The impact of sleep difficulties in children with attention deficit hyperactivity disorder on the family: a thematic analysis

Abstract

Study Objectives:

Attention deficit hyperactivity disorder is a complex but common neurodevelopmental condition characterized by symptoms of inattention, hyperactivity, and impulsivity associated with a significant level of academic, social, and functional impairment. Problems around sleep frequently co-occur with attention deficit hyperactivity disorder and are thought to affect 50% to 80% of children and adults with the condition. Sleep issues typically include trouble falling asleep, bedtime resistance, night-time waking, and early rising. The impact of these problems on families and parents is profound but poorly researched.

Methods:

Semistructured interviews took place with 12 mothers of children with attention deficit hyperactivity disorder who struggle with sleep. Participants were asked about sleeping patterns and issues, methods used to improve sleep, the impact on parents’ sleep and wider family life, and involvement with clinical services and support groups. Data were analyzed using thematic analysis.

Results:

Three themes were identified in the data: a constant battleground; the cumulative effect of lack of sleep: impact on functioning and the wider family; a mixed bag of strategies: the tried, tested, and needed. Long-term sleep issues and challenging behavior at bedtime had substantial negative effects on families. Parents experiencing sleep deprivation experienced functional impairments to daily life and well-being and strain on relationships with children and spouses.

Conclusions:

Findings revealed parents were consistently and profoundly impacted by their children’s sleep problems. Parents sought strategies and support in many different ways but were often unsuccessful.

Citation:

French B, Quain E, Kilgariff J, Lockwood J, Daley D. The impact of sleep difficulties in children with attention deficit hyperactivity disorder on the family: a thematic analysis. J Clin Sleep Med. 2023;19(10):1735–1741.

BRIEF SUMMARY

Current Knowledge/Study Rationale: Children with ADHD commonly have great difficulties with sleep including getting to sleep, staying asleep and less deep sleep. While this strongly impacts the children, it also affects their parents and families.

Study Impact: This study highlights new findings on the impact that sleep difficulties in children with ADHD has on the entire family, impacting the parents’ functioning, well-being, and family relationships. Bedtime and sleep-related activities are often a battleground for the family, and healthcare professionals should strongly consider the effect sleep difficulties have on the whole family, facilitating better support.

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder affecting approximately 5% of children globally.¹ ADHD is characterized by clusters of inattention, hyperactivity, and impulsivity resulting in a complex profile of difficulties² impairing academic, social, and everyday functioning.^3,4

ADHD is commonly comorbid with various conditions, such as dyspraxia, autism spectrum disorder, or anxiety and depression.⁵ Sleep difficulties also co-occur highly with ADHD and affect 50% to 73% of children.⁶ A study of more than 4000 children revealed that children experiencing moderate to severe sleep issues were 12 times more likely to have a diagnosis of ADHD.⁷ However, currently many ADHD guidelines fail to acknowledge the strong relationship between sleep and ADHD.⁸

ADHD sleep issues include difficulties with settling, increased time until sleep begins (sleep-onset latency), resistance at bedtimes, poor quality sleep, constant movement, frequent waking and getting up during the night, early waking, and tiredness in the morning.^9,10 Children with ADHD move through the sleep stages in a different way and sleep 1 hour per night less than their non-ADHD counterparts.¹¹ Compared to non-ADHD controls, children with ADHD experience a lower percentage of rapid eye movement sleep per night as well as higher levels of restless legs syndrome and periodic leg movements during sleep.^6,12 They also display more frequent arousals from slow wave sleep—the deepest stage of sleep.¹³ As a consequence of living with such difficulties, caregivers tend to also experience sleep that is shortened or disturbed,^11,14 negatively affecting family functioning and parental mental health.¹⁵ Additionally, parents experience significant stress around bedtimes¹⁶ with a substantial degree of resistance and struggle in parent-child interactions in the evenings.^17,18

ADHD medication such as methylphenidate¹⁹ may worsen sleep by reducing total sleep time and increasing sleep-onset latency.²⁰ However, the evidence surrounding the impact of Methylphenidate on sleep is mixed. A randomized controlled trial²¹ found that sleep problems when taking methylphenidate were positively correlated with sleep problems already experienced before starting the medication. This finding was supported by other studies,^22,23 suggesting that poorer sleep before medication was linked to poorer sleep on medication. However, sleep problems in children significantly increased as methylphenidate dosage increased, with children on the highest dose exhibiting worse sleep functioning than those on lower doses.²⁴ Issues with quality and quantity of sleep have been observed in medicated and nonmedicated children,²⁴ suggesting that this issue is highly pervasive and not specific to medication.

Strategies can be put in place to help sleep in children with ADHD. Guidelines recommend that sleep hygiene and behavioral interventions should be attempted before pharmacological interventions, such as melatonin.²⁵ Sleep hygiene refers to maintaining a reliable bedtime and waking schedule, daily physical activity, consistent wind-down routine, removal of naps, and avoidance of screens in the hour before bed. Studies evaluating the effect of sleep hygiene practices in ADHD have produced mixed findings. For instance, poor sleep hygiene did not lead to worse sleep problems for children with ADHD but did for children with autism spectrum disorder and neurotypical children, despite the ADHD group showing the poorest adherence to sleep hygiene.²⁶ Contrastingly, a cross-sectional study revealed that poor sleep hygiene practices were associated with higher rates of sleep problems²⁷ and sleep quality and ADHD symptoms improved after adoption of sleep hygiene principles.²⁸ Behavioral strategies can be taught through training sessions or manuals²⁹ and include management strategies and reinforcement of desired behavior.³⁰ A randomized controlled trial investigating the effect of behavioral strategies on ADHD symptoms and other factors³¹ found that the intervention group significantly benefitted from the sleep strategies on several outcomes, including ADHD symptomology, sleep duration, teacher-reported behavior, and working memory. Similarly, a brief sleep training program delivered to parents and clinicians strongly increased their confidence and competence in managing sleep in children with ADHD.³² Prescription melatonin is also commonly prescribed³³ with up to 44% of all melatonin prescribed by pediatricians used for patients with ADHD.³⁴ Randomized controlled trial studies suggest that melatonin significantly improve sleep-onset latency and total sleep time in children with ADHD.^35,36

Reduced sleep has innumerable consequences on daily cognitive functioning and physical and mental well-being.^37,38 A review of sleep deprivation and disruption in neurotypical children³⁹ found that lack of sleep for adolescents had negative impacts on psychosocial functioning, cognitive functions, and performance at school and increased their risk-taking behaviors. These findings illustrate the profound impact that poor sleep can have on any young person but are even more concerning for children with ADHD who already display some of these symptoms and are predisposed to sleep issues. Children with ADHD who struggle to sleep are more likely to have educational challenges, with more prevalent school absenteeism and tardiness¹⁵; poorer working memory compared with children with ADHD without sleep problems and non-ADHD children⁴⁰; and a decline in attention, suggesting that existing ADHD symptoms are exacerbated by lack of sleep.⁴¹

The current literature suggests significant negative effects of sleep issues on children with ADHD. However, the impact of ADHD-related sleep issues on parental well-being and family functioning have not been sufficiently explored. Gaining an insight into parents’ perspectives of these difficulties is an essential step in understanding the broader impact of sleep issues on the families. This study explores through semistructured interviews how parents of children with ADHD experience and manage aspects associated with sleep issues, including disrupted sleep and methods used to improve sleep.

METHODS

Participants

Twelve parents (all female, mean age:42.5 years) were recruited through online ADHD parent support groups. Parents had to be the primary caregiver of a child ages between 6 and 16 years (75% male, age range 6–14, mean age:10.1 years) with an ADHD diagnosis. Participants were excluded from taking part if they or their children had long-term health conditions that might impact on sleep, such as epilepsy, hyperthyroidism, fibromyalgia, or hypertension.^42,43

Procedure

Upon checking participants’ eligibility, written consent was obtained and parents were offered a choice of telephone or video interview over Microsoft Teams, which lasted 40 to 60 minutes. An interview schedule was developed covering topics such as sleeping patterns and issues, methods used to improve sleep, and impact on parent sleep and family life (supplemental material). Interviews were audio-recorded, transcribed verbatim, and anonymized. Ethical approval was granted by the hosting institution (ref. 2758).

Data analysis

Thematic analysis⁴⁴ was used to analyze the data. This enabled an inductive approach focused on analyzing patterns of meaning from participants’ experiences, focusing on what is important to them and why. Following transcription, the lead researcher first familiarized herself with the interview data, making notes in a diary of preliminary thoughts on the content of the interviews. A number of initial codes were identified and then systematically condensed following a discussion from the research team. Codes were then reviewed to construct five initial patterns of meaning, which were developed into themes using comparative analysis and thematic maps. Themes were refined into three final themes that encapsulated distinct experiences associated with parenting a child with ADHD who struggles with sleep.

RESULTS

Three themes were created: (1) a constant battleground; (2) the cumulative effect of lack of sleep: Impact on functioning and the wider family; (3) a mixed bag of strategies: the tried, tested, and needed.

A constant battleground

This theme highlights the difficulties and struggles associated with night-time routines including settling for sleep and staying in bed. Many children displayed sleep disturbances and difficulties at various points in the evening, night, and morning, and often these issues had been present throughout the child’s life. A prominent issue raised by parents reflected their child’s inability to fall asleep, characterized by long sleep-onset latencies. This appeared to be driven by difficulties winding down in the evening with children taking a long time to settle and often being hyperactive, bored, or seeking stimulation at bedtime. Several parents likened the winding down process to a “fight,” and these difficulties continued to occur despite methods or measures used to aid sleep, alluding to a feeling of futility and inevitability. Some parents conceptualized and understood their child’s difficulty initiating sleep in terms of a racing ADHD brain, which does not “switch off” to allow them to fall asleep, despite physical tiredness.

“It will just take her a really long time to settle down [.…] she couldn’t lie down and stay still cause it’s too boring” [P3]

“He often says, ‘you don’t understand. When I go to sleep, I don’t really go, nothing is quiet, it [his brain] just carries on.’” [P2]

Difficulties settling at bedtime could be heavily influenced by children experiencing anxiety, fears, and overthinking. For instance, ADHD symptoms being misunderstood created anxiety which later disrupted sleep.

“He’s always overthinking things and worried about stuff and he’s really scared about any noise or won’t go to the bathroom on his own.” [P9]

Parents reported that children were uncooperative with bedtime routine and resisted starting bedtime activities such as brushing teeth, putting pajamas on, and getting into bed. This noncompliance frequently led to arguments, hostility, and agitation, further hindering settling and relaxation and causing parents to dread bedtimes.

“Bedtime becomes hostile ground, doesn’t it? It’s the time that you come to dread because you know, it’s like, ‘here we go again.’” [P1]

Children often woke up in the night and left their beds. For some, this was to use the toilet or seek out stimulation, for instance by watching television, while others sought comfort or attention from parents. Children waking did not rouse all parents, but for many parents, their child’s nocturnal activities did disturb their sleep.

“We’ll be asleep, and he will wake us up, but not because he’s come to see us, but because he just got up in the middle of night and decided to play with Lego.” [P7]

Children were often energetic during the night and in the mornings. Children could wake up early in the morning appearing energized, despite late bedtimes and interrupted sleep, and did not compensate for the lack of sleep by lying-in the next morning. Some children appeared to manage well on consistently reduced sleep, but, for others, poor sleep resulted in ADHD symptoms being more apparent and behavior and mood being more challenging.

“It’s quite hard because I’ve got my son with ADHD, my husband with ADHD, they seem to function quite well without any sleep, and then they can’t understand why I can’t function properly.” [P5]

“Although he fights it. He is tired and he doesn’t realize it, so that’s when your behavioral challenges start. Sort of early evening.” [P4]

The cumulative effect of lack of sleep: impact on functioning and the wider family

This theme captures the detrimental and debilitating effects of interrupted sleep and sleep deprivation on parents and families’ well-being. Sleep difficulties resulted in parents’ sleep being negatively impacted, leading to significant functional, practical, and emotional impairment on the whole household.

Tiredness and sleep deprivation appeared to impair parents cognitively, for example worsening their memory and concentration. Sleep difficulties hindered parents’ ability to carry out daily tasks effectively and maintain careers. Some parents compared sleep deprivation to “torture” and likened its effects to that of “brain damage.” These issues also negatively affected their mental health and well-being. Parents’ mood was seriously impacted, including anxiety and feelings of hopelessness, leading them to seek professional help.

“I’ve had jobs, I’ve lost jobs, well left jobs because I can’t function at work … it just knocks my concentration […] I just sat at home and cry. Just not knowing what to do next and I’d feel so weak and helpless, it was horrible.” [P5]

Furthermore, parents added that the nature of ADHD means there is no recovery time or respite as children demand such a significant proportion of their attention and energy all day long. Sleep difficulties had a negative impact on parents’ ability to cope with the challenges associated with parenting a child with ADHD. Tiredness often made them more irritable and less understanding of their child’s needs.

“It just makes you more snappy […] he’s just not made up the same as us and he doesn’t cope with things the same as us, so it’s trying to put yourself in his situation and that becomes difficult when you’re tired and irritable.” [P4]

This impact on mental health meant that some parents were prescribed antidepressant or antianxiety medication to help them manage their mental health and a demanding home environment. Others experienced unpleasant and regrettable thoughts as a result of extreme tiredness.

“Sometimes I do look at him and think, ‘I really can’t cope with you’ if I’m being really honest […] And then I thought, ‘no, you can’t feel that way, you’re his mum.’” [P5]

Consistent sleep problems sometimes led parents to doubt their parenting abilities. Parents made comparisons between their children with ADHD and other children who do not experience sleep issues, resulting in feelings of inadequacy and self-reproach.

“It makes you feel like you don’t know what you’re doing, that you can’t cope. Why are everybody else’s children going to bed and going to sleep and having a nice bedtime story? And yours is up and down the stairs all evening.” [P10]

Acceptance of their child’s sleep issues was an approach that appeared to modify parents’ mindsets and improve well-being. It seemed that accepting and adapting the bedtime routine to better suit the child’s needs allowed parents to absolve themselves of feelings of blame and guilt and support coping.

“Since the diagnosis, it kind of gives you that acceptance inside that you’re not being a bad parent and that actually he’s got different needs and it’s not his fault that he can’t get to sleep.” [P9]

Children’s sleep issues often reduced the opportunities for parents to spend time with their spouse in the evenings. Difficulties settling and getting out of bed caused significant disruptions and impacted many aspects of couples’ time together. For instance, one parent reported that their choice of television program in the evening had to be closely monitored in case the child came downstairs. It was also mentioned that cosleeping with their child had a negative effect on their spousal relationship. Tiredness also led to more arguments and to resentment between spouses where sleep and workload were concerned.

“We don’t have much time together at all because the evenings are disturbed. One of us is always getting up and doing something.” [P10]

“Then you get resentful because you perceive that they’ve had more sleep than you, or that you have done more than them.” [P12]

Tiredness also impacted the relationships with other children. Siblings were reported to feel “hard-done-by” or as though they were taking a “backseat” due to the all-encompassing nature of raising a child with ADHD who demands a great deal of energy from already-exhausted parents. Parents were more prone to losing their temper at their other children as a result of tiredness and irritability.

“I might get bit cross with her quicker than I might normally because, you know, I’m fed up of nearly 12 years of sleep issues with her brother.” [P10]

A mixed bag of strategies: the tried, tested, and needed

This theme captures the tools, strategies, and support used by parents to improve their child’s sleep and bedtime routine, highlighting the trial and error nature of these difficulties with no “one size fits all.”

The effect of ADHD medication and melatonin was mixed with some parents highlighting its negative impact on children’s sleep, while others praised its beneficial impact on bedtime routine. ADHD medication allowed some children to engage with the wind-down process at bedtime and regulate their emotions, reducing meltdown, and improving the experience for the whole family. Prescription melatonin improved children’s behavior at bedtime by mellowing ADHD traits and allowing them to feel tired.

“I would say the resistance to us about engaging in the bedtime routine is not as much now (since starting medication), even though he’s taking longer to get to sleep and wind down, actually getting him to that place is a lot easier for him and for us.” [P1]

“I noticed that it (melatonin) brought him a sense of calm […] he did say, ‘it’s really nice to go to bed and my brain hasn’t got lots of information whizzing around in it. My brain is empty and it’s really nice.’” [P7]

However, parents also commented on the unreliable efficacy of melatonin over time as children become tolerant of the dosage. Additionally, melatonin seemed less efficient when children were anxious or emotionally dysregulated.

“Melatonin probably 50/50 works. If he’s particularly stressed out, or he’s had a meltdown a bit too close to bedtime, then it doesn’t work at all.” [P10]

Nonpharmacological methods were also used, typically including adjusting the child’s sleep environment or adopting aspects of sleep hygiene.

Parents removed electronic devices in the run-up to bedtime, in compliance with sleep hygiene guidelines. However, contrary to recommendations, some parents found that screens and devices had a positive effect on their child’s behavior and allowed them to wind down.

“We’ve been told to take screens away, but weirdly the screen time seems to calm him down rather than make him hyperactive or whatever.” [P2]

Alternative activities, such as playing, reading, and drawing, also seemed to help settling. Exercise and physical activity in the day had a positive effect on the child’s sleep often by inducing tiredness. As a result, the detrimental effects of COVID-19 and national lockdowns on children’s sleep were highlighted; restrictions on sports and clubs, lack of routine, and limits on activities with peers strongly affecting bedtimes.

“…at the weekends when the weather is good, we will go out and do a lot of walking and things like that […] On those days that he’s had a lot of physical exercise, he sleeps better. Definitely.” [P4]

“We couldn’t do normal things […] we couldn’t go to the swimming pool … even just meeting friends in the park, that would normally wear him out… well, he’s never worn out worn out but it helps to a certain extent with sleep.” [P9]

Some parents also used behavioral methods such as punishment and reinforcement to improve behavior at bedtime, for example discouraging getting out of bed by confiscating devices or awarding stars on a chart. These methods had mixed efficacy.

“If he was up and down, he lost his Xbox and then you have three warnings … But then there was the odd night where he would stay in bed, but not all the time, so negotiations would sort of work sometimes, depending on what mood he was in or what he was anxious about.” [P5]

Parents tried to implement a consistent and reliable bedtime routine for their children every night. While routine did not always improve children’s sleep, they felt it was still important. Strict bedtime routine benefitted everyone in the household, but maintaining it required a great deal of energy and commitment.

“(about implementing bedtime routine) I can’t tell you how incessant it is. It’s draining, constantly exhausted, from having to input the effort so that you get enough sleep. It’s weird.” [P8]

Parents also implemented different strategies and support to facilitate better sleep. Some parents used electronic timers and reminders to structure bedtime routine and allow children to stay on track with tasks and reduce resistance.

“10 minutes before bedtime he asks Alexa to set a timer. When that timer goes off, he knows it’s time for bed and then he’ll go up … He used to resist until we had Alexa, and because he has that 10-minute warning. He now accepts it.” [P5]

Sensory stimulation was often used. Tools such as music, audiobooks, white noise, and lights provided children with sleep-conductive stimulation to help support sleep, making a positive difference for some children. Cocooning, weighted blankets, or touch sensory tools were also used, and children were more settled when surrounded by or wrapped tightly in several blankets and duvets.

“So I still think she’s having trouble getting to sleep, but I don’t think she is panicking about it. And you know she’s feeling quite soothed by the weighted blanket […] She likes something really tight, confining her, then she wants to sleep.” [P3]

The perceived usefulness of clinical ADHD services and support groups was also explored. Using online peer support groups and forums for advice, education, and reassurance about sleep issues in ADHD was very beneficial. Parents often implemented the advice from these groups and were willing to try new ideas. Some parents attended courses and workshops facilitated by support groups and spoke positively about the experience of learning more about their child’s difficulties. Parents valued the lived experience that accompanied the information.

“I’ve recently joined quite a lot of the support groups online […] it is actually useful and reassuring that a lot of people have the same sort of issues when they’ve got kids with ADHD.” [P9]

In contrast, support from ADHD clinical services was less useful with a lack of understanding around sleep issues. Parents felt desperate for help with their child’s sleep but felt unsupported, regarding services’ recommendations for sleep as unhelpful or unsuitable, resulting in frustration, feelings of guilt, unmet needs, and an unimproved situation.

“The support that’s out there for sleep issues never really fitted with us or with him.” [P10]

These strategies and methods discussed worked with varying degrees of success but also show the breadth of support needed. There appeared to be a sense of exasperation at the invariable nature of children’s sleep despite many attempts to improve the situation.

“We tried everything. I’ve read every book there is on kids and sleeping […]. We’ve tried sleep courses. We tried cherry juice. We tried the rabbit who wanted to go to sleep. We’ve tried baths, we’ve tried lavender… I don’t think there’s anything we haven’t tried.” [P12]

DISCUSSION

This study explored the impact of sleep issues on the parents and families of children with ADHD, presenting an important insight into an underresearched topic.

Our findings show that children with ADHD experience a range of sleep problems, including issues falling asleep and settling in the evening, bedtime resistance, waking up during the night, long-term difficulties, and waking up early in the morning, echoing previous findings.^9,10 Similarly to previous studies,^16,41,45 our findings show that the extent to which children were affected by their sleep problems varied, but often a particularly poor night’s sleep heightened children’s ADHD symptoms the next day. Parents described a significant amount of stress at bedtimes owing to bedtime resistance and a struggle between parent and child^16–18 with anxiety and rumination prolonging and disrupting sleep-onset latency.^46,47

The negative impact of sleep problems on parents was discussed by all participants. All parents had experienced disrupted sleep at some stage in their child’s life, leading to psychological and functional impairments. This also impacted siblings and spouses, either directly through disrupted sleep themselves or indirectly through difficult family dynamics. This in-depth report of parental experience has not been well explored until now, but these findings parallel previous findings that parents’ sleep is shortened^11,14 and parental mental health is negatively affected.¹⁵ Some mothers in this study undertook most of the childcare responsibilities at bedtime and were more affected by sleep disturbances than their spouses, highlighting a sex disparity. The cumulative effect of sleep disturbance in parents strongly impacted interaction with spouses and other family members, demonstrating the wide impact on family dynamics.

Parents described multiple ways of getting help and support for their children with mixed results. Appraisals of the beneficial impact of ADHD medication varied. At times medication use facilitated effective wind-down, regulated emotion, and improved compliance with bedtime routines, benefitting parents and children despite potentially extending sleep-onset latency for the child with ADHD. However, for some families, higher dosage often negatively impacted sleep, reflecting the heterogeneity in the interactions between ADHD medication and sleep from published studies.^20,21 Similarly to other studies, parents using melatonin mostly highlighted its benefits and positive effect on sleep and bedtime behavior.^35,36,48 Behavioral strategies were also implemented. Interestingly, reducing exposure to screens worsened some children’s sleep and behavior, contrary to sleep hygiene principles and previous research.²⁸ Sensory strategies such as music or weighted blankets appeared effective for lessening stimulation-seeking, a finding corroborating previous research on concentration in ADHD.⁴⁹ Finally, while support from peer support groups were highly valued, parents described limited support from ADHD services, demonstrating the lack of understanding of the impacts of sleep difficulties in families of children with ADHD.

This study had several important strengths and limitations. Using qualitative methods and semistructured interviews allowed rich, in-depth data to be collected. Parents needed little encouragement to speak freely and openly about their child’s sleep issues and their own experiences. Findings underlined the detrimental impact of sleep issues on parents’ lives and the lack of relevant support. Experiences were largely consistent among participants, and our findings are consistent with previous studies while giving an added level of insight into parental experiences.

This study also had some limitations. First, there was a lack diversity in the sample including a lack of representation of the views of ethnic minorities, same-sex couples, and fathers. All participants were White British mothers. This limits the application of the findings as fathers or parents from other ethnic backgrounds may have different experiences. This lack of representation could reflect a flaw in the recruitment method as minority parents may be less likely to access support online and engage with online communities. Additionally, the participants’ children were mostly male. Girls with ADHD are underrepresented in research, and less is known about how sleep symptoms manifest in girls, therefore limiting the clinical generalization of the findings. Girls tend to be more inattentive than hyperactive,⁵⁰ which could have different repercussions on sleep. Third, as we recruited from ADHD support groups we were not able to confirm the child’s ADHD diagnosis, but during the interviews parents talked about their experiences during the assessment and diagnosis process, which provides reassurance on the validity of the children’s diagnostic status. Fourth, the sample size was moderate but sufficient for a qualitative study. Fifth, the participant age range was broad, and unfortunately it is very difficult to explore subgroup analysis (ie, younger vs older) in a qualitative data. Sixth, the study was conducted during the global pandemic, which may have an additional impact on children’s sleep. Parents in the interviews were also asked to reflect on sleep before the pandemic, and no parent specifically identified a pandemic-related change in sleep for their child. Finally, parents’ potential ADHD diagnosis was not evaluated. ADHD has a strong genetic component,⁵¹ and while one parent mentioned their diagnosis, it is very likely that other parents in this study would have ADHD. This would strongly impact not only their responses to sleep-time difficulties but also their own ability to sleep and is an important factor to take into consideration.

Findings from this study carry several implications for clinical practice and future research. First, findings on interactions with services could inform improved sleep support provision. Parents’ experiences reflected a lack of empathy, understanding, and acknowledgment of the child’s individual needs. Clinical services should avoid implicating parental blame and should instead recommend realistic strategies that sleep-deprived parents are able to follow. Second, parents from minority backgrounds and parents of female children should be targeted for participation in research as these groups were underrepresented in the present study. These groups may reveal unique barriers to accessing support that could further inform service provision. Furthermore, qualitative exploration of fathers’ perspectives on sleep is necessary as previous research finds disparities in ratings of ADHD symptoms between mothers and fathers.^52,53 Additionally, health care professionals and sleep teams should educate families further on the benefits of sleep and work with them to address these concerns. Finally, as ADHD medication was found to improve bedtime compliance but not sleep onset for some children, further mixed-methods research is warranted to examine the specific effect of ADHD medication on bedtime experiences.

The present study has widened our understanding of the impact of sleep issues in children with ADHD, highlighting the strong impact sleep difficulties have on children, parents, and the wider family and the parental desire to engage with strategies and seek support to help improve these issues.

DISCLOSURE STATEMENT

All authors have seen and approved the manuscript. The authors report no conflicts of interest.

ABBREVIATION

ADHD

attention deficit/hyperactivity disorder