Comparative Analysis of Sleep Patterns in Pediatric ADHD and Control Groups

Thesis Abstract

Sleep disturbances are increasingly recognized as a core feature of pediatric attention-deficit/hyperactivity disorder (ADHD), potentially impacting daytime functioning, cognitive performance, and metabolic health, yet robust comparative data against typically developing controls remain limited. This study addresses the gap by examining sleep patterns in a comparative cross-sectional framework to elucidate unique sleep profiles associated with pediatric ADHD and the extent to which these patterns relate to behavioral and cognitive outcomes. The aim is to characterize nocturnal and circadian sleep parameters in children aged 6–12 years diagnosed with ADHD (n=180) versus age- and sex-matched controls (n=180), and to determine how sleep variables mediate or moderate attentional, executive function, and mood indicators. Specific objectives are to (1) quantify objective sleep metrics via actigraphy over a 14-day monitoring period and collect parental reports using the Children's Sleep Habits Questionnaire (CSHQ); (2) assess daytime functioning with standardized measures including the Conners’ Continuous Performance Test (CPT-3), the Behavior Rating Inventory of Executive Function (BRIEF-2), and the Pediatric Daytime Sleepiness Scale (PDSS); (3) examine differences in sleep onset latency, total sleep time, sleep efficiency, wake after sleep onset, and circadian phase using wrist-worn actigraphy and melatonin onset timing in a subsample (n=80 per group); (4) test associations between sleep variables and behavioral outcomes using multivariate regression while controlling for comorbidities and stimulant medication status; and (5) explore whether child gender and ADHD presentation (combined, predominantly inattentive, predominantly hyperactive-impulsive) moderate sleep–outcome relationships. The methodology employs a cross-sectional design within which a stratified random sample of pediatric participants is drawn from clinical ADHD cohorts and community controls across three urban pediatric centers. Data collection instruments include actigraphy devices (wrist-worn accelerometers with 1-minute epochs), the CSHQ, CPT-3, BRIEF-2, PDSS, and a subsample collected for dim-light melatonin onset (DLMO) assessment to infer circadian phase. Validity and reliability of instruments are supported by prior research; actigraphy protocols adhere to standard scoring algorithms, and inter-rater reliability for behavioral measures is ensured via certified assessors. Data analysis comprises descriptive statistics to profile sleep parameters, mixed-model ANOVA to compare group differences in nocturnal metrics across nights, and multiple linear regression to identify sleep predictors of attention, executive function, and mood, with Bonferroni correction for multiple testing. Mediation analyses will test whether sleep quality mediates ADHD symptoms and daytime dysfunction, while moderation analyses will examine the influence of ADHD subtype and medication status. Theoretical framing integrates the Two-Process Model of Sleep Regulation and the Social Ecological Model to contextualize biological and environmental determinants of sleep in pediatric ADHD. Anticipated findings include shorter total sleep time, longer sleep onset latency, reduced sleep efficiency, and greater wake after sleep onset in the ADHD group relative to controls, with large effect sizes observed for sleep efficiency and daytime sleepiness. It is expected that poorer sleep quality will significantly predict poorer CPT-3 performance and greater executive function challenges on BRIEF-2, with sleep variables partially mediating the relationship between ADHD status and daytime impairment. The study contributes to knowledge by delineating objective and subjective sleep phenotypes in pediatric ADHD, clarifying the strength and direction of sleep–neurocognitive associations, and identifying sleep parameters that could be targeted in nonpharmacological interventions. The findings have implications for clinical assessment and management, emphasizing the need for routine sleep screening in pediatric ADHD and informing chronotherapeutic strategies and behavioral sleep interventions. Recommendations include integrating actigraphy-based sleep monitoring into standard ADHD evaluations, implementing parent-guided sleep hygiene and regularize bedtime routines, and prioritizing longitudinal research to establish causal pathways between sleep disturbances and functional outcomes in pediatric ADHD populations. Acknowledging limitations such as cross-sectional design, potential medication confounds, and generalizability constraints, the study nonetheless offers a rigorous, multi-method examination of sleep in pediatric ADHD and lays groundwork for subsequent longitudinal and interventional studies.