Adapted from ADHD Sleep Advice - ADDitude Magazine

People with ADHD know that their sleep can be disturbed by mental and physical restlessness, and that it can impact a person's ADHD treatment. But, as with most of our knowledge about ADHD, we are now starting to understand a stronger ADHD-sleep link, raising the awareness of issues concerning falling asleep, staying asleep, and waking.

Sleep disturbances associated with ADHD generally appear later in life, at around age 12 ½, on average. Consequently, the arbitrary age cutoff has prevented recognition of sleep disturbances in ADHD until recently, when studies of adults have become more common. Just as ADHD does not go away at adolescence, it does not go away at night either. It continues to impair life functioning 24 hours a day.

In early attempts to define the syndrome, sleep disturbances were briefly considered a criterion for ADHD, but were dropped from the symptoms list because evidence of them was thought to be too nonspecific. As research has expanded to include adults with ADHD, the causes and effects of sleeping disturbances have become clearer.

The THREE big sleep issues

No scientific literature on insomnia lists ADHD as a prominent cause of sleep disturbances. Most articles highlight sleep disturbance due to stimulant-class medications, rather than looking at ADHD as the cause. Yet people with ADHD know that the connection between their condition and sleep problems is real. 

The three most common sleep disturbances associated with ADHD are:

1. Initiation Insomnia 

About 75% of all adults with ADHD report inability to "shut off my mind so I can fall asleep at night." Many describe themselves as "night owls" who get a burst of energy when the sun goes down. Others report that they feel tired throughout the day, but as soon as the head hits the pillow, the mind clicks on. Their thoughts jump or bounce from one worry to another. Unfortunately, many of these adults describe their thoughts as "racing," prompting a misdiagnosis of bipolar mood disorder, when this is nothing more than the mental restlessness of ADHD.

Prior to puberty, 10 to 15 percent of children with ADHD have trouble getting to sleep. This is twice the rate found in children and adolescents who do not have ADHD. This number dramatically increases with age: 50 percent of children with ADHD have difficulty falling asleep almost every night by age 12 ½ by age 30, more than 70 percent of adults with ADHD report that they spend more than one hour trying to fall asleep at night.

2. Restless Sleep 

When individuals with ADHD finally fall asleep, their sleep is restless. They toss and turn. They awaken at any noise in the house. They are so fitful that bed partners often choose to sleep in another bed. They often awake to find the bed torn apart and covers kicked onto the floor. Sleep is not refreshing and they awaken as tired as when they went to bed.

3. Difficulty Waking 

More than 80 percent of adults with ADHD in my practice report multiple awakenings until about 4 a.m. Then they fall into "the sleep of the dead," from which they have extreme difficulty rousing themselves.

They sleep through two or three alarms, as well as the attempts of family members to get them out of bed. ADHD sleepers are commonly irritable, even combative, when roused before they are ready. Many of them say they are not fully alert until noon.

What's going on here?

There are several theories about the causes of sleep disturbance in people with ADHD, with a telling range of viewpoints. Physicians base their responses to their patients' complaints of sleep problems on how they interpret the cause of the disturbances. A physician who looks first for disturbances resulting from disorganized life patterns will treat problems in a different way than a physician who thinks of them as a manifestation of ADHD.

Thomas Brown, Ph.D., longtime researcher in ADHD and developer of the Brown Scales, was one of the first to give serious attention to the problem of sleep in children and adolescents with ADHD. He sees sleep disturbances as indicative of problems of arousal and alertness in ADHD itself. Two of the five symptom clusters that emerge from the Brown Scales involve activation and arousal:

• Organizing and activating to begin work activities.

• Sustaining alertness, energy, and effort.

Brown views problems with sleep as a developmentally-based impairment of management functions of the brain - particularly, an impairment of the ability to sustain and regulate arousal and alertness. Interestingly, he does not recommend treatments common to ADHD, but rather recommends a two-pronged approach that stresses better sleep hygiene and the suppression of unwanted and inconvenient arousal states by using medications with sedative properties.

The simplest explanation is that sleep disturbances are direct manifestations of ADHD itself. True hyperactivity is extremely rare in women of any age. Most women experience the mental and physical restlessness of ADHD only when they are trying to shut down the arousal state of day-to-day functioning in order to fall asleep. At least 75 percent of adults of both genders report that their minds restlessly move from one concern to another for several hours until they finally fall asleep. Even then, they toss and turn, awaken frequently, and sometimes barely sleep at all.

The fact that 80 percent of adults with ADHD eventually fall into "the sleep of the dead" has led researchers to look for explanations. No single theory explains the severe impairment of the ability to rouse oneself into wakefulness. Some ADHD patients report that they sleep well when they go camping or are out of doors for extended periods of time.

Baltimore-based psychiatrist Myron Brenner, M.D., noted the high incidence of ADHD individuals among the research subjects in his study of Delayed Sleep Phase Syndrome (DSPS). People with DSPS report that they can experience a normal sleep phase — for example, get into bed, fall asleep quickly, sleep undisturbed for eight hours, and awake refreshed — but that their brains and bodies want that cycle from 4 a.m. until noon. This is a pattern reported by more than half of adults with ADHD. Brenner hypothesizes that DSPS and the sleep patterns of ADHD have the same underlying disturbance of circadian rhythms. Specifically, he believes that the signal which sets the internal circadian clock (the gradual changes in light caused by the sun's setting and rising) is weak in people with ADHD. As a result, their circadian clock is never truly set, and sleep drifts into to the 4 a.m.-to-noon pattern or disappears entirely, until the sufferer is exhausted.

One hypothesis is that the lack of an accurate circadian clock may also account for the difficulty that many with ADHD have in judging the passage of time. Their internal clocks are not "set." Consequently, they experience only two times: "now" and "not now." Many of my adult patients do not wear watches. They experience time as an abstract concept, important to other people, but one which they don't understand. It will take many more studies to establish the links between circadian rhythms and ADHD.

How to get to sleep

No matter how a doctor explains sleep problems, the remedy usually involves something called "sleep hygiene," which considers all the things that foster the initiation and maintenance of sleep. This set of conditions is highly individualized. Some people need absolute silence. Others need white noise, such as a fan or radio, to mask disturbances to sleep. Some people need a snack before bed, while others can't eat anything right before bedtime. A few rules of sleep hygiene are universal:

• Use the bed only for sleep or sex, not as a place to confront problems or argue.

• Have a set bedtime and a bedtime routine and stick to it - rigorously.

• Avoid naps during the day.

• Get at least 20 minutes of bright light in the morning, either from natural light or a blue light.

Two more elements of good sleep hygiene seem obvious, but they should be stressed for people with ADHD.

• Get in bed to go to sleep. Many people with ADHD are at their best at night. They are most energetic, thinking clearest, and most stable after the sun goes down. The house is quiet and distractions are low. This is their most productive time. Unfortunately, they have jobs and families to which they must attend the next morning, tasks made harder by inadequate sleep.

• Avoid caffeine late at night. Although many people without ADHD report that coffee actually helps them to sleep, there is usually a fine line between the right amount and too much caffeine. Caffeine is a potent diuretic, and while it may help some fall asleep, it causes awakening two or three hours later to void the bladder.