Attention-Deficit/Hyperactivity Disorder (ADHD) is a disorder that begins in childhood and encompasses symptoms of inattention, hyperactivity, and impulsivity. These symptoms interfere with functioning at school, at work, and in social situations. ADHD is present in approximately 5% of children, and it is more common in boys. For a majority of people the disorder continues into adulthood, though careful managing can greatly improve quality of life for people with ADHD.
An estimated 25 to 50% of people with ADHD experience sleep problems, ranging from insomnia to secondary sleep conditions. Doctors are starting to realize the importance of treating sleep problems and the impact this can have on both ADHD symptoms and quality of life for ADHD patients and their families.
What’s the Connection Between ADHD and Sleep?
Beginning around puberty, people with ADHD are more likely to experience shorter sleep time, problems falling asleep and staying asleep, and a higher risk of developing a sleep disorder. Nightmares are also common in children with ADHD, especially those with insomnia. Sleep problems in ADHD tend to increase with age, though sleep problems in early childhood are a risk factor for future occurrence of ADHD symptoms.
Even those who are rarely hyperactive during the day may experience racing thoughts and a burst of energy at night that interfere with sleeping. For some, nighttime presents the perfect opportunity to “hyperfocus” on a project, as there are less distractions. Unfortunately, this makes it difficult to settle down for sleep and it can lead to a disrupted sleep-wake schedule. Over time, insomnia may worsen as people start to develop feelings of stress related to bedtime.
Many people with ADHD experience daytime sleepiness and difficulty waking up as a result of poor sleep. Others experience restless, non-refreshing sleep with multiple nighttime awakenings.
Sleep problems in ADHD appear to differ depending on the type of ADHD. Individuals with predominantly inattentive symptoms are more likely to have a later bedtime, while those predominantly hyperactive-impulsive symptoms are more likely to suffer from insomnia. Those with combined hyperactive-impulsive and inattentive ADHD experience both poor sleep quality and a later bedtime.
Many ADHD symptoms are similar to symptoms of sleep deprivation. Among others, adult ADHD sleep problems include forgetfulness and difficulty concentrating. In children, fatigue may present as being hyperactive and impulsive. Sometimes it can be difficult to tell whether these issues are brought on by ADHD or by a lack of sleep. This may lead to misdiagnoses or may allow sleep disorders to go undetected. Experts therefore recommend screening patients for sleep problems before prescribing medication for ADHD.
What’s the Biology Behind the ADHD-Sleep Connection?
ADHD sleep problems may be a side effect of impaired arousal, alertness, and regulation circuits in the brain. Other researchers believe that ADHD sleep problems can be traced to a delayed circadian rhythm with a later onset of melatonin production. Despite similarities between certain sleep disorders and ADHD symptoms, research has failed to find consistent sleep abnormalities in people with ADHD.
Some individuals find it easier to sleep with the calming effects of stimulant medications that are commonly prescribed for ADHD. However, for many people, stimulant medications cause a number of sleep problems in their own right. Co-existing disorders such as anxiety, depression, or substance abuse, as well as poor sleep hygiene, likely also play a role in sleep difficulties.
How Do ADHD Sleep Problems Affect Daily Life?
Though there is little research on the subject of ADHD with accompanying sleep disorders, children and adults with ADHD plus a sleep disorder often report more severe ADHD symptoms and a lower quality of life. They may also be more likely to suffer from depression, anxiety, hyperactivity, inattention, difficulty processing information, and a higher BMI. Over the long term, chronic sleep deprivation leaves people vulnerable to physical health problems.
Daytime sleepiness can have serious effects on school and work. People may judge a person with ADHD for sleeping at inappropriate times, without realizing that it is part of their condition and very difficult to avoid. Sudden bouts of sleepiness may also be dangerous while driving or performing other activities that require concentration.
Not sleeping well at night can also cause daytime fatigue. Individuals with ADHD-related sleep deprivation may feel grumpy, irritable, restless, or tired, or they may have trouble paying attention at school or at work. Sometimes, these symptoms may be mistaken for a mood disorder. In turn, anxiety and behavioral difficulties have been linked to a higher incidence of sleep problems for children with ADHD.
These problems also take their toll on families and caregivers of people with ADHD. Preliminary research shows that primary caregivers of children with ADHD as well as sleep problems are more likely to be depressed, anxious, stressed, and late to work.
Common Sleep Disorders Commonly in People With ADHD
In addition to generalized insomnia, people with ADHD have higher-than-normal rates of certain sleep disorders. Because ADHD symptoms often resemble the symptoms of these sleep disorders, underlying sleep disorders may go undiagnosed. Children in particular may have difficulty conveying what they are feeling, leading to a misdiagnosis of ADHD when in fact their problems stem from a sleep disorder. Or, they may have ADHD plus a sleep disorder.
- Circadian Rhythm Sleep Disorder: Most individuals with ADHD, particularly adolescents, are more alert in the evening. This atypical schedule can make it difficult to honor work or school commitments. A smaller pineal gland, irregularities in clock genes, and later melatonin release may be responsible for circadian rhythm sleep disorders in people with ADHD. Taking melatonin supplements at targeted times or using bright light therapy may help adjust your schedule.
- Sleep-Disordered Breathing: Sleep-disordered breathing (SDB), including snoring and sleep apnea, affects up to one-third of patients with ADHD. SDB leads to disturbed sleep and daytime sleepiness, and often causes symptoms typical of ADHD. The encouraging news is that treating SDB may reduce the need for stimulants in children believed to have ADHD. Studies suggest that removing the tonsils may help with ADHD and sleep apnea symptoms in children, while CPAP devices are a better choice for adults.
- Restless Legs Syndrome: People with restless legs syndrome (RLS) are plagued by tingling sensations in the legs that make it hard to fall asleep. RLS or other types of periodic limb movement disorders may occur in almost 50% of people with ADHD. Children with both ADHD and RLS appear to spend longer in stage one light sleep, which is not as restorative. Researchers believe RLS is caused by iron and dopamine deficiencies, which are also implicated in ADHD. RLS may be treated with iron supplements or dopaminergic agents.
- Narcolepsy: Individuals with narcolepsy tend to fall asleep suddenly during the day and may have difficulty sleeping soundly at night. Adults with narcolepsy are twice as likely to have had ADHD as a child. While the link between the two isn’t clear, researchers believe that the sleepiness brought on by narcolepsy might provoke ADHD symptoms. It’s also possible that both disorders might stem from a similar cause, such as a faulty gene or a problem with neurotransmitters. Narcolepsy is usually treated with medication.
Treating underlying sleep disorders is an important step toward improving sleep for people with ADHD. Ask your doctor for a sleep study to rule out any secondary sleep disorders that may need to be treated along with your ADHD. A good doctor should monitor potential sleep problems on an ongoing basis, as these tend to develop over time.
Sleep Tips for Children and Adults With ADHD and Sleep Problems
Experts are cautiously optimistic that sleep interventions may be key to improving not only sleep, but also ADHD symptoms and the effects of ADHD medication. Indeed, preliminary studies have found that behavioral sleep interventions improve sleep, ADHD symptoms, quality of life, daily functioning, behavior, and working memory.
For children, adolescents, and adults with ADHD, a consistent bedtime routine and healthy sleep hygiene practices can help reinforce the connection between bed and sleep. Try making gradual changes and note where you see improvements to develop a system that works for you. Some tips include:
- Cut out sugar, caffeine, and alcohol within a few hours of bedtime
- Avoid screen time for an hour before bed
- Avoid doing stimulating activities and projects that require hyperfocusing in the evening
- Make the bed a stress-free zone reserved for sleep and sex
- Get enough exercise and sunlight during the day
- Develop a bedtime routine that you enjoy, such as rereading a favorite book, spending time with pets, or taking a warm bath
- Keep the bedroom dark, cool, and quiet, using a white noise machine if necessary to block out intrusive noises
- Go to bed and wake up at the same time every day, choosing a time that is realistic and age-appropriate to get the recommended sleep for your age group
- Use a weighted ball blanket
People with ADHD also frequently have trouble waking up in the morning. For help getting out of bed, try using light therapy or plan something enjoyable for when you get out of bed, such as exercise or a nice breakfast
The Children and Adults with ADHD organization recommends using a rewards-based system for sleep problems in young children with ADHD. It may also help to offer reassurance by checking frequently on your child. For people of any age with ADHD, talking with a trusted confidant, keeping a worry journal, or using relaxation techniques such as guided imagery may help make bedtime less stressful.
Sleep medication may not be appropriate for people with ADHD, but you can talk to your doctor about adding supplements or tweaking your medication schedule to optimize it for sleep. Some people with ADHD find it helps alertness to take their medication about an hour before waking up. Adolescents and adults with sleep problems may benefit from cognitive behavioral therapy for insomnia (CBT-I).
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