INTERRELATION BETWEEN SLEEP
AND ADHD
Prof. Nahed Salah
Prof. of Neurology, Ain Shams Univeristy

Attention-Deficit/Hyperactivity Disorder
(ADHD) is a disorder that begins in childhood and encompasses
symptoms of inattention, hyperactivity, and impulsivity. These
symptoms interfere with functioning at school, at work, and in social
situations. ADHD is present in approximately 5% of children, and it is
more common in boys. For a majority of people the disorder continues
into adulthood, though careful managing can greatly improve quality of
life for people with ADHD

• What’s the Connection Between ADHD and Sleep?
• Common Sleep Disorders Commonly in People With ADHD
• Sleep Tips for Children and Adults With ADHD and Sleep Problems

The association of sleep with ADHD is multifaceted and complex.
Problems with sleep may be an intrinsic feature of ADHD, or may both exacerbate
and be exacerbated by the symptoms of the disorder.
Problems with sleep can, however, also lead to the development of ADHD or ADHD-
like symptoms, potentially resulting in misdiagnosis. The effects of restricted,
disordered or disturbed sleep can manifest as symptoms, behaviors or functional
impairments that are remarkably similar to those of ADHD .
The interrelationships are further complicated by the use of psychostimulant
medications to treat ADHD, which impair sleep in some patients but paradoxically
improve sleep in others via a calming effect. For these reasons, it has been
recommended that primary sleep disorders should be ruled out before initiating
ADHD medication .
Behavioral interventions targeted at improving sleep may benefit some patients
and should form part of the multimodal ADHD management plan recommended
for patients receiving pharmacotherapy .

• Psychiatric comorbidities are common in children with ADHD
• Psychiatric illnesses such as bipolar disorder, autism, post-traumatic stress
disorder and obsessive compulsive disorder often occur coincidently with ADHD,
and are also associated with sleep problems, which may both result from and
exacerbate comorbid psychiatric symptoms .
• Problems with sleep are likely to have adverse effects on health-related quality
of life for children with ADHD and their families and may also contribute to the
development of comorbid anxiety, depression or oppositional defiant disorder
• The interactions of comorbid disorders and associated medications with ADHD
and sleep disturbances are therefore important to consider when managing
patients.

The reciprocal nature of the relationships between ADHD and sleep may reflect the
functional and neuroanatomical overlap between brain regions involved in
attention, arousal and sleep regulation

• Sleep problems in children with ADHD are common and associated with poorer
child, caregiver, and family outcomes
• Up to 50% of parents of children with ADHD report difficulties with their
children's sleep, including difficulties initiating sleep (delayed onset sleep or
bedtime resistance) and maintaining sleep (frequent nocturnal awakenings or
restlessness).Daytime sleepiness, tiredness on waking, and nightmares are also
more common in children with ADHD than controls.

• Children with insufficient, fragmented, or poor-quality sleep have increased
impulsivity, hyperactivity, and aggressiveness as well as problems with mood,
academic performance, and neurocognitive functioning.
• Sleep problems in early childhood are a risk factor for future occurrence of ADHD
symptoms

Many ADHD symptoms are similar to symptoms of sleep deprivation.
In children, fatigue may present as being hyperactive and impulsive. Sometimes it
can be difficult to tell whether these issues are brought on by ADHD or by a lack of
sleep. This may lead to misdiagnoses or may allow sleep disorders to go
undetected. Experts therefore recommend screening patients for sleep problems
before prescribing medication for ADHD

Sleep problems in ADHD appear to differ depending on the type of ADHD.
Individuals with predominantly inattentive symptoms are more likely to have a later
bedtime, while those predominantly hyperactive-impulsive symptoms are more
likely to suffer from insomnia. Those with combined hyperactive-impulsive and
inattentive ADHD experience both poor sleep quality and a later bedtime.

Objective studies using polysomnography, an actigraph, and video
monitoring have shown that children with ADHD have:
• increased sleep latency,
• decreased rapid eye movement sleep percentages,
• and increased nocturnal activity.
• Other sleep problems identified include sleep-disordered breathing
(≤ 25%) and restless legs syndrome or periodic limb movement
disorder (≤ 36%).

What’s the Biology Behind the ADHD-Sleep Connection?
ADHD sleep problems may be a side effect of impaired arousal, alertness, and
regulation circuits in the brain. Other researchers believe that ADHD sleep
problems can be traced to a delayed circadian rhythm with a later onset
of melatonin production.

Effects of ADHD medications on sleep
ADHD medications are known to affect sleep in many individuals, and guidelines
recommend that sleep is carefully assessed before starting ADHD pharmacotherapy .
Pharmacotherapy with stimulants:
The effects of stimulants on sleep in patients with ADHD differ from patient to patient .
The sympathomimetic action of stimulants promotes wakefulness in most people.
While there is evidence that stimulants are associated with disrupted or disturbed sleep in
patients with ADHD , clinical experience also indicates that stimulants produce paradoxical
effects , whereby alleviation of symptoms can calm patients and promote sleep .
Furthermore, because of the potential for symptom rebound as blood drug concentrations
wane , an additional dose of a short-acting stimulant, or the use of a formulation with an
increased duration of action, may prevent sleep disturbances resulting from worsening of
hyperactivity or behavioral difficulties at bedtime .

How Do ADHD Sleep Problems Affect Daily Life?
• Children and adults with ADHD plus a sleep disorder often report more severe
ADHD symptoms and a lower quality of life. They may also be more likely to suffer
from depression, anxiety, hyperactivity, inattention and difficulty processing
information.
• Daytime sleepiness can have serious effects on school and work. People may
judge a person with ADHD for sleeping at inappropriate times, without realizing
that it is part of their condition and very difficult to avoid.
• Not sleeping well at night can also cause daytime fatigue. Individuals with ADHD-
related sleep deprivation may feel grumpy, irritable, restless, or tired, or they may
have trouble paying attention at school or at work. Sometimes, these symptoms
may be mistaken for a mood disorder. In turn, anxiety and behavioral difficulties
have been linked to a higher incidence of sleep problems for children with ADHD.

Recommended strategies for managing sleep disturbances during treatment
with ADHD medications
Monitoring: insomnia associated with stimulants may attenuate after 1–2 months (Lecendreux and
Cortese 2007)
Considering if it is possible to stop the medication
Implementing sleep hygiene/behavioral measures
Reviewing the possible causes of sleep problems
Treating RLS
Adding small, short-acting stimulant doses in the early evening (if rebound effect occurs)
Reducing stimulant dose
Switching to an alternative class of stimulant
Switching to an alternative stimulant formulation
Considering use of a non-stimulant (e.g., atomoxetine)
Considering melatonin treatment
Monitoring: insomnia associated with stimulants may attenuate after 1–2 months (Lecendreux and
Cortese 2007
Considering if it is possible to stop the medication
Implementing sleep hygiene/behavioral measures
Reviewing the possible causes of sleep problems
Treating RLS
Adding small, short-acting stimulant doses in the early evening (if rebound effect occurs)
Reducing stimulant dose
Switching to an alternative class of stimulant
Switching to an alternative stimulant formulation
Considering use of a non-stimulant (e.g., atomoxetine)
Considering melatonin treatment

Sleep Tips for Children and Adults With ADHD and Sleep
Problems
• Cut out sugar and caffeine within a few hours of bedtime
• Avoid screen time for an hour before bed
• Avoid doing stimulating activities and projects that require hyperfocusing in the evening
• Make the bed a stress-free zone reserved for sleep
• Get enough exercise and sunlight during the day
• Develop a bedtime routine that you enjoy, such as rereading a favorite book, spending
time with pets, or taking a warm bath
• Keep the bedroom dark, cool, and quiet, using a white noise machine if necessary to
block out intrusive noises
• Go to bed and wake up at the same time every day, choosing a time that is realistic and
age-appropriate to get the recommended sleep for your age group

Sleep hygiene
Healthy sleep practices include the following:
a regular sleep/wake schedule; adequate opportunity for sleep; calming and
structured bedtime routines;
avoidance of caffeine, large amounts of liquids, naps, exercise and alerting activities
(e.g., use of electronic devices) soon before bedtime;
sleeping only in bed and using the bed only for sleeping; and attention to
environmental factors such as bedroom furniture, lighting and temperature.

Conceptual model of the modes of interaction between ADHD and
sleep. ADHD attention-deficit/hyperactivity disorder

Conclusions
ADHD is commonly associated with specific sleep disorders.
The relationship between ADHD and sleep problems is complex and bidirectional,
and is modulated by interactions with ADHD medications and by psychiatric
comorbidities and associated medications. Understanding these associations and
relationships is important when assessing and managing patients with ADHD. As
recommended in current guidelines, primary sleep disorders (specifically SDB/OSA
and PLMD/RLS) should be ruled out before diagnosing or treating ADHD. Obesity
and psychiatric comorbidities (e.g., anxiety and depression) can also lead to sleep
problems, and need to be identified and treated appropriately. The multifaceted
effects of stimulant pharmacotherapy on sleep in patients with ADHD are
particularly important for clinicians to understand when evaluating treatment
options for patients. Stimulant medications may disrupt or improve sleep in
different patients, depending not only on the nature of the patient’s illness, but
also on the drug dose, class, formulation and duration of efficacy. Effective
management of sleep problems associated with ADHD and its treatment may not
only alleviate sleep-related symptoms, but also improve quality of life in parents of
children with disruptive bedtime behavior or insomnia.

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