Dr. Clara Faria Hello, welcome to the In Conversation podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Clara Faria, an ACAMH Young Person Ambassador, and in today’s episode, I have the pleasure to talk to Dr. Lena Keuppens from Leuven University. Dr. Keuppens is a Psychologist and PhD student whose research focuses on cognitive behaviour and sleep treatment for adolescents with ADHD. Today, we will be discussing her published paper in JCPP Advances, “Sleep Parameters and Problems in Adolescents with and without ADHD A Systematic Review and Meta-analysis,” which was also the winner of the 2024 ACAMH Awards in the category JCPP Advances Past Paper. If you’re a fan of our In Conversation series, please subscribe on your preferred streaming platform, let us know how we did, with a rating or review, and share with friends and colleagues. Welcome, Dr. Keuppens. Thank you so much for being here today. Can you start with an introduction of what you do and how you became interested in ADHD research? Dr. Lena Keuppens Thank you so much for having me, Clara. My love for research really took off during my master’s in psychology, where I had the privilege of working on my thesis about ADHD under the guidance of Saskia Van der Oord. That experience really sparked an interest in understanding ADHD. And then, after completing my master’s, a pursued a postgraduate Teacher training programme and went on to teach psychology courses in secondary schools. So, while teaching was quite fulfilling, it also made me aware of the challenges that neurodivergent adolescents, such as those with ADHD, face in the school system. So, this inspired me to go into research and in intervention strategies. So, when my teaching contract ended, Saskia Van der Oord actually had a PhD position focusing on sleep in adolescents with ADHD. So, I eagerly applied and I’m still very grateful to have been selected. During my PhD, I got to work together with the whole SIESTA team, so that includes Saskia Van der Oord, Finja Marten, Dieter Baeyens, Bianca Boyer and Marina Danckaerts, and we researched sleep in adolescents with ADHD and developed a sleep intervention to adDr.ess these sleep problems. And as you said, in addition to research, I also work as a Psychologist in the ADHD and Autism Team at a academic practice centre of the Faculty of Psychology and Educational Sciences at KU Leuven. So, I actually get to combine three things that I really love research, teaching and clinical work. Dr. Clara Faria That’s fantastic and it’s so interesting to know more about your journey and how you combine both the teaching, the clinical and the research aspects. And I’m really looking forward to our conversation today, especially as we have brilliant opportunity to do a little bit of a deep dive into this topic. In your paper, you looked at sleep parameters and sleep problems in adolescents with and without ADHD. Can you tell us a bit more about the rationale behind the paper and what led you to explore this topic specifically? Dr. Lena Keuppens Yes, thank you, I’m excited to discuss our paper. The rationale behind our paper stemmed from the significant prevalence of sleep problems in adolescents with ADHD, that is shown in previous research. For example, Langberg and colleagues, they found that actually, up to 72% of adolescents with ADHD experience sleep problems and moreover, specifically adolescence is a developmental period marked by significant changes in sleep patterns, behaviours, and also, an increase in sleep problems, which can be even more pronounced in those with ADHD. So, we wanted to provide a comprehensive comparison of objective and subjective sleep parameters, sleep problems and also, sleep hygiene. Dr. Clara Faria I just wanted to ask you, was this your first systematic review and meta-analysis? Because at ACAMH, we just started a new branch dedicated to early career Researchers, and we know many of them are eager to develop their skills in evidence synthesis, and I just wanted to know more about how was that process for you and if you would recommend any particular resources? Dr. Lena Keuppens What a lovely initiative. Yes, and this was actually my first systematic review and meta-analysis. The same goes for Finja Marten, the other First Author, and I think I can speak for the both of us when I say that we definitely learnt a lot doing this. We read a lot of papers on systematic review and meta-analysis, such as about the difference between fixed versus random-effects models and the different available tools to do the actual analyses. So, we ended up using RevMan from Cochrane, which is a really handy tool, and Cochrane also offers a handbook, and you can find YouTube videos on the different steps, and so, I can really recommend that. But we also considered other options, such as an R package written by [inaudible – 05: 07]. They also provide a step-by-step manual, but in the end, we went with RevMan. And I think for writing the paper, the PRISMA checklist gave a really nice overview of all the information that should be reported. I hope this helps a bit. Dr. Clara Faria: It certainly helps. Well, doing a deep dive now into the paper itself. In your paper, you look at several sleep parameters, both in adolescents with and without ADHD. It is a fantastic and very robust piece of work. What would you say were the main findings? Dr. Lena Keuppens: Thank you so much, Clara. Yeah, so the goal of the paper was to compare objective and subjective sleep parameters, sleep problems and sleep hygiene in adolescents with and without ADHD. And we ended up with 13 eligible studies, so in total, we had 2,465 adolescents with ADHD and 18,417 controls. And our findings showed that adolescents with ADHD report significantly more disturbed sleep parameters, subjectively measured, compared to their typically developing peers, such as total sleep time, sleep onset latency and sleep efficiency. And we also found that adolescents with ADHD report significantly more sleep problems, such as daytime sleepiness, more sleep disturbances in general and also, insomnia, at least when doing the analysis without a study with a poor score on the Newcastle-Ottawa Scale. And interestingly, the few studies, three actually, that used objective measures, did not find significant differences between the groups. And then, lastly, sleep hygiene. Well, unfortunately, there weren’t enough studies reporting a link between sleep hygiene and sleep comparing adolescents with and without ADHD, so we can’t say anything about that. Dr. Clara Faria: That’s a very comprehensive summary. Thank you, and listening to you talk about the results, I think the one that got me thinking the most was the fact on the papers that reported on objective sleep measures in ADHD, you didn’t have find a difference between adolescents with ADHD and adolescents without ADHD. And I was just wondering, did any particular result of the systematic review surprised you, and if that finding I just mentioned also surprised you and you want to discuss more about it, feel completely free to do so. Dr. Lena Keuppens: Yeah, in a way, I was surprised that we didn’t find differences on the objective outcomes. However, this is partially in line with findings of meta-analysis of sleep in chilDr.en and adults, so maybe it isn’t that surprising. And something else I do find surprising is that there is so little research on sleep hygiene in adolescents with ADHD because this is a factor that contributes to sleep problems and is actually quite modifiable, so can be used in interventions to improve sleep. So, that I think that is the most surprising of these findings. Dr. Clara Faria: In your paper, one thing I also thought was really interesting was that most included studies, as we’ve said, only looked at subjective sleep variables. Do you think that this might have an impact on the results and on the development of future interventions for sleep in youth with ADHD? Dr. Lena Keuppens: I think that it shows that we need to take the subjective experience of sleep problems seriously. After all, sleep problems are inherently subjective. This is also the case when clinically diagnosing insomnia, for example, basing on the International Classification of Sleep Disorders that I see as the tree, that is also purely based on subjective experiences. And also, intervention research, for example, that of Harvey and colleagues, has shown that objective sleep measures, or sleep parameters, might not accurately represent treatment changes, because the subjective perception still might be different. To give an example, falling asleep faster, in under two hours, might already be fast and an improvement for some individuals, while for others, lying awake for 20 minutes is already way too long. Dr. Clara Faria: Oh, that’s really interesting and yeah, I hadn’t thought about that, actually. The example you gave really helped me to clear, like, how subjective parameters not always reflect clinical severity or clinical practice. And well, still on subjective sleep parameters, well, reading your paper, as you’ve said, it was clear that one of the main takeaways was that subjectively parameters are worse in adolescents with ADHD compared to their typically developing peers. And considering the importance of sleep for mood regulation and for neurodevelopment, what would you say would be the next steps regarding interventions? And I know you published a pilot study on this topic recently and yeah, it would be great to have your view on it. Dr. Lena Keuppens: I think that the first step starts before intervention and should be to routinely include sleep assessments in the ADHD diagnostic process, or even GPs, General Practitioners, could ask about it, because sleep problems are often overlooked and Clinicians often only ask about it broadly, like, “How is your sleep?” And I think we should be asking more specific questions about sleep patterns, about bedtime routines and also, these sleep hygiene practices. So, then in the next step, regarding the development of sleep interventions, we would have to look at other research as well, because based on our meta-analysis, I can’t really say anything about it. So, when we look at the work, for example, of Martin and colleagues, or Bourchtein and colleagues, or Cusick and colleagues, they show that adolescents with ADHD show more inadequate sleep hygiene practices than their typically developing peers and that these inadequate sleep hygiene practices actually lead to sleep problems. So, that is, for example, why we included sleep hygiene as a main focus in the sleep intervention we developed for adolescents with ADHD, which we called SIESTA, which is the acronym for Sleep IntervEntion as Symptom Treatment for ADHD. And SIESTA is a CBT-I, so a cognitive behavioural therapy for insomnia intervention, specifically adapted to the needs of adolescents with ADHD, and it has seven individual sessions with the adolescent and two caregiver session. And in this pilot, we did ten adolescents with ADHD and self-reported sleep problems, and also their caregivers, they tried out SIESTA, and then afterwards, we did focus groups with adolescents and caregivers separately. When we look at those findings, adolescents and caregivers reported a high amount of ownership afterwards. They felt more confidence to change their sleep problems. So, upfront, adolescents were like, “I’m just a bad sleeper and there’s nothing I can do about it,” and so, it’s really nice to give them a bit of the power back and tell them that they can change it, and they also liked received action-oriented advice to improve their sleep. What they also really appreciated was that SIESTA is individually adaptive, so I think that’s an important thing to keep in mind when developing an intervention. For example, all the behaviour changes in SIESTA, they are offered in the form of experiments and adolescents can choose what they want to do, and after a week, the adolescents and Clinician evaluate whether this strategy works for the adolescent or not. We also asked about feedback to further improve SIESTA and some examples that show what should be taken into account when developing sleep interventions for adolescents with ADHD are offering structure in the sessions and also in the workbook, which is something we improved further, concrete examples to help adolescents formulate their goal. And we actually got the same feedback from caregivers, who also found it difficult to come up with positive communication phrases about sleep, for example. So, these things are all important to include, I think. Dr. Clara Faria: Yes, that sounds fascinating and nice that you explained the acronym. If I may add, you are also a Clinical Psychologist and in the beginning of our conversation, you mentioned those three spheres of teaching, research and clinical work. And I know you work with adolescents with ADHD, and I was just wondering if this is also something you see in your clinical practice? ‘Cause we know that sleep problems are very prevalent among adolescents with ADHD, ‘cause I think of – I think you have a really big strength that you combine both the clinical and the research aspect, ‘cause oftentimes, a common critique sometimes research receives is that the intervention we’re trying to develop is disconnected from the clinical reality. But in your case and in the case of SIESTA, all, like, the work you’ve done, it seems to be very embedded within the clinical context. Dr. Lena Keuppens: Yeah, I think I also saw it already when I was still teaching, that some of the adolescents in my classroom were lying on their tables, falling asleep. So, I think I already saw it there, as well, but of course, in the clinic here, we see it, too. Sleep problems are very prevalent, really something we are asking about now, because we did the research and we’re recommending all our colleagues to do so the same. I think it’s important to ask about it and I also had the privilege of giving the intervention as well, not to the treatment group of our study, but, like, to our control group. So, that was not part of the study, so I was not biased or anything. It was really fun, because after this pilot, of course, we did a large randomised controlled trial to test effectiveness of the intervention and that adds the context that I’m now talking about. So, it was a large study, with 92 participants, and then they were randomised into either receiving SIESTA next to their treatment as usual for ADHD, or randomised into the other group, which just continued with their treatment as usual. And then, we did a process measure and then, also a follow-up measure, and then, after that part, the group who didn’t receive the training was still offered it, although outside of the study, but still to offer everybody the same choice if they wanted to participate or not. Dr. Clara Faria: Well, really nice to see how the – all those aspects were integrating, and I am looking forward to reading the results of randomised clinical trial when they’re published. Thank you so much, Dr.. Keuppens, for sharing your research with us, and for more details on Dr.. Keuppens’ work, you can visit the ACAMH website, which is www.acamh.org, and you can also check our Twitter @ACAMH. ACAMH is spelt A-C-A-M-H, and do keep an eye out for other podcasts in the In Conversation series, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rating or a review, and do share with your friends and colleagues. Thank you so much for the listen.