ADHD and Sleep Disorders

Adults and children with ADHD often have trouble sleeping.  The connection between ADHD and sleeping is complex.  Researchers believe that sleep difficulties can worsen ADHD symptoms, but also that ADHD makes sleep more difficult.  People with sleep problems and ADHD often are told to try medication modifications, sleep hygiene methods (such as a strict sleep schedule) and melatonin, but sometimes these strategies don't work.  What can be done then? 

The first step is to get a better idea of what could be happening, so that you can better know what symptoms to look for.  This is a summary of some very common sleep disorders that are often found in people with ADHD, and what types of treatment to expect.

Primary ADHD sleep disorder

Symptoms:   This isn't an official diagnosis, but this is how the core symptoms of ADHD look when a person is trying to fall asleep.  They may have difficulty settling, racing thoughts (but not related to worries or fears), and physical restlessness not related to discomfort.  Some people have difficulty putting down that "one last thing" for fear they'll forget it in the morning.

Treatment:  To slow down brain activity prior to sleep try relaxation techniques such as mindfulness techniques, imagery (helpful audios can be found at Excel at Life) , and avoiding stimulating activities (like TV, video games, sports, work) for 1-2 hours before bedtime.  Strict sleep hygiene (regular schedule even on weekends, set an alarm if necessary) will help your body secrete hormones related to sleep at the same time every night.  If all of this fails, nonstimulant medication can be helpful.  Often doctors will recommend something like clonidine or guanfacine, both of which can be sedating.  Melatonin has also been shown to be helpful with primary ADHD sleep disorder.

Sleep apnea

Symptoms:  This disorder is characterized by loud snoring and breath holding.  It may be caused by enlarged tonsils, overweight, or strange neck positions while sleeping.  Patients are often sleepy during the day, although children may have the opposite reaction in an attempt to stay awake.

Treatment:  In children, the main treatment is surgery to remove the tonsils, which often is curative.  In adults, weight loss and/or a type of breathing machine worn over the nose (CPAP) usually helps with daytime sleepiness.

Periodic leg movement disorder/restless legs

Symptoms:  It is said that up to 40% of patients with ADHD also have restless legs, a disorder characterized by an uncomfortable sensation in lower extremities, temporarily relieved with movement, worse at rest, and worse at night.  Usually the person just cannot stay still while trying to fall asleep.  In children it is often heriditary.   Children often cannot describe symptoms and may resist bedtime or have difficulty falling asleep.

Treatment:  This disorder can be easily treated in some people because the condition can be much worse if the person is deficient in iron.   Taking an iron supplement may be all that is needed to find relief.  However, excessive iron can cause stomach problems or diabetes in the long term, so its important to get regular blood tests to know when to start and stop taking the supplement.  There are many other treatments for restless legs (none FDA approved in children), but so far, its not certain that treating with anything other than iron helps symptoms of ADHD.

Delayed sleep onset latency

Symptoms:  This is a fancy way of saying that a person's biological clock has a longer than 24 hour day.  The patient is not sleepy at bedtime and wakes up late (if allowed), with a normal or increased sleep duration.

Treatment:   To train the patient's biological clock back to normal, a strict schedule is necessary.  Aids to the process include melatonin at bedtime, bright light in the morning,  and avoidance of night time bright lights or screen time (including smart phones).

There are many other disorders that disrupt sleep, such as sleepwalking and seizures.   If you suspect these problems, you should discuss them with your physician.

References:

Carter, Kevin A., Nathanael E. Hathaway, and Catherine F. Lettieri. "Common Sleep Disorders in Children." American Family Physician 89.5 (2014): 368-77.

Miano, S., R. Donfrancesco, P. Parisi, J. Rabasco, A. R. Mazzotta, A. Tabarrini, O. Vitelli, and M. P. Villa. "Case Reports of Sleep Phenotypes of ADHD: From Hypothesis to Clinical Practice." Journal of Attention Disorders 17.7 (2013): 565-73. Web.