Attention deficit hyperactive disorder (ADHD) usually occurs when a child is about to hit puberty and sometimes continues into adulthood. Recent research has shown that roughly two-thirds of the children who are diagnosed with ADHD also have another medical condition of some sort; epilepsy, autism spectrum disorder (ASD), sleep disorders, obsessive-compulsive disorder (OCD), Tourette’s syndrome, intellectual disabilities and anxiety disorders are just some of the most common conditions that comorbid ADHD.
Some of these are topics for debate among professionals because of their controversy. For instance, studies show that people who have ADHD often score lower on intelligence quotient (IQ) tests compared to people without this disorder. It is possible, however, that this is due to distractibility or restlessness that comes with ADHD, and not necessarily due to lower intellectual capacity of the individuals undertaking these tests.
Sleep is a common issue among people with ADHD. Because of the symptoms and medication for ADHD, many people with this disorder experience difficulties falling asleep or staying asleep, have issues waking up in the morning, develop sleep-related breathing disorders, etc. Sleep deprivation and excessive daytime sleepiness are common results of ADHD-related sleep issues, further exacerbating the ADHD symptoms already present in an individual. However, in the other direction, sleep deprivation itself can cause very similar symptoms to those of ADHD, including hyperactivity, impulsivity, being distracted and unable to focus, not paying attention, irritability, etc. It makes it harder to differentiate between the two and diagnose ADHD in children. Persistent sleep issues often develop into sleep disorders. If not addressed, the combination of these two disorders can quickly turn into a big downwards-headed spiral, impairing all areas of a person’s life.
But let’s start from the beginning.
What is ADHD?
According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, attention deficit hyperactive disorder is a neurodevelopmental mental health disorder, whose main diagnostic symptoms fall under three categories:
- Inattentiveness – Symptomatic behaviors include difficulties in organizing and keeping focus, forgetfulness, regularly making careless mistakes, failing to perform tasks that require attentiveness over a longer period, difficulties with finishing tasks, etc.
- Hyperactivity behavior examples would be excessive talking, being restless, rocking, tapping, fidgeting, not being able to sit still, being impatient and often wearing other people out by being overly-active.
- Impulsivity behaviors demonstrate very little self-control or thinking before acting, making rash, sudden decisions, etc.
This disorder first occurs before a child hits puberty and potentially continues into adulthood. Depending on the dominant symptom group that an individual with ADHD might display, they can be classified into one of the following categories:
- Predominantly inattentive type
- Predominantly hyperactive-impulsive type
- Combined type
From their names, we can gather which category matches which group of symptoms. The root cause of this disorder remains unknown, although it is believed to be connected to certain substance (like alcohol, lead, and tobacco) consumption during pregnancy, premature birth, abnormalities in the brain and genetics. Environmental and social factors have been ruled out of the question, along with high sugar intake.
Because of the nature of their symptoms, people with ADHD are prone to problematic behavior in all aspects of their lives. Compared to people without this disorder, people with ADHD have about 20% higher incidence rate for substance abuse, an over 45% higher rate for teen pregnancy, over 20% more of them repeat a grade in school and roughly 40% more get arrested at some point. Children with ADHD might get in trouble with other kids or do poorly in school; adults have difficulties cultivating and maintaining relationships, keeping jobs and regularly fall behind on their responsibilities.
How Does ADHD Affect Sleep?
As mentioned in the introduction of this article, ADHD and sleep issues often occur simultaneously, and it is no surprise since both the ADHD symptoms and medications for managing this disorder can potentially cause sleep disturbances. Half of the children who have ADHD also experience sleep issues and heightened daytime sleepiness; common issues include bedtime anxiety, sleep onset and/or maintenance problems, difficulty waking up early, and occasional parasomnias (like nightmares or sleepwalking).
Some of the most common sleep disorders affecting people with ADHD are listed here:
- Insomnia is a sleep disorder highly prevalent in adults with ADHD, with the incidence rate of over 70%. The most commonly reported issue is with onsetting sleep; winding down can take these people over one hour before they finally fall asleep. If they don’t have this problem, people with ADHD struggle with maintaining sleep over the entire night. They wake up easily and often, sometimes have problems to fall back asleep, and their sleep is restless and less restorative. The incidence rate in children is about 50% higher than in children without ADHD.
- Obstructive sleep apnea and sleep-related breathing disorders. Sleep apnea is a breathing disorder that causes partial or total airway obstructions during sleep, causing snoring, gasping and even choking. It’s frequently developed in children with ADHD; along with other forms of breathing disorders, it strikes about one-third of all people with ADHD.
- Delayed sleep-phase syndrome is a circadian rhythm disorder that causes the timing of a person’s sleep-wake cycle to start later compared to a normal circadian cycle that’s based on the light-dark phase of the day. People with this disorder go to sleep and wake up later naturally, so if they have to adjust to a timetable that doesn’t fit their circadian rhythm, it often results in excessive daytime sleepiness and poorer performance at work or school.
- Restless legs syndrome (RLS) is a neurological disorder that causes people to, because of the sudden need or even pain, move their legs typically in periods of inactivity, often delaying sleep onset and resulting in daytime sleepiness. This problem is not so common among the general population, but over 50% of children and adults with ADHD suffer with it.
- Periodic limb movement disorder (PLMD). Similar to a phenomenon that a lot of people experience when a sudden leg jerk startles them from sleep, PLMD is a disorder that causes involuntary jerking of legs or arms during sleep that can last up to an hour at a time. It usually happens during light sleep and never during the REM-phase of sleep.
ADHD Medication and Sleep
Medication used to subside the symptoms of ADHD can be short-lasting (4-6 hours) or long-lasting (6-12 hours), and both often have an adverse effect on sleep and appetite, the latter of the two being worse. Because of the more consistent results and the ease of dosing them less frequently than the short-lasting pills, longer-lasting pills are regularly favored none the less.
Stimulant drugs and antidepressants are among the commonly used medications for ADHD; Adderall, Ritalin, Dexedrine, Aventyl, and Norpramin are some of the widely recognized drugs for treating this disorder, but they all have side-effects such as:
- Reduced appetite
- Elevated heart rate
Most importantly, they can all cause insomnia.
Suitable Treatments for People with ADHD and Sleep-Related Problems
The first option for a large portion of people with sleep issues or disorders is cognitive behavioral therapy (CBT). This treatment method doesn’t involve any medications in itself and can’t damage the patient no matter their sleep issue. That’s why CBT is often suggested even if it’s not certain whether a particular sleep disorder is present or not. It works by setting up a set of sleep-related “rules” to form a nighttime pattern which will minimize harmful behaviors and promote a healthy relationship with sleep. One such requirement is to avoid spending time in bed for anything barring sleep, in order to reassociate the two and shorten the time spent in attempts to relax and fall asleep.
For people with ADHD, another good treatment option is sleep restriction. It involves setting up the exact time when the patient will go to sleep and wake up every day. Whether the patient manages to fall asleep at the set time isn’t important; he/she is not to break from this schedule even if not fully rested in the morning, and additional rest is not allowed. Over time, this treatment trains the brain to prepare for sleep at bedtime, relieving sleep onset issues commonly reported among people with ADHD.
Light therapy can also be suitable for people with ADHD who have delayed sleep phase syndrome or other circadian rhythm disorders. The name of this treatment is quite explanatory; the patient uses a bright light at certain times of the day to reset or adjust the circadian rhythm, which is known to respond to light, among some other external stimuli. It helps to synchronize the patient’s sleep timing with the light-dark cycle of the day.
Sleep medication might be used to help with especially persistent sleep problems. However, these pills are not to be taken lightly, as they come with plenty of side-effects and often carry a dependency risk. Before opting for any medication, particularly if already using ADHD or some other type of medication, please make sure to discuss it carefully with a specialist.
Melatonin is a relatively safe way to achieve the sleep pill effect; it supplements the sleep-regulating hormone regularly secreted by the pineal gland in our brain. It doesn’t carry dependency risks and is preferable to sleep medication, especially for children. However, if taken in higher than the usual recommended dose (which is sometimes advised for children with ADHD), a potential side-effect is the increased risk for seizures; again, something to discuss with a doctor before taking any action. Don’t supplement without supervision!
Sleep Management Tips for Children and Adults with ADHD
- Set up a healthy routine. Take a hint from CBT and other therapy methods listed above; sleep hygiene is crucial for keeping a healthy relationship with sleep for a longer period. Set up a routine in a way that gradually relaxes you in preparation for sleep and don’t overcomplicate it – it should be easy to follow every day. Include things like brushing your teeth, using the bathroom, changing into PJs, maybe reading a book, switching off the lights and climbing into the bed to sleep.
- Make sure the way you wake up doesn’t stress you out. Instead of an annoying alarm tone, find a gentler way to ease into the day; if waking up a child with ADHD, first open the drapes and consider switching to a light-based alarm system. This will ease the irritability in the morning and set a far nicer tone for the rest of the day.
- Plan something to look forward to in the morning. Another good way to make yourself want to get up is setting up a “treat” to look forward to first thing in the morning. Maybe a breakfast prepared in advance and ready to be eaten, maybe your smartphone awaiting outside of the bedroom; even the simple act of picking out an outfit the evening before can help you dread waking up a bit less, if not put you in a good mood.
- Exercise. Important for pretty much everybody alive, exercise will help you de-stress and use up any extra energy that is stopping you from falling asleep. Also good for minimizing temper tantrums and hyperactivity symptoms that occur in a lot of people with ADHD.
- Keep it simple. Especially for children with ADHD, predictability in as many aspects of their life as possible helps avoid situations that might surprise and overstimulate them. Establishing routines that they can get used to, particularly in the afternoon and later, might make it easier for children with ADHD to settle in bed and fall asleep faster.
- Minimize your intake of stimulating substances like caffeine, alcohol, sugar, and foods high in fat. They will either delay the sleep onset or help you fall asleep but impair the quality of your sleep, resulting in excessive daytime sleepiness and exacerbated ADHD symptoms like irritability, hyperactivity, inability to wait, inattentiveness, lack of focus, etc.