Efficacy of Cognitive Behavioural Therapy for Insomnia and Bright Light Therapy in Adolescents With ADHD, Insomnia, and Evening Chronotype

Efficacy of Cognitive Behavioural Therapy for Insomnia and Bright Light Therapy in Adolescents With ADHD and Comorbid Insomnia and Evening Chronotype: A Randomised, Assessor Blind, Parallel-group Trial

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by persistent inattention, hyperactivity, and impulsivity. In adolescents and young people, ADHD is commonly accompanied by insomnia and circadian delay. These co-occurring sleep and circadian disturbances may negatively affect daytime functioning and overall clinical outcomes. Although cognitive behavioural therapy for insomnia (CBT-I) is considered the first-line treatment for insomnia, and bright light therapy may help address circadian issues, their efficacy in adolescents with ADHD and comorbid insomnia and eveningness remains unexplored. This study aims to evaluate whether CBT-I, with or without bright light therapy, improves insomnia, sleep, and circadian as well as other clinical outcomes, and cognitive functioning in youths with ADHD and whether these interventions can also lead to improvements in mood and other clinical symptoms, as well as cognitive functioning.

Inclusion criteria:

An adolescent who meets the following criteria will be eligible for taking part in this study:

1. aged 10-24 years old;
2. ADHD diagnosis confirmed by DISC-IV;
3. DSM-5 diagnosis of insomnia disorder with an ≥ 9 (suggested cut-off for adolescents);
4. Being classified as evening chronotype according to the score on the Horne-Östberg Morning-Eveningness Questionnaire (MEQ) and having a sleep onset time of 11:15pm or later for 12 year olds, 11:30pm or later for 13-14 year olds, 12:00am or later for 15-17 years old [64], 10:56pm or later for 18-24 years old at least 3 nights per week in the past 3 months and as confirmed by a 7-day sleep diary;
5. Written informed consent from the participant and their parent/guardian (for those aged under 18);
6. Being able to comply with the study protocol;
7. Either not on ADHD medication or stabilized on medications for at least 6 months.

Exclusion criteria:

An adolescent who meets one or more of the following criteria will be excluded from the study:

1. Substance abuse or dependence; a current or past history of manic or hypomanic episode, schizophrenia, ASD, organic mental disorders, or intellectual disabilities;
2. Prominent medical condition affecting sleep (e.g., severe eczema, GERD);
3. Clinically diagnosed sleep disorder other than insomnia disorder, such as narcolepsy, sleep-disordered breathing, and restless leg syndrome;
4. Concurrent, regular use of medications(s) known to affect sleep continuity and quality including both prescribed medications (e.g., hypnotics, steroids) and over-the-counter OTC medications (e.g., melatonin, Traditional Chinese Medicine, TCM), except for ADHD stimulants;
5. Ongoing psychological treatment for sleep problems;
6. With hearing or speech deficit;
7. Having a clinically significant suicidality (presence of suicidal ideation with a plan or an attempt).