ADHD and sleep problems: Why are you always tired?

Introduction

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder affecting people of all ages. The disorder is characterised by patterns of inattention, impulsivity, and hyperactivity that interfere with daily functioning. There are three main subtypes of ADHD, with individuals presenting as predominantly inattentive, predominantly hyperactive-impulsive, and a combined presentation, which involves the features of both inattention and hyperactivity-impulsivity.

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ADHD is often diagnosed in childhood and can persist into adolescence and adulthood. However, this does not mean that an ADHD diagnosis cannot be made in adulthood. While the exact cause of ADHD is unknown, identified risk factors include environmental and genetic factors. These risk factors include premature birth, low birth weight, maternal smoking during pregnancy, family history of ADHD, family conflicts, and even socio-economic status. 

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While the hallmark symptoms of ADHD include difficulties with attention, hyperactivity, and impulsivity, there's another aspect often overshadowed – sleep problems. Many individuals with ADHD struggle with sleep-related issues, leading to chronic fatigue and a range of health concerns. An estimated 50%-75% of adults with ADHD experience sleeping problems such as insomnia, difficulty initiating and maintaining sleep, and even sleeping for shorter periods of time. Individuals with inattentive ADHD subtypes are more likely to sleep at later times, while individuals with hyperactive or impulsive subtypes are more likely to experience insomnia.

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The individuals presenting with combined subtype of ADHD experience later bedtimes and poor sleep quality. Regardless of the subtype, it has been noted that several individuals with ADHD experience difficulty waking up in the morning and daytime sleepiness. 

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The ADHD-sleep connection

People with ADHD frequently report difficulties falling asleep, maintaining a regular sleep schedule, and experiencing restful sleep. Research suggests a complex interplay between ADHD symptoms and sleep problems, creating a cyclical pattern that exacerbates both conditions. Several factors contribute to the ADHD-sleep connection:

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• Neurotransmitter imbalance: ADHD is associated with an imbalance of neurotransmitters, particularly dopamine and norepinephrine, which play crucial roles in regulating attention and arousal. These neurotransmitters also influence the sleep-wake cycle. The dysregulation in their levels may disrupt the natural circadian rhythm, making it challenging for individuals with ADHD to achieve restful sleep.

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• Circadian rhythm disturbances: The circadian rhythm, the body's internal clock, governs the sleep-wake cycle. Individuals with ADHD often experience difficulties in maintaining a regular sleep pattern, leading to irregular sleep-wake cycles. This disruption can result in insufficient and poor-quality sleep, contributing to daytime fatigue.

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• Hyperactivity and impulsivity: Hyperactivity and impulsivity, hallmark features of ADHD, can persist into the evening hours, making it challenging for individuals to wind down and prepare for sleep. The constant activity and impulsive behaviour can delay the onset of sleep, further exacerbating sleep problems.

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• Procrastination and time management issues: Individuals with ADHD commonly struggle with procrastination and difficulties in managing time effectively. This can lead to late-night activities, such as work or entertainment, further delaying bedtime. The resulting sleep deprivation contributes to the fatigue experienced during the day.

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• Coexisting conditions: ADHD often coexists with other conditions that impact sleep, such as anxiety, depression, and sleep disorders like insomnia or sleep apnea. The combination of these factors can intensify sleep disturbances and amplify daytime tiredness.

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The vicious cycle of ADHD and sleep problems

The relationship between ADHD and sleep problems creates a vicious cycle. The symptoms of ADHD can directly contribute to sleep issues, and in turn, inadequate or disturbed sleep exacerbates ADHD symptoms. Understanding this cycle is crucial for developing effective strategies to break it and improve overall well-being.

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• ADHD symptoms disrupting sleep: The core symptoms of ADHD, including impulsivity, hyperactivity, and racing thoughts, can make it challenging for individuals to relax and prepare for sleep. The heightened alertness and constant mental activity can delay the onset of sleep, leading to reduced overall sleep duration.

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• Sleep problems worsening ADHD symptoms: Conversely, insufficient or poor-quality sleep can exacerbate ADHD symptoms. Sleep deprivation impairs cognitive function, attention, and impulse control, intensifying the challenges faced by individuals with ADHD in daily activities. This heightened symptomatology can make it even more difficult to establish and maintain healthy sleep habits.

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Strategies for Managing ADHD-Related Sleep Problems

Breaking the cycle of ADHD and sleep problems requires a multifaceted approach that addresses both the symptoms of ADHD and the specific challenges related to sleep. Here are some strategies that individuals with ADHD can consider:

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• Establishing a consistent sleep schedule: Creating and adhering to a consistent sleep schedule is crucial for regulating the circadian rhythm. Going to bed and waking up at the same time every day, even on weekends, helps train the body to anticipate sleep, promoting better sleep quality.

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• Stimulus control: This encourages people to go to bed only when they feel tired. This rests on the assumption that if the body is not tired, there is no point in forcing the body to sleep. Since individuals with ADHD live very “on the go,” throughout the day, they also believe that they will sleep instantly. Thus, with stimulus control and sleeping only when sleepy will reduce the amount of time spent in bed waiting for sleep, and also reduce associated frustration.

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• Sleep restriction: If one is finding it hard to go to sleep, they can try to get up again for a while and engage in relaxing activities (as noted below) and to return to bed only when one feels wound down. During this time, it is also important to not expose oneself to bright lights, short-form or long-form videos, or perform activities that make your brain alert. It can also be helpful to avoid activities that encourage hyper-fixation just before bed.

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• Creating a relaxing bedtime routine: Engaging in calming activities before bedtime can help individuals with ADHD transition from a state of hyperarousal to relaxation. Making these activities a habit or part of a ritual can also signal to the body that it is time to prepare for bed. These activities are things that are enjoyable and relaxing. This may include activities such as reading, listening to soothing music, or practising relaxation techniques like deep breathing or meditation, having a cup of caffeine-free tea, stretching, taking a hot shower, and yoga to reduce muscular tension and ease stress and anxiety.

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• Limiting stimulants and electronic devices: Stimulants such as caffeine and nicotine can exacerbate ADHD symptoms and interfere with sleep. Additionally, the blue light emitted by electronic devices can disrupt the production of the sleep hormone melatonin. Limiting the consumption of stimulants and avoiding screens at least an hour before bedtime can promote better sleep.

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• Creating a comfortable sleep environment: Optimising the sleep environment is essential for individuals with ADHD. This includes maintaining a cool, dark, and quiet bedroom, investing in a comfortable mattress and pillows, and minimising potential disruptions such as noise and light.

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• Aim to avoid taking worries and responsibilities to bed: The tendency to ruminate will only alert the mind more, keeping you awake. One can attempt to incorporate journaling habits or introducing to-do lists for key responsibilities before bed. This can help reduce anxiety associated with tasks to be planned and allows jobs to be set aside for more appropriate times.

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• Seeking professional support: Consulting with healthcare professionals, including physicians and sleep specialists, is crucial for individuals facing persistent sleep problems associated with ADHD. They can provide a comprehensive evaluation, identify coexisting conditions, and recommend appropriate interventions, including medication if necessary. In some cases, stimulant medication can improve sleep by reducing hyperactivity, letting the body relax and rest. 

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Conclusion

The relationship between ADHD and sleep problems is intricate and bidirectional. Understanding the factors contributing to sleep disturbances in individuals with ADHD is essential for developing targeted strategies to improve sleep quality and overall well-being. By addressing both the symptoms of ADHD and the specific challenges related to sleep, individuals can break the cycle of perpetual fatigue and embark on a path towards better health and improved daily functioning.

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Seeking professional guidance through the team of experts at Rocket Health and implementing lifestyle modifications can empower individuals with ADHD to regain control over their sleep and, consequently, their lives.

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References

“ADHD and sleep disorders diagnosis and management.” (n.d). CHADD. https://chadd.org/about-adhd/adhd-and-sleep-disorders-diagnosis-and-management/. 

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“ADHD and sleep disorders.” (n.d). CHADD. https://chadd.org/about-adhd/adhd-and-sleep-disorders/.

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“ADHD and sleep.” (n.d). NHS Berkshire Healthcare. https://www.berkshirehealthcare.nhs.uk/media/109514310/7-adhd-guide-sleep.pdf.

“Attention-deficit/ hyperactivity disorder (ADHD) in children.” (2019, June 25). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/adhd/symptoms-causes/syc-20350889. 

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Cirino, E. (2020, December 28). “ADHD and sleep disorders.” Healthline. https://www.healthline.com/health/adhd/sleep-problems.

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Hvolby, A. (2015). Associations of sleep disturbance with ADHD: Implications for treatment. Attention Deficit and Hyperactivity Disorders, 7(1), 1-18. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4340974/. 

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Pacheco, D. & Dimitriu, A. (2023, November 16). “ADHD and sleep.” Sleep Foundation. https://www.sleepfoundation.org/mental-health/adhd-and-sleep. 

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Watson, S. (2022, September 28). “Types of ADHD.” WebMD. https://www.webmd.com/add-adhd/childhood-adhd/types-of-adhd.