The Acceptability and Impact of Sleep Extension on Executive Functioning in Youth with Attention-Deficit/Hyperactivity Disorder: A Pilot Randomized Control Study

Abstract

Background and Objective: Adolescents with attention-deficit/hyperactivity disorder (ADHD) frequently experience impairments in executive functioning (EF), including difficulties with working memory, inhibitory control, and cognitive flexibility. Sleep problems are also highly prevalent in this population and may further exacerbate EF-related challenges. Emerging research suggests that improving sleep, particularly through increasing total sleep time (TST), may support better EF outcomes. However, few studies have directly tested sleep extension as an intervention for EF deficits in adolescents with ADHD. The present pilot study examined the acceptability and preliminary efficacy of a brief behavioral sleep extension intervention for adolescents with ADHD and comorbid sleep difficulties, with a focus on improving sleep outcomes and EF skills.Methods: Thirteen adolescents aged 11 to 17 years (M = 13.62, SD = 1.80) with a diagnosis of ADHD and comorbid sleep difficulties participated in a pilot randomized controlled trial. Participants were randomized into either a behavioral sleep extension intervention group (n = 9) or a routines-based control group (n = 4) following a two-week baseline period. The intervention included a brief, collaborative consultation focused on increasing total time in bed and improving sleep habits over a two-week period, supported by two follow-up phone calls. Sleep was measured using actigraphy, daily sleep diaries, and both self- and parent-report questionnaires (CRSP, CSHQ). EF was assessed pre- and post-intervention using the BRIEF (self- and parent-report) and performance-based tasks targeting working memory, inhibitory control, and cognitive flexibility (WJ-IV subtests, Digit Span Backward, Stop Signal Task, and Trail Making Test). Acceptability was assessed through post-intervention surveys with participants and caregivers. Results: The intervention group demonstrated longer TST, longer TIB, and reduced variability in sleep duration, relative to the control group, as measured by actigraphy. Although these changes were not statistically significant, medium to large effect sizes were observed for increased TST (Hedges’ g = 0.92), increased TIB (g = 0.82) and reduced coefficient of variability in sleep duration (g = -1.11). Improvements in executive functioning were also noted in the intervention group across multiple measures, with small to medium effect sizes favoring the intervention on self-reported working memory (g = -0.31) and global executive functioning (g = -0.38), and on performance-based inhibitory control (g = 0.61). Acceptability ratings were high among both adolescents and caregivers, who reported that the intervention was easy to follow and helped improve sleep. Conclusions: This pilot study provides preliminary evidence that a brief, individualized behavioral sleep extension intervention is both acceptable and potentially effective for adolescents with ADHD. While the small sample size limited statistical power, consistent medium-to-large effect sizes across objective sleep outcomes suggest the intervention may improve sleep duration, consistency, and select areas of executive functioning. Adolescents and caregivers reported high acceptability and engagement, and performance-based tasks indicated modest improvements in working memory and inhibitory control. These findings highlight the feasibility of delivering personalized, at-home sleep interventions for adolescents with ADHD and underscore the importance of further research with larger samples and longer follow-up to evaluate sustained effects and real-world implementation.