ADHD and Sleep

Healthful Vitality | 04/12/2019 | By Sarah Schulze, BSN, MSN | ADHD and Sleep

Attention deficit and hyperactivity disorder is disorder affecting typical neurodevelopment in children, with approximately 10% of children ages 6 to 17 years of age diagnosed (5). This article explores the relationship between ADHD and sleep and aims to offers useful tips for the best possible sleep. Attention deficit and hyperactivity disorder (ADHD) is characterized by difficulty paying attention, daydreaming, impulse control, fidgeting, rushing or making mistakes, and difficulty taking turns, among others. These symptoms can cause impaired parent-child relationships, poor school performance, and poor emotional regulation (4).

ADHD symptoms

Typically, ADHD symptoms are divided into three categories:

1) Hyperactive type

Hyperactive type, which involves restlessness, fidgeting, frequent movements, speaking out of turn, or risk-taking behaviors,

2) Inattentive type

Inattentive type, which involves daydreaming, trouble finishing tasks, requiring frequent redirection, forgetfulness, and poor attention to detail or

3) Combined type

Combined type, which involves symptoms of both hyperactivity and inattention (1).

Presently, the cause of ADHD is largely believed to be genetic and appears to have a strong hereditary link. Environmental factors such as tobacco smoke and drug exposure during pregnancy, brain injuries, elevated lead levels, underweight at the time of birth, or being born early all are hypothesized to be linked as well (1). Other environmental factors are believed to contribute to or worsen symptoms, including excessive “screen time” (TVs/phones/tablets/other electronics), poor diet, sedentary lifestyle, and irregular sleep schedule (1).

The link between ADHD and poor sleep

More and more, the link between ADHD and poor sleep is being studied and a sort of chicken-or-the-egg conundrum has developed. Due to the prevalence of sleep problems in children with ADHD, it is widely believed to be a symptom of the disorder and good sleep hygiene, as well as medications to help induce/maintain sleep, are common facets of ADHD treatment regimens. However, problems with sleep can often cause poor focus, restlessness, impulse control, poor school performance, and other issues similar to the symptoms of ADHD (2), leaving medical professionals deliberating which came first.

This link is still being studied, but there is some conjecture that addressing sleep as one of the primary contributors to ADHD and treating underlying sleep disorders may drastically improve ADHD outcomes and avoid or help minimize the need for traditional treatments such as stimulant medications (4). The following summary will touch on several areas of sleep as it relates to ADHD and implications for care of patients with ADHD. This issue is complex and nuanced, with research still developing, therefore keep in mind that this discussion will be fairly brief when compared to the full body of evidence available.

Good sleep habits are known to be beneficial to all children and adults, and many symptoms of daytime tiredness or sleep deprivation can be managed with simple routine and adequate sleep.

Tips for the best possible sleep

The National Sleep Institute offers several tips for the best possible sleep (3):

Set a bedtime

This is important for several reasons. A realistic and consistent bedtime can help ensure adequate number of hours of sleep per night (the recommended number varies for children based on age, but is typically between 8-13 hours per night), is predictable and provides routine for children so they know what to expect, and helps regulate circadian rhythm (3).

Pay attention to sleep space

Make sure children have a dark, quiet space to get comfortable at night. Outside light should be minimized, a white noise machine can help with distracting or loud outside noises, and there should be no TV or other screens. The room should be a comfortable temperature as well. Beds should be reserved for sleep and other activities such as working on homework or playing video games should take place elsewhere (3).

Good habits to manage ADHD and sleep disorder

Avoid caffeine and nicotine intake during the day

Keep wake times and bedtime the same each day, even on weekends. Avoid heavy meals right before bed (3). These tips and habits contribute to adequate hours of sleep and ensure that sleep is restful and restorative. Inadequate sleep can contribute to behavior issues or poor functioning during the day for children, and a thorough sleep history should start with these most basic of considerations (5).

Discourage screens in the bedroom

Unquestionably, screens in the bedroom should be discouraged. However, daytime screen usage should be monitored and regulated as well. Besides, the blue light from electronic devices can inhibit the body’s release of melatonin (or usage of synthetic melatonin that may have been taken). Furthermore, delaying sleep onset and impairing proper sleep cycles, making sleep less restful. Again, excessive screen time contributes to irritability and difficulty focusing for children with ADHD. Therefore, the link to sleep issues creates another reason to keep screen time under 2 hours per day and avoid screens during the hour before bedtime (3).

Other common sleep disorders seen in patients with ADHD

Notably, a few other common sleep disorders seen in patients with ADHD should be further explored. One of the most common is sleep-disordered breathing. Sleep-disordered breathing refers to irregular or impaired breathing (ranging from simple snoring to obstructive sleep apnea), leading to periods of hypoxia and fragmented or ineffective sleep cycles (5). In a complex process, this nighttime hypoxia can lead to systemic inflammation, increased vascular permeability, impaired blood-brain barrier, and resulting in cognitive impairment (5). When indicated, CPAP or tonsil and adenoidectomy could be considered in patients where a sleep disorder is contributing to behavioral issues (5).

Restless leg syndrome

Restless leg syndrome is an uncomfortable and irresistible urge to move the legs and is experienced by an estimated 44% of children with ADHD (2). Indeed, this is a neurological disorder that affects a person at rest. Essential to realizing symptoms are most commonly noted when trying to lie down at night but can also occur during the day when the child is expected to be sitting still, such as while sitting at a desk at school (3). Undoubtedly, the restless and fidgety movements interrupt sleep cycles and cause daytime tiredness.

Circadian rhythm disturbances

Circadian rhythm disturbances are also common in children with ADHD. They often have delayed melatonin secretion, a preference for a late bedtime, and difficulty waking in the morning (2). Bright light therapy and synthetic melatonin can help improve sleep if a circadian rhythm disturbance is suspected. Delayed school start times are also an emerging trend that can be helpful with this, as it allows students the chance to sleep later if they do not fall asleep until late (2).

It is essential to consider that the traditional treatment for ADHD, stimulant medications, may also contribute to sleep disturbances. While helpful with impulse control and organizing thoughts and actions, stimulant medications do just as their name suggests and stimulate the sympathetic nervous system. The common side effects are increased heart rate, jitteriness, decreased appetite, and sleep disruption. In addition, studies show an increased amount of time required to initiate sleep and more frequent nighttime awakenings are common side effects of methylphenidate drugs (2).

Several factors need to consider in evaluating a child with ADHD

There are many factors to consider when evaluating a child with ADHD. High priority should be given to assessing sleep habits, routine, and quality. These may reveal possible ways to manage symptoms and improve the overall quality of life. Much research still needs to be done regarding sleep disruptions and ADHD. And theories on which issue occurs first will continue to be debated as more evidence unfolds. As we continue to understand the link between the two better, we can minimize the impact of both disorders and achieve the optimum quality of life for affected patients.

Related Article: Why Does Sleep Music Matter?

References:

1. Centers for Disease Control and Prevention. (2018). What is adhd.
2. Hvolby, A. (2015). Associations of sleep disturbance with adhd: implications for treatment. Attention Deficit and Hyperactivity Disorders, 7(1). Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4340974/
3. National Resource Center on ADHD. (2015). ADHD, sleep and sleep disorders. Retrieved from: https://chadd.org/wp-content/uploads/2018/04/sleep.pdf
4. National Sleep Foundation (n.d.). ADHD and sleep. Retrieved from: https://www.sleepfoundation.org/articles/adhd-and-sleep
5. Um, Y. H., Hong, S.C., and Jeong, J. H. (2017). Sleep problems as predictors in attention-deficit hyperactivity disorder: causal mechanisms, consequences, and treatment. Clinical Psychopharmacology and Neuroscience, 15(1). Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5290714/  

Author:

Sarah Schulze is a board-certified pediatric Nurse Practitioner. She earned a B.S. in Nursing from Indiana State University and an M.S. in Nursing from the University of Illinois at Chicago.