Sleep Medicine 102 (2023) 64e75

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Sleep Medicine
journal homepage: www.elsevier.com/locate/sleep

Sleep interventions for children with attention deficit hyperactivity

disorder (ADHD): A systematic literature review
I. Larsson a, *, K. Aili b, M. Lo
€ nn a, c, P. Svedberg a, J.M. Nygren a, A. Ivarsson b, P. Johansson b
a
School of Health and Welfare, Department of Health and Care, Halmstad University, SE-30118, Halmstad, Sweden
b
School of Health and Welfare, Department of Health and Sport, Halmstad University, SE-30118, Halmstad, Sweden
c
Psychiatry Halland, Region Halland, SE-30231, Halmstad, Sweden

a r t i c l e i n f o a b s t r a c t

Article history: Objective/background: Healthy sleep is particularly important for children with attention deficit hyper-
Received 5 October 2022 activity disorder (ADHD), as sleep disturbances might aggravate disease symptoms. This review aims to
Received in revised form synthesize and report evidence on the effectiveness of sleep interventions in increasing sleep, quality of
21 December 2022
life (QoL), and ADHD symptoms among children with ADHD.
Accepted 24 December 2022
Available online 26 December 2022
Patients/methods: The systematic literature review follows the Cochrane Collaboration methodology
recommendations for literature reviews. Four databases were used based on the population, interven-
tion, control and outcome (PICO) framework. Controlled trials with minimum 20 children in each group,
Keywords:
Attention deficit hyperactivity disorder
aged 6e18, and published from 2005 and onwards were included. Results from the studies were reported
(ADHD) in forest plots and three of the seven review outcomes were synthesized in meta-analyses.
Children Results: The search identified 7710 records; of which 4808 abstracts were screened. After fulltext-
Effectiveness screening of 99 papers, eight papers from five studies were included. The studies included behavioral
Sleep sleep interventions and pharmacological interventions using melatonin and eszopiclone. For six of the
Sleep interventions seven outcomes, the effect sizes were small to moderate and the certainty of the evidence was low. For
Systematic literature review one outcome, sleep disturbances, the effect size was a moderate
0.49 standardized mean differences
(95% confidence interval
0.65;-0.33), with a moderate certainty of evidence for the behavioral in-
terventions for children aged 5e13 years with ADHD.
Conclusions: This review identified few and heterogeneous studies. A moderate certainty of evidence for
a moderate effect size was only obtained for sleep disturbances from the behavioral interventions. A low
certainty of the evidence for a moderate effect size was found for the total sleep time from the phar-
macological intervention using melatonin and one behavioral intervention, which indicates that these
sleep interventions impact sleep quantity and quality among children with ADHD.
© 2022 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).

1. Introduction
Sleep is crucial to health, well-being, and everyday functioning
in children [1,2]. Healthy sleep, with sufficient sleep duration and
quality, contributes to increased attention, improved behavior,
cognitive functions, and physical and mental health [3,4]. Thus,
sleeping problems significantly impact everyday life, for both the
* Corresponding author. School of Health and Welfare, Halmstad University, Box
823, S-30118, Halmstad, Sweden.
E-mail addresses: ingrid.larsson@hh.se (I. Larsson), katarina.aili@hh.se (K. Aili),
maria.lonn@hh.se (M. Lo €nn), petra.svedberg@hh.se (P. Svedberg), jens.nygren@hh.
se (J.M. Nygren), andreas.ivarsson@hh.se (A. Ivarsson), pia.johansson@hh.se
(P. Johansson).
child [5,6] and the whole family [5,7]. Healthy sleep is a key factor
for e.g., school results and subsequent successful transition into
adulthood and working life, for all children, but particularly for
children with neurodevelopmental disorders, such as attention
deficit hyperactivity disorder (ADHD) [8,9].
ADHD is one of the most common disorders among school-aged
children [10], with a prevalence of approximately 5% worldwide
[11]. Boys are about three times more likely to be diagnosed with
ADHD than girls [9]. ADHD is characterized by impulsivity, inat-
tention, and/or hyperactivity and affects many aspects of a child's
well-being, including physical, mental, and social health, along
with cognitive function, and thus also academic achievement
[9,12]. Therefore, living with ADHD has a substantial impact on
quality of life (QoL) and daily function, which in turn entails a

https://doi.org/10.1016/j.sleep.2022.12.021
1389-9457/© 2022 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
 €nn et al.
I. Larsson, K. Aili, M. Lo
significant burden on the individual [13], family [14], and society
[15].
Among children with ADHD, up to 70% experience sleep prob-
lems [16,17], compared to 20e30% of healthy peers [18], with an
even higher prevalence among girls with ADHD [16]. However, the
majority of children with ADHD have transient sleep problems, and
research shows that only 10% have persistent sleep problems
throughout a 12-month period [19]. The most common sleep
problems are higher bedtime resistance, sleep onset difficulties
[20], lighter sleep [21], poor sleep quality, fragmented sleep with
periods of nightly awakenings due to restlessness or movements
[5], and shorter sleep duration [5,22]. Research reports that chil-
dren with ADHD have between 30 and 60 min shorter sleep
duration and significantly more nightly awakenings compared to
healthy peers [20,23e25]. Sleep problems often lead to daytime
sleepiness, which affects health and well-being with a significant
impact on the children's functioning and QoL [26,27], and are likely
to exacerbate the negative behaviors associated with ADHD
[5,23,26,28]. Sleep problems are associated with impaired aca-
demic performance, higher parental stress, and poorer parental
health [7,29]. To reduce the symptoms of ADHD and facilitate
everyday life, children are often treated with various types of
pharmacological therapy, which might further increase the risk of
sleep problems [9,30e32].
Both pharmacological and non-pharmacological interventions
are available for treating sleep problems in children with ADHD;
one pharmacological treatment is melatonin. The prescription rate
of melatonin in Sweden has increased in recent decades [33e35] as
it is considered safe and effective for children [36]. Nevertheless, it
can cause side effects, such as morning drowsiness, increased
enuresis, headache, dizziness, diarrhea, rash, and hypothermia [37].
When parents are allowed to choose the treatment for their chil-
dren's sleep problems, they primarily prefer non-pharmacological
interventions [38]. Non-pharmacological sleep interventions are
often divided into parent-directed interventions and “other” non-
pharmacological interventions [39,40]. The intervention design
can further divide the parental-directed interventions into three
different types: 1) Comprehensive tailored interventions that
involve the development of individually tailored sleep manage-
ment plans, along with parent training and ongoing support during
implementation; 2) Comprehensive non-tailored interventions
that involve a “standard” sleep management plan with compre-
hensive content, including parent training and support during the
implementation; and 3) Non-comprehensive interventions,
tailored or non-tailored, which focus on a single subject area
related to sleep management (e.g., sleep hygiene or behavioral
strategies). “Other” non-pharmacological interventions include, for
example, weighted blankets, light therapy, dietary intervention, or
acupuncture [39,40].
Thus, several treatment alternatives are available in clinical
healthcare work with children with ADHD and sleep problems.
However, there is a lack of high-quality evidence that reports the
effectiveness of pharmacological and non-pharmacological sleep
interventions in children with ADHD [39]. In previous systematic
reviews on this topic, the authors argued that the findings need to
be treated with caution and highlighted the importance of rigorous
and comprehensive randomised controlled trials (RCT) [5,39e42].
Well-informed decisions in the clinical management of sleep
problems for children with ADHD require that high-quality evi-
dence on the effectiveness of sleep interventions is carefully
compiled. Thus, the evidence base should be formed by high-
quality controlled trials with outcome measures that assess as-
pects of sleep that are of importance to the children and their
families. Finally, to increase transparency and clarity, and in terms
of the strength of evidence, the review results should be reported
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Sleep Medicine 102 (2023) 64e75
according to established standards [43]. To our knowledge, no
previous systematic literature reviews on sleep interventions for
children with ADHD include syntheses of data in meta-analyses on
selected outcome measures from high-quality trials. We thus set
out to perform a systematic literature review to compile evidence
on sleep interventions for children with ADHD that would be
relevant for healthcare professionals in diverse healthcare settings
within high-income countries. Therefore, this study aims to syn-
thesize and report evidence on the effectiveness of sleep in-
terventions in increasing sleep, QoL, and ADHD symptoms among
children with ADHD.
2. Methods
2.1. Protocol and registration
The research protocol has been registered in the international
prospective register of systematic reviews, PROSPERO
(CRD42021191982).
2.2. Study design and research questions
The design of the systematic literature review and meta-analysis
was in accordance with the Cochrane Handbook for Systematic
Reviews of Interventions, including: selecting a research question,
determining inclusion and exclusion criteria, searching and
selecting studies, assessing bias, data synthesis, and evidence
grading [43]. The study approach also incorporated the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA 2020) [44].
The research question was: “What is the effectiveness of sleep
interventions on the outcomes of sleep, QoL, and functioning
among children with ADHD?”
2.3. Inclusion and exclusion criteria
The inclusion and exclusion criteria, considering the research
question, were based on an initial review of the literature and
several discussions between the authors, guided by the PICO
(population, intervention, comparison, outcome) framework [43].
See Table 1. Controlled clinical trials and intervention studies
examining sleep interventions among children with ADHD with
minimum group sizes of 20 children in each intervention and
control group, original articles published in English after 2005 re-
ported from high-income countries, i.e., members of OECD (to ac-
count for different physical and psychological contexts between
countries), were eligible for inclusion in the study.
2.4. Search strategy
This literature review is part of a more comprehensive ongoing
study that seeks to investigate the effectiveness and cost-
effectiveness of sleep interventions for children 6e18 years old.
Because sleep problems are widespread among children with
ADHD, this sub-population was of particular research interest.
The literature was searched in the following four electronic
databases: PubMed, Cumulative Index to Nursing and Allied Health
Literature (CINAHL), PsycINFO, and Cochrane, including Cochrane
Database of Systematic Reviews and Cochrane Central Register of
Controlled Trials. The Halmstad university librarians searched the
databases without any date and language restrictions until 29 April
2021.
The research team and the librarians jointly developed and
formulated the search strategy based on the comprehensive study
objectives and preliminary searches. Medical Subject Headings
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I. Larsson, K. Aili, M. Lo Sleep Medicine 102 (2023) 64e75

Table 1
Description of PICO in this literature review.

P Population Children with ADHD diagnosis, aged 6e18 years, with sleep disorders according to validated objective or subjective instruments, but without physical
health disorders.
I Intervention Any type of sleep intervention, i.e. both pharmacological and non-pharmacological interventions, implemented in non-hospital settings, including home,
institutional care, and treatment and diagnosis facilities, such as sleep laboratories.
C Comparator Any alternative sleep intervention, including standard care.
O Outcomes Sleep quality and quantity, using standard measurement instruments, including objective measures (polysomnography, actigraphy), and subjective
measures, including well-established questionnaires and sleep diaries. Health-related quality of life and functioning, i.e. symptoms of ADHD.

(MeSH) terms were identified in the MeSH database National Li-
brary of Medicine (NIH) and converted to corresponding index
terms in Cumulative Index to Nursing and Allied Health Literature
(CINAHL) and Psychological Information Database (PsycINFO) da-
tabases. The overall search terms used in the literature search were
“child”, “adolescent”, “sleep wake disorders” and “controlled clin-
ical trial”. The search strategy in each database included synonyms
combined with the Boolean operator “OR” to achieve sensitivity
within concepts. The concepts were combined with the Boolean
operator “AND” to ensure that each concept was represented in the
final search. After completing the literature search in the databases,
a total of 7710 articles were identified, and 1876 duplicate articles
were removed. See Table 2.
comparator (C) could be any alternative intervention. The study
design was controlled trials, and both intervention and control
groups should have a minimum group size of 20 children.
Randomization of participants into comparison groups was not
required. Results with follow-up measurements that included
fewer than 20 children were excluded. As no core outcome set was
available for sleep interventions for children [46], seven outcome
measures (O) that reflected sleep were selectively chosen during
the appraisal stage. Five outcomes on sleep issues were identified in
the included studies: sleep quantity (total sleep time - TST) and
sleep quality (sleep onset latency - SOL, sleep efficiency - SE, wake
after sleep onset e WASO, and sleep disturbances Children's Sleep
Habits Questionnaire- CSHQ), and one outcome each for QoL and
for behaviour, i.e. ADHD symptoms.

2.5. Study selection

The identified articles were delivered to an EndNote library and
were transferred into the abstract screening tool Rayyan [45]. The
study selection process was conducted in two screening phases:
first title and abstract and full-text. The search and screening re-
sults are reported in detail in a 2020 PRISMA flowchart, see Fig. 1. In
phase one, the titles and abstracts were independently screened
against the PICO and inclusion criteria by two researchers. Three
researchers were involved in phase one (IL, KA, PJ). The studies that
did not fulfill the eligibility criteria were excluded. In phase two, the
same researchers independently applied the eligibility criteria for
the full texts of all potential studies identified after the first phase.
In both phases, any discrepancies in the selection process were
discussed between the three researchers until consensus was
reached.
The included population (P) was children aged 6e18 years old
with ADHD. The included interventions (I) were both pharmaco-
logical and non-pharmacological sleep interventions, while the
2.6. Assessment of bias
Two researchers (IL, PJ) independently assessed the risk of bias
for each included study by using the Cochrane instrument for
assessing the risk of bias in RCT (RoB 2) [47], as all included studies
were RCTs. Consensus on the assessment was reached by discus-
sion. The risk of bias was assessed from five different domains: 1)
randomization process, 2) deviations from intended interventions,
3) missing outcome data, 4) measurement of the outcome, and 5)
selection of the reported result. The risk of bias was reported as
“low risk of bias”, “some concerns of bias” or “high risk of bias”. The
global risk of bias was an overall assessment. The bias assessment
results are visualized via the tool ROBVIS in Fig. 2. Studies with a
high risk of bias were excluded from the data synthesis.
2.7. Data synthesis
The study results are reported as differences in changes in mean

Table 2
Search strategy for selected databases.

Database Search strategy Date Number

PubMed #1 Adolescent[Mesh] OR "Child"[Mesh:NoExp] OR adolescence[Title/Abstract] OR adolescent[Title/Abstract] OR adolescents[Title/Abstract] 2021.4.29 1280

OR child[Title/Abstract] OR children[Title/Abstract
#2 Sleep Wake Disorders[Mesh] OR "sleep disorder*"[Title/Abstract] OR "sleep wake disorder*"[Title/Abstract] OR "sleeping
disorder*"[Title/Abstract] AND "controlled clinical trial"[Publication Type]
#1 AND #2
CINAHL #1 (MH "Adolescenceþ" OR MH "Child" OR MH "Child, Abandoned" OR MH "Child, Adopted" OR MH "Child, Gifted" OR MH "Child, 2021.4.29 371
Institutionalized" OR MH "Child, Medically Fragile" OR TI (adolescence OR adolescents OR children) OR AB (adolescence OR adolescents OR
children) OR MW (adolescence OR adolescents OR children))
#2 (MH "Sleep Disordersþ" OR "sleep* disorder*" OR TI "sleep* disorder*" OR AB "sleep* disorder*" OR MW "sleep* disorder*") AND (MH
"Controlled Before-After Studies" OR MH "Triple-Blind Studies" OR MH "Single-Blind Studies" OR MH "Double-Blind Studies" OR MH
"Randomized Controlled Trialsþ")
#1 AND #2
PsycINFO #1 noft(child OR children OR adolescent OR adolescents OR adolescence) 2021.4.29 3799
#2 MAINSUBJECT.EXACT.EXPLODE("Sleep Wake Disorders") OR noft("sleep disorder" OR "sleep wake disorder")
#1 AND #2
Cochrane #1 MeSH descriptor: [Adolescent] explode all trees OR 2021.4.28 2260
MeSH descriptor: [Child] this term only OR
(child OR children OR adolescent OR adolescents OR adolescence):ti,ab,kw
#2 MeSH descriptor: [Sleep Wake Disorders] explode all trees OR sleep* NEXT disorder* OR sleep* NEXT wake NEXT disorder*
#1 AND #2

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I. Larsson, K. Aili, M. Lo Sleep Medicine 102 (2023) 64e75

Fig. 1. PRISMA 2020 Flow diagram for the selection process of trials included in this systematic literature review
* Cochrane includes the databases Cochrane Database of Systematic Reviews (CDSR) (protocols excluded) and Cochrane Central Register of Controlled Trials (CENTRAL).

Fig. 2. Assessment of risk of bias.

outcome values between baseline (pre-test) and follow-up (post-
test) for the intervention and control group, with 95% confidence
intervals estimated using pooled standard deviations from the
intervention and control groups at baseline. The focus was thus on
assessing mean change due to treatment as compared to controls
[48]. Some outcome values were transformed into standardized
mean differences (SMD). The calculation of treatment-control SMD
was conducted by calculating the difference in change scores
divided by the pooled standard deviation [48]. More specifically, we
used the raw-score metric approach (i.e., using pre-test standard

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I. Larsson, K. Aili, M. Lo
deviations) in the calculation of SMD. In comparison to the change
score metric approach, this approach is more conservative because
it is not sensitive to heterogeneity in the correlation between pre-
and post-test scores. (For more information about the raw-score
metric approach, see, Morris and DeShon, 2002 [48].) The results
from included studies are reported in outcome-specific forest plots,
see Fig. 3. Only three outcomes, sleep disturbances, QoL, and ADHD
symptoms, could be synthesized in meta-analyses, and the
remainder of outcomes are reported narratively. A random effect
model was applied for the meta-analyses, with baseline sample
sizes as weights. All analyses were performed in STATA (version 16).
2.8. Evidence grading
In the final step of the review, the certainty of the evidence was
assessed by using the grading of recommendation assessment,
development and evaluation (GRADE) framework, considering the
following domains: 1) risk of bias, 2) indirectness, 3) inconsistency,
4) imprecision, and 5) other considerations (e.g., publication bias)
[49]. GRADE guidelines were also used for the statements on the
certainty of evidence and effect sizes [50]. The assessments were
performed independently by two researchers (IL, ML), with an
assessment consensus reached by discussion in the research group.
The final review results are summarized in an evidence table
inspired by the GRADE framework (Table 5).
3. Results
3.1. Study selection
The literature search for the effectiveness of sleep interventions
for children resulted in 7710 records, see Fig. 1. After duplicates
were removed and the language and time period criteria were
enforced, 4808 records were screened on abstract level. Of these,
4709 were excluded, leaving 99 papers for full-text assessment of
inclusion, whereof eight papers [51e58] from five studies
[51,52,54,57,58] were included in the systematic review. This
means that three papers (Hiscock et al., 2015; Sciberras et al., 2011;
Sciberras, Mulraney, et al., 2020) were based on findings from the
same study and that two papers (Van der Heijden et al., 2007;
Hoebert et al., 2009) are based on the same study.
3.2. Risk of bias
In the assessment of the risk of bias of the eight papers from the
five studies, three papers from two studies were assessed as having
a low overall risk of bias [53,54,57], while another four papers from
two studies were assessed as having some concerns [51,52,55,56],
see Fig. 2. One study [58] was assessed as having a high risk for bias,
and those results are not further reported. Bias due to missing
outcome data (domain 3 in RoB 2) was the issue most frequently
encountered in the studies.
3.3. Study characteristics
Four of the seven selected outcome measure included in the
studies were measured by objective instruments, i.e. actigraphy or
polysomnography: TST, SOL, SE, WASO, while three were self-
reported: sleep disturbances (CSHQ) [59], QoL (Pediatric Quality
of Life Inventory - PedsQL, TNO-AZL Questionnaire for Children's
Health-Related Quality of Life - TACQOL-P) [60,61] and ADHD
symptoms (ADHD Rating scale IV, CBCL) [62,63], see Table 3.
All seven papers from the four studies that form the basis for the
effectiveness evidence were performed as RCTs. Two studies, both
double-blinded, placebo-controlled trials, reported outcomes from
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Sleep Medicine 102 (2023) 64e75
pharmacological interventions with melatonin [57] and eszopi-
clone [54]; . Melatonin doses used in one of the RCT [57] were 3 mg
for body weight <40 kg and 6 mg for body weight >40 kg in fast-
release tablets or identical-appearing placebo tablets in accor-
dance with previous research on effectiveness and safety in chil-
dren [64,65]. Eszopiclone doses used in the other pharmacological
RCT were 2 mg for children aged 6e11 years and 3 mg for children
aged 12e17 years and was the first RCT evaluating the effectiveness
and safety of eszopiclone [54]. Two studies [51,52] reported results
from non-pharmacological, parental-directed, comprehensive in-
terventions compared with usual clinical care. These interventions
involved parent information about sleep, sleep hygiene strategies,
and a behavioral sleep management plan tailored to the child's
sleep problem [51,52] see Table 4. One study [54] included children
aged 6e11 years as well as 12e17 years, while the remaining
studies [51,52,57] only included children aged 5e13 years. The
proportion of participants on concurrent ADHD medication was
high in all studies except the melatonin study [57], only included
participants without simultaneous ADHD medication. In the
behavioural interventions [51,52], co-morbidity with autism spec-
trum disorder (ASD) was present in around 25 and 40 percent of the
participants, respectively. The follow-up periods ranged from 4
weeks to 6 months.
3.4. Results
3.4.1. Sleep interventions may increase total sleep time, TST, among
children with ADHD
Two studies reported changes in TST measured with actigraphy;
one pharmacological intervention with melatonin, compared with
placebo [57], and a non-pharmacological intervention with sleep
hygiene practices and standardized behavioral strategies,
compared with standard care [52]. Both studies reported more
larger increases in TST in the intervention group than in the control
group, with a statistically significant increase in the melatonin
study [57] of over 30 min at 4 weeks follow-up. In the non-
pharmacological study [52], TST was increased by around 15 min
at 3-month follow-up, see forest plot TST in Fig. 3.
3.4.2. Sleep interventions with the pharmacological melatonin may
reduce sleep onset latency, SOL, among children with ADHD but not
the pharmacological eszopiclone, but the evidence is very uncertain
Two studies reported changes in SOL measured with actigraphy
and polysomnography. Both pharmacological interventions, mela-
tonin [57] and eszopiclone [54], were compared with placebo. The
study on melatonin reports a statistically significant decrease in
SOL of nearly 25 min [57] compared to placebo at 4-week follow-
up, while in the high dose group of eszopiclone at 12-week
follow-up, the decrease in SOL was lower than in the placebo
group, leading to an increase in 8 min of SOL for eszopiclone [54],
see forest plot SOL in Fig. 3.
3.4.3. Sleep interventions with the pharmacological melatonin
increase sleep efficiency, SE, among children with ADHD, but the
behavioral intervention does not; however, the evidence is very
uncertain
Two studies reported changes in SE after treatment, one with
melatonin compared with placebo [57] and the other on sleep
hygiene practices and standardized behavioral strategies compared
with standard care [52]. Both studies involved children and
measured the outcome with actigraphy. The study on melatonin
[57] reported a statistically significant increase of SE by around 5
percent in the intervention group compared with the control
group. The other study on sleep hygiene practices [52] reported no
increase in SE, see forest plot SE in Fig. 3.
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I. Larsson, K. Aili, M. Lo Sleep Medicine 102 (2023) 64e75

Fig. 3. Forest plots.

Act ¼ Actigraphy data, CBCL ¼ Child Behavior Checklist, PedsQL ¼ Pediatric quality of life PSG ¼ Pediatric Daytime Sleepiness Scale (PDSS), TACQOL-P ¼ TNO-AZL Questionnaire for
Children’s Health-Related Quality of Life - Parent version

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I. Larsson, K. Aili, M. Lo
Table 3
Included outcome measures, measurement methods and number of studies reporting the outcome.
Outcome
1 Total sleep time (TST)
2 Sleep onset latency (SOL)
3 Sleep efficiency (SE)
4 Wake after sleep onset (WASO)
5 Sleep disturbances
6 QoL (Quality of life)
7 ADHD symptoms
a
CSHQ ¼ Children's Sleep Habits Questionnaire.
b
PedsQL ¼ Pediatric Quality of Life Inventory.
c
TACQOL-P ¼ TNO-AZL Questionnaire for Children's Health-Related Quality of Life - Parent version.
d
CBCL ¼ Child Behavior Checklist.
3.4.4. Sleep interventions may result in little to no reduction in
wake after sleep onset, WASO, among children with ADHD
Two studies reported change in WASO, one on eszopiclone
compared with placebo [54], and another on sleep hygiene prac-
tices and standardized behavioral strategies compared with stan-
dard care [52]. Both studies reported modest decreases in WASO
after the intervention compared with the control group (i.e. pla-
cebo and standard care, respectively): 6 min for eszopiclone [54],
and 1 min for the study on sleep hygiene practices and standard-
ized behavioral strategies [52]. No changes in WASO were statisti-
cally significant, see forest plot WASO in Fig. 3.
3.4.5. Behavioral sleep interventions probably decrease sleep
disturbances among children with ADHD
Two studies reported sleep disturbances in the total score from
the instrument CSHQ; both compare sleep hygiene strategies and
behavioral sleep management plans with standard care [51,52]. The
data were reported in SMD at 3-month follow-up. Both studies
reported statistically significant decreases in CSHQ scores for the
behavioral interventions compared with standard care, of 0.45 and
0.51 SMD, respectively. The meta-analysis, see panel CSHQ Fig. 4,
which combines the data from the studies, shows a statistically
significant medium effect size of 0.49 SMD in decreases of sleep
disturbances.
3.4.6. Sleep interventions may slightly increase quality of life (QoL)
among children with ADHD
Three studies reported changes in QoL, where two studies used
the instrument PedsQL [51,52] and one study used the instrument
TACQOL-P [57]. One study investigated melatonin compared with
placebo [57], while two studies compared sleep hygiene strategies
and behavioral sleep management plans with standard care [51,52].
One study reports two follow-up periods, 3 and 6 months [52]. The
data in the forest plot in Fig. 3 is reported in SMD. The melatonin
study reported no increase in QoL in the intervention group
compared with the control group [57]. One of the behavioral
intervention studies reported a statistically significant increase in
QoL of 0.71 SMD in the intervention group compared with the
control group, which is attenuated, to 0.43 SMD, at the longer
follow-up period but still statistically significant [52]. The other
behavioral intervention reported a more modest increase of 0.14
SMD at 6 months [51]. In the meta-analysis, see Fig. 4, the two
behavioral interventions are combined into a statistically non-
significant change of 0.27 SMD at 6 months follow-up, which is a
small effect size.
3.4.7. Behavioral sleep interventions, but not pharmacological with
melatonin, slightly decrease ADHD symptoms among children with
ADHD, but the evidence is very uncertain
Three studies reported changes in ADHD symptoms but used
Sleep Medicine 102 (2023) 64e75
Methods for measurements No. of included studies
Actigraphy 2
Actigraphy/Polysomnography 2
Actigraphy 2
Actigraphy/Polysomnography 2
CSHQa, [59] 2
PedsQLb, [60]/TACQOL-Pc, [61] 3
ADHD rating scale IV [62]/CBCLd, [63] 3
two different instruments; CBCL in one study [57] and ADHD rating
scale IV in two studies [51,52]. In one study, melatonin was
compared with placebo [57], while in two studies, hygiene strate-
gies and behavioral sleep management plans were compared with
standard care [51,52]. The two behavioral intervention studies re-
ported data at 3- and 6-month follow-up. The forest plot on ADHD-
symptoms in Fig. 3 reports the data in SMD. Children receiving
melatonin experience a decrease in ADHD symptoms, but to a
lesser extent than the placebo control group children, leading to an
overall increase in symptoms after the intervention [57]. However,
the two behavioral interventions reported decreased ADHD
symptoms, with SMDs ranging from
0.02 to
0.40 [51,52], of
which one study reported statistically significant decreases at 6-
month follow-up [52]. The trend over follow-up periods is
different in those studies; one reported larger decreases at 6
months than at 3 months follow-up [52], while in the other, the
decreases approach 0 at 6 months [51]. The two meta-analyses, see
Fig. 4, which combined the data from the two behavioral in-
terventions at 3 months and 6 months follow-up, respectively, re-
ported a decrease in symptoms of
0.21 SMD at both follow-ups,
which is generally considered a small effect size. However, at the
shorter follow-up, the effects were consistent in the studies, and
the meta-analysis result was statistically significant, while at the
longer follow-up one study reported a greater decrease in symp-
toms [52] while the other reported no effect [51].
3.5. Evidence grading
In Table 5 the review results are summarized in an evidence
table. Most of the review outcomes were assessed as having low or
very low certainty, mainly due to the differing types of in-
terventions. The effect sizes were generally considered small to
moderate. Only for the outcome sleep disturbances did the review
find a moderate effect size with a moderate certainty, which im-
plies that sleep interventions likely have some positive effects on
the sleep of children with ADHD.
4. Discussion
4.1. Principal findings
This systematic review aimed to report the evidence on the
effectiveness of pharmacological and non-pharmacological in-
terventions in increasing sleep quantity and quality, QoL, and
function among children with ADHD. Only four studies (two
pharmacological, and two non-pharmacological) fulfilled the in-
clusion criteria and could thus be included in the evidence base.
The four studies were heterogeneous; they included different types
of interventions, different follow-up periods, different measure-
ment methods and survey instruments, and different age groups,
70
 €nn et al.
I. Larsson, K. Aili, M. Lo Sleep Medicine 102 (2023) 64e75

Table 4
Characteristics of included studies.

Study Reference Country Age group No. of Type of design and intervention Outcomes Methods of measurement Follow-
participants (% boys; up
% ASD comorbidities,
% ADHD medication)

Hiscock et al., 2015, Children, 5e12 yrs RCT,Sleep behavior strategies compared with usual TST,SE,WASO,Sleep Actigraphy,CSHQ,PedsQL, 3
[52]},Associated I C clinical care disturbances,QoL,ADHD ADHD Rating scale IV months,6
paper,Sciberras et al. n (Total) 122 122 symptoms months
2011, 2020, Boys (%) 84 86
[55,56],Australia ASD (%) 23 27
ADHD 91 83
medication
(%)
Hiscock, et al. 2019, Children, 5e13 yrs RCT,Sleep behavior strategies compared with usual Sleep CSHQ,PedsQL, ADHD 3
[51],Australia I C clinical care disturbances,QoL,ADHD Rating scale IV months,6
n (Total) 183 178 symptoms months
Boys (%) 75 75
ASD (%) 40 37
ADHD 80 81
medication
(%)
Sangal et al. 2014, [54], USA Children 6e11 yrs, RCT (double-blind placebo),Pharmacological SOL,WASO Polysomnography 12 weeks
Children 12e17 yrs eszopiclone (2 mg for children aged 6e11 years and
I C 3 mg for children aged 12e17 years) compared with
n (Total) 160 160 placebo
n (6 86 85
e11 yrs)
n (12 74 75
e17 yrs)
Boys (%) 63 65
ASD (%) N/ N/
A A
ADHD 63 69
medication
(%)
Van der Heijden et al. 2007 Children, mean age RCT (double-blind placebo),Pharmacological TST,SOL,SE,QoL,ADHD Actigraphy,TACQOL- 4 weeks
[57],Associated 9 yrs melatonin in fast-release tablets (3 mg when body symptoms P,CBCL
paper,Hoebert et al. 2009, I C weight <40 kg [n ¼ 44] and 6 mg when body weight
[53],The Netherlands n (Total) 53 52 >40 kg [n ¼ 9]) compared with identical-appearing
Boys (%) 66 83 placebo tablets
ASD (%) N/ N/
A A
ADHD 0 0
medication
(%)

ASD ¼ Autism spectrum disorder.

C ¼ Control group.
CBCL ¼ Child Behavior Checklist.
CSHQ ¼ Children Sleep Health Questionnaire.
I ¼ Intervention group.
N/A ¼ Not Available.
PedsQL ¼ Pediatric quality of life.
QoL ¼ Quality of life.
RCT ¼ Randomised controlled trial.
SE ¼ Sleep efficiency.
SOL ¼ Sleep onset latency.
TACQOL-P ¼ TNO-AZL Questionnaire for Children's Health-Related Quality of Life - Parent version.
TST ¼ Total sleep time.
WASO ¼ Wake after sleep onset.

which led to a generally low certainty of the evidence. The excep-
tion is the outcome sleep disturbances that was assessed as having
a moderate effect size with a moderate certainty of evidence. As the
outcome was measured by the instrument CSHQ [59], that is spe-
cifically aimed at describing sleep difficulties among children, this
indicates that sleep interventions potentially increase the sleep
quantity and quality among children with ADHD, even though the
review results on other sleep related outcomes should be regarded
as inconclusive. However, that result is obtained from two studies
on tailored sleep behavior for children aged 5e13 at 3 months
follow-up [51,52]. As the instrument CSHQ aims to include a
comprehensive range of sleep quantity and quality issues, tailored
sleep behavior interventions appear to be a sound treatment choice
for children with ADHD and sleep problems. The effect size of TST
was reported to increase over 30 min at 4 weeks follow-up for
children using melatonin [57] and around 15 min at 3-month
follow-up after a behavioral intervention [52], which is consid-
ered as a moderate effect, although with low evidence. This
conclusion is based on research showing that an improvement in
TST rarely exceeds 30 min in sleep interventions [66,67] but is likely
to increase linearly over time [67]. Two RCTs reviewed investigated
two types of pharmaceutical treatment. Melatonin [57] showed
improvement in sleep outcomes but not in QoL nor ADHD function,
while eszopiclone [54] showed no effect in any of the included

71
 €nn et al.
I. Larsson, K. Aili, M. Lo
Fig. 4. Meta-analyses on selected outcomes.
sleep outcomes. As the eszopiclone study was the only study that
included children aged 6e11 and 12e17 years, we cannot report
any evidence on the effectiveness of sleep interventions for ado-
lescents. Although our results show some minor improvements in
sleep quantity and quality and decreased ADHD symptoms for
three months after interventions for the behavioral interventions,
72
Sleep Medicine 102 (2023) 64e75
the six month follow-up periods do not show sustained results
regarding QoL and ADHD behavior [51,52]. Evaluation of daytime
consequences over time is important besides sleep evaluation,
especially in children with ADHD, due to the bidirectional rela-
tionship between sleep and ADHD symptoms [68].
This systematic review included a specific search for health
 €nn et al.
I. Larsson, K. Aili, M. Lo Sleep Medicine 102 (2023) 64e75

Table 5
Summary evidence table.

Certainty assessment No. of Effect Certainty

participants
No. of Risk of Incon- Indirect- Impreci- Other Downrating due to Absolute,(95% CI) Size of
studies bias sistency ness sion considera- number of some concerns effect
tions

Total sleep time (TST), in minutes

2 Some None Seriousa Seriousb None No 170 n.a. Moderate 44,Low
Sleep onset latency (SOL), in minutes
2 None Very Seriousd Some None No 428 n.a. Moderate 4,Very
seriousc low
Sleep efficiency (SE), percentage of total sleep time in relation to time in bed
2 Some Very Seriousf Some None No 170 n.a. Moderate 4,Very
seriouse low
Wake after sleep onset (WASO), in minutes
2 Some None Seriousg Serioush None No 385 n.a. No effect 44,Low
Sleep disturbances, measured as the total score of the instrument CSHQ, transformed into SMD
2 Some None None None Some Yes 605
0.49,(-0.65;-0.33) Moderate 444
Moderate
Quality of life, (QoL) measured from several instruments, transformed into SMD
3 (2 in meta- Some None Seriousi Some None Yes 569 (464 in 0.27,(-0.02; 0.56) Small 44,Low
analysis) meta-analysis)
ADHD symptoms, measured from several instruments, transformed into SMD
3 (2 in meta- Some Some Seriousj Seriousk None Yes 705 (605 in 3 months: 0.21 (
0.37;
0.05),6 Small 4,Very
analysis) meta-analysis) months: 0.21 (0.58; 0.16) low
a
Different types of interventions in studies.
b
Both studies report broad confidence intervals.
c
One study reported increases in outcome while the other reported decreases.
d
Different measurement methods in studies.
e
One study reported increases in outcome while the other reported decreases.
f
Different types of interventions in studies.
g
Different types of interventions in studies.
h
Wide confidence intervals in studies.
i
Different types of interventions in studies.
j
Different types of interventions in studies.
k
Broad confidence interval in meta-analysis at 6 months.

economic evidence but found only one study that reported some
health economic results of a sleep intervention for children with
ADHD [51]. Due to the lack of details in the reporting of the cost-
effectiveness analysis and the inappropriate result reported, i.e.,
cost per percentage reduction in parent-reported sleep problems,
the study was deemed to be of insufficient health economic
methodological quality to become included in the evidence base.
Our review could, therefore, not include any health economic re-
sults. Apart from effectiveness considerations, decision-makers
also need to consider the resource implications of the chosen in-
terventions. Very effective interventions might be too resource-
demanding, i.e. too costly, to be possible to implement [69].
Our results mainly confirm the results of previously reported
systematic reviews: for children with neurodisabilities, sleep in-
terventions might positively affect sleep [39]. In particular, our
results show positive effects from non-pharmacological behavioral
interventions and sleep management programs as reported in
previous systematic reviews [40,42]. Also, for the particular group
of children with ADHD, sleep interventions may affect sleep [5],
including sleep hygiene practices [41]. These previous systematic
reviews have included a wide range of studies with different study
designs, such as uncontrolled observational studies, inadequate
numbers of participants, and unclear statistical analyses, which
might have led to elevated and unknown risks of systematic biases.
4.2. Strengths and limitations
The rigorous methods used in this review warrant that the re-
ported results are unbiased, as careful quality assessments have
eliminated studies that are not of the highest scientific standard
throughout the review process. The methodologies employed in
the review and the tools used to report the systematic review
process and results are those recommended by the Cochrane
Collaboration. The use of forest plots and meta-analyses on selected
outcomes and GRADE tools lead to a transparent reporting of re-
sults and ease of interpretation for stakeholders. The stringent
methodology, however, leads to the considerable drawback that
very few studies are included in the review, negatively affecting the
certainty of evidence. However, we believe the review methodol-
ogy enforces scientific rigor in the results.
Drawing conclusions from RCTs with different timeframes from
4 weeks to 6 months is a limitation in this review. There is a need
for standardized time frames in the evaluation of sleep in-
terventions in order to be able to compare the effectiveness of
different sleep interventions. The importance of longer follow-up
periods is highlighted in our two separate meta-analyses on
ADHD symptoms; at 3 months follow-up, the results from two
studies are consistent and statistically significant. However, at the
6-month follow-up, one study reports increased effectiveness from
the 3-month results and the other a decrease, leading to a statis-
tically insignificant long-term effect.
Seven different outcomes are included in the review results.
Most of the outcomes are directly related to sleep quantity and
quality, while the outcomes of QoL and ADHD symptoms were
chosen as they might be indirectly related to sleep difficulties but
also are important factors for the child and family. There is no
established core outcome set, i.e., an inventory of recommended
outcomes for trials and systematic reviews, for sleep interventions
for children [46,70]. We therefore opted for a fairly large number of
outcomes, given that no study included all of them. The measure-
ment methods of the objective outcomes differed among the
studies, as did the subjective self-reported instruments, adding to
the heterogeneity of the evidence base. In our review, sleep in the
pharmacological interventions was evaluated with objective

73
 €nn et al.
I. Larsson, K. Aili, M. Lo
measurements (actigraphy or polysomnography), while the non-
pharmacological interventions also included parent-reported as-
sessments with questionnaire data, such as the CSHQ and the
ADHD rating scale IV. A consensus on a core outcome set to use in
intervention studies targeting sleep among children is warranted.
4.3. Health policy implications
Sleep problems significantly impact children's functioning and
QoL [26,27] and are likely to exacerbate the negative behaviors
associated with ADHD [5,23,26,28]. In the long run, sleep problems
are also associated with impaired academic performance [71,72]. A
healthy sleep pattern for children is thus an important clinical goal.
However, this systematic review found only four studies with good
scientific quality: two on pharmacological interventions and two
on non-pharmacological sleep behavioral interventions. One of the
pharmacological interventions, i.e., melatonin, was found to be
effective for some of the sleep-related outcomes but not for the
outcome of ADHD symptoms. On the other hand, the two behav-
ioral interventions were shown to lead to decreased ADHD symp-
toms and parent-reported sleep disturbances among the children
at a 3-month follow-up. Based on these findings, we could not
determine whether any of the interventions suited better for chil-
dren with ADHD. Thus, for healthcare professionals working with
children with ADHD, the choice between treatment modality,
pharmacological or behavioral, has a weak evidence base, which
calls for further research to support practice.
5. Conclusions
The strict review methodology resulted in few and yet heter-
ogenous studies. A moderate certainty of the evidence for a mod-
erate effect size was only obtained for the sleep disturbances
outcome, based on the parent-reported composite instrument
CSHQ from two behavioral interventions. A low certainty of the
evidence for a moderate effect size was found for the total sleep
time, measured with actigraphy from the pharmacological inter-
vention using melatonin and one behavioral intervention. How-
ever, this result indicates that these sleep interventions impact
sleep quantity and quality among children with ADHD aged 5e13
years, even though no certain results could be obtained.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Availability of data and materials
Datasets are available through the corresponding author upon
reasonable request.
Funding source
This work was supported by the Knowledge Foundation (Grant
no. 20200012 and 2019/152), Swedish Research Council for Health
Working Life and Welfare (Forte) (Grant no. 2021-00664).
CRediT authorship contribution statement
Conceptualization, I.L., K.A., PS., J.M.N., and P.J.; methodology,
I.L., K.A., M.L., P.S., J.M.N., A.I., and P.J.; investigation, I.L., K.A., and P.J;
74
Sleep Medicine 102 (2023) 64e75
formal analysis, M.L., and A.I.; data curation, I.L., K.A., M.L., and P.J.;
writingdoriginal draft preparation, I.L., and P.J..; writingdreview
and editing, K.A., M.L., P.S., J.M.N., and A.I.; project administration,
I.L., K.A., PS., and J.M.N. All authors have read and agreed to the
published version of the manuscript.
Declaration of competing interest
The authors declare no conflicts of interest.
Acknowledgement
We would like to thank Luis Irgang Santos for his support in
screening the cost-effectiveness studies and the librarians Elisabet
Frigell and Anna Nistor.
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