Are my ADHD symptoms impacting my ability to sleep? Are my struggles with sleep contributing to my ADHD symptoms? Which problem emerged first?
This line of questioning can seem like a chicken/egg scenario and unfortunately, we do not conclusively know the answer.
It has been reported that sleep disorders and disturbances affect up to 80% of people diagnosed with ADHD,[1] making this one of the biggest comorbidities that we face. The biological cause for this is still poorly understood. However, after over a decade of research into the topic, there have been significant observations made that may lead us to the answer.
Does ADHD affect sleep?
Sleep research measures sleep quality in two main ways. One way is through subjective measures, such as data collected via self-report questionnaires. The other is through objective measures, such as data collected via sleep studies. Some research has found that, despite high subjective measures of sleep disturbance, the objective measures showed no significant difference compared to the control group.[2] If you have ever been through a sleep study and the doctor said that they had not found a distinct cause for your struggle, this might be why.
Sleep difficulties commonly observed among the ADHD population include trouble falling asleep, not feeling tired at the ‘right’ time, frequently waking up at night,[3] restlessness, and an increased number of sleep stage shifts.[4]
A partial explanation for difficulties falling asleep could be delayed melatonin onset. Our bodies naturally make and release melatonin, which is part of what causes us to feel sleepy. Many of us with ADHD have a delayed release of this hormone, causing us to feel sleepy later than is considered normal. At the start of one study, 77% of subjects with ADHD had a melatonin release after 9 pm.[5]
Does sleep affect ADHD?
In contrast, it has been clinically demonstrated that poor quality of sleep can have a detrimental effect on many ADHD symptoms.
Consistent lack of sleep can significantly increase the prevalence of inattentive and oppositional behaviors,[6][7] and impair the ability to emotionally self-regulate.[8] This leads to a decrease in overall school/work performance and quality of life.[9]
How do stimulants affect sleep?
Given what we know about this cyclical relationship between ADHD symptoms and sleep, it’s natural to consider how our medications might also impact this cycle. ADHD research shows that the answer varies by person and depends on the primary struggle with sleep.
For example, one study showed that stimulants may cause a delay in melatonin release,[10] leading to a later bedtime preference. Similar studies have also shown that stimulant medications can shorten the amount of time spent asleep.[11][12] Other studies have shown no measurable effects on subjective or objective measures of sleep.[13][14][15]
There is also anecdotal evidence to suggest that the use of stimulants can remove some barriers to falling asleep, such as racing thoughts, which makes a restful sleep easier to achieve. If you are curious about how medication may impact your sleep, make a list of questions and personal observations to discuss with your prescriber at your next appointment.
How to sleep with ADHD
How we choose to structure our day has a significant impact on our ability to sleep.
Below I have outlined suggestions to help restructure or adapt your daily routine to facilitate a better night’s rest:
1. Add More Dopamine
Incorporating more dopamine-stimulating activities throughout your daily routine can help to eliminate the desire for revenge bedtime procrastination – staying up late to have ‘me-time.’ Setting aside blocks of time throughout your day to enjoy activities that are meaningful and energizing to you will prevent feeling like you have spent your entire day in service to others. For more information on how to identify these activities for yourself, check out our other articles: ADHD and Dopamine & Examples of a Dopamenu!
2. Exercise
Incorporating exercise into your daily routine is a suggestion that I’m sure you have heard before. Getting at least 30 minutes of aerobic exercise can improve your quality of sleep that very same night.[16]
3. Adjust Nap Times
Avoiding naps after about 2 pm is another way to improve your sleep quality. When you take a nap, your body releases built-up adenosine, a neurotransmitter responsible for feelings of drowsiness. When you are awake, the body builds these levels back up.
4. Monitor Caffeine Intake
Caffeine can also disrupt the adenosine process by the very nature of how it works. Caffeine binds to the same neurotransmitters as adenosine, replacing the drowsy signal with a stimulant signal.[17] This is great for the mornings but has damaging implications for late afternoons or evenings.
5. Relaxing Evening Routine
It can be helpful to consider that our evening routine starts right after dinner. Those post-sunset hours may be best filled with relaxing activities, such as showers or reading.
6. Journaling
If you struggle with racing thoughts, journaling before bed may be a helpful tool to acknowledge these thoughts and get them out of your head. A small study showed that this habit was effective at reducing anxiety and improving sleep quality.
7. Bedroom Temperature
Keeping the temperature of your bedroom between 16-19° C (60-67°F) can help prevent waking up in the middle of the night from unintentional discomfort.
8. Consider a New Bedtime Trigger
Starting a new routine is usually not a quick fix – it requires retraining your brain to respond differently to a new stimulus. See if you can incorporate a new totem or trigger that will tell your brain it is time for sleep.
9. Regulate Circadian Rhythm
Our circadian rhythm, which is heavily impacted by natural sunlight, manages the release of melatonin within the body. Therefore, one of the best things you can do to normalize your circadian rhythm is to expose your face to direct sunlight around sunrise and sunset. Wearing sunglasses every time you are out in the sun could also be preventing this light from entering through the eyes, ultimately doing more harm than good.
10. Melatonin
The use of supplemental melatonin is a widely suggested and heavily researched treatment for combating a dysregulated circadian rhythm. One study that combined the use of melatonin and Bright Light therapies advanced the release of melatonin in subjects by up to 2 hours.[18]
11. Bright Light Therapy
Accessing the sun's natural rays is not always possible, particularly in dark, wintery climates. Research has found that Bright Light therapy is a viable alternative to natural sunlight.
12. Blue-light Filters
When enjoying screen time before bed, turning on an amber filter is key because the blue light from our screens can further disrupt our circadian rhythms.
I hope you enjoy experimenting with some of these suggestions! Remember, if you are looking for additional support with developing a personalized evening routine, our ADHD Coaches are trained to help.
Author:
Sarah R. is the Head Coach at Unconventional Organisation. She has worked in the field of social work over the past five years, worked with a diverse range of individuals and has a Bachelor of Sociology. You can read more about Sarah on our home page or connect with her by booking an ADHD Coaching intake appointment.
References
[1] Weiss, M. D., MD PhD, & McBride, N. M. M. (2020, November 16). ADHD: A 24-Hour Disorder. Psychiatric Times. Retrieved February 20, 2022, from https://www.psychiatrictimes.com/view/adhd-24-hour-disorder
[2] Díaz-Román, A., Mitchell, R., & Cortese, S. (2018). Sleep in adults with ADHD: Systematic review and meta-analysis of subjective and objective studies. Neuroscience and biobehavioral reviews, 89, 61–71. https://doi.org/10.1016/j.neubiorev.2018.02.014
[3] Wajszilber, D., Santiseban, J. A., & Gruber, R. (2018). Sleep disorders in patients with ADHD: impact and management challenges. Nature and science of sleep, 10, 453–480. https://doi.org/10.2147/NSS.S163074
[4] Ferri, R., Bruni, O., Novelli, L., Picchietti, M. A., & Picchietti, D. L. (2013). Time structure of leg movement activity during sleep in attention-deficit/hyperactivity disorder and effects of levodopa. Sleep medicine, 14(4), 359–366. https://doi.org/10.1016/j.sleep.2012.12.012
[5] van Andel, E., Bijlenga, D., Vogel, S., Beekman, A., & Kooij, J. (2021). Effects of chronotherapy on circadian rhythm and ADHD symptoms in adults with attention-deficit/hyperactivity disorder and delayed sleep phase syndrome: a randomized clinical trial. Chronobiology international, 38(2), 260–269. https://doi.org/10.1080/07420528.2020.1835943
[6] Becker, S. P., Epstein, J. N., Tamm, L., Tilford, A. A., Tischner, C. M., Isaacson, P. A., Simon, J. O., & Beebe, D. W. (2019). Shortened Sleep Duration Causes Sleepiness, Inattention, and Oppositionality in Adolescents With Attention-Deficit/Hyperactivity Disorder: Findings From a Crossover Sleep Restriction/Extension Study. Journal of the American Academy of Child and Adolescent Psychiatry, 58(4), 433–442. https://doi.org/10.1016/j.jaac.2018.09.439
[7] Waldon, J., Vriend, J., Davidson, F., & Corkum, P. (2018). Sleep and Attention in Children With ADHD and Typically Developing Peers. Journal of attention disorders, 22(10), 933–941. https://doi.org/10.1177/1087054715575064
[8] Becker, S. P., Tamm, L., Epstein, J. N., & Beebe, D. W. (2020). Impact of sleep restriction on affective functioning in adolescents with attention-deficit/hyperactivity disorder. Journal of child psychology and psychiatry, and allied disciplines, 61(10), 1160–1168. https://doi.org/10.1111/jcpp.13235
[9] Floros, O., Axelsson, J., Almeida, R., Tigerström, L., Lekander, M., Sundelin, T., & Petrovic, P. (2021). Vulnerability in Executive Functions to Sleep Deprivation Is Predicted by Subclinical Attention-Deficit/Hyperactivity Disorder Symptoms. Biological psychiatry. Cognitive neuroscience and neuroimaging, 6(3), 290–298. https://doi.org/10.1016/j.bpsc.2020.09.019
[10] Snitselaar, M. A., Smits, M. G., van der Heijden, K. B., & Spijker, J. (2017). Sleep and Circadian Rhythmicity in Adult ADHD and the Effect of Stimulants. Journal of attention disorders, 21(1), 14–26. https://doi.org/10.1177/1087054713479663
[11] Morash-Conway, J., Gendron, M., & Corkum, P. (2017). The role of sleep quality and quantity in moderating the effectiveness of medication in the treatment of children with ADHD. Attention deficit and hyperactivity disorders, 9(1), 31–38. https://doi.org/10.1007/s12402-016-0204-7
[12] Galland, B. C., Tripp, E. G., & Taylor, B. J. (2010). The sleep of children with attention deficit hyperactivity disorder on and off methylphenidate: a matched case-control study. Journal of sleep research, 19(2), 366–373. https://doi.org/10.1111/j.1365-2869.2009.00795.x
[13] Giblin, J. M., & Strobel, A. L. (2011). Effect of lisdexamfetamine dimesylate on sleep in children with ADHD. Journal of attention disorders, 15(6), 491–498. https://doi.org/10.1177/1087054710371195
[14] Vigliano, P., Galloni, G. B., Bagnasco, I., Delia, G., Moletto, A., Mana, M., & Cortese, S. (2016). Sleep in children with attention-deficit/hyperactivity disorder (ADHD) before and after 6-month treatment with methylphenidate: a pilot study. European journal of pediatrics, 175(5), 695–704. https://doi.org/10.1007/s00431-016-2695-9
[15] Ricketts, E. J., Sturm, A., McMakin, D. L., McGuire, J. F., Tan, P. Z., Smalberg, F. B., McCracken, J. T., Colwell, C. S., & Piacentini, J. (2018). Changes in Sleep Problems Across Attention-Deficit/Hyperactivity Disorder Treatment: Findings from the Multimodal Treatment of Attention-Deficit/Hyperactivity Disorder Study. Journal of child and adolescent psychopharmacology, 28(10), 690–698. https://doi.org/10.1089/cap.2018.0038
[16] Johns Hopkins Medicine. (n.d.). Exercising for Better Sleep. Retrieved February 20, 2022, from https://www.hopkinsmedicine.org/health/wellness-and-prevention/exercising-for-better-sleep
[17] Urry, E., & Landolt, H. P. (2015). Adenosine, caffeine, and performance: from cognitive neuroscience of sleep to sleep pharmacogenetics. Current topics in behavioral neurosciences, 25, 331–366. https://doi.org/10.1007/7854_2014_274
[18] van Andel, E., Bijlenga, D., Vogel, S., Beekman, A., & Kooij, J. (2021). Effects of chronotherapy on circadian rhythm and ADHD symptoms in adults with attention-deficit/hyperactivity disorder and delayed sleep phase syndrome: a randomized clinical trial. Chronobiology international, 38(2), 260–269. https://doi.org/10.1080/07420528.2020.1835943