Cognitive and Behavioral Effects of Sleep Restriction in Adolescents With ADHD

Teens with attention-deficit/hyperactivity disorder (ADHD) obtain less sleep than their
peers, with up to 75% of youth with ADHD obtaining insufficient sleep. This is noteworthy
since insufficient sleep is associated with a multitude of negative outcomes in typically
developing teens, including academic underachievement, emotion dysregulation, and mental
health problems - all outcomes that occur at higher rates among teens with ADHD. Our pilot
work demonstrates that insufficient sleep is correlated with depression, behavior problems,
and academic impairment in teens with ADHD specifically and insufficient sleep is clearly
associated with greater attentional problems in typical teens. However, no experimental study
has examined whether sleep duration is causally linked to attentional, behavioral, emotional,
and academic impairments in teens diagnosed with ADHD. If sleep problems contribute to
functional impairments in teens with ADHD, then they represent an overlooked treatment
target. Experimental studies provide the strongest test of causality, and studies using
at-home sleep restriction protocols in teens without ADHD show a causal link between
shortened sleep duration and impairment. However, administering an at-home sleep restriction
protocol may be especially challenging for teens with ADHD due to their difficulties with
organizing bedtime and wake activities, as well as differences from healthy teens in
biological circadian preference. Thus, a critical first step in examining sleep as causally
related to impairment in teens with ADHD is documenting the feasibility of using an at-home
sleep restriction protocol with this population. This study will (1) evaluate the feasibility
of using an at-home sleep restriction protocol in teens with ADHD, and (2) collect
preliminary data examining whether shortened sleep duration is causally linked to
attentional, behavioral, emotional, and academic impairment in teens with ADHD. These goals
will be accomplished by recruiting 54 teens with ADHD who will undergo a three-week sleep
manipulation protocol. Specifically, a cross-over design will be used that includes a week of
typical sleep followed by weeks of sleep restriction or sleep extension. Sleep functioning
will be assessed during these three weeks with daily sleep diary and objective sleep
measurement (i.e., actigraphy). After each sleep condition, teens and their parents will
complete subjective and objective measures of attention, behavior, mood, and academics.
Findings from this study will allow us to identify and address barriers to administering an
at-home sleep restriction and extension protocol to teens with ADHD and pursue larger-scale
experimental research examining sleep problems as causally linked to impairment. This
research is clinically significant since teens with ADHD frequently experience a range of
impairments that extend well into adulthood. If short sleep duration contributes to
functional impairments in teens with ADHD, then sleep represents a modifiable and overlooked
treatment target.

Inclusion Criteria:

- Between 14 and 17 years of age.

- Estimated IQ ≥ 70.

- Meet full DSM-5 criteria for ADHD.

- Sufficient English language ability necessary to complete study measures.

- If applicable, the family must be willing to discontinue any treatment with a
psychostimulant medication during the three-week sleep manipulation protocol.

Exclusion Criteria:

- Children with an autism spectrum disorder or diagnosed with psychosis, bipolar
disorder, or obsessive-compulsive disorder based on the K-SADS diagnostic interview
will be excluded.

- Children taking any psychiatric medication that is not a psychostimulant.

- Significant visual, hearing, or speech impairment.

- Organic brain injury or history of seizures.

- Symptoms of obstructive sleep apnea (OSA), periodic limb movement disorder (PLMD), or
delayed sleep phase syndrome (DSPS).

- Obligations that require bedtime later than 10pm or waking prior to 5:30am any morning
of the study.

- Daily consumption of >1 coffee or "energy drink" or >3 caffeinated sodas.

- Highly atypical sleep, defined as <6 hours or >9.5 hours on school nights per parent
and adolescent report.

- Inability or refusal to refrain from automobile driving or other high-risk tasks that
require vigilance during the sleep restriction week of the study.

- Finally, at the visit following the baseline week (week 1) of the sleep protocol, we
will exclude teens whose actigraphs reflect an inability to consistently arise within
1 hour of the agreed-upon time.