Previous studies have linked ADHD with self-harm, but the processes underlying this association are not fully understood. This research aims to investigate the role of sleep disturbances as a potential pathway between ADHD diagnosis and self-harm behaviors.
Materials and Methods:
The study included 90 youth aged between 11 and 18 years, divided into two groups: a case group of 45 youth diagnosed with ADHD and a control group of 45 youth without ADHD. Both groups completed the Inventory of Statements About Self-Injury to evaluate self-harm behaviors and the Sleep Disturbance Scale for Children to assess sleep disturbances. A path analysis was conducted to examine whether a significant proportion of the association between ADHD and self-harm was shared with sleep disturbances, while controlling for gender, youth education, family income, maternal education, and overall anxiety and depression scores.
Results:
An ADHD diagnosis was significantly associated with sleep disturbances (β = .62, p < .001) and self-harm behaviors (β = .35, p = .03). Additionally, sleep disturbances were significantly linked to self-harm (β = .51, p = .002) and played a significant role in the association between ADHD and self-harm (indirect effect β = .32, p = .001).
Conclusion:
These findings suggest that sleep disturbances account for a substantial proportion of the shared variance in the association between ADHD and self-harm. While the cross-sectional design limits causal interpretations, these results highlight the importance of addressing sleep issues in clinical care for ADHD to potentially reduce self-harm risks and improve outcomes for at-risk youth.
AkcayD.AkcayB.BozkurtO. (2020). Reliability and validity of Turkish Sleep Disturbance Scale for children. Anatolian Journal of Psychiatry, 21(1), 70–78. https://doi.org/10.5455/apd.65084
2.
AllelyC. S. (2014). The association of ADHD symptoms to self-harm behaviours: A systematic PRISMA review. BMC Psychiatry, 14(113), 1–13. https://doi.org/10.1186/1471-244X-14-133
AppelbaumM.CooperH.KlineR. B.Mayo-WilsonE.NezuA. M.RaoS. M. (2018). Journal article reporting standards for quantitative research in psychology: The APA Publications and Communications Board task force report. American Psychologist, 73(1), 3–25. https://doi.org/10.1037/amp0000191
5.
BarraS.GrubA.RoeslerM.Retz-JungingerP.PhilippF.RetzW. (2021). The role of stress coping strategies for life impairments in ADHD. Journal of Neural Transmission, 128(7), 981–992. https://doi.org/10.1007/s00702-021-02311-5
6.
BildikT.SomerO.Kabukcu-BasayB.BasayO.OzbaranB. (2013). The validity and reliability of the Turkish version of the Inventory of Statements About Self-Injury. Turkish Journal of Psychiatry, 24(1), 49–57. https://www.turkpsikiyatri.com/PDF/C24S1/en/241otnfjjk07.pdf
7.
BourchteinE.LangbergJ. M.EadehH. M. (2020). A review of pediatric nonpharmacological sleep interventions: Effects on sleep, secondary outcomes, and populations with co-occurring mental health conditions. Behavior Therapy, 51(1), 27–41. https://doi.org/10.1016/j.beth.2019.04.006
8.
BruniO.OttavianoS.GuidettiV.RomoliM.InnocenziM.CortesiF.GiannottiF. (1996). The sleep disturbance scale for children (SDSC) construction and validation of an instrument to evaluate sleep disturbances in childhood and adolescence. Journal of Sleep Research, 5(4), 251–261. https://doi.org/10.1111/j.1365-2869.1996.00251.x
9.
ChorpitaB. F.YimL.MoffittC.UmemotoL. A.FrancisS. E. (2000). Assessment of symptoms of DSM-IV anxiety and depression in children: A revised child anxiety and depression scale. Behaviour Research and Therapy, 38(8), 835–855. https://doi.org/10.1016/S0005-7967(99)00130-8
10.
ConnersC. K. (1997). The Conners Rating Scales – Revised manual. Multi-health Systems.
11.
ConnersC. K.SitarenosG.ParkerJ. D.EpsteinJ. N. (1998). The revised Conners’ Parent Rating Scale (CPRS-R): Factor structure, reliability, and criterion validity. The Journal of Abnormal Child Psychology, 26, 257–268. https://doi.org/10.1023/A:1022602400621
12.
CorteseS.FaraoneS. V.KonofalE.LecendreuxM. (2009). Sleep in children with attention-deficit/hyperactivity disorder: Meta-analysis of subjective and objective studies. Journal of the American Academy of Child and Adolescent Psychiatry, 48(9), 894–908. https://doi.org/10.1097/CHI.0b013e3181ac09c9
13.
DerinS.SelmanS. B.CoskunM. (2023). Gambling disorder in adolescents with attention-deficit/hyperactivity disorder: A case study. Psychiatry Research Case Reports, 2(2), 100160. https://doi.org/10.1016/j.psycr.2023.100160
GormezV.KılıncaslanA.OrengulA. C.EbesutaniC.KayaI.CeriV.NasirogluS.FilizM.ChorpitaB. (2017). Psychometric properties of the Turkish version of the revised child anxiety and depression scale-child version in a clinical sample. Psychiatry and Clinical Psychopharmacology, 27(1), 84–92. https://doi.org/10.1080/24750573.2017.1297494
16.
GvionY.ApterA. (2011). Aggression, impulsivity, and suicide behavior: A review of the literature. Archives of Suicide Research, 15(2), 93–112. https://doi.org/10.1080/13811118.2011.565265
17.
HawtonK.SaundersK.TopiwalaA.HawC. (2013). Psychiatric disorders in patients presenting to hospital following self-harm: A systematic review. Journal of Affective Disorders, 151(3), 821–830. https://doi.org/10.1016/j.jad.2013.08.020
HinshawS. P. (2015). Self-harm as a developmental outcome in girls with ADHD: Clinical significance and underlying mechanisms. The ADHD Report, 23(6), 1–6. https://doi.org/10.1521/adhd.2015.23.6.1
20.
HuLBentlerP. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal, 6(1), 1–55. https://doi.org/10.1080/10705519909540118
21.
HysingM.SivertsenB.StormarkK. M.O’ConnorR. C. (2015). Sleep problems and self-harm in adolescence. The British Journal of Psychiatry, 207(4), 306–312. https://doi.org/10.1192/bjp.bp.114.146514
KaufmanJ.BirmaherB.BrentD.RaoU.FlynnC.MoreciP.WilliamsonD.RyanN. (1997). Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): Initial reliability and validity data. Journal of the American Academy of Child & Adolescent Psychiatry, 36(7), 980–988. https://doi.org/10.1097/00004583-199707000-00021
25.
KhazaieH.ZakieiA.McCallW. V.NooriK.RostampourM.Sadeghi BahmaniD.BrandS. (2021). Relationship between sleep problems and self-injury: A systematic review. Behavioral Sleep Medicine, 19(5), 689–704. https://doi.org/10.1080/15402002.2020.1822360
26.
KlonskyE. D.GlennC. (2009). Assessing the functions of non-suicidal self-injury: Psychometric properties of the inventory of statements about self-injury (ISAS). Journal of Psychopathology and Behavioral Assessment, 31, 215–219. https://doi.org/10.1007/s10862-008-9107-z
27.
LereyaS. T.WinsperC.HeronJ.LewisG.GunnellD.FisherH. L.WolkeD. (2013). Being bullied during childhood and the prospective pathways to self-harm in late adolescence. Journal of the American Academy of Child and Adolescent Psychiatry, 52(6), 608–618. https://doi.org/10.1016/j.jaac.2013.03.012
28.
LundahlA.KidwellK. M.Van DykT. R.NelsonT. D. (2015). A meta-analysis of the effect of experimental sleep restriction on youth’s attention and hyperactivity. Developmental Neuropsychology, 40(3), 104–121. https://doi.org/10.1080/87565641.2014.939183
29.
Lunsford-AveryJ. R.DavisJ. L.WilloughbyM. T. (2024). Circadian rhythm dysfunction and clinical heterogeneity in pediatric ADHD: A critical need for innovation in assessment and treatment. JCPP Advances, 12281, 1–4. https://doi.org/10.1002/jcv2.12281
30.
Lunsford-AveryJ. R.KrystalA. D.KollinsS. H. (2016). Sleep disturbances in adolescents with ADHD: A systematic review and framework for future research. Clinical Psychology Review, 50, 159–174. https://doi.org/10.1016/j.cpr.2016.10.004
31.
MaxwellS. E.ColeD. A.MitchellM. A. (2011). Bias in cross-sectional analyses of longitudinal mediation: Partial and complete mediation under an autoregressive model. Multivariate Behavioral Research, 46(5), 816–841. https://doi.org/10.1080/00273171.2011.606716
32.
MedicG.WilleM.HemelsM. E. (2017). Short-and long-term health consequences of sleep disruption. Nature and Science of Sleep, 9, 151–161. https://doi.org/10.2147/NSS.S134864
OwensJ., Adolescent Sleep Working Group, and Committee on Adolescence. (2014). Insufficient sleep in adolescents and young adults: An update on causes and consequences. Pediatrics, 134(3), 921–932. https://doi.org/10.1542/peds.2014-1696
PreacherK. J.SeligJ. P. (2012). Advantages of Monte Carlo confidence intervals for ındirect effects. Communication Methods and Measures, 6(2), 77–98. https://doi.org/10.1080/19312458.2012.679848
SinghP.SinghA. (2023). Emotion regulation difficulties and health-risk behaviours in adolescents. Behaviour Change, 40(2), 86–102. https://doi.org/10.1017/bec.2022.5
39.
SwannellS. V.MartinG. E.PageA.HaskingP.JohnN. J. S. (2014). Prevalence of nonsuicidal self-injury in nonclinical samples: Systematic review, meta-analysis and meta-regression. Suicide and Life-Threatening Behavior, 44(3), 273–303. https://doi.org/10.1111/sltb.12070
40.
SwansonE. N.OwensE. B.HinshawS. P. (2014). Pathways to self-harmful behaviors in young women with and without ADHD: A longitudinal examination of mediating factors. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 55(5), 505–515. https://doi.org/10.1111/jcpp.12193
41.
TamL. Y. C.TaechameekietichaiY.AllenJ. L. (2024). Individual child factors affecting the diagnosis of attention deficit hyperactivity disorder (ADHD) in children and adolescents: A systematic review. European Child and Adolescent Psychiatry. Advance online publication. https://doi.org/10.1007/s00787-024-02590-9
42.
TaylorM. R.BodenJ. M.RucklidgeJ. J. (2014). The relationship between ADHD symptomatology and self-harm, suicidal ideation, and suicidal behaviours in adults: A pilot study. Attention Deficit and Hyperactivity Disorders, 6(4), 303–312. https://doi.org/10.1007/s12402-014-0139-9
43.
UnalF.OktemF.CuhadarogluF. C.Cengel KulturS. E.Foto OzdemirD.OztopD.… ArtikA. (2019). Reliability and Validity of the Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime Version (K-SADS-PL-DSM-5-T): Turkish Adaptation. Turkish Journal of Psychiatry, 30(1), 42–50. https://doi.org/10.5080/u23408
44.
WajszilberD.SantisebanJ. A.GruberR. (2018). Sleep disorders in patients with ADHD: Impact and management challenges. Nature and Science of Sleep, 10, 453–480. https://doi.org/10.2147/NSS.S163074
45.
WardJ. H.CurranS. (2021). Self-harm as the first presentation of attention deficit hyperactivity disorder in adolescents. Child and Adolescent Mental Health, 26(4), 303–309. https://doi.org/10.1111/camh.12471
46.
XiaY.YangY. (2019). RMSEA, CFI, and TLI in structural equation modeling with ordered categorical data: The story they tell depends on the estimation methods. Behavior Research Methods, 51, 409–428. https://doi.org/10.3758/s13428-018-1055-2
47.
YamauchiY.FujiwaraT.OkuyamaM. (2015). Factors ınfluencing time lag between ınitial parental concern and first visit to child psychiatric services among ADHD children in Japan. Community Mental Health Journal, 51(7), 857–861. https://doi.org/10.1007/s10597-014-9803-y
48.
YinH.YangD.YangL.WuG. (2022). Relationship between sleep disorders and attention-deficit–hyperactivity disorder in children. Frontiers in Pediatrics, 10(919572), 1–7. https://doi.org/10.3389/fped.2022.919572
49.
YoonS. Y.JainU.ShapiroC. (2012). Sleep in attention-deficit/hyperactivity disorder in children and adults: Past, present, and future. Sleep Medicine Reviews, 16(4), 371–388. https://doi.org/10.1016/j.smrv.2011.07.001
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
