Categories: 2010, December
by Gina Pera
IT'S MIDNIGHT. IF RAJ STAYS UP MUCH LATER, HE WILL
BE USELESS AT WORK TOMORROW. He is already one careless
mistake from losing his job. Against all logic, this highly intelligent
computer scientist fights both the internal command ("go to bed now")
and encroaching fatigue. "It's not that if I went to bed, I could not
fall asleep immediately. I could. It's that I will actively
refuse to go to bed," he explains. "Instead, I will endlessly
scan the Internet, as though my life depends on finding the newest
headline. Next thing I know, I awaken at three o’clock in the
morning with my head on the keyboard, having won the battle but lost the
war." Recently diagnosed with ADHD, Raj had no clue that this is a
common pattern with other adults who have ADHD until he spoke about it
at the local CHADD group.
At eight-year-old Adrianna's home, nighttime can turn nightmarish very
quickly. "Just ten more minutes!" she will desperately plead. Her
parents usually relent rather than increase sleep-wrecking tension for
the entire household. (Adrianna might be tiny but she is
determined.) The family's therapist attributes the bedtime
dramatics to oppositional defiance. In other words, complying with
bedtime routines might simply be another thing the child refuses to do
without a battle. Adrianna's mother has her doubts: "From the time she
was a small baby, my girl had trouble 'settling down' and going to
sleep. So unlike her older brother. And when she finally did go to
sleep, the slightest noise could awaken her. I figured she had
unfortunately inherited my light sleeper disposition, but now I see that
for both of us, ADHD might have more to do with it than I ever
Forty-three-year-old Janelle never attributed her own internal bedtime
battles to ADHD, diagnosed five years ago, until a recent surprise
discovery. "I've always tended to get really ramped up right after
climbing into bed, even if I was dead tired only thirty minutes
earlier," she explains. "It was as though all the thoughts I never had
time for throughout the day's whirlwind hit me as soon as my head hit
the pillow. At least that's how I explained it to myself. Of course, I
must admit I typically had little trouble going to sleep if I was
getting up the next morning to do something fun.” The
sleeping pills Janelle's physician prescribed left her too groggy the
next day. A revelation came when one afternoon, facing a long drive home
after a business dinner, she took a “booster” dose of her
long-acting stimulant medication. “I fully expected to be kept
awake for hours, but instead I fell asleep much faster than I usually
do,” she says. “Plus, I felt more rested the next morning
than I have in decades.”
THESE STORIES ILLUSTRATE ONLY A FEW OF THE
MYRIAD WAYS IN WHICH ADHD CAN AFFECT SLEEP in both
children and adults, creating a sleep deprivation that can both
intensify ADHD symptoms and make them harder to treat. (Read the story
of one late-diagnosis adult in the Lived Experience column in this
It is estimated that about eighty percent of people with ADHD struggle
with sleep. In fact, 1980s-era diagnostic criteria for ADHD included
"restless sleep," later dropped because the causes were deemed
"nonspecific." Recent research, however, is zeroing in on ADHD's
specific potential effects on sleep. As with ADHD symptoms
themselves, these effects are highly variable. In other words, don't
expect one-size fits-all remedies. Not melatonin. Not sleep medications.
Not a double shot of scotch. Instead, know that specific challenges
require specific treatments. And that's the critical piece when it comes
to ADHD and sleep.
A July 2010 survey of child psychiatrists highlighted insomnia as a
major problem among children in mental health treatment, with at least a
quarter of these patients receiving sleep medication, ranging from
antihistamines to sedating medications for ADHD (such as alpha-agonists
like clonidine) and antidepressants (trazodone). The trouble is, we have
little data about these medications' safety and effectiveness in
treating this population. Behavioral-developmental pediatrician Judith
Owens, a sleep expert with Hasbro Children's Hospital in Rhode Island
who conducted the study, has called for better evidence-based
understanding of appropriate treatment.
Clinical child psychologist Reut Gruber agrees on the need for better
guidelines, pointing out that pediatricians and psychiatrists generally
have not received good education about sleep. "They do not have the
background or the tools they might need to make a good diagnosis," she
says. "The first step will be to arrive at a good diagnosis, and then to
make sure that you have tried every strategy possible before resorting
to medication. That is, medication can be useful but you need to be
clear about why you're using it." In her work at McGill University's
Douglas Institute, Gruber is researching the role of sleep in ADHD and
the genetics of sleep.
What then are the issues, specifically, that can come between people
with ADHD and their ability to consistently get a good night's sleep? It
boils down to four categories:
Difficulty going to bed.
Can you physically get yourself to bed no matter what
remains unviewed on YouTube?
and tasks remain left undone?
• delicious silence hangs in the
• burst of energy comes to you when
the sun goes down?
Difficulty falling asleep.
Can you nod off at the designated hour within a reasonable
amount of time without
• hyperactive thoughts flooding your
• knowing that the slightest sound or
slimmest shaft of moonlight might awaken you (it usually does!)?
Staying asleep (or sleeping
Once you fall asleep, will your sleep be disturbed by
• the slightest noise or slimmest
shaft of moonlight?
• tossing and turning until you're
tangled up in the sheets?
• restless legs syndrome or sleep
apnea? (Note: These are specific sleep disorders but commonly
co-existing with ADHD; they are most reliably diagnosed through sleep
studies, which might include a polysomnogram or a home-based portable
• unaddressed allergies that leave you
with a stuffy nose that obstructs breathing?
Awakening from the “sleep of the
You would expect being hard to rouse at seven o’clock in
the morning if you had finally drifted off at three o’clock. But
even people with ADHD who have slept a reasonable number of hours
experience trouble transitioning to an alert state.
The neurobiology of ADHD itself
As you can guess, these four categories typically
overlap and cross-pollinate. For example, you might delay getting
yourself into bed because you dread facing those hyperactive thoughts
once again. Or maybe it is your daytime challenges around
organization that make a bedtime routine nothing short of the impossible
dream. It's important to sit down and analyze where you suspect the key
problems lie. Experts recommend starting with good "sleep hygiene," the
basic principles that promote good sleep (see the sidebar below).
All that said, there remains one overarching culprit that can conspire
in cunning ways to steal your shuteye: the neurobiology of ADHD itself.
It's easier to understand when you remember that, at the core, ADHD is a
condition of dysregulation, including motivation, arousal, and
What does motivation have to do with sleep? Consider Kristin's
explanation: "I always have trouble getting myself to bed when I have to
work the next day. In my mind, it's like, Oh, I had better take
advantage of this free time, because tomorrow I'll be at work all
day. On the other hand, if I'm booked for a Las Vegas weekend
getaway the next morning, there's no problem going to bed!"
What about arousal and alertness? Blake is the poster boy for category
four. He routinely goes to bed at ten o’clock at night with his
alarm clock set for six o’clock. He nods right off and snoozes
undisturbed. Yet, when that alarm goes off, it does not faze him. (It's
loud, too; his wife calls it the "thermonuclear alarm.") Finally, Blake
heard about the two-alarm strategy for people with ADHD: Set the first
alarm in order take the stimulant medication conveniently placed on the
nightstand with a glass of water, and set the second alarm thirty
minutes later to allow the medication to kick in and promote
arousal and alertness. Children and adults find this
"We need to keep in mind that ADHD is a medical, physiological
disorder," says Patricia Quinn, MD, a developmental pediatrician based
in Washington, DC. "Before even discussing the other issues—for
example, the adults who say, 'I like to stay up late, because
the house is quiet'—we must remember that ADHD is associated with
distinct physiological issues. For the most part, the most common sleep
problems we are talking about with ADHD are not volitional, not
something you choose to do."
Quinn points to EEG studies done since the 1980s indicating that people
with ADHD can have less REM sleep, do not get into stage four sleep (the
second stage of deep sleep, where the brain is making slow delta waves),
and experience more arousals (awakening or tossing and turning) than
people who do not have ADHD. This means they do not get as much
restorative sleep as they should. In addition, there is typically
trouble with sleep onset—that is, falling asleep.
Let us now examine two neurophysiologic issues that commonly affect ADHD
and sleep and strategies for supporting good sleep in people of all ages
Surprise! Sleep requires
Are you shocked to learn that the most significant ADHD-related obstacle
to sleep might be disorganization? No, not the kind of
disorganization that leaves you climbing over piles of books and
clothing just to reach the bed (although that, too, can be a factor if
living with clutter leaves you depressed and anxious). Rather, consider
the disorganized brain.
"A disorganized brain cannot go to sleep," Quinn explains. By contrast,
an organized brain can focus on the task at hand while tuning
out distracting stimuli, whether it is focusing on paperwork or on
Fortunately, the same strategy that organizes the ADHD-affected brain
during the day might also help at night: stimulant medication. Why?
Because, as Janelle discovered accidentally in the story related
earlier, the stimulant engages the inhibitory systems in the
brain—the "brakes," if you will—that keep doze-distracting
thoughts and sensations in check.
This solution stands in marked contrast to the popular myth that
stimulants are the primary cause of ADHD-related sleep
problems. If the physician does not ask about a patient's
lifelong issues with sleep, however, problems might be
mistakenly attributed to the stimulants. Of course, stimulants
might disturb sleep for some people (though a change in the
type of stimulant or the dose might resolve that problem). Sometimes,
too, a coexisting condition such as anxiety or depression might be the
problem; if that condition is left untreated, it can be exacerbated by
the stimulant—and, even independently of stimulants, can thwart
restful sleep. The point is that a stimulant can help some
people get to sleep, though typically a lower dose than the daytime
What about non-stimulant ways to "organize the brain," especially for
children and babies? For starters, there is the time-honored tradition
of rocking and the rhythm of lullabies. At least one popular book has
recommended calming fussy babies by wrapping them tightly; that is also
helping them to organize their brain. Quinn explains: "The
tight wrapping provides feedback through their joints; those
deep-pressure receptors stimulate the brain and help to organize
Many adults swear by a simple white-noise machine for their children and
even themselves. "If it's absolutely quiet, babies and even adults can
get too distracted by every little noise," Quinn says. "The white-noise
machine triggers the brain's 'brakes' to shut out all the small
distractions." In this way, the white noise helps to integrate and
organize the stimuli in the brain instead of leaving stimuli scattering
in all directions and keeping you awake.
Circadian rhythm, melatonin, and resetting
your internal clock
There is an old joke about people with ADHD having two
kinds of time: Now and Not Now. At least one study
shows measurable challenges around judging the accurate passage of time;
that is, even having a "sense" of time. Now researchers hypothesize that
time-trouble might be a 24/7 issue, not restricted to waking hours. In
fact, these challenges might spring from a "dysregulated" internal
clock, causing a condition called "delayed sleep phase."
Reut Gruber explains: "We humans have a biological clock in our brain,
meaning our internal rhythm is usually about twenty-five hours. Yet our
days are twenty-four hours. So the brain uses cues from the environment
to synchronize our internal clock with external daylight. One of these
cues is light. What happens in delayed sleep phase is [that] the
synchronization is not happening. There is a misalignment between
external time and our internal time."
In practical terms, some people with ADHD have difficulty establishing a
sleep cycle that is "in sync" with the rest of the world. In fact, one
study found a common pattern in more than half of the adults with ADHD
studied: They slept best from four o’clock in the morning to noon.
That might work fine for the lucky souls who can wrap their
waking hours around such a schedule; for most of us, however, it is not
What and where is this internal clock anyway? The term refers to the
so-called circadian rhythm within most living creatures' brains that
regulates periods of rest and alertness. For most humans, that circadian
cycle is mostly constant. When the rhythm is stable, we feel sleepy at
roughly the same time each evening and awaken naturally at the same time
each morning. Circadian rhythm is influenced by two factors:
external stimuli, including
exposure to light and the timing of exercise, bedtime, and naps. (See
the tips on sleep hygiene.)
internal hormones, such as
The most benign way to try resetting your clock is through focusing on
the external stimuli. For example, make a habit of getting light
exposure first thing in the morning and dimming your household lights in
As for melatonin, it's a common buzzword among people with ADHD when
they share sleep strategies, and for good reason. Melatonin plays a role
in regulating a dysregulated internal clock. As an over-the-counter
supplement, melatonin supplements have traditionally been used to help
shift workers and long-distance travelers adjust their circadian rhythm.
It's even used to help blind people establish a day-and-night cycle.
Melatonin is a hormone produced by the brain's tiny pineal gland, which
is no larger than a grain of rice. This pinecone-shaped gland (hence the
name) secretes melatonin in sync with circadian rhythms, releasing more
in the dark and less in the light. Darkness causes the body to produce
more melatonin, which signals the body to prepare for sleep. Melatonin
levels normally rise during mid-to-late evening, remain high throughout
the night, and drop during early morning. Yet, many factors can upset
this rhythm, such as insufficient exposure to light in the morning or
keeping bright lights on in the house during the evening.
Melatonin supplements are generally considered safe in low doses for
short-term and long-term use, but be sure to talk with your doctor about
taking them or giving them to your child. Gruber warns: "We do not
really have any safety insurance; these over-the-counter products are
not regulated by the FDA." She recommends starting with establishing
routines and trying light therapy before trying melatonin.
Light therapy can simply mean making sure you get morning sunlight
exposure and dim the household lights each evening. It can also mean
using a light box of the type that is used to help people with seasonal
affective disorder (SAD). Generally you use the lights for about thirty
minutes each morning, with the bright lining shining indirectly toward
your eyes (never directly). Talk to your physician about this
or read up on trusted medical websites online.
Light therapy and melatonin will not help, Gruber reminds, if your issue
is not one of circadian rhythm. "The key is to understand the complexity
of ADHD-related sleep issues rather than reduce the complexity and
provide the same treatment for everyone," she says.
“Things are only going to be worse if you are walking around
sleep-deprived and have ADHD,” Quinn reminds. “It is a real
issue that needs to be confronted and treated in order to make
Before turning to medication or melatonin to
promote sleep, experts advise trying the principles of so-called sleep
hygiene, as detailed below.
Consistent bedtime routines, for example, help both children and adults.
“But, of course, if this is a challenge for the parents, you
cannot expect them to easily do it for the child,” says clinical
psychologist Reut Gruber, director of the Attention, Behavior and Sleep
Lab at McGill University's Douglas Mental Health Institute. “So,
it's important that parents become educated in what needs to be done and
Moreover, know that neurobiological challenges to sleep might travel in
tandem with behavioral challenges. “You need to distinguish
between those people who truly have delayed sleep phase, for example,
versus those who are not willing to go to bed. There might simply be
big-time resistance,” Gruber explains. Her latest research study
attempts to statistically predict whether a child's longer-than-average
“sleep latency” (the amount of time it takes to fall asleep
after the lights have been turned off) can be predicted by their
circadian rhythm. “I'm still analyzing the data, but right now it
seems that both circadian rhythm and behavioral tendencies are
Here are the basic guidelines of good sleep for everyone.
Fix a bedtime and an awakening
time. The body can get accustomed to falling asleep at a
certain time. Even if you are retired or not employed, this is an
essential part of good sleeping habits. Patricia Quinn, a developmental
pediatrician based in Washington, DC, advises sticking to this schedule
even on the weekends. “If you stay up late and sleep in,”
she says, “it's like taking a trip across three time zones each
weekend.” In other words, you have the equivalent of jet lag.
Sleep in a well-ventilated room
at a comfortable temperature. Most find a cool (but not cold)
room best for sleeping.
Block out all distracting noise
and eliminate as much light as possible.
Reserve the bed for sleep (and
for adults, sex). This trains your body that the bed is
associated with sleeping, not playing video games, watching movies, or
surfing the Internet. (Light reading, however, for a half hour might
help you wind down.)
Avoid heavy, spicy, or sugary
foods for four to six hours before bedtime. These can also
affect your ability to stay asleep.
Avoid alcohol for four to six
hours before bedtime. Even though alcohol helps some people get
to sleep, for most there is a wake-up effect a few hours later.
Try a light snack before
bed. Warm milk and foods high in the amino acid tryptophan
Exercise regularly, but not
right before bed. Regular exercise can deepen sleep, but
strenuous exercise within the two hours before bedtime can inhibit
Practice relaxation techniques
before bed. Slow stretches and deep breathing can reduce
anxiety and muscle tension.
Leave your worries at the
bedroom door. Some people write down their worries from the day
as a means of easing their minds.
Establish a bedtime
ritual. Perhaps a warm bath or a few minutes of
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