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. 2026 Jun 2;35(5):e70381. doi: 10.1111/jsr.70381

Psychometric Properties of the PROMIS Pediatric Sleep Disturbance and Sleep‐Related Impairment Self and Proxy Short Forms in Early Adolescents With and Without ADHD

Stephen P Becker 1,2,✉, Melissa C Miller 1,2, G Leonard Burns 3
PMCID: PMC13619014  PMID: 42227222

ABSTRACT

This study evaluated the psychometric properties and psychopathology correlates of the Patient‐Reported Outcome Measurement Information System (PROMIS) Pediatric Sleep Disturbance and Sleep‐related Impairment Self and Proxy Short Forms in early adolescents with and without attention‐deficit/hyperactivity disorder (ADHD). Participants were 341 early adolescents (ages 10–12 years; 52.2% female), with approximately half meeting diagnostic criteria for ADHD. Adolescents and their caregivers completed short form versions of the PROMIS Pediatric Sleep Disturbance and Sleep‐related Impairment Self and Proxy Forms, in addition to measures of ADHD, anxiety, and depressive symptoms. Adolescents with ADHD were significantly more likely to be taking melatonin (33.7%) compared to adolescents without ADHD (14.9%). Across informants, the PROMIS paediatric sleep measures demonstrated strong internal consistency, moderate convergent validity, and partial evidence of discriminant validity. As expected, adolescents with ADHD had higher scores in both sleep disturbance and sleep‐related impairment than their non‐ADHD peers across both informants, and most differences remained when participants taking stimulant medications were excluded from analyses. No sex differences in either sleep disturbance or sleep‐related impairment scores were present across either adolescent or parent informant. Both sleep disturbance and sleep‐related impairment were consistently associated with higher levels of psychopathology across parent, teacher, and adolescent reports, with daytime impairment showing particularly strong and unique associations with depression. This study provides psychometric support for the PROMIS Pediatric Sleep Disturbance and Sleep‐related Impairment Self and Proxy Short Forms in early adolescents, including youth with ADHD who frequently experience sleep disturbances and sleep‐related impairment.

Keywords: adolescence, attention‐deficit/hyperactivity disorder, patient‐reported outcomes, PROMIS, sleep, sleepiness, validation

Sleep health plays a vital role in child and adolescent development (Meltzer et al. 2021). Adequate, good‐quality sleep is necessary for optimal functioning across cognitive, socioemotional, academic, and physical health domains (Becker et al. 2015a; Carskadon et al. 1998; Dewald et al. 2010; Matricciani et al. 2019). Consequently, there is growing emphasis on the importance of clinicians and researchers systematically assessing and monitoring sleep problems and their related impairments in youth (Spruyt 2019; Van Meter and Anderson 2020).

Although numerous self‐ and caregiver‐report tools exist for evaluating paediatric sleep (Bevans et al. 2019), relatively few have undergone comprehensive psychometric testing. Item content often varies across informants and developmental stages, and some measures are lengthy or otherwise impractical for many clinical or research settings (Spruyt and Gozal 2011). To address these issues, patient‐reported paediatric sleep measures were developed following the rigorous standards of the Patient‐Reported Outcomes Measurement Information System (PROMIS) initiative (Bevans et al. 2019; Forrest et al. 2018). These instruments were modelled after two PROMIS adult sleep measures: sleep disturbance (capturing sleep quality and difficulties with initiation and maintenance) and sleep‐related impairment (assessing daytime sleepiness, fatigue, and cognitive challenges linked to insufficient or poor sleep) (Buysse et al. 2010).

The PROMIS paediatric sleep measures, available in both child self‐report and parent‐proxy formats, were created using a methodologically rigorous process. Item generation drew from PROMIS adult item banks, qualitative interviews with experts, children, and caregivers, and a systematic literature review. Content was refined through cognitive interviews with children and caregivers, yielding an initial set of 43 items spanning sleep disturbance and sleep‐related impairment (Bevans et al. 2019). These items were tested in a large U.S. sample, including both community participants and families recruited from a paediatric sleep clinic (Forrest et al. 2018). Exploratory and confirmatory factor analyses supported two distinct item banks (15 items for sleep disturbance, 13 items for sleep‐related impairment), as well as eight‐ and four‐item short forms for each scale (Bevans et al. 2019). The measures demonstrated excellent reliability and precision, strong convergent validity with existing sleep and fatigue measures, and expected group differences (e.g., higher scores in children with clinical sleep problems) (Forrest et al. 2018). More recently, strong psychometric support was found for the short versions of the parent proxy versions of the PROMIS paediatric sleep scales in a nationally representative sample of over 5500 Spanish children ages 5–16 years (Becker et al. 2024a).

Although research to date provides a strong foundation and initial evidence for the validity of the PROMIS paediatric sleep instruments, additional research is warranted to support their use across developmental periods and in specific subgroups including clinical populations. Youth with attention‐deficit/hyperactivity disorder (ADHD) experience especially high rates of sleep disturbances and sleep‐related impairment (Becker 2020; Bondopadhyay et al. 2022). Although estimates vary, up to half of caregivers of children with ADHD indicate their child has moderate or severe sleep problems (Sung et al. 2008), and among early adolescents 28% experience clinically elevated sleep disturbances (Becker et al. 2019b). Sleep problems are variable in youth with ADHD, including difficulties in initiating and maintaining sleep, sleep anxiety/bedtime resistance, night wakings, and parasomnias (Becker, Langberg, et al. 2019; Sciberras et al. 2023). Daytime‐related impairments, such as daytime sleepiness, are also highly common in ADHD, affecting approximately 40% of early adolescents with ADHD (Langberg et al. 2017). Both nighttime sleep disturbances and sleep‐related impairments are related to poorer functioning in adolescents with ADHD, with evidence from cross‐sectional (Langberg et al. 2017; Loram et al. 2021), prospective (Becker et al. 2015b), and experimental (Becker et al. 2019a; Becker et al. 2020) studies.

Despite the prevalence and impact of sleep disturbances and sleep‐related impairments in youth with ADHD, no study has directly examined the PROMIS paediatric sleep measures in youth diagnosed with ADHD. There has also been limited investigation of sex differences on these measures, and there is evidence that females with ADHD experience more sleep problems than males with ADHD (Becker et al. 2018). In the initial validation study of the PROMIS paediatric sleep disturbance and sleep‐related impairment measures (Forrest et al. 2018), scores did not differ by sex, though other research has reported higher scores in female compared to male children receiving treatment for cancer (Daniel et al. 2020), pointing to the need for additional research examining sex differences in specific clinical populations. In addition, in the initial validation study, scores on both the child self‐report sleep disturbance and sleep‐related impairment scales were higher in youth (ages 8–17) with a parent‐reported diagnosis of ADHD (Forrest et al. 2018). However, ADHD was not directly assessed (including whether children met criteria for ADHD currently), the caregiver proxy versions were not examined in the subsample with ADHD, and the short form versions were also not evaluated in regards to ADHD. There is promising emerging evidence supporting the psychometric properties of the PROMIS paediatric sleep measures in children with chronic illnesses and other neurodevelopmental disorders (e.g., autism) (Meltzer et al. 2020), and studies that directly examine these measures in youth with ADHD are needed.

1. Objectives

The first objective evaluated the reliability of the parent and adolescent sleep disturbance and sleep‐related impairment measures for the total sample, sex, and ADHD diagnostic sample. Based on previous research (Becker, Burns, et al. 2024a; Forrest et al. 2018) using the PROMIS paediatric sleep scales, we expected the self and proxy short forms to demonstrate adequate (> 0.70) internal consistency in the full sample, as well as separately by sex and diagnostic status.

The second objective evaluated the convergent and discriminant validity of the sleep disturbance and sleep‐related impairment measures across adolescents with and without ADHD and their parents. It was expected that the same trait with different sources correlations would show moderate convergent validity (i.e., parent proxy sleep disturbance with adolescent sleep disturbance correlation and the parent proxy sleep‐related impairment with adolescent sleep‐related impairment correlation would be moderate [~0.30–0.40 in magnitude; Daniel et al. 2020]). It was also predicted that these two convergent correlations would be significantly larger than the two discriminant correlations (i.e., [1] parent proxy sleep disturbance with adolescent sleep‐related impairment; [2] parent proxy sleep‐related impairment with adolescent sleep disturbance correlations), thus providing support for the discriminant validity of the two sleep measures.

The third objective examined the influence of sex and ADHD diagnostic status on the sleep disturbance and sleep‐related impairment measures for parents and adolescents. It was expected that females and males would not differ significantly on the sleep measures (Forrest et al. 2018). In contrast, adolescents with an ADHD diagnosis were expected to have higher scores on the parent and adolescent sleep measures (Forrest et al. 2018; Meltzer et al. 2020).

The fourth objective evaluated parent‐ and adolescent sleep disturbance and sleep‐related impairment scores in relation to multi‐informant (parent, teacher, adolescent self‐report) measures of anxiety, depression, ADHD inattention (ADHD‐IN), and ADHD hyperactivity/impulsivity (ADHD‐HI). It was expected that both sleep disturbance and sleep‐related impairment would be correlated with significantly higher psychopathology scores (Meltzer et al. 2020). In comparing the magnitude of correlations between the sleep disturbance and sleep‐related impairment scores in relation to psychopathology scores, we expected that sleep‐related impairment scores would be more strongly associated with at least some psychopathology domains, particularly in relation to teacher ratings of psychopathology given the daytime context in which teachers interact and observe students.

2. Methods

2.1. Participants

Participants were 341 early adolescents (ages 10–12 years) enrolled in a broader study of attention problems and mental health. Participant and caregiver/family characteristics are summarized in Table 1. There were approximately an equal number of female and male adolescents, with slightly over one‐third of participants being people of colour. Approximately half of the sample met diagnostic criteria for ADHD based on the Kiddie Schedule for Affective Disorders and Schizophrenia for School‐Age Children (K‐SADS; Kaufman et al. 2013) conducted with the adolescent's caregiver (primarily biological mothers). Almost one‐quarter of the sample was currently taking melatonin, with melatonin use significantly higher among adolescents with ADHD (33.7%) compared to adolescents without ADHD (14.9%), Χ 2(1) = 16.62, p < 0.001.

TABLE 1.

Sample characteristics (N = 341).

Adolescent Characteristics Caregiver/Family Characteristics
M ± SD n (%)
Age 10.90 ± 0.80 Relationship to Child
Biological Mother 293 (85.9)
n (%) Biological Father 26 (7.6)
Sex Stepmother 2 (0.6)
Female 178 (52.2) Adoptive Mother 14 (4.1)
Male 163 (47.8) Adoptive Father 1 (0.3)
Foster Mother 1 (0.3)
Race Grandmother 3 (0.9)
American Indian/Alaskan 1 (0.3) Grandfather 1 (0.3)
Asian 8 (2.3)
Black 72 (21.1) Household Income c
Multiracial 48 (14.1) Under $20,000 15 (4.5)
White 212 (62.2) 20,001–40,000 37 (11.1)
40,001–60,000 34 (10.2)
Hispanic/Latin 32 (9.4) 60,001–80,000 38 (11.4)
80,001–100,000 34 (10.2)
Psychiatric diagnoses a 100,001–120,000 45 (13.5)
ADHD—PR 166 (48.7) Over $120,000 130 (39.0)
Any externalizing (ODD)—PR a 24 (7.0)
Any anxiety—PR 52 (15.2) Highest Primary Caregiver Education d
Any anxiety—SR 39 (11.4) High school degree or less 25 (7.4)
Any depression—PR 5 (1.5) Partial college/vocational 51 (15.1)
Any depression—SR 8 (2.3) College graduate 141 (41.7)
No diagnosis 150 (44.0) Graduate/professional degree 121 (35.8)
Medication and Melatonin Use b
Stimulant medication 75 (22.0)
Non‐stimulant ADHD medication 19 (5.6)
Anxiety/mood medication 24 (7.0)
Antipsychotic medication 1 (0.3)
Melatonin supplement 82 (24.0)
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Abbreviations: ADHD = attention‐deficit/hyperactivity disorder. Anxiety disorders = presence of generalized anxiety disorder, social phobia, panic disorder, and/or posttraumatic stress disorder (PTSD). Any depression = presence of major depression or dysthymia. ODD = oppositional defiant disorder. PR = parent‐report. SR = adolescent self‐report.

a

Current psychiatric diagnoses were assessed using the Kiddie Schedule for Affective Disorders and Schizophrenia for School‐Age Children (K‐SADS). Only caregivers were administered the ODD and PTSD modules. No participants met criteria for conduct disorder.

b

Current medication and melatonin use was assessed using a parent‐completed form. Stimulant medication includes amphetamine or methylphenidate preparations. In adolescents without a diagnosis of ADHD, 5 were taking a stimulant medication, 6 were taking an anxiety/mood medication, and 26 were taking melatonin; none were taking a non‐stimulant ADHD medication or an antipsychotic medication; all other participants taking a medication/melatonin were in the ADHD group.

c

Eight caregivers did not provide family income.

d

Three caregivers did not provide education.

2.2. Procedures

All procedures were approved by the Cincinnati Children's Hospital Medical Center Institutional Review Board. Caregivers and adolescents provided informed consent and assent, respectively. Adolescents and their caregivers were recruited for a prospective longitudinal study on adolescent mental health from a variety of sources, including media advertisements, community flyers, e‐mail distribution within a Midwestern children's hospital, and letters to school/paediatrician partners. To ensure a range of inattention symptoms was represented in the sample, several versions of advertising materials were generated (e.g., some specifying attentional difficulties, and some not targeting any attentional problems).

Interested caregivers completed a brief REDCap eligibility survey that included initial inclusion criteria. Families meeting initial inclusion criteria were scheduled for an in‐person research visit, during which remaining eligibility criteria were assessed. In addition to being ages 10–12 years, inclusion criteria included a standardized score ≥ 80 for overall intelligence on the Peabody Picture Vocabulary Test, 5th Edition (Dunn 2019), willingness to discontinue stimulant medications for ADHD 24 h prior to their research visit, and sufficient English language ability to complete the measures. Adolescents were excluded if the caregiver reported a previous diagnosis of autism spectrum disorder, bipolar disorder, or psychosis, or a significant visual, hearing, or speech impairment precluding their ability to complete the measures. For additional details, see Becker et al. (2024b).

2.3. Measures

2.3.1. Demographic Characteristics and Medication Use

Caregivers completed a demographic form to gather the information reported in Table 1. Medication and melatonin use were assessed with an adaptation of the Service Assessment for Children and Adolescents (SACA) (Stiffman et al. 2000).

2.3.2. Kiddie Schedule for Affective Disorders and Schizophrenia for School‐Age Children (K‐SADS)

The K‐SADS (Kaufman et al. 2013) is a semi‐structured diagnostic interview based on the DSM‐5 with good reliability and validity (Jarbin et al. 2017). In the present study, interviews conducted with the adolescent's caregiver were used to assess ADHD, oppositional defiant disorder (ODD), and conduct disorder (CD), whereas interviews conducted with the adolescent were used to assess generalized anxiety disorder, social phobia, panic disorder, post‐traumatic stress disorder, major depression, and persistent depressive disorder modules. The K‐SADS was administered by trained graduate students, postdoctoral fellows, or clinical psychologists.

2.3.3. PROMIS Paediatric Sleep Disturbance and Sleep‐Related Impairment Scales

Adolescents completed short form versions of the PROMIS Paediatric Sleep Disturbance and Sleep‐Related Impairment scales, and parents completed the parent proxy versions. For the current study, three items from the Sleep Disturbance scale were used to assess perceptions of sleep difficulties, including difficulty falling asleep, having a problem with sleep, and having trouble sleeping (one of the four items asking about sleeping through the night on the Sleep Disturbance scale was inadvertently not administered). The 4‐item Sleep‐Related Impairment scale assesses the perceived functional impairments during wakefulness associated with sleep problems or impaired alertness (items assess being sleepy during the day, having a hard time concentrating because of being sleepy, having a hard time getting things done because of being sleepy, and having problems during the day because of poor sleep). Items are rated on a 5‐point scale (1 = not at all or never, 2 = a little bit or rarely, 3 = somewhat or sometimes, 4 = quite a bit or often, 5 = very much or always) for the past seven days, with higher scores indicating greater difficulties. Exact wording of the items can be found online (www.healthmeasures.net). Mean scale scores were used in the analyses, with higher scores indicating a greater impairment. Reliability coefficients for the current study are included in the Results section.

2.3.4. Child and Adolescent Behaviour Inventory (CABI)

Parents and teachers completed the 9‐item ADHD‐IN, 9‐item ADHD‐HI, 6‐item depression, and 6‐item anxiety scales from the CABI (Burns et al. 1997–2021). Each item is rated with 6‐point anchors for the past month (0 = almost never [never or about once per month], 1 = seldom [about once per week], 2 = sometimes [several times per week], 3 = often [about once per day], 4 = very often [several times per day], and 5 = almost always [many times per day]). Earlier studies support the factor structure, reliability (internal consistency, test–retest, and interrater) and validity of CABI scale scores from the United States (Burns and Becker 2021, 2022; Burns et al. 2022). Other studies from Iran, South Korea, Spain, Turkey, and the United States also support the psychometric properties of CABI scale scores (Başay et al. 2021; Burns et al. 2021; Jung et al. 2021; Sadeghi‐Bahmani et al. 2022; Sáez et al. 2019; Servera et al. 2018). Reliability coefficients (i.e., alpha) in the current study for caregiver and (teacher) CABI ADHD‐IN, ADHD‐HI, depression, and anxiety scores were 0.97 (0.96), 0.93 (0.95), 0.85 (0.88), and 0.78 (0.78), respectively. In the present study, mean symptom scores were used as outcome variables (external correlates) of interest with higher scores indicating higher frequency of symptoms.

2.3.5. Behavioural Assessment System for Children, Third Edition (BASC‐3)

The BASC‐3 Self‐Report of Personality (SRP) (Reynolds and Kamphaus 2015) is a well‐established multidimensional measure to evaluate emotional and behavioural functioning in youth. Consistent with other studies examining ADHD symptom dimensions (Barden et al. 2023; Childs et al. 2022), the BASC‐3 SRP Attention Problems and Hyperactivity clinical scales were used to obtain self‐report measures of ADHD‐IN and ADHD‐HI in the current study. Some items are true/false items and others are rated on a four‐point scale (1 = never to 4 = almost always). Consistent with BASC‐3 SRP forms, participants ages 10 and 11 completed the BASC‐3 SRP child version, and participants age 12 completed the BASC‐3 adolescent version. The Attention Problems scale consists of 9 items on the BASC‐3 SRP‐C and 8 items on the BASC‐3 SRP‐A; the Hyperactivity scale consists of 8 items on both versions. T‐scores were used in the current study, with higher scores indicating greater difficulties.

2.3.6. Screen for Child Anxiety Related Emotional Disorders (SCARED)

The SCARED (Birmaher et al. 1997) is a child self‐report measure designed to screen for anxiety disorders in children and adolescents. The 41 items included in the measure were developed using the DSM‐IV criteria for general anxiety disorder (GAD), separation anxiety disorder (SAD), panic disorder, social phobia, and school phobia. Items are rated on a 3‐point scale for the past three months (0 = not true, 1 = sometimes true, 2 = often true), with higher scores indicating greater symptom severity. In the current study, reliability (alpha) for the SCARED was 0.92, with mean scores used in analyses.

2.3.7. Children's Depression Inventory, Second Edition (CDI‐2)

The CDI‐2 (Kovacs 2010) is a self‐report measure of depressive symptoms in the preceding two weeks. The CDI‐2 consists of 28 items rated on a 3‐point scale, with higher scores indicating a higher severity of depressive symptoms. In the current study, reliability (alpha) for the CDI‐2 was 0.86, with mean scores used in analyses.

2.4. Analytic Approach

For objective 1, SPSS (Version 29) was used to calculate the reliability coefficients (alpha) for the scores on the parent proxy sleep disturbance, parent proxy sleep‐related impairment, adolescent sleep disturbance, and adolescent sleep‐related impairment measures for the total sample, sex, and diagnostic status (ADHD group, comparison group without ADHD). For objective 2, the Mplus statistical software (version 8.8) was used to determine the convergent and discriminant correlations for sleep disturbance and sleep‐related impairment measures across parents and adolescents. The Mplus model constraint procedure was used to determine if the convergent correlations were significantly larger than the discriminant correlations, that is, a test of discriminant validity. For objective 3, the SPSS software was also used to compare the means (t‐tests) on the four sleep measures across sex and diagnostic status. For objective 4, the Mplus software was used to determine the correlations of the parent and adolescent sleep disturbance and sleep‐related impairment measures with the parent and teacher ratings of the adolescent psychopathology (i.e., anxiety, depression, ADHD‐IN, and ADHD‐HI) and adolescents' self‐reports of anxiety, depression, ADHD‐IN, and ADHD‐HI. The Mplus model constraint procedure was used to determine if the correlations of the sleep measures with the outcomes differed significantly. The robust maximum likelihood estimator (MLR) was used for the Mplus analyses.

3. Results

3.1. Reliability Coefficients for the Parent and Adolescent Sleep Measures

Table 2 shows the reliability coefficients (alphas) for the parent and adolescent sleep disturbance and sleep‐related impairment measures for the total sample, sex, and ADHD diagnostic status. Given the sleep disturbance measure contained only three items and the sleep‐related impairment measure contained four items, the reliability coefficients were moderate to strong (0.74 to 0.91 with 17 of the 20 coefficients 0.80 or higher).

TABLE 2.

Reliability coefficients (Alphas) for parent proxy and adolescent sleep measures.

Sleep Measures Total Sample (N = 341) Females (n = 178) Males (n = 163) No ADHD Diagnosis (n = 175) ADHD Diagnosis (n = 166)
Parent Proxy Sleep Disturbance 0.88 0.85 0.91 0.84 0.88
Parent Proxy Sleep‐Related Impairment 0.90 0.90 0.90 0.88 0.91
Adolescent Sleep Disturbance 0.84 0.83 0.84 0.83 0.83
Adolescent Sleep‐Related Impairment 0.79 0.84 0.74 0.76 0.81
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Abbreviation: ADHD = attention‐deficit/hyperactivity disorder.

3.2. Convergent and Discriminant Validity of Sleep Disturbance and Sleep‐Related Impairment Measures

Table 3 shows the correlations among the sleep disturbance and sleep‐related impairment measures for parents and adolescents. The same trait—different source correlations showed statistically significant (p < 0.001) convergent validity that were moderate in magnitude (i.e., the parent proxy sleep disturbance with adolescent sleep disturbance correlation was 0.31, SE = 0.06, and the parent proxy sleep‐related impairment with the adolescent sleep‐related impairment correlation was 0.28, SE = 0.06). The two convergent validity correlations were significantly (ps < 0.05) larger than the discriminant correlation for parent proxy sleep disturbance with adolescent sleep‐related impairment measures. The two convergent correlations, however, were not significantly (ps > 0.05) larger than the discriminant correlation for parent proxy sleep‐related impairment with adolescent sleep disturbance measures. There was thus partial support for discriminant validity (i.e., same trait‐different source correlations being larger than different trait‐different source correlations).

TABLE 3.

Convergent and discriminant (SEs) correlations for sleep disturbance and sleep‐related impairment measures for parents and adolescents.

Parent Proxy Sleep Disturbance Parent Proxy Sleep‐Related Impairment Adolescent Sleep Disturbance Adolescent Sleep‐Related Impairment
Parent Proxy Sleep Disturbance
Parent Proxy Sleep‐Related Impairment 0.58 (0.04)
Adolescent Sleep Disturbance 0.31 (0.06) 0.25 (0.05)
Adolescent Sleep‐Related Impairment 0.17 (0.06) 0.28 (0.06) 0.64 (0.04)
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Note: Convergent correlations are in bold. The two convergent correlations (i.e., parent proxy sleep disturbance with adolescent sleep disturbance nighttime [0.31] and parent proxy sleep‐related impairment with adolescent sleep‐related impairment with [0.28]) were both significantly larger (ps < 0.05) than the parent proxy sleep disturbance with adolescent sleep‐related impairment discriminant correlation (0.17). The two convergent correlations, however, were not significantly larger (ps > 0.05) than the parent proxy sleep‐related impairment with the adolescent sleep disturbance correlation (0.25). All correlations were significant at p < 0.01.

3.3. Sex and ADHD Diagnosis Differences on Parent and Adolescent Sleep Measures

Table 4 shows the differences on the parent and adolescent sleep measures as a function of adolescent sex and ADHD diagnosis. Females and males did not differ significantly (ps > 0.20) on the four sleep measures. In contrast, adolescents with an ADHD diagnosis had significantly higher scores (ps < 0.01) on each of the four sleep measures (d values from 0.33 to 0.65).

TABLE 4.

Sex and ADHD diagnostic status differences on parent proxy and adolescent sleep measures.

Sleep Measures Females (n = 178) Males (n = 163) d No ADHD Diagnosis (n = 175) ADHD Diagnosis (n = 166) d
M SE M SE M SE M SE
Parent Proxy Sleep Disturbance 1.96 a 0.07 2.07 a 0.09 0.11 1.71 a 0.06 2.34 b 0.09 0.65
Parent Proxy Sleep‐Related Impairment 1.70 a 0.06 1.71 a 0.06 0.01 1.51 a 0.05 1.91 b 0.07 0.54
Adolescent Sleep Disturbance 1.88 a 0.08 2.05 a 0.09 0.15 1.79 a 0.08 2.15 b 0.09 0.33
Adolescents Sleep‐Related Impairment 1.78 a 0.07 1.88 a 0.07 0.12 1.67 a 0.06 1.99 b 0.08 0.37
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Note: Row means with different superscripts for gender and diagnostic status differ at p < 0.01.

Abbreviation: ns = nonsignificant.

There is longstanding interest in the extent to which stimulant medications in particular may negatively impact sleep (see Stein et al. 2022). Although recent evidence suggests that any effects of stimulant medication use on sleep in adolescents with ADHD are small and inconsistent (Wiggs et al. 2024), we conducted independent samples t‐tests to determine if participants with and without ADHD in the current study differed in their self and parent proxy sleep scores when participants taking a stimulant medication for ADHD (per parent report) were removed. This resulted in 96 participants with ADHD (95 with self‐report ratings) and 170 participants without ADHD. Adolescents with ADHD who were not taking a stimulant medication had significantly higher scores on the parent proxy sleep disturbance, parent proxy sleep‐related impairment, and adolescent self‐reported sleep‐related impairment than adolescents without ADHD (ts = 5.37, 5.08, and 1.98, respectively; ds = 0.68, 0.65, and 0.25, respectively; all ps < 0.05). Adolescents with ADHD who were not taking a stimulant did not significantly differ from adolescents without ADHD in their ratings of sleep disturbance (t = 1.70, p = 0.078, d = 0.23).

3.4. Correlations of Sleep Measures With Outcome Measures

Table 5 shows the correlations of the parent and adolescent sleep measures with parent ratings, teacher ratings, and adolescent self‐report measures of anxiety, depression, ADHD‐IN, and ADHD‐HI. Scores on the parent and adolescent sleep measures were associated with significantly (p < 0.05) higher scores on the parent, teacher, and adolescent measures of anxiety, depression, ADHD‐IN, and ADHD‐HI with one exception (i.e., a non‐significant association of parent proxy sleep disturbance with teacher rated anxiety). In addition, the parent and adolescent sleep‐related impairment measures had significantly (ps < 0.05) stronger correlations than the parent proxy and adolescent sleep disturbance measures with parent and teacher ratings of adolescent depression. Finally, the parent proxy sleep disturbance measure had a significantly (p < 0.05) stronger correlation than parent proxy sleep‐related impairment with parent ratings of ADHD‐HI.

TABLE 5.

Correlations (SEs) of parent proxy and adolescent sleep disturbance and sleep‐related impairment measures with parent, teacher, and adolescent outcome measures.

Measures Parent Proxy Adolescent
Sleep Disturbance Sleep‐Related Impairment Sleep Disturbance Sleep‐Related Impairment
Parent
Anxiety 0.38 (0.05) a 0.32 (0.05) a 0.20 (0.05) a 0.19 (0.05) a
Depression 0.29 (0.05) a 0.39 (0.05) b 0.17 (0.05) a 0.30 (0.05) b
ADHD‐IN 0.32 (0.05) a 0.32 (0.05) a 0.17 (0.05) a 0.20 (0.05) a
ADHD‐HI 0.32 (0.05) a 0.17 (0.05) b 0.16 (0.05) a 0.18 (0.05) a
Teacher
Anxiety 0.10 (0.06) ns, a 0.17 (0.06) a 0.10 (0.06) ns 0.16 (0.06) a
Depression 0.15 (0.06) a 0.27 (0.06) b 0.16 (0.06) a 0.26 (0.06) b
ADHD‐IN 0.12 (0.06) a 0.15 (0.06) a 0.15 (0.06) a 0.23 (0.06) a
ADHD‐HI 0.09 (0.06) a 0.13 (0.06) a 0.22 (0.06) a 0.20 (0.06) a
Adolescent
Anxiety 0.18 (0.05) a 0.20 (0.05) a 0.35 (0.05) a 0.39 (0.05) a
Depression 0.20 (0.05) a 0.27 (0.05) a 0.48 (0.05) a 0.54 (0.04) a
ADHD‐IN 0.27 (0.05) a 0.27 (0.05) a 0.41 (0.05) a 0.42 (0.04) a
ADHD‐HI 0.19 (0.05) a 0.12 (0.05) a 0.39 (0.05) a 0.42 (0.05) a
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Note: Parent proxy sleep disturbance and parent proxy sleep‐related impairment correlations for the same outcome with different superscripts differ at p < 0.05. Adolescent sleep disturbance and adolescent sleep‐related impairment correlations for the same outcome with different superscripts differ at p < 0.05. All correlations are significant at p < 0.05 unless indicated as non‐significant (ns).

4. Discussion

This study provides novel evidence supporting the psychometric properties and potential clinical utility of the PROMIS Paediatric Sleep Disturbance and Sleep‐Related Impairment Self‐ and Proxy‐Report Short Forms in early adolescents, including those with ADHD. Across informants, the measures demonstrated strong internal consistency, moderate convergent validity, and partial evidence of discriminant validity. As expected, adolescents with ADHD had higher scores in both sleep disturbance and sleep‐related impairment than their non‐ADHD peers across both informants, and most differences remained when participants taking stimulant medications were excluded from analyses. No sex differences emerged for either sleep disturbance or sleep‐related impairment across adolescent or parent informants. Finally, both sleep disturbance and sleep‐related impairment were consistently associated with higher levels of psychopathology across parent, teacher, and adolescent reports, with daytime impairment showing particularly strong and unique associations with depression.

4.1. Psychometric Properties of the PROMIS Paediatric Sleep Measures

Consistent with prior validation studies (Bevans et al. 2019; Forrest et al. 2018), the present findings indicate that the PROMIS paediatric sleep measures capture both nighttime and daytime aspects of sleep functioning with strong internal reliability. Convergent validity was supported by moderate same‐trait, cross‐informant correlations, generally comparable though somewhat smaller in magnitude to those found in other clinical samples (Daniel et al. 2020). The smaller cross‐informant correlations in the current study may be due to our use of briefer short form versions (3 Sleep Disturbance items and 4 Sleep‐Related Impairment Items) than in the Daniel et al. (2020) study (8 items), as well as potentially focusing on a sample of early adolescents with approximately half diagnosed with ADHD. Although discriminant validity was only partially supported, this pattern is not fully unexpected given the strong links between nighttime sleep problems and daytime functioning. Overall, our findings support the utility of the PROMIS four‐item short forms as brief yet psychometrically sound tools for research and clinical practice.

4.2. ADHD And Sex Differences in Sleep

In line with hypotheses and prior research (Becker 2020; Meltzer et al. 2020), adolescents with ADHD exhibited significantly greater sleep disturbance and sleep‐related impairment compared to their peers without ADHD. The medium effect sizes observed underscore the high rate and importance of sleep difficulties in this population and highlight the PROMIS short forms' sensitivity to clinically meaningful differences. Further, most differences between the ADHD and comparison groups remained when participants taking a stimulant medication were removed from the analyses, which is in line with recent research suggesting that any effects of stimulant medication use on sleep in adolescents with ADHD are small and inconsistent (Wiggs et al. 2024). It would be valuable for future studies to examine the PROMIS paediatric sleep scales as youth with ADHD are undergoing medication titration or changes in medications.

In contrast, no sex differences were found in the current study across either PROMIS paediatric sleep/sleep‐related impairment scale or informant, consistent with the initial PROMIS validation study (Forrest et al. 2018). Other studies have reported some mixed findings regarding sex differences, including one study using the PROMIS measures finding no differences when self‐report was used or the PROMIS sleep‐reported impairment scale, but higher sleep problems for females than males on the parent proxy of the PROMIS sleep‐related impairment scale (Daniel et al. 2020). It may be that sex differences in sleep are small or informant‐specific, vary depending on specific sleep domains not fully captured by the PROMIS short forms, and emerge later in adolescence, pointing to the importance of future longitudinal research.

4.3. Associations With Psychopathology

As anticipated, both sleep disturbance and sleep‐related impairment correlated with greater anxiety, depression, and ADHD symptoms across informants. Notably, sleep‐related impairment was more consistently and strongly associated with depressive symptoms, particularly in teacher ratings and adolescent self‐report. These findings align with developmental models positing that insufficient or poor‐quality sleep disrupts affect regulation and contributes to internalizing difficulties (Becker et al. 2015a; Loram et al. 2021). Conversely, parent‐reported sleep disturbance demonstrated relatively stronger associations with hyperactivity/impulsivity, consistent with prior work linking behavioural dysregulation to poor sleep hygiene and bedtime resistance (Langberg et al. 2017). Together, these results highlight the importance of assessing both nighttime sleep disturbance and daytime impairment, as each domain confers unique associations with clinical outcomes.

4.4. Clinical and Research Implications

The current findings support the PROMIS paediatric sleep short forms as efficient, psychometrically valid instruments for assessing sleep functioning in early adolescents, including youth with ADHD. Their brevity and dual informant format make them practical for both research protocols and clinical evaluations where time is limited. Clinically, incorporating these measures may facilitate the systematic identification of sleep problems, inform treatment planning, and allow for the monitoring of intervention outcomes. From a research perspective, the ability of the PROMIS measures to differentiate adolescents with ADHD and to capture meaningful associations with psychopathology suggests they may serve as valuable endpoints in clinical trials and longitudinal studies of adolescent sleep and mental health.

4.5. Strengths, Limitations, and Future Directions

Several limitations should be acknowledged. First, the cross‐sectional design precludes conclusions about temporal or causal relationships between sleep and psychopathology. Longitudinal and experimental studies are needed to clarify directionality and mechanisms of association. Second, although ADHD was carefully diagnosed via structured interview, sleep disorders (e.g., obstructive sleep apnea, circadian rhythm disorders) were not directly assessed and may have contributed to the observed sleep difficulties. Third, one item on the Sleep Disturbance scale assessing sleeping through the night was not used in this study which may limit comparison with other studies; future research will need to incorporate this item when examining the psychometric properties of this scale, including both the short and full versions. Fourth, the study focused on early adolescence (ages 10–12), and findings may not generalize to younger children or older adolescents, and it remains important to examine the psychometric properties and clinical validity across developmental periods and clinical populations in which these scales will be used. Finally, although parent and adolescent reports were collected, objective measures such as actigraphy were not included; previous research did not find associations between the PROMIS paediatric sleep scales and results from polysomnography (Forrest et al. 2018), and future multi‐method validation research is needed. As most of the caregivers in the current study were mothers, it would also be important for future research to examine the PROMIS parent proxy forms across mothers, fathers, and other caregivers (e.g., foster caregivers, grandparents).

4.6. Conclusion

This study extends the evidence base for the PROMIS Paediatric Sleep Disturbance and Sleep‐Related Impairment Self‐ and Proxy‐Report Short Forms by demonstrating strong psychometric properties, sensitivity to ADHD‐related differences, and meaningful associations with psychopathology in early adolescence. The findings underscore the importance of assessing both nighttime and daytime dimensions of sleep and associated impairment in youth and highlight the PROMIS measures as brief, psychometrically robust tools for clinical and research contexts.

Author Contributions

G. Leonard Burns: conceptualization, writing – original draft, formal analysis, writing – review and editing, methodology. Melissa C. Miller: writing – original draft, writing – review and editing, conceptualization, methodology. Stephen P. Becker: conceptualization, investigation, funding acquisition, writing – original draft, methodology, writing – review and editing, project administration, data curation, supervision, resources.

Funding

This research was supported by award number R01MH122415 from the National Institute of Mental Health (NIMH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Ethics Statement

This study has been approved by the Cincinnati Children's Hospital Medical Center Institutional Review Board (IRB; study #2020–0605).

Consent

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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