Treating Insomnia in Children with ADHD

Insomnia commonly complicates the clinical presentation and treatment in children with ADHD.

Stimulant therapy may provide significant relief for daytime attention and hyperactivity symptoms. However, stimulants do not appear to help with comorbid insomnia. In fact, stimulant therapy may cause more problems with insomnia in ADHD.

Behavioral treatments are known to be effective in children without ADHD. Now we have a recently published study showing the effectiveness of behavioral treatment of insomnia in children with ADHD.

Harriet Hiscock and colleagues from Australia conducted a randomized controlled trial of behavioral treatment in 244 children with ADHD between 5 and 12 years of age.

The primary elements of the behavioral intervention included:

• Two direct consultations with a psychologist or pediatrician
• One phone follow up consultation
• Education on sleep, sleep cycles and sleep cues
• Sleep hygiene instruction, i.e. set sleep time, limit caffeine after 3 pm

A novel element in this study was to not limit outcome measures to sleep variables but also to look for changes in ADHD symptoms. The authors were able to identify the following key findings in their study:

• Intervention children had fewer sleep problems at 3 and 6 months
• Intervention children also had greater improvement in ADHD symptoms
• Improved sleep appeared to mediate up to 50% of improvement in ADHD symptoms
• Actigraphy (sleep monitoring device) showed 10 minutes longer sleep per night in the intervention group
• Teachers were also able to identify improvement in the children with the sleep intervention

Another important finding was the relatively small number needed to treat for significant benefit in this study: four. This suggests a strong therapeutic effect that deserves consideration for the general childhood ADHD population.

This is an important study with significant implications for treatment and further research. This is re-enforced by lack of safe and effective drug treatment for insomnia in children.

Readers with more interest in this study can access the free full-text manuscript by clicking on the PMID link below.

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Hiscock H, Sciberras E, Mensah F, Gerner B, Efron D, Khano S, & Oberklaid F (2015). Impact of a behavioural sleep intervention on symptoms and sleep in children with attention deficit hyperactivity disorder, and parental mental health: randomised controlled trial. BMJ (Clinical research ed.), 350 PMID: 25646809

Brief Behavioral Therapy for Insomnia in Older Adults

Insomnia is a common complaint in the general population and among patients treated by primary care physicians.  This is particularly true for older adults who experience physiological changes in sleep with aging.  Clinicians commonly prescribe hypnotics for insomnia and the use of these types of drugs is increasing in the United States and elsewhere.  Behavioral and psychological interventions may be overlooked or bypassed in the sequencing of interventions for complaints of insomnia.

 I had previously posted on the promise of cognitive behavioral therapy for insomnia.  This therapy appears to be effective across a variety of patient groups including those with an underlying psychiatric diagnosis.  Now, a recent study in elderly subjects finds support for an even briefer intervention for those with primary insomnia.

Buysse and colleagues from the University of Pittsburgh and the Cleveland Clinic have recently published a randomized control trial of brief behavioral therapy intervention (BBTI) for primary insomnia in a group of adults averaging 71-72 years of age.  The brief intervention included direct contact with a single masters level nurse practitioner for an initial 45 to 60 minute session followed by a 20 minute direct contact session in 2 weeks.  Two 20-minute phone sessions were scheduled at one and three weeks following the initial contact session.  The authors note the sessions focused on customizing for each subject the four key elements of sleep education and stimulus control:

1. reduce the total amount of time in bed
2. get up at the same time daily regardless of sleep duration
3. do not go to bed unless feeling sleepy
4. do not stay in bed unless asleep

The control group was provided educational material that included information related to behavioral treatment of insomnia but did not include personalized contact session with the nurse practitioner.  Outcome was measured by whether subjects continued to meet criteria for insomnia as well as other secondary measures.

The BBTI group demonstrated a 67% response rate compared to only 25% response in the control group.  Remission of an insomnia diagnosis was noted in 55% of the BBTI group compared to only 13% of the control.  Most psychometric, sleep diary and actigraphy measures improved more in the BBTI group more than the control group.  Interestingly, there were no differences between the groups in polysomnography sleep lab measures including sleep latency, total sleep time and sleep efficiency.

The authors note attractive features of BBTI including:

• it is easily taught to nurse practitioners and other clinicians
• it includes a workbook that allows patients to follow exercises aimed at reducing insomnia
• the strict behavioral approach limits some of the stigma associated with psychological treatment approaches in primary care

This study supports a stepped care approach for older adults with primary insomnia.  Following careful assessment to rule out another sleep disorder, i.e. sleep apnea or an untreated psychiatric disorder, i.e. depression or anxiety disorder, a trial of brief behavioral therapy may be a good first step.  Patients who fail to respond to this step may be candidates for consideration of hypnotic or other pharmacological interventions.

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Buysse, D., Germain, A., Moul, D., Franzen, P., Brar, L., Fletcher, M., Begley, A., Houck, P., Mazumdar, S., Reynolds, C., & Monk, T. (2011). Efficacy of Brief Behavioral Treatment for Chronic Insomnia in Older Adults Archives of Internal Medicine, 171 (10), 887-895 DOI: 10.1001/archinternmed.2010.535