ADHD Paradox (Again): It’s harder to get to sleep AND feels worse without sleep.

ADHD and sleep are one of those weird, paradoxical pairings that make me amazed at how many of us succeed in spite of the constant tug of war going on in our brains.

There have been times when my sleep was disrupted - new baby, new puppy, extra anxiety - and I know personally how enormous the impact of not getting enough hours of sleep can be on our overall mental health.

What is the deal with ADHD and sleep?

Did you know that 70% of adults with ADHD have sleep problems? The issues range from falling asleep to staying asleep, to waking up, and they're not just minor inconveniences. These sleep problems can have a profound impact on our daily lives and long-term health. If we are not getting enough sleep, we are more likely to struggle with impulsive behaviours, low mood or difficulty focusing.

It’s not clear whether ADHD on its own is the cause of the sleep problems or if the sleep problems are a part of the ADHD: in DSM-III, restless sleep was a part of the diagnostic criteria (the list of clues doctors look for when deciding if the patient has ADHD or something else that looks like it). What has become more clear is that ADHD leads to a higher number of people not getting enough sleep at every stage of life compared to people without ADHD. For teenagers, when we expect sleep problems to really kick in, the difference is still significant, so it’s a double-whammy when young people are dealing with a lot of physical, educational, emotional and social demands.

The Big 3: ‘NBF’ - neurobehavioral functions

The three main areas that are going to be hit most with lack of sleep are

• sustained attention

• working memory

• inhibitory control (being able to stop yourself before you do something)

Although non-ADHD people will find these affected if sleep is disturbed, if they’re measured against ADHD people with sleep problems the impact is more significant, even when we account for people who are ‘evening chronotypes’ - that is, their best time of day for work and focus is in the evening.

Adults with ADHD and sleep

Like a LOT of ADHD problems it’s only in the last decade that studies are looking at how sleep is affected by ADHD in adulthood too - I’m not sure why researchers thought it would just disappear when we reached 18 but I’m glad it’s being studied at last.

So you might be someone who struggles with getting to sleep - you might naturally have a delayed sleep cycle, so you won’t fall asleep until 2 or 3am - or you might be someone who has so much going on during the day the only time you get space for your thoughts or taking time to unwind is at bedtime - or you might be someone who experiences the ‘hyperactive’ thought part of ADHD as your head hits the pillow.

Maybe the problem is staying asleep - and this one needs some careful attention. One of the symptoms of clinical depression and also anxiety is disturbed sleep - 97% of people in this study reported sleep problems and 59% said they woke during the night; if you are experiencing the other symptoms of depression or anxiety, please go see your doctor as soon as you can.

If you’re not depressed and are having problems staying asleep, this could be caused by our hyperactivity being expressed in thinking about things from the day. Often it’s just because our busy brain is making us wake up: it’s literally part of the complex of brain based differences that are gathered into ADHD.

Finally, you might be someone who really struggles to wake up - and I’ve met a few people who literally sleep through any kind of intervention and permanently find waking a challenge. There’s no answer or study that has really explained this one, especially when you look at the number of ADHD patients who struggle getting to sleep and staying asleep.

One theory is that our ‘circadian clock’ - the rhythm that gets us up and helps us go to sleep - is just never properly ‘set’ in some ADHD people but again, there’s not enough evidence to really explain what’s happening.

Homeo-what now?

There are two main processes that tell our bodies when to sleep and when to wake: homeostatic process and circadian process. Simplifying them as much as possible -

• Homeostasis: the longer we are awake, the more our body will send signals saying ‘time to rest now’. These include chemicals like adenosine which builds up the longer we stay awake.

• Circadian: this is a rhythm that responds to our environment and signals like light, will help our bodies adjust to different sunrise and sunset times.

They both work together - it’s not one or the other - and the process is incredibly complex. It’s not as simple as ‘take more adenosine if you can’t sleep’ - which would be really handy, right?

ADHD, sleep and Alzheimer’s

There’s also some question about the relationship between ADHD and Alzheimer's - both also appear to be related to sleep although there’s no answer to which causes the other, or if they are caused by something else.

Inadequate sleep can lead to a buildup of beta-amyloid plaques in the brain, a hallmark of Alzheimer's disease. There is a strong genetic relationship between ADHD & Alzheimer’s (and possibly Parkinson’s), although for now it’s unclear if one causes the other - both seem to be connected to ‘metabolic disregulation’ - that is the insulin resistance, type 2 diabetes and inflammation that we often find creeping up in middle age. This is a wake-up call (pun intended) for all of us to take our sleep seriously. It’s also related to our diet - which we know (again) is often much poorer in untreated, or under-supported ADHD.

How can we improve sleep with ADHD?

Having scared ourselves silly with the long term impact on our health of sleep problems, what do we do about it?

Layering - not just about winter clothing

Whenever you try to address a challenge that you’re having with ADHD, think about stacking up layers of support. It’s unlikely one thing alone will be the answer.

Depending on where your sleep problem is happening, you might need to target different parts of your daily routine and overall life.

Daily Habits

• Set a standard bed and wake time and stick to them: even at the weekends

• Make sure you are setting aside all tech (including phones, laptops, tablets etc) at least one hour before you want to get into bed

• Get into bed 45 minutes before you want to be asleep. I know, it’s a long time but you actually need that adjustment time.

• Have your medication by the bed with water, so that you can have it with water as soon as you wake.

• If you don’t take meds, make sure that you have found YOUR ideal trigger so that you get up as soon as you wake (I have two dogs so….)

• Some people find that sunrise/sunset alarms are ideal for triggering this waking especially if you live in a country where the winter nights are long. This also helps avoid the changing seasonal waking time (yes, we are also more prone to SAD, Seasonal Affective Disorder).

• Other habits include avoiding caffeine, cola or chocolate after midday - I know - so that you are not accidentally having stimulants that can stay in your system for a long time.

Lifestyle Changes

There are, of course, a long list of things that you can adjust - my best advice is to choose the one that YOU find most interesting and that appeals to your sparkles first. Does the idea intrigue you? Is it a challenge that you think would be achievable without a superhuman effort? Then choose it, keep it playful or gamify it and see how it goes.

• Daily Exercise (again!): thirty minutes of aerobic exercise, ideally outside in daylight, every day. It doesn’t have to be sprinting, but it definitely has a positive effect on everything (including the dreaded inflammation).

• Stress Management: it’s very normal for adults to ONLY find time to think and work in the late evening. Guess what - that’s not going to help your sleep. If this is something you struggle with, try to carve out ten to fifteen minutes during each day just for you - and become conscious of when you’re doing it. It can include mindfulness or self-compassion practices but really, the important thing is to expand into that space for yourself, instead of leaving it until the end of the day.

• If you find yourself with a brain full of thoughts and noise at bedtime, find a way to dump them. You might want to make a voice note, dump them in a thought journal, make sketchy scribbles - whatever works for your brain. Keep whatever you use next to your bed in case it continues once you get into bed (this is not neurotypical ‘sleep hygiene’… as always, experiment and see if it helps).

• Prepare for tomorrow before you go to bed. Make the transition into the next day as simple as possible. Your own routine might be different, but for me I have a glass of water at 10pm, look over my meetings for the next day, check what my teen is going to be doing, lay out some clothes and make sure that I’ve got my bag with things needed near the door. Do I do it every night? No, because our routine has been significantly adapted for our ADHD/ASC household - and that means we don’t have to get to school or the office on time.

which brings me to the last point.

Big Life Vision

This is a long term, privilege dependent position - but ADHD is a neurodevelopmental, life long condition. It’s possible that our sleep needs will change across our lifetime but it’s worth thinking of how much you can adapt your work and household to a a different kind of life routine and pattern. This is not the 1950s and we don’t have to worry about what our neighbours will think.

You might be a long way from being able to adapt your daily routine - and for most kids, school starts at a time designed for getting their parents into work rather than when they’re most ready for learning… but are there any steps you can think of that might get you closer? If you’re not tied in to school, and working - are there ways your employer could offer flexible working? Can you work 10-7 instead of 8-5? Is there a way for you to think of working independently - either as a contractor or for yourself?

Play with ideas - don’t shoot them down too quickly - and see what you can come back to in time. Start small and you might be surprised at where you end up.

Sleep is not a luxury; it's a necessity. As we continue to explore ADHD, let's commit to giving sleep the attention it deserves. After all, a well-rested brain is a more effective brain, and who doesn't want that?

Bonus section: ADHD and the use of Melatonin

Disclaimer: I am not a doctor, psychologist, psychiatrist or medical professional. This is a combination of personal experience, client reports and scientific data found online.

I just read an interview with a ‘renowned sleep doctor’ on a big podcast. I find most podcasts hard to listen to, I’ll be honest, so I do love a transcript.

The very qualified doctor said (direct quote) “If your child has a sleep problem, and you give them a pill, they now have two problems. They have a sleep problem, they have a pill problem. Okay. 99% of children do not need a pill to sleep. Okay, now, I want to be clear, there's some that do, right? If you've got a child who had a major psychotic episode or a mental breakdown or has been in rehab, or what have you, many of those children need a pill to sleep based on their neuro chemistry and things like that.”

Wow.

Now - let’s be very very clear - I am talking to the parents who have:

• kept a sleep diary according to experts they work with

• have a consistent bedtime schedule

• have minimised stimulation in the kids evening (after 5/6pm, it’s all calm)

• are making sure their kids are fed, watered, clean, CONNECTED with, feeling safe and loved

• have ruled out all other issues with medical support (and are being consistent with that sleep schedule)

If you are doing all of that and your kid can’t sleep, or it takes 4-5 hours for them to fall asleep every single night - take the (small, legal) amount of melatonin. That means discuss with your paediatrician or psychiatrist and do NOT buy them online or in the pharmacy.

Why am I so passionate about this?

Because ADHD and autism are neurological differences that can absolutely change the ability of your child’s brain to switch off. Some of them will genuinely be deficient in melatonin. 99.99% of the world does not have access to genetic testing to determine if that’s the case. So, like ADHD meds, we try them and assess the impact.

Some kids will not respond to melatonin. Some kids with ADHD actually need a small immediate release stimulant - that’s right, a stimulant can help at bedtime because our brains are different. It’s not a ‘thinking style’ or an ‘identity’ - it’s a neurological, genetic difference.

[I spent the first 6 years of my child’s life wondering what we were doing wrong - even when doing all of the above - and co-sleeping, sitting by the bed for 4-5 hours every night, then sleeping on the floor, etc - and not one of the recommended strategies worked. Melatonin worked. We all got more sleep. We all got better sleep. We all, eventually, returned to our own beds. YOU KNOW YOUR CHILD - AND YOU KNOW YOUR OWN NEED FOR SLEEP.]

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Further reading

Sobanski E, Schredl M, Kettler N, Alm B. Sleep in adults with attention deficit hyperactivity disorder (ADHD) before and during treatment with methylphenidate: a controlled polysomnographic study. Sleep. 2008 Mar;31(3):375-81. doi: 10.1093/sleep/31.3.375. PMID: 18363314; PMCID: PMC2276739.

Díaz-Román A, Mitchell R, Cortese S. Sleep in adults with ADHD: Systematic review and meta-analysis of subjective and objective studies. Neurosci Biobehav Rev. 2018 Jun;89:61-71. doi: 10.1016/j.neubiorev.2018.02.014. Epub 2018 Mar 2. PMID: 29477617.

Gruber R, Gauthier-Gagné G, Little C, Fu Z. The Associations between the Homeostatic and Circadian Sleep Processes and the Neurobehavioral Functioning (NBF) of Individuals with ADHD-A Systematic Review. Brain Sci. 2023 Jul 28;13(8):1134. doi: 10.3390/brainsci13081134. PMID: 37626491; PMCID: PMC10452539.

Gabay L, Miller P, Alia-Klein N, Lewin MP. Circadian Effects on Attention and Working Memory in College Students With Attention Deficit and Hyperactivity Symptoms. Front Psychol. 2022 May 16;13:851502. doi: 10.3389/fpsyg.2022.851502. PMID: 35651563; PMCID: PMC9150742.

Nutt D, Wilson S, Paterson L. Sleep disorders as core symptoms of depression. Dialogues Clin Neurosci. 2008;10(3):329-36. doi: 10.31887/DCNS.2008.10.3/dnutt. PMID: 18979946; PMCID: PMC3181883.

Deboer T. Sleep homeostasis and the circadian clock: Do the circadian pacemaker and the sleep homeostat influence each other's functioning? Neurobiol Sleep Circadian Rhythms. 2018 Mar 1;5:68-77. doi: 10.1016/j.nbscr.2018.02.003. PMID: 31236513; PMCID: PMC6584681.

Grünblatt E, Homolak J, Babic Perhoc A, Davor V, Knezovic A, Osmanovic Barilar J, Riederer P, Walitza S, Tackenberg C, Salkovic-Petrisic M. From attention-deficit hyperactivity disorder to sporadic Alzheimer's disease-Wnt/mTOR pathways hypothesis. Front Neurosci. 2023 Feb 16;17:1104985. doi: 10.3389/fnins.2023.1104985. PMID: 36875654; PMCID: PMC9978448.

Zhang L, Du Rietz E, Kuja-Halkola R, Dobrosavljevic M, Johnell K, Pedersen NL, Larsson H, Chang Z. Attention-deficit/hyperactivity disorder and Alzheimer's disease and any dementia: A multi-generation cohort study in Sweden. Alzheimers Dement. 2022 Jun;18(6):1155-1163. doi: 10.1002/alz.12462. Epub 2021 Sep 9. PMID: 34498801.

Fluegge K, Fluegge K. Antecedent ADHD, dementia, and metabolic dysregulation: A U.S. based cohort analysis. Neurochem Int. 2018 Jan;112:255-258. doi: 10.1016/j.neuint.2017.08.005. Epub 2017 Aug 12. PMID: 28811268.

Kimland EE, Dahlén E, Martikainen J, Célind J, Kindblom JM. Melatonin Prescription in Children and Adolescents in Relation to Body Weight and Age. Pharmaceuticals (Basel). 2023 Mar 6;16(3):396. doi: 10.3390/ph16030396. PMID: 36986495; PMCID: PMC10058986.

Rolling J, Rabot J, Schroder CM. Melatonin Treatment for Pediatric Patients with Insomnia: Is There a Place for It? Nat Sci Sleep. 2022 Oct 27;14:1927-1944. doi: 10.2147/NSS.S340944. PMID: 36325278; PMCID: PMC9621019.

Zisapel N. Assessing the potential for drug interactions and long term safety of melatonin for the treatment of insomnia in children with autism spectrum disorder. Expert Rev Clin Pharmacol. 2022 Feb;15(2):175-185. doi: 10.1080/17512433.2022.2053520. Epub 2022 Mar 17. PMID: 35285365.

Parvataneni T, Srinivas S, Shah K, Patel RS. Perspective on Melatonin Use for Sleep Problems in Autism and Attention-Deficit Hyperactivity Disorder: A Systematic Review of Randomized Clinical Trials. Cureus. 2020 May 28;12(5):e8335. doi: 10.7759/cureus.8335. PMID: 32617211; PMCID: PMC7325410.