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The Effects of Sleep Treatment on Symptoms of ADHD, Sleep Quality, Fatigue, and Depressive Symptoms in Adults

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Title: The Effects of Sleep Treatment on Symptoms of ADHD, Sleep Quality, Fatigue, and Depressive Symptoms in Adults
Language: English
Authors: Mirte van der Ham (ORCID 0000-0002-7094-7510), Denise Bijlenga, Nina Molenaar, Daniëlle E. J. Starreveld (ORCID 0000-0002-9381-7954), Mylène N. Böhmer, Ravian Wettstein (ORCID 0000-0001-6929-4770), Glenn Dumont, Aartjan T. F. Beekman, Sandra Kooij (ORCID 0000-0002-8644-6323)
Source: Journal of Attention Disorders. 2026 30(3):354-369.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
Peer Reviewed: Y
Page Count: 16
Publication Date: 2026
Document Type: Journal Articles
Reports - Research
Descriptors: Sleep, Attention Deficit Hyperactivity Disorder, Symptoms (Individual Disorders), Fatigue (Biology), Depression (Psychology), Adults, Program Effectiveness, Intervention, Foreign Countries, Drug Therapy
Geographic Terms: Netherlands
DOI: 10.1177/10870547251379103
ISSN: 1087-0547
1557-1246
Abstract: Background: Sleep problems are highly prevalent in adults with ADHD. Sleep problems and ADHD symptoms can cause, amplify, and maintain each other. We studied the effects of additive treatment for sleep problems on self-reported symptoms of ADHD as primary outcome, with subscales of inattention and hyperactivity-impulsivity, objective, performance-based ADHD symptoms, sleep quality, fatigue, and depressive symptoms as secondary outcomes. Methods: Preliminary open-label randomized controlled trial of adult patients diagnosed with ADHD and a positive screening for at least one sleep disorder. Participants were recruited between March, 2020 and May, 2023, during the COVID-19 pandemic. Seventy patients (60% female, mean age 27.9 years [SD = 8.2]) were randomized to a 12-week period of: (1) ADHD treatment as usual (TAU, n = 25), (2) ADHD TAU + sleep treatment (n = 22), or (3) stand-alone sleep treatment (n = 33). Outcome measures were assessed at baseline, and after 6 and 12 weeks of treatment. A total of 20% of participants did not complete the post-treatment assessment. Primary analyses compared changes between groups 1 and 2. Exploratory within-group analyses were conducted to assess improvements in the stand-alone sleep treatment group. All performed analyses were pre-specified. Results: Primary analysis showed no significant difference in the reduction of subjective ADHD symptoms between the ADHD TAU + sleep treatment group and the ADHD TAU group ([beta] = -1.30, 95% CI [-5.57, 2.96], d = 0.21). The ADHD TAU + sleep treatment group did show significantly larger improvements in subjective sleep quality ([beta] = -1.98, 95% CI [-3.65, -0.30], d = 0.42) and fatigue ([beta] = -6.52, 95% CI [-12.33, -0.70], d = 1.59) compared to the ADHD TAU group. Pre-specified, exploratory within-group analysis showed a significant reduction in subjective ADHD symptoms in the stand-alone sleep treatment group ([beta] = -4.80, 95% CI [-7.60, -2.01], d = 0.62). Conclusion: Adding sleep treatment to standard ADHD treatment did not lead to significantly greater reductions in subjective or objective, performance based ADHD symptoms. However, combined treatment showed the largest improvements in sleep quality and fatigue, suggesting that such an approach may offer additional benefits. Subjective ADHD symptoms improved in the stand-alone sleep treatment group, but to a lesser extent than the other groups. Future studies with greater statistical power are needed, with long-term effects and quality of life as important outcomes.
Abstractor: As Provided
Entry Date: 2026
Accession Number: EJ1496346
Database: ERIC
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  Value: <anid>AN0191330926;gs001mar.26;2026Feb05.05:30;v2.2.500</anid> <title id="AN0191330926-1">The Effects of Sleep Treatment on Symptoms of ADHD, Sleep Quality, Fatigue, and Depressive Symptoms in Adults </title> <p>Background: Sleep problems are highly prevalent in adults with ADHD. Sleep problems and ADHD symptoms can cause, amplify, and maintain each other. We studied the effects of additive treatment for sleep problems on self-reported symptoms of ADHD as primary outcome, with subscales of inattention and hyperactivity-impulsivity, objective, performance-based ADHD symptoms, sleep quality, fatigue, and depressive symptoms as secondary outcomes. Methods: Preliminary open-label randomized controlled trial of adult patients diagnosed with ADHD and a positive screening for at least one sleep disorder. Participants were recruited between March, 2020 and May, 2023, during the COVID-19 pandemic. Seventy patients (60% female, mean age 27.9 years [ SD = 8.2]) were randomized to a 12-week period of: (<reflink idref="bib1" id="ref1">1</reflink>) ADHD treatment as usual (TAU, n = 25), (<reflink idref="bib2" id="ref2">2</reflink>) ADHD TAU + sleep treatment (n = 22), or (<reflink idref="bib3" id="ref3">3</reflink>) stand-alone sleep treatment (n = 33). Outcome measures were assessed at baseline, and after 6 and 12 weeks of treatment. A total of 20% of participants did not complete the post-treatment assessment. Primary analyses compared changes between groups 1 and 2. Exploratory within-group analyses were conducted to assess improvements in the stand-alone sleep treatment group. All performed analyses were pre-specified. Results: Primary analysis showed no significant difference in the reduction of subjective ADHD symptoms between the ADHD TAU + sleep treatment group and the ADHD TAU group (β = −1.30, 95% CI [−5.57, 2.96], d = 0.21). The ADHD TAU + sleep treatment group did show significantly larger improvements in subjective sleep quality (β = −1.98, 95% CI [−3.65, −0.30], d = 0.42) and fatigue (β = −6.52, 95% CI [−12.33, −0.70], d = 1.59) compared to the ADHD TAU group. Pre-specified, exploratory within-group analysis showed a significant reduction in subjective ADHD symptoms in the stand-alone sleep treatment group (β = −4.80, 95% CI [−7.60, −2.01], d = 0.62). Conclusion: Adding sleep treatment to standard ADHD treatment did not lead to significantly greater reductions in subjective or objective, performance based ADHD symptoms. However, combined treatment showed the largest improvements in sleep quality and fatigue, suggesting that such an approach may offer additional benefits. Subjective ADHD symptoms improved in the stand-alone sleep treatment group, but to a lesser extent than the other groups. Future studies with greater statistical power are needed, with long-term effects and quality of life as important outcomes.</p> <p>Keywords: adult ADHD; clinical trial; CBT-I; ADHD symptoms; chronotherapy</p> <hd id="AN0191330926-2">Introduction</hd> <p>ADHD is a neurodevelopmental disorder characterized by inattention, impulsivity, and/or hyperactivity. It has a worldwide prevalence of approximately 8% in children, and 3% in adults ([<reflink idref="bib4" id="ref4">4</reflink>]; [<reflink idref="bib5" id="ref5">5</reflink>]). Sleep problems and disorders are common in adults with ADHD ([<reflink idref="bib16" id="ref6">16</reflink>]; [<reflink idref="bib47" id="ref7">47</reflink>]). The most common sleep disorder in adults with ADHD is the delayed sleep phase syndrome (DSPS), which is characterized by a delayed sleep-wake rhythm, difficulty falling asleep, and waking at socially conventional times, and is associated with significant burden ([<reflink idref="bib1" id="ref8">1</reflink>]; [<reflink idref="bib9" id="ref9">9</reflink>]; [<reflink idref="bib46" id="ref10">46</reflink>]; [<reflink idref="bib49" id="ref11">49</reflink>]). The prevalence of DSPS has previously been estimated at ca. 26% to 36%, based on self-reports ([<reflink idref="bib9" id="ref12">9</reflink>]; [<reflink idref="bib47" id="ref13">47</reflink>]) however, when looking at objectively assessed delayed sleep phase without having the DSPS diagnosis, it's prevalence can be as high as 78% in adults with ADHD ([<reflink idref="bib49" id="ref14">49</reflink>]). Other symptoms of sleep disorders, such as insomnia, restless legs syndrome (RLS)/periodic limb movement disorder (PLMD), and sleep-related breathing disorders (SBD) symptoms are also common in ADHD (range = 20%–80%; [<reflink idref="bib34" id="ref15">34</reflink>]; [<reflink idref="bib38" id="ref16">38</reflink>]; [<reflink idref="bib47" id="ref17">47</reflink>]; [<reflink idref="bib50" id="ref18">50</reflink>]; [<reflink idref="bib54" id="ref19">54</reflink>]; [<reflink idref="bib55" id="ref20">55</reflink>]). Moreover, in adults with ADHD, sleep problems are highly comorbid with other psychiatric disorders such as depression and anxiety ([<reflink idref="bib47" id="ref21">47</reflink>]).</p> <p>Symptoms of ADHD can be difficult to distinguish from those of sleep problems, as both may involve lack of concentration and focus, difficulty applying structure to daily life, and daytime fatigue ([<reflink idref="bib9" id="ref22">9</reflink>]). Additionally, shared genetic factors – such as polymorphisms in the CLOCK gene, particularly the T3111c single-nucleotide polymorphism (SNP), which have been associated with both a longer-than-24-hr circadian rhythm and increased ADHD symptoms – have been identified in individuals with both ADHD and delayed sleep patterns ([<reflink idref="bib6" id="ref23">6</reflink>]; [<reflink idref="bib13" id="ref24">13</reflink>]). These overlapping factors may in part explain the high comorbidity between ADHD and sleep problems. Moreover, ADHD medication can further complicate this relationship, as stimulants may delay sleep onset in some individuals, while in others they may actually improve sleep by reducing daytime symptoms and evening hyperactivity.</p> <p>Treatment of sleep problems and disorders is often not incorporated in standard ADHD care in clinical practice. For ADHD, recommended treatment consists of a combination of cognitive behavioral therapy (CBT), psychological coaching, and pharmacological treatment with psychostimulants ([<reflink idref="bib32" id="ref25">32</reflink>]). For sleep disorders, a variety of treatment options is available, depending on the specific type of sleep disorder. Evidence from pediatric ADHD populations suggests that treating sleep problems can lead to reduction of ADHD symptoms. For example, behavioral interventions for sleep problems resulted in improved psychosocial outcomes in children with ADHD ([<reflink idref="bib14" id="ref26">14</reflink>]; [<reflink idref="bib29" id="ref27">29</reflink>]). Similarly, adenotonsillectomy in children with obstructive sleep apnea (OSA) and ADHD was shown to reduce self-reported ADHD symptoms ([<reflink idref="bib22" id="ref28">22</reflink>]; [<reflink idref="bib27" id="ref29">27</reflink>]). However, little is known about the effect of targeted sleep treatments on ADHD symptoms in adults. One randomized controlled trial found that treatment of DSPS with low-dose melatonin (0.5 mg) reduced subjective ADHD symptoms by 14% in adults with both DSPS and ADHD ([<reflink idref="bib46" id="ref30">46</reflink>]). Earlier pilot studies found reduction of ADHD symptoms following bright light therapy aimed at advancing the circadian rhythm ([<reflink idref="bib21" id="ref31">21</reflink>]; [<reflink idref="bib43" id="ref32">43</reflink>]). To our knowledge, no studies for other common sleep disorders in adults with ADHD have been conducted to assess the effectiveness of sleep treatment on ADHD symptomatology.</p> <p>The current study aimed to investigate the effect of additive sleep treatment for various sleep problems, administered alongside ADHD treatment as usual (TAU), on subjective ADHD symptoms (primary outcome), as well as on subjective inattention, subjective hyperactivity-impulsivity, objective, performance-based ADHD symptoms, subjective sleep quality, fatigue, and depressive symptoms (secondary outcomes) in adults with ADHD. We hypothesized that a combined ADHD TAU + sleep treatment would be more effective than ADHD TAU alone in reducing ADHD symptoms, sleep problems, fatigue, and depressive symptoms. Additionally, we explored whether stand-alone sleep treatment could significantly improve ADHD symptoms and secondary outcomes in the absence of ADHD TAU. Such an intervention may offer a relatively accessible option to improve well-being in patients who do not wish to pursue further ADHD treatment.</p> <p>Of note, the present study was conducted during a period that coincided with the COVID-19 pandemic, a global event that substantially altered daily life, health care access, and psychological well-being. In individuals with ADHD, the pandemic has been associated with increased symptom burden, greater sleep disruption, and shifts in routines that may either exacerbate or mask core symptoms ([<reflink idref="bib41" id="ref33">41</reflink>]). In the Netherlands, public health measures included periods of nationwide lockdown, school closures, and a shift to remote care delivery; however, compared to other countries such as the United States, these policies were relatively uniform and less politicized, and access to essential services remained relatively stable. Given the overlap of our recruitment period with this unique context, it is important to consider how the pandemic may have influenced both symptom presentation and response to intervention.</p> <hd id="AN0191330926-3">Materials and Methods</hd> <p></p> <hd id="AN0191330926-4">Study Design, Setting, and Participants</hd> <p>Participants for this pragmatic open-label randomized controlled trial were patients of PsyQ, department of adult ADHD, and persons from the referral list at the ADHDcentraal clinic in The Hague, The Netherlands. These are both specialized clinics for the diagnosis and treatment of ADHD in adults. New patients within PsyQ were informed about the study shortly before or after their first consultation at the clinic. At ADHDcentraal, persons on the referral list for a first consultation were approached and asked about their interest in participating in the study. When interested, more extensive screening was done by telephone by one of the researchers. During this screening, detailed information about the study was provided and inclusion and exclusion criteria were checked. Inclusion criteria were age 18 to 50 years, a diagnosis of ADHD (combined, inattentive, or hyperactive/impulsive type), understanding the Dutch language, and a positive screening on the Holland Sleep Disorders Questionnaire (HSDQ) for any of the following sleep disorders: delayed sleep phase syndrome (DSPS), restless legs syndrome (RLS)/periodic limb movement disorder (PLMD), sleep-disordered breathing (SBD), and/or insomnia. The HSDQ is a validated screening tool (Cronbach's alpha =.9) for insomnia, circadian rhythm sleep disorder (CRSD), hypersomnolence, restless legs syndrome (RLS)/periodic limb movement disorder (PLMD), and sleep-related breathing disorders (SBD). The mean total score indicates general sleep problems ([<reflink idref="bib28" id="ref34">28</reflink>]). The DSPS subscale was constructed at our clinic to screen for DSPS, in consultation with the author of the HSDQ, as the existing subscale CRDS screens for all circadian rhythm sleep disorders and not specifically for DSPS, which is very prevalent in our population. The DSPS subscale was based on two HSDQ items: "I have difficulty falling asleep at night" and "I sleep poorly because I don't manage to fall asleep at a normal hour and wake up at a normal hour in the morning." This subscale has not been validated yet.</p> <p>Exclusion criteria were: a comorbid psychiatric disorder requiring immediate treatment, a current/history of psychotic disorder (suspected) intellectual disability, pregnancy, or an active wish to conceive (in females), using ADHD or sleep medication in the prior month, previous treatment for a sleep problem, or any somatic comorbidity affecting sleep (e.g., diabetes). Participants were informed verbally and in writing, and signed informed consent before participation.</p> <p>This study was approved by the Medical Ethics Committee of Leiden, The Hague, and Delft (protocol #NL68572.058.18). Participants were recruited between March 1, 2020 and May 31, 2023, a period that overlapped with the COVID-19 pandemic. Recruitment was briefly paused during the initial outbreak in spring 2020, in line with national guidelines, but resumed once safety protocols were established. During the early months of recruitment, the Netherlands experienced a series of nationwide lockdowns, school closures, and remote work mandates. These measures fluctuated in intensity but gradually eased by mid-2022, with most restrictions lifted by the end of that year. Importantly, Dutch pandemic policy was coordinated nationally and characterized by relatively consistent adherence across regions, minimizing heterogeneity in participant exposure to pandemic-related stressors. Data collection was completed on October 28, 2023. The trial has been registered at the Dutch national trial register (NL-OMON54573: https://onderzoekmetmensen.nl/en/trial/54573).</p> <hd id="AN0191330926-5">Procedures and Interventions</hd> <p>Figure 1 depicts the study timeline. After the T0 assessments, participants were randomized into one of three treatment groups: (<reflink idref="bib1" id="ref35">1</reflink>) ADHD treatment as usual (TAU); (<reflink idref="bib2" id="ref36">2</reflink>) ADHD TAU + sleep treatment, or; (<reflink idref="bib3" id="ref37">3</reflink>) stand-alone sleep treatment. Treatment was given for 12 weeks. Follow-up assessments took place during treatment (T1, at week 7) and directly after treatment (T2, at week 14).</p> <p>Graph: Figure 1. Flowchart of the inclusion process, treatment allocation, study procedures, and measurements. Note. TAU = treatment as usual; HSDQ = Holland Sleep Disorders Questionnaire; MCTQ = Munich Chronotype Questionnaire; MEQ = Morningness-Eveningness Questionnaire; ADHD-RS = ADHD Rating Scale; PSQI = Pittsburgh Sleep Quality Index; MAF = multidimensional assessment of fatigue; QIDS = quick inventory of depressive symptomatology; PSG = polysomnography.</p> <hd id="AN0191330926-6">ADHD Treatment As Usual (TAU)</hd> <p>Treatment as usual for ADHD consisted of individual or group CBT for ADHD, psychological coaching, and pharmacological treatment following the Dutch Guidelines on Adult ADHD ([<reflink idref="bib24" id="ref38">24</reflink>]) The pharmacological treatment for ADHD consisted of an individualized dosage of psychostimulants such as methylphenidate or (lis) dexamphetamine, following the PsyQ treatment protocol, as published in ([<reflink idref="bib32" id="ref39">32</reflink>]).</p> <hd id="AN0191330926-7">Treatment of Sleep Disorders</hd> <p>All participants in the ADHD TAU + sleep treatment group and stand-alone sleep treatment group received protocolled sleep treatment, following guidelines of the American Academy of Sleep Medicine (AASM; [<reflink idref="bib3" id="ref40">3</reflink>]; [<reflink idref="bib20" id="ref41">20</reflink>]; [<reflink idref="bib37" id="ref42">37</reflink>]; [<reflink idref="bib53" id="ref43">53</reflink>]). The treatments for sleep disorders were individually tailored, based on the diagnosed sleep disorder(s):</p> <p></p> <ulist> <item> - DSPS was treated with low-dose (0.5 mg) melatonin administered in the late afternoon, or 1 to 3 mg melatonin taken 1 hr before the desired bedtime. Bright light therapy (BLT) in the morning was offered to some participants based on physician's and participant's preferences. The timing of BLT was individually determined by the physician. Both low-dosage melatonin, and/or BLT are evidence-based treatments for advancing the sleep phase ([<reflink idref="bib3" id="ref44">3</reflink>]; [<reflink idref="bib17" id="ref45">17</reflink>]; [<reflink idref="bib33" id="ref46">33</reflink>]).</item> <p></p> <item> - Primary and secondary insomnia, as well as subclinical overall poor sleep quality, were treated using an adapted version of cognitive behavioral therapy for insomnia (CBT-I), delivered in either group or individual settings. CBT-I is the first-line non-pharmacological treatment for insomnia, targeting difficulties with sleep initiation, staying asleep, and nocturnal rumination by modifying maladaptive sleep-related behaviors and cognitions ([<reflink idref="bib20" id="ref47">20</reflink>]; [<reflink idref="bib51" id="ref48">51</reflink>]). At PsyQ, a CBT-I-based group therapy protocol was created and adapted for patients with ADHD, consisting of five sessions spread over the period of study participation. The first two sessions were primarily focused on setting individual goals regarding sleep, psycho-education (covering sleep and ADHD, the circadian rhythm, melatonin, and light) and sleep hygiene strategies. In the third session, bedtime restriction was introduced and explained. The fourth and fifth sessions focused on cognitive therapy exercises, such as recording negative thoughts and beliefs about sleep. Participants kept a sleep diary and set weekly achievable goals to improve their sleep. The choice between group and individual therapy was based on the participant's and therapist's preferences. Participants who received the individual treatment followed the same protocol at their own pace and in consultation with their therapist.</item> <p></p> <item> - RLS/PLMD treatment consisted of pharmacological treatment by the physician following (inter) national guidelines, and included iron supplementation, selective calcium ion channel antagonists such as pregabalin and gabapentin, or dopamine agonists such as pramipexole or ropinirole ([<reflink idref="bib2" id="ref49">2</reflink>]; NHG-werkgroep: [<reflink idref="bib35" id="ref50">35</reflink>]; [<reflink idref="bib53" id="ref51">53</reflink>]).</item> <p></p> <item> - SBD such as obstructive sleep apnea (OSA) was treated with sleep position training and/or continuous or automatic positive airway pressure (PAP) therapy, by a pulmonologist-somnologist at the Nederlands Slaap Instituut (NSI), which is a large sleep clinic in the Netherlands ([<reflink idref="bib37" id="ref52">37</reflink>]).</item> </ulist> <hd id="AN0191330926-8">Assessments</hd> <p></p> <hd id="AN0191330926-9">Baseline Characteristics</hd> <p>General and lifestyle characteristics (sex, age, smoking, and alcohol and caffeine use) were self-reported at T0. ADHD subtype (combined, inattentive, or hyperactive/impulsive type), psychiatric comorbidity, and socio-demographics (employment status, children/no children, living with housemates/alone) were collected from the electronic patient files. Diagnostic assessments for sleep disorders were conducted during a first consultation at PsyQ by an experienced therapist. During this consultation, the therapist assessed whether sleep disorders were present, such as a DSPS, insomnia, or RLS, following DSM-5 criteria. Additionally, an at-home overnight polysomnography was conducted and evaluated by a pulmonologist-somnologist at the NSI to assess PLMD and SBD, as well as to gather additional information on sleep characteristics. In summary, sleep disorder diagnoses were established prior to treatment using a combination of clinical assessment and objective polysomnography data. Only participants randomized into the ADHD TAU + sleep treatment group and stand-alone sleep treatment group were informed about the results of the diagnostic assessments for sleep disorders during an additional consultation with the somnologist at the NSI. Participants in the ADHD TAU group did not receive the results of their diagnostic sleep assessments until after the study period, in order to prevent self-treatment.</p> <hd id="AN0191330926-10">Treatment Characteristics</hd> <p>The total number of consultations with the therapist and physician, as well as information on ADHD medication use, melatonin use, light therapy, RLS medication, iron suppletion, and continuous positive airway pressure (CPAP) therapy use were retrieved from electronic patient files.</p> <hd id="AN0191330926-11">Primary Outcome</hd> <p></p> <hd id="AN0191330926-12">Subjective ADHD Symptoms</hd> <p>The primary outcome of this study was self-reported ADHD symptoms, assessed using the ADHD Rating Scale total score (ADHD-RS). The original ADHD-RS, developed for use in children, included 18 items corresponding to the DSM-IV criteria for ADHD ([<reflink idref="bib19" id="ref53">19</reflink>]). For the present study, we used an adapted version validated for adults, which consists of 23 items and is widely used in adult ADHD assessment (Cronbach's α =.83 for inattention,.75 for hyperactivity, and.72 for impulsivity; [<reflink idref="bib30" id="ref54">30</reflink>]). The instrument assesses how often ADHD-specific symptoms are currently experienced by the participant, using a response scale from 0 (never/rarely) to 3 (very often). For the calculation of the total (and subscale) scores, 10 thematically related items were combined into five items, each based on the rounded up mean of two items. These where combined with the remaining 13 items, resulting in a total score range of 0 to 54, with higher scores indicating more severe ADHD symptoms.</p> <hd id="AN0191330926-13">Secondary Outcomes</hd> <p></p> <hd id="AN0191330926-14">Subjective Inattention and Hyperactivity-Impulsivity</hd> <p>Self-reported inattention and hyperactivity-impulsivity symptoms were assessed using the corresponding subscales of the ADHD-RS. Subscale scores were calculated by summing the items related to inattention and to hyperactivity-impulsivity separately, with each subscale ranging from 0 to 27.</p> <hd id="AN0191330926-15">Objective, Performance-Based ADHD Symptoms</hd> <p>Objective, performance-based ADHD symptoms were measured with the Quantified Behavior Test (QbTest; [<reflink idref="bib45" id="ref55">45</reflink>]): a 20-min computerized test that measures objective levels of attention, impulsivity, and (hyper) activity using an infra-red motion-tracking system. During the test, stimuli (squares and circles, in blue or red), are shown on the screen. The participant is instructed to respond only to a stimulus that matches the previous stimulus (a "target"), by pressing a clicker. A missed target (omission) is considered an instance of inattention, while a false positive (commission, the participant pressed the clicker while there was no target) is considered an instance of impulsivity. Reaction time and reaction time variation (RTV) are also recorded. Head movements are tracked using a reflector attached to a headband, which is placed around the participant's head with the reflector on the middle of the forehead. The reflector corresponds to an infrared camera opposite the participant, providing various parameters for motor activity, which is used as a measure for hyperactivity. For this study, standardized outcome scores (<emph>Z</emph>-scores) were used, which are norm-corrected scores with norm groups matched for age and sex ([<reflink idref="bib45" id="ref56">45</reflink>]). These standardized scores are QbInattention, QbImpulsivity, and QbActivity. A standardized score reflects the standard deviation from the norm group mean, where a score <1 is considered "normal" as compared to the norm group, a score of 1 to 1.5 is slight atypical, and >1.5 atypical (i.e., deviant from the norm group, and suggestive of increased ADHD symptomatology). Negative scores indicate better scores compared to the norm group. A change score of ≥0.5 is considered clinically relevant.</p> <hd id="AN0191330926-16">Subjective Sleep Quality</hd> <p>Subjective sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI). This validated questionnaire contains 10 items about a person's sleep habits in the past month (Cronbach's alpha =.83). The item scores are combined into seven component scores ranging from 0 (good sleep quality) to 3 (poor sleep quality), the sum of which forms the PSQI global score, ranging from 0 (good sleep quality) to 21 (poor sleep quality; [<reflink idref="bib11" id="ref57">11</reflink>]). A 3-point decrease on the PSQI global score is considered a clinically relevant improvement of sleep quality ([<reflink idref="bib10" id="ref58">10</reflink>]; [<reflink idref="bib23" id="ref59">23</reflink>]; [<reflink idref="bib39" id="ref60">39</reflink>]).</p> <hd id="AN0191330926-17">Fatigue</hd> <p>Fatigue was measured using the validated Multidimensional Assessment of Fatigue questionnaire (MAF, Cronbach's alpha =.93; [<reflink idref="bib7" id="ref61">7</reflink>]). The MAF contains 16 items, measuring four dimensions of fatigue: severity, distress, influence on daily living, and timing. Each item is scored on a scale from 0 (no [impact of] fatigue) to 10 (severe [impact of] fatigue). The Global Fatigue Index (GFI) is calculated by summing the (averages of group of) individual items, and ranges from 1 (no fatigue) to 50 (severe fatigue; [<reflink idref="bib7" id="ref62">7</reflink>]). A 5-point decrease on GFI is considered a clinically relevant decrease of fatigue ([<reflink idref="bib25" id="ref63">25</reflink>]; [<reflink idref="bib36" id="ref64">36</reflink>]).</p> <hd id="AN0191330926-18">Depressive Symptoms</hd> <p>Depressive symptoms were measured using the Quick Inventory of Depressive Symptoms (QIDS; [<reflink idref="bib42" id="ref65">42</reflink>]), a validated questionnaire which contains 16 items about the extent to which the participants experienced certain mood-related symptoms in the past 7 days, on a scale from 0 (no symptoms) to 3 (severe symptoms; Cronbach's alpha =.86). A total score is calculated based on the sum of all individual items, ranging 0 to 27, normal (0–5) to very severe (>21).</p> <hd id="AN0191330926-19">Statistical Analyses</hd> <p>All analyses were pre-specified in a pre-analysis plan. First, descriptive statistics of the study population were computed. Linear mixed models for longitudinal data were then used to examine changes over time in primary and secondary outcome variables, comparing the ADHD TAU + sleep treatment group to the ADHD TAU group. Additionally, separate linear mixed model analyses for primary and secondary outcomes were conducted to assess within-group treatment effects (trends) for ADHD TAU, ADHD TAU + sleep treatment, and stand-alone sleep treatment between baseline (T0) and follow-up (T2), with time included as an independent variable. We did not compare the stand-alone sleep treatment to ADHD TAU or combined treatment groups, as sleep treatment was not designed to address the full range of ADHD symptoms and was therefore not expected to be as effective as interventions that include targeted ADHD treatment. Although item-level missing data on questionnaire responses were minimal (0.1%), imputation of these responses was done for the mixed model analyses, as total scores could not be computed when even a single item response was missing, leading to substantial missingness at the total score level. For questionnaire data (ADHD-RS, MAF, and QIDS) or component scores (PSQI), missing item scores were replaced with the participant's mean score on the remaining items of the same questionnaire. If more than 50% of a questionnaire's items were missing, and in case of dropout at follow-up measurement, the questionnaire was set to missing. For independent variables that were not part of a recurring questionnaire, missing values were imputed using the overall sample mean. Data was not imputed in case of drop-out at follow-up measurement.</p> <p>Cohen's <emph>d</emph> was calculated for both between-group and within-group comparisons. For between-group comparisons, Cohen's <emph>d</emph> was computed as the difference between the mean change scores (12-week follow-up minus baseline) of the two groups, divided by the pooled standard deviation of the change scores. For within-group comparisons, Cohen's <emph>d</emph> was calculated by dividing the mean change from baseline to 12 weeks within each group by the standard deviation of the baseline scores.</p> <p>Given the preliminary nature of the study, covariates were not included in order to maintain model simplicity and preserve statistical power. However, sensitivity analyses including corrections were conducted when statistically significant results were found, and reported in cases of substantial differences between models. Data were analyzed according to the intention-to-treat (ITT) principle, with additional per-protocol analyses conducted for comparison.</p> <p>The power analyses that were conducted to guide the design of the study ([<reflink idref="bib8" id="ref66">8</reflink>]) were revised after a review of the methods found them to be overly optimistic. Based on the final sample size for the primary outcome (n = 25 for the ADHD TAU group and n = 22 for the ADHD TAU + sleep treatment group), we recalculated statistical power, using G*Power version 3.1, to detect a clinically meaningful between-group difference between baseline and T2 (Cohen's d = 0.5) at an alpha level of.05. Given the randomized design, this between-group comparison reflects a valid estimate of treatment effect. The resulting power was 0.39. As a result, the current trial should be considered preliminary, and confidence intervals are reported alongside point estimates to aid interpretation of the magnitude and uncertainty of observed effects (see Limitations Section).</p> <hd id="AN0191330926-20">Results</hd> <p></p> <hd id="AN0191330926-21">Study Participation and Baseline Characteristics</hd> <p>The flow of participant inclusion is presented in Figure 1. Figure 2 depicts the distribution of participant recruitment over the course of the study period. Baseline characteristics are reported in Tables 1 and 2. In total, 70 participants were enrolled and completed baseline measurements, of which 42 were female (60%), with an average age of 27.9 years. Our sample was overall highly educated (81% with college/university degree). Most participants were diagnosed with ADHD combined subtype (74%), whereas 26% had the primarily inattentive subtype of ADHD.</p> <p>Graph: Figure 2. Distribution of participant recruitment over time.</p> <p>Table 1. Baseline Characteristics per Treatment Group.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th /><th align="center">Total<xref ref-type="table-fn" rid="tfn2">a</xref></th><th align="center">ADHD TAU</th><th align="center">ADHD TAU + sleep treatment</th><th align="center">Sleep treatment</th></tr><tr><th align="left">Baseline characteristic</th><th align="center"><italic>N</italic> = 70</th><th align="center"><italic>n</italic> = 25</th><th align="center"><italic>n</italic> = 22</th><th align="center"><italic>n</italic> = 23</th></tr></thead><tbody><tr><td colspan="5">Sociodemographics</td></tr><tr><td>Female sex</td><td>42 (60.0%)</td><td>14 (56.0%)</td><td>14(63.6%)</td><td>14 (60.9%)</td></tr><tr><td>Age in years</td><td>27.91 (8.21)</td><td>29.48 (9.26)</td><td>28.00 (7.77)</td><td>26.13 (7.34)</td></tr><tr><td colspan="5">Educational level</td></tr><tr><td> Secondary/vocational</td><td>13 (18.6%)</td><td>5 (20.0%)</td><td>1 (4.5%)</td><td>7 (30.4%)</td></tr><tr><td> College/university</td><td>57 (81.4%)</td><td>20 (80.0%)</td><td>21 (95.5%)</td><td>16 (69.6%)</td></tr><tr><td colspan="5">Employment status</td></tr><tr><td> Employed</td><td>33 (47.1%)</td><td>12 (48.0%)</td><td>12 (54.5%)</td><td>9 (39.1%)</td></tr><tr><td> Unemployed</td><td>5 (7.1%)</td><td>3 (12.0%)</td><td>1 (4.5%)</td><td>1 (4.3%)</td></tr><tr><td> Student</td><td>32 (45.7%)</td><td>10 (40.0%)</td><td>9 (40.9%)</td><td>13 (56.5%)</td></tr><tr><td>Children at home (yes)</td><td>13 (18.6%)</td><td>5 (20.0%)</td><td>3 (13.6%)</td><td>5 (21.7%)</td></tr><tr><td>Living with housemate(s) or spouse (yes)</td><td>54 (77.1%)</td><td>19 (76.0%)</td><td>16 (72.7%)</td><td>19 (82.6%)</td></tr><tr><td colspan="5">Lifestyle</td></tr><tr><td>Alcohol (n of glasses per day) median (IQR)</td><td>4.0 (8)</td><td>4.0 (11)</td><td>2.0 (6)</td><td>3.0 (9)</td></tr><tr><td>Caffeine (n of glasses per day) median (IQR)</td><td>3.0 (3)</td><td>3.0 (2)</td><td>2.5 (3)</td><td>2.0 (3)</td></tr><tr><td>Smoking (yes)</td><td>25 (36.2%)</td><td>8 (32.0%)</td><td>8 (36.2%)</td><td>9 (40.9%)</td></tr><tr><td colspan="5">ADHD characteristics</td></tr><tr><td colspan="5">ADHD subtype</td></tr><tr><td> Combined</td><td>52 (74.3%)</td><td>20 (80.0%)</td><td>14 (63.6%)</td><td>18 (78.3%)</td></tr><tr><td> Inattentive</td><td>18 (25.7%)</td><td>5 (20.0%)</td><td>8 (36.4%)</td><td>5 (21.7%)</td></tr><tr><td colspan="5">Sleep disorder diagnosis</td></tr><tr><td>Delayed sleep phase syndrome (DSPS)</td><td>63 (90.0%)</td><td>22 (88.0%)</td><td>20 (90.9%)</td><td>21 (91.3%)</td></tr><tr><td>Insomnia</td><td>30 (42.9%)</td><td>9 (36.0%)</td><td>12 (54.5%)</td><td>9 (39.1%)</td></tr><tr><td>Restless legs syndrome (RLS)/periodic limb movement disorder (PLMD)</td><td>9 (12.9%)</td><td>5 (20.0%)</td><td>2 (9.1%)</td><td>2 (8.7%)</td></tr><tr><td>Sleep-related breathing disorder (SBD)</td><td>5 (7.1%)</td><td>2 (8.0%)</td><td>1 (4.5%)</td><td>2 (8.7%)</td></tr><tr><td>No sleep diagnosis – subclinical sleep problems<xref ref-type="table-fn" rid="tfn3">b</xref></td><td>1 (1.4%)</td><td>0 (0.0%)</td><td>0 (0.0%%)</td><td>1 (4.3%)</td></tr><tr><td colspan="5">Other</td></tr><tr><td>Psychiatric comorbidity (yes)</td><td>25 (35.7%)</td><td>11 (44.0%)</td><td>9 (40.9%)</td><td>5 (21.7%)</td></tr><tr><td>Self-reported somatic comorbidity (yes)</td><td>23 (32.9%)</td><td>7 (28.0%)</td><td>8 (36.4%)</td><td>8 (34.8%)</td></tr><tr><td>Antidepressant use (yes)</td><td>5 (7.1%)</td><td>2 (8.0%)</td><td>1 (4.5%)</td><td>2 (8.7%)</td></tr></tbody></table> </ephtml> </p> <p>1 <emph>Note</emph>. Data are <emph>n</emph> (%), mean (<emph>SD</emph>), or median (IQR, if indicated).</p> <ulist> <item>2 At baseline, all variables had <emph>n</emph> < 5 missing values.</item> <item>3 Subclinical sleep problems: 1 participant was not diagnosed due to dropout, but reported symptoms of RLS and parasomnia.</item> </ulist> <p>Table 2. Outcome Variables at T0 per Treatment Group.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th /><th align="center">Total<xref ref-type="table-fn" rid="tfn5">a</xref></th><th align="center">ADHD TAU</th><th align="center">ADHD TAU + sleep treatment</th><th align="center">Sleep treatment</th></tr><tr><th align="left">Outcome variable</th><th align="center"><italic>N</italic> = 70</th><th align="center"><italic>n</italic> = 25</th><th align="center"><italic>n</italic> = 22</th><th align="center"><italic>n</italic> = 23</th></tr></thead><tbody><tr><td colspan="5">Primary outcome</td></tr><tr><td>ADHD-RS total score</td><td>36.11 (6.79)</td><td>37.16 (6.72)</td><td>35.59 (7.44)</td><td>35.48 (6.38)</td></tr><tr><td colspan="5">Secondary outcomes</td></tr><tr><td colspan="5">ADHD-RS</td></tr><tr><td> Inattention subscale</td><td>19.51 (3.43)</td><td>19.96 (3.61)</td><td>19.36 (3.62)</td><td>19.17 (3.11)</td></tr><tr><td>Hyperactivity-impulsivity subscale</td><td>16.60 (4.98)</td><td>17.20 (4.82)</td><td>16.23 (5.86)</td><td>16.30 (4.34)</td></tr><tr><td colspan="5">Qbtest</td></tr><tr><td> QbActivity</td><td>2.38 (1.05)</td><td>2.36 (1.34)</td><td>2.32 (1.07)</td><td>2.46 (.65)</td></tr><tr><td> QbImpulsivity</td><td>0.81 (1.13)</td><td>0.61 (1.13)</td><td>0.84 (1.25)</td><td>1.00 (1.03)</td></tr><tr><td> QbInattention</td><td>1.06 (.97)</td><td>1.08 (1.04)</td><td>0.70 (.89)</td><td>1.39 (.87)</td></tr><tr><td>Sleep quality (PSQI global score)</td><td>8.53 (3.03)</td><td>9.51 (3.12)</td><td>8.17 (2.65)</td><td>7.82 (3.12)</td></tr><tr><td>Global Fatigue Index (MAF)<xref ref-type="table-fn" rid="tfn6">b</xref></td><td>32.22 (7.04)</td><td>31.87 (7.20)</td><td>33.35 (8.08)</td><td>31.48 (5.89)</td></tr><tr><td>Depressive symptoms (QIDS)</td><td>9.59 (3.85)</td><td>11.05 (3.84)</td><td>8.21 (3.62)</td><td>9.33 (3.68)</td></tr></tbody></table> </ephtml> </p> <ulist> <item>4 <emph>Note</emph>. Data are <emph>n</emph> (%), mean (<emph>SD</emph>), or median (IQR, if indicated).</item> <item>5 At baseline, all variables had <emph>n</emph> < 5 missing values. Missing questionnaire items (ADHD-RS, PSQI, MAF, and QIDS) and Qbtest scores (QbActivity) were imputed using single imputation.</item> <item>6 At T0, one participant had >50% missing values on MAF items. Therefore, total MAF score was not computed for this person. <emph>N</emph> = 69.</item> </ulist> <p>At screening, the most common sleep problem was DSPS (77%), followed by insomnia (69%), RLS/PLMD (49%), and SBD (14%). After diagnostic assessment, the most commonly confirmed sleep disorder was DSPS (90%), followed by insomnia (43%) and RLS/PLMD (13%). Forty-three (61%) participants had two or more sleep disorders, with the most common combination being DSPS and (secondary) insomnia (<emph>n</emph> = 25, 36%). Twenty-five (36%) participants had one or more comorbid psychiatric disorders.</p> <p>Fifty-six participants completed the first follow-up measurement (T1). Fifty-four participants completed all study measurements. Dropout (Figure A1 in Appendix) was due to dissatisfaction with treatment allocation (<emph>n</emph> = 5, of which 4 in sleep treatment group and 1 in ADHD TAU + sleep treatment group), urgency for treatment of comorbid psychiatric condition (<emph>n</emph> = 7), physical illness (<emph>n</emph> = 2), no-show for follow-up measurement (<emph>n</emph> = 1), and due to COVID-19 restrictions (<emph>n</emph> = 1). The intended sample size of 3 × 20 (60 total) participants was not reached due to difficulties with recruiting enough individuals who met the inclusion criteria within the available recruitment period.</p> <hd id="AN0191330926-22">Treatment Characteristics</hd> <p>Table 3 presents treatment-related characteristics of the three groups at T1 and T2. The median number of treatment sessions during the study period was notably higher in the ADHD TAU + sleep treatment group (median = 16.5), compared to ADHD TAU (median = 11.0) and sleep treatment groups (median = 7.0). The majority of patients in the ADHD TAU + sleep treatment and sleep treatment groups used melatonin at the time of T2 (72% and 65% respectively), whereas other forms of sleep treatment (light therapy, RLS medication, iron suppletion, and CPAP use) were less common, ranging 6% to 12% in both groups. ADHD medication was used by 95% in the ADHD TAU group, and 78% in the ADHD TAU + sleep treatment group. At T2, there was one protocol violation, as a participant in the ADHD TAU group had used melatonin. However, per protocol analyses yielded results consistent with the intention-to-treat analyses.</p> <p>Table 3. Treatment Characteristics at T1 and T2 per Treatment Group.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th /><th align="center">ADHD TAU</th><th align="center">ADHD TAU + sleep treatment</th><th align="center">Sleep treatment</th></tr><tr><th align="left">Treatment characteristic</th><th align="center"><italic>n</italic> = 20</th><th align="center"><italic>n</italic> = 19</th><th align="center"><italic>n</italic> = 17</th></tr></thead><tbody><tr><td colspan="4">T1</td></tr><tr><td> Number of treatment sessions (median (IQR))</td><td>6.0 (2.0)</td><td>8.0 (5.0%)</td><td>4.0 (2.0)</td></tr><tr><td> ADHD medication (yes)</td><td>20 (100.0%)</td><td>16 (84.2%)</td><td>0 (0.0%)</td></tr><tr><td> Melatonin (yes)</td><td>0 (0.0%)</td><td>10 (52.6%)</td><td>10 (58.8%)</td></tr><tr><td> Light therapy (yes)</td><td>0 (0.0%)</td><td>0 (0.0%)</td><td>2 (11.8%)</td></tr><tr><td> RLS medication (Pregabalin)</td><td>0 (0.0%)</td><td>0 (0.0%)</td><td>1 (5.9%)</td></tr><tr><td> Iron suppletion (Ferrous Fumarate)</td><td>0 (0.0%)</td><td>2 (10.5%)</td><td>0 (0.0%)</td></tr><tr><td> CPAP use</td><td>0 (0.0%)</td><td>0 (0.0%)</td><td>1 (5.9%)</td></tr><tr><td colspan="4">T2<xref ref-type="table-fn" rid="tfn8">a</xref></td></tr><tr><td> Number of treatment sessions (median (IQR))</td><td>11.0 (4.0)</td><td>16.5 (7.0)</td><td>7.0 (3.0)</td></tr><tr><td> ADHD medication (yes)</td><td>18 (94.7%)</td><td>14 (77.8%)</td><td>0 (0.0%)</td></tr><tr><td> Melatonin (yes)</td><td>1 (5.3%)<xref ref-type="table-fn" rid="tfn9">b</xref></td><td>13 (72.2%)</td><td>11 (64.7%)</td></tr><tr><td> Light therapy (yes)</td><td>0 (0.0%)</td><td>1 (5.6%)</td><td>2 (11.8%)</td></tr><tr><td> RLS medication (Pregabalin)</td><td>0 (0.0%)</td><td>1 (5.6%)</td><td>2 (11.8%)</td></tr><tr><td> Iron suppletion (Ferrous Fumarate)</td><td>0 (0.0%)</td><td>1 (5.6%)</td><td>1 (5.9%)</td></tr><tr><td> CPAP use</td><td>0 (0.0%)</td><td>0 (0.0%)</td><td>1 (5.9%)</td></tr></tbody></table> </ephtml> </p> <ulist> <item>7 <emph>Note</emph>. Data are <emph>n</emph> (%) unless otherwise indicated (median, interquartile range (IQR)). Only data on participants with at least one follow-up measurement are reported (<emph>n</emph> = 56). CPAP = continuous positive airway pressure</item> <item>8 <emph>N</emph> = 54 at T2, one drop-out in ADHD TAU, one dropout in ADHD TAU + sleep treatment group</item> <item>9 Violation of protocol.</item> </ulist> <hd id="AN0191330926-23">Effects of ADHD TAU + sleep treatment vs. ADHD TAU</hd> <p></p> <hd id="AN0191330926-24">Primary Outcome</hd> <p>Table 4 and Figures 3 and 4 present the results of the linear mixed model analyses examining the effects of additive sleep treatment on primary and secondary outcomes. No statistically significant difference in ADHD-RS total score reduction was observed between the ADHD TAU + sleep treatment group and the ADHD TAU group (β = −1.30, 95% CI [−5.57, 2.96]), with a small effect size (Cohen's <emph>d</emph> = 0.21).</p> <p>Table 4. Results of Linear Mixed Model Analyses on the Additive Effects of ADHD TAU + sleep Treatment, as Compared to ADHD TAU on ADHD Symptoms, Sleep, and Depressive Symptoms.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left">Outcome variable</th><th align="center"><italic>B</italic></th><th align="center"><italic>95% CI</italic></th><th align="center"><italic>p</italic></th><th align="center"><italic>d</italic></th></tr></thead><tbody><tr><td>ADHD-RS total score</td><td>−1.30</td><td>[−5.57, 2.96]</td><td>.543</td><td>0.21</td></tr><tr><td>ADHD-RS inattention subscale</td><td>−0.89</td><td>[−3.48, 1.69]</td><td>.492</td><td>0.25</td></tr><tr><td>ADHD-RS hyperactivity-impulsivity subscale</td><td>−0.42</td><td>[−2.59, 1.75]</td><td>.701</td><td>0.11</td></tr><tr><td>QbActivity</td><td>0.14</td><td>[−0.41, 0.70]</td><td>.607</td><td>0.08</td></tr><tr><td>QbImpulsivity</td><td>−0.004</td><td>[−0.48, 0.48]</td><td>.988</td><td>0.14</td></tr><tr><td>QbInattention</td><td>0.18</td><td>[−0.24, 0.60]</td><td>.389</td><td>0.47</td></tr><tr><td>Sleep quality (PSQI global score)</td><td>−1.98</td><td>[−3.65, −0.30]</td><td>.021</td><td>0.42</td></tr><tr><td>Global Fatigue Index (MAF)<xref ref-type="table-fn" rid="tfn11">a</xref></td><td>−6.52</td><td>[−12.33, −0.70]</td><td>.029</td><td>1.59</td></tr><tr><td>Depressive symptoms (QIDS)</td><td>0.61</td><td>[−0.58, 2.79]</td><td>.580</td><td>0.40</td></tr></tbody></table> </ephtml> </p> <ulist> <item>10 <emph>Note</emph>. For all outcomes, a negative beta means a decrease in symptoms for the ADHD TAU + sleep treatment group compared to the ADHD TAU group. Effect sizes (Cohen's d) are based on the difference in change scores (T0–T2) between both groups. B = regression coefficient; CI = confidence interval.</item> <item>11 At T1, one participant had >50% missing values on MAF items. Therefore, total MAF score was not computed for this person. N = 55.</item> </ulist> <p>Graph: Figure 3. Results of the linear mixed model analyses on the effects of ADHD TAU + sleep treatment versus ADHD TAU on all primary and secondary outcomes, over time. Y axis represents the mean. Error bars represent 95% confidence intervals.</p> <p>Graph: Figure 4. Results of the linear mixed model analyses on the effects of ADHD TAU + sleep treatment versus ADHD TAU on all primary and secondary outcomes. X -axis represents regression coefficients. A lower regression coefficient means a larger effect.</p> <hd id="AN0191330926-25">Secondary Outcomes</hd> <p>We found mostly small (<emph>d</emph> < 0.5), non-significant effect sizes for subjective inattention and hyperactivity-impulsivity on the ADHD-RS subscales (β = −.89, 95% CI[−3.48, 1.69], <emph>d</emph> = 0.25 and β = −.42, 95% CI [−2.59, 1.75], <emph>d</emph> = 0.11), as well as for objective, performance-based hyperactivity (β =.14, 95% CI [−0.41, 0.70], <emph>d</emph> = 0.08), impulsivity (β = −.004, 95% CI [−0.48, 0.48], <emph>d</emph> = 0.14), and inattention (β =.18, 95% CI [−0.24, 0.60], <emph>d</emph> = 0.47). The ADHD TAU + sleep treatment group did show significantly greater improvements in subjective sleep quality as measured by the PSQI, compared to the ADHD TAU group, with a small effect size (β = −1.98, 95% CI [−3.65, −0.30], <emph>d</emph> = 0.42), and significantly greater improvements, with a large effect size, in fatigue, as measured by the MAF (β = −6.52, 95% CI [−12.33, −0.70], <emph>d</emph> = 1.59). For depressive symptoms, a small effect size was observed, but the difference between groups was not statistically significant (β =.61, 95% CI [−0.58, 2.79], <emph>d</emph> = 0.40).</p> <hd id="AN0191330926-26">Within Group Trends Between T0 and T2</hd> <p>To explore how each treatment, and especially the stand-alone sleep treatment, influenced the outcomes over time, changes between T0 and T2 were analyzed. Table 5 presents the results of linear mixed model analyses examining within-group trends across all primary and secondary outcomes. In the stand-alone sleep treatment group, statistically significant improvements with medium effect sizes were observed for subjective ADHD symptoms (ADHD-RS; β = −4.80, 95% CI [−7.60, −2.01], <emph>d</emph> = 0.62), the inattention subscale (β = −2.74, 95% CI [−4.37, −1.12], <emph>d</emph> = 0.74), and objective, performance-based hyperactivity (Qbtest; β = −.45, 95% CI [−0.86, −0.04], <emph>d</emph> = 0.52). Sleep quality and fatigue improved across all treatment groups, with small to medium effect sizes in the ADHD TAU group (β = −1.47, 95% CI [−2.78, −0.15], <emph>d</emph> = 0.61 and β = −4.93, 95% CI [−8.88, −0.97], <emph>d</emph> = 0.55) and large effect sizes in the combined group (β = −2.65, 95% CI [−4.00, −1.30], <emph>d</emph> = 0.99 and β = −11.01, 95% CI [−14.62, −7.39], <emph>d</emph> = 0.90) and the stand-alone sleep treatment group (β = −2.76, 95% CI [−4.33, −1.19], <emph>d</emph> = 1.49 and β = −12.59, 95% CI [−17.70, −7.48], <emph>d</emph> = 0.83)</p> <p>Table 5. Results of Linear Mixed Model Analyses of Within-group Trends (Change Between T0 and T2) on Primary and Secondary Outcomes.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th /><th align="center" colspan="4">ADHD TAU (<italic>n</italic> = 25)</th><th align="center" colspan="4">ADHD TAU + sleep treatment (<italic>n</italic> = 22)</th><th align="center" colspan="4">Sleep treatment (<italic>n</italic> = 23)</th></tr><tr><th align="left">Outcome variable</th><th align="center"><italic>B</italic></th><th align="center">95%CI</th><th align="center"><italic>p</italic></th><th align="center"><italic>d</italic></th><th align="center"><italic>B</italic></th><th align="center">95% CI</th><th align="center"><italic>p</italic></th><th align="center"><italic>d</italic></th><th align="center"><italic>B</italic></th><th align="center">95% CI</th><th align="center"><italic>P</italic></th><th align="center"><italic>d</italic></th></tr></thead><tbody><tr><td>ADHD-RS total score</td><td>−10.31</td><td>[−13.93, −6.69]</td><td><.001</td><td>1.40</td><td>−11.56</td><td>[−14.41, −8.72]</td><td><.001</td><td>1.52</td><td>−4.80</td><td>[−7.60, −2.01]</td><td>.001</td><td>0.62</td></tr><tr><td>ADHD-RS inattention subscale</td><td>−6.34</td><td>[−8.45, −4.23]</td><td><.001</td><td>1.54</td><td>−7.19</td><td>[−9.06, −5.32]</td><td><.001</td><td>1.66</td><td>−2.74</td><td>[−4.37, −1.12]</td><td>.002</td><td>0.74</td></tr><tr><td>ADHD-RS hyperactivity-impulsivity subscale</td><td>−4.00</td><td>[−5.85, −2.14]</td><td><.001</td><td>0.89</td><td>−4.33</td><td>[−5.98, −2.69]</td><td><.001</td><td>0.81</td><td>−2.12</td><td>[−3.65, −0.59]</td><td>.008</td><td>0.36</td></tr><tr><td>QbActivity</td><td>−1.17</td><td>[−1.63, −0.71]</td><td><.001</td><td>0.97</td><td>−0.96</td><td>[−1.46, −0.45]</td><td><.001</td><td>0.72</td><td>−0.45</td><td>[−0.86, −0.04]</td><td>.032</td><td>0.52</td></tr><tr><td>QbImpulsivity</td><td>−0.54</td><td>[−0.95, −0.14]</td><td>.010</td><td>0.38</td><td>−0.73</td><td>[−1.16, −0.31]</td><td>.001</td><td>0.50</td><td>−0.43</td><td>[−0.81, −0.04]</td><td>.031</td><td>0.27</td></tr><tr><td>QbInattention</td><td>−1.29</td><td>[−1.63, −0.95]</td><td><.001</td><td>1.49</td><td>−0.88</td><td>[−1.20, −0.55]</td><td><.001</td><td>1.00</td><td>−0.25</td><td>[−0.62, 0.12]</td><td>.175</td><td>0.25</td></tr><tr><td>Sleep quality (PSQI global score)</td><td>−1.47</td><td>[−2.78, −0.15]</td><td>.029</td><td>0.61</td><td>−2.65</td><td>[−4.00, −1.30]</td><td><.001</td><td>0.99</td><td>−2.76</td><td>[−4.33, −1.19]</td><td><.001</td><td>1.49</td></tr><tr><td>Global Fatigue Index (MAF)<xref ref-type="table-fn" rid="tfn13">a</xref></td><td>−4.93</td><td>[−8.88, −0.97]</td><td>.016</td><td>0.55</td><td>−11.01</td><td>[−14.62, −7.39]</td><td><.001</td><td>0.90</td><td>−12.59</td><td>[−17.70, −7.48]</td><td><.001</td><td>0.83</td></tr><tr><td>Depressive symptoms (QIDS)</td><td>−3.99</td><td>[−5.50, −2.47]</td><td><.001</td><td>1.16</td><td>−2.25</td><td>[−4.04, −0.46]</td><td>.015</td><td>0.62</td><td>−3.24</td><td>[−5.07, −1.41]</td><td><.001</td><td>0.81</td></tr></tbody></table> </ephtml> </p> <ulist> <item>12 <emph>Note</emph>. For all outcomes, a negative beta means a decrease in symptoms. Effect sizes (Cohen's d) are based on the difference between T0 and T2. B = regression coefficient; CI = confidence interval.</item> <item>13 At T1, one participant had >50% missing values on MAF items. Therefore, total MAF score was not computed for this person. N = 55.</item> </ulist> <hd id="AN0191330926-27">Discussion</hd> <p>In this open-label randomized controlled trial, we investigated whether the addition of targeted sleep treatment to standard ADHD care could enhance treatment outcomes in adults with ADHD. While the combined treatment did not lead to significantly greater reductions in subjective ADHD symptoms compared to ADHD TAU alone, participants in the combined group experienced clinically meaningful improvements in sleep quality and daytime fatigue, with a large effect size in the latter. Secondary within-group analyses further revealed that a stand-alone sleep treatment was associated with significant improvements with medium effect sizes in subjective total ADHD symptoms, subjective inattention, and objective, performance-based hyperactivity and significant improvements with large effect sizes on sleep related outcomes.</p> <p>Although additive effects were plausible, the combined treatment did not yield statistically superior outcomes in ADHD symptom reduction compared to ADHD TAU alone after 12 weeks, despite greater treatment intensity (more treatment sessions). One likely explanation lies in the robust effects of ADHD TAU itself. In our study, ADHD TAU resulted in a 28% reduction in ADHD-RS scores, close to the 30% threshold generally considered clinically meaningful ([<reflink idref="bib31" id="ref67">31</reflink>]; [<reflink idref="bib44" id="ref68">44</reflink>]). These results are consistent with previous studies showing substantial reductions in ADHD symptoms following pharmacological treatment (ADHD TAU; [<reflink idref="bib15" id="ref69">15</reflink>]; [<reflink idref="bib52" id="ref70">52</reflink>]). Given this already strong treatment response, the potential for detecting additional symptom reduction from the additive sleep treatment may have been limited, particularly in a trial underpowered to detect small additive effects. The original power analyses used to guide the study design were found to be overly optimistic, having assumed a large effect size appropriate for comparisons to a placebo or waitlist-control group, rather than to an active and effective treatment. Consequently, this study should be considered preliminary and hypothesis-generating. Nevertheless, our findings align with a growing body of research suggesting that sleep treatment may offer benefits beyond core ADHD symptom reduction. In particular, the observed improvements in sleep quality and daytime fatigue in the combined treatment group are consistent with findings from pediatric studies showing that interventions targeting sleep can reduce ADHD-related impairments ([<reflink idref="bib14" id="ref71">14</reflink>]; [<reflink idref="bib22" id="ref72">22</reflink>]; [<reflink idref="bib27" id="ref73">27</reflink>]; [<reflink idref="bib29" id="ref74">29</reflink>]). The present study adds to this evidence by providing novel insights into the effects of treating sleep problems in adults with ADHD, a population for which limited data are available. To our knowledge, this is the first RCT to compare the effectiveness of additive sleep treatment targeting a range of sleep disorders to ADHD TAU assessing both subjective and objective, performance-based ADHD symptoms. Previous studies have largely focused on DSPS, showing that chronotherapeutic interventions such as melatonin and BLT can advance sleep timing and modestly improve ADHD symptoms ([<reflink idref="bib21" id="ref75">21</reflink>]; [<reflink idref="bib43" id="ref76">43</reflink>]; [<reflink idref="bib46" id="ref77">46</reflink>]). Our finding that additive sleep treatment resulted in improved sleep quality and symptom reduction in daytime fatigue adds to these results and suggests that sleep regulation may play a broader role in ADHD management. These findings support theoretical models proposing that circadian dysregulation contributes to ADHD pathophysiology ([<reflink idref="bib9" id="ref78">9</reflink>]; [<reflink idref="bib13" id="ref79">13</reflink>]), and that addressing sleep-wake misalignment may improve executive functioning and daytime regulation. Our secondary analyses on within-group trends, which showed several medium effect sizes, do suggest a reduction of ADHD symptoms over time after a stand-alone sleep treatment, although these results should be interpreted with caution, as comparison with waitlist-control group is lacking. Such a control is essential to rule out alternative explanations for symptom improvement, including natural changes following referral to specialized care, regression to the mean, and non-specific therapeutic effects such as clinician attention or engagement, particularly in those receiving CBT-I.</p> <p>Several limitations should be considered. In addition to the study being underpowered, potential selection bias may have affected the generalizability of our results. Participants were recruited from a clinical referral list and may have been incentivized to enroll due to faster access to diagnostic evaluation. Conversely, the possibility for randomization to the stand-alone sleep treatment group may have discouraged some individuals from participating, given the delay in accessing ADHD-specific treatment. While several exclusion criteria were applied during screening, the number of individuals excluded for each reason was not systematically recorded, which limits insight into the screening process. Also, dissatisfaction with treatment allocation during the study led to dropout (Figure A1 in Appendix). Approximately 20% of participants dropped out before the post-treatment assessment. While this rate is comparable to similar behavioral trials, it may have introduced bias, and should be considered when interpreting the results. In addition, the open-label design is a methodological limitation, particularly given that almost all outcomes were based on self-report questionnaires. Without blinding, participants' awareness of their treatment allocation may have influenced how they perceived and reported changes, potentially introducing reporting bias. Furthermore, while we used a comprehensive set of questionnaires to measure ADHD symptoms, sleep, fatigue, and depressive symptoms, we did not measure broader outcomes such as overall (mental) wellbeing or quality of life. This is a notable omission, as prior studies have found a positive effect of CBT-I on quality of life in patients with medical conditions, even in the absence of significant changes in clinical symptoms ([<reflink idref="bib18" id="ref80">18</reflink>]; [<reflink idref="bib26" id="ref81">26</reflink>]; [<reflink idref="bib40" id="ref82">40</reflink>]). This might also be the case in psychiatric disorders such as ADHD, thus, future studies should incorporate such measures to evaluate the full impact of treatment. Lastly, it may have been beneficial to include an additional measurement, several weeks post-treatment, as elements of sleep treatment, in particular CBT-I, are aimed at long-term improvements rather than quick relief. Recent studies have shown evidence for sustained clinical effects after CBT-I ([<reflink idref="bib12" id="ref83">12</reflink>]; [<reflink idref="bib48" id="ref84">48</reflink>]).</p> <p>One important contextual factor is that this trial was conducted during the COVID-19 pandemic. The public health measures in place during some of the study period, including lockdowns, school closures, and restrictions on in-person interactions, may have influenced both baseline symptom levels and participants' engagement with treatment. For example, elevated stress or disrupted routines during the early pandemic could have heightened symptom expression or sleep problems at baseline. However, the study's randomized controlled design helps to mitigate potential confounding from these temporal dynamics, as randomization was preserved throughout recruitment. Additionally, recruitment occurred steadily from mid-2020 onward, following a brief initial pause, with participants enrolled across both more restrictive and more normalized periods of the pandemic. As such, enrollment was not clustered within a single phase of the pandemic, reducing the likelihood that treatment effects are attributable to specific contextual shifts. Furthermore, the centralized and relatively stable public health approach in the Netherlands limits the risk of substantial contextual heterogeneity across participants. While the trial's timing may limit generalizability to non-pandemic conditions, it also provides valuable insight into the feasibility and effectiveness of combined ADHD and sleep treatment under real-world stressors.</p> <hd id="AN0191330926-28">Conclusion</hd> <p>In conclusion, there was no statistically significant evidence that an additive sleep treatment to standard ADHD treatment enhances ADHD symptom reduction in adults with ADHD. However, it does suggest that sleep-focused interventions may improve sleep quality and daytime fatigue, outcomes that are highly relevant in this population frequently suffering from chronic sleep loss and exhaustion, which is often overlooked in standard care. The observed improvements over time in the stand-alone sleep treatment group further highlight the potential of sleep-focused strategies as a complementary or even alternative approach for those patients that are reluctant to initiate ADHD-specific pharmacotherapy. Sleep treatment is relatively easy to implement and may provide a pragmatic first step for improving wellbeing in adults with ADHD. Improved sleep quality and wellbeing may enable patients with ADHD to deal better with the side-effects of ADHD medication, for instance with the sleep onset difficulties associated with the use of medication. Larger, fully powered RCTs are now needed to confirm our findings, explore underlying mechanisms, and examine effects on broader outcomes such as daytime functioning, overall mental wellbeing, and quality of life.</p> <p>Graph: Figure A1. Distribution of (reasons for) dropout before T1 measurement.Note. Based on n = 70 total participants at baseline, of which n = 25 in ADHD TAU group, n = 22 in ADHD TAU + sleep treatment group, n = 23 in sleep treatment group.</p> <p>We thank Petra Blom & Reinier de Groot (NSI) for the coordination of referrals and diagnosing of sleep disorders in our participants, Mikkel Hansen & Robert Nolen (QbTech) for providing the Qbtest data, Marlies van der Sluis, Ingrid Verwoerd & Daphne Isarin (ADHDcentraal) for the first screening of potential participants for our study at ADHDcentraal, and Jos Twisk (Amsterdam UMC) for his advice on the statistical analyses.</p> <ref id="AN0191330926-29"> <title> References </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596</bibtext> </blist> <blist> <bibl id="bib2" idref="ref2" type="bt">2</bibl> <bibtext> Anguelova G. V., Vlak M. H. 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Annals of Clinical Psychiatry, 23(3), 213–224. https://<ulink href="http://www.ncbi.nlm.nih.gov/pubmed/21808754">www.ncbi.nlm.nih.gov/pubmed/21808754</ulink></bibtext> </blist> </ref> <ref id="AN0191330926-30"> <title> Footnotes </title> <blist> <bibtext> Mirte van der Ham</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibtext>https://orcid.org/0000-0002-7094-7510 Daniëlle E. J. Starreveld</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibtext>https://orcid.org/0000-0002-9381-7954 Ravian Wettstein</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibtext>https://orcid.org/0000-0001-6929-4770 Sandra Kooij</bibtext> </blist> <blist> <bibtext>Graph https://orcid.org/0000-0002-8644-6323</bibtext> </blist> <blist> <bibtext> This study was approved by the Medical Ethics Committee of Leiden, The Hague, and Delft (protocol #NL68572.058.18).</bibtext> </blist> <blist> <bibtext> All study participants signed written informed consent before study participation.</bibtext> </blist> <blist> <bibtext> Written informed consent was obtained from all participants to publish the results of our study.</bibtext> </blist> <blist> <bibtext> The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The trial was funded by Parnassia Groep and Nederlands Slaap Instituut (NSI).</bibtext> </blist> <blist> <bibtext> The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Sandra Kooij is the owner of the ADHD Powerbank, an online educational video platform on ADHD. The other authors have no conflicts of interest to declare.</bibtext> </blist> <blist> <bibtext> Data is not (yet) available in a relevant public data repository, but may be shared on request.</bibtext> </blist> </ref> <aug> <p>By Mirte van der Ham; Denise Bijlenga; Nina Molenaar; Daniëlle E. J. Starreveld; Mylène N. Böhmer; Ravian Wettstein; Glenn Dumont; Aartjan T. F. Beekman and Sandra Kooij</p> <p>Reported by Author; Author; Author; Author; Author; Author; Author; Author; Author</p> <p></p> <p>Mirte van der Ham is a PhD student at PsyQ Expertise Center Adult ADHD, affiliated with the Amsterdam UMC. She has a background in health sciences and her research interests include neurodiversity and sleep.</p> <p>Denise Bijlenga, PhD, is a senior researcher, psychologist and somnologist at the Sleep-Wake Center of SEIN in Heemstede, Netherlands and Leiden University Medical Center. Her research mainly focuses on the relationship between sleep and mental health, with specific expertises in psychometrics, methodology and statistics.</p> <p>Nina Molenaar, MD, PhD, is a clinical epidemiologist, researcher and medical guideline developer. She is specialized in psychiatry and pregnancy and study methodology.</p> <p>Daniëlle E. J. Starreveld, PhD, is a senior researcher and psychologist at Parnassia Groep, the Hague. Her research focuses on ADHD, sleep, light treatment, females with ADHD, implementation, methodology and statistics.</p> <p>Mylène N. Böhmer, PhD, is a psychologist and postdoctoral researcher. She is specialized in sleep, mood and light treatment in various populations, actigraphy, innovative research methodology and statistics.</p> <p>Ravian Wettstein, MD, works as a clinician at ADHDcentraal and is a PhD candidate investigating both non-pharmacological and pharmacological aspects of ADHD treatment, with an emphasis on real-world effectiveness, quality of life (QoL), and factors influencing clinical decision-making at the Amsterdam UMC/AMC.</p> <p>Glenn Dumont, PhD, is a clincial pharmacologist and associate professor of pharmacotherapy at the departement of hospital pharmacy of Amsterdam UMC, location AMCand specializes in psychopharmacology.</p> <p>Aartjan Beekman, MD, PhD, is a psychiatrist and professor of Psychiatry and former head of the department of Psychiatry Amsterdam UMC. He is specialized in clinical epidemiology, prevention and effect studies in common mental disorders.</p> <p>Sandra Kooij is a psychiatrist and professor on adult ADHD at Amsterdam UMC/VUmc and PsyQ, the Hague, the Netherlands. She focusses on ADHD, sleep and health, as well as females with ADHD and hormonal moodchanges across the lifespan.</p> </aug> <nolink nlid="nl1" bibid="bib16" firstref="ref6"></nolink> <nolink nlid="nl2" bibid="bib47" firstref="ref7"></nolink> <nolink nlid="nl3" bibid="bib46" firstref="ref10"></nolink> <nolink nlid="nl4" bibid="bib49" firstref="ref11"></nolink> <nolink nlid="nl5" bibid="bib34" firstref="ref15"></nolink> <nolink nlid="nl6" bibid="bib38" firstref="ref16"></nolink> <nolink nlid="nl7" bibid="bib50" firstref="ref18"></nolink> <nolink nlid="nl8" bibid="bib54" firstref="ref19"></nolink> <nolink nlid="nl9" bibid="bib55" firstref="ref20"></nolink> <nolink nlid="nl10" bibid="bib13" firstref="ref24"></nolink> <nolink nlid="nl11" bibid="bib32" firstref="ref25"></nolink> <nolink nlid="nl12" bibid="bib14" firstref="ref26"></nolink> <nolink nlid="nl13" bibid="bib29" firstref="ref27"></nolink> <nolink nlid="nl14" bibid="bib22" firstref="ref28"></nolink> <nolink nlid="nl15" bibid="bib27" firstref="ref29"></nolink> <nolink nlid="nl16" bibid="bib21" firstref="ref31"></nolink> <nolink nlid="nl17" bibid="bib43" firstref="ref32"></nolink> <nolink nlid="nl18" bibid="bib41" firstref="ref33"></nolink> <nolink nlid="nl19" bibid="bib28" firstref="ref34"></nolink> <nolink nlid="nl20" bibid="bib24" firstref="ref38"></nolink> <nolink nlid="nl21" bibid="bib20" firstref="ref41"></nolink> <nolink nlid="nl22" bibid="bib37" firstref="ref42"></nolink> <nolink nlid="nl23" bibid="bib53" firstref="ref43"></nolink> <nolink nlid="nl24" bibid="bib17" firstref="ref45"></nolink> <nolink nlid="nl25" bibid="bib33" firstref="ref46"></nolink> <nolink nlid="nl26" bibid="bib51" firstref="ref48"></nolink> <nolink nlid="nl27" bibid="bib35" firstref="ref50"></nolink> <nolink nlid="nl28" bibid="bib19" firstref="ref53"></nolink> <nolink nlid="nl29" bibid="bib30" firstref="ref54"></nolink> <nolink nlid="nl30" bibid="bib45" firstref="ref55"></nolink> <nolink nlid="nl31" bibid="bib11" firstref="ref57"></nolink> <nolink nlid="nl32" bibid="bib10" firstref="ref58"></nolink> <nolink nlid="nl33" bibid="bib23" firstref="ref59"></nolink> <nolink nlid="nl34" bibid="bib39" firstref="ref60"></nolink> <nolink nlid="nl35" bibid="bib25" firstref="ref63"></nolink> <nolink nlid="nl36" bibid="bib36" firstref="ref64"></nolink> <nolink nlid="nl37" bibid="bib42" firstref="ref65"></nolink> <nolink nlid="nl38" bibid="bib31" firstref="ref67"></nolink> <nolink nlid="nl39" bibid="bib44" firstref="ref68"></nolink> <nolink nlid="nl40" bibid="bib15" firstref="ref69"></nolink> <nolink nlid="nl41" bibid="bib52" firstref="ref70"></nolink> <nolink nlid="nl42" bibid="bib18" firstref="ref80"></nolink> <nolink nlid="nl43" bibid="bib26" firstref="ref81"></nolink> <nolink nlid="nl44" bibid="bib40" firstref="ref82"></nolink> <nolink nlid="nl45" bibid="bib12" firstref="ref83"></nolink> <nolink nlid="nl46" bibid="bib48" firstref="ref84"></nolink>
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  Data: The Effects of Sleep Treatment on Symptoms of ADHD, Sleep Quality, Fatigue, and Depressive Symptoms in Adults
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  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Mirte+van+der+Ham%22">Mirte van der Ham</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-7094-7510">0000-0002-7094-7510</externalLink>)<br /><searchLink fieldCode="AR" term="%22Denise+Bijlenga%22">Denise Bijlenga</searchLink><br /><searchLink fieldCode="AR" term="%22Nina+Molenaar%22">Nina Molenaar</searchLink><br /><searchLink fieldCode="AR" term="%22Daniëlle+E%2E+J%2E+Starreveld%22">Daniëlle E. J. Starreveld</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-9381-7954">0000-0002-9381-7954</externalLink>)<br /><searchLink fieldCode="AR" term="%22Mylène+N%2E+Böhmer%22">Mylène N. Böhmer</searchLink><br /><searchLink fieldCode="AR" term="%22Ravian+Wettstein%22">Ravian Wettstein</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-6929-4770">0000-0001-6929-4770</externalLink>)<br /><searchLink fieldCode="AR" term="%22Glenn+Dumont%22">Glenn Dumont</searchLink><br /><searchLink fieldCode="AR" term="%22Aartjan+T%2E+F%2E+Beekman%22">Aartjan T. F. Beekman</searchLink><br /><searchLink fieldCode="AR" term="%22Sandra+Kooij%22">Sandra Kooij</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-8644-6323">0000-0002-8644-6323</externalLink>)
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Attention+Disorders%22"><i>Journal of Attention Disorders</i></searchLink>. 2026 30(3):354-369.
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  Data: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
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  Data: Y
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  Group: Src
  Data: 16
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  Label: Publication Date
  Group: Date
  Data: 2026
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  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Sleep%22">Sleep</searchLink><br /><searchLink fieldCode="DE" term="%22Attention+Deficit+Hyperactivity+Disorder%22">Attention Deficit Hyperactivity Disorder</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Fatigue+%28Biology%29%22">Fatigue (Biology)</searchLink><br /><searchLink fieldCode="DE" term="%22Depression+%28Psychology%29%22">Depression (Psychology)</searchLink><br /><searchLink fieldCode="DE" term="%22Adults%22">Adults</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Effectiveness%22">Program Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Drug+Therapy%22">Drug Therapy</searchLink>
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  Data: <searchLink fieldCode="DE" term="%22Netherlands%22">Netherlands</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1177/10870547251379103
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1087-0547<br />1557-1246
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Background: Sleep problems are highly prevalent in adults with ADHD. Sleep problems and ADHD symptoms can cause, amplify, and maintain each other. We studied the effects of additive treatment for sleep problems on self-reported symptoms of ADHD as primary outcome, with subscales of inattention and hyperactivity-impulsivity, objective, performance-based ADHD symptoms, sleep quality, fatigue, and depressive symptoms as secondary outcomes. Methods: Preliminary open-label randomized controlled trial of adult patients diagnosed with ADHD and a positive screening for at least one sleep disorder. Participants were recruited between March, 2020 and May, 2023, during the COVID-19 pandemic. Seventy patients (60% female, mean age 27.9 years [SD = 8.2]) were randomized to a 12-week period of: (1) ADHD treatment as usual (TAU, n = 25), (2) ADHD TAU + sleep treatment (n = 22), or (3) stand-alone sleep treatment (n = 33). Outcome measures were assessed at baseline, and after 6 and 12 weeks of treatment. A total of 20% of participants did not complete the post-treatment assessment. Primary analyses compared changes between groups 1 and 2. Exploratory within-group analyses were conducted to assess improvements in the stand-alone sleep treatment group. All performed analyses were pre-specified. Results: Primary analysis showed no significant difference in the reduction of subjective ADHD symptoms between the ADHD TAU + sleep treatment group and the ADHD TAU group ([beta] = -1.30, 95% CI [-5.57, 2.96], d = 0.21). The ADHD TAU + sleep treatment group did show significantly larger improvements in subjective sleep quality ([beta] = -1.98, 95% CI [-3.65, -0.30], d = 0.42) and fatigue ([beta] = -6.52, 95% CI [-12.33, -0.70], d = 1.59) compared to the ADHD TAU group. Pre-specified, exploratory within-group analysis showed a significant reduction in subjective ADHD symptoms in the stand-alone sleep treatment group ([beta] = -4.80, 95% CI [-7.60, -2.01], d = 0.62). Conclusion: Adding sleep treatment to standard ADHD treatment did not lead to significantly greater reductions in subjective or objective, performance based ADHD symptoms. However, combined treatment showed the largest improvements in sleep quality and fatigue, suggesting that such an approach may offer additional benefits. Subjective ADHD symptoms improved in the stand-alone sleep treatment group, but to a lesser extent than the other groups. Future studies with greater statistical power are needed, with long-term effects and quality of life as important outcomes.
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  Data: 2026
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  Data: EJ1496346
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1496346
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        Value: 10.1177/10870547251379103
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      – Text: English
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        PageCount: 16
        StartPage: 354
    Subjects:
      – SubjectFull: Sleep
        Type: general
      – SubjectFull: Attention Deficit Hyperactivity Disorder
        Type: general
      – SubjectFull: Symptoms (Individual Disorders)
        Type: general
      – SubjectFull: Fatigue (Biology)
        Type: general
      – SubjectFull: Depression (Psychology)
        Type: general
      – SubjectFull: Adults
        Type: general
      – SubjectFull: Program Effectiveness
        Type: general
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Foreign Countries
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      – SubjectFull: Drug Therapy
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      – SubjectFull: Netherlands
        Type: general
    Titles:
      – TitleFull: The Effects of Sleep Treatment on Symptoms of ADHD, Sleep Quality, Fatigue, and Depressive Symptoms in Adults
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      – PersonEntity:
          Name:
            NameFull: Mirte van der Ham
      – PersonEntity:
          Name:
            NameFull: Denise Bijlenga
      – PersonEntity:
          Name:
            NameFull: Nina Molenaar
      – PersonEntity:
          Name:
            NameFull: Daniëlle E. J. Starreveld
      – PersonEntity:
          Name:
            NameFull: Mylène N. Böhmer
      – PersonEntity:
          Name:
            NameFull: Ravian Wettstein
      – PersonEntity:
          Name:
            NameFull: Glenn Dumont
      – PersonEntity:
          Name:
            NameFull: Aartjan T. F. Beekman
      – PersonEntity:
          Name:
            NameFull: Sandra Kooij
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 03
              Type: published
              Y: 2026
          Identifiers:
            – Type: issn-print
              Value: 1087-0547
            – Type: issn-electronic
              Value: 1557-1246
          Numbering:
            – Type: volume
              Value: 30
            – Type: issue
              Value: 3
          Titles:
            – TitleFull: Journal of Attention Disorders
              Type: main
ResultId 1