Running head: AN INTEGRATIVE REVIEW

An Integrative Review

Samantha Yoon

Bon Secours Memorial College of Nursing

Nursing Research NUR 4122

Dr. Christine Turner, PhD, RN

1 November 2017

“I pledge…”
AN INTEGRATIVE REVIEW 2

Abstract

The purpose of this integrative review concerns the effects of stimulant medication on

sleep disturbance in adolescents diagnosed with attention deficit hyperactivity disorder

(ADHD). There has been a large spike in the diagnosis of ADHD in the recent years and the

current treatment is stimulant medications, which can cause sleep disturbances in the

adolescents being treated. The research compiled was analyzed and reviewed to determine

their usefulness to the researcher’s PICOT question, “Are adolescents with ADHD at

increased risk for sleep disturbance compared with adolescents with ADHD without

medication treatment over the first six months of treatment?” The Bon Secours eLibrary

database was used with key terms to find relating articles. The researcher found that four

out of the five articles resulted in sleep disturbances from stimulant medication use in the

adolescent. However, several articles were outdated, which could prompt the further need

of research done on this issue.

AN INTEGRATIVE REVIEW 3

An Integrative Review

In the past decade, there has been a noticeable rise in the diagnosis of Attention-

Deficit/Hyperactivity Disorder (ADHD) in adolescents. This in turn means that a large

majority of these children are being treated with stimulant medications to appease their

inattention, hyperactivity, and impulsivity (Moreau, Rouleau, & Morin, 2014). Stimulant

medications, like Methylphenidate (MPH), a first line and commonly used ADHD treatment,

could be causing sleep disturbances in adolescents. The aim of this integrative review is to

accumulate relevant literature in relation to the researcher’s PICOT question, “Are

adolescents with ADHD at increased risk for sleep disturbance compared with adolescents

with ADHD without medication treatment over the first six months of treatment?” While

there is ample amount of research on adolescents with ADHD and stimulant treatment of

ADHD, there is not a large amount of current research within the past five years on the

specific effect of stimulant use on sleep disturbance in adolescence. The researcher’s

interest came from her personal witness at her job, a retail pharmacy, where many

adolescent patients are on ADHD stimulant medication and need a daily nighttime

medication to help “bring them down” to be able to sleep.

Design and Research Methods

This integrative review goes over five research studies that were searched through

the Bon Secours eLibrary cross-search database. The key terms used to locate these articles

include: “adolescent,” “ADHD,” “sleep disturbance,” “stimulant medication”, and

“methylphenidate.” Initially, the search criteria was limited for a five year range from 2017,

however there was not much success in finding anything closely relevant, so the timespan
AN INTEGRATIVE REVIEW 4

was expanded. This review includes three quantitative and two qualitative studies that

relate to the PICOT question.

Findings/Results

The findings and results from each article presented different outcomes on

correlation of stimulant medications and sleep disturbance in children diagnosed with

ADHD. A summary of each article is presented in the appendix. Four articles (Day &

Abmayr, 1998; Corkum, Panton, Ironside, MacPherson, & Williams, 2007; Moreau, Rouleau,

& Morin, 2014; Vigliano, Galloni, Bagnasco, Delia, Moletto, Mana, & Cortese, 2016) collected

similar results of stimulant medication effects, whereas the remaining article (Cockcroft,

Ashwal, & Bentley, 2009) had opposite findings in the results.

Positive Sleep Disturbances

A study conducted by Moreau et al., (2014) expressed the purpose of their study

was to characterize the sleep of children with ADHD and find possible side effects of

stimulant medications for their treatment. This study had forty-one, child participants that

wore an Actiwatch-64 device which recorded motor movement from sleep to wake time;

while the parents recorded a sleep diary and answered a Child Behavior Checklist,

Children’s Sleep Habits Questionnaire, and an Insomnia Severity Index for Children. With

the results from the actigraph and parental report, the conclusion was that children with

ADHD treatment indeed have “…longer sleep onset latency, lower sleep duration and

efficiency, and higher nocturnal motor activity…as well as having more difficulty initiating

sleep” (Moreau et al., 2014).

Similarly, Day & Abmayr (1998) found results that came in close comparison to the

previous article summarized. Day & Abmayr saw that the association of sleep disturbance
AN INTEGRATIVE REVIEW 5

and ADHD and its treatment were unclear. For ADHD and the treatment it was important to

determine the sleep quality and quantity of the children using stimulants. Due to the time

frame of this study, the authors were limited to resources in collecting data in comparison

of what is available today. Data was collected from parents of children with ADHD by a

detailed behavioral questionnaire by three separate phone interviews with equal time in

between each. The interview included the same forty questions, which were descriptors of

sleep related behaviors in their children. Parents of children with ADHD reported

significantly less sleep in their children in comparison to the control group of children

without ADHD. For the ADHD group, the biggest and most common issue was the

reluctance of the child to settle down to sleep and bedtime preparation (Day & Abmayr,

1998). However, the study did find that the differences in the sleep duration were not very

different from one another in the study and control group.

Corkum et al. (2007) conducted a study on adolescents with ADHD who take a

stimulant medication, Methylphenidate immediate-release, who are also medication naïve.

The purpose of this study was to determine the consequences of the drug use on sleep. This

study also used an actigraph, sleep diary, and a sleep disturbance scale for children.

Corkum et al. showed that children treated with MPH had negative changes in sleep in

which the participants lost about fifty-seven minutes of sleep in comparison to not being on

medication. The authors also found that it took an average time of sixty-nine minutes to

fall asleep with MPH treatment. This result was extreme in comparison to the participants’

baseline of thirty minutes to fall asleep, and the forty-two minutes it took while on a non-

stimulant treatment; however, the quality of sleep was not affected by medication in this

study (Corkum et al., 2007).

AN INTEGRATIVE REVIEW 6

Vigliano et al., (2016) researched long-term effects of stimulant medications in

children with ADHD treatment. The researchers studied polysomnograph (PSG) readings of

each child from their sleep. Each child’s baseline was established with the PSG then were

recorded from time of going to bed and wake time. Findings showed that there was a

“significant increase in duration of awakening, reduction of sleep efficiency, and an

increase of percentage in light sleep compared to the non-ADHD group” (Vigliano et al.,

2016). However, parents reported that use of stimulant seemed to have a noticeable effect

on the children for the first days or week of treatment but then returned to baseline when

adjusted to the medication. The results are contradictory from what the PSG showed and

what the parents report.

Negative Sleep Disturbance

The last research study conduced by Cockcroft et al., (2009) focused on the use of

MPH on daytime sleepiness and its cause of difficulties in falling asleep and night. Cockcroft

et al., (2009) utilized a twelve, open-ended question survey for the parents and the Wits

Faces Sleepiness Scale completed by the studied children. Results showed that there was

no difference in sleep length, disturbance or general bedtime behavior between the ADHD

medicated group and non-medicated group.

Discussion/Implications

The articles discussed had a four out of five agreement of a positive relationship

between stimulant medication treatment for children with ADHD and their sleep

disturbance. With these positive results, this review supports the PICOT question set by the

researcher and gives further insight. Although, all of the data was not consistently the
AN INTEGRATIVE REVIEW 7

same, the similarities showed a significant issue in the sleep disturbances of the

participants.

There is not an abundant amount of research out there specific to this age group and

sleep disturbances from stimulant medications, however the results of these studies clearly

represent a need for further studies to find possible counter treatments to reverse or help

the issues in bedtime preparation and sleep quality and quantity.

Limitations/Conclusions

All five articles had a specific limitation of a small sample size. Each research article

identified this as a primary issue. A larger sample size would be able to find more accurate

results. Four out of the five articles went beyond the five years that is allowed for research

use, which makes the research not as dependable. It is also a limitation that the researcher

is not experienced in fulfilling an integrative review.

The diagnosis of ADHD in adolescents and the stimulant use for treatment has a

large presence in today’s society. In most cases, in regards to the articles, the stimulant

medications used to treat adolescents with ADHD caused them to have sleep disturbances.

Sleep quality and quantity is important and the loss of sleep determined in the research is

detrimental as Corkum et al., (2007) explains that, “even with an hour loss can demonstrate

poorer academics, behavior, and cognitive performance.” It is imperative to further find

issues of not only MPH use but also other stimulant medications and it’s long-term effects

on the growth and development of adolescents.

AN INTEGRATIVE REVIEW 8

References

Cockcroft, K., Ashwal, J., & Bentley, A. (2009). Sleep and daytime sleepiness in

methylphenidate medicated and un-medicated children with attention

deficit/hyperactivity disorder (ADHD). African journal of psychiatry, 12(4).

Corkum, P., Panton, R., Ironside, S., MacPherson, M., & Williams, T. (2007). Acute

impact of immediate release methylphenidate administered three times a day on

sleep in children with attention-deficit/hyperactivity disorder. Journal of Pediatric

Psychology, 33(4), 368-379. https://doi.org/10.1093/jpepsy/jsm106

Day, H. D., & Abmayr, S. B. (1998). Parent reports of sleep disturbances in stimulant

medicated children with attention‐deficit hyperactivity disorder. Journal of clinical

psychology, 54(5), 701-716.

Moreau, V., Rouleau, N., & Morin, C. M. (2014). Sleep of children with attention deficit

hyperactivity disorder: actigraphic and parental reports. Behavioral sleep

medicine, 12(1), 69-83.

Vigliano, P., Galloni, G. B., Bagnasco, I., Delia, G., Moletto, A., Mana, M., & Cortese, S. (2016).

Sleep in children with attention-deficit/hyperactivity disorder (ADHD) before and

after 6-month treatment with methylphenidate: a pilot study. European journal of

pediatrics, 175(5), 695-704.

 APA Citation
methylphenidate medicated and un-medicated children with attention-
deficit/hyperactivity disorder (ADHD). African journal of psychiatry, 12(4).
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/Method/Philosophi
cal Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
NUR 4122/4222. REV 10.9.2017
Cockcroft, K., Ashwal, J., & Bentley, A. (2009). Sleep and daytime sleepiness in
 Methyphenidate is widely used for ADHD treatment and daytime sleepiness, but
could be causing difficulties in falling asleep at night as well
 Not discussed
 Quantitative experimental
 Approved by Committee of Research on Human Subjects of the University of
Witwatersrand
 23 children
 16 boys, 7 girls
 age from 6.4 to 12.7 years old
 3 South African Gauten Department of Education
 School psychologist requested letters be sent to parents of children diagnosed with
ADHD to participate in study
 Study group: medicated group
 Control group: unmedicated group
 Parental questionnaire—12 open ended questions
 Wits Faces Sleepiness Scale completed by children
 No significant differences between medicated and un-medicated groups for:
 Time of going to bed
 Sleep latency
 Awakening time
 Prevalence of daytime naps

Findings/Discussion
Appraisal/Worth to
practice
NUR 4122/4222. REV 10.9.2017
 Manner of morning awakening
 Comments on child’s daytime sleepiness by parents or teachers
 ONLY the medicated group had snoring, apnea/gasping, restlessness, frequent
changes in sleep position and enuresis
 No difference in sleep length or disturbance was found between two groups
 No different in bedtime behavior between both groups
 Limitations included small sample size
 Information is useful for comparison in the effects of methyphendiate in both treated
and un-treated children
 APA Citation Corkum, P., Panton, R., Ironside, S., MacPherson, M., & Williams, T. (2007). Acute
impact of immediate release methylphenidate administered three times a day on
sleep in children with attention-deficit/hyperactivity disorder. Journal of Pediatric
Psychology, 33(4), 368-379.

Background/Problem  Given the large amount of children on stimulant medication and its possible side
Statement effects on sleep, consequences of the drug use on sleep must be understood and
known
 Assess sleep quality and quantity in children who are medication naïve and treated
with Methyphenidate TID for ADHD
Conceptual/theoretical  Not discussed
Framework

Design/Method/Philosophi  Quantitative experimental

cal Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
 Standardized clinical blind medication trial—one week of baseline, placebo, low and
moderate MPH dose TID
 28 children
 20 males, 8 females
 Ages between 6 and 12
 Recruitment from referrals from specialty ADHD clinic at community hospital in mid
sized Canadian town
 Approval granted by hospital and university research ethics board
 Written parental and child verbal assent prior to participation
 Medication naïve children with ADHD with dosing of MPH TID based on weight

Measurement Tool/Data  Conner’s Parent and Teacher Rating Scale-Short

Collection Method  Actigraphy
 Sleep diary
 Sleep Disturbances Scale for Children
NUR 4122/4222. REV 10.9.2017
Data Analysis
Findings/Discussion
Appraisal/Worth to
practice
NUR 4122/4222. REV 10.9.2017
 Efficacy of MPH dosing was proven in all different types of ADHD
 Actigraphy: significant reduction in total sleep time (~57 min less) and increased
sleep onset latency (~40 min longer); no change in awakening frequency or sleep
efficiency
 Sleep diary: same as actigraphy
 Sleep questionnaire: data found to be insignificant
 Reports by parents and teachers of evidence of ADHD behaviors significantly
subsiding with MPH TID treatment compared to baseline
 Significant negative changes in sleep of the children in which the participants lost
~57 minutes of sleep (while on meds, in comparison to meds)
 Sleep time is significant and the loss is detrimental, even with an hour loss can
demonstrate poorer academics, behavior, and cognitive performance
 Takes an average of 69 min to fall asleep with MPH tx vs. 30 min baseline and 42
min on nonstimulant tx
 Quality of sleep was not affected by medication
 States clearly of limitations of the study:
 Small, homogenous sample (Caucasian, rural, middle class, low rates of
comorbidity)
 Lack of knowledge of whether findings during acute trial would continue over time
 Suggestion: PSG study to determine sleep quality
 APA Citation
medicated children with attention‐deficit hyperactivity disorder. Journal of clinical
psychology, 54(5), 701-716.
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/Method/Philosophi
cal Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
NUR 4122/4222. REV 10.9.2017
Day, H. D., & Abmayr, S. B. (1998). Parent reports of sleep disturbances in stimulant‐
 “No study that specifically and systemically evaluated the behavioral side effects of
simulant medication with hyperactive children, insomnia is the most frequently cited
side effect of stimulant pharmacotherapy in children with ADHD”
 The association of sleep disturbances and ADHD and it’s treatment is unclear at this
time
 It is important to determine how often sleep disturbances occur in children being
treated for ADHD with stimulants
 Previous studies have only studied global ratings of sleep disturbance
 This study will further additional research in terms of specific sleep issues in
children with ADHD
 Qualitative
 Recruitment from large metropolitan area suburbs
 Direct contact or though a physician or counselor
 60 children
o Study group: 16 boys, 4 girls
o Counter study group: 11 boys, 9 girls
o Control: 14 boys, 6 girls
 Age 5-12 years
 Study group: children diagnosed with ADHD
 Counter study group: children with psychiatric diagnosis other than ADHD
 Control group: children with no clinical diagnosis
 Detailed behavioral questionnaire from parental reports
o Questions from Simonds and Parraga study
o 40 items as descriptors of sleep related behavior
Data Analysis
Findings/Discussion
Appraisal/Worth to
practice
NUR 4122/4222. REV 10.9.2017
 Three separate phone interviews
 First interview got baseline information, demographic info, current medications, and
child’s sleep behavior in past 6 months
 Second interview: parents recalled past 2 weeks of children’s sleep behavior
 Third interview: same as second interview, and asked again of current medications
children were taking at that time
 Parents of children with ADHD reported significantly less sleep in their children in
comparison to control group
 Differences in sleep duration was not extremely different
 Parents of children with ADHD reported more difficulties in children’s sleep in
comparison to the other 2 groups
 Biggest issue for ADHD group was the children’s reluctance to settle down for sleep
and bedtime preparation
 First study to get detailed parental reports of sleep related behaviors in
psychostimulant medicated children
 Consistent with variability in sleep disturbances associated with ADHD and its
treatment with other studies
 Dated study but information is useful
 APA Citation
hyperactivity disorder: actigraphic and parental reports. Behavioral sleep
medicine, 12(1), 69-83.
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/Method/Philosophi
cal Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
NUR 4122/4222. REV 10.9.2017
Moreau, V., Rouleau, N., & Morin, C. M. (2014). Sleep of children with attention deficit
 Characterize the sleep of children with ADHD and the potential effects of
psychostimulant medication use and psychiatric comorbidity
 Past studies that look at the association with ADHD treatment and its symptoms are
inconsistent with results
 Specific framework not discussed
 Quantitative
 41 children
 mean age: 9.74 years
 10 children were medication free
 31 on different medications for ADHD
 Study approved by Universite Laval institutional review bord
 Parents signed written consent and children gave verbal consent before
participation
 Study group: children diagnosed with ADHD
o Exclusion criteria: presence of serious medical illness, use of psychoactive
medication, and IQ <80
 Control group: healthy children with same age group and exclusion criteria
o Actigraphy
o Sleep diary
o Child Behavior Checklist
o Children’s Sleep Habits Questionnaire
o Insomnia Severity Index for Children
 Actigraph: significant sleep onset latency and nocturnal motor activity in ADHD
group compared to control group
Findings/Discussion
Appraisal/Worth to
practice
NUR 4122/4222. REV 10.9.2017
 Children with ADHD treatment have longer sleep onset latency, lower sleep duration
and efficiency, and higher nocturnal motor activity
 Children with ADHD also have more difficulty initiating sleep
 Limitations include:
o A specific and small sample size, large amount of girls (when diagnosis is
predominantly a male dominated diagnosis)
 This study is useful for specific questions in terms of the effect of psychostimulant
medications in children
 APA Citation Vigliano, P., Galloni, G. B., Bagnasco, I., Delia, G., Moletto, A., Mana, M., & Cortese,
S. (2016). Sleep in children with attention-deficit/hyperactivity disorder (ADHD)
before and after 6-month treatment with methylphenidate: a pilot study. European
journal of pediatrics, 175(5), 695-704.

Background/Problem  Long term effects of psychostimulants for treatment of ADHD are unclear
Statement  Quality and quantity of sleep in children impact their emotional and cognitive
development, which in turn exacerbates ADHD symptoms
 Short term effects of psychostimulant medications have been assessed however
long term effects have not—this is to compare polysomnography (PSG) in sleep of
kids with ADHD before pharmacologic therapy, and in children without ADHD, and
PSG changes in kids with ADHD after 6 months
Conceptual/theoretical  Not discussed
Framework

Design/Method/Philosophi  Quantitative experimental

cal Underpinnings

Sample/ Setting/Ethical  11 children with ADHD

Considerations
Major Variables Studied
(and their definition), if
appropriate
 Were diagnosed with ADHD at Division of Child Neuropsychiatry, Martini Hospital,
Turin, Italy, between March 2010 and 2013
 Comparison group non-ADHD 22 children
 Parental consent
 Study group: children with ADHD treated with methyphenidate
 Control group: children without ADHD

Measurement Tool/Data  Parents gave evaluation of sleep from questionnaire

Collection Method  Electroencephalographic record (EEG) was used to record sleep until spontaneous
wake

NUR 4122/4222. REV 10.9.2017

Data Analysis
Findings/Discussion
Appraisal/Worth to
practice
NUR 4122/4222. REV 10.9.2017
 PSG reading: children with ADHD at baseline had significant increase duration of
awakening, reduction of sleep efficiency, and increase of % in light sleep compared
to non-ADHD group
 MPH led to increase in stage II duration, decreased REM latency, and no change in
sleep onset latency
 Parents reported MPH did effect children first days/weeks of treatment but then
adjusted
 Researches found significant increase in global movement and duration of wakings
in sleep with children with ADHD treatment
 Some information is useable
 Not completely worthy of practice
 Limitations stated: sample size too small, only included objective data