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Sleep in Children With Attention-Deficit/

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 REVIEW

Sleep in Children With Attention-Deficit/

Hyperactivity Disorder: Meta-Analysis of Subjective
and Objective Studies
SAMUELE CORTESE, M.D., PH.D., STEPHEN V. FARAONE, PH.D., ERIC KONOFAL, M.D., PH.D.,
AND MICHEL LECENDREUX, M.D.

ABSTRACT
Objective: To perform a meta-analysis of subjective (i.e., based on questionnaires) and objective (i.e., using poly-
somnography or actigraphy) studies comparing sleep in children with attention-deficit/hyperactivity disorder (ADHD) versus
controls. Method: We searched for subjective and objective sleep studies (1987Y2008) in children with ADHD (diagnosed
according to standardized criteria). Studies including subjects pharmacologically treated or with comorbid anxiety/depressive
disorders were excluded. Results: Sixteen studies, providing 9 subjective and 15 objective parameters and including a total
pooled sample of 722 children with ADHD versus 638 controls, were retained. With regard to subjective items, the meta-
analysis indicated that children with ADHD had significantly higher bedtime resistance (z = 6.94, p < .001), more sleep onset
difficulties (z = 9.38, p < .001), night awakenings (z = 2.15, p = .031), difficulties with morning awakenings (z = 5.19, p < .001),
sleep disordered breathing (z = 2.05, p = .040), and daytime sleepiness (z = 1.96, p = .050) compared with the controls. As for
objective parameters, sleep onset latency (on actigraphy), the number of stage shifts/hour sleep, and the apnea-hypopnea
index were significantly higher in the children with ADHD compared with the controls (z = 3.44, p = .001; z = 2.43, p = .015; z =
3.47, p = .001, respectively). The children with ADHD also had significantly lower sleep efficiency on polysomnography (z =
2.26, p = .024), true sleep time on actigraphy (z = 2.85, p = .004), and average times to fall asleep for the Multiple Sleep
Latency Test (z = 6.37, p < .001) than the controls. Conclusions: The children with ADHD are significantly more impaired
than the controls in most of the subjective and some of the objective sleep measures. These results lay the groundwork
for future evidence-based guidelines on the management of sleep disturbances in children with ADHD. J. Am. Acad. Child
Adolesc. Psychiatry, 2009;48(9):000Y000. Key Words: ADHD, sleep, polysomnography, actigraphy, meta-analysis.

Although somewhat overlooked by child and adolescent
psychiatrists in clinical practice,1,2 parent-reported sleep
complaints in children diagnosed with attention-deficit/
hyperactivity disorder (ADHD) are frequent, even in
Accepted April 20, 2009.
This article was reviewed under and accepted by Ad Hoc Editor Garry Walter,
M.D., Ph.D.
Drs. Cortese, Konofal, and Lecendreux are with the Robert Debré Hospital.
Dr. Faraone is with SUNY Upstate Medical University.
The authors thank Drs. R. Gruber, R. Kirov, S. Mayes, and S. Miano for
having provided supplemental data from their studies to be included in the present
meta-analysis.
This article is the subject of an editorial by Dr. Eric Taylor in this issue.
Correspondence to Michel Lecendreux, M.D., Centre Pédiatrique, des
Pathologies du Sommeil, Hôpital Robert Debré, 48 Boulevard Sérurier, 75019
Paris, France; e-mail: michel.lecendreux@rdb.aphp.fr.
0890-8567/09/4809-0000Ó2009 by the American Academy of Child and
Adolescent Psychiatry.
DOI: 10.1097/CHI.0b013e3181ac09c9
the absence of stimulant medication. According to a
review of the literature by Corkum et al.,3 25% to 55%
of parents complain of sleep problems in these patients.
Sleep issues are relevant to the management of chil-
dren with ADHD. Such problems can be a significant
source of distress for these children and/or their parents
(e.g., references 4Y6). They may also worsen symptoms
of ADHD.7 Therefore, the appropriate assessment and
treatment of sleep problems might improve the quality
of life of children with ADHD and their families and
reduce the severity as well as the impairment of ADHD.
However, to appropriately manage sleep complaints in
patients with ADHD, it is necessary to better char-
acterize them and understand the specific sleep altera-
tions underlying these complaints.
Studies that addressed these issues may be divided
into subjective and objective ones. The former have used
sleep questionnaires (including several sleep items) filled

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Copyright @ 2009 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
CORTESE ET AL.
out by the parents or, less frequently, by the children/
adolescents themselves. The latter have used the gold
standard for the objective and standardized assessment
of sleep, that is, multichannel polysomnography
(PSG), as well as other techniques such as actigraphy
(a wristwatch-like device that measures sleep/wake
periods), infrared video camera, and the Multiple
Sleep Latency Test (MSLT, used to assess daytime
sleepiness by means of polysomnographic recording).
Objective studies measure sleep parameters related to
sleep continuity and/or architecture.
Results from both subjective and objective sleep stud-
ies in ADHD have been inconsistent.3,8Y11 Whereas
some authors found that specific subjective sleep items or
objective sleep parameters were significantly more severe
in children with ADHD compared with controls, other
studies failed to replicate these results. It is possible that
some potential confounding factors account, at least in
part, for the discrepancies among studies.
The methods used to assess ADHD differed across
studies, ranging from simple evaluation of symptoms of
hyperactivity/impulsivity or inattention to more rigor-
ous application of DSM diagnostic criteria. Moreover,
some studies did not exclude or did not control for the
effect of psychiatric comorbidity or medications, which
may have an impact on sleep.
To combine the results of the studies controlling for
these potential confounders, in 2005, Cortese et al.12
conducted a systematic review of subjective and objective
studies and a meta-analysis of objective sleep parameters,
including pertinent studies added on PubMed from
January 1987 (when the American Psychiatric Associa-
tion first published the DSM-III-R,13 to consider only
children with appropriate and standardized ADHD
diagnosis) to October 2005. Cortese et al.12 were not
able to perform a meta-analysis of subjective measures
because of the paucity of data that could be included in a
formal meta-analysis. They concluded that children with
ADHD had significantly higher daytime sleepiness and
apnea-hypopnea index (AHI), as well as more move-
ments during sleep compared with controls, although
no significant alterations of sleep macro-architecture or
continuity were found.
Since, in the last 3 years, there has been a considerable
increasing interest in sleep disturbances associated with
ADHD, leading to a series of new publications in the
field, we felt it useful to update the results of the
previous work on objective sleep parameters by Cortese
2 WWW.JAACAP.COM
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et al.,12 using the same inclusion/exclusion criteria (that
we consider appropriate) and to extend the meta-
analysis also to subjective sleep measures, given that,
currently, no meta-analyses on subjective sleep para-
meters in children with ADHD have been published.
METHOD
We first performed a PubMed search, for the articles added on
PubMed between 1987 and October 2005, to confirm the appro-
priateness of the studies included in the previous meta-analysis by
Cortese et al.12 and to confirm that they had found all eligible studies
from that period. We used the following key words in all possible
combinations: ADHD, attention-deficit/hyperactivity disorder, atten-
tion, hyperactivity, sleep, sleepiness, and alertness. Then, we performed
a search of original studies added on PubMed from October 2005
to November 2008, using the same search strategy and applying
the same inclusion/exclusion criteria. After the PubMed search,
references from each relevant article added on PubMed after 1987,
including another meta-analysis of polysomnographic studies,14 one
systematic review,8 and 14 scholarly reviews3,9Y11,15Y24 of the litera-
ture were examined to determine if any relevant studies had been
missed during the database searches. In addition, we examined the
available abstract books of the most relevant meetings of child and
adolescent psychiatry or sleep disorders (Meeting of the American
Academy of Child and Adolescent Psychiatry, Congress of the
European Society for Child and Adolescent Psychiatry, Congress
of the International Association for Child and Adolescent Psychiatry
and Allied Professions, Meeting of the Associated Professional
Sleep Societies, and Congress of the World Association of Sleep
Medicine) to find additional potential relevant studies. We contacted
the authors when data presented in their studies were incomplete. We
also contacted experts in the field to find other possible recent
completed research.
As in Cortese et al.,12 inclusion criteria for an article to be retained
were as follows: participants aged 18 years or younger, diagnosis of
ADHD according to standardized criteria (DSM-III-R, DSM-IV, or
DSM-IV-TR; no sleep studies on children with hyperkinetic disorder
according to International Statistical Classification of Diseases, 10th
Revision, criteria were available), inclusion of a control group, studies
reporting at least one subjective and/or at least one objective mea-
sure of sleep functioning, and data presented in a manner amena-
ble to meta-analysis. We did not include case reports or descriptive
reports without comparison groups or data analyses. We excluded
studies in which the diagnosis of ADHD was not made according
to standardized criteria, and we did not consider data from studies
that failed to exclude relevant psychiatric comorbid disorders that
may have an impact on sleep (anxiety or depressive disorders). Given
the high comorbidity between ADHD and oppositional defiant
disorder (ODD)1 and considering that most of the studies in the
field did not exclude subjects with comorbid ODD, we decided to
retain in the meta-analysis also those studies analyzing children with
ADHD plus ODD. Finally, we excluded studies that included sub-
jects pharmacologically treated. In each study, we searched for
relevant sleep parameters listed in Table 1.
Effect sizes for dependent measures in each study were expressed
as standardized mean differences. The standardized mean difference
is computed by taking the mean of the control group minus the
mean of the ADHD group and dividing the result by the pooled SD
J. AM. A CAD. C HILD ADOLESC. PSYCHIATRY, 48:9, SEPTEMBER 2009
 SLEEP AND ADHD: META-ANALYSIS

of the groups. Studies were weighted according to the number of
participants included. Our meta-analysis used the random effects
model of DerSimonian and Laird.25 We used the I2 index to assess
the heterogeneity of effect sizes.26 Its value lies between 0 and 100
and estimates the percentage of variation among effect sizes that can
be attributed to heterogeneity. A significant I2 suggests that the
effect sizes analyzed are not estimating the same population effect
size. Following Higgins et al.,26 we discuss I2 thresholds of 25%,
50%, and 75% to demarcate low, moderate, and high heterogeneity.
RESULTS
Selected Studies
All the eight objective studies27Y34 published from
1987 to October 2005 included in Cortese et al.12 were
confirmed as appropriate to be included in the present
meta-analysis. Among the five subjective studies35Y39
reviewed by Cortese et al.,12 two36,39 presented data
suitable for the meta-analysis. The other three arti-
cles35,37,38 did not report data as mean and SD, and
therefore, it was not possible to pool their data with those
from the other selected studies. We also confirmed that
the search by Cortese et al.12 did not miss other pertinent
studies published between 1987 and October 2005.
The PubMed search for the period October 2005
to November 2008 yielded 31 original research
articles.4,5,40Y68 Nine articles44Y46,58,61,62,64Y66 were
excluded because they failed to include a control
group. Three studies40,43,59 examined sleep in treated
children with ADHD, and therefore, they were not
considered for the meta-analysis. Five articles48,50,
53,54,60
were not included because the authors did not
perform a formal diagnosis of ADHD. Three studies
were not included because they analyzed the relation
between ADHD and sleep disturbances in particular
populations (obese children,41 children scheduled for
adenotonsillectomy,42 and children with ADHD plus
tic disorders,51 respectively), and therefore, their
subjects are not representative of the general clinical
ADHD population. Two studies63,68 were not included
because they were epidemiological surveys without a
comparison between ADHD and control subjects. The
study by Lim et al.55 was not retained because data on
comorbidities and medication status were available only
for a subset of subjects. The article by Wiggs et al.67 was
not included because the authors did not perform a
formal diagnosis of psychiatric comorbidities. Finally,

TABLE 1
Subjective and Objective Sleep Parameters Included in the Meta-Analysis
Parameter Description
Subjective parameters
Bedtime resistance Includes behaviors such as the child refusing to get ready for bed, refusing to remain in the bed, or
requiring a parent to be present at bedtime. It is generally included in the diagnostic category: ‘‘limit
setting sleep disorders.’’ It is often the result of parental difficulties in setting limits and managing
behavior. Alternative reasons for bedtime resistance include inappropriate sleep schedule, delayed
sleep phase, nighttime fears, and restless legs syndrome.
Sleep onset difficulties Difficulty with falling asleep (within 20 min after going to bed according to some authors,
e.g., Owens et al.39). Several factors may contribute to sleep onset difficulties, including
psychopathologies (e.g., mood disorders), inappropriate sleep hygiene, or objective sleep disorders
(e.g., restless legs syndrome).
Night awakenings Night wakings, which may require parental intervention for the child to return to sleep. They occur
for many different reasons. They are often related to inappropriate sleep onset associations
(conditions that the child learns to need to fall back to sleep): for example, when a child develops
bedtime sleep onset associations that are not readily available during the night (e.g., having parental
presence), prolonged night wakings may occur. Risk factors include cosleeping, breast-feeding,
sleep-disrupting events (e.g., illness), difficult temperament, insecure maternal child attachment,
and maternal depression. Night wakings may also occur in children with medical concerns such as
reflux and pain, underlying sleep disrupting conditions such as periodic limb movement disorder,
obstructive sleep apnea, or inadequate sleep hygiene.
Sleep duration Duration of total sleep, as perceived by the parent or the child. Sleep disorder is defined inconsistently
in the different studies, as time asleep at night, as time asleep plus in bed awake at night, or as total
time asleep across 24 h.

(Continued)

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CORTESE ET AL.
Parameter
Difficulties with morning
awakenings
Daytime sleepiness
Sleep disordered breathing
Restless sleep
Parasomnias
Objective parameters
Sleep onset latency evaluated
with polysomnography
Sleep onset latency evaluated
with actigraphy
No. of stage shifts in total sleep time No. of shifts from one sleep stage to another during the total sleep time.
No. of stage shifts/h sleep
Percentage of stage 1
Percentage of stage 2
Percentage of slow-wave sleep
REM sleep latency
Percentage of REM
Sleep efficiency assessed
with polysomnography
SE assessed with actigraphy
True sleep on actigraphy
Night wakings on actigraphy
Average times to fall asleep at
Multiple Sleep Latency Test
Apnea-hypopnea index
Note: CPS = cycles per second; REM = rapid eye movement.
4 WWW.JAACAP.COM
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TABLE 1
Continued
Description
Includes behaviors such as the child refusing to wake up by himself or having difficulty getting out of
bed in the morning. It may be the consequence of inadequate sleep or the result of parental
difficulties in setting limits and managing behavior.
It is characterized by persistent tiredness and lack of energy with a tendency to fall asleep. Causes of
daytime sleepiness include chronic sleep deprivation, underlying sleep disrupters (e.g., obstructive
sleep apnea, restless legs syndrome, periodic limb movements in sleep), psychiatric disorders (e.g.,
mood disorders), and neurological causes (e.g., posttraumatic hypersomnia). An excessive daytime
sleepiness with an urge to fall asleep is the hallmark of narcolepsy. It can be found also in Kleine-
Levin syndrome.
A clinical spectrum that includes primary snoring, upper airway resistance syndrome (characterized by
snoring and increased respiratory effort), partial obstructive hypoventilation hypopneas
(characterized by snoring, increased respiratory effort, and arousals), and obstructive sleep apnea
(characterized by snoring, apneic pauses, and arousals). The diagnosis of sleep disordered breathing
requires a polysomnographic recording. Parents may report some of the associated symptoms (e.g.,
snoring, pauses in breathing).
Sleep characterized by excessive movements of some parts of the body or the whole body.
Parasomnias are defined as undesirable physical events or experiences that occur during entry into
sleep, within sleep, or during arousals from sleep. They include sleepwalking, sleep terrors,
nightmare disorder, enuresis, and sleep-related groaning.
The time in minutes from lights off to the first epoch of stage 2 sleep.
Time in minutes from getting into bed/‘‘lights out’’ to actigraphically defined sleep onset (the first
10-min interval in which there is activity in no more than 1 epoch that is above the threshold set
for determining ‘‘wake’’). Because individuals can be immobile and awake, actigraphy tends to
underestimate sleep onset latency.
No. of shifts from one sleep stage to another in an hour of sleep.
Percentage of stage 1 sleep (defined by disappearance of the EEG alpha pattern and the establishment
of theta waveforms [2Y7 cps] and slow rolling eye movement) in total sleep time (equivalent to total
sleep episode less awake time).
Percentage of stage 2 sleep (defined by the appearance of low-frequency high-amplitude discharges [K
complexes] and brief high-frequency [12Y14 cps], variable-amplitude discharges [sleep spindles] on
a background of theta waveforms) in total sleep time.
Percentage of stage 3 (characterized by slow-wave, high-amplitude, and low-frequency [0.5Y2 cps]
delta waveforms in at least 20% of total sleep time) + stage 4 (characterized by slow waves in more
than 50% of total sleep time) in total sleep time.
The time from sleep onset to the first appearance longer than 2 min of REM sleep (defined by rapid
bursts of back-and-forth eye motion, muscle atonia, and EEG waveform [theta and beta activity]
typical of lighter sleep stages).
Percentage of REM sleep in total sleep time.
Ratio of total sleep time, assessed with polysomnography, to nocturnal time in bed.
Ratio of total sleep time, assessed with actigraphy, to nocturnal time in bed.
Sleep time (assessed by actigraphy) excluding all periods of wakefulness.
No. of wakings during night, as assessed by actigraphy, that last at least 5 min.
Means of average times on all Multiple Sleep Latency Test nap opportunities to fall asleep. The lower
it is, the higher the sleepiness during daytime.
The no. of apnea and hypopnea episodes per hour (apnea is defined as a cessation of airflow for at least
10 s; hypopnea is defined as a 50% reduction in airflow (measured with a validated technique) or a
reduction in airflow associated with a 3% fall in arterial oxygen saturation and/or an arousal).
J. AM. A CAD. C HILD ADOLESC. PSYCHIATRY, 48:9, SEPTEMBER 2009

the article by Huang et al.49 was excluded because the
ADHD population was a selected one (children with
ADHD plus mild obstructive sleep apnea). (Full details
of the excluded studies are available on request.) There-
fore, we retained six studies4,5,47,52,56,57 published
between October 2005 and November 2008.
As for data presented in abstract form, we found 12
works69Y80 on sleep and ADHD. Six studies70,72,74Y77
were not retained because they did not include a con-
trol group. Two abstracts71,80 were not considered be-
cause they did not control or exclude for psychiatric
comorbidities. The abstract by Bixler et al.69 did not
specify diagnostic criteria and was therefore not selected.
Data presented by O’Brien and Mindell79 were not
considered because the authors did not perform a formal
diagnosis of ADHD. Data presented in abstract form
by Gruber et al.73 were published in a recent article,47
which we retained in the meta-analysis as an original
research study. The abstract by Mick et al.78 did not
provide data useful for the present meta-analysis (the
term insomnia used by these authors is not sufficiently
specific and may refer to different sleep disturbances).
Therefore, none of the above-mentioned abstracts
provided data useful for the present meta-analysis.
In conclusion, after this rigorous selection, we retained
16 articles4,5,27Y34,36,39,47,52,56,57 for use in the present
updated meta-analysis, including eight objective
studies27Y34 and two subjective studies36,39 selected in
the previous meta-analysis by Cortese et al.12 Among
the 16 selected articles,4,5,27Y34,36,39,47,52,56,57 six
reports,4,5,36,39,47,56 provided subjective data, and 13
articles4,5,27Y34,47,52,57 provided objective data (the stud-
ies by Owens et al.,5 Gruber et al.,47 and Hvolby et al.4
provided both objective and subjective data). Among
the 13 objective studies,4,5,27Y34,47,52,57 nine27,28,31Y34,
47,52,57
reported PSG measures, and four4,5,29,30 provided
actigraphic data. The characteristics of the 16 selected
studies4,5,27Y34,36,39,47,52,56,57 are summarized in Table 2.
Results From Subjective Studies
Effect sizes with 95% confidence intervals for each
parameter from each individual subjective study are
shown in Figure 1, along with the pooled effect-size
estimates obtained from the meta-analysis. The meta-
analysis indicated that, when considering the pooled
effect-size, the children with ADHD had significantly
higher bedtime resistance (BR; z = 6.94, p < .001, I2 =
79.2%) as well as more sleep onset difficulties (SOD;
J. AM . ACAD. CHILD ADOLESC. PSYCH IAT RY, 48:9, SEPTEMBER 2009
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SLEEP AND ADHD: META-ANALYSIS
z = 9.38, p < .001, I2 = 90.4%), night awakenings (NA;
z = 2.15, p = .031, I2 = 56.3%), difficulties with
morning awakenings (DMA; z = 5.19, p < .001, I2 =
59.9%), and sleep disordered breathing (SDB; z = 2.05,
p = .040, I2 = 0.0%) compared with the controls. The
children with ADHD were also described by their
parents as more sleepy during the day compared with
the controls (z = 1.96, p = .050, I2 = 51.7%). The
children with ADHD did not significantly differ from
the controls on parasomnias (PAs; z = 1.73, p = .084,
I2 = 61.2%), restless sleep (z = 0.44, p = .657, the I2
statistics are not reported because only one retained
study assessed this item), and sleep duration (z = 1.44,
p = .150, I2 = 89.9%), at least as reported by the parents.
Results From Objective Studies
Effect sizes with 95% confidence intervals for each
parameter from each individual objective study are
shown in Figure 2, along with the pooled effect-size
estimates obtained from the meta-analysis. Sleep
onset latency measured with actigraphy (SOL-a), the
number of stage shifts/hour sleep (SHIFTS/h), and
the AHI were significantly higher in the children
with ADHD compared with the controls (z = 3.44,
p = .001, I2 = 86.9%; z = 2.43, p = .015, I2 = 73.3%;
and z = 3.47, p = .001, I2 = 0.0%, respectively). The
children with ADHD had a significantly lower sleep
efficiency evaluated with PSG (SE-PSG) and true
sleep time evaluated with actigraphy (TS) than the
controls (z = 2.26, p = .024, I2 = 2.7%; z = 2.85,
p = .004, I2 = 53.9%, respectively). The average times
to fall asleep considering all the MSLT nap oppor-
tunities were significantly lower in the children
with ADHD than the controls (z = 6.37, p < .001,
I2 = 95.6%).
The other objective parameters, that is, the percent-
age of stage 1 (ST1%; z = 0.43, p = .665, I2 = 54.4%),
percentage of stage 2 (ST2%; z = 1.39, p = .164, I2 =
0.0%), percentage of slow-wave sleep (z = 0.90, p = .370,
I2 = 24.6%), and percentage of rapid eye movement
(REM%; z = 1.49, p = .138, I2 = 76.7%), as well as the
sleep onset latency evaluated with PSG (SOL-PSG; z =
1.15, p = .249, I2 = 0.0%), the sleep efficiency evaluated
with actigraphy (SE-a; z = 1.52, p = .130, I2 = 44.4%), the
night wakings on actigraphy (z = 0.59, p = .554, I2 =
7.5%), the REM sleep latency (z = 0.28, p = .779, I2 =
0.0%), and the number of stage shifts in total sleep time
(SHIFTS; z = 0.49, p = .626, I2 = 0.0%) did not
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CORTESE ET AL.

TABLE 2
Subjective and Objective Studies Included in the Meta-Analysis
Age (Mean T SD) or Type of Parameters Used in the Meta-Analysis
First Author (Year) Subjects Age Range, y (0 = Subjective, 1 = Actigraphic, 2 = PSG)
Gruber et al. (2000)29 38 ADHD 6Y14 1
64 Controls 7.5Y11.5
Owens et al. (2000)39 57 ADHD 5Y10 0
46 Controls 5Y10
Lecendreux et al. (2000)34 30 ADHD 7.8 T 1.6 2
22 Controls 8.4 T 1.4
Konofal et al. (2001)33 31 ADHD 5Y10 2
21 Controls 5Y10
LeBourgeois et al. (2004)36 45 ADHD 9.8 T 2.8 0
29 Controls 9.2 T 2.5
Huang et al. (2004)31 88 ADHD 6Y12 2
27 Controls 6Y12
Kirov et al. (2004)32 17 ADHD 8.1Y14.3 2
17 Controls 8.0Y14.4
Gruber and Sadeh (2004)30 24 ADHD 7Y11 1
25 Controls 7.67Y10.4
Cooper et al. (2004)27 18 ADHD 10.5 T 3.0 2
20 Controls 10.0 T 3.9
Golan et al. (2004)28 34 ADHD 12.4 T 4.6 2
32 Controls 12.0 T 3.6
Miano et al. (2006)57 20 ADHD 6Y13 2
20 Controls 6Y13
Kirov et al. (2007)52 18 ADHD 8.2Y14.9 2
18 Controls 8.0Y15.6
Mayes et al. (2008)56 189 ADHD Not provided for this subgroup 0
135 Controls 6Y12
Gruber et al. (2009)47 15 ADHD 8.93 T 1.39 0 and 2
23 Controls 8.61 T 1.27
Owens et al. (2008)5 53 ADHD 10.2 T 2.0 0 and 1
42 Controls 10.3 T 2.6
Hvolby et al. (2008)4 45 ADHD 5.9Y10.11 0 and 1
97 Controls 6.0Y11.1
Note: Studies are listed in chronological order of publication. ADHD = attention-deficit/hyperactivity disorder; PSG = polysomnography.

significantly differ between the children with ADHD
and the controls.
DISCUSSION
To our knowledge, this is the first meta-analysis
including data from both subjective and objective
studies comparing sleep disturbances in nonmedicated
children with ADHD (without mood or anxiety
disorders) versus controls. It provides an update to the
two available meta-analyses12,14 of objective sleep
parameters in children with ADHD published approxi-
mately 3 years ago, as well as the first meta-analysis of
subjective sleep parameters.
A note of caution should be expressed in the inter-
pretation of our results because our rigorous selection
led to a rather limited number of studies to be included in
the meta-analysis. Moreover, the sample size varies con-
siderably for the different sleep parameters. However,
although further studies are still needed, our meta-
analysis does at least allow more precise estimates than
those of any individual study: the combined sample size
is 271 children with ADHD versus 200 controls in the
nine PSG studies,27,28,31Y34,47,52,57 160 ADHD versus
228 controls in the four actigraphic studies,4,5,29,30 and
404 ADHD versus 372 controls in the six subjective
studies4,5,36,39,47,56 (total pooled sample of 722 child-
ren with ADHD versus 638 controls). This is the largest

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 SLEEP AND ADHD: META-ANALYSIS

Fig. 1 Confidence interval plots of effect size from subjective studies. Point estimates and 95% confidence intervals for effect size are given in terms of the absolute
or standardized difference in means. Effect sizes lower than 0 indicate higher values in the children with attention-deficit/hyperactivity disorder compared with the
controls. The results for individual studies are combined in an overall meta-analysis estimate of effect size, shown in the last line of each plot. Confidence intervals
that exclude 0 can be considered statistically significant at the nominal 5% level.

available pooled sample providing data on subjective and
objective measures of sleep in children with ADHD.
Moreover, it is noteworthy that, although in the previous
systematic review by Cortese et al.12 covering a period of
approximately 20 years (1987 to October 2005), the
authors found 13 pertinent studies27Y39; in the last 3
years, six methodologically sound studies4,5,47,52,56,57
(according to our criteria) were published, reflecting the
growing interest for this topic as well as improvements in
methodology.
We first discuss the results from the meta-analysis of
subjective and then from objective studies.
Subjective Studies
The children with ADHD had significantly more
difficulties than the controls in most of the parentally
rated sleep items, suggesting that ADHD is a condi-
tion described by the parents as impairing not only
during the daytime but also in the evening and early
morning.

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CORTESE ET AL.

Fig. 2 A, Confidence interval plots of effect size from objective studies (first part). B, Confidence interval plots of effect size from objective studies (second part).

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Fig. 2 Continued
Several explanations may be considered as to why BR,
SOD, NA, and DMA were more problematic for the
children with ADHD. It is possible that the difficulties
reported as significantly higher in the children with
ADHD refer to inappropriate behavior in the context of
problematic parentYchild interaction. It has been
reported that ‘‘many families of children with ADHD
have inappropriate sleep habits including environ-
mental, scheduling, and sleep practice,’’81 which may
contribute to sleep initiation and maintenance problems
as well as to difficult morning awakenings. Another
possible explanation is that symptoms of ADHD, such
as restlessness in the evening and poor organization,
contribute to difficult behavior during the evening and
early morning, even in the context of appropriate sleep
J. AM . ACAD. CHILD ADOLESC. PSYCH IAT RY, 48:9, SEPTEMBER 2009
Copyright @ 2009 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
SLEEP AND ADHD: META-ANALYSIS
habits established by the parents. As we previously
mentioned, some of the children with ADHD included
in the meta-analysis presented with comorbid ODD,
which can contribute to problematic behavior during
the evening and early morning. Therefore, the inclusion
of children with ADHD plus ODD prevented us from
teasing out the effect of ODD and ADHD itself on
difficult sleep behaviors. However, because it has been
reported that 54% to 84% of the children and
adolescents with ADHD meet criteria for ODD,1 we
felt that the exclusion of studies assessing children with
ADHD plus ODD would have been inappropriate. As
clinicians, we would like to point out that it is some-
times difficult in the day-to-day practice to understand
if difficult behaviors in the evening or early morning are
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CORTESE ET AL.
due to ODD, ADHD itself, or to a combination of
both. It is possible that the high heterogeneity in stud-
ies for the above-mentioned parameters (as suggested by
I2 = 79.2%, 90.4%, 56.3%, and 59.9% for BR, SOD,
NA, and DMA, respectively) is due, at least in part, to
the different prevalence of comorbid ODD or opposi-
tional behaviors in the sample of the studies retained in
the meta-analysis. Another explanation for the signifi-
cantly higher rate of difficult sleep behaviors in the
children with ADHD is that parents of the children
with ADHD may more likely report high levels of
daytime and sleep-related problematic behaviors in a
sort of ‘‘negative halo effect.’’ However, as we will dis-
cuss later, it is also possible that objective sleep alter-
ations contribute to difficult behaviors around sleep
time. Parents may consider the difficult behaviors
around sleep time as the expression of a general oppo-
sitional attitude, thus ignoring the cause of the child’s
behavior, which may be the expression of an underly-
ing real sleep disturbance that manifests itself with
behavioral difficulties.
Finally, given the selection criteria of the present
meta-analysis, we can exclude the possibility that med-
ications and comorbid mood and anxiety disorders
contributed to the sleep difficulties described by parents.
Therefore, we conclude that problematic sleep behaviors
in the children with ADHD cannot be explained by the
effects of medication status or non-ODD psychiatric
comorbidity.
The other two items that were significantly and
independently higher in the children with ADHD were
daytime sleepiness and SDB. Because the analysis of
objective parameters suggested that the children with
ADHD may present with a significant alteration of
arousal and with sleep breathing disorders, we will
discuss these results later along with the discussion of
objective findings.
The items PA and sleep duration were not signif-
icantly different between the children with ADHD
and the controls. However, the high heterogeneity in
studies for these two parameters, 61.2% and 89.9%,
respectively, suggests that this conclusion should be
considered with caution. As for the item PA, because it
includes several different conditions (e.g., sleepwalking,
sleep terrors, nightmares, enuresis, sleep-related eating
disorders) that are not consistently explored in all the
studies, the study methodology relevant to this item
could be refined with a standardized definition of the
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conditions included under the subjective item PA. As
for the item sleep duration, the high heterogeneity
in studies could be due to the fact that parents may
differently interpret this item (e.g., from lights off to
wake up or the time the child actually sleeps); moreover,
it may be difficult for a parent to accurately estimate
sleep duration if the child sleeps in another room.
Therefore, a more consistent subjective definition of
‘‘sleep duration’’ should be provided in future studies.
Only one study56 retained in our meta-analysis
provided subjective data on restless sleep, and therefore,
further studies on parental estimation of sleep move-
ments are needed.
Finally, we point out that none of the retained studies
included items on restless legs syndrome, which recently
has received special attention by sleep researchers and
clinicians interested in ADHD.82
Objective Studies
From the forest plots reported in Figure 2, it is evi-
dent that several parameters did not significantly differ
between the children with ADHD and the controls.
However, the children with ADHD significantly dif-
fered from the controls on six objective parameters.
Sleep onset latency measured with actigraphy resulted
significantly higher in the children with ADHD com-
pared with the controls. This suggests that the BR and
SOD reported by parents in their ADHD children, and
often interpreted as oppositional behavior, might be
determined, at least in part, by intrinsic longer sleep
onset latency, independent from psychiatric comorbid-
ities or medication status. However, the result for SOL-a
should be considered with caution because it derived
mostly from the effect of one study.4 Moreover, it has
been reported that sleep onset latency tends to be the
least reliable sleep parameter measured by actigraphy.83
Consistent with this, the test of heterogeneity for SOL-a
was large (I2 = 86.9%) and highly significant, suggesting
that SOL-a is not measured similarly across laboratories.
Furthermore, the SOL-PSG did not differ between the
children with ADHD and the controls, and this mea-
sure was not significantly heterogeneous (I2 = 0.0%),
suggesting that it might be a more reliable way to es-
timate sleep onset latency. However, this measure may
be of limited usefulness to assess if the children with
ADHD have an intrinsic disturbance of sleep onset. In
fact, it has been suggested that the children with
ADHD present with a night-to-night variability in sleep
J. AM. A CAD. C HILD ADOLESC. PSYCHIATRY, 48:9, SEPTEMBER 2009

patterns.29 It is possible that parents are more likely to
recall, and thus report as ‘‘typical,’’ those nights on
which a child has significant BR or difficulty falling
asleep. Objective measures, such as SOL-PSG, during
just few nights may not capture this potential variability.
Therefore, we conclude that, at present time, because of
methodological limitations, data from objective studies
(both those using PSG and those relying on actigraphic
measures) cannot indicate if SOD reported by parents in
their children with ADHD may be due to underlying
objective sleep alterations.
The parameters ST1%, ST2%, percentage of stage
slow-wave sleep, REM%, and REM sleep latency did
not significantly differ between the children with
ADHD and the controls. The lack of differences for
these measures cannot be attributed to between-study
heterogeneity because we found significant hetero-
geneity for only two measures (moderate for ST1%,
I2 = 54.4%, and high for REM%, I2 = 76.7%), whereas
I2 for the other measures were less than 25%, suggesting
that, in general, PSG provides consistent measures of
sleep architecture parameters in different laboratories
because most of the laboratories adopt standardized
definitions of sleep architecture parameters. It has been
hypothesized that some alterations in sleep architecture,
in particular in REM sleep, may contribute to executive
dysfunctions,84 which are common (although not
universal) in the children with ADHD.85 However,
past literature has provided mixed findings on REM
duration and other sleep macro-architecture para-
meters.8 Indeed, the pooled analysis of all data on
sleep architecture suggested no significant alterations in
REM sleep and other parameters of macro-architecture.
This is a major finding, confirming the conclusions of
the previous meta-analysis by Cortese et al.,12 as well as
those of Sadeh et al.14
Although the stages of sleep macro-architecture may
not be significantly different in the children with
ADHD and the controls, the analysis of the other
parameters that were significantly different in the
subjects with ADHD (SE-PSG, TS, and SHIFTS/h)
suggests that sleep in the children with ADHD may
indeed be significantly more compromised and frag-
mented. The low heterogeneity in studies for SE-PSG
confirms that PSG is a reliable method to assess sleep
efficiency and supports the notion of a lower sleep
efficiency in the children with ADHD than in the
controls. This objective alteration might contribute to
J. AM . ACAD. CHILD ADOLESC. PSYCH IAT RY, 48:9, SEPTEMBER 2009
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SLEEP AND ADHD: META-ANALYSIS
subjective complaints of poor sleep. However, given the
paucity of studies contributing to this result and the
high heterogeneity for TS, and SHIFTS/h, a note of
caution should be used before concluding that sleep in
the children with ADHD is significantly more com-
promised and fragmented than that in the controls.
Abnormal movements in sleep might be one of the
causes of this fragmentation. Unfortunately, it was not
possible to pool data on measures of movements in sleep
(general movements in sleep and periodic limb move-
ments in sleep) because the retained studies27,28,31Y33,47
used different indices to quantify movements in sleep.
However, the descriptive analysis of these studies does
indicate that general sleep movements32,33 and periodic
limb movements27,28,31,32,47 may be significantly more
elevated in the children with ADHD than in the
controls.
Apnea-hypopnea index resulted significantly higher
in the children with ADHD than in the controls. The
pooled analysis of the subjective parameter SDB, as
previously reported, indicated that also the subjective
evaluation of parents pointed to significantly more
impairment associated with sleep breathing. The I2 =
0.0% for AHI suggests that the standardized definition
of AHI across laboratories provides a reliable estimation
of this parameter among studies. Moreover, the ab-
sence of significant heterogeneity in parental estimation
of SDB also indicated that not only the objective
parameter AHI but also the symptoms such as snoring
and difficult breathing can be consistently estimated by
parents across different studies. The mean values of
AHI in the children with ADHD in the three objective
studies27,28,31 were not elevated (1.0, 5.8, and 3.57,
respectively). However, if one assumes, as suggested
by Chervin,86 that moderate values of AHI between 1
and 5 are suggestive of pediatric obstructive sleep apnea
deserving clinical attention (which is still controver-
sial86,87), all the previous data concur to suggest that
SDB may be more frequent in the children with ADHD
than in the controls. According to Chervin,86 mild
SDB, in an AHI range of 1 to 5 and sometimes less,
rather than more severe SDB, may be particularly
common in the children with ADHD, perhaps because
more severe SDB may cause enough daytime sleepiness
or other problems that could mask hyperactivity.
However, the causal contribution of SDB to ADHD,
if any, remains to be established in detail. It has been
reported that adenotonsillectomy can significantly
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CORTESE ET AL.
reduce rates of ADHD (diagnosed according to DSM
criteria) in the children referred for adenotonsill-
ectomy.42 Given the limited evidence and the metho-
dological issues relating to the definition of pediatric
‘‘pathological’’ AHI, it is not possible to accurately es-
timate the prevalence of the children with ADHD who
have SDB and might benefit from adenotonsillectomy.
As for MSLT studies, the average times to fall asleep
(considering all the MSLT nap opportunities) were
significantly lower in the children with ADHD than in
the controls, indicating that the children with ADHD
show a tendency to be sleepier than the controls during
daytime. Also, the subjective item daytime sleepiness
was significantly higher in the pooled analysis of
the subjective studies. Interestingly, excessive daytime
sleepiness substantially overlaps with the construct of
slow cognitive tempo, which has been proposed as a
dimension of behavior/cognition that has the potential
to better characterize youths with inattentive-type
ADHD than do current DSM-IV symptoms.68 How-
ever, excessive daytime sleepiness might also characterize
a subset of children with combined-type ADHD.
According to the hypoarousal theory of ADHD first
defined by Weinberg and Harper,88 the children with
ADHD are sleepier than the controls and might use
excessive motor activity as a strategy to stay awake and
alert. Interestingly, recent data on cyclic alternating
pattern in the subjects with ADHD confirmed that they
may present with a hypoaroused state.57 The nature of
excessive daytime sleepiness has to be determined:
excessive daytime sleepiness might be a primary disorder
or the consequence of some other sleep alteration.
However, a note of caution should be used because a
limited number of studies provided data on daytime
sleepiness in the children with ADHD and because of
the high heterogeneity in both MSLT objective
studies28,34 and subjective studies39,47,56 providing
data on daytime sleepiness. It is possible that hetero-
geneity in MSLT studies is due to different methodol-
ogy used by Lecendreux et al.34 (four nap opportunities,
each one lasting 20 minutes) and Golan et al.28 (five nap
opportunities, each one lasting 30 minutes) and to the
different mean ages of the patients (approximately 8
years in Lecendreux et al.34 and approximately 12 years
in Golan et al.28). The moderate heterogeneity in the
parental estimation of their child’s daytime sleepiness
could be due to the fact that it may be difficult to
consistently estimate daytime sleepiness in the children
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with ADHD, given that hyperactivity might ‘‘mask’’
excessive daytime sleepiness.
Night wakings on actigraphy (which was consistently
reported in studies, as indicated by a low I2 (7.5%),
suggesting the reliability of actigraphy for this measure)
was not significantly different between the children with
ADHD and the controls, indicating that the higher
parental rating of NA is not supported by objective
actigraphic data. However, actigraphy only estimates
awakenings on the basis of movement and cannot mea-
sure cortical awakenings. It is not clear why the SE-a
and the SHIFTS did not differ between the subjects
with ADHD and the controls, considering that a sig-
nificant difference was found for SE-PSG and in the
SHIFTS/h. Although it is possible that methodolo-
gical differences in the studies contributed to this
discrepancy, between-study heterogeneity was not high
for either SHIFTS or SE-a (I2 = 0.0% and 44.4%,
respectively).
CONCLUSIONS
The pooled analysis of 16 methodologically sound
studies4,5,27Y34,36,39,47,52,56,57 published between 1987
and 2008 has shown that the children with ADHD
are significantly more impaired than the controls in
most of the parentally reported sleep items (concerning
problematic behaviors around bedtime and in early
morning) as well as in some actigraphic and poly-
somnographic measures indicating fragmented sleep,
poor sleep efficiency, SDB, and excessive daytime
sleepiness. Our review also indicates that, for some
sleep parameters (restless sleep, PA, DMA, SHIFTS/h,
and time to fall asleep during MSLT), only one or two
studies are available, which highlights the need for
further research.
Given the limited number of studies retained in our
review, we do not believe that evidence-based guidelines
for the management of sleep disturbances associated
with ADHD can be inferred by the present meta-
analysis. However, we do think that our results lay the
groundwork for future evidence-based guidelines.
Moreover, the pathophysiological hypotheses suggested
by our findings on objective studies may set the ground-
work for potential innovative neurobiological studies
on ADHD inspired by sleep/alertness mechanisms.
This body of research will form the theoretical basis
for a better assessment and management of sleep dis-
turbances in the children with ADHD, thus allowing
J. AM. A CAD. C HILD ADOLESC. PSYCHIATRY, 48:9, SEPTEMBER 2009

a better quality of life for these patients and their
families.
Disclosure: Dr. Cortese has received financial support to attend medical
meetings from Eli Lilly & Company and Shire Pharmaceuticals, and has
been co-investigator in studies sponsored by GlaxoSmithKline, Eli Lilly
& Company, and Genopharm. Dr. Faraone receives research support from
or has been on advisory boards for the following: Shire Laboratories, Eli
Lilly & Company, Pfizer, McNeil Pharmaceutical, and the National
Institutes of Health. Dr. Konofal has served on the advisory boards for
Shire and UCB. He has consulted for Shire. He has served as a medical
writer for Remidica and Janssen-Cilag. He has served on the speakers_
bureau of UCB and served as a principal investigator in clinical trials for
Eli Lilly & Company and Janssen-Cilag. Dr. Lecendreux has received
industry research funding from Shire. He has served as a consultant for
UCB and Shire. He has served as an investigator for Eli Lilly &
Company and Shire.
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