The Relationship Between ADHD and Sleep

I’ve been interested for a long time in the relationship between ADHD and sleep; particularly in the risk of misdiagnosis of ADHD for what may be sleep problems. In both adults and children with ADHD, sleep problems are common—often significantly more common than in the general population. What’s more, the symptoms of sleeplessness and the symptoms of ADHD, including difficulty with focus, mood swings, and hyperactivity, are often very similar—so similar that it can be difficult to distinguish between the two.

Sleep deprivation and ADHD have long been recognized as having a relationship. But they also have tended to be viewed as separate conditions. A new theory suggests that separation may not be entirely accurate and that sleep problems and ADHD may be even more closely connected than we thought.

At a conference in Paris last fall, an international group of scientists proposed a theory linking the symptoms of ADHD to disruptions in normal circadian rhythm function—disruptions that also can bring about chronic problems with sleep.

The scientists were careful to make clear: They’re not attributing all ADHD symptoms to circadian rhythm dysfunction. But they do say that there is significant evidence of a very close association between ADHD and sleeplessness and suggest that disruptions to normal circadian rhythms may be one important underlying factor that contributes to both conditions.

How scientists are tying ADHD to circadian rhythms

Scientists developed their theory after closely examining the body of research that explores sleep and ADHD—research that shows approximately 75 percent of adults and children with ADHD have problems sleeping. But it’s more than the prevalence of sleep problems in people with ADHD that suggests a strong link. They point to other connections between sleeplessness and ADHD symptoms that suggest an underlying role for circadian rhythm disruption, including:

• Delays in timing of the body’s release of the “sleep hormone” melatonin. Melatonin levels rise and fall according to circadian rhythms, and delays to the nightly increase in melatonin can lead to problems falling and staying asleep. People with ADHD experience delays in the release of their nighttime melatonin, one important sign of a circadian rhythm that’s out of sync.
• The very high prevalence of sleep disorders in adults and children with ADHD. (We’ll look at these more closely in a moment.)
• The tendency among adults and children with ADHD to be more alert during evening hours. Because of melatonin release and other circadian-driven changes, we’re biologically wired to be less alert at night. Alertness and hyperactivity at night are common symptoms of ADHD, and also suggest an underlying issue with circadian rhythms.

What is ADHD?

Let’s take a quick step back and look briefly at the basics of ADHD. Attention deficit hyperactivity disorder is a condition that affects brain activity, leading to behavioral symptoms including:

• Inattentiveness
• Hyperactivity
• Mood swings
• Impulsiveness

The symptoms associated with ADHD often become noticeable around the time a child starts school. In an estimated 50-65 percent of cases, childhood ADHD continues into adulthood. Boys are approximately three times as likely as girls to be diagnosed with ADHD. The symptoms of ADHD can differ among genders, with girls less likely to exhibit hyperactivity and aggression, and more likely to exhibit some of the less overtly disruptive symptoms, including inattention. Some scientists think this may explain, at least in part, why boys are diagnosed more frequently than girls.

How common is ADHD? Estimates vary, but studies indicate ADHD affects approximately 5 to 7 percent of children and more than 3 percent of adults. Diagnosis of ADHD in children and adults has been on the rise for several years. Diagnosis of ADHD in adults can be complicated, in part because of the presence of other conditions with similar symptoms, including substance abuse, depression, and anxiety. Diagnosis of ADHD in children can also be complex, because of the presence of other conditions, including problems with hearing or eyesight, the presence of learning disabilities or differences, anxiety, depression, or changes in a child’s family life or routine.

Because the symptoms of sleep deprivation and sleep disorders are often very difficult to distinguish from ADHD symptoms, both adults and children may be at risk for misdiagnosis of ADHD for what is fundamentally a sleep issue.

Common sleep problems and disorders linked to ADHD

The children and adults with ADHD who I treat come to me with a range of sleep problems. And the scientific evidence strongly indicates that sleep problems, including symptoms of insomnia, are significantly more common in adults and children with ADHD than in the general population. Often, adults and children with ADHD have:

• Trouble falling and staying asleep
• Experiencing unrefreshing, restless sleep
• Trouble relaxing at bedtime—this one is especially true for kids, but happens to adults, too
• Nightmares
• Insufficient sleep, and chronic sleep debt

There are also several sleep disorders that occur more frequently in people with ADHD, including:

RLS: Restless Leg Syndrome

As many as 44 percent of people with ADHD also suffer from RLS, a sleep disorder and neurological disorder that is characterized by uncomfortable sensations in the legs, most often at night and when sedentary. Among the general population, estimates suggest roughly seven to 10 percent of people have RLS. This number gets larger as we get older. RLS can be highly disruptive to sleep, interfering with your ability to fall asleep and stay sleep—and leading to difficulty with daily functioning.

PLMS: Periodic Limb Movements in Sleep

People with PLMS experience twitching movements to the legs, feet, and sometimes arms during sleep itself. Research shows that as many as 26 percent of children with ADHD have PLMS, compared to 1.2 percent of children in the general population. And in children, the symptoms of PLMS are very similar to the symptoms of ADHD, including hyperactivity, inattentiveness and restlessness, mood swings, and difficulty with academic performance. (Many people with RLS also have PLMS, but PLMS often exists independently of RLS.)

OSA and other forms of sleep-disordered breathing

Sleep-disordered breathing refers to a spectrum of conditions, including snoring, where normal breathing is compromised during sleep. Obstructive sleep apnea is one of the most serious forms of sleep-disordered breathing. The symptoms of snoring and particularly of OSA can be very similar to the symptoms of ADHD: distractedness and difficulty focusing, emotional reactivity and moodiness, hyperactivity, impulsivity, restlessness, and daytime tiredness.

Research has found half of children with ADHD show symptoms of sleep-disordered breathing, compared to 22 percent of children without ADHD. Research also indicates that 20-30 percent of people with ADHD also have obstructive sleep apnea.

OSA is closely linked to obesity—being overweight or obese increases the risk for sleep apnea, as well as snoring. Many people aren’t aware that there’s also a link between obesity and ADHD.

What you can do to improve sleep and circadian rhythms

We’ve got a lot still to learn about the underlying factors that lead to ADHD—and whether circadian rhythm disruptions are a cause of ADHD symptoms, as well as sleeplessness. What’s clear is that sleep is more difficult for people with ADHD, and sleeping poorly makes ADHD symptoms worse. The fundamental sleep hygiene strategies that are important to all of us are even more important for children and adults with ADHD.

They include:

Keeping sleep-wake routines consistent.

Circadian rhythms, and sleep patterns, can be reinforced by consistency—or undermined by irregularity. For both children and adults with ADHD, regular bed and wake times can help strengthen sleep and the underlying circadian rhythms that support sleep.

Extend the "power down hour" before bed.

Bedtime resistance is often a big problem in children with ADHD. In addition to keeping consistent bedtimes, children with ADHD can benefit from a longer, quieter, darker wind-down period before bedtime arrives.

Shut down the screens, dim the lights, and engage in quiet activities like reading.

This goes for adults, too! Adults with ADHD are often night owls who have trouble settling down for bed. Keep the lights low, stay away from your smartphone for at least an hour before bedtime, and try mind-body relaxation techniques like meditation or gentle yoga to help you unwind.

Get plenty of daytime exercise.

Plenty of physical activity can help reduce restlessness and hyperactivity, and other behavioral symptoms associated with ADHD, as well as enhance and protect brain function. And exercise gives a terrific boost to sleep. Regular physical activity can help both children and adults with ADHD. Just make sure nobody is doing any vigorous exercise within four hours of bedtime—unless you’re among the small percentage of people who relax after exercise. Just remember, most of us become more alert and energized.

Avoid stimulants.

For adults, avoiding caffeine after the morning, as well as steering clear of stimulants like nicotine and alcohol, can help avoid excessive alertness in the evenings, as well as the restlessness and anxiety associated with ADHD. Children with ADHD can benefit from avoiding sugar and caffeine, which might exacerbate both behavior symptoms of ADHD and sleep problems.

Use light therapy.

Research shows that in adults, morning light therapy improves symptoms of ADHD and shifts sleep toward an earlier circadian timing. Light therapy is used to treat circadian rhythm sleep disorders. Bright light exposure early in the day can help “reset” the body’s circadian clock. It’s important to undertake light therapy in consultation with a sleep specialist or physician, to ensure that you consume light at the right times and for the right durations. On your own, go ahead and get plenty of morning sunlight—it’s the best light therapy around.

Diet and supplement strategies for ADHD and sleep

Always consult your doctor before you begin taking a supplement or make any changes to your existing medication and supplement routine, or to your child’s. This is not medical advice, but it is information you can use as a conversation starter with your physician, or your child’s pediatrician, at your next appointment.

Given the similarities of their symptoms—and what increasingly looks like a potentially shared underlying mechanism—it’s not surprising that many of the diet and supplements doctors recommend for ADHD also benefit sleep.

Omega 3 fatty acids

Remember the omega 3s we looked at recently? These polyunsaturated fatty acids may not only be beneficial for sleep in adults and children, but they may also help to reduce the symptoms of ADHD, including:

• Inattention
• Impulsiveness
• Restlessness
• Aggression
• Difficulty completing tasks
• Trouble with cooperation
• Reduced academic performance

Omega 3s have been shown to boost sleep quality, make falling asleep easier, and increase melatonin. In one study, children who received supplemental omega 3s slept an average of an additional hour a night and woke up much less frequently throughout the night.

Omega 3s play an important role in cognitive development, cognitive function and performance, and cognitive protection, from infancy to old age. Unfortunately, the typical Western diet is low in omega 3 fatty acids. Good dietary sources of omega 3s include many types of fish, grass-fed meat and animal products, walnuts, and flaxseeds.

Magnesium

The essential mineral magnesium has broad benefits and protections for the brain and body, including for mood, behavior, and sleep. Healthy levels of magnesium also promote relaxation, in part because of magnesium’s ability to increase levels of the calming neurotransmitter GABA. Maintaining magnesium levels also can have a stabilizing effect on mood.

Low magnesium in children has been linked to several of the hallmark symptoms of ADHD, including impulsive behavior, hyperactivity, and inattention. Studies have found as many as 95 percent of children with ADHD may be deficient in magnesium. A recent, small study found supplemental magnesium improved cognitive function in children with ADHD who were magnesium deficient. Other research has suggested supplemental magnesium may improve behavioral symptoms in children with ADHD.

Magnesium-rich foods include dairy products, dark leafy green vegetables, beans, and whole grains.

Iron

Did you know iron deficiency is the most common nutritional deficiency worldwide? As anyone whose experienced anemia can attest, iron deficiency saps your energy, leaves you feeling tired, sluggish, and fuzzyheaded during the day, and can make it harder to sleep well at night.

There is evidence that a lack of iron may be linked to ADHD in children. An essential mineral, iron is important to cognitive, emotional, and behavioral development and functioning. Research indicates iron deficiency may increase the risk for ADHD, as well as mood disorders and autism spectrum disorder, ASD. Iron deficiency—which causes anemia—also can interfere with sound, restful sleep and cause unhealthful changes to sleep cycles, in adults and children.

Good dietary sources of iron include fish, especially shellfish; poultry and red meat; vegetables including broccoli and spinach; beans; and tofu

Valerian root

As an herbal supplement, valerian is well-known and well-studied for its benefits to sleep. Valerian has relaxing, sedating effects, and increases levels of the calming neurotransmitter GABA, which promotes relaxation and sleep. A 2014 study found a combination of valerian and lemon balm significantly reduced hyperactivity and restlessness, and improved focus and sleep in children. (The children in this study exhibited signs of hyperactivity and trouble with concentration, but did not meet the diagnostic criteria for ADHD.)

Vitamin D

There’s evidence that low levels of Vitamin D are more common in children with ADHD than in the general population. Vitamin D is critical for sleep, as well as for mental and physical health. In recent years, scientists have increasingly focused on the importance of Vitamin D to brain development, brain function, and brain protection. A lack of Vitamin D has been associated with mood disorders, including depression, as well as with autism spectrum disorder, ASD.

Unfortunately, Vitamin D deficiencies are common, with an estimated 50 percent or more of adults and children in the U.S. lacking sufficient amounts. Sunshine is your best source of Vitamin D. Exposure to the sun on your skin triggers the body’s Vitamin D synthesis. Dietary sources include fatty fish, including salmon, tuna, and sardines; eggs; dairy products; and Vitamin D-fortified juices and cereals.

Melatonin

Melatonin is considered a powerful antioxidant, important to brain function, and protection against neurological dysfunction. It’s also been found to reduce cognitive impairment that’s associated with sleep deprivation. Research has found melatonin can improve sleep in children with ADHD. But remember, melatonin is a hormone and not something we like to use, especially in young girls. Cherries are a prime source of dietary melatonin. A recent study found that both melatonin and serotonin levels improved significantly among tart cherry juice drinkers. Other good dietary sources of melatonin include foods rich in tryptophan (including poultry, other meat, fish, spinach, and soybeans, among many others) and several foods found in the Mediterranean diet (including tomatoes, bell peppers, and walnuts).

We don’t yet know exactly how ADHD and disrupted sleep are related, and what role circadian rhythm disruptions may play in connecting the two. But the overlap between the two conditions is striking. As scientists continue to investigate this complex relationship, we may come to view ADHD and sleeplessness not as two separate conditions, but as two different expressions of a single, underlying problem.