The Role of Sleep and ADHD
By Robert Wilford, PhD
The common symptoms of Attention Deficit Hyperactivity Disorder (ADHD) are difficulty concentrating, hyperactivity, forgetfulness, and inattentiveness. Patients who are on medications like Adderall or Ritalin can generally overcome these impairments during the day, but at night, it is a different story entirely. What can be managed during the day with drugs is often uncontrolled at bedtime.
For a while, the American Psychiatric Association (APA) ignored sleep disturbance symptoms in ADHD patients, because it subscribed to the theory that all ADHD symptoms would manifest themselves by seven years of age. More recently, it’s been found that sleep disturbances actually do show up in ADHD patients, but not until 12 ½ years old on average. In addition, the symptom of insomnia is often attributed to the stimulant medications used to treat ADHD, rather than the ADHD condition itself.
There are some specific sleep issues that ADHD patients have to contend with from day to day. The four main ones are initiation insomnia, restless sleep, difficulty waking, and intrusive sleep. “Initiation insomnia” is a condition in which the brain won’t shut off. In fact, many ADHD patients report getting a burst of energy in the evening, roughly around the time when other people get sleepy. This problem results in “perverse sleep”––that is, the desire to be awake when you’re asleep, and the desire to be asleep when you’re awake. While not every ADHD patient suffers from this, it is one condition that can crop up.
“Restless sleep” is essentially light, fitful sleep, which can of course be brought about by initiation insomnia. It’s the kind of sleep where there’s a great deal of tossing and turning, and ADHD patients will wake up to find that they don’t feel sufficiently rested. Along with this is “difficulty waking,” which stems from the earlier problem of restless sleep. Basically, after tossing and turning until about 4 AM, they’ll fall into extremely deep sleep––so deep that they sleep through morning alarms. When they finally do wake up, they tend to feel sluggish and lethargic for the rest of the day until about the evening, when initiation insomnia starts again.
One other condition that might show up is something called “intrusive sleep”––or, if you prefer, “hyper focus.” This is a condition in which ADHD patients who are awake will suddenly find themselves extremely drowsy, and sometimes immediately fall asleep. This occurs when patients are disengaged from an activity. This is a sudden shift from paying attention to extreme boredom, and in non-ADHD individuals, it can be likened to a feeling of highway hypnosis.
While it can be difficult to completely eliminate these issues, they can be helped by adhering to a few general guidelines. First, it is advised to avoid caffeine after 5 PM. As a stimulant, caffeine can make most people hyper to the point where they have difficulty falling asleep on time, but an ADHD patient should be extra wary about ingesting anything that could make him or her more tired within a few hours of bedtime.
The next thing to avoid is video games. Video games have their place as entertainment, but not close to bedtime. They tend to get you excited, not calm you down. For those predisposed to becoming more energetic at sundown, video games are likely to exacerbate the problem; likewise, it’s a good idea to avoid strenuous or demanding activities in the evening. If you limit physical activity at least a few hours before bedtime, that will help a great deal.
Finally, try your best to set a consistent bedtime and stick to it. One of the biggest difficulties that ADHD patients face is the Circadian rhythm disorder (in other words, it’s possible for them to sleep well, but not at a typical time of day). Many sleep fine from 4 AM to 11:00 AM, but not from 10 PM to 6 AM, for example. If you can adhere to a consistent bedtime, this will improve the odds of a having proper Circadian rhythm. Hopefully these nuggets of wisdom can help, but either way, it is important to seek an expert in both sleep and ADHD for guidance and advice, as well as possible treatment options. There’s no doubt that ADHD can make sleep challenging, but once you are armed with knowledge and strategies to compensate for it, you may be able to overcome sleep problems once and for all.