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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

Minding Your Mind Minding Your Mind

The Link Between ADHD and Sleep Problems

March 19, 2014

By Michael Craig Miller M.D.

Harvard Medical School

Parents and clinicians report that sleep problems affect 25% to 50% of children and adolescents with attention deficit hyperactivity disorder (ADHD). The most typical problems include resisting getting into bed and difficulty falling asleep.

Although the sleep of children with ADHD is similar to that of other youths, children with ADHD appear to be more active during the night (they move more). And their sleep patterns vary more from one night to the next.

Clinicians have tried to figure whether sleep disorders cause attention problems or whether ADHD causes sleep problems. But it's impossible to know.

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Understanding the Relationship

Many factors are probably involved when it comes to sleep problems in kids with ADHD. And these factors almost certainly interact with one another.

Biology. Brain circuits that control attention and sleep may be one common root of the problem. Or a faltering biological clock (that is, an unsteady circadian rhythm) may be a culprit. One study reported that medication-free children with ADHD who have trouble falling asleep have a delay in their nighttime increase of melatonin (a chemical that is involved in sleep onset) when compared with unmedicated children with ADHD who do not have insomnia.

Behavior. Symptoms such as hyperactivity and an inability to settle down may contribute to resistance at bedtime. Likewise, poor sleep at night can worsen behavior during the day. This leads to a negative cycle that affects both sleep quality and ADHD symptoms.

According to one study, hyperactive behavior may result from the brain not being aroused enough — at least in some children. Researchers measured sleep quality and daytime alertness in youths with ADHD. Children with ADHD have a similar quality of sleep as do children without ADHD. Children with ADHD, however, were less alert and more likely to be sleepy during the day.

Other conditions. Anxiety, depression, learning disorders and conduct disorders are also common in people with ADHD. Any of these alone may contribute to sleep problems. Children with ADHD and anxiety or depression, for example, may chew over the day's events or worry about the day to come. Distressing thoughts may keep them awake.

Children may also develop sleep disorders along with ADHD. Two of the most common are sleep-disordered breathing (affecting up to 25% of children with ADHD) and restless legs syndrome (affecting as many as 36%). In different ways, these disorders contribute to fitful sleep or waking several times during the night.

Stimulants. About one-third of children with ADHD who are not taking medicine experience chronic insomnia. This suggests that difficulty falling asleep may be a basic part of ADHD. Nevertheless, research also suggests that stimulants used to treat children and adolescents with ADHD probably make insomnia worse in some youngsters.

One option for children is to take stimulants only early in the day. However, some may experience a "rebound" effect. Their mood or behavior changes as the stimulant drug wears off. For these children, lowering the stimulant dose, using a time-release formula, or switching to a nonstimulant drug may be worth considering.

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Helping Kids Sleep Better

Treatment options for sleep problems in people with ADHD are generally the same as for other people. The first step consists of lifestyle changes and behaviors that promote sleep. Psychotherapy or medications provide additional options when necessary.

Sleep hygiene. A current view is that people can learn how to sleep better. "Sleep hygiene" describes behaviors that promote good sleep. These include maintaining a regular sleep-and-wake schedule, using the bedroom only for sleeping and keeping the bedroom free of distractions — a television, computer or game system.

Caffeine. Coffee and tea aren't the only drinks that have this stimulant. Some soft drinks, such as cola, orange and citrus sodas, contain a lot of caffeine. Chocolate drinks and candy also have it. It's important to avoid caffeine after noon, because this substance can remain in the system for 12 hours or more.

Physical activity. Regular exercise during the day, especially aerobic activity, helps people fall asleep faster, spend more time in deep sleep and awaken less often during the night. As an added bonus, physical activity also helps expend some of the energy that may contribute to hyperactivity and restlessness. It may be hard to sleep right after exercising, however, so it's worth avoiding physical activity in the hours just before bedtime.

Light therapy. If the circadian rhythm — your body's natural sleep-wake pattern — is off, light therapy may be worth a try. Morning light therapy (similar to that prescribed for seasonal affective disorder) may help adults improve daytime alertness and focus. A case report found similar benefits for younger patients.

Cognitive behavioral therapy. People who sleep poorly can become preoccupied with problems while lying in bed. Cognitive behavioral techniques can help them slow their thoughts down while building more confidence that they can enjoy a good night's sleep.

Medications. Preliminary research in children with ADHD and insomnia suggests that melatonin in the evening may help them regulate their sleep cycles. Antidepressants and other medications to treat co-occurring disorders, such as depression or anxiety, may help if obsessive thoughts are the problem. There are also a variety of sleep aids, but these have generally not been studied in children.

Be patient. It's harder to develop good sleep habits if sleep becomes a struggle. The goal is to help your child learn one of the most important life skills: knowing how to get a good night's sleep. That could provide a lifetime of benefit.

Gruber R, et al. "Instability of sleep patterns in children with attention-deficit/hyperactivity disorder." Journal of the American Academy of Child and Adolescent Psychiatry. April 2000; 39(4): 495-501.

Van der Heijden KB, et al. "Idiopathic chronic sleep onset insomnia in attention-deficit/hyperactivity disorder: A circadian rhythm sleep disorder." Chronobiology International. 2005; 22(3): 559-70.

Lecendreux M, et al. "Sleep and alertness in children with ADHD." Journal of Child Psychology and Psychiatry. September 2000; 41(6): 803-12.

Golan N, et al. "Sleep disorders and daytime sleepiness in children with attention-deficit/hyperactive disorder." Sleep. March 15, 2004; 27(2): 261-66.

Gruber R. "Sleep characteristics of children and adolescents with attention deficit-hyperactivity disorder." Child and Adolescent Psychiatry Clinics of North America. October 2009; 18(4): 863-76.

Rybak YE, et al. "An open trial of light therapy in adult attention-deficit/hyperactivity disorder." Journal of Clinical Psychiatry. October 2006; 67(10): 1527-35.

Owens JA. "Sleep disorders and attention-deficit/hyperactivity disorder." Current Psychiatry Reports. October 2008; 10(5): 439-44.

Michael Craig Miller, M.D. is editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 25 years.


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