探討睡眠延長介入對注意力不足過動症學齡兒童的神經認知功能之影響

研究背景與目的：美國國家睡眠基金會（National Sleep Foundation, NSF）對於學齡期兒童（6-13歲）每日建議睡眠量為9-11小時，睡眠量不足會影響兒童的日間功能，像是注意力不集中、過動、衝動或學業表現降低等情形（Fallon, Acebo, Arnedt, Seifer, Carskadon, 2001）。Owens（2015）指出依據注意力不足過動症（Attention Deficit Hyperactivity Disorder, ADHD）學齡兒童家長報告約70%兒童具有睡眠問題，於起始與維持睡眠方面具有較多困擾，導致睡眠量不足。因此本研究欲探討針對ADHD學齡兒童進行睡眠延長介入，是否能改善睡眠情形、日間注意力及神經認知功能表現。研究方法：本研究共納入26位ADHD學齡兒童，介入組14位，控制組12位。介入組共進行七週，第一週為基線期，紀錄睡眠型態並進行前測，第二、三週為介入期，提供家長睡眠衛教資訊及行為介入策略，協助增加兒童的夜間睡眠量，於第三週紀錄睡眠模式並進行後測，結束後一個月再進行追蹤評估。控制組共進行三週，期間不進行介入。研究工具方面使用睡眠活動腕錶（Actigraphy）與睡眠日誌（sleep log）評估睡眠型態；使用家長自陳式兒童睡眠習慣問卷評估睡眠問題；使用兒童行為檢核表、克氏注意力持續度表現測驗第三版、聽覺序列加法測驗、記憶廣度測驗、劍橋神經認知測驗組合的空間工作記憶測驗與威斯康辛卡片分類測驗探討神經認知功能表現。研究結果：介入組經睡眠延長介入後能顯著增加睡眠量（約18分鐘）與躺床時間（約29分鐘），而控制組則沒有差異。睡眠問題方面，兒童睡眠習慣問卷的入睡延遲向度具有交互作用（F = 5.98, p = .022），分析單純主要效果顯示基線期時介入組的入睡延遲問題較多。神經認知功能測驗方面，注意力持續度表現測驗的替代性錯誤率（F = 8.67, p = .005）、記憶廣度測驗總分（F = 5.31, p = .019）及逆序背誦（F = 5.82, p = .014）與威斯康辛卡片分類測驗的非固著性錯誤指標（F = 12.31, p = .001）呈現介入效果。討論：經睡眠延長介入後使ADHD學齡兒童擁有更充足的睡眠，而睡眠量的增加有利於個體具有較多認知資源及心理警覺性以提升認知作業表現（Dewald-Kaufmann et al., 2013）。研究也發現部分神經認知功能表現於追蹤期使能呈現改善效果，建議後續研究可延長介入與追蹤時程，探討睡眠改善之長期介入效果。本研究突顯ADHD學齡兒童除了日間行為問題之外，夜間睡眠困擾同樣為值得重視的議題。

關鍵字

注意力不足過動症；學齡期；睡眠延長介入；神經認知功能

並列摘要

Background and purpose: The National Sleep Foundation (NSF) recommends 9-11 hours of sleep per day for school-age children (6-13 years old), and insufficient sleep can affect children's daytime functioning, such as inattention, hyperactivity, impulsivity, or reduced academic performance (Fallon, Acebo, Arnedt, Seifer, Carskadon, 2001). Owens (2015) revealed that parents of school-aged children with Attention Deficit Hyperactivity Disorder (ADHD) report that approximately 70% of children have sleep problems and more problems with disorders of initiating and maintaining sleep which results not only sleep disturbances but also insufficient sleep. Therefore, this study was aim to investigate whether sleep extension intervention for school-aged children with ADHD could improve sleep and neurocognitive functions. Methods: A sample of 26 school-aged children with ADHD participated in the study: 14 in intervention group and 12 in control group. Both groups were assessed with sleep patterns, behavior questionnaires and neurocognitive tests as baseline in first week. From the second week onwards , parents of intervention group were provided with sleep hygiene and behavioral intervention strategies to increase their child's nocturnal sleep, and the control group didn’t received any intervention until the end of third weeks. Participants (and parents as appropriate) completed the Child Sleep Habit Questionnaire (CSHQ), Child Behavior Checklist (CBCL), sleep log, neurocognitive assessment [Continuous Performance Test 3rd Ed. (CPT-3), Paced Auditory Serial Addition Task (PASAT), Digit Span test, Spatial Working Memory (SWM) of the Cambridge Neurocognitive Test Automated Battery, and the Wisconsin Card Sorting Test (WCST)] and wore actigraphy before and after the intervention and follw-up. Results: The intervention group significantly increased the total sleep time (about 18 minutes) and time in bed (about 29 minutes) compared to baseline, while there was no difference in the control group. For sleep disturbances, there was interaction of groups and intervention in sleep-onset delay subscale of the CSHQ (F = 5.98, p = .022), and the simple main effect analysis showed that the intervention group had more sleep-onset delay problems at baseline. Moreover, the intervention effects were evident on the commission errors of the CPT-3 (F = 8.67, p = .005); the total score (F = 5.31, p = .019) and the backward score (F = 5.82, p = .014) of the Digit Span Test; and the Nonperseverative errors of the Wisconsin Card Sorting Test (F = 12.31, p = .001). Discussion: This trial found that the sleep extension has beneficial effects on school-aged children with ADHD. Sufficient sleep was associated with greater cognitive resources and alertness to improve cognitive performance (Dewald-Kaufmann et al., 2013). The study also found that some of the neurocognitive function indices showed signifant improvement during the follow-up period, suggesting that future studies could extend the intervention and follow-up to explore the long-term sleep extension effect on neurocognitive functions and behavioral performance. This study highlights that not only daytime dysfunction but also nocturnal sleep disturbance is worthy to evaluate and intervention for school-age children with ADHD.