What is ADHD?
ADHD is short for attention deficit/hyperactivity disorder. It describes a group of behaviors related to hyperactivity, inattentiveness and impulsive reactions. Most people think of ADHD as a problem that only children face, but in fact about 70% of children with ADHD grow up to be adults with ADHD symptoms.
About a third of children diagnosed with ADHD were diagnosed between 2 and 5 years of age. ADHD symptoms usually appear in the preschool years whereas sleep problems can appear somewhat later, at 7 or as late as 12 years of age.
What are the symptoms of ADHD? (Diagnosis)
To diagnose ADHD; professionals use the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth edition (DSM-5). It lists out the criteria for ADHD and is divided into two groups of symptoms: inattention and hyperactivity/impulsivity.
- Careless, not paying attention to detail at school or work.
- Unable to keep attention on tasks or play.
- Seems to not pay attention when talked to.
- Often loses focus, doesn’t follow instructions, doesn’t finish tasks.
- Can’t organize their time.
- Avoids tasks that require mental effort.
- Loses things often.
- Gets distracted easily.
- Fidgeting, squirming.
- Leaves seat at inappropriate moments.
- (For children) Runs around, climbs at inappropriate moments; (for adults) feeling restless.
- Not able to play or do enjoyable activities quietly.
- Frequently overly active.
- Talks too much.
- Answering without waiting to hear the end of the question.
- Can’t wait for his/her turn.
- Interrupts and intrudes others in conversation, games, etc.
If a child is younger than 16, he/she needs to exhibit at least six symptoms of any of these groups; and if the person is 17 and older, he/she needs to have at least five symptoms. They need to last for over 6 months and be present to the point that they disrupt school or work.
Some symptoms may overlap with symptoms of other problems, so adults with ADHD may be misdiagnosed with narcolepsy or idiopathic hypersomnia, whereas children with ADHD may be misdiagnosed with sleep deprivation and vice versa.
Types of ADHD
Having the above-mentioned symptoms in mind, a person may be either of these three ADHD types:
- Predominantly Inattentive is someone who has had enough symptoms of inattentiveness for over six months, but not of hyperactivity or impulsivity.
- Predominantly Hyperactive/Impulsive is someone who has had enough symptoms of hyperactivity or impulsivity for over six months, but not of inattentiveness.
- Combined Presentation means that a person has shown symptoms of both groups for more than six months.
Please note that one person’s ADHD presentation may change over time as the symptoms may change.
Sleep problems in ADHD patients
There is a high number of sleep disturbances that children and adults with ADHD can experience. They include:
- Insomnia (difficulty falling asleep and/or staying asleep),
- Strong sleep inertia (difficulty waking up or shaking off drowsiness),
- Excessive daytime sleepiness,
- Sleep apnea (or other types of sleep-disordered breathing),
- Restless legs syndrome,
- Periodic limb movement disorder,
- Delayed sleep-phase disorder (circadian rhythm disorder),
- Nightmares, sleepwalking, and bedwetting (in children).
A study in children reported that if sleep problems are treated appropriately, it may be the solution to attention and hyperactivity problems for some.
When adults are sleep-deprived they tend to show signs of tiredness; but children become hyperactive and show symptoms like impulsivity, frequently making mistakes, not focusing and being irritable. For this reason, special attention should be paid in distinguishing ADHD from sleep deprivation in children.
Insomnia is characterized by having trouble falling asleep and/or staying asleep. People with ADHD have both – many report that, as soon as they turn the lights off, their mind starts racing with ideas and thoughts. Children may strongly protest sleep time, whether due to the disorder itself, or due to other factors – evening activities, lack of sleep schedule, or overall poor sleep environment.
As people with ADHD have restless sleep; they may be frequently woken up by their own excessive body movements, snoring (especially if they also suffer from sleep apnea), or nightmares.
Typically, their sleep is light in the first half of the night, but as the morning approaches, they are not easily woken up.
Sleep inertia is the feeling of grogginess in the morning. Many people with ADHD will sleep over several alarms and frequently sleep in. Some report not being able to become fully alert until noon.
Sleep inertia is particularly dangerous if the person is driving. Research has shown that sleep inertia is more debilitating than staying up all night.
Excessive daytime sleepiness
Excessive daytime sleepiness in ADHD adults is manifested through fatigue, lack of energy and focus, inability to follow orders or react properly. Children, on the contrary, may be more disruptive and move around more – but they are also not able to focus or follow orders.
Taking long naps during the day is not recommended because then there is more possibility to get an energy spike at night.
Obstructive sleep apnea
Sleep apnea is closely related to obesity and is more common in men than in women, but it is not uncommon for individuals with ADHD to have sleep apnea, regardless of age and weight.
Sleep apnea occurs usually because a person has narrow airways. They usually snore loudly and frequently stop breathing during the night. This stops oxygen flow to the brain, so the person wakes up to change the position. Numerous awakenings are bad for the sleep quality because they prevent the sufferer to reach deep, restorative sleep stages and feel refreshed in the morning.
Restless legs syndrome
Those who suffer from restless legs syndrome complain of unpleasant sensations when they are still, so they constantly have an urge to move their feet and legs. When they go to bed, the itchy, aching, pulling sensations return. Restless leg syndrome may be keeping them awake for a long time at night.
Periodic limb movement disorder
Periodic limb movement disorder (PLMD) is basically involuntary movements of the body during sleep. Other characteristics of this disorder are difficulty falling and staying asleep and excessive daytime sleepiness. Limb movements may occur several times per minute and they continue throughout the non-REM sleep stages.
Delayed sleep-phase disorder
The delayed sleep-phase disorder is a circadian rhythm disorder, that is, a problem in the functioning of the inner biological clock. It means that their circadian clock is ‘set’ to at least two hours later than that of other people, meaning that while most adults go to bed at about 11pm-12am, they will be sleepy at about 2am or later.
This naturally leads to getting up late, difficulty waking up and functioning in the first half of the day. It can be especially bothersome if the person has morning tasks and obligations.
Medications and sleep
Some of the sleep problems may be side-effects of ADHD medications.
One study lists methylphenidate, amphetamine, dextroamphetamine, pemoline, and ADHD as sleep-affecting drugs for children. This is because these drugs shorten total sleep time, increase the time it takes to fall asleep, the ability to stay asleep, and daytime sleepiness.
However, the authors also note that methylphenidate, if taken in the late afternoon, may have a calming effect in that it reduces activity at night and helps with better sleep quality.
A new theory on ADHD – is it primarily a sleep problem?
In 2017, the European College of Neuropsychopharmacology (ECNP) has given us an interesting proposal about the nature of ADHD.
Namely, about 75% of all ADHD patients have sleep problems, and an increasing body of research has shown that ADHD has a lot to do with sleep – so these authors have taken a new view. They assume that ADHD is primarily a problem of irregular circadian sleep.
At the ECPN Conference, professor Sandra Kooij said “We believe this because the day and night rhythm is disturbed, the timing of several physical processes is disturbed, not only of sleep, but also of temperature, movement patterns, timing of meals, and so on. If you review the evidence, it looks more and more like ADHD and sleeplessness are two sides of the same physiological and mental coin”.
In the further explanation, she stated that about 75% of ADHD patients have shown typical delayed sleep phase symptoms – with the low melatonin levels (the hormone that makes us sleepy) at night, changes in sleep-related movement, high body temperature, and evening alertness – all of which indicate a delay in circadian rhythm.
Moreover, most of the patients benefited from taking melatonin supplements in the evening and having bright light therapy in the morning – two simple actions which reset the circadian rhythm.
New FDA-approved medical device – treating ADHD in sleep
The Food and Drug Administration (FDA) has cleared marketing and use of the first-ever device for treating ADHD in April 2019. The Monarch external Trigeminal Nerve Stimulation (eTNS) System device can be obtained solely by prescription.
This system is a drug-free treatment option for ADHD – it is a device of the size of a smartphone and is attached to the forehead of a patient. It sends out mild electrical pulses to the trigeminal nerve and stimulates it. The trigeminal nerve leads to parts of the brain believed to be involved in ADHD.
How exactly this system works is still not completely clear, but what scientists do know is that neuroimaging shows an increase in brain activity of the regions which regulate attention, emotions, and behavior – three key problematic points for ADHD patients.
A clinical trial has shown that children who used the Monarch eTNS System improved their points on an ADHD rating scale. ADHD rating scales are used by clinicians to monitor ADHD symptoms – if the score is high, the symptoms are worse.
The chart below shows the results in ADHD improvement after eight weeks of using the device.
On their website, the NeuroSigma company advertises the device for treating ADHD, epilepsy, and depression in patients older than 7.
The FDA announcement states that the Monarch eTNS System can be used for patients age 7-12, who are not taking any ADHD prescription medication. It should not be used in children younger than 7, those who wear an insulin pump or have active implantable pacemakers or neurostimulators. The Monarch eTNS System should also not be used close to an MRI machine or a cellphone, because they can interrupt the signals from the device.
How to sleep better with ADHD?
ADHD-related sleep problems are successfully mitigated by practicing good sleep hygiene. This means making a set of healthy rules which should become your habit.
Sleep hygiene may require you to change some of the non-desirable habits and incorporate new ones. This usually means you need a little self-discipline and some good will – but it pays off greatly.
What feels good before bed may be individual, but there’s a list of scientifically proven things that impair our sleep quality and delay sleep time as well as things that make sleeping better and more restorative.
These pieces of advice are useful for children and adults.
What you should avoid:
- Technology use and white LED lights. Artificial light prior to sleep leads to sleep disturbances and/or inability to fall asleep. It sends out the wrong information to our brain – informing that it’s daytime, so the brain stays alert for a longer time. Social media should be especially avoided because it raises our dopamine or makes us anxious, both of which leads to an inability to fall asleep.
- Psychoactive substances – alcohol, marijuana, and caffeine. The first two may help with falling asleep, but they deprive you of valuable sleep stages – alcohol prevents you from reaching deep sleep, and marijuana REM sleep. Caffeine, especially if taken after 6 pm, will almost certainly affect your sleep – either delay your sleep time or change sleep architecture, resulting in lower quality sleep. Check the level of caffeine in your tea, chocolate, and sodas.
- Big meals. It’s normal for some to need a snack before bed, but a big, greasy, heavily-seasoned meal – that’s a recipe for poor sleep. Your body will keep you awake while it’s breaking down all the food, and even if you fall asleep, you won’t be able to enjoy restorative sleep.
- Entertainment, work or stress. This includes loud music, movies, phone calls, finishing work (which often requires staying up), or doing anything that causes stress to you personally.
What you should do:
- Make a bedtime routine. A certain routine, followed in the same order every night helps the body relax, wind down, and prepare for sleep. People with ADHD may need more time for unwinding. You can begin your routine about two hours prior to bed with dimming the lights, shutting down electronics and doing some easy activities, like putting away clothes and choosing tomorrow’s outfit. Then take a shower, have a cup of tea or warm milk and go to bed. A bedtime routine is a must for children – they sleep much better with it.
- Respect your sleep schedule. If you know how much sleep you or your child needs, you can make a sleep schedule that will allow that amount of sleep time. At first, you may experience difficulty falling asleep and strong sleep inertia (grogginess), but make sure to get up at the dedicated time. Slowly, over the course of several days, your inner clock will adjust to your new schedule and it will become easy for you to follow it.
- Sleep environment: Turn off electronics, make your room quiet, cool and dark. Loud sounds and strong light arouse the brain. If you live in an area with a lot of light pollution, think about purchasing blackout curtains or a sleep mask.
- Many people and children need white noise (a combination of all frequencies) to sleep better. This can be made by a running fan, for example. Some turn to white noise machines because the white noise helps them relax and it cancels the background sounds. Sound cancellation may be particularly important because individuals with ADHD are more likely to wake up due to any noise at night.
- High temperature also makes it difficult to fall asleep, because lowering outside temperature helps lower the core body temperature – an important factor for good sleep. Keep the room temperature about 65°F – if it’s warmer, use a lighter bed cover. If you are putting your child to bed, make sure he is comfortable – not too hot and not too cold.
- Get proper physical exercise. This is one of the excellent ways to battle insomnia, but also to increase your deep, restorative sleep at night. Just make sure not to exercise at night time – do it during the day, and, if possible, try to catch as much sunlight as possible in the morning and throughout the day.