44–0.63), and cooperativeness (r = − 0.26–0.42).
Conclusion
ADHD symptoms may be common in patients with obesity seeking bariatric treatment and are positively associated with disordered eating, internalizing features, and maladaptive character traits.
Level of Evidence: V, cross sectional descriptive study.
Graphical Abstract
... Sleep is in uenced by skin and core body temperatures(Magnussen 1939;Van Den Heuvel et al. 1998;Van Veen et al. 2010). A decrease in core body temperature aids the onset of sleep(Barrett et al. 1993). ...
Insomnia is a growing health concern globally, which can obstruct daytime functionality, reduce overall quality of life, and result in various diseases including depression, anxiety disorders and cardiovascular diseases. Increasing literature have focused on the potential role of ambient temperature in sleep problems, but the association remains inconclusive. This study aimed to explore a short-term association of ambient temperature with emergency department (ED) visits for insomnia in the capital city of South Korea. Using the National Emergency Department Information System database from 2008 to 2017, 7,855 patients who visited ED for insomnia (International Classification of Disease, 10th revision code F51.0 and G47.0) were identified. A time-stratified case-crossover design was employed using a conditional logistic regression model. A distributed lag non-linear model was utilized to explore potential non-linear and lag effects of ambient temperature on ED visits for insomnia. Odds ratio (OR) for temperature with maximum ED visits for insomnia (MaxIT) and that for temperature with minimum ED visits for insomnia (MinIT) were calculated and compared. A significant association was found between ambient temperature and ED visits for insomnia. Total insomnia increased significantly at a high temperature (MaxIT: 29.3℃, OR: 2.09 [95% CIs: 1.43–3.04]) compared to that at a MinIT (-8.9℃). Furthermore, the association between high temperature and insomnia was found to be stronger in females, 35–49 age group, and patients without comorbidities. The risk of insomnia is significantly increased in high ambient temperature. Our findings provide insights for proactive public health strategies for managing insomnia during global temperature rise.
... Some studies have shown the antioxidant properties of Capparis spinosa in diabetic rats and also showed that Capparis spinosa contains antioxidant compounds that may prevent ROS-induced liver damage due to increased levels of reduced glutathione (GSH) as a scavenger, reduce the main free radicals (Okur et al., 2018). In line with the present results, previous studies showed that Capparis spinosa extract had the effect of reducing blood lipids in diabetic rats (Van Veen et al., 2010), so this extract may be considered a food supplement for diabetic patients (Archana et al., 2022;Sun et al., 2023). ...
... Content: Prevalence of delayed circadian rhythm in ADHD [80] and effect of psychostimulants on late sleep [81]. How women with ADHD tackle stress and experience impairment [10] in social functioning and with time perception. ...
Background: The diagnostics and treatment of attention-deficit/hyperactivity disorder (ADHD) in women remain insufficient. Fluctuations of reproductive hormones during the premenstrual period, postpartum period, and (peri)menopause are neglected, even though they impact ADHD symptoms and associated mood disorders. Therefore, we created a female-specific treatment group for women with ADHD and premenstrual worsening of ADHD and/or mood symptoms. Methods: We describe the group programme and underlying rationale, offering a qualitative analysis of the participants’ evaluation. Results: The seven bi-weekly sessions foreground the menstrual cycle and address several ADHD-specific topics in relation to this cyclical pattern. Concurrently, women track their menstrual cycle and (fluctuating) ADHD and mood symptoms with an adjusted premenstrual calendar. In total, 18 women (25–47 years) participated in three consecutive groups. We analysed the evaluation of the last group. Participants experienced the group as a safe and welcoming space. Recognition was valued by all. The topics discussed were deemed valuable, and the structure suited them well. Completing the premenstrual calendar augmented the awareness and recognition of individual cyclical symptoms. A lifespan approach increased self-understanding. Participants took their menstrual cycle more seriously, prioritising self-acceptance and self-care. Conclusions: Exploring a cyclical approach in a group setting seems to be a positive addition to treatment for female ADHD.
... How does the menstrual cycle influence the (experienced) boundaries? Content: Prevalence of delayed circadian rhythm in ADHD [82] and effect of psychostimulants on late sleep [83]. How women with ADHD tackle stress and experience impairment [39] in social functioning and with time perception. ...
Diagnosis and treatment of Attention-Deficit/Hyperactivity Disorder (ADHD) in women remain insufficient. Fluctuations of reproductive hormones during the premenstrual period, postpartum period and (peri)menopause are neglected, even though they impact ADHD symptoms and as-sociated mood disorders [1]. Therefore, we created a female-specific treatment group for women with ADHD and premenstrual worsening of ADHD and/or mood symptoms. We describe the group programme and underlying rationale, offering a qualitative analysis of the participants’ evaluation. The 7 two-weekly sessions foreground the menstrual cycle and address several ADHD-specific topics in relation to this cyclical pattern: emotional regulation; impulsivity; setting boundaries, and triggers. Concurrently, women track their menstrual cycle and (fluctuating) ADHD and mood symptoms with an adjusted premenstrual calendar. In total, 18 women (25-47yrs) participated in three consecutive groups. We analysed the evaluation of the last group. Participants experienced the group as a safe and welcoming space. Recognition was valued by all. The topics discussed were deemed valuable and the structure suited them well. Completing the premenstrual calendar augmented awareness and recognition of individual cyclical symptoms. Discussing ADHD throughout the lifespan increased self-understanding. Participants took their menstrual cycle more seriously, prioritising self-acceptance and self-care in the luteal phase of the cycle. Exploring a cyclical approach in a group setting seems to be a positive addition to treatment for female ADHD.
... ADHD is a lifelong developmental disorder of self-regulation and Executive Function (EF) (Barkley, 2013) and is associated with academic, psychological, and social impairments (Dipeolu, 2011;Fleming & McMahon, 2012). These impairments are present as a function of the impact of dopamine and norepinephrine pathways (Brown 2013) which affect motivation and management of emotions (Barkley, 2013), sustained effort (Brown 2013), sleep and alertness (Van Veen et al., 2010) and mind wandering (O'Callaghan et al., 2021). Alexander and Farrelly (2018) note that there is no single anatomical area of the brain that accounts for the neuropathology of ADHD, but rather multiple parallel and intersecting connections which affect EF, risk and reward processing, and attention. ...
In Ireland, 5 % of university students registering with disability services in higher education have ADHD, increasing annually. Student services nationally report a significant increase in requests for assessment, diagnosis, and support for ADHD in university. This mixed method study investigated the experiences of undergraduate and postgraduate students with a diagnosis of ADHD in one HEI in Ireland to determine (i) institutional and systemic challenges, (ii) facilitators of successful progression through university, and (iii) an evidence-base to inform effective support. Data analysis encompassed responses from an online survey, anonymized longitudinal data extracted from disability services student progression reports, and qualitative data extrapolated from open-ended survey responses and individual, in-depth interviews. Findings indicate a need for ADHD friendly university campuses, adoption of Universal Design for Learning, increasing ADHD awareness within the university community, targeted ADHD supports, and optimizing the sensory environment.
... In a study of 40 adults with ADHD, 78% suffered from sleep onset insomnia (SOI). In this group, dim light melatonin onset (DLMO), which is a marker of the endogenous biological clock, occurred 1.3 h later compared to DLMO in the non-SOI group, and as much as 1.8 h later than in an age and sex-matched control group [80]. ...
Background
Light therapy (LT) for Seasonal Affective Disorders (SAD) has been a well-known and effective treatment for 40 years. The psychiatric university clinic of Groningen, the Netherlands was an early adopter and started research and treatment of SAD in 1987. Research projects on mechanisms, the role of the circadian system, treatment optimization, and investigating new areas for the effects of light treatment have been carried out ever since, leading to a widespread interest across the country.
Objective
To provide an overview and description of the historical development of LT for mental disorders in the Netherlands.
Methods
A non-systematic, review of research on light treatment for mental problems in the Netherlands, published since 1987 was conducted.
Results
The fields of LT and chronotherapy are strongly based in the scientific interests of both chrono-biologists and therapists in the Netherlands. LT has shown effectiveness in treating mood disorders. Likewise, results for other mental disorders have shown some promise, but so far, the outcomes are not always unequivocal and have not always been based on robust data. Ongoing research is discussed.
Conclusions
LT, and in addition exposure to the right light at the right time is an important issue in mental health. Over the past 3 decades research on light and LT in the Netherlands has become well established and is still growing.
... doi:10.1080/07420528.2020.1835943Most individuals with ADHD have a delayed circadian rhythm.21 Delayed sleep phase syndrome (DSPS) is diagnosed when a persistently delayed circadian rhythm is not brought on by other diseases or medications. ...
... The exact neurobiological mechanisms predisposing patients with ADHD to suffer from sleep disorders remain unknown, but they seem related to a circadian dysfunction in which the dim light melatonin onset (DLMO) is significantly delayed [34,35]. Therefore, the nighttime administration of exogenous melatonin (aMT) is a common therapeutic resource to advance the DLMO and correct these sleep/wake cycle alterations with a suitable safety profile for pediatric populations [36,37]. ...
Objective:
Only a few studies assessing the sleep effects of low doses of melatonin (aMT) have been performed in the past, most of them in adults, and only one in subjects with attention-deficit/hyperactivity disorder (ADHD). The aim of this study was to provide evidence of the changes induced by aMT doses as low as 1 mg in the sleep pattern of pediatric patients with ADHD under treatment with methylphenidate (MPH).
Methods:
Children and adolescents (7-15 years) with ADHD who were receiving extended-release MPH were recruited. A seven-week sleep diary was collected prior to starting a four-week treatment with 1 mg of aMT (30 min before bedtime). Seven-day actigraphic assessments of sleep were performed before and after treatment.
Results:
Twenty-seven patients (17 males, 62.96%) participated in the study, who had been receiving MPH for 1.57 (1.11) months. A significant increase in sleep duration (TST) was observed after one month of treatment (463 (49) min to 485 (41) min; p < 0.040), with nonsignificant improvements in sleep-onset latency (SOL), nocturnal awakenings, or sleep efficiency. Only minor adverse effects were reported.
Conclusion:
Low doses of melatonin (1 mg) are able to increase TST in children and adolescents with ADHD receiving treatment with psychostimulants, with an adequate tolerability profile. Further placebo-controlled trials adjusting the time of aMT administration to the individual circadian profile should explore the effects of low doses of this hormone to shorten SOL in this population of patients.
... If impulsivity is present with ADHD, BED may develop or be exacerbated while inattentiveness associated with ADHD may lead to difficulty focusing on ILT goals. Sleep disturbances associated with ADHD can lead to altered sleep schedules and/or insufficient sleep duration [84], which in turn lead to delayed onset of melatonin, high levels of ghrelin, and leptin resistance. ...
Introduction
Newer pharmacotherapy agents (anti-obesity medication [AOM]) are revolutionizing the management of children and adolescents with obesity. Previously, treatment based on intensive behavioral therapy involved many patient and family contact hours and yielded improvements in obesity status of 1-3 percent of the 95th percentile of the body mass index (BMI). Newer AOMs are yielding more clinically significant improvement of 5-18 percent. This review provides guidance for practitioners in the care of children and adolescents with obesity who frequently have complex medical and behavioral health care needs. Specifically, we discuss the use of newer AOMs in these complex patients.
Methods
This review details an approach to the care of the child and adolescent with obesity using AOMs. A shared decision-making process is presented in which the provider and the patient and family collaborate on care. Management of medical and behavioral components of the disease of obesity in the child are discussed.
Results
Early aggressive treatment is recommended, starting with an assessment of associated medical and behavioral complications, weight promoting medications, use of AOMs and ongoing care. Intensive behavioral therapy is foundational to treatment, but not a specific treatment. Patients and families deserve education on expected outcomes with each therapeutic option.
Conclusions
The use of new AOMs in children and adolescents has changed expected clinical outcomes in the field of pediatric obesity management. Clinically significant improvement in obesity status occurs when AOMs are used early and aggressively. Ongoing, chronic care is the model for optimizing outcomes using a shared decision-making between provider and patient/family. Depending on the experience and comfort level of the primary care practitioner, referral to an obesity medicine specialist may be appropriate, particularly when obesity related co-morbidities are present and pharmacotherapy and metabolic and bariatric surgery are considerations.
... 40 The most common sleep disorder is delayed circadian rhythm, which is seen in the majority of adults with ADHD. 41 In one report, melatonin treatment advanced the circadian rhythm, although the reduction of ADHD symptoms seen in that study was not attributed to the change in circadian rhythm. 42 Sleep disorders are more frequent and severe in adults with ADHD compared with other psychiatric outpatients, and it has been suggested that sleep disturbances are an intrinsic feature of adult ADHD rather than a consequence of comorbid psychiatric conditions. ...
Purpose
Most previous studies that described associations between adult attention-deficit/hyperactivity disorder (ADHD) and sociodemographic characteristics were focused on individuals diagnosed with ADHD, and few studies investigated ADHD traits in the general population. Additionally, some workers, who experienced no problems while at university and successfully graduated from university, developed ADHD traits after finding employment. This study described associations between ADHD traits and sociodemographic characteristics among Japanese workers who were university graduates.
Patients and Methods
Participants were randomly selected workers (n=1240) from across Japan who completed a self-administered online survey. ADHD traits were measured using an adult ADHD Self-report Scale, with scoring rules applied to reflect the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. Information was collected on sociodemographic characteristics including sex, age, socioeconomic status, working time, and health-related behaviors. We performed partial correlation analysis to estimate trend associations and used analysis of covariance to compare adjusted averages. This model was adjusted for all variables.
Results
Males had higher levels of ADHD traits than females (p = 0.001), and younger age was associated with higher levels of ADHD traits (p < 0.001). Workers with low incomes had higher levels of ADHD traits than workers with high incomes (p = 0.009). More frequent consumption of midnight meals was associated with higher levels of ADHD traits (p < 0.001), although there were no differences for breakfast, lunch, and dinner. Those who did not get enough rest from sleep had higher levels of ADHD traits (p = 0.007).
Conclusion
Results for high levels of ADHD traits among workers were consistent with previous studies for adults diagnosed with ADHD, even though all participants had successfully graduated from university. Assessment of these ADHD traits may support prevention of health deterioration related to these ADHD traits.
... It is also available in the literature that neuroendocrine regulation of appetite and food intake is associated with sleep duration and sleep restriction may support the development of obesity (Copinschi, 2005). It has been reported in studies that the disruption in circadian rhythm is compensated by other unhealthy habits (such as leaving home without breakfast, and uncontrolled eating attacks during the day) and that both circadian disruption and short sleep duration are associated with general health problems such as obesity and other cardiovascular and metabolic risk factors (Sakarya, 2018;Van Veen et al., 2010). Both insomnia and night eating scores were associated with nocturnal chronotype. ...
Objective
In our study, we aimed to evaluate eating-attitudes in adult-ADHD, and to examine its relationship with sociodemographic, clinical, AgRP, and biochemical parameters.
Method
The study included 70 adult-patients and 47 healthy-controls. The DIVA2.0, SCID-1 was administered to the participants. Eating-Attitudes Test (EAT), Night-Eating Questionnaire (NEQ), Barratt Impulsivity Scale (BIS-11) were filled by the participants.
Results
We found that psychological state affect eating-attitudes in adult-ADHD ( p = .013), emotional eating is more common, nocturnal chronotype is dominant ( p < .001), NES is more frequent ( p < .001), waist circumference measurement is higher ( p = .030), and lipid profile is deteriorated ( p < .001). AgRP levels were significantly lower in patients treated with methylphenidate ( p = .021). Those who received methylphenidate treatment had less NES than those who did not. Deterioration in eating-attitudes and symptom severity of night eating in ADHD, it was positively correlated with clinical severity of ADHD and impulsivity. In addition, age and increase in night eating symptoms were predictors of deterioration in eating attitudes in adult-ADHD. We found that impaired eating-attitudes and impulsivity severity were also predictors of NES ( p = .006, p = .034).
Conclusion
The necessity of adult-ADHD treatment has been demonstrated by the deterioration in eating-attitudes and cardiometabolic risk dimensions and the underlying mechanisms.
... Within patients with insomnia, however, there is little evidence for circadian rhythm disturbances, potentially rendering the monitoring of circadian rhythms with actigraphy superfluous in this group. While van Veen et al. (2010) reported an attenuated 24 h amplitude of the rest-activity pattern and lower interdaily stability of adults with insomnia comorbid with ADHD, no differences in inter-or intradaily rhythm variables were found in children with ADHD and insomnia (van der Heijden et al., 2005). The few other studies published on diurnal rhythm variables in insomnia also failed to find differences between patients and controls (Kim, Lim, Kwon, & Lee, 2020;Natale et al., 2009), with the actual numbers of null results possibly being much larger due to the file drawer problem (Rosenthal, 1979). ...
In the past decades, actigraphy has emerged as a promising, cost-effective, and easy-to-use tool for ambulatory sleep recording. Polysomnography (PSG) validation studies showed that actigraphic sleep estimates fare relatively well in healthy sleepers. Additionally, round-the-clock actigraphy recording has been used to study circadian rhythms in various populations. To this date, however, there is little evidence that the diagnosis, monitoring, or treatment of insomnia can significantly benefit from actigraphy recordings. Using a case-control design, we therefore critically examined whether mean or within-subject variability of actigraphy sleep estimates or circadian patterns add to the understanding of sleep complaints in insomnia. We acquired actigraphy recordings and sleep diaries of 37 controls and 167 patients with varying degrees of insomnia severity for up to 9 consecutive days in their home environment. Additionally, the participants spent one night in the laboratory, where actigraphy was recorded alongside PSG to check whether sleep, in principle, is well estimated. Despite moderate to strong agreement between actigraphy and PSG sleep scoring in the laboratory, ambulatory actigraphic estimates of average sleep and circadian rhythm variables failed to successfully differentiate patients with insomnia from controls in the home environment. Only total sleep time differed between the groups. Additionally, within-subject variability of sleep efficiency and wake after sleep onset was higher in patients. Insomnia research may therefore benefit from shifting attention from average sleep variables to day-to-day variability or from the development of non-motor home-assessed indicators of sleep quality.
El trastorno por déficit de atención e hiperactividad (TDAH) ha sido tradicionalmente concebido como una condición privativa de la infancia. Sin embargo, una creciente evidencia sugiere que el TDAH persiste en la vida adulta, manifestándose de diversas maneras. A pesar de su prevalencia y de las significativas consecuencias en la vida cotidiana, el TDAH en adultos ha sido considerablemente subestimado y subdiagnosticado, lo que resulta en una carga sustancial tanto para los individuos afectados como para su entorno familiar y social. Esta revisión exhaustiva se propone explorar la complejidad del TDAH en la adultez y aborda su etiología, definición y presentación clínica, los factores de riesgo, las comorbilidades más frecuentes, los métodos de evaluación y los aspectos neuropsicológicos, así como los enfoques farmacoterapéuticos y los no farmacoterapéuticos para su tratamiento. Además, se examinan las implicaciones para el diagnóstico y el tratamiento, destacando la importancia de una comprensión integral de esta condición. A través de este documento, la Asociación Argentina de Psiquiatría Biológica (AAPB) aspira no solo a recopilar y analizar la evidencia sobre el TDAH en adultos, sino también a proporcionar una guía útil para los profesionales de la salud que tratan esta patología. Así, el objetivo final de este artículo es contribuir al desarrollo de estrategias efectivas para la evaluación y el manejo del TDAH, y mejorar de este modo la calidad de vida de los pacientes.
Attention Deficit Hyperactivity Disorder (ADHD) has traditionally been understood as a condition primarily associated
with childhood. However, growing evidence indicates that ADHD persists into adulthood, manifesting in various ways.
Despite its prevalence and significant impact on daily life, adult ADHD has been considerably underestimated and underdiagnosed,
resulting in a substantial burden for affected individuals, as well as their families and social environment.
This comprehensive review aims to explore the complexity of ADHD in adulthood by addressing its etiology, definition,
clinical presentation, risk factors, common comorbidities, evaluation methods, and neuropsychological aspects, alongside
both pharmacotherapeutic and non-pharmacotherapeutic approaches for treatment. Additionally, the implications for
diagnosis and treatment are examined, emphasizing the need for a thorough understanding of this condition.
Through this document, the Argentine Association of Biological Psychiatry (Asociación Argentina de Psiquiatría Biológica,
AAPB) not only seeks to compile and analyze the evidence on adult ADHD but also to provide a practical guide for
healthcare professionals treating this disorder. The ultimate goal of this article is to contribute to the development of
effective strategies for the evaluation and management of ADHD, ultimately improving the quality of life for patients.
Sleep disturbances (SD) are commonly reported concerns among parents and caregivers of children and adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD). While it is widely acknowledged that SD can worsen various aspects of children and adolescents’ well-being (e.g., academic performance and emotional/behavioral state), a comprehensive clinical characterization of ADHD and SD is currently lacking. To address this gap, 136 children and adolescents diagnosed with ADHD (aged 6 to 14 years) were retrospectively selected by reviewing electronic health records of hundreds of patients with neuropsychiatric disorders referred to the children’s hospital. Participants were divided into two groups based on the presence of SD, assessed via a parent-report questionnaire (94 ADHD without SD and 42 ADHD with SD). Standardized measures of adaptive behavior, academic performance, ADHD-related and emotional/behavioral symptoms were collected. Results documented that the group of ADHD with SD obtained worse scores in specific aspects of adaptive behavior (conceptual and practical domains), academic performance (text comprehension, writing), ADHD symptoms (inattention) and emotional/behavioral difficulties (especially, mood/emotional regulation and stress) compared to those with ADHD without SD. In addition, our results established a relationship between sleep problems and diverse clinical aspects of children and adolescents with ADHD, while controlling for age, cognitive level, gender, ADHD symptoms severity, and Body Mass Index. From a clinical perspective, our study suggests that the presence of SD in patients with ADHD may serve as an indicator for strengths and weaknesses in this population, even demonstrating an independent relationship with specific clinical dimensions. Implications to improve clinical diagnostic and therapeutic interventions are discussed.
Background
Sleep problems are common in adults with ADHD and may be bidirectionally associated with ADHD severity and other psychiatric symptoms. We investigated the prevalence of positive screenings for various sleep disorders, and their association with psychiatric comorbidities in a large sample of adults with ADHD from a specialized outpatient clinic.
Methods
We included data of 3,691 adult patients diagnosed with ADHD, who had filled out a screener for sleep disorders (Holland Sleep Disorders Questionnaire (HSDQ)) as part of routine diagnostic assessment. The HSDQ screens for the sleep disorders insomnia, parasomnia, hypersomnia, circadian rhythm sleep disorders (CRSD), restless legs syndrome (RLS)/periodic limb movement disorder (PLMD), and sleep-related breathing disorders (SBD). As delayed sleep phase syndrome (DSPS) is very frequent in ADHD, we additionally screened for DSPS. Psychiatric comorbidities were diagnosed through clinical assessment and the Mini International Neuropsychiatric Interview (M.I.N.I.) Plus, which assesses 26 psychiatric disorders following the classification of the DSM-5. All data were retrieved from the electronic patient files.
Results
Mean age was 35.4 and 49.4% of the patients were female. About 60% of the adults with ADHD screened positive for any sleep disorder. Highest prevalences were found for symptoms of DSPS (36%), insomnia (30%), and RLS/PLMD (29%). Sleep problems in adults with ADHD were associated with comorbid depression, anxiety, substance use disorder, personality disorder, and post-traumatic stress disorder.
Conclusion
Adults with ADHD often report sleep problems, which are associated with specific psychiatric comorbidities. Systematic screening for sleep disorders in adult patients with ADHD can contribute to a better understanding of their complaints and may aid improved and integrated treatment for the sleep and psychiatric problems.
The overt expression of circadian rhythms is a manifestation of the suprachiasmatic nucleus (SCN). This integrated complex function based on the transcriptional/translational feedback loops (TFFLs), neurotransmitters, genes, networking, and synchronization is essential for this molecular mechanism to operate effectively. Neurotransmitters by participating in the entrainment to the environmental light conditions and synchronization contribute to the robustness of the rhythm. Neurotransmitter signaling is the hallmark of circadian rhythm expression. Even during development, neuropeptides contribute to the dramatic cellular, genetic, and network circuit changes. Participating neurotransmitters are seen in afferent inputs, efferent output, and the SCN. There are numerous neurotransmitters involved in SCN function. Astrocytes co-exist with neurons in the SCN. Autonomous clocks seen in astrocytes can drive circadian behavior like neurons. Astrocytes and neurons are acting as two arms of the clock. Coupling through glutamate released from astrocytes gives additional evidence for the role of astrocytes. Glutaminergic signaling from astrocytes may also be responsible for timekeeping. The neurotransmitters can independently and in combination execute the functions making SCN a unique pacemaker for the overt expression of circadian rhythms. This reassessment also highlights its role in underlying molecular mechanisms, genetic linkage, and the recently known role of astrocytes.
Patients with neurodevelopmental disorders, such as autism spectrum disorder, often display abnormal circadian rhythms. The role of the circadian system in these disorders has gained considerable attention over the last decades. Yet, it remains largely unknown how these disruptions occur and to what extent they contribute to the disorders' development. In this review, we examine circadian system dysregulation as observed in patients and animal models of neurodevelopmental disorders. Second, we explore whether circadian rhythm disruptions constitute a risk factor for neurodevelopmental disorders from studies in humans and model organisms. Lastly, we focus on the impact of psychiatric medications on circadian rhythms and the potential benefits of chronotherapy. The literature reveals that patients with neurodevelopmental disorders display altered sleep-wake cycles and melatonin rhythms/levels in a heterogeneous manner, and model organisms used to study these disorders appear to support that circadian dysfunction may be an inherent characteristic of neurodevelopmental disorders. Furthermore, the pre-clinical and clinical evidence indicates that circadian disruption at the environmental and genetic levels may contribute to the behavioural changes observed in these disorders. Finally, studies suggest that psychiatric medications, particularly those prescribed for attention-deficit/hyperactivity disorder and schizophrenia, can have direct effects on the circadian system and that chronotherapy may be leveraged to offset some of these side effects. This review highlights that circadian system dysfunction is likely a core pathological feature of neurodevelopmental disorders and that further research is required to elucidate this relationship.
FASE, https://www.trialregister.nl/, #NTR3831.
Sleep problems and sleep disorders are common comorbidities in individuals with attention-deficit/hyperactivity disorder (ADHD) across the lifespan. Sleep problems/disorders contribute significantly to the impairment experienced by children and adults with ADHD. Despite the high prevalence of sleep problems/disorders and the impact of these on daytime functioning, screening and assessment of sleep are not often conducted as part of an initial ADHD diagnostic assessment or follow-up assessments. As such, treatment for sleep problems/disorders is often not implemented. In Sect. 10.1 of this chapter, we provide an overview of what is known about sleep and its functions and explore how ADHD and sleep problems/disorders are related. In Sect. 10.2, we provide information about the assessment of sleep problems, including assessment tools and approaches, and how these may be modified for individuals with ADHD. In Sect. 10.3, information about the main sleep disorders in individuals with ADHD is provided, along with best clinical practice for the treatment of these disorders in individuals with ADHD. In Sect. 10.4, we present a case study that highlights sleep problems across childhood, adolescence, and adulthood in an individual with ADHD, along with assessment information. The reader is encouraged to consider a case formulation using a biopsychosocial model and develop a treatment plan using the 4Ps model. This chapter is concluded with the take-away messages about ADHD and sleep problems/disorders.
In many clinical trials involving transcranial electrical stimulation (tES), target electrodes are typically placed over DLPFC with the assumption that this will primarily stimulate the underlying brain region. However, our study aimed to evaluate the electric fields (EF) that are actually delivered and identify prefrontal regions that may be inadvertently targeted in DLPFC tES. Head models were generated from the Human Connectome Project database's T1 + T2‐weighted MRIs of 80 healthy adults. Two common DLPFC montages were simulated; symmetric‐F4/F3, and asymmetric‐F4/Fp1. Averaged EF was extracted from (1) the center of the target electrode (F4), and (2) the top 1% of voxels showing the strongest EF in individualized EF maps. Interindividual variabilities were quantified with the standard deviation of EF peak location/value. Similar steps were repeated with 66 participants with methamphetamine use disorder (MUDs) as an independent clinical population. In healthy adults, the group‐level location of EF peaks was situated in the medial‐frontopolar, and the individualized EF peaks were positioned in a cube with a volume of 29 cm ³ /46 cm ³ (symmetric/asymmetric montages). EFs in the frontopolar area were significantly higher than EF “under” the target electrode in both symmetric (peak: 0.41 ± 0.06, F4:0.22 ± 0.04) and asymmetric (peak: 0.38 ± 0.04, F4:0.2 ± 0.04) montages (Heges' g > 0.7). Similar results with slight between‐group differences were found in MUDs. We highlighted that in common DLPFC tES montages, in addition to interindividual/intergroup variability, the frontopolar received the highest EFs rather than DLPFC as the main target. We specifically recommended considering the potential involvement of the frontopolar area as a mechanism underlying the effectiveness of DLPFC tES protocols.
Because the endogenous circadian pacemaker is a very strong determinant of alertness/sleep propensity across the 24 h period, its mistiming may contribute to symptoms of insomnia (e.g., difficulties initiating sleep and maintaining sleep) and to the development of insomnia disorder. Despite the separation of insomnia and circadian rhythm disorders in diagnostic nosology implying independent pathophysiology, there is considerable evidence of co-morbidity and interaction between them. Sleep onset insomnia is associated with later timed circadian rhythms and can be treated with morning bright light to shift rhythms to an earlier timing. It is also possible that the causal link may go in both directions and that having a delayed circadian rhythm can result in enough experiences of delayed sleep onset to lead to some conditioned insomnia or insomnia disorder further exacerbating a delayed circadian rhythm. Early morning awakening insomnia is associated with an advanced circadian phase (early timing) and can be treated with evening bright light resulting in a delay of rhythms and an improved ability to sleep later in the morning and to obtain more sleep. There is some evidence suggesting that sleep maintenance insomnia is associated with a blunted amplitude of circadian rhythm that may be treated with increased regularity of sleep and light exposure timing. However, this is an insomnia phenotype that requires considerably more circadian research as well as further insomnia clinical research with the other insomnia phenotypes incorporating circadian timing measures and treatments.
The circadian system plays a key role in the sleep-wake cycle. A mismatch between the behavioral timing of sleep and the circadian timing of sleepiness/alertness can contribute to insomnia. Patients who report primarily difficulty falling asleep or early morning awakenings may benefit from circadian interventions administered adjunctively to cognitive-behavioral therapy for insomnia. Specific circadian interventions that clinicians may consider include bright light therapy, scheduled dim light, blue-blocking glasses, and melatonin. Implementation of these interventions differs depending on the patient's insomnia subtype. Further, careful attention must be paid to the timing of these interventions to ensure they are administered correctly.
Objective:
Polysomnographic findings in neurodevelopmental disorders have been reported, but previous studies have had several limitations. The purpose of this study was to characterize sleep structure in untreated adults diagnosed with ADHD, excluding ADHD-related sleep disorders as determined by polysomnography and multiple sleep latency testing.
Methods:
This study included 55 patients aged 18 years or older who visited the Kurume University Hospital Sleep Clinic between April 2015 and March 2020. The diagnosis of ADHD was determined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (ADHD group, n = 28; non-ADHD, n = 27).
Results:
The ADHD group had significantly longer slow wave sleep (SWS) duration than the non-ADHD group (ADHD: 68.3 ± 31.0 minutes vs. non-ADHD: 43.4 ± 36.6 minutes; p = .0127).
Conclusions:
The increased SWS volume observed in drug-naïve adult patients with ADHD may be related to the pathogenesis of this disorder.
In general, poor sleep is common in children with a neurodevelopmental disorder (Esbensen AJ, Schwichtenberg AJ. Sleep in neurodevelopmental disorders. Int Rev Res Dev Disabil. 2016;51:153–91. Schreck KA, Richdale AL. Sleep problems, behavior, and psychopathology in autism: inter-relationships across the lifespan. Curr Opin Psychol. 2020;34:105–11) and is related to additional difficulties for these children, such as increased daytime behaviour problems, poorer adaptive behaviour, and worsened academic functioning. Furthermore, sleep problems in children with neurodevelopmental disorders have a negative impact on families, particularly parents including increased parenting stress and poorer parent mental health(Cotton S, Richdale A. Brief report: parental descriptions of sleep problems in children with autism, Down syndrome, and Prader–Willi syndrome. Res Dev Disabil. 2006;27(2):151–61. Richdale AL, Baker EK. Sleep in individuals with an intellectual or developmental disability: recent research reports. Curr Dev Disord Rep. 2014;1(2):74–85. Martin CA, Papadopoulos N, Chellew T, Rinehart NJ, Sciberras E. Associations between parenting stress, parent mental health and child sleep problems for children with ADHD and ASD: systematic review. Res Dev Disabil. 2019;93:103463). This chapter examines sleep problems in the two most common neurodevelopmental disorders, Autism Spectrum Disorder (autism) and Attention-Deficit/Hyperactivity Disorder (ADHD). Additionally, as examples of sleep difficulties that commonly co-occur in a range of genetically determined neurodevelopmental disorders associated with developmental delay and intellectual disability (ID), we describe sleep in the X-linked disorders (Fragile X syndrome [FXS] and Rett syndrome), and the chromosome 15 imprinting disorders (Prader-Willi syndrome [PWS] and Angelman syndrome [AS]).
To date, there has been relatively little research into how the neurobiological mechanisms of sleep regulation may be affected in attention deficit hyperactivity disorder (ADHD). This chapter gives a broad overview of the neurobiology of sleep and explores possible neurobiological processes that may explain the association between sleep problems and ADHD. The chapter discusses the reciprocal inhibition between a system that promotes wakefulness, attention, and alertness, and a system that induces sleep. It highlights the nuclei and neurotransmitters of the ascending arousal system and the sleep-inducing system, and the mechanisms that drive the transition between the two systems. It also covers the homeostatic and circadian regulation that drives sleep to occur. This summary of the growing literature reveals that anomalies in particular neural circuitry or neurotransmitter systems may contribute to both difficulties in the regulation of sleep and the behavioral and cognitive deficits that characterize ADHD, however, the relationship may not be straightforward.
Disturbed sleep cycles are the principal cause of institu-tionalization in dementia, and therefore represent a major clinical problem. They may arise from dysfunc-tion within the circadian clock of the hypothalamus that times and consolidates wakefulness, or from neuro-pathology in output pathways and/or target sites of the clock speci®cally controlling sleep and wakefulness. To determine the relationship of disturbed activity cycles to other circadian clock-controlled rhythms, cross-sectional and longitudinal actigraphy and serial sampling of saliva were used to compare the impact of early Alzheimer's dementia on activity/rest and cortisol rhythms in home-dwelling subjects. Mildly demented subjects had daily activity rhythms comparable to those of healthy age-matched subjects. Moderately demented subjects exhibited a range of disturbances of the activ-ity/rest cycle, with reduced stability, increased fragmentation and loss of amplitude. Within the moderately demented group, however, the degree of circadian disruption was not correlated with the individual severity of dementia. All groups of subjects, mild, moderate with normal activity cycles and moderate with abnormal activity cycles, exhibited robust daily pro®les of sal-ivary cortisol, with highest levels in the morning (08:00 h) and an evening nadir (20:00±24:00 h). Salivary corti-sol levels tended to be higher in the moderately demented subjects in the afternoon, but this effect was not speci®c to those with abnormal activity/rest patterns. The actimetric data con®rm that deterioration of activ-ity/rest cycles is a common and progressive feature in home-dwelling Alzheimer's patients, occurring early in the disease but after the measurable onset of dementia. The maintenance of highly rhythmic daily cortisol pro-®les in association with disturbed activity pro®les, both on an individual and on a group basis, demonstrates that loss of circadian control to activity/rest cycles is not a consequence of global circadian disruption in early dementia. Rather, pathology may develop in discrete elements of the circadian clockwork and/or its output systems that control activity/rest, sleep and wakefulness. Further characterization of this pathology will facilitate more effective management of sleep patterns in home-dwelling demented patients. Abbreviations: ANOVA = analysis of variance; HPA = hypothalamo-pituitary-adrenal; IS = inter-daily stability; IV = intra-daily variability; MMSE = Mini-Mental State Examination; NPCRA = non-parametric circadian rhythm analysis; PSG = polysomnographic; RA = rhythm analysis; SCN = suprachiasmatic nuclei of the hypothalamus
Actigraphy is a method used to study sleep-wake patterns and circadian rhythms by assessing movement, most commonly of the wrist. These evidence-based practice parameters are an update to the Practice Parameters for the Use of Actigraphy in the Clinical Assessment of Sleep Disorders, published in 1995. These practice parameters were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. Recommendations are based on the accompanying comprehensive review of the medical literature regarding the role of actigraphy, which was developed by a task force commissioned by the American Academy of Sleep Medicine. The following recommendations serve as a guide to the appropriate use of actigraphy. Actigraphy is reliable and valid for detecting sleep in normal, healthy populations, but less reliable for detecting disturbed sleep. Although actigraphy is not indicated for the routine diagnosis, assessment, or management of any of the sleep disorders, it may serve as a useful adjunct to routine clinical evaluation of insomnia, circadian-rhythm disorders, and excessive sleepiness, and may be helpful in the assessment of specific aspects of some disorders, such as insomnia and restless legs syndrome/periodic limb movement disorder. The assessment of daytime sleepiness, the demonstration of multiday human-rest activity patterns, and the estimation of sleep-wake patterns are potential uses of actigraphy in clinical situations where other techniques cannot provide similar information (e.g., psychiatric ward patients). Superiority of actigraphy placement on different parts of the body is not currently established. Actigraphy may be useful in characterizing and monitoring circadian rhythm patterns or disturbances in certain special populations (e.g., children, demented individuals), and appears useful as an outcome measure in certain applications and populations. Although actigraphy may be a useful adjunct to portable sleep apnea testing, the use of actigraphy alone in the detection of sleep apnea is not currently established. Specific technical recommendations are discussed, such as using concomitant completion of a sleep log for artifact rejection and timing of lights out and on; conducting actigraphy studies for a minimum of three consecutive 24-hour periods; requiring raw data inspection; permitting some preprocessing of movement counts; stating that epoch lengths up to 1 minute are usually sufficient, except for circadian rhythm assessment; requiring interpretation to be performed manually by visual inspection; and allowing automatic scoring in addition to manual scoring methods.
Individuals with ADHD often report sleep problems. Though most studies on ADHD and sleep examined children or nonclinically diagnosed adults, the present study specifically examines nonmedicated adults with ADHD to determine whether inattentive and hyperactive-impulsive symptoms are associated with sleep problems.
A total of 22 nonmedicated adults diagnosed with ADHD are assessed with a DSM-IV-based interview and the Pittsburg Sleep Quality Index (PSQI).
The number of hyperactive-impulsive symptoms indicate a positive correlation with sleep duration, habitual sleep efficiency, and global PSQI score. No significant associations are found between inattentive symptoms and sleep quality.
The results show that sleep problems are associated with hyperactive and impulsive symptoms in nonmedicated adults with ADHD. These findings provide information on the nature of sleep problems without the confounding effects of medication associated with ADHD. Treatment of sleep problems, especially in those with hyperactive-impulsive symptoms, may help ameliorate ADHD symptomatology.
There is considerable epidemiological evidence that shift work is associated with increased risk for obesity, diabetes, and cardiovascular disease, perhaps the result of physiologic maladaptation to chronically sleeping and eating at abnormal circadian times. To begin to understand underlying mechanisms, we determined the effects of such misalignment between behavioral cycles (fasting/feeding and sleep/wake cycles) and endogenous circadian cycles on metabolic, autonomic, and endocrine predictors of obesity, diabetes, and cardiovascular risk. Ten adults (5 female) underwent a 10-day laboratory protocol, wherein subjects ate and slept at all phases of the circadian cycle-achieved by scheduling a recurring 28-h "day." Subjects ate 4 isocaloric meals each 28-h "day." For 8 days, plasma leptin, insulin, glucose, and cortisol were measured hourly, urinary catecholamines 2 hourly (totaling approximately 1,000 assays/subject), and blood pressure, heart rate, cardiac vagal modulation, oxygen consumption, respiratory exchange ratio, and polysomnographic sleep daily. Core body temperature was recorded continuously for 10 days to assess circadian phase. Circadian misalignment, when subjects ate and slept approximately 12 h out of phase from their habitual times, systematically decreased leptin (-17%, P < 0.001), increased glucose (+6%, P < 0.001) despite increased insulin (+22%, P = 0.006), completely reversed the daily cortisol rhythm (P < 0.001), increased mean arterial pressure (+3%, P = 0.001), and reduced sleep efficiency (-20%, P < 0.002). Notably, circadian misalignment caused 3 of 8 subjects (with sufficient available data) to exhibit postprandial glucose responses in the range typical of a prediabetic state. These findings demonstrate the adverse cardiometabolic implications of circadian misalignment, as occurs acutely with jet lag and chronically with shift work.
Recent evidence has been accumulating that the sleep of individuals with attention deficit hyperactivity disorder (ADHD) is not only disrupted in a nonspecific way but that ADHD has an increased association with simple sleep related movement disorders such as restless legs syndrome/periodic limb movements in sleep (RLS/PLMS), rhythmic movement disorder (body rocking and head banging), and parasomnias, such as disorders of partial arousal (sleep walking, sleep terrors, and confusional arousals). In addition increased associations have been reported between ADHD and hypersomnias such as narcolepsy and sleep apnea as well as circadian rhythm disorders, such as delayed sleep phase syndrome. These relationships are reviewed and the implications for such associations are explored. Patients with sleep disorders should be queried about the symptoms of ADHD and vice versa.
Sleep problems were analyzed in children with ADHD (Attention-deficit hyperactivity disorder).
Scales were completed by parents of 135 control children and 681 children with ADHD combined type (ADHD-C) or inattentive type (ADHD-I) with or without comorbid oppositional defiant disorder (ODD), anxiety, or depression.
Children with ADHD-I alone had the fewest sleep problems and did not differ from controls. Children with ADHD-C had more sleep problems than controls and children with ADHD-I. Comorbid anxiety/depression increased sleep problems, whereas ODD did not. Daytime sleepiness was greatest in ADHD-I and was associated with sleeping more (not less) than normal. Medicated children had greater difficulty falling asleep than unmedicated children.
Differences in sleep problems were found as a function of ADHD subtype, comorbidity, and medication.
Actigraphy is a method used to study sleep-wake patterns and circadian rhythms by assessing movement, most commonly of the wrist. These evidence-based practice parameters are an update to the Practice Parameters for the Use of Actigraphy in the Clinical Assessment of Sleep Disorders, published in 1995. These practice parameters were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. Recommendations are based on the accompanying comprehensive review of the medical literature regarding the role of actigraphy, which was developed by a task force commissioned by the American Academy of Sleep Medicine. The following recommendations serve as a guide to the appropriate use of actigraphy. Actigraphy is reliable and valid for detecting sleep in normal, healthy populations, but less reliable for detecting disturbed sleep. Although actigraphy is not indicated for the routine diagnosis, assessment, or management of any of the sleep disorders, it may serve as a useful adjunct to routine clinical evaluation of insomnia, circadian-rhythm disorders, and excessive sleepiness, and may be helpful in the assessment of specific aspects of some disorders, such as insomnia and restless legs syndrome/periodic limb movement disorder. The assessment of daytime sleepiness, the demonstration of multiday human-rest activity patterns, and the estimation of sleep-wake patterns are potential uses of actigraphy in clinical situations where other techniques cannot provide similar information (e.g., psychiatric ward patients). Superiority of actigraphy placement on different parts of the body is not currently established. Actigraphy may be useful in characterizing and monitoring circadian rhythm patterns or disturbances in certain special populations (e.g., children, demented individuals), and appears useful as an outcome measure in certain applications and populations. Although actigraphy may be a useful adjunct to portable sleep apnea testing, the use of actigraphy alone in the detection of sleep apnea is not currently established. Specific technical recommendations are discussed, such as using concomitant completion of a sleep log for artifact rejection and timing of lights out and on; conducting actigraphy studies for a minimum of three consecutive 24-hour periods; requiring raw data inspection; permitting some preprocessing of movement counts; stating that epoch lengths up to 1 minute are usually sufficient, except for circadian rhythm assessment; requiring interpretation to be performed manually by visual inspection; and allowing automatic scoring in addition to manual scoring methods.
To investigate whether ADHD-related sleep-onset insomnia (SOI) is a circadian rhythm disorder, we compared actigraphic sleep estimates, the circadian rest-activity rhythm, and dim light melatonin onset (DLMO) in ADHD children having chronic idiopathic SOI with that in ADHD children without sleep problems. Participants were 87 psychotropic-medication-naïve children, aged 6 to 12 yrs, with rigorously diagnosed ADHD and SOI (ADHD-SOI) and 33 children with ADHD without SOI (ADHD-noSOI) referred from community mental health institutions and pediatric departments of non-academic hospitals in The Netherlands. Measurements were 1 wk, 24 h actigraphy recordings and salivary DLMO. The mean (+/-SD) sleep onset time was 21:38 +/- 0:54 h in ADHD-SOI, which was significantly (p < 0.001) later than that of 20:49 +/- 0:49 h in ADHD-noSOI. DLMO was significantly later in ADHD-SOI (20:32 +/- 0:55 h), compared with ADHD-noSOI (19:47 +/- 0:49 h; p < 0.001). Wake-up time in ADHD-SOI was later than in ADHD-noSOI (p = 0.002). There were no significant between-group differences in sleep maintenance, as estimated by number of wake bouts and activity level in the least active 5 h period, or inter- and intradaily rhythm variability. We conclude that children with ADHD and chronic idiopathic sleep-onset insomnia show a delayed sleep phase and delayed DLMO, compared with ADHD children without SOI.
Previous studies in children with attention-deficit/hyperactivity disorder and attention deficit disorder (ADHD/ADD) have shown impaired sleep quality with increased nocturnal motor activity. However, polysomnographic findings are not unequivocal. Up to now, in adults with ADHD, only 1 case-control polysomnographic study with small sample size has been performed. We investigated objective and subjective sleep quality in adultADHD, including an electroencephalogram spectral power analysis.
Single-blind comparative study.
University medical center.
Twenty adult unmedicated ADHD patients without current comorbid major depression, drug abuse, or comorbid axis-II disorder and 20 sex- and age-matched control subjects.
N/A.
Conventional polysomnographic parameters and sleep electroencephalogram spectral power analysis was calculated for the 2 laboratory nights. Subjective sleep parameters were estimated by sleep questionnaires to assess the relationship between objective and subjective sleep measurements.
Adult ADHD patients showed increased nocturnal motor activity (as indicated by heightened indexes of periodic leg movements in sleep), which was significantly inversely correlated with subjective total sleep time. Although ADHD patients displayed significantly increased objective total sleep time, the subjective ratings documented impaired sleep quality in those with ADHD. Other polysomnographic sleep patterns and spectral electroencephalogram parameters did not differ between ADHD patients and normal controls.
Similar to children, adults with ADHD show increased nocturnal motor activity. Otherwise, sleep does not seem to be impaired in ADHD patients. However, the dissociation between objective and subjective sleep parameters points to a misinterpretation of sleep quality in patients with ADHD.
Our objective was to estimate the lifetime prevalence of psychopathology in a sample of youth with and without attention deficit hyperactivity disorder (ADHD) through young adulthood using contemporaneous diagnostic and analytic techniques.
We conducted a case-control, 10-year prospective study of ADHD youth. At baseline, we assessed consecutively referred male, Caucasian children with (n=140) and without (n=120) DSM-III-R ADHD, aged 6-18 years, ascertained from psychiatric and pediatric sources to allow for generalizability of results. At the 10-year follow-up, 112 (80%) and 105 (88%) of the ADHD and control children, respectively, were reassessed (mean age 22 years). We created the following categories of psychiatric disorders: Major Psychopathology (mood disorders and psychosis), Anxiety Disorders, Antisocial Disorders (conduct, oppositional-defiant, and antisocial personality disorder), Developmental Disorders (elimination, language, and tics disorder), and Substance Dependence Disorders (alcohol, drug, and nicotine dependence), as measured by blinded structured diagnostic interview.
The lifetime prevalence for all categories of psychopathology were significantly greater in ADHD young adults compared to controls, with hazard ratios and 95% confidence intervals of 6.1 (3.5-10.7), 2.2 (1.5-3.2), 5.9 (3.9-8.8), 2.5 (1.7-3.6), and 2.0 (1.3-3.0), respectively, for the categories described above.
By their young adult years, ADHD youth were at high risk for a wide range of adverse psychiatric outcomes including markedly elevated rates of antisocial, addictive, mood and anxiety disorders. These prospective findings provide further evidence for the high morbidity associated with ADHD across the life-cycle and stress the importance of early recognition of this disorder for prevention and intervention strategies.
The following test of the circadian phase-shift hypothesis for patients with winter depression (seasonal affective disorder, or SAD) uses low-dose melatonin administration in the morning or afternoon/evening to induce phase delays or phase advances, respectively, without causing sleepiness. Correlations between depression ratings and circadian phase revealed a therapeutic window for optimal alignment of circadian rhythms that also appears to be useful for phase-typing SAD patients for the purpose of administering treatment at the correct time. These analyses also provide estimates of the circadian component of SAD that may apply to the antidepressant mechanism of action of appropriately timed bright light exposure, the treatment of choice. SAD may be the first psychiatric disorder in which a physiological marker correlates with symptom severity before, and in the course of, treatment in the same patients. The findings support the phase-shift hypothesis for SAD, as well as suggest a way to assess the circadian component of other psychiatric, sleep, and chronobiologic disorders.
Humans show large differences in the preferred timing of their sleep and activity. This so-called "chronotype" is largely regulated by the circadian clock. Both genetic variations in clock genes and environmental influences contribute to the distribution of chronotypes in a given population, ranging from extreme early types to extreme late types with the majority falling between these extremes. Social (e.g., school and work) schedules interfere considerably with individual sleep preferences in the majority of the population. Late chronotypes show the largest differences in sleep timing between work and free days leading to a considerable sleep debt on work days, for which they compensate on free days. The discrepancy between work and free days, between social and biological time, can be described as 'social jetlag.' Here, we explore how sleep quality and psychological wellbeing are associated with individual chronotype and/or social jetlag. A total of 501 volunteers filled out the Munich ChronoType Questionnaire (MCTQ) as well as additional questionnaires on: (i) sleep quality (SF-A), (ii) current psychological wellbeing (Basler Befindlichkeitsbogen), (iii) retrospective psychological wellbeing over the past week (POMS), and (iv) consumption of stimulants (e.g., caffeine, nicotine, and alcohol). Associations of chronotype, wellbeing, and stimulant consumption are strongest in teenagers and young adults up to age 25 yrs. The most striking correlation exists between chronotype and smoking, which is significantly higher in late chronotypes of all ages (except for those in retirement). We show these correlations are most probably a consequence of social jetlag, i.e., the discrepancies between social and biological timing rather than a simple association to different chronotypes. Our results strongly suggest that work (and school) schedules should be adapted to chronotype whenever possible.
The links between sleep and attention-deficit hyperactivity disorder (ADHD) have been a topic for intense ongoing research and clinical interest. Previous narrative literature reviews conveyed a consensus that parents of children with ADHD are more likely to report sleep problems in their children in comparison to parents of control children. However, when objective measures are considered the results appear to be more complex and inconsistent. This review is based on a meta-analysis of relevant polysomnographic studies. We assessed measures related to sleep architecture, breathing disorders, and periodic limb movements in sleep (PLMS), and the role of potential moderators such as age, gender, and other methodological factors. The meta-analysis revealed only one significant combined effect that indicates that children with ADHD are more likely than controls to suffer from PLMS. Factors such as age, gender, inclusion of adaptation night, and comorbidity appear to play a moderating role in the associations between sleep characteristics and ADHD. To provide new insight regarding the links between sleep and ADHD research in this field should adopt new strict guidelines and consider the role of multiple pertinent moderating factors.
To examine the association between sleep-related problems and symptoms of attention-deficit/hyperactivity disorder (ADHD) in a community sample of young adults in Taiwan.
A college-based cross-sectional survey.
Two thousand two hundred eighty-four first-year college students (aged 18-20) in a university in Taiwan.
Each student completed a questionnaire regarding sleep schedule (self-estimated total sleep duration and sleep need), sleep problems (dyssomnia, parasomnia, and snoring), and the Chinese version of the Adult ADHD Self-Report Scale. Subjects were grouped separately for the inattention and hyperactivity subscales into highly likely ADHD (2.3%, 0.7%), probable ADHD (21.3%, 5.7%), and probably non-ADHD (76.4%, 93.6%) groups according to the scoring scheme of the subscales of the Adult ADHD Self-Report Scale. Results showed that, for both inattention and hyperactivity symptoms, the highly likely ADHD and probable ADHD groups were more likely than the non-ADHD group to have a variety of current and lifetime sleep problems. No significant difference in sleep problems was found between the highly likely ADHD and probable ADHD groups. Inattention, but not hyperactivity, was associated with greater sleep need and greater difference between sleep need and self-estimated nocturnal sleep duration. Hyperactivity, but not inattention, was associated with decreased nocturnal sleep duration.
Consistent with prior findings from children and adolescents, ADHD symptoms in young adults are related to sleep problems. Further studies on adults with ADHD should help to refine our understanding of the causal basis for any implications of this association.
Little is known about the epidemiology of adult attention-deficit hyperactivity disorder (ADHD).
To estimate the prevalence and correlates of DSM-IV adult ADHD in the World Health Organization World Mental Health Survey Initiative.
An ADHD screen was administered to respondents aged 18-44 years in ten countries in the Americas, Europe and the Middle East (n=11422). Masked clinical reappraisal interviews were administered to 154 US respondents to calibrate the screen. Multiple imputation was used to estimate prevalence and correlates based on the assumption of cross-national calibration comparability.
Estimates of ADHD prevalence averaged 3.4% (range 1.2-7.3%), with lower prevalence in lower-income countries (1.9%) compared with higher-income countries (4.2%). Adult ADHD often co-occurs with other DSM-IV disorders and is associated with considerable role disability. Few cases are treated for ADHD, but in many cases treatment is given for comorbid disorders.
Adult ADHD should be considered more seriously in future epidemiological and clinical studies than is currently the case.
To investigate parameters of sleep, activity, and circadian rhythm, as well as the effects of methylphenidate on these variables, in adults with ADHD.
1) Baseline group comparison; 2) Double blind, placebo-controlled, cross-over medication trial.
Data collection took place during daily lives of participants.
39 normal controls and 33 adults with ADHD for baseline comparisons; 31 adults with ADHD in medication trial.
Treatment with placebo and methylphenidate during medication trial.
Actigraphy and sleep log data were collected for 7 consecutive nights and days to obtain baseline values for ADHD and normal controls. Repeated measurements during placebo and methylphenidate treatment were conducted for the ADHD group. Actigraphic sleep estimates showed that ADHD subjects took longer to fall asleep, had lower sleep efficiency, and had shorter within-night periods of uninterrupted sleep. These findings were consistent with subjective complaints. Actigraphic measures of ADHD subjects showed continuously elevated daytime activity levels, resulting in a 24-hour pattern that was more stable and less variable than in controls. Methylphenidate led to a later bedtime, later sleep onset, and reduction in sleep duration. However, number and total duration of nocturnal awakenings decreased, while mean duration of within-night periods of uninterrupted sleep increased, indicating more consolidated sleep.
Our data suggest that sleep problems are inherent in adults with ADHD and that methylphenidate reduced total sleep time but improved sleep quality by consolidating sleep.
Background: Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that is associated with long-term reduced quality of life and impaired functioning. ADHD is commonly associated with sleep disturbances that can contribute to many difficulties in a child’s life. This study aims to elucidate this complex relationship by utilizing a subset of the Adolescent Brain Cognitive Development (ABCD) database. Methods: The population included a group of children with ADHD age 10-13 years (n=212) and a matched typically developing (TD) group (n=212). Sleep data was obtained through Fitbit actigraphy measures, and the Parent Sleep Disturbance Scale (SDS). Behavioural and emotional subscores were obtained from the Child Behaviour Checklist (CBCL). Results: There were no significant correlations between the actigraphy and SDS sleep data. SDS sleep data were significantly different between ADHD and control groups, while actigraphy data was not. Sleep latency (measured by actigraphy) and 3 out of 6 of the SDS subscores were significantly related to behavioural scores. Conclusions: The results of this study indicate that sleep may not be an important mediator of behaviour and emotional responses in children with ADHD. Future studies should explore both influences on sleep parameters as well as behaviour and other measures important to families.
Attention-deficit–hyperactivity disorder (ADHD) is one of the most common childhood psychiatric disorders, estimated to affect 5–10% of school-aged children worldwide.1 According to the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition – Text Revision (DSM-IV-TR),2 ADHD is defined by a persistent and age-inappropriate pattern of inattention, hyperactivity–impulsivity or both. Onset before the age of seven years and impaired functioning in two or more settings are required for the diagnosis. Impairing symptoms of ADHD may persist into adulthood in up to 60% of cases.3
Restless legs syndrome (RLS) is a sensorimotor disorder characterised by an irresistible urge to move the legs, which is often accompanied by uncomfortable sensations in the legs or, less frequently, other body parts. These sensations are relieved by movement and are worse in the evening or night and when resting. The diagnosis of RLS is based on the revised criteria developed by the International Restless Legs Syndrome Study Group (IRLSSG).4 Although RLS has traditionally been considered to be a disorder of middle to older age, several case reports have shown that it may occur in childhood.5 However, children may report RLS symptoms differently from adults, in part because of their limited ability to describe RLS sensations. In addition, the clinical presentation of RLS may differ in children. Considering these particularities, the IRLSSG has proposed a set of criteria specific to children.4
Polysomnographically, RLS may be associated with periodic limb movements in sleep (PLMS) in about 80% of patients, in both adults and children.4 PLMS are defined as movements that occur in series of four or more, lasting between half a second and five seconds, have an amplitude of one-quarter or more of the toe dorsiflexion during calibration and are separated by intervals of four to 90 seconds. RLS per se and/or associated PLMS may lead to significant sleep fragmentation. Therefore, RLS is a recognised, although sometimes overlooked, cause of insomnia
Fourteen consecutive children who were newly diagnosed with attention-deficit hyperactivity disorder (ADHD) and who had never been exposed to stimulants and 10 control children without ADHD underwent polysomnographic studies to quantify Periodic Limb Movements in Sleep (PLMS) and arousals. Parents commonly gave both false-negative and false-positive reports of PLMS in their children, and a sleep study was necessary to confirm their presence or absence. The prevalence of PLMS on polysomnography was higher in the children with ADHD than in the control subjects. Nine of 14 (64%) children with ADHD had PLMS at a rate of >5 per hour of sleep compared with none of the control children (p <0.0015). Three of 14 children with ADHD (21%) had PLMS at a rate of >20 per hour of sleep. Many of the PLMS in the children with ADHD were associated with arousals. Historical sleep times were less for children with ADHD. The children with ADHD who had PLMS chronically got 43 minutes less sleep at home than the control subjects (p = 0.0091). All nine children with ADHD who had a PLMS index of >5 per hour of sleep had a long-standing clinical history of sleep onset problems (>30 minutes) and/or maintenance problems (more than two full awakenings nightly) thus meeting the criteria for Periodic Limb Movement Disorder (PLMD). None of the control children had a clinical history of sleep onset or maintenance problems. The parents of the children with ADHD were more likely to have restless legs syndrome (RLS) than the parents of the control children. Twenty-five of 28 biologic parents of the children with ADHD and all of the biologic parents of the control children were reached for interview. Eight of twenty-five parents of the children with ADHD (32%) had symptoms of RLS as opposed to none of the control parents (p = 0.011). PLMS may directly lead to symptoms of ADHD through the mechanism of sleep disruption. Alternative explanations for the association between ADHD and RLS/PLMS are that they are genetically linked, they share a common dopaminergic deficit, or both.
Epidemiological data reveal parallel trends of decreasing sleep duration and increases in metabolic disorders such as obesity, diabetes and hypertension. There is growing evidence that these trends are mechanistically related. The seasonal expression of the thrifty genotype provides a conceptual framework to connect circadian and circannual rhythms, sleep and metabolism. Experimental studies have shown sleep deprivation to decrease leptin, increase ghrelin, increase appetite, compromise insulin sensitivity and raise blood pressure. Habitually short sleep durations could lead to insulin resistance by increasing sympathetic nervous system activity, raising evening cortisol levels and decreasing cerebral glucose utilization that over time could compromise beta-cell function and lead to diabetes. Prolonged short sleep durations could lead to hypertension through raised 24-h blood pressure and increased salt retention resulting in structural adaptations and the entrainment of the cardiovascular system to operate at an elevated pressure equilibrium. Cross-sectional and longitudinal epidemiological studies have shown associations between short sleep duration and obesity, diabetes and hypertension. If metabolic changes resulting from sleep restriction function to increase body weight, insulin resistance and blood pressure then interventions designed to increase the amount and improve the quality of sleep could serve as treatments and as primary preventative measures for metabolic disorders.
Several previous studies have shown that Attention Deficit Hyperactivity Disorder (ADHD) is common in children with Restless Legs Syndrome and ADHD is more common in adults with this syndrome. This pilot study examined the prevalence of Restless Legs Syndrome in adults with ADHD, showing six of 30 adult ADHD participants (20%) had Restless Legs Syndrome. This estimate exceeds the prevalence (7.2%) for a previously published control group. These six adults had more severe ADHD symptomatology than those without Restless Legs Syndrome based on the overall Conners' Adult ADHD Rating Scale. Such results suggest that symptoms of Restless Legs Syndrome may occur often in adults with ADHD and might worsen the symptoms of ADHD. Replication with a larger sample size is in order.
To examine whether sleep impairment is associated with attention-deficit/hyperactivity disorder (ADHD) in adults.
In a study conducted from 1998 to 2003, we identified sleep characteristics in a community sample of 182 cases of DSM-IV ADHD or ADHD not otherwise specified and 117 non-ADHD controls aged 18 to 55 years. Attention-deficit/hyperactivity disorder status, current and lifetime psychiatric comorbidity, and pharmacologic treatment of ADHD were identified with the Structured Clinical Interview for DSM-IV and with modules from the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic Version. Sleep problems were characterized by self-report. We separately accounted for the contribution of age at ADHD onset, ADHD pharmacotherapy, lifetime bipolar disorder, and the following lifetime and current comorbidities: depression, generalized anxiety, substance abuse, and multiple anxiety disorders.
Adults with ADHD went to bed later than control subjects and had a wider range of bedtimes (mean +/- SD = 18 +/- 92 min vs 54 +/- 69 min before midnight; P < .001), were more likely to take over an hour to fall asleep (OR = 5.22, P = .001), and were more likely (P < .003) to experience difficulty going to bed, going to sleep, sleeping restfully, or waking in the morning. Adults with ADHD experienced daytime sleepiness more often (OR = 2.23, P = .003) and reported more sleep problems (mean +/- SD = 6.7 +/- 2.5 vs 4.3 +/- 2.2; P < .001) than controls. All sleep impairments were significantly associated with ADHD independent of contributions to sleep disruption from ADHD pharmacotherapy, comorbidities likely to contribute to sleep disturbance, and age at ADHD onset.
Sleep disturbances that are not attributable to comorbid mental health conditions or ADHD pharmacotherapy are associated with ADHD in adulthood. Clinicians and researchers should consider the potential contribution of sleep disruption to the clinical presentation of adults with ADHD.
We present a novel condition, designated as a primary disorder of vigilance, that has symptoms which overlap those of attention deficit-hyperactivity disorder. Vigilance is the state of being watchful, awake, and alert. When vigilance is lost, the individual has difficulty sustaining attention. The most obvious evidence of lowered vigilance is motor restlessness (fidgeting and moving about, yawning and stretching, talkativeness, or a combination of these) to improve alertness when sitting or standing still or when involved in tasks requiring continuous mental performance. When prevented from being active to stay awake, persons with lowered vigilance will stare off, daydream, show minor hyperactivity, and finally may fall asleep. They will also have decreasing attention to current activities and usually avoid or lose interest in structured or repetitive activities (complaining of boredom and monotony). The primary disorder of vigilance (for which criteria have been established) is a dominantly inherited condition with onset in early childhood and worsening symptoms with age. Persons with the primary disorder of vigilance have a remarkably kind and caring temperament. When untreated this disorder can cause chronic failure at school and work, but when properly recognized it responds well to treatment with stimulant medication and schedules that avoid sameness and repetition.
Exogenous melatonin, which can be used to treat certain circadian rhythm disorders, maximally advances delayed rhythms when administered 5 hours before the endogenous melatonin starts to increase. The time of the start of the endogenously melatonin is defined as Dim Light Melatonin Onset (DLMO). The DLMO concentration has been defined in serum to be 10 pg/ml. Because of the greater practicability of frequent saliva sampling over blood sampling, we have validated radioimmunoassay (RIA) measurements of melatonin in saliva in patients diagnosed as suffering from a typical circadian rhythm disorder: Delayed Sleep Phase Syndrome (DSPS). Based on these results we have defined the equivalent salivary DLMO concentration to be 4 pg/ml.
The Sleep Disorders Questionnaire (SDQ) is a 176-item questionnaire designed to diagnose the presence of common sleep disorders. This study set out to assess the validity of a Dutch translation of the SDQ. Scores on 145 questionnaires were analyzed. A cluster analysis of these scores revealed the following clusters: healthy, depression, insomnia, narcolepsy, and apnea. The cluster classification proved correct for 67% of the subjects, as determined on the basis of polysomnography. These results show that the Dutch SDQ is a reasonably valid instrument for diagnosing sleep disorders.
Nightly restlessness in patients with Alzheimer's disease (AD) is probably due to a disorder of circadian rhythms. Transcutaneous electrical nerve stimulation (TENS) was previously reported to increase the strength of coupling of the circadian rest activity rhythm to Zeitgebers in early stage Alzheimer's disease (AD) patients. It was investigated in the present study whether TENS could also improve the rest activity rhythm of patients in a midstage. Sixteen patients who met the NINCDS ADRDA criteria for probable AD, and the stage 6 criteria of the Global Deterioration Scale were treated with TENS or placebo. Rest activity rhythm was assessed using actigraphy. Compared to the control group, stimulated patients showed an improvement in the rest activity rhythm of similar magnitude as observed previously in patients in an early stage. It is concluded that TENS increased the coupling between the rest activity rhythm and supposedly stable Zeitgebers in an advanced stage of AD.
There is evidence from clinical, epidemiological, and neuroimaging studies that attention-deficit hyperactivity disorder (ADHD) and seasonal affective disorder (SAD) may have several features in common. To assess seasonal affective symptoms in adults with ADHD, 115 individuals attending an adult ADHD clinic in Toronto, Ontario, Canada were asked to complete the Seasonal Pattern Assessment Questionnaire (SPAQ). From this clinic population of 115, a total of 56 completed SPAQs were returned. Assuming that all individuals failing to complete the SPAQ were nonseasonal and depending on which case-finding criteria were used, the rate of SAD in the overall clinic sample was estimated at either 10.4% (Terman criteria) or 19.1% (criteria of Kasper et al.). These prevalence rates are significantly greater than the rates reported in large population surveys at similar latitudes. There was an apparent relationship between female gender, impulsive-subtype ADHD, and seasonality. Future studies to examine whether core symptoms of ADHD fluctuate across the seasons and to assess the efficacy of light therapy in "seasonal" ADHD patients would be of great theoretical and clinical interest.
Fourteen consecutive children who were newly diagnosed with attention-deficit hyperactivity disorder (ADHD) and who had never been exposed to stimulants and 10 control children without ADHD underwent polysomnographic studies to quantify Periodic Limb Movements in Sleep (PLMS) and arousals. Parents commonly gave both false-negative and false-positive reports of PLMS in their children, and a sleep study was necessary to confirm their presence or absence. The prevalence of PLMS on polysomnography was higher in the children with ADHD than in the control subjects. Nine of 14 (64%) children with ADHD had PLMS at a rate of >5 per hour of sleep compared with none of the control children (p <0.0015). Three of 14 children with ADHD (21%) had PLMS at a rate of >20 per hour of sleep. Many of the PLMS in the children with ADHD were associated with arousals. Historical sleep times were less for children with ADHD. The children with ADHD who had PLMS chronically got 43 minutes less sleep at home than the control subjects (p = 0.0091). All nine children with ADHD who had a PLMS index of >5 per hour of sleep had a long-standing clinical history of sleep onset problems (>30 minutes) and/or maintenance problems (more than two full awakenings nightly) thus meeting the criteria for Periodic Limb Movement Disorder (PLMD). None of the control children had a clinical history of sleep onset or maintenance problems. The parents of the children with ADHD were more likely to have restless legs syndrome (RLS) than the parents of the control children. Twenty-five of 28 biologic parents of the children with ADHD and all of the biologic parents of the control children were reached for interview. Eight of twenty-five parents of the children with ADHD (32%) had symptoms of RLS as opposed to none of the control parents (p = 0.011). PLMS may directly lead to symptoms of ADHD through the mechanism of sleep disruption. Alternative explanations for the association between ADHD and RLS/PLMS are that they are genetically linked, they share a common dopaminergic deficit, or both.
Ocular exposure to early morning room light can significantly advance the timing of the human circadian pacemaker. The resetting response to such light has a non-linear relationship to illuminance. The dose-response relationship of the human circadian pacemaker to late evening light of dim to moderate intensity has not been well established. Twenty-three healthy young male and female volunteers took part in a 9 day protocol in which a single experimental light exposure6.5 h in duration was given in the early biological night. The effects of the light exposure on the endogenous circadian phase of the melatonin rhythm and the acute effects of the light exposure on plasma melatonin concentration were calculated. We demonstrate that humans are highly responsive to the phase-delaying effects of light during the early biological night and that both the phase resetting response to light and the acute suppressive effects of light on plasma melatonin follow a logistic dose-response curve, as do many circadian responses to light in mammals. Contrary to expectations, we found that half of the maximal phase-delaying response achieved in response to a single episode of evening bright light ( approximately 9000 lux (lx)) can be obtained with just over 1 % of this light (dim room light of approximately 100 lx). The same held true for the acute suppressive effects of light on plasma melatonin concentrations. This indicates that even small changes in ordinary light exposure during the late evening hours can significantly affect both plasma melatonin concentrations and the entrained phase of the human circadian pacemaker.