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 DOI: 10.1177/002221940203500308

2002 35: 268J Learn DisabilDaniel Stein, Ruth Pat-Horenczyk, Shulamit Blank, Yaron Dagan, Yoram Barak and Thomas P. Gumpel

Sleep Disturbances in Adolescents with Symptoms of Attention-Deficit/Hyperactivity Disorder  

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Sleep Disturbances in Adolescentswith Symptoms of Attention-Deficit/Hyperactivity DisorderDaniel Stein, Ruth Pat-Horenczyk, Shulamit Blank, Yaron Dagan,Yoram Barak, and Thomas P. Gumpel

Abstract

We evaluated 32 nonmedicated male adolescents diagnosed with attention-deficit/hyperactivity disorder (ADHD) in childhood, 35 maleadolescents similarly diagnosed who were receiving methylphenidate (MPH), and 77 control boys. Both ADHD groups completed self-

report questionnaires assessing sleep disturbances; weekday and holiday sleep duration; and symptoms of ADHD, anxiety, and depres-sion. Parents and teachers rated the severity of the participants’ ADHD. The control group completed self-report questionnaires assess-ing sleep disturbances. We found that nonmedicated participants and controls did not differ in the severity of sleep disturbance. Incontrast, the medicated participants demonstrated a significantly greater severity of sleep disturbance compared with the nonmedicatedparticipants and reported elevated levels of symptoms of ADHD, anxiety, and depression. Specific analyses showed that depressivesymptoms contributed significantly to the degree of sleep disturbance when controlling for ADHD diagnosis and MPH treatment. Thesefindings suggest that among adolescents with ADHD symptoms, the severity of symptoms of depression may contribute to the degreeof sleep disturbance in addition to the effect of their primary disorder and MPH treatment.

leep disturbances have been ex-tensively studied in children withattention-deficit / hyperactivity

disorder (ADHD; Prince, Wilens, Bie-derman, Spencer, & Wozniak, 1996).Studies relying on parent reports haveusually demonstrated more sleep dis-turbances in these children than stud-ies based on objective measurementsof sleep (Ball, Tiernan, Janusz, & Furr,1997; Greenhill, Puig-Antich, Goetz,Hanlon, & Davis, 1983). Two parentreport-based studies have found thatalmost half of the children with ADHD

have sleep problems, compared to 25%and 10%, respectively, of controls

(Allen, Singer, Brow, & Salam, 1992;Trommer, Hoeppner, Rosenberg, Arm-strong, & Rothstein, 1988). The types ofsleep disturbances described in chil-dren with ADHD include decreased

sleep efficiency (Dagan et al., 1997),shorter sleep onset (Ramos-Platon,Vela-Bueno, Espinar-Sierra, & Kales,1990), difficulties in falling asleep

(Dixon, Monroe, & Jakim, 1981; Ramos-Platon et al., 1990), and difficulties .

with morning awakening (Barkley, .

1990; Trommer et al., 1988). Restless .

sleep (Greenhill et al., 1983), related toan increase in sleep activity (Daganet al., 1997) and to body movementsduring sleep (Porrino et al., 1983), hasalso been reported in these children.The picture concerning sleep distur-

bance in children with ADHD is

further complicated because many ofthem are treated with methylpheni-date (MPH; Zuddas, Anchilletta, Mug-lia, & Cianchetti, 2000). Insomnia oc-curs in children treated with MPH

(Ahmann et al., 1993; Barkley, 1990;Prince et al., 1996), both because of adirect effect and because of a reboundeffect as the drug wears off (Greenhill,1995). Recently, several studies relyingon parent reports and self-reports (Ballet al.,1997; M. A. Stein et al.,1996), rat-

ings supplied by hospital staff (Kent, ’

Blader, Koplewitz, Abikoff, & Foley,

1995), or actigraphic recordings of

sleep activity (M. A. Stein et al., 1996)have assessed in detail the effect of

MPH on sleep. These studies did notfind elevated rates of sleep distur-

bances (Ball et al., 1997; Kent et al.,1995; M. A. Stein et al., 1996) andshowed only a slight decrease in totalsleep time (M. A. Stein et al., 1996)when accepted dosages of MPH werecompared with placebo (Kent et al.,1995; M. A. Stein et al., 1996) or when

comparing between medicated andnonmedicated children with ADHD

(Ball et al., 1997). Our research groupalso has not found a significant differ-ence in sleep duration between chil-dren with ADHD treated with MPHand their siblings without ADHD

(Ring et al., 1998).In contrast to the extensive literature

on sleep disturbances in young chil-dren with ADHD, this topic has rarelybeen addressed in adolescence. This is

surprising, as puberty is known to af-

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269

fect the patterns of both ADHD

(Hechtman, 1989) and sleep. In this re-spect, intrinsic biological processes as-sociated with typical maturation havebeen found to be involved in the devel-

opmental tendency of many teenagersto fall asleep and to wake up signifi-cantly later than younger children (An-drade, Benedito, Domenice, Arnhold,& Menna-Barreto, 1993; Carskadon,Vieira, & Acebo, 1993). The daytimesleepiness and fatigue associated withinsufficient sleep and decreased sleepquality during weekdays (Andrade etal., 1992; Carskadon, 1990; Carskadonet al., 1993) may be especially deleteri-ous to youngsters with ADHD (Dahl,1996a).This study represents an extension

of the literature related to sleep dis-turbances in ADHD, with a specificemphasis on sleep disturbances in ado-lescents diagnosed with ADHD inchildhood. We evaluated whether the

presence of symptoms of depressionand anxiety would influence sleepamong these adolescents, as these fac-tors may aggravate ADHD symptoma-tology (Weiss, 1996) and lead to dis-turbed sleep (Handford, Matison, &

Kales, 1996). The influence of MPH on

sleep in students who received the

medication was also assessed. Accord-

ingly, we had three hypotheses:

1. Adolescents diagnosed withADHD in childhood would havemore sleep disturbances than acontrol group.

2. Sleep disturbance in these adoles-cents would be correlated with a

greater severity of depressive andanxiety symptoms.

3. Adolescents treated with MPH

would demonstrate more sleepdisturbances than nonmedicated

participants with ADHD.

Method

ParticipantsThe nonmedicated (n = 32) and med-icated (n = 35) boys diagnosed with

ADHD in childhood were recruitedfrom a special education school in

Jerusalem, Israel. This high school catersto secondary school students with spe-cific learning disabilities, ADHD, orboth.

Child and adolescent psychiatristsassessed all participants in childhoodwith a structured questionnaire ascer-taining the diagnosis of ADHD accord-ing to the criteria of the Diagnostic andStatistical Manual of Mental Disorders,third edition (DSM-III; American Psy-chiatric Association, 1987), with eachitem evaluated as either existing or notexisting. Furthermore, the children’steachers completed the Conners TeacherRating Scale (CTRS; Conners, 1973) toassess the severity of ADHD symp-toms. All children were diagnosedwith ADHD according to the struc-tured questionnaire, and their CTRSscores were higher than 15, supportingthe diagnosis of ADHD (Conners,1973).On reaching the eighth grade, these

students were evaluated again byeducational psychologists of the

psychological-educational service ofthe Jerusalem municipality with a bat-tery of psychoeducational tests (i.e., in-telligence and criterion- and norm-

referenced achievement tests) used inthe diagnosis of specific learning dis-abilities. Among these tests, partici-pants also completed the CancellationTask test (Byrne, Bawden, DeWolfe, &

Beattie, 1998; Landau, Gross Tsur,Auerbach, Van der Meere, & Shalev,1999) to assess ADHD symptoms. Ac-cordingly, all students were consideredto exhibit ADHD symptomatology tothe extent required by the Israeli Min-istry of Education for enrollment in aspecial education facility (i.e., the re-sults of the psychoeducational tests

combined with the evaluations of li-

censed educational psychologists de-termined that the student was unlikelyto benefit from placement in a generaleducation framework; Gumpel, 1996).Before the students entered this

study, their records were reviewed bythe school’s clinical and educational

psychologists (who did not participate

in the study) and by experienced childand adolescent psychiatrists (first andthird authors). The existence and

severity of ADHD symptomatologyat that time were established by theteachers’ responses to the CTRS andto a structured questionnaire evalu-ating current ADHD symptomatology(ADHD-Q) according to DSM-IV crite-ria (American Psychiatric Association,1994). Interrater reliability of the teach-ers for the CTRS and the ADHD-Q was.87 and .90, respectively.The participants were assessed by

two child and adolescent psychiatrists(first and third authors) by means ofthe 10 screening criteria of the Struc-tured Clinical Interview for DSM-IV AxisI Disorders-Patient Edition (SCID-I/P,version 2.0; First, Spitzer, Gibbon, &

Williams, 1995). These criteria screenfor panic disorder; agoraphobia; so-cial phobia; simple phobia; obsessive-compulsive disorder; anorexia nervosa;bulimia nervosa; and alcohol, drug, andmedication abuse. The participantswere also assessed by means of theSCID-I screening items for depressivedisorders, bipolar disorders, and schiz-ophrenic disorders. Each item was

rated as present, questionable, or not pres-ent. Interrater reliability of the two psy-chiatrists for the SCID-I was .91.

Participants who answered posi-tively on any of the SCID-I screeningitems were excluded from the study.Thus, participants were required to

have no Axis I disorder with the ex-

ception of ADHD and specific devel-opmental disorder. We did not screenfor oppositional disorder and conductdisorder, but the policy of this specifichigh school is not to accept studentswith severe behavioral problems. Thestudents could nevertheless have symp-toms associated with anxiety or de-pression that did not reach the crite-rion for a full-blown disorder (i.e., theycould have questionable responses forthese SCID-I screening items).

Additional exclusion criteria were as

follows:

1. current or lifetime medical and

neurological disorder;

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2. current or lifetime use of anypsychotropic medication; and

3. evidence of mental retardation

(information derived from astructured questionnaire and fromthe participants’ school records).

Only boys diagnosed with ADHD inchildhood and fulfilling all exclusioncriteria were eligible for participation.Of the 150 boys in this school, 95 met

the inclusion and exclusion criteria. Of

these, 50 boys had not been receivingany medication for the treatment ofADHD for at least 6 months prior tothe study, and 32 of them agreed toparticipate in the study. Another 45students were treated with methyl-phenidate (MPH) according to the rec-ommendations of a multidisciplinaryteam, including their teachers, theschool’s educational and clinical psy-chologists, and child and adolescentpsychiatrists. Of these students, 37

agreed to participate in the study.The participants’ dose of MPH was

stable for a period of at least 1 monthbefore entering the study. The medica-tion was administered either as a sin-

gle daily dose in the morning or twicea day, in the morning and at noon, ineach case not later than 2:00 p.m. Themean daily dose of MPH was 18 mg(SD = 5.7; range = 10-30 mg). No dif-ferences in demographic characteris-tics or severity of ADHD sympto-

1Note. ADHD = attention-deficit/hyperactivity disorder.

I

an = 35. bn = 32. cn = 77. dEuropean descent. emiddle Eastern descent. ]

matology were found for either the (

medicated or the nonmedicated group i

between students who participated ]

and students who refused to partici- ;

pate in the study. t

The control group consisted of male 1

adolescents studying in a general edu- ]

cation high school in Jerusalem, Israel. ’

Exclusion criteria were any current or ilifetime medical, neurological, or men- ’tal disorder, assessed similarly to the <

research participants. Of 98 eligible <

students, 77 agreed to participate in the <

study. No differences were found for ;

any of the demographic variables in- ]

troduced between the nonmedicated, ’medicated, and control groups. Demo- i

graphic data for the three groups are :

provided in Table 1. <

1

Instruments 1 .]

The participants completed a struc- ’

tured demographic questionnaire as- ;

sessing age, country of birth and ethnic :

origin, and current and lifetime med- : Iical conditions. The teachers corrobo- 4

rated the participants’ information ; iwith a similar questionnaire. <

The Mini Sleep Questionnaire (MSQ; I

Zomer, Peled, Rubin, & Lavie, 1985) 1

evaluated the presence and severity of ]

sleep disorders. This questionnaire in- <

cludes the following 10 items: initial,middle, and terminal insomnia; rest- ,

less sleep; hypersomnia; morning and 1

daytime fatigue; headaches followingawakening; snoring; and the use of hyp-notics. Each item is rated on a 7-pointscale from 1 (never) to 7 (always). Thetotal score of the questionnaire com-bines the scores for all 10 items. The

MSQ has been validated in more than1,000 Israeli adults of different agegroups (from 20 to 70; Zomer et al.,1985) as well as in more than 800 Israelichildren between the ages of 10 and 12

(Epstein, Chillag, & Lavie, 1998). It suc-

cessfully discriminates patients withsleep apnea and periodic leg move-ments from nonclinical individuals.

The analysis of the MSQ among typicaladult populations has consistentlyshown that the mean range for all in-dividual scales is between 2.0 and 2.1,and the mean total MSQ score (i.e.,total score divided by the number ofitems assessed) is between 2.1 (SD =

1.3) and 2.4 (SD = 1.5). A total MSQscore of 24 or below indicates typicalsleep, whereas scores in the ranges of25 to 27, 28 to 30, and more than 30 in-dicate mild, moderate, and severe

sleep problems, respectively (Zomeret al., 1985). In addition to using theMSQ, we assessed sleep duration ac-cording to the participants’ preferredhours of going to sleep and waking upon weekdays and holidays.The abridged Conners Teacher Rating

Scale (CTRS; Conners, 1973) and Con-ners Parent Rating Scale (CPRS; Conners,1994) assessed the severity of ADHDsymptomatology. These two scales

each include 10 items relating to dis-turbances in concentration, hyperac-tivity, and impulsivity. Each item is

rated on a 4-point scale from 0 (never)to 3 (always). Scores higher than 15 areindicative of ADHD (Conners, 1973,1994). The validity and reliability ofthese rating scales in differentiating be-tween Israeli children and adolescentswith and without ADHD (Margalit,1981, 1983; Ring et al., 1998) and in

evaluating the effects of psycho-pharmacological treatments (Levine,Ring, Barak, Elizur, & Belmaker, 1995;Weizman, Weitz, Szekely, Tyano, & Bel-

maker, 1984) have been demonstrated

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previously. In the present study, theparticipants completed the CTRS, asthis is considered the most widely usedscale for assessing ADHD symptoma-tology among Israeli children and ado-lescents (Margalit, 1981).The presence of symptoms of de-

pression was assessed with the self-

rating Beck Depression Inventory (BDI;Beck, Ward, Mendelson, Mock, & Er-

baugh, 1961). The self-rating State TraitAnxiety Inventory (STAI; Spielberger,Gorsuch, & Lushene, 1970) assessedthe severity of anxiety symptoms. TheSTAI evaluates the degree of anxietysymptoms at the time of examination(anxiety state) as well as the generaltendency to display anxiety (anxietytrait). The validity and reliability of theBDI (D. Stein et al., 1997) and the STAI(Teichman & Melineck, 1979) in Israeliadolescents have been demonstrated

previously.Participants’ parents completed the

following questionnaires relating to

their children: a structured demo-

graphic and clinical questionnaire sim-ilar to that of the participants, the

ADHD-Q, and the CPRS. In a prelimi-nary evaluation, the ADHD-Q was

completed by the therapists, parents,and teachers of 15 adolescents diag-nosed with ADHD who were treatedin an outpatient psychiatric setting.ADHD was diagnosed in all cases ac-cording to this questionnaire by all dif-ferent raters.

Procedure

The Israel Ministry of Education andthe principals of the two participatingschools approved the study. Parentsand students were told that they weretaking part in a study evaluating ado-lescent sleep-related behaviors; par-ticipation was voluntary. Written in-formed consent was obtained from the

parents prior to inclusion in the study.Research assistants individually dis-

tributed questionnaires to the studentswith ADHD. Students and parents re-ceived coded numbers, and their

names were known only to the princi-

pal investigator. The control partici-pants responded only to the MSQ.Twenty-one parents of the nonmed-

icated adolescents with ADHD and all

parents of the medicated adolescentswith ADHD returned the study ques-tionnaires. No differences were foundin any of the demographic or clinicalparameters between nonmedicatedstudents whose parents participatedand those whose parents did not par-ticipate in the study. Responses of

teachers were received for all nonmed-icated and medicated students with

ADHD.

Statistical AnalysisThe three groups were compared usinga one-way ANOVA followed by pair-wise follow-up comparisons to evalu-ate differences among the means of the

total MSQ. A chi-square analysis wasused to assess the differences in the fre-

quencies of the four categories of sleepdisturbance (no disturbances, mild,moderate, and severe disturbances)

among the three groups.Follow-up t tests for independent

samples and chi-square tests were usedto evaluate the differences in sleep du-ration during weekdays and holidays,ADHD parameters, and symptoms of

anxiety and depression between thenonmedicated and medicated par-ticipants.

Note. ADHD = attention-deficit/hyperactivity disorder.an = 35. bn = 32. cn = 77. dmini Sleep Questionnaire score (MSQ) < 24. EMSO = 25-27. IMSQ = 28-30.9MSQ ~! 31.

Pearson correlation coefficients and

Spearman rhos were used to evaluatethe correlations between total MSQscores and mean weekday and holidaysleep duration and the different inter-val and ordinal variables assessingsymptoms of ADHD, anxiety, and de-pression. We also conducted multipleregression analyses to examine whethersymptoms of depression and anxietywould contribute to sleep disturbancesamong adolescents with ADHD. Spe-cifically, we assessed whether therewere differences in students with andwithout diagnosable ADHD (accord-ing to their teachers’ CTRS being > 15

or < 15, respectively) in terms of thecontribution of anxiety and depressivesymptoms and medication status to

their total MSQ score.

Results

The comparison of the three groups fortotal MSQ score showed a significantbetween-group difference, F(2, 65) =

~ 4.18, p < .05, q2 = .05, with a moderateeffect size. Specifically, the medicatedstudents had a significantly elevatedtotal MSQ score (M = 31.45, SD = 10.8)compared with both the nonmedicatedparticipants (M = 26.62, SD = 8.6) andthe controls (M = 26.53, SD = 7.5).

Table 2 presents the between-groupdifferences in severity of sleep distur-

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272

bances according to the different MSQcategories. Fifty-nine controls (77%),26 nonmedicated students (81 %), butonly 19 medicated students (55%) re-ported only mild sleep disturbances, ornone. Differences in these frequenciesfor the 12 cells (4 sleep problems by3 participant groups) were significant,x2 = 14.06, p < .05. The nonmedicated

and medicated participants with ADHDreported similar mean weekday sleepduration (M = 7.92, SD = 1.2, and M =

8.85, SD = 1.2 hours, respectively) andmean holiday sleep duration (M = 9.43,SD = 1.7, and M = 9.45, SD = 1.6 hours,respectively).

Table 3 summarizes the differencesbetween the nonmedicated and med-icated participants for ADHD, anxiety,and depressive symptoms. The resultsshow moderate to very large effectsizes (.46-4.07). Specifically, the med-icated students showed significantlymore ADHD symptoms as reported bytheir teachers (CTRS) and their parents(ADHD-Q). Additional analyses re-

vealed that 21 (60%) of the 35 med-icated participants obtained a teacher-rated CTRS score of 15 or more,

indicative of full-blown ADHD at thetime of evaluation, compared with 5(15%) of the 32 nonmedicated partici-

Note. ADHD-Q = ADHD symptomatology questionnaire; CTRS = Conners Teacher Rating Scale; CPRS = t,Conners Parent Rating Scale; STAI = State Trait Anxiety Inventory; BDI = Beck Depression Inventory.an = 32. bn = 35. ctwo tailed, df = 65. 9*p < .05. **p < .001. S

pants, x2 = 15.24; p < .01. It is interest- I

ing that these 5 nonmedicated partici- Il

pants had a significantly elevated total a

MSQ score (M = 32.81, SD = 8.1) com- s

pared with the 27 nonmedicated par-ticipants with no current full-blown s

ADHD (M = 26.05, SD = 9.1), t(30) = P

2.89, p < .01, d = .75, with a strong ef- r

fect size. v

Table 3 also shows significant be- P

tween-group differences in symptoms t~

of anxiety and depression. The medi-cated participants with ADHD demon- i:

strated severe state anxiety (the mean t

STAI score of 49.11 represents the 95th

percentile) and trait anxiety (the mean a

STAI score of 51.76 represents the 95th c

percentile; Teichman & Melineck, 1979), s

and their mean score on the BDI (17.68) s

reflected moderate depression symp- s

toms (Rotherham-Borus & Trautman, j.

1988). In contrast, the nonmedicated e

participants with ADHD showed mod- r

erate state anxiety (the mean score of F39.77 represents the 79th percentile) I

and trait anxiety (the mean score of t

43.13 represents the 81st percentile) e

and no depression (mean BDI = 7.92). k

We examined the correlations of the ¡.

total MSQ scores and sleep duration in k

the nonmedicated and medicated par- t

ticipants with the ADHD, anxiety, and

repression measures, using the Bon-ferroni correction to keep the chance of:1. Type I error below .05. The total MSQscore of the nonmedicated participantswas found to correlate with the STAI

state, r = .29, p < .001, and trait, r = .25,? < .001, dimensions. Among the med-icated participants, total MSQ scorewas correlated with the BDI, r = .55,p < .001. No relationship was found be-tween medicated and nonmedicated

participants’ mean sleep duration dur-ing weekdays and holidays and any ofthe variables introduced.Two separate multiple regression

analyses were conducted to assess the:ontribution of anxiety and depressivesymptoms and medication status to

sleep disturbance (total MSQ score) instudents with and without a definite

ADHD diagnosis. The regressionequation for the ADHD group was sig-nificant, R2 = .43, adjusted R2 = .39,F(1, 13) = 9.79, p < .05, with only theBDI scores significantly contributing tothe total MSQ score. The regressionequation for the non-ADHD groupwas also significant, R2 = .19, adjustedR2 = .17, F(1, 38) = 8.77, p < .05, againwith only the BDI significantly con-tributing to the MSQ score.

Discussion

Our results show that contrary to ourfirst hypothesis, the nonmedicated maleadolescents diagnosed with ADHD inchildhood did not demonstrate a

greater severity of sleep disturbances,as rated with the MSQ, compared withthe controls. Our second hypothesiswas confirmed, in that the severity ofsleep disturbance among the nonmed-icated participants was correlated withthe severity of anxiety symptoms,whereas among the medicated partici-pants with ADHD it was correlatedwith the severity of symptoms of de-pression. In keeping with our third hy-pothesis, students treated with MPHhad significantly elevated scores on thetotal MSQ, as well as a significantlygreater percentage of moderate andsevere sleep problems, compared with

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their nonmedicated peers and withcontrols. The severity of depressivesymptomatology was found to con-

tribute significantly to the degree ofsleep disturbances (total MSQ) in par-ticipants with and without full-blownADHD, independent of their primaryADHD symptoms and MPH treat-ment.

The findings of this study are of im-portance because sleep disturbances inadolescents with ADHD have receivedlittle attention in the scientific litera-ture. Nevertheless, our design allowsat present only preliminary conclu-sions. The overall lack of sleep distur-bances among the nonmedicated ado-

lescents diagnosed with ADHD inchildhood may be due to the fact that

only a few of them had a full-blowndisorder at the time of the study. In-deed, these few students showed more

sleep disturbances than the nonmedi-cated participants who did not cur-rently have a full-blown disorder.These findings suggest that amongadolescents having a definite ADHDdiagnosis, daytime symptoms maycontinue into the night (Porrino et al.,1983).From a different perspective, the sleep

of our control adolescents was consid-

erably more disturbed than typicallyfound for average Israeli adults. As

noted elsewhere, the analysis of theMSQ among typical Israeli popula-tions between the ages of 20 and 70 hasshown that the mean range for all in-dividual scales is between 2.0 and 2.1

and that the mean total MSQ score(total score divided by the number ofitems assessed) is between 2.1 ± 1.3

and 2.4 ± 1.5 (Zomer et al., 1985). Incontrast, although the mean total MSQscore of our controls was only slightlyelevated (2.65 ± 0.7), the mean score for7 of the 10 individual scales was above

2.1 (results not shown). The most dis-

turbing findings were obtained for

morning fatigue (5.00 ± 1.8) and pro-longed fatigue (3.00 ± 1.7), probably re-flecting the influence of insufficient

weekday sleep related to the tendencyof adolescents to go to sleep at a rela-tively late hour (Andrade et al., 1993;

Carskadon et al., 1993). This pattern isgreatly enhanced in Israeli middle andhigh school students, for whom schooldays often start as early as 7:15 (Ep-stein et al., 1998). It is interesting thatthe mean duration of sleep duringweekdays and holidays for our non-medicated and medicated studentswith ADHD was in the range of find-

ings for average Israeli adolescents (7.3± 1.1 hours and 9.3 ± 1.8 hours, respec-tively ; Epstein et al., 1998). Our find-ings add to several recent studiesbased on actigraphic monitoring andparental ratings that show either nochange in sleep duration when com-paring children diagnosed with ADHD,regardless of MPH treatment, withcontrols (Dagan et al., 1997) or only aslight decrease in sleep duration whencomparing MPH treatment and

placebo (M. A. Stein et al., 1996).Compared with the nonmedicated

participants, the medicated studentswith ADHD showed a significantlygreater severity of sleep disturbances.This was evident both in the total MSQscore and in the elevated rate of mod-

erate and severe sleep disturbances.The medicated students also demon-strated a significantly greater severityof teacher-rated ADHD symptomatol-ogy (and also to some extent of parent-rated ADHD symptoms) as well as ofsymptoms of depression and anxietycompared with the nonmedicated par-ticipants. Although studying in the

same special education facility, thesetwo groups may represent two distinct

subtypes of ADHD. One possible spec-ulation concerning the overall worsecondition of the medicated partici-pants is that perhaps most of themhad the hyperactive-impulsive type,whereas the nonmedicated group pri-marily had the inattentive type, of

ADHD. Of interest are the data show-

ing that the differences in ADHD

symptomatology between the medi-cated and the nonmedicated partici-pants were revealed primarily by theirteacher-rated rather than by their self-rated CTRS scores. This suggests thatadolescents diagnosed with ADHDmay be less accurate than their teach-

ers in describing their symptoms(Smith, Pelham, Gnagy, Molina, &

Evans, 2000).Our study design does not enable us

to separate among the medicated par-ticipants the relative effect of MPH ora possible rebound effect (as the med-ication was not administered after 2:00

p.m.) on their greater sleep disturbancefrom the influence of their elevatedADHD symptomatology or higher lev-els of symptoms of depression andanxiety. Nevertheless, we used corre-lational analyses with Bonferroni cor-rections for the medicated and non-medicated students and separateregression analyses for participantswith and without full-blown ADHD to

investigate the factors that contributeto sleep disturbance (total MSQ). Ourfindings suggest that elevated depres-sive symptoms (and to some extent

also elevated anxiety symptoms) con-tributed particularly to sleep distur-bance in our participants, independentof the effect of severity of ADHD

symptomatology and MPH treatment.Depression may be of particular rele-vance for sleep disturbance in adoles-cents with ADHD, as there is a consid-erable overlap in the neurobehavioralsystems underlying dysregulation ofsleep, attention, arousal, and emotions(Dahl, 1996b). Furthermore, depressivesymptoms may persist in these adoles-cents even when their primary ADHDsymptoms have decreased (Hechtman,1989).The present study has several limita-

tions. The diagnosis of ADHD in child-hood was made by independent childand adolescent psychiatrists, preclud-ing the assessment of interrater relia-bility. Our sample was relatively small,and we assessed adolescents diag-nosed with ADHD in childhood who

did not necessarily fulfill the criteriafor the full-blown disorder at the time

we evaluated them. Allocation of stu-dents to MPH treatment was based onclinical judgment rather than on a stan-dardized, randomized clinical trial. This

precludes any definite conclusions

concerning the influence of MPH onsleep disturbance. Not all parents of

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274

the nonmedicated students returned

the questionnaires, and parents andteachers of the control participantswere not assessed. Lastly, the designwas cross-sectional, comparing differ-ent samples rather than being a longi-tudinal evaluation of one sample withand without medication.

Our study also has several strengths.These relate to the assessment of ado-

lescents in the community (school)rather than in clinical settings andto the obtaining of information con-cerning sleep disturbances and ADHDsymptomatology with standardizedinstruments from several sources,

including participants, parents, andteachers.

Our findings may have some impli-cations for the educational practitioner.First, parental guidance and supportshould be provided to assist parents indeveloping a home policy regardingsleep times, particularly for adoles-cents with more severe ADHD and in

the context of MPH treatment. Such a

practice has been outlined by Kayser,Wacker, Derby, and Andelman (1997)in their use of applied behavioral tech-niques to reduce sleep problems in

medicated and nonmedicated childrenwith ADHD.

Second, we agree with other authors

(Dagan et al., 1997; Dahl, 1996a) thatADHD-related inattentiveness and be-havior problems are adversely affectedby the disturbed sleep patterns amongadolescents with ADHD. These ad-

verse effects may cause increasedADHD symptoms in early morningschool performance caused by diffi-

culty in waking up, or they may causedecreased performance later in theschool day. A grid system such as thatdeveloped by Touchette, MacDonald,and Langer (1985) may assist the prac-titioner to delineate these different sit-

uations, allowing for appropriate envi-ronmental modifications.

In summary, the present study didnot find a greater severity of sleep dis-turbances among nonmedicated maleadolescents diagnosed with ADHD inchildhood compared to control partic-ipants. This finding may reflect the

lack of full-blown ADHD in most of

these boys at the time of the study orthe relatively greater severity of sleepdisturbances in our control participantscompared with typical adult popula-tions. Sleep disturbance among malestudents receiving methylphenidatetreatment was significantly greater com-pared with the nonmedicated group.Longitudinal studies evaluating largersamples of adolescents diagnosed withADHD during adolescence with morerigorous criteria before, during, and fol-lowing the administration of methyl-phenidate are required to verify thesepreliminary findings.

ABOUT THE AUTHORS

Daniel Stein, MD, is the director of the Pedi-atric Psychosomatic Department at the ChaimSheba Medical Center, Tel Hashomer, Israel, anda senior lecturer in the Psychiatric Division,Sackler Faculty of Medicine, Tel Aviv Univer-sity, Tel Aviv, Israel. His research interests in-clude eating disorders, sleep disorders, and ado-lescent suicide. Ruth Pat-Horenczyk, PhD, isa clinical psychologist at the Center for EatingDisorders and Obesity at the Chaim Sheba

Medical Center, Tel Hashomer, Israel. Her re-search interests include eating disorders andsleep disorders. Shulamit Blank, MD, is thedirector of the Eating Disorders Unit at theKaplan Medical Center, Rehovot, and the Ara-zim Institute for Children, Rishon Le-Zion,Israel. Her research interests include eating dis-orders, behavioral disturbances, and attention-

deficit/hyperactivity disorder. Yaron Dagan,MD, DSc, is the director of the Institute for Fa-tigue and Sleep Medicine at the Chaim ShebaMedical Center, Tel Hashomer, Israel, and a se-nior lecturer at the Sackler Faculty of Medicine,Tel Aviv University, Tel Aviv, Israel. His re-search interests include the physiology and psy-chology of sleep and sleep disorders and thestudy of fatigue. Yoram Barak, MD, is the di-rector of the Psychogeriatric Department at theAbarbanel Mental Health Center, Bat Yam, Is-rael, and a senior lecturer in the Psychiatric Di-vision, Sackler Faculty of Medicine, Tel AvivUniversity, Tel Aviv, Israel. His research inter-ests include dementia and its treatment, mul-

tiple sclerosis, and schizophrenia. Thomas P.Gumpel, PhD, is an assistant professor cur-rently at the Department of Special Education,The School of Education at the Hebrew Univer-sity of Jerusalem, Israel. His research interestsinclude social skills training and sociometric

status, school violence, item response theorymodeling, and international comparative policyanalysis in special education. Address: DanielStein, Pediatric Department C (Pediatric Psy-chosomatic Department), The Chaim Sheba

Medical Center, Tel Hashomer, 52621, Israel;e-mail: dstein@netvision.net.il

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