The optimal system of care for the management of delayed sleep onset in adult ADHD in the UK: a modified Delphi consensus

Philip Asherson^1*Giovanni Giaroli^2,3Paul Gringas^1,4Heidi Phillips^5,6Hugh Selsick⁷Michael Smith⁸Dietmar Hank⁹

• ¹King's College London, London, England, United Kingdom
• ²Queen Mary University of London, London, United Kingdom
• ³The Giaroli Centre, London, United Kingdom
• ⁴Guy's and St Thomas' NHS Foundation Trust, London, London, United Kingdom
• ⁵Royal College of General Practitioners, London, United Kingdom
• ⁶Swansea University, Swansea, Wales, United Kingdom
• ⁷University College London Hospitals NHS Foundation Trust, London, United Kingdom
• ⁸Leeds and York Partnership NHS Foundation Trust, Leeds, United Kingdom
• ⁹Avon and Wiltshire Mental Health Partnership NHS Trust, Chippenham, United Kingdom

IntroductionSleep-related disorders affect a significant number of individuals with ADHD, the most common of which has been found to be delayed sleep phase syndrome/delayed sleep onset. The presence of a sleep disorder can exacerbate ADHD symptoms and impair cognitive functions. Despite the significance of these issues, they are often overlooked, potentially leading to unsafe self-medication practices and illicit substance abuse. While the literature supports the efficacy of melatonin in treating delayed sleep onset among children and adolescents with ADHD, evidence in adults is less well-established. This consensus study aims to establish consensus among healthcare professionals regarding the overall management of adults with ADHD experiencing delayed sleep onset in the UK, with the aim of guiding good clinical practice.MethodsThe process employed a modified Delphi methodology. A literature review was conducted to understand the current evidence base. A steering group of seven experts from the UK attended a virtual meeting in April 2024. During this meeting, facilitated by an independent moderator, the group identified six primary domains. Based on these domains, 40 statements were developed into an online survey for testing with a wider panel of peers.Stopping criteria for consensus rounds were established as a survey duration of four months, a target of 200 responses, and the requirement that at least 90% of the statements achieve the consensus threshold of ≥75% agreement.ResultsA total of 212 responses were received from healthcare professionals experienced in managing adult patients with ADHD and sleep disorders in the UK. All proposed statements achieved consensus, with 90% of statements achieved ≥90% agreement (n=36/40). ConclusionBased on the agreement levels achieved, the steering group developed a series of recommendations for the management of delayed sleep onset in adult ADHD in the UK. Given the prevalence of sleep disorders in this population, a comprehensive management approach is essential. This should include effective treatments, such as melatonin, which could be initiated in primary care and monitored by general practitioners for newly diagnosed patients. It is also important that treatment for delayed sleep onset is continued as individuals transition from childhood into adulthood.