Are kids with ADHD more likely to have unhealthy habits?

Healthy lifestyle choices can benefit any child, but they may have increased effects when it comes to battling the symptoms of attention-deficit/hyperactivity disorder (ADHD), according to a new report.

The new study, published in the Journal of Attention Disorders, sought to examine the effects of various lifestyle behaviors on children with ADHD compared with their peers.

The research team found that children with ADHD have significantly more unhealthy behaviors, such as poor water consumption and sleep and excessive screen time, than their peers.

Kathleen Holton, PhD, MPH, lead study author and assistant professor in the department of health sciences at the Center for Behavioral Neuroscience at American University in Washington, DC, says she believes the study’s findings are valuable to clinical practice.

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“Healthy behavior change could be an important topic of conversation between pediatricians and parents during appointments,” says Holton. “My hope is that pediatricians will inquire about these healthy lifestyle behaviors and encourage parents to implement changes over time. Most pediatricians are already discussing some lifestyle behaviors (such as reducing screen time) with parents; however, greater benefit may be realized from looking at all these lifestyle behaviors together.”

Attention-deficit/hyperactivity disorder is increasingly linked to poor health outcomes, and researchers believe ADHD may be exacerbated by unhealthy behaviors that contribute to those poor health outcomes.

The study examined children aged 7 to 11 years with well-characterized ADHD. The children were recruited from the community through advertisements and mass mailings, and potential participants were screened with lifestyle questionnaires targeting healthy lifestyle behaviors such as water versus sweetened beverage consumption, multivitamin use, screen time, physical activity, and sleep.

Researchers then identified the association between ADHD status and total healthy lifestyle behaviors based on multivariable ordered logistic regression.

The research team found a “robust association” of ADHD with a less healthy lifestyle than children in the control group: Children with ADHD were almost twice as likely to have fewer healthy lifestyle behaviors, even after adjustment for age, sex, intelligence quotient, ADHD medication use, household income, and comorbid psychiatric disorders.

“These results underscore the importance of considering unhealthy lifestyle behaviors as a feature of ADHD that may be an important target for preventive or secondary intervention,” according to the report.”

In terms of physical health, children in the ADHD study group consumed less water, more sweetened beverages, and exercised less than their peers.

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Water consumption, which researchers say is an important and often overlooked aspect of childhood health, was low across all study groups, but children in the ADHD study group were less likely to consume the recommended 3 cups per day compared with the control group (28% vs 38%, respectively). Children with ADHD also were more likely to consume artificially sweetened drinks that researchers say could contribute to ADHD symptoms. More research is warranted to determine the effects of artificial sweeteners on ADHD, according to the study authors.

Parents of children with ADHD were more likely, however, to provide their children with multivitamin or fish oil supplements, the study notes.

Children with ADHD also had more trouble falling asleep, with 45% of parents reporting sleep problems compared with 9% in the control group.

The observations of poor sleep were made in the ADHD group even when stimulant medication use was mostly ruled out as a cause. Poor sleep in all age groups has been associated with psychological and cognitive impairments, but this critical element could have greater effects in children with ADHD.

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Lifestyle choices, such as limited screen time and caffeine intake before bed, and promoting daytime physical activity all are important for promoting sleep hygiene, according to the study findings .

“Benefits of improved sleep hygiene were noted in a recent study where pediatricians taught parents (through handouts) about sleep hygiene issues like using a set bedtime, maintaining bedtime routines, removal of all media from the bedroom, and avoiding caffeine consumption,” the researchers note. “Results from this study showed improvements in ADHD symptoms, sleep, and health-related quality of life. The current recommendation for children aged 6 to 13 years is to aim for 9 to 11 hours of sleep per night.”

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Children in the ADHD group spent considerably more time using media than their counterparts, according to the report, with 48% of children in the ADHD group and 35% of children in the control group spending more than 2 hours on average per school day using some form of media.

“The rapidly growing use of screens by children of all ages, from [television] and gaming in older children to use of iPads by infants [aged younger than 1 year], is of increasing concern,” the authors write. A recent meta-analysis confirms a small but reliable association of screen time with increased symptoms of ADHD, which appears, based on a small number of experimental and prospective studies, to have a causal component. Furthermore, a child having a television in his or her bedroom has been associated with increased overall screen time by approximately 32%, and the presence of a television in the bedroom has been associated with increased sleep problems as well.

The American Academy of Pediatrics currently recommends just 1 to 2 hours of screen time per day and removal of televisions from bedrooms.

There is a correlation between screen time and physical activity as well. Citing data from the National Survey of Children’s Health, the researchers note that children and adolescents aged 5 to 17 years with ADHD were 32% more likely to watch television for an hour or more each day and 20% more likely to participate in sports than their non-ADHD peers.

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Physical activity is noted to improve attention and mood-both important factors contributing to ADHD, according to the study findings. Exercise is also important in the development of executive function, which researchers say is a key driver in the inattention and disorganization that is hallmark to ADHD.

Reading, although not often used as a marker of healthy behavior, was included in the study based on the theory that it might reduce screen time and improve academic success and health literacy. Researchers found that the children with ADHD-a group that often struggles with reading and spelling-were less likely than the control group to spend an hour or more each day reading. The research team suggests that reading on a daily basis, particularly at bedtime in lieu of screen activities, may be beneficial for learning and sleep hygiene rituals in children with ADHD.

Researchers also note that the lifestyle factors examined in the study influence one another. For example, increased exercise and increased thirst may lead to more water consumption, which can offset screen time and improve sleep. Reduction in caffeinated beverages also may prevent their diuretic effect and increase water intake, as well as prevent sleep problems.

Clinical recommendations should focus on integrated healthy behaviors although, practically, too many recommendations can also overwhelm parents, according to the report. The research team therefore recommends that step-by-step changes that could lead to a cascade of other improvements be recommended rather than an overall or complete lifestyle change.

“It is possible that ADHD leads to less healthy behaviors, due, perhaps, to impulsivity, inattention, dysphoric mood, family disorganization, or other factors. It is also possible that poor health behaviors contribute to, or exacerbate, ADHD. As it becomes more clear that the association of ADHD with lifestyle behaviors is robust, the importance of evaluating potential benefits of lifestyle intervention on ADHD continues to grow,” the study notes. “At the same time, ample evidence indicates that there is reason to hope that lifestyle changes may help children with ADHD to improve.”