Clinical Pediatrics

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Sleep-related Disorders in ADHD: A Review

Kristiaan B. van der Heijden, Marcel G. Smits and W. Boudewijn Gunning
Clin Pediatr (Phila) 2005; 44; 201
DOI: 10.1177/000992280504400303

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 Sleep-related Disorders in ADHD: A Review
Kristiaan B. van der Heijden, Msc1
Marcel G. Smits, MD, PhD2
W. Boudewijn Gunning, MD, PhD3

Introduction missing. The present review dis- tice it is usually not possible to
cusses studies published after the make PSG registrations during

T he relationship of atten-
tion-deficit/hyperactivity
disorder (ADHD) with
sleep-related disorders has re-
ceived remarkable interest. The
comorbidity warrants close atten-
tion since sleep-related disorders
impinge on the same functional
domains as those impaired in
ADHD, such as sustained atten-
tion, inhibition, and working
memory. Hence, it has been al-
leged that sleep-related disorders
might possibly lead to an aggrava-
tion or mimicry of the symptoms
of ADHD. A second reason for the
interest is that stimulants, the
treatment of f irst choice for
ADHD, are notorious for their
deleterious effect on sleep.
A vast number of studies on
the issue of sleep in ADHD has re-
cently been published, including
several reviews1-3 and book chap-
ters.4,5 However, a clear overview
of the recent findings with a focus
on the clinical implications is yet
Clin Pediatr. 2005;44:201-210
1Department of Child and Adolescent Psychiatry, University of Amsterdam; 2Centre for Sleep-
Wake Disorders and Chronobiology, Hospital Gelderse Vallei, Ede; 3Centre for Sleep/Wake
Disorders, Kempenhaeghe, Heeze, The Netherlands.
Reprint requests and correspondence to: Kristiaan B. van der Heijden, Msc, Department of
Child and Adolescent Psychiatry, Academic Medical Center, University of Amsterdam,
Meibergdreef 9, Amsterdam, The Netherlands.
© 2005 Westminster Publications, Inc., 708 Glen Cove Avenue, Glen Head, NY 11545, U.S.A.
date of the introduction of DSM-
IV.6 The sleep disorders that have
been linked to ADHD are dis-
cussed separately. First, elemen-
tar y methodological aspects of
more than 2 consecutive nights.
Actigraphy assesses physical
motion with an actiwatch, a small
device with the size of a normal
wristwatch, which stores the re-
sleep assessment are summarized. sulting information. Actigraphy
can be performed during many
consecutive days and nights. Sev-
Assessment of Sleep eral studies have indicated that
for healthy subjects the agree-
Polysomnography (PSG) is ment rates between actigraph-
considered to be the gold stan- based and PSG-based minute-by-
dard in sleep research. It usually minute sleep-wake scoring are
records 2 or more electrophysio- above 90%;9-13 however, its accu-
logical measures such as elec- racy in estimating sleep reference
troencepalography (EEG) and times (e.g., sleep onset time, time
electromyography (EMG). Conse- of awakening) is only moderate.
quently, PSG permits assessment The accuracy of actigraphy de-
of sleep architecture. PSG is rela- clines as the quality and quantity
tively expensive and often re- of sleep diminish, such as for pa-
quires people to sleep in labora- tients with sleep-related disor-
tory settings, which is known to ders13-15 and major depression.16
potentially change habitual sleep PSG and actigraphy measure sleep
patterns and induce a lower sleep more or less objectively.
efficiency at the first night of the Subjective methods of sleep
sleep laboratory measurements: assessment can be obtained di-
the “first-night effect”.7,8 In prac- rectly from subjects themselves by
means of a clinical history, sleep
questionnaires, or sleep logs. In
case subjects themselves are not
able to supply the information
needed, bedpartners or parents
are requested to record the infor-
mation. The validity and reliabil-
ity of sleep questionnaires and
sleep logs are debateable. Re-
search has revealed that people
are not accurate assessors of their
own sleep behavior, nor are they

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 van der Heijden, Smits, Gunning
for the sleep of someone else.17
Sleep questionnaires and sleep
logs are frequently used for in-
traindividual comparisons, e.g., to
assess treatment effects.
Breath-related
Sleep Disorders
Breath-related sleep disorders
(SDB) (Table 1) are often associ-
ated with behavioral problems
that show much similarity to char-
acteristics of ADHD.18-21 Although
hyperactivity is often shown at re-
ferral in children with suspected
SDB, it is not displayed more of-
ten in children with a PSG-con-
firmed diagnosis of SDB.22
Children with diagnosed
ADHD do not significantly more
often show symptoms of SDB
when assessed with 1 or 2 items in
a questionnaire. 23-26 When as-
sessed with a questionnaire com-
prising 6 snoring- and SDB-re-
lated items, children with ADHD
show elevated scores as compared
to psychiatric controls. 27 How-
ever, 3 recent PSG studies have
found the presence of SDB in
ADHD to be negligible.28-30
PSG studies have demon-
strated that the complaints of
SDB, which are often ventilated
by parents of ADHD children, can
often not be confirmed on inves-
tigation.28,29 Such discrepancies
between parental and objective
measures have also been found
for other sleep problems in
ADHD, as will be discussed later.
To summarize, attention
deficit and behavioral problems
can often be found in children
with SDB. Children with ADHD
often have symptoms of SDB, as
reported by their parents. How-
ever, objective studies do not sup-
port that SDB occurs more often
in ADHD.
202 CLINICAL PEDIATRICS
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Treatment Motor restlessness during
Adenotonsillectomy is the first sleep can be a manifestation of a
line of treatment, and continuous periodic limb movement disorder
positive airway pressure is an op- (PLMD) (Table 1). Hyperactivity
tion for those who are not candi- and inattention have been found
dates for surger y or do not re- to be increased in children with
spond to surger y (for clinical PLMD.42 Another study revealed
practice guidelines, see reference significantly correlated PLMD and
31). Treatment of SDB establishes ADHD scores, which were both as-
a significant reduction in aggres- sessed with questionnaires.21
sion, inattention, and hyperactiv- Whether children with ADHD
ity,32-34 and in case of concurrent show increased PLMs has been
ADHD normalizes typical electro- studied extensively. They were
physiological features of ADHD.35 found to show significantly more
Case reports have been published often PLMD as compared to nor-
of patients in whom a diagnosis of mal controls. 30,43,44 Others re-
ADHD had been made formerly vealed that it is not the number of
but who after treatment for SDB PLMs per se, but rather the num-
could be weaned from methyl- ber of PLMs that are associated
phenidate. 36 Therefore, treat- with arousals that is increased in
ment of SDB in ADHD should children with ADHD. However,
first be focussed on SDB. Stimu- this was the case in children with
lant treatment for ADHD is not ADHD who were referred to a
likely to affect SDB severity.29 sleep clinic, but not in children
with ADHD who were recruited in
a community survey.38,42 Two re-
Motor Restlessness cent studies showed no increased
During Sleep indexes of PLMs in children with
ADHD but found the highest
Before 1980, reports of high PLM indexes in the ADHD
group. 19,29 However, in these 2
nocturnal activity in hyperactive
studies no formal DSM-IV diagno-
children were so common that
sis of ADHD was made.
the American Psychiatric Associa-
tion decided to enclose it in the Restless legs (Table 1) has also
criteria of attention deficit disor- been studied in association with
der in the DSM-III.37 This crite- ADHD. These studies indicated
rion was omitted in later revisions that symptoms of ADHD, 45 but
of the diagnostic manual. not ADHD itself as a disorder,27
Indeed, several parental obser- were related to restless legs syn-
vation studies demonstrated that drome (RLS).
children with ADHD show higher The overall conclusion is that
levels of activity during their sleep there is ample support that chil-
or have more restless sleep than dren with ADHD show increased
controls.19,24,25,29,38,39 This has been motor restlessness during sleep.
confirmed by studies using more Whether these movements are
objective methods such as actigra- manifestations of PLMD/RLS re-
phy or infrared camera record- mains unresolved since the results
ings.40,41 PSG showed a high fre- on this issue are very inconsistent.
quency of short movement-related The inconsistency of findings
epochs in children with ADHD; might have resulted from the dif-
however, the total time of move- ferences in ADHD diagnosis,
ments was not elevated as com- which has been mentioned previ-
pared to normal controls.30 ously. Stimulant use was found
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 Sleep-related Disorders in ADHD

Table 1

CLINICAL FEATURES AND DIAGNOSTIC METHODS OF SLEEP-RELATED DISORDERS ASSOCIATED WITH ADHD

Sleep Disorder Clinical Description Diagnostic Methods

Periodic limb movement Repetitive flexions of the toes, feet, legs, 1) Surface electromyographic recordings.
disorder (PLMD)46 thighs, and/or the arms in which
2) Medical history: Diagnosis of PLMD
electromyographic bursts last 0.5 to 5
requires impact on either sleep or daytime
seconds, 5–90 seconds between each
functioning.
movement, in series of 4 or more
movements during any sleep stage.

Restless legs syndrome 1) Desire to move the legs usually 1) Medical history. 2) Family history:
(RLS)46,89,90 associated with paraesthesias Having a positive family history of RLS is
(disagreeable sensations). 2) Motor supportive of the diagnosis. 3) PLMD: The
restlessness. 3) Worsening of symptoms presence of PLMD is supportive of the
at night. 4) Worsening of symptoms at diagnosis.
rest relieved by activity. 5) The sensations
often lead to insomnia.

Breath-related sleep Subtypes: (1) Obstructive sleep apnea 1) PSG. 2) SDB can be misinterpreted as
disorders (SDB)91,92 (OSAS), defined as a cessation or near a limb movement disorder. Therefore,
cessation of respiration for a minimum recording and scoring of leg movements
of 10 seconds; (2) Upper airway must be an integral part of PSG
resistance syndrome (UARS), defined as evaluations.
a reduction of airflow for a minimum of
10 seconds; and (3) snoring. SDB often
leads to sleep fragmentation and
excessive daytime sleepiness.

Insomnia93,94 Difficulty initiating or maintaining sleep. 1) Medical history. 2) Useful adjuncts:

Sleep logs, actigraphy, self-administered
questionnaires, symptom checklist,
or psychological screening tests.

Excessive daytime sleepiness Subtypes: (1) Monosymptomatic EDS: 1) Medical history. 2) PSG when sleep
(EDS)95 Manifestation solely by excessive disturbances are suspected. 3) Severity
daytime sleepiness; (2) polysymptomatic assessment by means of a multiple sleep
EDS, characterized by excessive daytime latency test (MSLT), the maintenance of
sleepiness, nocturnal sleep of wakefulness test (MWT), the Oxford Sleep
abnormally long duration, and signs of Resistance (OSLER) test, and several
sleep drunkenness on awakening. questionnaires.

Disturbed sleep architecture Disturbance of sleep architecture: PSG

Sleep stages, cycles, and their
interrelationships.

Nocturnal enuresis (NE)96,97 Frequent occurrence of normal complete The diagnostic procedure of primary
uncontrolled micturition during sleep in nocturnal enuresis is limited to the
children older than 5 years of age. patient’s history.
PSG = polysomnography.

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 van der Heijden, Smits, Gunning
not to be related to PLMD in
ADHD29,43 and, therefore, is un-
likely to have played a role in the
inconsistency.
Assertions have been made
that ADHD and PLMD might be
genetically linked with the
dopaminergic system as common
factor.41,44 As yet, no studies have
addressed this genetic issue.
Treatment
Treatment of RLS or PLMD in
children with ADHD should be-
gin with standard treatment strat-
egy, which is the alleviation of any
diseases or deficiencies underly-
ing the RLS or PLMD and im-
provement of sleep hygiene if pos-
sible. 46 The phar macologic
therapy that is best studied and
most successful is use of dopamin-
ergic agents.46,47 However, these
have been studied in only a few
children. Dopaminergic therapy
in 7 children with PLMD and co-
morbid ADHD improved symp-
toms of PLMD as well as those of
ADHD in all children.48 The tol-
erability of dopaminergic agents
(modaf inil) combined with
methylphenidate (8 hours after
modafinil) was good in healthy
volunteers.49 The effect of stimu-
lant treatment on motor restless-
ness during sleep is negligible.29
Insomnia
Patients with ADHD often ex-
perience difficulties with settling
and falling asleep, such as in in-
somnia (Table 1). This has been
confirmed by many studies using
insomnia items on parent ques-
tionnaires. 19,23-26,38,39,50-52 One
such study failed to find a rela-
tionship between ADHD and
parental ratings of sleep onset
problems.40 Studies in which par-
ents were asked to record sleep
onset, latency, or duration re-
204 CLINICAL PEDIATRICS
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vealed no differences between ADHD children.56 This might in-
children with ADHD and con- dicate that in children with
trols.29,50,53 ADHD behavioral practices are
Studies of insomnia in ADHD harder to apply. One of the rea-
have also been done with objec- sons is probably that in a substan-
tive measures such as polysomno- tial number of cases the insomnia
graphy 19,29,38,41,54 and actigra- is caused or aggravated by the
phy.40,52,53 None of these revealed treatment of ADHD with stimu-
significant differences between lants, 26,57-60 although 1 study
children with ADHD and controls found no effects of stimulants on
in sleep onset time, sleep latency, polysomnographically assessed
or sleep duration. sleep latency and total sleep dura-
Summarizing, it seems that tion.29 The efficacy of melatonin
parents of children with ADHD in combination with methyl-
are more likely to experience phenidate for the treatment of in-
sleep onset problems than other somnia seems promising and
parents. The presence of such safe.61
problems is not supported by
studies comparing average sleep
onset/offset times of children Disturbed Sleep
with ADHD and controls. This dis- Architecture
crepancy is not due to incongru-
ence between subjective and ob- Many studies have focused on
jective methods. Rather, it seems sleep architecture disturbances
to be due to a difference in how (Table 1) in ADHD before the in-
parents are asked to assess their troduction of the DSM-IV studies.
child’s sleep problems: by means These revealed shorter rapid eye
of retrospective ratings of insom- movement (REM) latencies, re-
nia or by prospective assessments duced REM sleep, increased delta
of sleep reference times (both sleep percentage, reduced as well
subjective). Studies in which both as increased number of sleep
were measured resulted in signifi- spindles (see reference 2, p 643,
cant retrospective results and no for review). However, the results
signif icant prospective re- were very inconsistent and often
sults.19,25,50,52 An explanation for in conflict with each other.
this discrepancy could be the high There are 7 recent studies that
variance of sleep onset and offset focused on sleep architecture dis-
found in ADHD,53,55 which possi- turbances in ADHD. Two found
bly results in sleep onset problems no significant differences in sleep
on several days in the week. Such architecture between children
a weekly sleep pattern might lead with ADHD and controls with
to statistically significant results DSM-IV reading disorders. 41,54
when parents are asked for the One study found a significantly
presence of sleep onset problems, higher number of sleep cycles in
but not, however, when sleep on- ADHD.30 In 3 other recent studies
set/offset times are averaged over REM sleep was found to be signif-
the week. icantly decreased in ADHD chil-
dren as compared to normal con-
Treatment trols.19,38,44 However, in 1 other
In American pediatrics, the study REM sleep was increased.62
prescription of sleep medication Two studies demonstrated an in-
in children with ADHD is 2- to 4- creased REM sleep latency.19,38 In
fold greater as compared to non- contrast, 1 study found an in-
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 Sleep-related Disorders in ADHD
creased absolute duration of REM
sleep and shorter sleep latencies
in ADHD.30
REM sleep disturbances have
been associated with PLMD28 and
insomnia. 63 Note that in those
studies where disturbances of
REM sleep were found, PLMD
and REM were not excluded,
whereas in those studies contra-
dicting these findings, these 2 co-
morbid factors were indeed ex-
cluded. Hence, confounding
might have played a role in the
latter studies.
To conclude, many different
sleep architecture disturbances
have been found in ADHD; how-
ever no 1 is specifically associated
with ADHD. Confounding by
other sleep disorders might have
skewed the findings of several
studies.
Treatment
Specific treatment options for
sleep architecture disturbances
do not exist. Although the effect
of stimulant use on sleep architec-
ture is largely unknown, 1 recent
study revealed that stimulants do
not affect REM latency or the per-
centage REM/total sleep.29
Nocturnal Enuresis
Noctur nal enuresis (NE)
(Table 1) is, after insomnia, 1 of
the most common pediatric sleep-
related disorders. It often causes
distress and impairment of self-es-
teem;64 however, it does not result
in disturbances of sleep architec-
ture.65,66
Several studies have addressed
the relationship of ADHD and
NE. The majority have shown
higher rates of NE in children
with ADHD as compared with
normal controls 19,24,26,38,51,67,68
and clinical controls.24 Two stud-
ies did not find any relation-
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ship.25,50 However, in 1 of these agents (tricyclic antidepressants
studies 28% of the children with [TCAs], desmopressin) and usu-
ADHD were using tricyclic antide- ally have success rates of 70–80%.
pressants, which are known to It is unknown whether these treat-
have a therapeutic effect on NE. ment options are as effective in
The relationship between ADHD as in non-ADHD children.
ADHD and NE seems to be less Note that TCAs combined with
profound at higher ages (adoles- stimulants might lead to abnormal
cents). 67,68 Furthermore, it has heart rhythms and increased blood
been shown that although NE pressure. Studies of the effect of
generally implies an increased stimulants on NE have yielded very
risk for psychopathology, the in- inconsistent results.24,26,29
creased risk seems to be missing
in children with NE and ADHD.69
Both NE70-72 and ADHD73-75 have Excessive Daytime
been proved to be genetically Sleepiness
transmittable. However, 1 study
has shown that the patterns of in- In children, excessive daytime
heritance of NE and ADHD are sleepiness (EDS) (Table 1) may
independent of each other.76 not overtly present as falling
To conclude, there is consid- asleep during the day or as ‘sleepy
erable evidence for a link between behavior’ such as yawning. In fact,
ADHD and NE. The conjoined sleepy children may instead ex-
presence does not entail extra risk hibit hyperactivity, inattention, or
for other psychopathology. Issues behavioral problems.18,78 In child-
with respect to the prognosis of hood EDS, somnolence may oc-
NE in ADHD are still unresolved. cur only when the child is not en-
A limitation of most studies on gaged in stimulating mental
NE in ADHD is that they failed to action or lively physical activity.
make a distinction between pri- The multiple sleep latency test
mar y and secondar y nocturnal (MSLT) measures the ease of
enuresis, although these 2 sub- falling asleep over the course of a
types of NE are distinct in back- day in a dark laboratory setting
ground, prognosis, and treat- and forms the gold standard in
ment. 77 In primar y nocturnal the assessment of daytime sleepi-
enuresis, children have never ness. One study using an MSLT in
achieved complete nighttime 32 boys with ADHD, not treated
control, always wetting at least 2 with stimulants, and 22 matched
times a month. Secondary noctur- controls, indicated that the chil-
nal enuretics are completely dry dren with ADHD showed a higher
at night for a period of at least 6 physiological tendency to fall
months and then begin wetting asleep during the day as com-
again. Secondary enuresis often pared to normal controls. 54 A
occurs after personal or familial more recent study confirmed
disturbance (e.g., school prob- these findings. 62 Furthermore,
lems) and might therefore be this study demonstrated that the
found relatively more frequent in sleepiness was not related to the
ADHD. presence of a sleep disorder such
as SDB or PLMD, although chil-
Treatment dren with concomitant PLMD
The usual treatments for NE showed a significantly shorter
consists of bladder training, sleep latency than those without
alarm systems, or pharmacologic PLMD only in the late afternoon.
CLINICAL PEDIATRICS 205
 van der Heijden, Smits, Gunning
Note that both studies showed
that EDS in ADHD was not re-
lated to poorer sleep quality or
quantity.
Subjective measures of EDS
(as reported by parents) also
showed significantly more sleepi-
ness in children with ADHD
and/or learning disorder as com-
pared to normal controls.79
It is yet unknown what mecha-
nisms underlie the suggested asso-
ciation between ADHD and EDS.
Usually sleepiness during the day in
children is caused by sleep depriva-
tion, sleep fragmentation, and
stress of schoolwork.80 However, the
above-cited studies showed that
EDS in ADHD cannot be explained
by a reduced sleep quantity or qual-
ity or by the presence of concomi-
tant sleep-related disorders. One of
the theories behind ADHD is that
these patients suffer from a dysreg-
ulation of arousal.53-55,62,81 This dys-
regulation has been related to
EDS in ADHD.62 Unstable sleep
patterns have been found in
ADHD53,55 and have also been re-
lated to arousal dysregulation.
Other studies have underlined the
importance of arousal regulation
for various cognitive functions
and have linked arousal dysregu-
lation to cognitive dysfunctions
in ADHD.82,83 The importance of
the arousal dysregulation in
ADHD is further corroborated by
the very beneficial effect of psy-
chostimulants.
Weinberg and Brumback have
suggested a distinctive disorder
from ADHD, primary disorder of
vigilance (PDV), which is charac-
terized by a combined display of
the inability to sustain alertness or
wakefulness and decreased atten-
tion to current activities.84,85 They
assert PDV can be discerned from
ADHD by the presence of a car-
ing, compassionate, affectionate,
kind temperament, which is often
absent in ADHD.
206 CLINICAL PEDIATRICS
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Treatment there is no specific disturbance
Psychostimulants are the most related to ADHD.
effective treatment strategy for 6. There is high evidence that
EDS as well as for ADHD. Cur- nocturnal enuresis is more likely
rently, the majority of children di- to occur in children with ADHD
agnosed with ADHD receive stim- than in children without ADHD.
ulant medication, with rates as 7. There is limited to moder-
high as 85% in the United ate evidence that children with
States.86 ADHD show increased excessive
daytime sleepiness.
8. There is limited evidence
Conclusions that children with ADHD are likely
to show unstable sleep patterns.
Review of the current litera-
ture on sleep-related disorders in
ADHD led us to draw the follow- Clinical Implications
ing conclusions.
1. SDB, PLMD, RLS, and in-
1. There is high evidence that somnia may manifest with symp-
symptoms of ADHD are more toms of ADHD. A child present-
likely to be seen in children with ing with symptoms of ADHD
sleep disordered breathing, peri- should therefore be submitted to
odic limb movement disorder, a rigorous and careful evaluation
and insomnia. of potential sleep problems as
2. Symptoms of sleep disor- part of the clinical history. When
dered breathing (SDB) are re- sleep-related disorders are sus-
ported more often by parents of pected, subsequent supplemen-
children with ADHD than by par- tary investigations might be car-
ents of children without ADHD. ried out.
However, there is high evidence 2. Clinicians working with chil-
that SDB is not more prevalent in dren with ADHD should be wary
ADHD. of comorbid insomnia, particu-
3. Increased nocturnal motor larly when the child is treated with
restlessness is more often seen in stimulants. Knowing the clinical
ADHD. However, there is only history is important to determin-
moderate evidence that children ing possible predisposing, precip-
with ADHD have a higher risk for itating, and perpetuating factors.
periodic limb movements or ele- Additional sleep assessment at
vated scores of periodic limb home can provide more objective
movements as compared to non- information about sleep duration
ADHD children. Restless legs syn- and fragmentation. Sleep assess-
drome seems to be related to ment should last a week to cap-
symptoms of ADHD but not to ture possible sleep pattern insta-
ADHD as a disorder. bilities. Discrepancies between
4. Insomnia is more often re- findings of the inter view and
ported among parents of children sleep assessment should be dis-
with ADHD than among parents cussed with the parents and (if
of children without ADHD. Fur- possible) the child to identify the
ther conclusions are hindered cause of the discrepancy.
due to methodologic limitations. 3. Clinicians should be aware
5. There is high evidence that of the relationship between
disturbances of sleep architecture ADHD and nocturnal enuresis
can be found in ADHD; however, and of the possible negative psy-
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 Sleep-related Disorders in ADHD
chological consequences of noc-
turnal enuresis. Asking for mic-
tion problems should be part of
the history taking in children with
ADHD.
4. Excessive daytime sleepiness
can occur covertly in children with
ADHD and may be displayed only
when the child is not engaged in a
stimulating activity. Daytime
sleepiness can be a weighing fac-
tor in the decision whether or not
to prescribe stimulants.
Implications for
Future Studies
Several methodologic issues
may be important for future stud-
ies. First, the majority of the stud-
ies discussed are focused on com-
parison of group means. Another
approach is to compare numbers
of cases, such as the presence of a
particular disorder, between dif-
ferent groups. Such patient-di-
rected approaches yield addi-
tional clinically important
information. However, this ap-
proach has hardly been used in
the research on sleep in ADHD.
We support a combined use of
both methodologic approaches in
order to reach the highest level of
relevant information.
An issue related to this is the
absence of consensus criteria on
childhood insomnia. In studies
of insomnia in children a pa-
tient-directed approach is ham-
pered owing to the lack of con-
sensus criteria on the diagnosis
of insomnia in children. Insom-
nia criteria in the present classi-
fication systems are still solely fo-
cused on the adult population.
An effort should be made to es-
tablish age-dependent insomnia
criteria for children. Such crite-
ria have been proposed previ-
ously;87 however, they have not
yet been implemented.
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Third, we found that only a 3. Ball JD, Koloian B. Sleep patterns
few studies took into account the among ADHD children. Clin Psychol
composition of their sample with Rev. 1995;15:681-691.
regard to ADHD subtypes (DSM- 4. Brown TE, Modestino EJ. Attention-
deficit disorders with sleep/arousal
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