Attention Deficit Hyperactivity
Disorder (ADHD) is one of the most common neurodevelopmental disorders that can
develop in both children and adults, characterized by an inability to maintain
attention according to the level of growth, restlessness, and/or
hyperactive-impulsive psychomotor behavior1. Children with ADHD may
have troubles paying attention, hyperactivity, and impulsivity and may
adversely impact social, academic, or other activities 2. ADHD, a
perennial neurodevelopmental disorder that impacts 2.5% of adults and 5% of
children and adolescents globally 3.
There is no clear data available on the prevalence of ADHD children in
Indonesia but there are a number of studies that can describe the prevalence of
ADHD. The previous survey discovered that a significant proportion of primary
school students (26.2%) experience ADHD in the capital city of Indonesia4
and the other research by Paramashanti et
al (2018) in Bantul-DIY reported ADHD prevalence was 29.19% 5.
ADHD is typically accompanied by a number of comorbidities, making it
challenging and complicated to manage6. Most children and
adolescents with ADHD have comorbid conditions, often multiple comorbidities or
at least one comorbid. The results of a study by Radmanovic (2020) reveal that
sleep disturbance is one of the comorbid ADHD and other comorbidities such as
learning difficulties, speech-language difficulties, mood disorders, and eating
disorders7. Therefore, the association between sleep disorder and
ADHD are complex, multi-directional, and multifactorial and are often
associated with poorer daily functioning8.
Compared to 7% of the general population, patients with ADHD reported sleep
alteration 25-55% of the time9. Hodgkins et al (2013)
provided data that as many as 25-55% of parents reported that their children
with ADHD had sleep disorders10. Based on this description, this
study was conducted with the aim of assessing sleep disturbance and their
influencing factors in ADHD children, so that the results of this study can
provide appropriate prevention and treatment.
Study design and data
A cross-sectional design was carried out from May to
October 2022 at Soerojo Hospital. Purposive sampling technique was used to select a total of 60 respondents. The
inclusion criteria were ADHD pediatric patients aged 6-15 years accompanied by
parents or caregivers willing to participate in the study, therefore informed consent was obtained from the child's parent or
caregivers. Meanwhile, ADHD children with
comorbidities such as schizophrenia/psychotic disorders and/or other mental
disorders: anxiety disorders, mood disorders, dissociative disorders,
personality disorders, substance intoxication or drug withdrawal,
autism, and mental retardation were excluded. This study was approved by The
Ethics Committee, Soerojo Hospital issued on 28 April 2022 (No: 22/KEH/IV/2022).
Data collection begins with determining the sample based
on inclusion and exclusion criteria. Respondents who agree to participate in
the research will sign an informed consent and be recruited as a sample. Data
obtained by distributing questionnaires to respondents. The questionnaire
consists of questions related to sleep disturbances in children with ADHD. We also
collected data about the demographic characteristics of respondents and the
influencing factors of sleep disturbance that consist of: history of
therapy, comorbidities, Low Birth Weight (LBW), malnutrition, screentime, and
socio-economic conditions of parents.
We measured all subjects’ weight and height and plotted
it into CDC growth charts to measure malnutrition; other data were collected
through interviews with their parents. The SDSC (Sleep Disturbance Scale for
Children) questionnaire was distributed to get sleep disturbance data. SDSC is
a sleep disturbance screening instrument for standardizing the assessment,
identifying specific limits, and identifying sleep disturbance in children using
a sleep scoring system (Herwanto et al., 2018). SDSC questionnaire contains 26 question items divided into 6
sleep disturbance type :1) SHY (Sleep Hyperhidrosis); 2) DIMS (Difficulty in
Initiating and Maintaining Sleep); 3) SBD (Sleep Breathing Disorder); 4) DOES
(Disorder Of Excessive Somnolence);5) DOA (Disorders Of Arousal );6) SWTD
(Sleep–WakeTransition Disorder). The questions are scored on a Likert scale of
1 to 5 and the sum of the scores determines a total sleep score (Total SDSC).
The validated and reliable Indonesian version of the Sleep Disturbance Scale
for Children (SDSC) questionnaire was adopted in this study (Natalita et al.,
The distribution and proportion of the demographic and clinical profile of
children with ADHD, sleep disturbance, and influencing factors were analyzed
using univariate analysis. Meanwhile, the chi-square test was used in bivariate analysis to
determine the association between influencing factors and sleep disturbance. Two variables are statistically significant if the
calculated ρ-value is less than 0.05. Data was analyzed using the
The study was conducted at the child and adolescent
mental health clinic at Soerojo Hospital for four months from May to August
2022. There were 60 respondents who met the inclusion and exclusion criteria in
this study with the following basic characteristics.
The proportion of ADHD children
between the ages of 5 - 11 years is 3 times higher than that of children with
ADHD aged > 12 years, which is 75% versus 25% (3:1). Meanwhile, based on
gender data, it is known that the number of ADHD children is 54 (90%) boys and
6 (10%). Among all child respondents, 8 (13%) had a history of low birth
weight, 2 (3%) had comorbid asthma and 7 (12%) had comorbid epilepsy.
It is known that the prevalence of sleep disturbance in ADHD
children is 12 or 20% of the total respondents with ADHD. The data was obtained
based on a questionnaire answered by parents according to the sleep habits of
children with ADHD. Hyperhidrosis disorder during sleep (13%) was the most
common type of sleep disturbance found in this study. Followed by the type of
disorder in initiating sleep and maintaining sleep (3%) and breathing disorders
during sleep (3%) and excessive somnolence (1%). It was found that there was 1
child with ADHD who had 2 types of sleep disturbance at once, namely
respiratory disorders and hyperhidrosis during sleep.
Based on table 3, there are 8/45 children with ADHD aged
5-11 years having sleep disturbance. Among all ADHD children who have sleep
disturbance, 10 of them are male. It is also
known that 7 out of 35 ADHD children receiving pharmacological ADHD therapy
have sleep disturbance. There are 2 of all
respondents have asthma and both have sleep disturbance. In addition, there are 4 out of 7 ADHD children with
epilepsy who have sleep disturbance.
Among ADHD children with sleep disturbance, one child had a history of low birth weight, 6 children
had non-ideal nutritional status or malnutrition, and 7 children had screen
time exceeding the recommendation. There are 7 ADHD children with sleep
disturbance who have mothers with low levels of
education (< high school) and 5 children with lower socioeconomic
The results of bivariate analysis of relationship between
sleep disturbance and each factor are presented in table
6. Based on the chi-square test for bivariate
analysis, it was found that comorbid asthma had a statistical relationship with
sleep disturbance in ADHD children (ρ-value 0.037) and the OR value was 1.2,
which means that ADHD children who have asthma are 1.2 times more likely to
have sleep disturbance. In addition, epilepsy
comorbidity also has a relationship with sleep disturbance in ADHD children (ρ-value
0.025) with an OR value of 7.5, which means that ADHD children who have
epilepsy have a 7 times greater risk of having sleep disturbance.
ADHD is a chronic neurodevelopmental behavior disorder
characterized by symptoms of inattention, impulsivity and hyperactive behavior11.
The result of this study indicates that children with ADHD are found more in
boys than girls and a higher proportion of ADHD in children aged 5 to 11 years
than aged >12 years.
ADHD children are more susceptible to having sleep difficulties12. Sleep disorders
have been identified as a comorbid condition in 25–50% of children and
adolescents with ADHD10. ADHD is multidirectional and multifactorial along with
other conditions, one of which is sleep disorder13. Sleep disorders affect
the quantity, quality, and timing of sleep, causing daytime distress and functional impairment14.
Types of sleep disturbances were measured using SDSC
questionnaire and categorized into 6 types including DIMS (Difficulty in Initiating
and Maintaining Sleep); SBD (Sleep Breathing Disorder); DOA (Disorders Of Arousal ); SWTD (Sleep–Wake
Transition Disorder); DOES (Disorder Of Excessive Somnolence); and SHY (Sleep
Hyperhidrosis)15,16. Results of this study, 13% of ADHD respondents had sleep
hyperhidrosis. According to Zeron et al. (2020), while ADHD combined-type
patients experience more severe sleep breathing problems and sleep
hyperhidrosis, ADHD inattentive patients have problems with substantial
behavioral sleep, including problems falling asleep and staying asleep,
sleep-wake transition abnormalities, and excessive daytime somnolence17.
ADHD patients who scored high on the sleep hyperhidrosis subscale were
more likely to have night sweats and had shorter sleep durations. According to the SDSC questionnaire, type of sleep
hyperhidrosis consists of two points, including falling asleep sweating and
night sweating 15,16.
In addition to sleep hyperhidrosis, disorder of
initiating and maintaining sleep was identified in 3% of ADHD respondents.
These results are consistent with previous research conducted at Child Development
Polyclinic Dr. Sardjito Hospital, Yogyakarta knew that 64,8% of ADHD children
experienced sleep disorders with the majority having disorders of initiating
and maintaining sleep (48.1%), sleep-wake transition disorders (14,6%), and
disorders of excessive somnolence (1,9%)18. Disorder of initiating and maintaining consists of
several points including sleep duration, sleep latency, unwillingness to
go to bed, difficulties falling asleep, anxiety before falling asleep,
nighttime awakenings, and difficulty getting back to sleep after awakenings15,16.
The results of this study also found that 3% of ADHD
respondents experienced sleep breathing disorders. In a narrative review of
sleep disorders in ADHD patients19, thirteen research examined the sleep characteristics of individuals with
sleep breathing disorders and ADHD.
Sleep breathing disorders are characterized by irregular breathing and/or ventilation during sleep and research has
shown that higher sleep breathing disorders symptoms are correlated to higher
total ADHD symptoms. This correlation is stronger for hyperactivity, then
impulsivity, and also poor social skills, and lower academic performance. The first
line treatment for ADHD children with sleep breathing disorders is surgical
removal of the tonsils or adenoids. Sleep breathing
disorders consist of three points including breathing problems, sleep apnoea,
In this study, disorders of excessive somnolence were
found with the least number (1%). In a study conducted by Cohen and colleagues
(2013) on 186 children aged from 2 to 18 years consisting
of 109 boys and 77 girls. The SDSC questionnaire was given to their parents to
complete. The questionnaires were separated into three groups: ADHD (62
patients), epilepsy (58 patients), or other (66), according to their primary
neurologic diagnosis. Total abnormal sleep scores for fifty children. Initiating
and maintaining sleep (24.7%), arousal nightmares (23.1%), and excessive
sleepiness (25.3%) were the three most prevalent sleep disorders20.
Disorders of excessive somnolence consist of several points including distress
and tiredness when waking up, daytime somnolence, sleep paralysis, and sleep attacks 16.
Furthermore, the results of the bivariate statistical
analysis, it is known that epilepsy and asthma are comorbidities in ADHD
children associated with sleep disorders. Clinical studies estimate a
prevalence of 30-40% for ADHD in children with epilepsy, which is substantially
higher than in the general pediatric population21. According to
studies, ADHD is the most prevalent problem among preschoolers and school-aged
children with epilepsy, affecting both males and girls equally. The presence of
sleep disturbance in children with epilepsy is related to impaired GABA
release. Decreased GABA or increased acetylcholine and norepinephrine are
responsible for the pathophysiology of sleep disorders
in children with epilepsy. The pathophysiology of epilepsy causes prolonged sleep
onset, sleep phase disorder, prolongation of NREM 1 and 2 phases, decreased
sleep spindle density, and decreased REM phase 22. The results of
these studies are consistent with the bivariate statistical analysis in this
study, that there is an association between comorbid epilepsy and sleep disturbance
in ADHD children (ρ-value 0.025).
Besides epilepsy, comorbid asthma is also one of the
factors associated with sleep disturbance in ADHD children. The bivariate
analysis results showed a significant association between comorbid asthma and
sleep disturbance in ADHD children (ρ-value
0.037). These results are consistent with previous research by Furtado et al,
which stated that asthma causes sleep disorders,
based on clinical experience there is a significant interaction between
respiratory function disorders and sleep quality. Uncontrolled history of
comorbid asthma in children or adolescents could be functional condition and progression, impaired growth, as well as attention deficit disorders, excessive
drowsiness, psychological issues, increased school absences, and inadequate academic
performance that impact their QoL23.
Hypoxia and breathing maintenance activities exacerbate attention problems that
children with asthma may experience. Additionally, difficulty breathing at
night might disrupt sleep, aggravating attention deficit hyperactivity disorder
Based on the description, it is known that sleep
disorders are one of the comorbidities highly prevalent in ADHD children.
Therefore, proper assessment of sleep disorders is needed, especially for those
who have sleep problems, so early treatment can be given, and should be noted
that sleep disturbances and ADHD have a reciprocal relationship associated with
poorer daily functioning. The results of the study are expected to be a
scientific basis for identifying the risk of sleep disorders in ADHD children
so appropriate prevention and management can be carried out.
The limitation of this study was the research sample
consisted of ADHD children who were already undergoing therapy. The obtained
pharmacological or non-pharmacological therapy has the potential to cause bias
in the measurement of sleep disorders.
Based on the identification using the SDSC questionnaire,
20% of ADHD children have sleep disturbance. The types of
sleep disturbance experienced by respondents in this study were sleep
hyperhidrosis (SHY), a disorder of initiating and maintaining sleep (DIMS),
sleep breathing disorders (SBD), and disorders of excessive somnolence (DOES).
There is a research respondent who has more than one type of sleep disturbance.
In this study, ADHD children who had comorbid asthma and
epilepsy were more likely to have sleep problems. Although the association
between sleep disturbance and ADHD are
complex (multi-directional and multifactorial). Based on the results of this
study and supported by a number of previous studies, an initial screening of
sleep disturbance in pediatric patients with ADHD is required in order to
provide effective prevention and treatment.
The authors thank all of the
respondents who contributed to this study. We are also grateful to Soerojo
Hospital for the support and funding sources in this research.
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