Kids' Poor Bedtime Habits May Bring ADHD Misdiagnosis

Study Suggests That No Set Bedtime, Bed Sharing Linked to Behavior Problems

By Daniel J. DeNoon
WebMD Health News

Reviewed by Laura J. Martin, MD

Sept. 20, 2011 -- A child's bedtime habits could result in behavior problems -- and a misdiagnosis of ADHD, a new study suggests.

The study is based on a survey of 704 parents of children ages 2 to 13. The parents, mostly mothers, filled out brief questionnaires in randomly selected pediatricians' waiting rooms.

The results strongly suggest that several behavior problems are much more common in kids who:

  • Have no set bedtime
  • Share a bed with parents or siblings

These kids, the study found, are much more likely than regular-bedtime, sleep-alone kids to:

  • Throw tantrums or have meltdowns
  • Hit, kick, or push their parents
  • Have low self-confidence
  • Have their parents get notes from school about their behavior
  • Have their parents advised that their children should take medicine for behavior or learning problems

Not all these behaviors are typical of kids with ADHD (attention deficit hyperactivity disorder). They are not sufficient or even necessary for a diagnosis of ADHD. Yet study leader Robert M. Pressman, PhD, a child psychologist, says many such kids have been diagnosed with ADHD.

"It looks and feels like ADHD but it is not," Pressman tells WebMD. "We are using the term 'faux ADHD' to describe it."

Parents were far more likely to report each of these symptoms if their children did not sleep alone and did not have a set bedtime.

"It was an extremely strong association," Pressman says. "We found that children who were bed sharing and who had no regular bedtime had these behaviors eight to 10 times more."

Bedtime, Sleep, and 'Faux ADHD'

Andrew Adesman, MD, chief of developmental and behavioral pediatrics at Cohen Children's Medical Center in New Hyde Park, N.Y., finds Pressman's study interesting but warns against over-interpreting the results. Adesman was not involved in the study.

"It is tempting to think that sleep problems are causing the behavior issues, but even the authors don't jump to that conclusion," Adesman tells WebMD. "It is worth noting that while we know sleep deficits can cause behavioral issues, we also know that kids with ADHD have greater problems with sleep difficulties."

Pressman says he's looking at this issue in ongoing studies. Giving troubled kids a firm bedtime and getting them to sleep alone, he says, has dramatic and rapid effects on their daytime behavior.

"We have noticed beyond a shadow of a doubt that these behaviors change dramatically, within five days to a week -- not a long time," Pressman says.

Pressman emphasizes that a focus on bedtime issues is not a treatment for kids who truly have ADHD. But he says many kids with behavior problems are wrongly diagnosed with ADHD. Adesman agrees.

"Not every child with attention issues or restlessness has ADHD," he says. "There can be a multitude of other problems, one of which could be a sleep disorder."

Adesman notes that the relationships between ADHD, sleep, and behavior are complex. He says there's likely no single answer to the questions raised by the Pressman study. However, he notes that altering a family's bedtime rituals likely affects overall parenting style.

"Perhaps parents who are more willing to give in to a child's sleep-behavioral problems may be more prone to have children with manipulative behavior and aggression," Adesman suggests. "And parents who have trouble setting limits on daytime behavior are also more likely to have difficulties with nighttime behavior."

Setting a Bedtime

So how can parents start getting their children to have a consistent bedtime?

Pressman says the underlying idea is that bedtime is a clear expectation of what occurs -- a rule, not a command.

"Nobody likes to be told what to do," he says. "But if the amusement park opens at 10, you can argue about it but it won't change. It is not imposed on anyone, it is just there."

Implementing such a rule requires a meeting of the whole family, because every family member has to be on board.

Pressman says there are five key points:

  • It must be clear. "There must be very little room for negotiation," Pressman says. "The child does have an opportunity to discuss, but there is no real negotiation."
  • It has to be doable.
  • It has to be time specific. "Saying 'You have to go to bed between 8 and 9 is not clear," Pressman says.
  • It has to be enforceable. Until bedtime becomes routine, parents have to be at home to enforce the new rule. Leaving it to a babysitter won't work.
  • 100% consistency for two weeks. Over the first two weeks of the new bedtime rule, there can be no exceptions. Later on, a child can stay up late to go to the ball game, but not at first.

Pressman elaborates on these points and offers advice on specific situations in his book Good Nights Now.

Adesman notes that while Pressman focuses on parenting issues, true ADHD is not caused by bad parenting.

"Children with ADHD can pose difficult problems at bedtime. It is not a question of parent limitations," he says. "It is legitimate to acknowledge that there are reasons besides ADHD where kids can have behavior problems. But we have to be careful when talking about causes."

The Pressman study appears in the Sept. 15 online edition of the American Journal of Family Therapy.


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SOURCES: Pressman, R.M. and Imber, S.C. American Journal of Family Therapy, published online Sept. 15, 2011.Robert Pressman, PhD, New England Center for Pediatric Psychology, Providence, R.I.Andrew Adesman, MD, chief of developmental & behavioral pediatrics, Steven and Alexandra Cohen Children's Medical Center of New York, New Hyde Park, N.Y.Touchette, E. Pediatrics, published online Oct. 19, 2009.Gruber, R. Sleep, 2009; vol 32: pp 343-350. ©2011 WebMD, LLC. All Rights Reserved.