Medically reviewed by Smita Patel, DO, Susan Kerrigan, MD and Marianne Madsen on January 19, 2023
Ever wondered why your teenager is struggling to sleep? Research shows a strong correlation between sleep and ADHD—and it’s not clear who’s the chicken and who’s the egg in this conundrum.
Attention-Deficit/Hyperactivity Disorder (ADHD) generally 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 most people, the disorder continues into adulthood, though careful management of the condition can greatly improve quality of life for people with ADHD.
Approximately between 20 to 50% of people with ADHD experience sleep problems. These can range from insomnia to secondary sleep conditions. Doctors today 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.
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 seem to increase with age.
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 that are 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 with 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. 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 misdiagnosis or may cause sleep disorders to go undetected. Experts therefore recommend screening patients for sleep problems before prescribing medication for ADHD.
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.
Sleep Disorders that Commonly Occur in People who have ADHD
In addition to generalized insomnia, people with ADHD can tend to have higher rates of some sleep disorders than the norm. 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 together with a sleep disorder such as these:
- Circadian Rhythm Sleep Disorder: Most individuals with ADHD, particularly adolescents, tend to be more alert in the evening. This type of schedule can make it difficult to honor work or school commitments. Taking melatonin supplements at specific times or using bright light therapy may help adjust the schedule of someone struggling with circadian rhythm sleep disorder.
- Restless Leg Syndrome: People with restless legs syndrome (RLS) are bothered by tingling sensations in the legs that make it hard to fall asleep. RLS seems to occur in almost 50% of people with ADHD. It appears that children with both ADHD and RLS spend longer in stage one light sleep, which is not as restorative. RLS can be treated with iron supplements or dopaminergic agents.
- Sleep-Disordered Breathing: Sleep-disordered breathing (SBD) includes snoring and sleep apnea and affects up to one-third of people diagnosed with ADHD. SDB leads to disturbed sleep and daytime sleepiness, and often causes symptoms typical of ADHD. The promising 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.
Tips to avoid sleepless nights
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. In fact, preliminary studies have found that behavioral sleep interventions improve sleep, ADHD symptoms, quality of life, daily functioning, behavior, and working memory. This is really encouraging.
For children, adolescents, and adults with ADHD, healthy sleep hygiene which includes a consistent bedtime routine and other practices can help reinforce the connection between bed and sleep. It is suggested to start with small changes and to record what helps. Some tips include:
- Avoid screen time for an hour before bed
- Get enough exercise and sunlight during the day
- Cut out sugar, caffeine, and alcohol within a few hours of bedtime
- Avoid doing stimulating activities and projects that require hyperfocusing in the evening
- Make the bed a stress-free zone reserved for sleep and sex
- 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 blanket
People with ADHD tend to 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. For young children, a behavioral rewards chart can be effective.
Sleep medication may not be appropriate for people with ADHD, but a doctor can suggest adding supplements or tweaking the medication schedule to optimize it for sleep. Some people with ADHD find it helps alertness to take their medication about an hour before getting out of bed for the day. Adolescents and adults with sleep problems may benefit from cognitive behavioral therapy for insomnia (CBT-I).
Written by Joanne Myers
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