adhd, sleep problems, and executive functioning: what are ...€¦ · responses to assigned tasks...

ADHD, Sleep Problems, and Executive ADHD, Sleep Problems, and Executive

Functioning: What are the links?Functioning: What are the links?

Roger E. Lauer, Ph.D.Roger E. Lauer, Ph.D.

Center for Neuropsychology, Center for Neuropsychology, Learning & DevelopmentLearning & Development

Ann ArborAnn ArborAnn ArborAnn Arbor

734.994.9466734.994.9466

CNLD.ORGCNLD.ORG__________________________________________

In conjunction with: In conjunction with:

Isabelle Isabelle Beaulieu, Ph.DBeaulieu, Ph.D..Oakland Neuropsychology CenterOakland Neuropsychology Center

Bloomfield HillsBloomfield Hills

248.644.9466248.644.9466OAKLANDNEUROPSYCH.COMOAKLANDNEUROPSYCH.COM

CNLD.org

Everything you ever wanted to know

about sleep….

…but were too tired to ask!

Everything you always wanted to know Everything you always wanted to know about ADHD and sleep…..about ADHD and sleep…..

….but forgot to ask!!….but forgot to ask!!

Goals for TalkGoals for Talk

Review the importance of sleepReview the importance of sleep

Discuss the basics of sleepDiscuss the basics of sleep

Talk about evaluation of sleep problemsTalk about evaluation of sleep problems

Examine the connection of ADHD and Examine the connection of ADHD and Examine the connection of ADHD and Examine the connection of ADHD and sleepsleep

Review impact of sleep on ADHD & Review impact of sleep on ADHD & executive functions (EFs)executive functions (EFs)

Address solutions for EF & sleep Address solutions for EF & sleep problemsproblems

Importance of SleepImportance of SleepActivity you devote 1/3 of your time toActivity you devote 1/3 of your time to

Rest & recovery from stresses of life, but Rest & recovery from stresses of life, but actually a actually a dynamic activity dynamic activity during which during which processes processes vitalvital to health & wellto health & well--being take being take place.place.place.place.

Essential to maintain mood, memory & Essential to maintain mood, memory & cognitive performance (executive cognitive performance (executive functions).functions).

Chronic lack of sleep can lead to heart Chronic lack of sleep can lead to heart disease, high blood pressure, stroke, disease, high blood pressure, stroke, weight gain and diabetesweight gain and diabetes

How much sleep do you need?How much sleep do you need?

International Bedroom Poll International Bedroom Poll (NSF, 2013)(NSF, 2013)

22% of Americans struggle with insomnia every night.

Medications can interfere with sleepMedications can interfere with sleep

Medications may wake you at night with Medications may wake you at night with nausea, night sweats or need to use the nausea, night sweats or need to use the bathroom.bathroom.

Stimulants in medications can cause poor Stimulants in medications can cause poor Stimulants in medications can cause poor Stimulants in medications can cause poor quality sleep or lack of sleep (e.g., steroids, quality sleep or lack of sleep (e.g., steroids, antidepressants, meds for migraines, heart antidepressants, meds for migraines, heart disease, hypertension and allergies).disease, hypertension and allergies).

Medications can interfere with sleepMedications can interfere with sleep

Misuse of sleeping pills can impact sleep Misuse of sleeping pills can impact sleep as they are intended for shortas they are intended for short--term use term use (e.g., tolerance, rebound insomnia, (e.g., tolerance, rebound insomnia, daytime sleepiness, strange behaviors daytime sleepiness, strange behaviors daytime sleepiness, strange behaviors daytime sleepiness, strange behaviors while sleepingwhile sleeping-- walking, binge eating, walking, binge eating, driving).driving).

Medications impact length of slow wave Medications impact length of slow wave sleep (SWS) and REM sleep, as well as sleep (SWS) and REM sleep, as well as cause arousals.cause arousals.

Common Sleeping PillsCommon Sleeping Pills

Adults using sleep aidsAdults using sleep aids

Basics of Basics of SleepSleep

•• Necessary for lifeNecessary for life

•• Often overlooked as possible source of Often overlooked as possible source of daytime problemsdaytime problems

•• Set by environmental and biological clocksSet by environmental and biological clocks•• Set by environmental and biological clocksSet by environmental and biological clocks

•• Sleep/Wake Cycle: Homeostasis & Sleep/Wake Cycle: Homeostasis & Circadian RhythmsCircadian Rhythms

SleepSleep--Wake Cycle (8/16):Wake Cycle (8/16):

2 main processes2 main processes

HomeostasisHomeostasis

Body maintains a “Body maintains a “steady statesteady state” including sleep, ” including sleep,

blood pressure, body temperature, etc...blood pressure, body temperature, etc...

When you wake up the drive for sleep starts When you wake up the drive for sleep starts

and peaks in evening.and peaks in evening.

Brain process not fully understood but one Brain process not fully understood but one Brain process not fully understood but one Brain process not fully understood but one

hypothesis is role of neurotransmitter hypothesis is role of neurotransmitter

adenosine.adenosine.

Awake = adenosine ; need for sleep Awake = adenosine ; need for sleep

Asleep = adenosine ; need for sleep Asleep = adenosine ; need for sleep

CaffeineCaffeine-- works by blocking adenosine works by blocking adenosine

receptorsreceptors

Figure Above: An fMRI image - the yellow area shows increased frontal lobe activity after the subjects ingested 100 mg of caffeine (about 2 cups of coffee).

Circadian RhythmsCircadian Rhythms

Cyclical changes like body temperature, Cyclical changes like body temperature, hormone levels and sleep over a 24hormone levels and sleep over a 24--hour hour period.period.

Driven by brain’s biological clock (group of Driven by brain’s biological clock (group of neurons in the hypothalamus called neurons in the hypothalamus called neurons in the hypothalamus called neurons in the hypothalamus called suprachiasmaticsuprachiasmatic nucleus (SCN).nucleus (SCN).

2424--hour rhythms synchronized to hour rhythms synchronized to environment and work/social schedules.environment and work/social schedules.

HumansHumans-- lightlight is strongest synchronizing is strongest synchronizing agent. agent.

Circadian RhythmsCircadian Rhythms

Light & Darkness “set” biological clock & Light & Darkness “set” biological clock & help determine when to wake up or go to help determine when to wake up or go to sleep.sleep.

Homeostatic systemHomeostatic system-- makes us sleepier makes us sleepier as go through day.as go through day.as go through day.as go through day.

Circadian systemCircadian system-- tends to keep us up as tends to keep us up as long as there is daylight.long as there is daylight.

Circadian systemCircadian system-- intolerant of major intolerant of major alterations in sleep/wake schedules (e.g., alterations in sleep/wake schedules (e.g., travel, graveyard shift).travel, graveyard shift).

- Complex System

Sleep rhythmSleep rhythm

Sleep StagesSleep Stages

Sleep ArchitectureSleep Architecture

Predictable pattern of REM and nonPredictable pattern of REM and non--REM REM sleep alternating through the night.sleep alternating through the night.

Complete sleep cycle: every 90Complete sleep cycle: every 90--110 110 minutes repeated 4minutes repeated 4--6 times per night.6 times per night.minutes repeated 4minutes repeated 4--6 times per night.6 times per night.

As night wears on, REM increases and As night wears on, REM increases and slow wave sleep decreases.slow wave sleep decreases.

MorningMorning-- mostly stages 1 & 2, and REM.mostly stages 1 & 2, and REM.

REM increases and slow wave sleep decreases

Functions of Functions of Slow Wave Sleep Slow Wave Sleep (SWS(SWS-- delta waves)delta waves)

•• RestorativeRestorative phase of phase of sleepsleep for for

recuperationrecuperation of of mindmind--body system.body system.

•• GrowthGrowth hormone hormone secretedsecreted for for healinghealing

muscles & muscles & repairingrepairing tissues.tissues.

•• StrengtheningStrengthening of immune systemof immune system

•• PreparesPrepares for for memorymemory consolidationconsolidation

•• Glial Glial cellscells in in brainbrain are are restoredrestored withwith

sugarssugars to to provideprovide energyenergy for the for the brainbrain

Problems associated with SWSProblems associated with SWS

BedwettingBedwetting

Night terrorsNight terrors

SleepSleep--walkingwalkingSleepSleep--walkingwalking

SleepSleep--related eating disorderrelated eating disorder

Functions of REM SleepFunctions of REM Sleep

•• RecallRecall & & learninglearning: formation of new : formation of new

memoriesmemories

•• StimulatesStimulates the central the central nervousnervous system system

& restores & restores brainbrain chemistrychemistry to a normal to a normal & restores & restores brainbrain chemistrychemistry to a normal to a normal

balancebalance

•• PhysiologicalPhysiological support for dreamingsupport for dreaming

Problems associated with REM sleepProblems associated with REM sleep

REM behavior disorderREM behavior disorder-- moving limbs or moving limbs or engaging in activities associated with engaging in activities associated with waking.waking.

Sleep talking, shouting, screaming, hitting Sleep talking, shouting, screaming, hitting Sleep talking, shouting, screaming, hitting Sleep talking, shouting, screaming, hitting or punching.or punching.

Sleep walkingSleep walking

ADHD and Sleep ProblemsADHD and Sleep Problems

Adults and children react Adults and children react

differently to being tireddifferently to being tiredAdults become sluggish Children tend to overcompensate

and speed up

ADHD or Sleep Problems?ADHD or Sleep Problems?

ADHD symptomsADHD symptoms

InattentionInattention

HyperactivityHyperactivity

ImpulsivityImpulsivity

DistractibilityDistractibility

Sleep deprivation symptomsSleep deprivation symptoms

HyperactivityHyperactivity

Inattention and daydreamingInattention and daydreaming

Impulsivity and restlessnessImpulsivity and restlessness

Oppositional and aggressive Oppositional and aggressive DistractibilityDistractibility

Difficulty waiting or taking Difficulty waiting or taking

turnsturns

Oppositional and aggressive Oppositional and aggressive behaviorsbehaviors

Moodiness and irritabilityMoodiness and irritability

Difficulty waking up in the Difficulty waking up in the morningmorning

** Unlike adults, many children who are sleep deprived do not present with complaints of daytime sleepiness.

ADHD and Sleep problemsADHD and Sleep problems

•• Common, Highly Interrelated & Common, Highly Interrelated & HeterogenousHeterogenous

For exampleFor example::

•• Sleep problems may Sleep problems may mimicmimic ADHD symptoms.ADHD symptoms.

•• Sleep problems may Sleep problems may exacerbateexacerbate ADHD ADHD symptoms.symptoms.

•• Sleep problems may Sleep problems may exacerbateexacerbate ADHD ADHD symptoms.symptoms.

•• Sleep problems may be Sleep problems may be associatedassociated with or with or exacerbated by ADHD.exacerbated by ADHD.

•• Medications used to treat ADHD may result in Medications used to treat ADHD may result in sleep problems (varies by duration of sleep problems (varies by duration of treatmenttreatment-- greater frequency when start greater frequency when start meds).meds).

Research FindingsResearch Findings•• ADHD is strongly associated with ADHD is strongly associated with

•• difficulty falling asleep, difficulty falling asleep, •• achieving adequate sleep duration, andachieving adequate sleep duration, and•• tiredness during the day. tiredness during the day.

•• 50% to 80% of adults with ADHD report sleep 50% to 80% of adults with ADHD report sleep •• 50% to 80% of adults with ADHD report sleep 50% to 80% of adults with ADHD report sleep problems.problems.

•• Delayed sleep onset is a common side effect Delayed sleep onset is a common side effect of stimulants.of stimulants.

•• Delayed sleep phase syndrome is another Delayed sleep phase syndrome is another side effect to the point of day/night reversal, side effect to the point of day/night reversal, particularly in teens.particularly in teens.

Research FindingsResearch Findings

•• Reported sleep problems in adults with Reported sleep problems in adults with ADHD include: daytime sleepiness, ADHD include: daytime sleepiness, insomnia, delayed sleep phase syndrome, insomnia, delayed sleep phase syndrome, fractured sleep, restless fractured sleep, restless leg syndrome leg syndrome and and sleep disordered breathing/sleep apnea. sleep disordered breathing/sleep apnea.

•• More vulnerable to adverse sleep effects if More vulnerable to adverse sleep effects if •• More vulnerable to adverse sleep effects if More vulnerable to adverse sleep effects if person has a preperson has a pre--existing sleep disorder existing sleep disorder prior to stimulant treatment or coprior to stimulant treatment or co--morbid morbid anxiety or depression.anxiety or depression.

•• For a subset of adults, stimulant medication For a subset of adults, stimulant medication may actually lead to improved sleep.may actually lead to improved sleep.

Screening for sleep problems in ADHDScreening for sleep problems in ADHD

Disorders that ‘mimic’ ADHD

should first be ruled-out

Screening for Sleep Screening for Sleep ProblemsProblems

•• MedicalMedical historyhistory w/ MDw/ MD

•• SleepSleep--wakewake agendaagenda•• SleepSleep--wakewake agendaagenda

•• WristWrist actigraphyactigraphyRecords movements that can be

used to estimate sleep parameters

using software programs.

Screening for Sleep ProblemsScreening for Sleep Problems

•• Sleep Sleep studystudy

•• SleepSleep DisordersDisorders CentersCenters

•• UMMC (734.936.9068)UMMC (734.936.9068)

•• St. St. Joe’sJoe’s (734.712.2276)(734.712.2276)

•• NeuropsychologicalNeuropsychological

investigationsinvestigations

Sleep Sleep DisordersDisorders

•• InsomniasInsomniasDifficulty Difficulty initiating andinitiating and

maintaining maintaining sleepsleep

•• HypersomniasHypersomniasDisorders of excessive Disorders of excessive somnolencesomnolence

Sleep DisordersSleep Disorders

•• ParasomniasParasomniasEpisodic Episodic behavioral behavioral

manifestations in sleepmanifestations in sleep

•• Disorders of the sleepDisorders of the sleep--wake schedule wake schedule

Examples Examples of of ParasomniasParasomnias

•• Rhythmic behaviors (body rocking, head Rhythmic behaviors (body rocking, head banging)banging)

•• Bruxism (teeth grinding)Bruxism (teeth grinding)

•• Enuresis (bedwetting)Enuresis (bedwetting)•• Enuresis (bedwetting)Enuresis (bedwetting)

•• Night TerrorsNight Terrors

•• Sleep walkingSleep walking

•• Talking Talking while while sleepingsleeping

•• REM Sleep Behavior DisorderREM Sleep Behavior Disorder

Symptoms of Sleep ApneaSymptoms of Sleep Apnea

•• Disordered Disordered sleep, snoringsleep, snoring, agitation, agitation

•• Morning headaches, nausea, and sore throatMorning headaches, nausea, and sore throat

•• Daytime sleepiness (prolonged unrefreshing Daytime sleepiness (prolonged unrefreshing

naps, difficulty staying awake while sitting)naps, difficulty staying awake while sitting)

•• Rapid Rapid changes in changes in personality (irritability, personality (irritability,

mood mood swings)swings)

•• Cognitive Cognitive deficits (alertness, deficits (alertness, processing processing

speed, attention, memory problems and IQ speed, attention, memory problems and IQ

decline)decline)

Brain Brain works while we works while we sleepsleep

REM sleep and memory REM sleep and memory consolidationconsolidation

AllAll--nighters will nighters will negatively impact frontal negatively impact frontal AllAll--nighters will nighters will negatively impact frontal negatively impact frontal lobes lobes (EFs) and (EFs) and memory memory functioningfunctioning

EF EF skillsskills, such as creativity, planning, , such as creativity, planning, problemproblem--solvingsolving

Vulnerable areas: math, sciences, oral Vulnerable areas: math, sciences, oral presentations, debates, etcpresentations, debates, etc..

• Greater impact: creative, divergent and innovative

aspects of thinking.

Effects of sleep loss Effects of sleep loss

on EFson EFs

• Less impact: convergent and rule-based reasoning,

decision making and planning tasks.

• Some aspects of higher level cognitive capacities

remain degraded by sleep deprivation despite

restoration of alertness and vigilance with stimulant

countermeasures.

Brain Activity During SleepBrain Activity During Sleep

Red & Yellow areas: active

Blue areas: less active

Rested vs. Sleep Deprived BrainRested vs. Sleep Deprived Brain

Rested

Well rested brain (top) shows greater activity on fMRI scan during an attention

task than a brain after 24 hours of sleep deprivation.

Sleep deprived

Brain Activity in ADHDBrain Activity in ADHD

Delayed brain maturation in ADHD From Shaw P.From Shaw P.et al.,et al., (2007)(2007)

>2 year delay

0-2 year delay

Ns: ADHD=223; controls = 223

Metaphor for Metaphor for Executive Functions Executive Functions

(EF)(EF)

EFs are the EFs are the brain’s conductorbrain’s conductor, which , which instructs other regions to perform, or be instructs other regions to perform, or be silenced, and generally coordinates their silenced, and generally coordinates their synchronized activity synchronized activity (Goldberg, 2001)(Goldberg, 2001)synchronized activity synchronized activity (Goldberg, 2001)(Goldberg, 2001)

Meta-

Cognition

Working Memory

Initiate

Plan/Organize

Monitor

Organization

of Materials

Definition of EFsDefinition of EFs

Behavioral

Regulation

Initiate

Inhibit

Shift

Emotional Control

Behavioral Definitions for EFsBehavioral Definitions for EFs

InhibitInhibit: Control impulses; stop behavior: Control impulses; stop behavior

ShiftShift: Move freely from one : Move freely from one activity/situation to another; transition; activity/situation to another; transition; activity/situation to another; transition; activity/situation to another; transition; problemproblem--solve flexiblysolve flexibly

Emotional ControlEmotional Control: Modulate emotional : Modulate emotional responses appropriatelyresponses appropriately

Behavioral Definitions for EFsBehavioral Definitions for EFs

InitiateInitiate: Begin activity; generate ideas: Begin activity; generate ideas

Working MemoryWorking Memory: Hold information in mind : Hold information in mind for purpose of completing a taskfor purpose of completing a task

Plan/OrganizePlan/Organize: Anticipate future events; set : Anticipate future events; set goals; develop steps; grasp main ideasgoals; develop steps; grasp main ideas

MonitorMonitor: Check work; assess own : Check work; assess own performanceperformance

Methods of Assessing EFMethods of Assessing EF

MicroMicro MacroMacro

PerformancePerformance

TestsTestsObservationsObservationsStructural &Structural &

Functional Functional

ImagingImaging

GeneticsGenetics

ImagingImaging

3 4

Goal:

Problem:

Count the number of moves

40

45

50

55

60

65

70

Inhib

it

ShiftEm

otiona

l

WM

Plan/O

rgM

ateria

lsM

onitor

EF EF performance testsperformance testsGrouping/sorting testsGrouping/sorting tests: : categorization, concept categorization, concept

formation, classification formation, classification & judgment& judgment

20 questions20 questions: concept formation: concept formation

Tower testsTower tests: : inhibition, planning & problem inhibition, planning & problem solvingsolving

StroopStroop teststests: inhibition : inhibition & cognitive & cognitive flexibilityflexibilityStroopStroop teststests: inhibition : inhibition & cognitive & cognitive flexibilityflexibility

Fluency testsFluency tests: : categorization categorization and fast retrievaland fast retrieval

TrailTrail--making testsmaking tests: scanning, sequencing, speed: scanning, sequencing, speed

Proverb testsProverb tests: abstraction : abstraction

Theory of MindTheory of Mind (Baron(Baron--Cohen): perspective takingCohen): perspective taking

EF Help: The Basics

Pay close attention to emotional and behavioral Pay close attention to emotional and behavioral responses to assigned tasks once you know EF responses to assigned tasks once you know EF weaknesses (e.g., initiation, shifting, organization). weaknesses (e.g., initiation, shifting, organization).

Task avoidanceTask avoidance-- consider possibility cannot do it given consider possibility cannot do it given EF struggles or delays. EF struggles or delays. EF struggles or delays. EF struggles or delays.

EssentialEssential to figure out what EF’s task requires and ask to figure out what EF’s task requires and ask yourself whether the person possesses these skills yourself whether the person possesses these skills (e.g., initiation and sequencing/working memory; (e.g., initiation and sequencing/working memory; managing social conflict). managing social conflict).

Foundation for InterventionFoundation for Intervention

Begin by Begin by developing a relationship developing a relationship with the with the person that is emotionally supportive.person that is emotionally supportive.

Emphasize that you Emphasize that you wantwant the person to the person to succeed (e.g., build selfsucceed (e.g., build self--esteem & esteem & resiliency). resiliency). resiliency). resiliency).

Help the person to Help the person to understand their struggles understand their struggles and that there are strategies they can use to and that there are strategies they can use to improve performance. improve performance.

Underscore that it is Underscore that it is notnot an ability issue, but an ability issue, but a problem with performance.a problem with performance.

Solutions to ADHD Sleep problemsSolutions to ADHD Sleep problems

Adjust ADHD MedicationAdjust ADHD Medication


Stick to a Sleep Schedule 7 days a weekStick to a Sleep Schedule 7 days a week

Wake up and go to bed at the same time Wake up and go to bed at the same time every dayevery day


••ExerciseExercise: boosts the effect of natural sleep : boosts the effect of natural sleep hormones like melatonin. Morning is ideal, hormones like melatonin. Morning is ideal, not 2not 2--3 hours before bed.3 hours before bed.

••Reserve bed for sleep and sexReserve bed for sleep and sex-- keep keep electronics out of bedroom.electronics out of bedroom.electronics out of bedroom.electronics out of bedroom.

••Keep environment comfortableKeep environment comfortable: quiet, dark : quiet, dark & cool environment, examine location of & cool environment, examine location of bed, comfortable pillow & bedding, use white bed, comfortable pillow & bedding, use white noise or ear plugs.noise or ear plugs.


Start a sleep ritualStart a sleep ritual: signals the body and : signals the body and mind that it’s time for sleep (e.g., glass of mind that it’s time for sleep (e.g., glass of warm milk, bath, calm music).warm milk, bath, calm music).

Do not napDo not nap: Can interfere with restorative : Can interfere with restorative value of nightvalue of night--time sleep.time sleep.value of nightvalue of night--time sleep.time sleep.

EatEat-- but not too much: small healthy snackbut not too much: small healthy snack

Avoid alcohol, caffeine and tobaccoAvoid alcohol, caffeine and tobacco: wine : wine and chocolate should not be a bedtime and chocolate should not be a bedtime snacksnack-- both act as stimulants. Also, avoid both act as stimulants. Also, avoid acidic foods that cause heartburn. acidic foods that cause heartburn.


DeDe--stressstress: daytime worries can surface at : daytime worries can surface at night and stress is a stimulant. Learn night and stress is a stimulant. Learn relaxation (breathing, mindfulness, yoga).relaxation (breathing, mindfulness, yoga).

Limit time spent in bedLimit time spent in bed: If cannot fall : If cannot fall asleep get up and start routine again.asleep get up and start routine again.asleep get up and start routine again.asleep get up and start routine again.

Get checkedGet checked: an urge to move your legs, : an urge to move your legs, snoring or a burning pain in your stomach snoring or a burning pain in your stomach are symptoms of 3 common sleep are symptoms of 3 common sleep disruptersdisrupters-- restless leg syndrome, sleep restless leg syndrome, sleep apnea and GERD.apnea and GERD.

Why Why NNo Electronics?o Electronics?

Small electronic devices emit sufficient light to

miscue the brain and promote wakefulness.

Using electronics as sleep aid to relax leads to

later bed time, less sleep, and increased fatigue.

Having TV in bedroom causes later bedtimes, Having TV in bedroom causes later bedtimes,

more difficulty initiating sleep, and shorter total

sleep times.

Texting and emailing in bed, even once per week,

dramatically increases self-reported daytime

sleepiness.

But what about...

Where to start if you think Where to start if you think you may you may

have sleep problems?have sleep problems?

Talk to your Talk to your physician and physician and report any report any sleep concernssleep concerns

Keep sleep logKeep sleep log

Request a sleep Request a sleep studystudyRequest a sleep Request a sleep studystudy

Obtain comprehensive neuropsychological Obtain comprehensive neuropsychological assessment to help determine source and assessment to help determine source and severity of problem (sleep deprivation? severity of problem (sleep deprivation? ADHD?) and ADHD?) and to help to help at at work, school work, school and and home.home.

ReferencesReferences

National Sleep FoundationNational Sleep Foundation

American Academy of Sleep American Academy of Sleep MedicineMedicine

American Sleep Apnea AssociationAmerican Sleep Apnea Association

American Association of Respiratory CareAmerican Association of Respiratory CareAmerican Association of Respiratory CareAmerican Association of Respiratory Care

Society of Behavioral Sleep MedicineSociety of Behavioral Sleep Medicine

National Resource Center for ADHDNational Resource Center for ADHD

Workplace Strategies for Mental Health Workplace Strategies for Mental Health

CENTER FOR NEUROPSYCHOLOGY, LEARNING & DEVELOPMENT

adhd, sleep problems, and executive functioning: what are ...€¦ · responses to assigned tasks...

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