ADHD and Sleep
More than 6 million children in the United States are affected by attention-deficit/hyperactivity disorder (ADHD), and it affects nearly 1 in every 20 adults as well. While many people are familiar with the general symptoms of ADHD, they may not know about its deep and complex connection with sleep.
Sleeping problems are common among people with ADHD, and a lack of sleep can cause a person to experience ADHD-like symptoms. Because of the intricate relationship between sleep and ADHD, it is important to consider how people with this condition can get more high-quality sleep on a consistent basis.
This guide explains the basics of ADHD. It covers the types, symptoms, diagnosis, and treatment of this condition. It also explores the connection between ADHD and sleep and offers practical steps for both children and adults with ADHD to improve their rest each night.
What is ADHD?
ADHD is a mental health condition that is associated with a limited attention span, excessive activity, and impulsiveness. It is considered to be a neurodevelopmental disorder, meaning that it affects the brain and can impact a person’s ability to acquire or retain certain functions or skills.
ADHD frequently begins early in life and is commonly thought of as a childhood disorder, but it affects adolescents and adults as well. It is believed that ADHD affects up to 11% of school-aged children and lasts into adulthood for an estimated two-thirds of people who are diagnosed in their youth. ADHD can also be diagnosed in adults because in many cases the symptoms were not recognized or formally diagnosed with ADHD during childhood.
What Are the Types of ADHD?
ADHD is considered to have 3 types or forms: inattentive, hyperactive/impulsive, and combined.
What Are the Symptoms of ADHD?
The symptoms of ADHD are different depending on the type that a person has, so it is important to remember that not everyone with ADHD exhibits the same patterns of behavior.
For the inattentive type of ADHD, the most common signs include failure to notice details, making careless mistakes, not listening or paying attention, difficulty following instructions, problems with organization, frequently forgetting or losing things, and being distracted easily.
For the hyperactive/impulsive type, the most common signs are frequent fidgeting, difficulty sitting or staying still, difficulty doing activities quietly, talking constantly including by interrupting, excessive running or climbing (even when not supposed to be), and problems waiting or taking turns.
What Are the Impacts of ADHD?
Whether it affects a child, adolescent, or adult, ADHD can have significant consequences for a person’s life. People with ADHD frequently struggle in school or work environments. They may have difficulty with regimented schedules and detailed requirements and tasks. Inattentiveness can make it hard to receive good grades, and hyperactivity and impulsivity can contribute to disciplinary problems in school.
As a result, many people with ADHD have reduced academic achievement, and an estimated 60% have learning disorders. Behavioral problems, such as temper tantrums, are also believed to affect 60% of people with ADHD. These difficulties can impact home life and social relationships, creating problems with parents and friends. People with ADHD may have a harder time in organized activities related to youth sports, community groups, and religious organizations.
People with ADHD have a higher frequency of abuse of alcohol and drugs. They can be more prone to confrontations with authority that can lead to legal problems.
What Causes ADHD?
There is no single cause of ADHD. Research points to it having a genetic element, but to date, there is no apparent, isolated cause.
Without knowing a cause, researchers have identified certain risk factors that appear to be associated with a higher risk of having ADHD. Some of these risk factors include a low birth weight, infection of the brain, brain injury, iron deficiency, lead exposure, obstructive sleep apnea, and prenatal exposure to alcohol, tobacco, or cocaine.
It is important to remember that having one or more of these risk factors does not mean that a person will develop ADHD. These are simply factors that have been observed to coincide at a higher rate in people who have ADHD. Studies point to brain differences in people with ADHD as existing from birth.
Does Eating Sugar or Food Additives Cause ADHD?
Studies do not support the idea that food additives or sugary food or drinks as contributing to the development of ADHD. The brain changes associated with ADHD appear to exist starting from birth or very early in life and are not caused by diet.
Is ADHD the Same as ADD?
In the past, ADHD was referred to as Attention Deficit Disorder (ADD). Because many patients also demonstrated hyperactivity, the condition was reclassified as ADHD, and this terminology is now preferred by medical professionals.
How is ADHD Diagnosed?
There is no laboratory or imaging test that can determine whether or not a person has ADHD. Instead, it must be diagnosed by a doctor who reviews a person’s symptoms.
According to the specific diagnostic criteria, a child must show at least 6 symptoms of either inattentiveness or of hyperactivity and impulsivity. Those symptoms must last for 6 months or more and be more severe than would be expected for their age. They must also be present in at least two different environments, which frequently are at home and at school. As a result, both parents and teachers are commonly involved in determining if a child has ADHD.
A diagnosis of ADHD requires working with a health professional who can help rule out the possibility that the symptoms are being caused by another condition. For example, some learning disabilities and mood or anxiety disorders can cause symptoms that present like ADHD.
In adults, the diagnostic process is similar but requires that at least some of the symptoms were present during childhood.
How is ADHD Treated?
There are two primary treatments for ADHD: behavior modification and medication. Many children receive combined therapy that employs both of these approaches.
Behavior-based treatment can include multiple elements. Talk therapy with a counselor may be useful in certain circumstances. A popular type of talk therapy is known as cognitive behavioral therapy (CBT), and it can include things like goal-setting, role-playing, and self-reflection to reduce symptoms of ADHD. Behavior modification also incorporates improving a person’s ability to work within specific schedules and routines. These strategies can enhance focus, organization, and impulse control.
Parents may work with doctors or other specialists to adapt their parenting techniques to better fit the needs of a child with ADHD. A plan for school, including necessary accommodations for learning difficulties, can play a role in managing ADHD and reducing its impact.
Treatment of ADHD often involves medication. Psychostimulants are the class of drugs that are most commonly prescribed for this condition. It may seem counterintuitive to prescribe a stimulant, but in people with ADHD, these drugs typically have a calming influence on ADHD patients.
Stimulants can have side effects including impacts on mood, sleep, and appetite. They can cause headaches, stomach aches, and elevated blood pressure. In most children, though, side effects are minimal. Long-term stimulant use can affect growth, so pediatricians usually keep a close eye on the development of children who use stimulants for an extended time.
Most children take stimulants every day. They can be taken with a slow-release formulation in a once-a-day tablet or may be taken multiple times per day. Sometimes doctors recommend a “drug holiday” when a person with ADHD does not take their medication, if, for example, they are on vacation and do not need to be as focused as when they are in school.
Medication for ADHD can be combined with behavioral modification. It is normal for behavior-focused therapy to be tried first and then supplemented with medication if symptoms persist. This is especially true in patients under 5 years old.
What is the Relationship Between ADHD and Sleep?
Sleep problems are common in people with ADHD with research studies finding that between 25% and 55% of patients report sleep disturbances. ADHD often occurs alongside other conditions that can affect sleep, and sleep deprivation may contribute to ADHD symptoms.
Overall, there is a complex relationship between sleep and ADHD, and this relationship is still not fully understood. For example, it is not known if ADHD causes sleep disturbances, if sleep loss contributes to ADHD, or if they are both a byproduct of a shared underlying neurological condition.
Even without a complete understanding of the neurobiology of ADHD and sleep, the existing research does cast light on a number of key ways in which they are related. In the following sections, we will explore what is known about the connection between sleep and ADHD.
How Does ADHD Affect Sleep?
People with ADHD report a wide range of sleeping problems. These include not wanting to go to bed, waking up earlier than desired, having a hard time falling asleep, waking up during the night, and encountering noticeable daytime sleepiness.
It is difficult to say exactly why people with ADHD have these sleep difficulties. In people with hyperactivity, the urge to move may prevent calming down to go to sleep. In addition, there are several other factors that may contribute to poor sleep in people with ADHD.
Co-Existing Health Conditions
Many people with ADHD have other physical and mental health problems that can be a barrier to good sleep. It is thought that as many as 87% of childhood ADHD patients have at least one other health problem. These can include conditions known to interfere with sleep including anxiety disorders -- such as obsessive-compulsive disorder (OCD) or post-traumatic stress disorder (PTSD) -- bipolar disorder, and autism.
Rates of obesity are considerably higher in people with ADHD, including in adults who were diagnosed with ADHD as children. Obesity has a link to various sleep problems including obstructive sleep apnea (OSA).
Sleep-Disordered Breathing (SDB)
Independent of obesity, people with ADHD have an elevated risk of OSA and other types of sleep-disordered breathing. One study found that 25-30% of patients with ADHD had OSA compared to 3% of the general population. OSA and other types of breathing problems can interrupt sleep by causing frequent nighttime awakenings.
Restless Leg Syndrome (RLS) and Periodic Limb Movement Disorder (PLMB)
People with Restless Leg Syndrome feel a strong need to move their legs when they try to rest. If they don’t move their legs, they feel an unpleasant sensation. RLS makes it difficult to get settled in to fall asleep and to stay asleep through the night, and it is believed that up to 44% of children with ADHD may have RLS.
Periodic Limb Movement Disorder (PLMD) often occurs with RLS and involves frequent involuntary movements of the legs. These muscle jerks or twitches can cause nighttime awakenings, harming sleep quantity and quality. Like RLS, PLMD is much more common in people with ADHD than in people without the condition.
In addition to disrupting sleep, both of these conditions may create a negative association with going to bed, contributing to the desire of many ADHD patients to stay awake and resist bedtime.
Circadian Rhythm Issues
One proposed cause of sleeping problems in people with ADHD is differences in their circadian rhythms compared to people who do not have ADHD. For example, they may have delayed production of melatonin, a substance that the body makes to help transition the body to its period of nightly sleep.
Studies have found that children with ADHD can have major inconsistency in their nightly sleep, and this may interfere with their ability to develop comfortable sleep routines and bedtimes.
The sleep experience can vary remarkably between people with ADHD. Some people do not have sleep problems at all, and in people with sleep issues, the severity can be very different from person to person. As a result, it is important for parents and health professionals to remember that the problems and solutions for children with ADHD are complex and variable.
Sleeping Problems in Adults With ADHD
Though the bulk of the research about ADHD, including its relationship with sleep, has focused on children, studies in adults with ADHD have found that sleep problems remain common in this population. In fact, sleeping problems may be even more common than in children.
How Does Sleep Affect ADHD?
A lack of sleep can cause a person to exhibit signs that are quite similar to those of ADHD. Because of the importance of sleep to our mental and physical health, there is a line of thinking that ADHD may be caused or exacerbated by sleep deprivation.
To date, no experimental study has directly shown this to be the case. However, several studies have found that children with reduced sleep have ADHD-like symptoms. The impact of these sleep disruptions may be magnified during adolescence. Because the brain experiences considerable development during this period, lack of sleep may directly affect how ADHD progresses during that time and afterward, including into adulthood. Worsening ADHD symptoms from lack of sleep may then contribute to a negative feedback loop, creating additional sleep disturbances and further symptoms.
How Do ADHD Medications Affect Sleep?
An added wrinkle in the relationship between ADHD and sleep is how stimulant medications prescribed as ADHD treatment can affect sleep. Research about the effect of these medications is inconclusive, and evidence indicates that the effects may vary based on the specific patient.
In people without ADHD, stimulants can cause significant sleep disturbances. However, these drugs affect people with ADHD differently. It is for this reason that they show effectiveness in reducing symptoms for many patients.
For some people with ADHD, the calming effect of stimulants extends to sleep. In these patients, stimulants do not cause any sleep disruption. In fact, some patients take a dose of stimulant medication shortly before bedtime in order to reduce the chances of a rebound of symptoms in the night that can occur as their medication wears off.
In other people with ADHD, stimulants can cause problems with falling asleep or staying asleep. Even though the drugs may reduce their ADHD symptoms during the day, sleep disturbances can be a side effect, and because lack of sleep can cause ADHD symptoms, this side effect may alter the overall efficacy of the medication in these patients.
The difference in patient experiences makes it difficult to generalize about the impact of stimulants on sleep in people with ADHD. Clinical guidelines recommend that doctors assess sleep before prescribing stimulants because this allows them to know whether sleep problems started before or after initiating the treatments.
In patients who have sleep problems only after using stimulants, doctors can try prescribing different medications, dosages, or dosing schedules to try to identify an approach that does not interrupt sleep. Steps to improve sleep hygiene, as discussed in later sections, may also be part of addressing sleeping problems related to ADHD medications.
How Can People With ADHD Improve Sleep?
The sheer complexity of the relationship between sleep and ADHD makes it impossible to find one-size-fits-all solutions to sleeping problems in people with this condition. Nevertheless, there are a number of steps that may help both children and adults with ADHD get better and more consistent sleep.
Work With Health Professionals
A good way to get started in addressing sleeping problems is to talk with a doctor.
For someone who has sleeping problems and signs of ADHD but who hasn’t been diagnosed, consulting with a doctor can help determine if this diagnosis and subsequent treatment is appropriate.
For people who have already been diagnosed with ADHD, it can be normal to think that sleeping problems are just an inevitable consequence of the condition. But the truth is that there may be ways that a doctor can work to reduce the impact of ADHD on sleep. They can assess sleep quality and rule out other conditions that might be harming sleep.
Poor sleep isn’t something that ADHD patients have to just deal with. Making a health professional aware of the type and frequency of sleep disturbances is a first step in getting help. A sleep journal, in which a person tracks their nightly sleep, may help in that process by providing insight into any notable trends in sleep and its impact on daytime ADHD symptoms.
Part of visiting with a doctor is reviewing medications. For people taking stimulants for ADHD, this includes discussing the specific medication, its dosage, and the daily schedule for taking it. For people who do not take stimulants, a discussion with the doctor can address whether they would be appropriate to begin taking. In both cases, a doctor can offer vital insight into the benefits and risks of different pharmacotherapy approaches.
A review of medications goes beyond just stimulants. Some patients with ADHD have other health conditions, and medications for those conditions may have effects on sleep as well. A broad review of daily medications can help assess whether these drugs are having any negative impact on sleep.
Behavioral Treatment and Talk Therapy
Another way that a doctor can help is by making suggestions for behavior therapy. These strategies can build routines that reduce the symptoms of ADHD.
Doctors frequently can offer referrals to specialists who work with parents to optimize their methods for behavior treatment. This can include suggestions for how to work with teachers and other adults involved in the life of a child with ADHD.
Behavior treatment can include talk therapy, which is a type of psychotherapy that helps a person understand and manage a mental health condition. CBT has proven to be effective for a wide range of conditions, and it can play a role in improving sleep as well. CBT for Insomnia, also known as CBT-I, has a demonstrated track record of improving sleep outcomes for people with cognitive and mental health issues.
Optimize Sleep Hygiene
While there is no guaranteed way to improve sleep, there is a general consensus that optimizing sleep hygiene makes it easier to get consistent, high-quality sleep. Sleep hygiene is comprised of the bedroom environment and sleep-related habits.
There are overarching principles of good sleep hygiene, but in practice, these principles are applied to suit the needs of each individual. As a result, they provide an opportunity for both children and adults with ADHD to find the best ways to make their bedroom and their sleep routines work for them.
Cultivating a Good Sleep Environment
Our ability to fall asleep and stay asleep is affected by our environment. Making sure the bedroom promotes sleep can set a person with ADHD up for success when it comes to getting a good night’s sleep. The following list describes some important parts of the sleep environment.
Promote Positive Sleep Habits
Creating good routines is a component of behavioral treatment for ADHD. Routines also play a role in our sleep, and the following section reviews general suggestions for promoting sleep-supporting habits.
Learn More About ADHD and Sleep
If you’re looking to keep learning about ADHD and sleep, the following resources provide helpful information and sources of support.
- MedlinePlus: Attention Deficit Hyperactivity Disorder. This page created by the U.S. National Library of Medicine (NLM) is a portal for information about various aspects of ADHD in both children and adults.
- U.S. Centers for Disease Control and Prevention (CDC): Attention-Deficit / Hyperactivity Disorder. The CDC’s page on ADHD provides background information for parents and health professionals. The CDC also offers data and statistics about ADHD.
- Family Doctor: ADHD. Family Doctor is a website of American Academy of Family Physicians (AAFP), a medical professional organization. This page, written for parents, covers critical information about ADHD and gives suggestions for questions that parents can ask their childrens’ doctor.
- Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). CHADD is a national organization that has a wealth of information to help people affected by ADHD. Their website provides detailed resources, and they also have a telephone helpline at 1-800-233-4050.
- Center for Parent Information and Resources (CPIR). The CPIR is an organization that provides a hub for over 100 Parent Centers across the country. These centers offer resources and support to parents who have children with disabilities and developmental disorders. A list of Parent Centers is available at https://www.parentcenterhub.org/find-your-center/.
- Learning Disabilities Association of America (LDAA). The LDAA works to support people in coping with various types of learning disabilities. The organization has resources available for individuals, parents, educators, and health professionals.
- National Center for Learning Disabilities (NCLD). NCLD advocates on behalf of children with learning disabilities. They support research and programs to empower children, parents, teachers, and doctors so that people with learning disabilities can succeed in all aspects of life.
College Students With ADHD
- American Academy of Child and Adolescent Psychology (AACAP): College Students with ADHD. ADHD can pose problems for students at any age, and this page focuses specifically on how it may affect college students.
- National Institute of Mental Health (NIMH): Could I Have Attention-Deficit/Hyperactivity Disorder (ADHD)? The NIMH, an agency of the U.S. National Institutes of Health (NIH), offers this page for adults who think that they may have symptoms of ADHD.
- Healthy Children: Behavior Therapy for Children with ADHD. This page from Healthy Children, a program of the American Academy of Pediatrics (AAP), is designed for parents to help them understand techniques that they can use as part of behavior therapy for ADHD.
Cognitive Behavioral Therapy for Insomnia
- Psychology Today: Cognitive Behavioral Treatment for Insomnia (CBT-I) Defined. For a quick introduction to CBT-I, check out this article written by Allison Siebern, Ph.D., a Stanford professor and sleep psychologist.
- National Institute on Drug Abuse (NIDA): Stimulant ADHD Medications. This summary from NIDA, a component of the NIH, describes stimulant medications and discusses their potential benefits and downsides.
- Osmosis: Attention Deficit Hyperactivity Disorder (ADHD/ADD). This animated introduction to ADHD provides an easy-to-understand review of the known causes, symptoms, and the neurobiology of this condition.
- Mayo Clinic: Adult ADHD. In this program from Mayo Clinic Radio, Dr. Robert Wilfahrt, a doctor at the clinic, gives an overview of the prevalence, symptoms, and treatments for adult ADHD.
- University of Michigan Medicine: Behavioral Treatments for ADHD. In this talk, pediatric psychologist Blake Lancaster, Ph.D., reviews the existing research about behavioral therapy for ADHD. This video involves more complex medical terminology but goes in-depth about specific research studies.
Restless Leg Syndrome
- Restless Legs Syndrome Foundation (RLSF): The RLS Foundation is a nonprofit group that works to increase understanding of RLS and promote research into its causes and treatments. Their website includes useful information for patients about RLS.
- Harvard University: Sleep Health and Education. General information about sleep, including the biology of sleep, is available from this site created by the Sleep Medicine program at Harvard Medical School.
- The National Sleep Foundation (NSF). NSF is a national organization that provides useful information about sleep including conditions that affect sleep and methods to try to get better sleep.