Use of ball blanket in attention-deficit/hyperactivity disorder sleeping problems

Use of Ball Blanket in attention-defi cit/hyperactivity disorder sleeping problems Hvolby A, Bilenberg N. Use of Ball Blanket in attention-defi cit/hyperactivity disorder sleeping problems. Nord J Psychiatry 2011;65:89–94. Objectives: Based on actigraphic surveillance, attention-defi cit/hyperactivity disorder (ADHD) symptom rating and sleep diary, this study will evaluate the effect of Ball Blanket on sleep for a sample of 8–13-year-old children with ADHD. Design: Case–control study. Setting: A child and adolescent psychiatric department of a teaching hospital. Participants: 21 children aged 8–13 years with a diagnosis of ADHD and 21 healthy control subjects. Intervention: Sleep was monitored by parent-completed sleep diaries and 28 nights of actigraphy. For 14 of those days, the child slept with a Ball Blanket. Main outcome measures: The sleep latency, number of awakenings and total length of sleep was measured, as was the possible infl uence on parent- and teacher-rated ADHD symptom load. Results: The results of this study will show that the time it takes for a child to fall asleep is shortened when using a Ball Blanket. The time it takes to fall asleep when using the Ball Blanket is found to be at the same level as the healthy control sub-jects. Teacher rating of symptoms show an improvement in both activity levels and attention span of approximately 10% after using the Ball Blankets. Conclusions: The results of this study show that the use of Ball Blankets is a relevant and effective treatment method with regard to minimizing sleep onset latency. We fi nd that the use of Ball Blankets for 14-days improves the time it takes to fall asleep, individual day-to-day variation and the number of awakenings to a level that compares with those found in the healthy control group. Furthermore, we fi nd that the use of Ball Blankets signifi cantly reduces the number of nights that the ADHD child spends more than 30 min falling asleep from 19% to 0%. Allan Hvolby, M.D., Ph.D., Department of Child and Adolescent Psychiatry, Region of Southern Denmark, Gl. Vardevej 101, 6715 Esbjerg N, Denmark, E-mail: hvolby@dlgmail.dk; Accepted 11 June 2010. Attention-defi cit/hyperactivity disorder (ADHD) is the disorders—such as sleep-related breathing disorders or most common problem presented to Child and Ado- periodic limb movement disorders—can often be mis- lescent Mental Health Services (CAMHS). The disorder taken for ADHD, as they are very similar to core symp-affects 3–5% of all school-aged children (1). The core toms of ADHD. These disorders are found to be related Nord J Psychiatry Downloaded from informahealthcare.com by University of Lund on 05/19/11 symptoms of the disorder—inattention, hyperactivity and to hyperactivity and inattentiveness (9–14), and the very impulsivity—are associated with a high rate of comor- treatment of the sleep disorders has reduced—or even bidity (e.g. oppositional defi ant disorder, anxiety and cured—both hyperactivity and inattentiveness (15, 16). It depression; 2–4), as well as academic underachievement, has also been proposed that an unstable sleep schedule poor social relations and sleep disturbances. Sleep diffi cul- could be the result of biological immaturity, or it could ties was even included in the diagnostic criteria for ADHD be a dysfunction somehow related to inattentiveness. in the DSM III (5) and are often included in ADHD rat- Likewise, it has been suggested that instability of the ing scales, e.g. Conners’ Rating Scale for parents (6). sleep–wake system may play a role in the irregularity of It has been theorized that sleep deprivation in chil- dren with ADHD could be a result of a primary sleep Sleep problems are furthermore interesting because disorder, or that it could be related to dysregulation of learning diffi culties are rather frequent in children with arousal mechanisms as implicated in the aetiology of ADHD (15), and several studies have documented a link ADHD (7). We know that sleep diffi culties with no between sleep disorder and learning diffi culties (18–23). explanatory cause can be mistaken for ADHD (8), and Parents of children with ADHD often report that their that the kind of symptoms observed in primary sleep child has sleep diffi culties. Little need for sleep, diffi culties falling asleep, restless sleep, frequent awakenings and fatigue in the morning are often reported problems (24–26). The children themselves also report sleep diffi -culties more often than children without ADHD (27). Self-report studies show that more than half the children with ADHD report subjectively experienced sleep diffi -culties (24, 28, 29). This could be of great theoretical importance in the clinical work. Recent studies point out that the majority of sleep dif- fi culties found with reference to ADHD may result from a mix-up of comorbidity and medical treatment. Compar-ing children with ADHD against clinical controls, Mick et al. (30) found no signifi cant sleep diffi culties in chil-dren with ADHD when comorbidity (anxiety, opposi-tional defi ant disorder and depression) and treatment with stimulants were taken into account, but only few studies have addressed this possible connection, and the picture is far from clear. However, other studies have documented a higher degree of insomnia and more individual variation in time to sleep latency in medically naïve children with ADHD compared with children with other psychiatric diagnoses and healthy children (29, 31–35). It is diffi cult to judge the extent and nature of sleep problems in children with ADHD because the range of studies addressing this issue suffer from methodological problems (e.g. too small sample sizes, wavering diagnostic criteria and different status of medication and comorbidity; 4). From clinical practice, we know that parents of chil- dren with ADHD are alarmed by their child’s sleeping strongest stimulation of the sensory system. The Ball problems and the diffi culties this causes in the family Blanket with a mixture of plastic and polystyrene balls setting. The ADHD-diagnosed children themselves even is a somewhat lighter blanket for those who need slightly report sleep diffi culties more frequently than children with- milder stimulation of the sensory system. The blanket out ADHD. More than half the children with ADHD claim with polystyrene balls provides the lightest stimulation of to have sleep diffi culties (25, 27, 28). In a study using the sensory system. For this project, the Ball Blanket actigraphy, Hvolby et al. (35) found increased sleep onset (adult size 140 × 200 cm) with 50-mm plastic balls and latency and an increased day-to-day variability in the a weight of 7 kg has been used. For more information, sleep–wake pattern of children with ADHD compared The design of the Ball Blanket (Fig. 1) is based on Nord J Psychiatry Downloaded from informahealthcare.com by University of Lund on 05/19/11 the American occupational therapist and psychologist, Aims
A. Jean Ayres’s, theories of sensory integration (36). It Based on actigraphic surveillance, ADHD symptom rating
works because the weight from the loose balls inside the (ADHD-RS; 37) and sleep diary, this study will evaluate
blanket press certain points of the body, stimulating both the effect of Ball Blankets on sleep in a sample of
the sensation of touch and the sense of muscle and joint. 8–13-year-old ADHD children. The sleep latency, number
The many sensory impressions transmit inhibitory impulses of awakenings and total length of sleep will be measured,
to the central nervous system. This increases the sense as will the possible infl uence on parent- and teacher-rated
of the body and its limits, and it provides confi dence. ADHD symptom load.
The Ball Blanket has been used in psychiatric inpatient
wards for some years as a tranquillizing method and has,
in non-scientifi c and unpublished works, diminished the Methods
use of medical tranquilisers.
Participants
The Ball Blanket is produced with balls of various A total of 21 children (19 boys and two girls) aged sizes and weights. The blanket with plastic balls provides 8–13 years, with an average age of 10.0 years, were most weight and pressure, and provides therefore the involved. All had been referred to a child and adolescent USE OF BALL BLANKET IN ADHD SLEEPING PROBLEMS psychiatric department and diagnosed with ADHD. Sleep
Fourteen children were medicated with methylpheni-
To obtain an objective view of the sleep pattern, actigraphs date, two with dexamphetamine sulphate and two with (Basic Mini Motionlogger, Ambulatory Monitoring Inc., atomoxetine. One child was treated with a combination New York)—a wrist-watch-sized activity sensor worn on of methylphenidate and atomoxetine and two children the dominant wrist—was used. Actigraphy is an established were not medicated. Three children got melatonin at and well-reputed method of sleep examination. Findings bedtime. All medications remained unchanged during are consistent with those obtained by the polysomnographic the test period. methods, with an agreement rate of 95% (38). Sleep record- None of the participating children had been referred ing took place in the children’s own home, which is an for sleeping problems nor did they have major sensory- additional advantage, as the children’s sleep does not seem motor handicaps (blindness, deafness and paralysis), to have been negatively affected (39). autism and psychosis. All had an estimated full-scale IQ The children wore the actigraph for a consecutive period of 28 nights (40). Surveillance took place in Psychiatric comorbidity is shown in Table 1. three consecutive periods; fi rst 7 nights without the Ball Blanket to obtain the baseline sleeping pattern, then 14 nights using the Ball Blanket and fi nally 7 nights with- Diagnostic measures
Each participant in the referred group was subjected to When uploaded to the computer, the accumulated data thorough clinical assessment. The diagnostic evaluations was analysed according to the Actigraphic Scoring Analysis were based on face-to-face parent interviews and a clini- Program (41). Study of frequency and pattern of movement cal assessment, and the hyperkinetic disorder (ADHD) permits detection of basic sleep–wake patterns. The vari- was diagnosed in accordance with the ICD-10 ables generated were ‘sleep onset latency’ (time between Classifi cation of Mental and Behavioural Disorder. parents noting lights out and actigraphically measured fi rst sleep onset), ‘number of wakes after sleep onset’, ‘length Table 1. Descriptive characteristics of children and parents. of each wake’ and ‘total duration of sleep’ (actual sleep time, excluding sleep latency and wakes after sleep onset). During the same 7–14–7 night period, a sleep diary was completed by the parents to provide a subjective assessment of sleep–wake patterns and to provide more accurate actigraphical measurements. Parents were instructed to observe and specify their children’s sleep- ing and waking states (bedtime, lights out, observed wakes and times the child woke up). Thus we were able to calculate sleep onset latency (time between parents noting lights out and actigraphically measured fi rst sleep onset). Also, parents and teachers rated the load of inattentive and hyperactive/impulsive symptoms on the As a control group, 21 matched children were sampled from a Danish actigraphic norm-population (42). Nord J Psychiatry Downloaded from informahealthcare.com by University of Lund on 05/19/11 The results of this study (Table 2) show that sleep onset latency was reduced when using the Ball Blankets. With- out the use of Ball Blankets, the average sleep onset latency was 23.1 min, which fell to 14.0 min when using the Ball Blanket—a fall of 39.4%. The time it took for the child to sleep can furthermore be seen as being at the same level as sleep onset latency for healthy control children—whilst the time increases—to 20.5 min—when the blanket is removed. ADHD, attention-defi cit/hyperactivity disorder; There is likewise an improvement in the average of PDD-NOS, pervasive developmental disorder—not otherwise specifi ed. * Two parents in the family. Two biological parents or one biological parent individual longest sleep onset latency. The difference between the longest and shortest individual sleep onset Table 2. Actigraphic sleep parameters. Sleep onset latency (minutes), mean (s) Average of longest sleep onset latency (minutes), mean (s) Difference between longest and shortest individual sleep onset Number of awakening (number), mean (s) Average time awake (minutes), mean (s) Total sleep time (minutes), mean (s) Sleep onset latency (average) Ͼ30 min (%) (n ϭ total number of nights in each group) s, standard deviation; ns, not signifi cant (signifi cance level P Ͻ 0.01). Actigraphic sleep parameters in minutes averaged for each child, and fraction of children with an average sleep onset latency Ͼ30 min. Data analysed with one-way analysis of variance (ANOVA). * Chi-squares with two degrees of freedom. latency and the average number of awakenings during Parents have a tendency to overestimate the length of time it takes to go to sleep, both in the period with and An interesting fi nd is that the proportion of children without the use of the Ball Blanket. However, as the that spent longer than 30 min on average falling asleep; table shows, this phenomenon is found at the same level 19% spent more than 30 min on average falling asleep in the healthy control group. before and after using the Ball Blanket, whilst no In Tables 4a and 4b, the ratings of ADHD symptoms children had an average of more than 30 min when are shown from teachers and parents respectively. Teacher using the blanket. ratings show a non-signifi cant improvement in both activ- Likewise, the proportion of single nights when more ity level and attention—approximately 10% from before than 30 min were spent falling asleep fell from 27.7% to the Ball Blanket is used to scoring after 14 nights with 14.8% when using the blanket, which is the same level the Ball Blanket. The tables also show a continued, fur-as the healthy control children. At the same time, the ther improvement in both parameters in the week after proportion of single nights during which the child fell the Ball Blanket has been removed again. asleep within 15 min rose from 38.5% to 68.7%. Parent rating shows the same tendency, though with Table 2 shows that the sleep parameters described a smaller improvement in activity and attention, but with deteriorate again when the Ball Blanket is not used. an improvement in behavioural disturbance symptoms Parents’ evaluation of the sleep is shown in Table 3. of 13%. Parents experience that their child falls asleep more
quickly, even if the subjective effect is small than with
the actigraph measurement. Likewise, parents evaluate Discussion
Nord J Psychiatry Downloaded from informahealthcare.com by University of Lund on 05/19/11 that the sleep onset latency falls from an average of 36.7 Previous studies found that non-medicated children min to 26.9 min, which is an improvement of 26.7%. with ADHD had longer sleep onset latency, and that Table 3. Parental versus actigraphic estimated sleep onset latency. Difference (between actigraphic and parent est.), mean (s) s, standard deviation; ns, not signifi cant (signifi cance level P Ͻ 0.01). Parents’ estimation (by sleep diary) of sleep onset latency (time between parents noting lights out and parents noting fi rst sleep onset), compared with the objectively (actigraphically) measured sleep onset latency (time between parents noting lights out and actigraphically measured fi rst sleep onset). * Data analysed with three-way analysis of variance (ANOVA), adjusted for gender and family type. USE OF BALL BLANKET IN ADHD SLEEPING PROBLEMS Table 4a. Attention-defi cit/hyperactivity disorder (ADHD) rating scale (score (standard deviation))—rated by teachers. signifi cantly more children with ADHD spend more than Other studies have highlighted the importance of 30 min (on average) falling asleep (35). An increased sleep in relation to learning diffi culties, behaviour, con-intra-individual day-to-day variability in sleep onset centration and motor skills disturbances. Treating sleep latency in children with ADHD compared with healthy problems in children with ADHD is therefore relevant children and children with other psychiatric diagnoses (9–14, 18–23). has also been documented (16). The results of this study show that the use of Ball Previous studies (8–11, 35) show a relationship Blankets is a relevant and effective method of treatment between sleep diffi culties and an increased magnitude of with regard to reducing sleep onset latency ADHD symptoms, inattention and hyperactivity. Treat- We fi nd that the use of Ball Blankets for 14 days ment with Ball Blankets appears therefore to improve improves sleep onset latency, individual day-to-day varia-sleep and this study has furthermore shown a small tion and number of awakenings to a level comparable decrease in the severity of ADHD symptoms, as evalu- with those found in the healthy control group. ated by both teachers (approximately 10% improvement), We furthermore fi nd that the use of Ball Blankets sig- and by parents (approximately 6%). In both evaluations, nifi cantly reduces the number of nights in which the the improvement appears to continue even when use of ADHD child spends more than 30 min falling asleep the Ball Blanket has stopped. In accordance with other studies (31–33, 35), The weakness in this study is the relatively small study we found poor correspondence between parental group and the short length of time in which the Ball recordings of sleep problems and the objective mea- Blanket was used. It is conceivable that a longer period surements (actigraphy). We found disagreement both using the Ball Blanket would give more signifi cant with and without the use of Ball Blankets. Corkum et al. results, especially with regard to improving ADHD symp-(43) claims that the lack of correspondence between toms. The present study has not included possible differ-objective and subjective measurements of especially sleep ences between subtypes of ADHD. This study has not onset latency, which is the most frequently reported examined whether medication with central stimulating problem area, is related to the children’s problematic medicine has any effect on the results. behaviour around bedtime. In addition, the individually As far as we are aware, this is a unique study that based day-to-day variation in the sleep pattern of demonstrates that the Ball Blanket can be a good alter-children with ADHD found in this study may well native when treating sleep diffi culties in children with contribute towards making the problem appear ADHD and a supplement to medical treatment for its Nord J Psychiatry Downloaded from informahealthcare.com by University of Lund on 05/19/11 greater than it really is. These phenomena may play an core symptoms.
important role in parents’ experiences of their child’s Acknowledgements — The authors has no confl icts of interest
problems falling asleep. Parents may recall “worst case” Financial support: The project is fi nancially supported by Protac. The author has no obligations to Protac regarding this manuscript. Table 4b. Attention-defi cit/hyperactivity disorder (ADHD) rating scale (score (standard deviation))—rated by parents. Declaration of interest: The authors report no confl icts
attentional and learning disorders. Devel Behav Pediat 1998;19:178–86. of interest. The authors alone are responsible for the con- 21. Mercier L, Pivik RT, Busby K. Sleep pattern in reading disabled 22. Dahl RE. The impact of inadequate sleep on children’s daytime cognitive function. Pediat Neurol 1996;3:44–50. 23. Kaplan BJ, McNicol J, Conte RA, Moghadam HK. Sleep References
disturbance in preschool-aged hyperactive and non hyperactive 1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4rd edition (DSM-IV). Washington, 24. Trommer B, Hoeppner JB, Rosenberg RS, Armstrong KJ, Rothstein DC: American Psychiatric Association; 1994. JA. Sleep disturbance in children with attention defi cit disorder. 2. Biederman J, Faraone S, Milberger S, Guite J, Mick E, Chen L, et al. A prospective 4-years follow-up study of attention-defi cit 25. Dall RE, Puig-Antich J. Sleep disturbances in child and adolescent hyperactivity and related disorders. Arch Gen Psych 1996;53: psychiatric disorders. Paediatrics 1990;17:32–7. 26. Owens J A, Maxim R, Nobile C, McGuinn M, Msall M. Parental 3. Barkley RA, Attention-defi cit hyperactive disorder, a and self-report of sleep in children with attention defi cit hyperactive clinical workbook. New York: Guilford Publications Inc., disorder. Arch Pediatr Adolesc Med 2000;154:549–55. 27. Ball J D, Tiernan M, Janusz J, Furr A. Sleep patterns among 4. Corkum P, Moldofsky H, Hogg-Johnson S, Humphries T, children with attention defi cit hyperactive disorder. A re-examination Tannock R. Sleep problems in children with attention-defi cit/ of parent perception. J Paediat Psychol 1997;22:389–98. hyperactive disorder: Impact of subtype, comorbidity, and 28. Greenhill L, Puig-Antic J, Goetz R, Hanlon C, Davies M. Sleep stimulant medication. J Am Acad Child Adolesc Psychiatry architecture and REM sleep measures in prepubertal children with attention defi cit disorder with hyperactivity. Sleep 1983;6:91–101. 5. American Psychiatric Association. Diagnostic and statistical 29. Corkum P, Moldofsky H, Hogg-Johnson S, Humphries T, Tannock R. manual of mental disorders, 3rd edition, revised (DSM-III-R). Sleep problems in children with attention-defi cit/hyperactive disorder: Washington DC: American Psychiatric Association; 1987. Impact of subtype, comorbidity, and stimulant medication. J Am 6. Goyette CH, Conners CK, Ulrich RF. Normative data on revised Acad Child Adolesc Psychiatry 1999;38:1285–93. Conners Parent and Teacher Rating Scales. J Abnorm Child 30. Mick E, Biederman J, Jetton J, Faraone S V. Sleep disturbance associated with attention defi cit hyperactive disorder: The impact of 7. Barkley RA. Behavioral inhibition, sustained attention, and psychiatric comorbidity and pharmacotherapy. J Child and Adol executive functions: Constructing a unifying theory of ADHD. 31. Konofal E, Lecendreux M, Bouvard M P, Mouren-Simeoni M-C. 8. Hvolby A, Bilenberg N, Jørgensen JI. Søvnrytmeforstyrrelse kan High levels of nocturnal activity in children with attention defi cit ligne symptomer på opmærksomhedsforstyrrelse. Ugeskr Læger hyperactive disorder. A video analysis. Psychiatry Clin Neurosci 9. Chervin RD, Dillon JE, Bassetti C, Ganoczy DA, Pituch KJ. 32. Lecendreux M, Konofal E, Bouvard M P, Mouren-Simeoni M-C, Symptoms of sleep disorders, inattention, and hyperactivity in Falissard B. Sleep and alertness in children with ADHD. J Child 10. Chervin RD, Archbold KH. Hyperactivity and polysomnographic 33. Palm L, Persson E, Bjerre I, Elmquist D, Blennow G. Sleep and fi ndings in children evaluated for sleep-disordered breathing. Sleep wakefulness in preadolescent children with defi cits in attention, motor control and perception. Acta Pædiatr 1992;81:618–24. 11. Chervin RD, Archbold KH, Dillon JE, Panahi P, Pituch KJ, 34. Busby K, Firestone P, Pivik R T. Sleep patterns in hyperkinetic and Dahl RE, Guilleminault C. Inattention, hyperactivity, and symptoms of sleep-disordered breathing. Pediatrics 2002;109: 35. Hvolby A, Jørgensen J, Bilenberg N. Actigraphic and parental reports of sleep diffi culties in children with attention-defi cit/ 12. Divgi V. What about sleep? Arch Pediatr Adolesc Med hyperactivity disorder. Arch Pediatr Adolesc Med 2008;162:323–9. 36. Ayres, A. Jean. Sensory integration and the child. Los Angeles, 13. Picchietti DL, England SJ, Walters AS, Willis K, Verrico T. Periodic CA: Western Psychological Services; 1982. limp movement disorder and restless legs syndrome in children 37. DuPaul GJ, Power TJ, Anastopoulos A, Reid R. ADHD rating with attention-defi cit hyperactive disorder. J Child Neurol scale—IV. New York: The Guilford Press; 1998. 38. Sadeh A, Alster J, Urbach D, Lavie P. Actigraphically based 14. Picchietti DL, Underwood DJ, Farris WA, Walters AS, automatic bedtime sleep–wake scoring: Validity and clinical Shah MM, Dahl RE, et al. Further studies on periodic limp applications. J Ambulat Monitor 1989;2:209–216. Nord J Psychiatry Downloaded from informahealthcare.com by University of Lund on 05/19/11 movement disorder and restless legs syndrome in children with 39. Sadeh A, Lavie P, Scher A, Tirosh E, Epstein R. Actigraphic home- attention-defi cit hyperactive disorder. Movement Dis 1999;14: monitoring sleep-disturbed and control infants and young children: A new methods for pediatric assessment of sleep–wake patterns. 15. Walters AS, Mandelbaum DE, Lewin DS, Kugler S, England SJ, Miller M. Dopaminergic therapy in children with restless legs/ 40. Acebo C, Sadeh A, Seifer R et al. Estimating sleep patterns with periodic limb movements in sleep and ADHD. Pediatr Neurol 2000; monitoring in children and adolescent: How many nights are necessary for reliable measures? Sleep 1998;22:95–103. 16. Gruber R, Sadeh A, Raviv A. Instability of sleep patterns in children 41. Action4 version 1.05, Ambulatory Monitoring, Inc. with attention defi cit hyperactive disorder. J Am Acad Child adolesc 42. Hvolby A, Jørgensen J, Bilenberg N. Søvn og søvnproblemer hos danske børn i alderen 6–11 år. Ugeskr Læger 2008;170:448–51. 17. Aronen E T, Paavonen E J, Fjällberg M, Soininen M, Törrönen J. 43. Corkum P, Tannock R, Moldofsky H. Sleep disturbance in children Sleep and psychiatric symptoms in school-age children. J Am Acad with attention defi cit hyperactive disorder. J Am Acad Child Child adolesc Psychiatry 2000;39:502–508. 18. Taras H, Potts-Datema W. Sleep and student Performance. School Allan Hvolby, M.D., Ph.D., Department of Child and Adolescent 19. Sadeh A, Gruber R, Raviv A. Sleep, neurobehavioural functioning Psychiatry, Region of Southern Denmark, Gl. Vardevej 101, 6715 and behavioral problems in school-aged children. Child Devel Niels Bilenberg, M.D., Ph.D., Professor, Department of Child and 20. Marcotte AC, Thatcher PV, Butters M, Bortz J, Acebo C, Adolescent Psychiatry, Region of Southern Denmark, University Carscadon MA. Parental report of sleep problems in children with Hospital of Odense, Sdr. Boulevard 29, 5000 Odense, Denmark.

Source: http://portal.arb.lu.se/atprog/201102/atpa52/hvolby_ball_blanket_2010.pdf