Abstract
Study Objectives:
The current study examined the impact of home confinement (lockdown) because of the COVID-19 pandemic on the sleep patterns of children and adolescents with attention-deficit hyperactivity disorder (ADHD).
Methods:
Nine hundred ninety-two parents of children and adolescents with ADHD filled out an anonymous online survey through the ADHD family association website. The survey investigated the sleep patterns and disturbances (using a modified version of the Sleep Disturbance Scale for Children) and screen exposure time before and during lockdown.
Results:
During lockdown, 59.3% of children and 69.4% of adolescents with ADHD reported a change of bedtime, with a significant increase in patients with ADHD who went to sleep at 11 pm or later. Sleep duration, in contrast, resulted in 2 opposing processes with more children and adolescents sleeping either less than 6 hours/night or 10–11 hours/night. Among children and adolescents, respectively, 19.9% and 22% slept less than they did before lockdown, whereas 21.4% and 27.4% slept for more hours. Bedtime delay and decreased sleep duration were associated with an increase in screen time exposure. Moreover, patients with ADHD reported an increase in sleep disturbances when compared to their previous condition, mainly including difficulties falling asleep, anxiety at bedtime, night awakenings, nightmares, and daytime sleepiness.
Conclusions:
Lockdown impacted sleep-wake rhythms by strengthening the maladaptive sleep patterns reported in usual-life conditions in children and adolescents with ADHD.
Citation:
Bruni O, Giallonardo M, Sacco R, Ferri R, Melegari MG. The impact of lockdown on sleep patterns of children and adolescents with ADHD. J Clin Sleep Med. 2021;17(9):1759–1765.
Key words: COVID-19, attention-deficit hyperactivity disorders, sleep-wake patterns, sleep disorders, children, adolescents
BRIEF SUMMARY
Current Knowledge/Study Rationale: Children and adolescents with attention-deficit hyperactivity disorder are easily intolerant of forced restrictions and rules, which may result in them being particularly vulnerable to the lockdown experience and showing alterations of their sleep patterns. Furthermore, the limitations of activities and relationships because of lockdown may cause an increase in screen exposure time that may affect the sleep of patients with attention-deficit hyperactivity disorder.
Study Impact: Our findings highlight that lockdown impacted sleep-wake rhythms by strengthening the maladaptive sleep patterns reported in usual-life conditions in children and adolescents with attention-deficit hyperactivity disorder and significantly delayed bedtime and increased daytime screen exposure particularly in patients who reduced their sleep duration. The increase in sleep disturbances, mainly difficulties falling asleep, anxiety at bedtime, night awakenings, nightmares, and daytime sleepiness may further affect daytime functioning in children and adolescents with attention-deficit hyperactivity disorder.
INTRODUCTION
The lockdown restrictions for the COVID-19 pandemic has caused critical physical and mental health problems in the entire population because of social isolation and the impossibility of engaging in varied and satisfying activities.1,2 One of the most frequently reported consequences caused by the confinement regards the alteration of sleep-wake rhythms in children, adolescents, and their families.3,4 Considering the crucial role that sleep plays on developmental processes, the individuation of the impact of confinement on sleep-wake patterns and sleep disturbances has represented a crucial field of investigation for child and adolescent psychiatrists.
Based on previous studies, 2 important factors have associated the altered sleep patterns in children and adolescents and the adult population with lockdown: stress and anxiety linked to COVID-19 infection,5 and the increased use of media and screen exposure because of the greatly reduced possibility of alternative activities.3
Most studies have been conducted on the general population, although it is reasonable to expect that patients with developmental disorders might be a population at higher risk.
Children and adolescents with attention-deficit hyperactivity disorder (ADHD) are often intolerant of forced restrictions and of accepting rules.6 Therefore, changes imposed by lockdown with a lack of specific rhythms (school, sports, or leisure activities) can potentially promote critical variations in their sleep patterns. Moreover, because the restrictions significantly limit pleasant activities, the consequent use of social media and television may represent an important aspect that interferes with a regular sleep schedule.3,7 Understanding the impact of lockdown on the sleep of children and adolescents with ADHD and evaluating the factors that promote unhealthy changes represent a research area of high priority.
Therefore, the aims of this study were (1) to assess sleep patterns and sleep disturbances in Italian children and adolescents with ADHD confined at home during the COVID-19 pandemic, as compared to their sleep habits before confinement; and (2) to identify the relationship between screen exposure time and sleep patterns during the lockdown period.
METHODS
Participants
A total of 992 participants (male = 847 [85.4%], female = 145 [14.6%]; mean age, 11.52 years; standard deviation, 3.17) completed the survey. All parents with a child or adolescent who was diagnosed with ADHD by a child and adolescent psychiatrist were informed of the survey through the Italian ADHD Family Association website.
The total sample can be considered as representative for the entire Italian territory with a participation of all regions, 20 metropolitan cities, and 78.3% (72/92) of the Italian provinces. Data reported in this study were part of a wider research project designed with multiple purposes regarding the psychological impact of home confinement in Italy. There was no monetary or credit compensation for participating in the study. The study was approved by the Ethics Committee of the Department of Developmental and Social Psychology, Sapienza University, Rome and was conducted in accordance with the Declaration of Helsinki.
Procedures
An anonymous online survey to be completed by parents was arranged for this study to evaluate the effect of lockdown on sleep patterns and disturbances and on the use of social media and total daily screen exposure time in children and adolescents with ADHD.
Data were collected with a survey advertised through the national ADHD Family Association website, for a limited time window (from June 4–June 21, 2020), targeting patients with ADHD aged 5 to 18 years. Before accessing the survey, parents were asked to read the written consent form and to agree to participate in the study. Informed consent represented a required field for advancing in the compilation of the questionnaire.
The questions investigated sleep habits (duration and bedtime) and sleep disturbances to evaluate the differences before and during lockdown, along with the demographic information of the parent completing the survey (sex, caregiver education) and family composition. Moreover, screen exposure time (2–3 hours/day, half of the day, most of the day), excluding the hours spent for online lessons, and device preferences (video games, internet, television, mobile phones) were also assessed.
Instruments
The Sleep Disturbance Scale for Children by Bruni, Ottaviano, et al8 investigates the occurrence of sleep disturbances based on 26 items in a Likert-type scale, with values 1–5 (higher numerical values reflect a higher clinical severity of symptoms). For the purpose of this study and to facilitate the compilation of responses by parents, we selected specific questions to evaluate the prevalence before and during lockdown. Some questions were grouped into 1 (ie, sleep-disordered breathing) and other questions, not relevant for the time period, were excluded. The final questionnaire was composed of 13 items.
Statistical analyses
Descriptive statistics were applied to characterize sociodemographic variables, sleep patterns, and sleep disturbances. Data were reported as frequencies and percentages. The McNemar nonparametric χ2 test was used to compare sleep patterns and sleep disturbances and the use of social media, before and during lockdown.
To assess the changes occurring during lockdown, bedtime and sleep duration were recoded into 3 categories: bedtime was classified as delayed, anticipated, or no change, and sleep duration was classified as increased, decreased, or no change; a cross-tabulation analysis was then conducted between bedtime, sleep duration and screen exposure time.
The χ2 test was used to compare children vs adolescents on sleep patterns and sleep disturbances during the lockdown. For all comparisons, P values < .05 were considered as statistically significant. Statistical analyses were performed using SPSS software release 17.0 (SPSS Inc., Chicago, IL).
RESULTS
The total sample was composed of 528 children (441 male (83.5%), 87 female (16.5%); age range, 5–11.11 years; mean age, 9.1 years; standard deviation, 1.63) and 464 adolescents (406 male (87.5%), 58 female (12.5%); age range, 12–17.1 years; mean age, 14.3 years; standard deviation, 1.92]. The sex composition of the 2 age groups was not statistically different (χ2 = 3.130; P = .077).
The family economic status of the entire sample was high in 3%, middle in 75.2%, and low in 21.8%. Mothers were the main compilers of the survey (88.6%).
As for the education level, the majority of compilers had a graduate (29%) or high school degree (52.6%); middle school was reported by 17.9% and elementary school by 0.5%. The family composition was reported as follows: parents with 1 offspring member, 31.3%; parents with 2 offspring members, 51.9%; parents with 3 offspring members, 13.3%; and parents with ≥ 4 offspring members, 3.5%.
During lockdown, we found a significant delay of bedtime in both children and adolescents: There was a significant reduction in the number of patients with ADHD who went to bed at 8–10 pm, with an increase in the number of patients with ADHD who went to bed at 11 pm or later (Table 1). Compared to children, there was a higher percentage of adolescent patients who went to bed ≥ 12 am and a lower percentage at 8–10 pm and 10–11 pm (Table 1).
Table 1.
Comparison of bedtime before and during lockdown in children and adolescents with ADHD and age groups comparison.
| Bedtime | Before, n (%) | During, n (%) | χ2 | P < | C vs A | ||
|---|---|---|---|---|---|---|---|
| χ2 | P < | ||||||
| 8–10 PM | C | 452 (85.6) | 165 (31.2) | 285.003 | .0001 | 42.3877 | .0001 |
| A | 239 (51.5) | 64 (13.8) | 169.140 | .0001 | |||
| 10–11 PM | C | 66 (12.5) | 176 (33.3) | 66.006 | .0001 | 10.135 | .001 |
| A | 151 (32.5) | 112 (24.1) | 7.482 | .006 | |||
| 11 PM–12 am | C | 7 (1.3) | 136 (25.8) | 117.871 | .0001 | 0.330 | NS |
| A | 49 (10.6) | 127 (27.4) | 38.006 | .0001 | |||
| ≥ 12 AM | C | 5 (0.9) | 41(7.8) | 34.028 | .0001 | 98.449 | .0001 |
| A | 22 (4.7) | 152 (32.8) | 126.068 | .0001 | |||
A = adolescents; ADHD = attention-deficit hyperactivity disorder; C = children; NS = not significant.
Bedtime was delayed in 59.3% (313/528) of children and 69.4% (322/464) of adolescents, and no change was reported by 40.7% (215/528) of children and 29.7% (138/464) of adolescents. Only 0.9% (4/464) of adolescents advanced their bedtime (Figure 1).
Figure 1. Bedtime changes during lockdown.
In contrast, with regard to sleep duration, we found trends in the opposite directions. There was an increased percentage of patients who slept < 6 hours/night (with higher rates in adolescents) and a higher rate of participants who slept ≥ 10–11 hours/night (with higher rates in children), whereas the percentage of patients who slept 8–9 hours per night decreased (Table 2).
Table 2.
Comparison of sleep duration before and during lockdown in children and adolescents with ADHD and age groups comparison.
| Hours | Before, n (%) | During, n (%) | χ2 | P < | C vs A | ||
|---|---|---|---|---|---|---|---|
| χ2 | P < | ||||||
| < 6 | C | 14 (2.7) | 28 (5.3) | — | .004* | 18.604 | .0001 |
| A | 26 (5.6) | 61 (13.1) | 21.811 | .0001 | |||
| 6–7 | C | 78 (14.8) | 85 (16.1) | .371 | NS | 5.590 | .018 |
| A | 132 (28.4) | 102 (22) | 5.923 | .015 | |||
| 8–9 | C | 318 (60.2) | 269 (50.9) | 12.909 | .0001 | 2.991 | NS |
| A | 271 (58.4) | 210 (45.3) | 20.112 | .0001 | |||
| 10–11 | C | 114 (21.6) | 139 (26.3) | 4.608 | .032 | 10.680 | .001 |
| A | 31 (6.7) | 82 (17.7) | 30.120 | .0001 | |||
| ≥ 12 | C | 4 (0.8) | 7 (1.3) | — | NS* | — | NS† |
| A | 4 (0.9) | 9 (1.9) | — | NS* | |||
*McNemar binomial distribution. †χ2 Fisher test in interage group comparison. A = adolescents; ADHD = attention-deficit hyperactivity disorder; C = children; NS = not significant.
During lockdown, sleep duration changed in 41.3% of children and in 49.4% of adolescents; in particular, sleep duration decreased in 19.9% and 22%, increased in 21.4% and 27.4%, and was maintained in 58.7% and 50.6% of children and adolescents, respectively (Figure 2).
Figure 2. Sleep duration changes during lockdown.
Figure 3 reports the interaction between bedtime and sleep duration, showing that among patients who delayed bedtime, a high percentage of children (77.9%) and adolescents (82.7%) increased sleep duration but also that a high percentage of children (83.8%) and adolescents (89.2%) decreased sleep duration, and 44.2% of children and 53.6% of adolescents did not change sleep duration.
Figure 3. Cross-tabulation between bedtime delay and sleep duration.
A = adolescents, C = children.
Figure 4 shows that among participants who did not change their bedtime, 22.1% of children and 15.7% of adolescents increased sleep duration, 16.2% of children and 9.8% of adolescents decreased sleep duration, and 55.8% of children and 46% of adolescents maintained the same sleep duration (Figure 4).
Figure 4. Cross-tabulation between maintained bedtime and sleep duration.
A = adolescents, C = children.
Finally, among 4 (0.9%) adolescents who anticipated bedtime, 2 increased sleep duration, 1 reduced it, and 1 maintained the same sleep duration.
Both children and adolescents with ADHD significantly increased the use of leisure screen time during lockdown, with the exception of the use of television (Table S1 (44.7KB, pdf) in the supplemental material). Age group comparison highlighted that children made greater use of television and that adolescents spent more time with the internet and their mobile phone (Table S1 (44.7KB, pdf) ). Overall, we observed that 64.2% of children and 72% of adolescents spent half or most of the time/day in front of a screen.
Table 3 reports the cross-tabulation between screen exposure time and delayed and maintained bedtime. Adolescents with bedtime delay used screen time most of the day at a significantly higher percentage than those who maintained the same bedtime. Conversely, children and adolescents who maintained their bedtime used screen time for 2–3 hours per day at a significantly higher percentage.
Table 3.
Cross-tabulation of screen time use and bedtime.
| Screen Time | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Most of the Day | Half-Day | 2–3 H | |||||||
| % (n) | χ2 | P | % (n) | χ2 | P | % (n) | χ2 | P | |
| Children | |||||||||
| Bedtime delayed | 36.1 (113/313) | 1.384 | .239 | 33.5 (105/313) | 4.304 | .038 | 24.6 (77/313) | 7.757 | .005 |
| Bedtime maintained | 31.2 (67/215) | — | — | 25.1 (54/215) | — | — | 35.8 (77/215) | — | — |
| Adolescents | |||||||||
| Bedtime delayed | 56.2 (181/322) | 16.433 | .0001 | 23.6 (76/322) | 1.717 | .424 | 13 (42/322) | 29.422 | .0001 |
| Bedtime maintained | 36.2 (50/138) | — | — | 18.1 (25/138) | — | — | 34.1 (47/138) | — | — |
Table 4 includes the cross-tabulation between screen exposure time and sleep duration. Children and adolescents with a decreased sleep duration used screen time most of the day at a significantly higher percentage than those who maintained or increased sleep duration. Conversely, children and adolescents who maintained the same sleep duration used screen time for 2–3 hours per day at a significantly higher percentage.
Table 4.
Cross-tabulation of screen time use and sleep duration.
| Screen Time | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Most of the Day | Half-Day | 2–3 H | |||||||
| % (n) | χ2 | P | % (n) | χ2 | P | % (n) | χ2 | P | |
| Children | |||||||||
| Duration increased | 36.3 (41/113) | 14.529 | .001 | 29.2 (33/113) | 0.271 | .873 | 26.5 (30/113) | 8.460 | .015 |
| Duration maintained | 28.4 (88/310) | — | — | 31.0 (96/310) | — | — | 33.5 (104/310) | — | — |
| Duration decreased | 48.6 (51/105) | — | — | 28.6 (30/105) | — | — | 19.0 (20/105) | — | — |
| Adolescents | |||||||||
| Duration increased | 53.5 (88/127) | 15.934 | .0001 | 23.6 (30/127) | 0.325 | .850 | 13.4 (17/127) | 15.884 | .0001 |
| Duration maintained | 41.7 (98/235) | — | — | 21.7 (51/235) | — | — | 26.8 (63/235) | — | — |
| Duration decreased | 64.7 (66/102) | — | — | 20.6 (21/102) | — | — | 10.8 (11/102) | — | — |
Based on the Sleep Disturbance Scale for Children, during lockdown, both children and adolescents with ADHD showed an increase of sleep disturbances mainly related to falling asleep, anxiety at bedtime, night awakenings, and daytime sleepiness when compared to previous conditions (Table 5). In comparing the different age groups, we found that children reported an increase in nightmares, anxiety at bedtime, and bruxism, whereas adolescents showed an increase in daytime sleepiness (Table 5).
Table 5.
Comparison of sleep disturbances before and during lockdown in children and adolescents with ADHD and age groups comparison.
| Before, n (%) | During, n (%) | χ2 | P < | C vs A | |||
|---|---|---|---|---|---|---|---|
| χ2 | P < | ||||||
| Difficulty falling asleep | C | 130 (24.6) | 247 (46.8) | 77.780 | .0001 | 0.005 | NS |
| A | 152 (32.8) | 216 (46.6) | 24.951 | .0001 | |||
| Anxiety at bedtime | C | 103 (19.5) | 166 (31.4) | 38.828 | .0001 | 34.334 | .0001 |
| A | 56 (12.1) | 72 (15.5) | 5.114 | .024 | |||
| Hypnic jerks | C | 80 (15.2) | 97 (18.4) | 4.830 | .028 | 3.807 | .051 |
| A | 59 (12.7) | 64 (13.8) | 0.485 | NS | |||
| Rhythmic movements | C | 33 (6.3) | 42 (8.0) | — | .078* | 7.218 | .007 |
| A | 13 (2.8) | 18 (3.9) | — | NS* | |||
| > 2 awakenings/night | C | 50 (9.5) | 94 (17.8) | 31.879 | .0001 | 3.310 | NS |
| A | 36 (7.8) | 63 (13.6) | 13.796 | .0001 | |||
| Restless sleep | C | 223 (42.2) | 214 (40.5) | 0.985 | NS | 2.584 | NS |
| A | 160 (34.5) | 165 (35.6) | 0.254 | NS | |||
| Snoring/apnea | C | 33 (6.3) | 31 (5.9) | — | NS* | 0.630 | NS |
| A | 41 (8.8) | 33 (7.1) | — | NS* | |||
| Sleepwalking | C | 38 (7.2) | 46 (8.7) | — | NS* | 5.381 | .020 |
| A | 29 (6.3) | 23 (5) | — | NS* | |||
| Sleep terrors | C | 28 (5.3) | 27 (5.1) | — | NS* | 5.044 | .025 |
| A | 10 (2.2) | 11 (2.4) | — | NS* | |||
| Bruxism | C | 91 (17.2) | 82 (15.5) | 1.939 | NS | 10.932 | .001 |
| A | 60 (12.9) | 40 (8.6) | 12.033 | .001 | |||
| Nightmares | C | 80 (15.2) | 132 (25) | 27.094 | .0001 | 25.891 | .0001 |
| A | 49 (10.6) | 57 (12.3) | 1.633 | NS | |||
| Daytime sleepiness | C | 61 (11.6) | 86 (16.3) | 6.940 | .008 | 27.824 | .0001 |
| A | 90 (19.4) | 141 (30.4) | 26.882 | .0001 | |||
*Binomial distribution. A = adolescents; ADHD = attention-deficit hyperactivity disorder; C = children; NS = not significant.
Daytime sleepiness in patients who delayed their bedtime vs those who maintained their bedtime was significantly prevalent in children (60/313 = 19.2% vs 26/215 = 12.1%; χ2 = 4.681; P = .031) and in adolescents (113/322 = 35.1% vs 27/138 = 19.6%; χ2 = 15.934; P <.001). Furthermore, daytime sleepiness in patients who reduced their sleep duration vs those who maintained their sleep duration increased in children (29/105 = 27.6% vs 39/310 = 12.6%; χ2 = 11.066; P = .004) and in adolescents (44/102 = 43.1% vs 48/235 = 20.4%; χ2 = 15.934; P <.001). Interestingly, adolescents who increased their sleep duration (49/127 = 38.6%) also showed higher daytime sleepiness than those who maintained their sleep duration.
No differences were found for cosleeping (children, 23.7% vs 24.8%; adolescents, 7.8% vs 7.3%) and for the use of over-the-counter products for sleeping (children, 18% vs 19.5%; adolescents, 21.3% vs 21.1%).
DISCUSSION
Our results show that lockdown restrictions for the COVID-19 pandemic affected the sleep-wake rhythm of patients with ADHD, disrupting in a dramatic way the previous habits of bedtime and sleep duration. Approximately 60% of children and 70% of adolescents reported a delay in their bedtime, and approximately 40% of children and 50% of children and adolescents also showed a significant change in their sleep duration. These percentages are higher than those reported among children and adolescents without ADHD.7 Moreover, as reported in other studies in children and in the adult general population,3,9,10 our results show that the delay of bedtime and reduced sleep duration were related with the increased time of screen exposure.
In general, accordingly with several reports conducted in preschool children11 and in older children and adults,3,12 the lockdown condition causes the disruption of previous sleep-wake habits, independently by age and mental health condition. Altogether, the lockdown seems to be a reinforcing factor of the maladaptive sleep habits and the instability of the sleep-wake system that have already been reported in patients with ADHD in general.13 Different studies have reported an increase of sleep duration in children and adolescents without ADHD during lockdown,5,12,14 probably because home confinement allowed a better alignment with their sleep requirements.15,16
Our findings provide further critical information and highlight that both children and adolescents who delayed bedtime showed either an increased or a decreased sleep duration. However, only the participants with ADHD who delayed bedtime and decreased sleep duration reported an increased time of screen exposure. It is noteworthy that in other studies in children and in the adult general population,3,8,9 delayed bedtime was related to screen exposure but sleep duration remained unchanged or increased.
Furthermore, we observed an increase in daytime sleepiness that was related, in both age groups, with a bedtime delay and a decrease of sleep duration. In adolescents, we also saw an increase in daytime sleepiness that was associated with an increase in sleep duration.
This finding is alarming considering that in Italy, regular academic activities at school have been interrupted for adolescents, and the persistence of this condition could represent a risk factor for the stabilization of disrupted sleep patterns and screen addiction. A further critical data point is the increase of sleep disturbances recorded during the lockdown. Under normal conditions, several studies reported a high prevalence of parent-reported sleep disturbances in school-aged children with ADHD,17–19 with approximately one-third of children who experienced chronic sleep-onset insomnia,20 night awakenings, restless sleep, and difficult morning awakening.13,17,21–23 Our findings highlight that lockdown also increased the vulnerability to sleep disturbances common among children and adolescents with ADHD, with the aggravating circumstance of anxiety at bedtime and nightmares presumably linked to worries about COVID-19 infection.
Some limitations of this study must be acknowledged. First, we did not specifically evaluate the influence of psychiatric comorbidity, and therefore we cannot exclude the influence of psychiatric comorbidity on habits and sleep disorders. Second, although the survey was conducted after only a few days from the end of strict lockdown and in the presence of lighter restrictions, we cannot exclude a memory bias of the parents. Nevertheless, the large sample size of our study, representative of the Italian population with ADHD, makes us confident that our findings reflect the impact of the lockdown experience on the sleep patterns of this population. The major challenge after the pandemic will be to identify its sequelae and to assess whether patients with ADHD will experience long-term disrupted sleep habits. It is crucial that sleep concerns be part of research initiatives aimed at mitigating the consequences of COVID-19 pandemic–related restrictions in children and adolescents with ADHD.
DISCLOSURE STATEMENT
All authors have read and approved the final manuscript. The authors report no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
ACKNOWLEDGMENTS
The authors gratefully acknowledge the Italian President of the Family Association of ADHD (AIFA), Patrizia Stacconi, all regional referents, and parents who have participated in this study. Author contributions: Each author made a substantive intellectual contribution to the study. Oliviero Bruni: conceptualization and study design, data analysis, data interpretation, revision of the manuscript, approval of the final manuscript as submitted. Martina Giallonardo: data collection and interpretation, revision of the manuscript, approval of the final manuscript as submitted. Roberto Sacco: data analysis, data interpretation, revision of the manuscript, approval of the final manuscript as submitted. Raffaele Ferri: revision of the manuscript, approval of the final manuscript as submitted. Maria Grazia Melegari: conceptualization and study design, data analysis, data collection and interpretation, preparation and revision of the manuscript, approval of the final manuscript as submitted.
ABBREVIATION
- ADHD,
attention-deficit hyperactivity disorder
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