Osman S. Ipsiroglu, · Gerhard Klösch, · Mark Stein, · Sarah Blunden, ·Serge Brand, · Stefan Clemens, · Samuele Cortese, · Alexander Dück, ·Thomas Dye, · Paul Gringras, · Hans-Jürgen Kühle, · Kate Lawrence, ·Michel Lecendreux, · Silvia Miano, · Julian Mollin, · Lino Nobili, · Judy Owens, ·Parveer Kaur Pandher, · Dena Sadeghi-Bahmani, · Angelika Anita Schlarb, ·Barbara Schneider, · Rosalia Silvestri, · Susan Smith, · Karen Spruyt, ·Margaret Danielle Weiss 

Abstract: Attention deficit hyperactivity disorder (ADHD) is a widespread neurodevelopmental disorder. Currently, the diagnosis and treatment of ADHD in children and adolescents is primarily centred on daytime functioning and the associated impairment of academic performance, although disrupted and restless sleep have been frequently reported in individuals with ADHD. Further, it has been recognised that sleep disorders not only intensify existing ADHD symptoms but in some cases can also mimic ADHD symptoms in the paediatric population with primary sleep disorders. Under the title ‘The blind spot: sleep as a child’s right issue?’, professionals from diverse disciplines, including medicine and social sciences as well as individuals with an interest in ADHD and sleep medicine, including laypeople, have initiated a unifying discourse. The objective of this discourse is to improve our understanding of the diagnosis and treatment of ADHD and disruptive behaviours and to develop personalised and precision medicine.
Research has shown that the existing, primarily descriptive and categorical diagnostic systems do not capture the heterogeneous nature of youth with attentional and behavioural difficulties and the phenotypic expressions thereof, including nighttime behaviours and sleep. New strategies for clinical phenotyping and the exploration of patient-reported behaviours are necessary to expand our understanding and develop personalised treatment approaches. In this position paper, we outline gaps in the clinical care of ADHD and related sleep disturbances, review strategies for closing these gaps to meet the needs of individuals with ADHD, and suggest a roadmap for escaping the one-size-fits-all approach that has characterised ADHD treatment algorithms to date.
Keywords: Behavioural medicine · Restless legs syndrome · Periodic limb movements in sleep · Vigilance ·Sleep disordered breathing

Osman S Ipsiroglu, Serge Brand, Barbara Schneider, Gerhard Klösch

Abstract: Die Forderung, dass der Schlaf bei der Behandlung des ADHS unbedingt mehr berücksichtigt werden muss, kann jedoch nicht darüber hinwegtäuschen, dass generell das Thema Schlaf und Schlafstörungen in der Kindermedizin zu wenig Beachtung findet. Das liegt zum einem an der geringen Dichte von Kinderschlafmedizinern in Deutschland und Österreich, hat aber andererseits auch mit einem Mangel an schlafmedizinischem Grundwissen zu tun, nicht zuletzt als Folge des Fehlens schlafrelevanter Themen im Regelstudium Humanmedizin. Diese multifaktorielle Gemengelage über Schlaf als ein blinder Fleck in der medizinischen Versorgung von Kindern und Jugendlichen führt zu einer in vielen Bereichen nicht mehr zeigemäßen medizinischen Grundversorgung. 

Um hier Lösungen zu finden, wurde unter Beteiligung der involvierten Fachgesellschaften ein Diskussionsprozess gestartet. Vorrangiges Ziel dabei ist die Schaffung einer gemeinsamen Sprache, um begriffliche und konzeptionelle Missverständnisse zu vermeiden, sowie eine Phänotypisierung der unterschiedlichen ADHS-Subtypen durchzuführen, wodurch eine ‚Personalisierung‘ in der Behandlung und Betreuung von PatientInnen möglich wird. Doch über die Diskussion zur Aktualisierung der ADHS-Leitlinie hinaus bedarf es einer Reihe zusätzlicher Maßnahmen, die in diesem Beitrag an Hand von 7 Thesen abgehandelt werden.

Gerhard Klösch, Josef Zeitlhofer, Osman Ipsiroglu

Abstract: Vigilance deficits can be observed after a period of prolonged, continuous wakefulness. In this context there has been extensive research targeting the impact of sleep deficits on different aspects of vigilance, but the underlying concept of vigilance was hardly ever addressed and discussed.

One reason for this shortcoming is the unclear and ambiguous definition of the term vigilance, which is commonly used interchangeably with sustained attention and even wakefulness. This confusion is the result of a wide range of misleading definitions, starting in the 1940s, as psychologists redefined the concept of vigilance suggested by British Neurologist, Henry Head, in 1923. Nevertheless, the concept of vigilance is still useful and innovative, especially in treating sleep problems in children and young adults.

This paper reviews the current usage of the term vigilance in sleep-wake-research and describes not only the benefits, but even more clearly, its limitations. By re-focusing on the definitions given by Henry Head, the concept of vigilance is an innovative way to gather new insights into the interplay between sleep- and daytime behaviors. In addition, future research on vigilance should consider three perspectives: 1^st vigilance perceived as a process to allocate resources, 2^nd vigilance associated with compensatory behaviors and 3^rd the role of vigilance in human environmental interactions. This approach, understood as a conceptual framework, provides new perspectives by targeting sleep-wake behaviors as a ‘real life’ outcome measure, reflecting both physical and cognitive performance as well as sleep quality and quantity.

Keywords: vigilance, sleep- wake behaviors, children sleep disorders, daytime sleepiness, alertness

Nadia Beyzaei, Seraph Bao, Yanyun Bu, Linus Hung, Hebah Hussaina, Khaola Safia Maher, Melvin Chan, Heinrich Garn, Gerhard Kloesch, Bernhard Kohn, Boris Kuzeljevic, Scout McWilliams, Karen Spruyt, Emmanuel Tse, Hendrik F. Machiel Van der Loos, Calvin Kuo, Osman S. Ipsiroglu

Background: Behavioral observations support clinical in-depth phenotyping but phenotyping and pattern recognition are affected by training background. As Attention Deficit Hyperactivity Disorder, Restless Legs syndrome/Willis Ekbom disease and medication induced activation syndromes (including increased irritability and/or akathisia), present with hyperactive-behaviors with hyper-arousability and/or hypermotor-restlessness (H-behaviors), we first developed a non-interpretative, neutral pictogram-guided phenotyping language (PG- PL) for describing body-segment movements during sitting. 

Methodology & results: The PG-PL was applied for annotating 12 1-min sitting-videos (inter-observer agreements >85%->97%) and these manual annotations were used as a ground truth to develop an automated algorithm using OpenPose, which locates skeletal landmarks in 2D video. We evaluated the algorithm’s performance against the ground truth by computing the area under the receiver operator curve (>0.79 for the legs, arms, and feet, but 0.65 for the head). While our pixel displacement algorithm performed well for the legs, arms, and feet, it predicted head motion less well, indicating the need for further investigations. Conclusion: This first automated analysis algorithm allows to start the discussion about distinct phenotypical characteristics of H-behaviors during structured behavioral observations and may support differential diagnostic considerations via in-depth phenotyping of sitting behaviors and, in consequence, of better treatment concepts.

Keywords: Movement disorders, sleep-related movement disorders, misdiagnosis, over-medication, adverse drug reactions