In Conversation… Dr Emma Sciberras on Sleep and Anxiety in ADHD

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Dr Emma Sciberras discusses sleep and anxiety in ADHD, around 70% of children with ADHD will have sleep problems and anxiety can exacerbate ADHD symptoms.

They talk about how to recognise sleep problems in ADHD, sleep hygiene including screen time, a bedtime pass and ‘checking in’. Her own research on the associations between sleep hygiene and sleep problems in adolescents with ADHD.

As well as exciting funding for new intervention development, to improve social anxiety in those with ADHD, one of the most commonly experienced forms of anxiety.

You can listen to this podcast directly on our website or on the following platforms;
SoundCloudiTunesSpotifyCastBox, DeezerGoogle Podcasts and Radio.com (not available in the EU).

 

Dr Emma Sciberras

Dr Emma Sciberras is also an Associate Professor in the School of Psychology at Deakin University. She leads the ADHD research lab and Intervention Streams of the Deakin Child Study Centre and Centre for Social and Early Emotional Development, Deakin University. She is also an honorary research fellow in the Department of Paediatrics at the University of Melbourne.

Transcript

Interviewer: Hello. Welcome to the ‘In Conversation’ podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. Today, I’m interviewing Dr. Emma Scibberras, Associate Professor at the Faculty of Health School of Psychology at Deakin University in Melbourne, Australia. Today, we’ll be looking at ADHD, sleep and anxiety. Emma, welcome. Thank you for joining me. Can you say a little about yourself?

Dr. Emma Sciberras: Hello, and thank you so much for having me. I’m an Associate Professor in psychology at Deakin University and I’m also a clinical psychologist. I’ve been working in the area of ADHD for about 15 years now and lead a programme of research which is about trying to understand what helps children with ADHD to have good outcomes over time, and with a real focus on the development of new behavioural interventions to help improve outcomes.

Interviewer: And as mentioned, we’re looking today at ADHD, sleep and anxiety. What issues arise for children and young people with ADHD when it comes to sleep?

Dr. Emma Sciberras: Sleep problems are really common in children with ADHD and used to be part of the diagnostic criteria for ADHD. There’s lots of research which has looked at this over the past decade which has shown that about seventy per cent of children with ADHD will have sleep problems. And these kinds of sleep problems have been found to have an independent impact on functioning for children with ADHD. So if you have both ADHD and a sleep problem, research has shown that the symptoms of ADHD are worse, general daily functioning is worse and associated mental health difficulties appear to be worse too.

The sleep difficulties in this group also seem to be quite varied. So they might vary from difficulty getting your child into bed if they have ADHD. It might be worries or anxiety about bedtime or nighttime insomnia. And there’s also biologically-based sleep problems too, like obstructive sleep apnea, for example, that seem to have a high prevalence in children with ADHD. And other things like restless leg syndrome, which is an experience of unpleasant feelings in the legs that makes it really hard to settle off and go to sleep. So it’s a really broad range of sleep problems that seem to be elevated in this group.

Interviewer: Would sleep apnea normally be not common in children?

Dr. Emma Sciberras: I guess there’s many different things that we want to look out for. Looking at whether or not there’s any snoring at nighttime and looking at whether or not there does tend to be any interruption in breathing overnight. But sleep apnea is actually more common than you’d expect. It’s quite common in toddlers and pre-schoolers. And research has shown that children who are presenting with those kinds of sleep difficulties, if they receive treatment, you do see a decrease in hyperactivity symptoms. So it’s a really important thing to keep an eye out for in children generally, but also particularly in children with ADHD.

Interviewer: Emma, you recently published a study looking at the associations between sleep hygiene and sleep problems in adolescents with ADHD. Can you share some of the findings?

Dr. Emma Sciberras: That study was published in the Journal of Attention Disorders, and in that study we were really interested in whether using healthy sleep strategies was related to the actual experience of sleep problems overnight. And the reason we were interested in this in adolescents with ADHD is that there is research showing that sleep problems continue to be high in adolescents with ADHD, but there’s no treatment research yet in adolescents with ADHD.

So we really wanted to try to understand what particular treatment targets might be. And in that study we found that using healthy sleep practices were associated with fewer sleep problems in adolescents with ADHD, like less difficulties falling asleep and getting back to sleep if they woke up in the night. So this supports the idea that perhaps one way of improving sleep problems in adolescents with ADHD could be to help adolescents to engage in healthier sleep practices.

And the kinds of healthy sleep practices we looked at were things like minimising caffeine use, for example, minimising screen time before bed, trying to avoid really changing the sleep pattern from weekdays to weekend. So we expect to have a bit of variation between what we do on on weekdays and weekends, but if there’s a huge amount of variation that can be disruptive to our regular sleep patterns too.

Based on that research and some other research that we’ve been doing, we’ve now commenced a randomised control trial which is examining whether we can use a brief behavioural sleep treatment approach to improve sleep in adolescents with ADHD. That study, we were just about to launch just before Covid-19. So it’s just on pause at the moment. But we hope to get back into that project in the latter half of this year.

Interviewer: How might a parent or teacher or health professional come to recognise that a person with ADHD also has associated sleep problems? What would the signs be?

Dr. Emma Sciberras:Yes. So given the amount of research now that points to how common sleep problems are in children with ADHD, I do think it’s really important that all assessments for ADHD include some kind of brief screen for sleep problems. And, ideally, review appointments for children with ADHD should also include something brief about this. Assessing for sleep problems can be really brief initially. It can be asking some general questions about sleep duration, whether children are waking in the night, and looking at whether or not their sleep-wake patterns are generally consistent.

And in some of our research we have just used a very brief single item measure asking parents whether or not their child’s sleep is a problem or not. And then we asked them whether it’s a mild, moderate or severe problem. And that sounds like quite a simple question, but we’ve found that that corresponds really well with sleep diary measures. And it’s also parents’ responses on that measure are also associated with the things you might expect to be associated with sleep problems, like ADHD symptoms being more severe and increased mental health difficulties.

So they’re the kinds of questions, I guess, that clinicians might be able to initially use to get a bit of a sense of whether sleep seems to be a problem. And then if it is, they can go into some more detailed assessment strategies.

But I guess for parents and for teachers, general signs of sleep problems may be the young person appearing quite sleepy during the day, for example. So if they’re falling asleep in class, that’s not a good sign. If young people are still really tired when they’re waking up in the morning and they’re not feeling refreshed from their sleep or they seem to be a bit more irritable or grumpy, and that seems to be related to having a bit of a poor night’s sleep. They’re the kinds of things that you’d be looking out for.

But it can be a bit tricky for teachers to perhaps identify the sleepiness associated with a poor night’s sleep the night before if children are taking stimulant medication, for example, because they might not see as much of the manifestation of some of that daytime sleepiness in the classroom.

Interviewer: A lot of parents will talk about their teenage children being terrible in the morning and sleeping in class. If they hadn’t considered ADHD before, is that something they should consider?

Dr. Emma Sciberras: In adolescents we see, and it’s across the board for adolescents, we see a lot of changes in biology that impact on sleep. So in adolescents more generally there are changes biologically. We have the onset of puberty. And there’s also environmental changes. So adolescents shifting to high school environment, which is a lot more independent. I guess what we see generally across the board is a bit of a shift in sleep during this time. And this isn’t specific to ADHD. But we do see that, in children with ADHD, it can exacerbate existing sleep difficulties.

So the main sleep problem that we see emerging at that time is something called delayed sleep phase. And this is where, because of these different biological processes that are changing in adolescents, we see a shift towards preference for a later bedtime and then wanting to sleep in in the morning. And it’s like you might experience if you’ve ever had jet lag before, and your whole sleep cycle has just shifted.

And so it makes it really, really hard for parents because they’re having to drag their adolescents out of bed. And they will just prefer to be sleeping in. And so that’s why we see a bit of sleep catch-up happening in adolescents on the weekends, where they prefer to go with that pattern of sleep.

But there are some different strategies you can use to try to shift that sleep cycle back to where it might need to be to function well at school. And in the US, there’s been whole population-based initiatives where they’ve actually pushed back the start time of school to allow adolescents to sleep more in the mornings.

Interviewer: Returning to children with ADHD, once it becomes clear that a child with ADHD does have sleep issues, where can parents and carers go to get help? And you’ve already talked a little bit about the assessment, but what can they expect in terms of how their child or young person will be assessed?

Dr. Emma Sciberras: Yes. So, I think a first step would be for parents to see the usual person or professional that they’re seeing for their child’s care and to go to your next appointment with them to have a chat about any concerns that you have about sleep. And that then gives that professional the opportunity to provide an assessment and maybe even strategies for the sleep difficulty that they’re experiencing. Or if they don’t have that expertise, they can then refer on to another professional that has that expertise.

And when you go through these kinds of assessments for sleep difficulties, the best way to go about that is a pretty thorough clinical history. So that involves asking lots of different questions about sleep routines and patterns. When I ask about a sleep history, I try to understand, when the child gets home from school, what’s the regular routine for that family?

And what time does a bedtime routine start in the night? What is involved in a bedtime routine? What’s the regular bedtime? How long does it take them to fall asleep at night? Do they wake at night? Do they have any nightmares or night terrors? What time they usually wake up in the morning. So lots of questions like that to try to understand what might be happening.

If there are more biologically-based sleep problems, like obstructive sleep apnea, for example, then they might refer on for an overnight sleep study. But you wouldn’t generally do that if it’s a sleep difficulty that seems to be more behavioural in nature. But that’s one thing that could be considered. Some clinicians, and probably the minority, may also use wearable devices to understand sleep, so things like actigraphy, wristwatches that you have to track movement overnight, which you then translate to inferring information about sleep.

So that’s another way that you might be able to get a better handle on sleep overnight. But probably more commonly, clinicians might use a sleep diary where they get parents and the young person to fill out a diary over a seven-night or a 14-day period to understand the patterns of sleep.

Interviewer: So once they’ve had that clear picture, if it looks like some intervention is needed, what would be offered and what helps? I know you’ve carried out research looking at sleep interventions and outcomes. So can you talk through some of the key takeaways from your research and some of those interventions?

Dr. Emma Sciberras: Yes. So there’s now a number of randomised control trials that have shown some evidence for treating sleep problems in children with ADHD using behavioural interventions, which is really exciting. So the research seems to be pretty consistent across the existing trials. The one that we did tested a brief two session sleep programme in children with ADHD. And we compared that sleep programme to the care that the children were generally receiving from their practitioners.

And in that study we found that using brief behavioural strategies led to lasting benefits in terms of sleep, up to 12 months later. But we also found that other aspects of functioning were improved. We saw small improvements in ADHD symptoms. We saw improvements in quality of life. We found some initial improvements or differences between children who received the intervention and those that didn’t in terms of working memory. Again, small in that particular area, but these are consistent with some of the other trials that have shown benefits for not only sleep but broader aspects of psychosocial health, which is good.

So I think the consistent thing across these studies is that the first step for improving sleep is to really look at some of those healthy sleep strategies to check off that they are being used by the family at the moment. So these seem pretty basic, but they can be hard for us to follow. So, for example, making sure the child is going to bed at a time that’s appropriate for their age, or setting a bedtime, for example.

Some of the children that we’ve seen in our research don’t have a bedtime. So a very, very first step that we would do is get the child into a consistent bedtime. And if they’re going to bed too early, for example, they’re not going to be tired enough to fall asleep at the time that their parents want them to fall asleep. If they go to bed too late, they could get really overtired and that makes it hard for them to settle down. So we work with families to work out what’s the ideal bedtime for them. And that depends on what time the child needs to be awake in the morning. So it will differ between families.

We also then look at whether we can implement a calm and relaxing and consistent bedtime routine. And we try to have that about 30 minutes to an hour before bedtime. So for some younger children, for example, that could involve having a bath, brushing teeth, reading a book, so on. For children that are a bit more anxious, other things to help with relaxing could be deep breathing or view imagery or meditation-type approaches.

One of the big ones is around screens before bed. This is a really tricky one to change. So, many of the families in our research have said that children are using screens right up until bedtime. And we try to limit screen time slowly, initially. So, for example, if a child’s used to doing that and we were to come in and say, okay, tomorrow night you’re not going to use it for two hours before bed or an hour before bed, going to be really hard for the child and the family to actually implement.

So we might even start with let’s switch it off ten minutes before bed, for example. And then gradually stretch it out longer if the family is open to that. So really trying to use an approach where we’re setting children and families up for success, rather than telling them to do something that maybe we wouldn’t do ourselves before bedtime. And just looking at the child’s bedroom environment, just to make sure that it’s cool and comfortable. And just checking things like caffeine use and that children are getting regular physical activity.

So that’s just a flavour of some of the healthy kinds of sleep strategies that we generally want to look at for all kids to make sure that they seem okay. We do some tweaks, helping with any of those things that need addressing. And then we would get into more specific strategies, depending on the nature of the child’s sleep problem.

Interviewer: And in terms of specific strategies, is that more CBT-based type?

Dr. Emma Sciberras: So that’s a great question. So one of the common difficulties we see in children with ADHD is a difficulty getting the child to go to bed. And so even if they’ve got their consistent bedtime, a parent might take their child to bed and the child may come in and out of the bedroom. So they’re just refusing to go to bed. And this can be really severe for families. It can go on for hours and hours. And some parents have told us that their child might be coming in and out of the bedroom up to 20 times before they go to sleep. Yes. So it’s really, really challenging.

One of the strategies we use for that kind of sleep problem is something called the checking method. So this involves, rather than just putting the child into bed and just hoping and crossing your fingers that tonight’s the night that they’re not going to come out of the bedroom, you be proactive and you check on the child at very frequent intervals.

So if they’re coming in and out of the bedroom quite a lot, it might be going and checking every two minutes to start with, until they fall asleep. And that helps children to get used to staying in bed with the reassurance that you’re there to help them. And then once children get used to that, you can slowly increase the checks to five minutes and ten minutes and so on.

And we also use something called a bedtime pass in conjunction with that. And this is more for younger kids that are doing this, so more primary school-age children. Where you have a little pass that you can make up. The parent can make up with the child, the child puts it under their pillow and the child then receives a small reward in the morning for only using their pass once.

And so the pass allows them to come out of the bedroom to do that one thing, that last thing that they want to do. And they get a reward. And I like to give a double reward if they don’t even use the pass at all. And using those two things together seems to really help children to stay in the room, because if the parent’s there checking, it’s very hard for the child to be coming in and out.

I guess for children that are experiencing more worries and anxiety at bedtime, we use CBT strategies before, and we use some really simple strategies like using worry books or worry boxes, visual imagery, relaxation. We also try to make a time where parents and children can connect during the day about any worries and anxiety, so it’s not just before bed. Because we find that that’s a natural time of the day to talk about what’s happened during the day and so on.

And sometimes that can bring up some really big feelings just before bedtime that can be hard to make… it can be hard for children to relax and go off to bed. And we also use some general rewards for brave behaviour too.

And when I talk about rewards, I’m talking about little incentives to help children to change some of their sleep-related behaviour. And we’re rewarding them for trying some of the strategies, not for actually falling asleep, because that might be outside their control.

And we always make these fun and family-based. So it might be choosing a board game to play, for example, or getting to choose a dinner. So we try to make them relational-based rather than really expensive things that parents are expected to buy. And we only ever set a reward around a goal that we think is achievable for the child too. So we try to make it fun.

I guess in terms of with older adolescents, you can also use some more simple cognitive behavioural interventions, where you’re actually looking at whether or not there are any negative thoughts about sleep that adolescents are having that are making sleep more stressful. We can work with the adolescents around shifting some of those thoughts.

The other one I’ll describe, actually, is just some of the strategies you would use to shift that delayed sleep phase that we were talking about before that adolescents experience. And for that one we use something called bedtime fading. So that involves temporarily setting the bed time later to when the child’s naturally falling asleep.

So if an adolescent isn’t falling asleep until 11:30 at night and the parent’s expecting them to go off to sleep at 9:30, they’re just not going to fall asleep at that time. It’s just so hard to shift your patterns from one night to the next by two hours. It’s really, really difficult. So bedtime fading involves, in this instance, you’d put the adolescent… You’d say, okay, let’s go with 11:30. Okay. You’re going to go to bed at 11:30 tonight.

And then you slowly bring it forward once the adolescent’s falling asleep within about 20 minutes or so. That just helps to offset any of the negative thoughts that might happen about trying to lie there and fall asleep when you can’t. And just, yes, creates that positive association between actually going into bed and falling asleep. And then you just keep moving that bedtime forward to the point in which you get to the desired bedtime.

And that strategy can be used for younger children too that seem to have gotten into a pattern where they’re just falling asleep much later than you’d expect. So you can use that for younger children too. But the key thing with that strategy is that you need to make sure that the young person is being woken up at the same time each morning. So it has to be the desired wake time. Because if they just sleep in in the morning, then they’re not going to get as tired in the night to fall asleep at that slightly earlier bedtime.

Interviewer: Emma, you touched on anxiety, and I know you’ve been doing some work on this. I think you’ve got a paper that’s due to be released but it’s not quite yet. Can you summarise what you’re looking at?

Dr. Emma Sciberras: Yes. So we did… So in 2014, we did a big project looking at anxiety in children with ADHD. And that study had around 390 children with ADHD. And in that study we did detailed diagnostic interviews with parents to assess whether or not children experience clinical levels of anxiety. And we were really surprised in that study to find that 64 per cent of children with ADHD met the full criteria for one or more anxiety disorders. And we also found that anxiety made everything much worse. So, like sleep. So it made ADHD symptoms worse. It was associated with poor daily functioning and so on. And so this led us to wonder about how to actually manage anxiety in children with ADHD.

And when we embarked on this work, there were a handful of small studies that had been done in the field that seemed promising. But no large… no randomised control trials. We did a pilot randomised control trial. And this was just very small. And that was published in the Journal of Attention Disorders. And that examines whether or not it’s feasible or acceptable to families and young people to use cognitive behavioural therapy approaches to address anxiety in children with ADHD. And that was a really promising pilot study.

So we decided to embark on a larger trial. And that’s included over 200 children with ADHD and anxiety. And we’re currently analysing our data. And that project has involved the testing of a ten-session cognitive behavioural therapy intervention. We’ve done it one-on-one with children with ADHD and their parents. And we’ve looked at outcomes over a 12-month period. So I look forward to being able to share those results when they’re available. But we’re excited about that trial and excited about being able to communicate the findings soon.

Interviewer: Emma, as we mentioned before, we’re in the midst of the coronavirus pandemic. I’m wondering what impact you believe this is having on children and young people with ADHD and also their families?

Dr. Emma Sciberras: We’re currently running a study to better understand the impact of the current situation on children with ADHD and their families. And so we hope to be able to comment based on what parents have actually told us once we have the data. But I guess in terms of what we might expect, we anticipate that, for some families, lockdown will be really challenging.

It’s hard. It’s really difficult for all of us managing work at home, children at home, home learning. And for children with ADHD, it could be that, having this lockdown experience, with less opportunity for getting outside, regular exercise, potentially having less routine with sleep and things like, that could be making behaviour worse.

However, anecdotally, some parents… In planning for our Covid study, we’ve been working with consumers in designing some elements of that project. And  they’ve told us that there’s actually some positive benefits that they’ve experienced. So, for example, getting to better understand their child’s learning style and their child being less distracted when learning in a one-to-one environment with them, for example. And some parents have also said that staying at home has reduced some stresses for young people with ADHD related to going to school and social interactions, which we know can be challenging for children with ADHD. So I suspect there’s going to be a lot of variation in the impact.

And I guess what our project will be able to do is understand that variation. And we’re looking at, for those that are finding it difficult, what are the kinds of supports that might be helpful? And the other element of our project is that it is longitudinal. So we will be tracking changes in sleep and anxiety over time too. So we look forward to being able to comment on that too in the coming months.

We’re interested in whether we could see impact on sleep due to changes in our circadian rhythm or internal body clock. So, for example, being in lockdown could mean that there’s less exposure to natural light and less routine in our days. I know, for me, I think my routine is probably the same but definitely I’m getting less exposure to natural light.

And those kinds of things can impact on the regulation of our internal body clock. And the general regularity of our day helps our internal body clock to stay on track. Things like waking up at the same time, having breakfast and lunch and dinner at the same time. All of those things just give our body the signals of the time of the day. So we’re really interested in whether or not this current situation has any impact on sleep. And so that’s some of the reasons why we expect that there might be. However, the opposite could also be true. There may be some children with ADHD that are actually getting into better routines during the lockdown period. So, yes, we’re really excited to delve into this.

Interviewer: Emma, what else is in the pipeline that you are working on or further research that excites you that you’d like to mention today?

Dr. Emma Sciberras: Yes. So, look, I’m really excited to have been recently awarded a large government grant in Australia. And that will commence next year. And that will fund my programme of research in ADHD over the next five years. And this is a big grant. There’s a number of different projects that will be running as part of that grant. And there’s a stream in there about new intervention development. So we’ll be doing some work on trying to look at how to improve social anxiety in children with ADHD.

So when I talked about the anxiety research that we’ve been doing, what I didn’t mention was that the most common types of anxiety that children with ADHD experience are generalised anxiety, which is where you just have a general pattern of worry about all kinds of things in daily life; separation anxiety, which is a fear of being away from a caregiver; and social anxiety, which is that worry about doing embarrassing things.

And one thing I will say about the trial that we have conducted is that we do feel that there may… that the kinds of CBT approaches we use may have been better suited to separation anxiety and generalised anxiety. And so we’re really interested in how to better improve social anxiety in children with ADHD, because it’s something that’s really, really common.

And it can get in the way of doing all kinds of things at school, like reading aloud in front of the classroom, which kids are often expected to do. Give presentations. Children with ADHD appear to be experiencing anxiety about these kinds of things ’cause they’re things that they genuinely find to be difficult. So one element of this grant will be looking at really starting from scratch, really, because there isn’t a lot about how to address this particular aspect of anxiety in children with ADHD. So we’re going to be starting from the beginning.

We’re also looking at ways to provide brief parent support that can be implemented into healthcare post-diagnosis. In the recently revised NICE clinical guidelines for ADHD, one of the things that they raise in there is it’s unclear what the optimal level of brief types of parenting interventions are for children with ADHD. And we’re really interested in how we can help parents, at that timepoint of diagnosis, to better understand what ADHD is and different kinds of approaches that might be helpful from a parenting perspective.

In that grant there’s a whole stream of research that we have planned on addressing stigma related to ADHD. And we’re planning to do a series of studies to better understand stigma and ways to change the narrative about ADHD in Australia. Because from all of the research that I’ve been doing, it always comes up. It’s something that families find incredibly difficult. And we’re really interested in trying to understand how we can change the narrative of what ADHD is and how it’s treated and so on. And to get evidence-based messages out to the community about it.

Interviewer: Why is evidence-based research so important when it comes to child and young people’s mental health?

Dr. Emma Sciberras: Yes. Look, that’s a really good question. I think evidence-based research is important to ensure that we’re providing the best available care to children and young people when they are coming through the doors in clinic. Understanding what ADHD is and the common difficulties associated with ADHD then helps to ensure that those things are being assessed in clinic. If we understand what the best treatments are, and we have evidence for those, those kinds of treatments can be implemented in clinical environments. So I guess the hope is that, if you are using these evidence-based approaches, that hopefully that will lead to improved outcomes over time.

And I think parents and young people, they expect to be receiving information about the best available evidence. So it’s really important. And I know in the UK, you’ve recently had the revised NICE guidelines for ADHD, which really puts the evidence out there in a really accessible way. And in Australia, we’re also working on revising the clinical guidelines for ADHD in our country too at the moment.

Interviewer: As you’ve described, really, your work is focused on developing new behavioural interventions, or much of your work is, for children with ADHD. And this relates to the point you just made on evidence-based research. How do you go about translating your research into practice?

Dr. Emma Sciberras: Yes. So many interventions that are tested in clinical trials are never really tested in real-life settings. And that’s a problem because, as a psychologist, sometimes you read about particular interventions and then you try to implement them into your practice, and it actually doesn’t work neatly like you’ve read about. And it really just doesn’t quite work. And so we really need to see much more research that’s testing interventions in real-life settings.

So the other thing I’d say about it too is that, in order to ensure that it can be translated into practice, the groups that you’re trying to translate to need to be engaged from the outset. So, for example, with that big grant that I talked about, there’s a whole focus on translation which will happen from the beginning of the grant. So not just an afterthought at the end.

We recently did a project that was published in the Journal of Child Psychology and Psychiatry, which was looking at the real-life implementation of our sleep intervention. So we did our randomised control trial, which was a tightly-controlled study that we ran. So it’s called an efficacy trial. We found good results for that. And so then we tested it in what we call an effectiveness trial, where we trained up paediatricians and psychologists in real-life practice to deliver this intervention to their actual patients.

And that study found that you can train paediatricians and psychologists up in brief assessment strategies for sleep and being able to give brief sleep advice. And we also found that children in that trial had improved sleep over time.

The difference between that trial and our other efficacy trial was, in our efficacy trial, we found a whole range of improved outcomes, which included ADHD symptoms and quality of life and other aspects of daily functioning. But we didn’t see those improvements in the implementation trial.

And the reason for that is unclear, but I’m wondering whether it’s got to do with the intervention dosage. Because in the efficacy trial, because our team can more closely monitor that, the participants seem to receive more of a high dose of our sleep intervention than it was actually possible in real life, which was really interesting.

And the other thing about our implementation trial was that, because it was real life, parents had to pay their usual practitioner to receive that intervention. So one difference we found between the two trials was also that we had a higher consent rate for our first trial, which was providing a free intervention. Whereas when it was something that parents had to decide, yes, I want to go and see my practitioner for help with this, we saw a difference, I think, in consent rates of about 20 per cent.

So I think in the first trial it was around 70 per cent and it was much lower in the implementation trial. But I think that’s really important to think about when we’re developing interventions. Do parents want to engage in these interventions? And how will they be funded? Do parents have the capacity to be able to pay for some of these interventions? So I think having a cost-effectiveness element is really important. And that’s one of the things we did in that paper that looks at the implementation side of things.

Interviewer: Finally, what is your takeaway message for those listening to our conversation?

Dr. Emma Sciberras: Sleep and anxiety are really common in children with ADHD. They have an independent impact on functioning for children with ADHD, and it’s really important that they are assessed in clinical practice. So questions about sleep and anxiety should be included routinely in the assessment for ADHD. But also should be asked about in review appointments too.

We don’t yet have a strong evidence base for the treatment of anxiety in children with ADHD. We hope to add to that soon. But we do have an emerging evidence base for the treatment of sleep problems in children with ADHD that shows that it is feasible to use behavioural interventions to address some of the sleep problems that are experienced by this group, and that these kinds of interventions do improve sleep and have some benefits for broader psychosocial health. And in the papers that we’ve published, we outline a number of the different strategies that we use. And so you can use these kinds of interventions in your practice to try to improve sleep in this population.

Interviewer: Excellent. Thank you ever so much, Emma. For more details on Dr. Emma Scibberras, please visit the ACAMH website, www.acamh.org, and Twitter @ACAMH.

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