Several years back, a new patient came to see me to find out if he had ADHD. He had all the classic symptoms: procrastination, forgetfulness, a propensity to lose things, and, of course, the inability to pay attention consistently. But one thing was unusual. His symptoms had started only two years earlier, when he was 31.
I treat a lot of adults for ADHD, but the presentation of this case was a violation of an important diagnostic criterion: Symptoms must date back to childhood. It turned out that he first started having these problems the month he began his most recent job, one that required him to rise at 5 a.m., despite the fact that he was a night owl.
The patient didn’t have ADHD, I realized, but a chronic sleep deficit. I suggested some techniques to help him fall asleep at night, like relaxing for 90 minutes before getting into bed at 10 p.m. If necessary, he could take a small amount of melatonin. When he returned to see me, two weeks later, his symptoms were almost gone. I suggested that he call if they recurred. I never heard from him again.
The Sleep Theory For ADHD
Many theories are thrown around to explain the rise in the diagnosis and treatment of ADHD in children and adults. According to the Centers for Disease Control and Prevention, 11 percent of school-age children have now received a diagnosis of the condition. I don’t doubt that many people do, in fact, have ADHD; I regularly diagnose and treat it in adults. But what if a substantial number of cases are sleep disorders in disguise?
For some people — especially children — sleep deprivation does not necessarily cause lethargy; it makes them hyperactive and unfocused. Researchers and reporters are increasingly seeing connections between dysfunctional sleep and what looks like ADHD, but those links are not yet understood by parents and doctors.
We all get less sleep than we used to. The number of adults who reported sleeping fewer than seven hours each night went from 2 percent in 1960 to more than 35 percent in 2011. Good sleep is crucial for children, who need delta sleep — the deep, rejuvenating, slow-wave kind — for proper growth and development. Yet today’s youngsters sleep about an hour less than children did a hundred years ago. And for all ages, stressful daytime activities — marked by nonstop 14-hour schedules and inescapable melatonin-inhibiting iDevices — often impair sleep. It might be a coincidence, but our sleep-restricting lifestyle became more extreme in the 1990s, the decade that saw the explosion in ADHD diagnoses.
A number of studies have shown that a huge proportion of children with an ADHD diagnosis also have sleep-disordered breathing, like apnea or snoring, restless leg syndrome, or non-restorative sleep, in which delta sleep is frequently interrupted. One study, published in 2004 in the journal Sleep, looked at 34 children with ADHD. All of them showed a deficit of rejuvenating delta sleep, compared with only a handful of the 32 control subjects.
A 2006 study in the journal Pediatrics showed something similar, from the perspective of a surgery clinic. This study included 105 children between ages five and 12. Seventy-eight of them were scheduled to have their tonsils removed because they had problems breathing in their sleep, while 27 children scheduled for other operations served as a control group. Researchers measured the participants’ sleep patterns and tested for hyperactivity and inattentiveness, consistent with standard protocols for validating an ADHD diagnosis. Of the 78 children getting the tonsillectomies, 28 percent had ADHD, compared with only 7 percent of the control group.
Even more stunning was what the study’s authors found when they followed up with the children. A full half of the original ADHD group who received tonsillectomies — 11 of 22 children — no longer met the criteria for the condition. In other words, what had appeared to be ADHD had been resolved by treating a sleeping problem.
But ADHD-like symptoms may persist even after a sleeping problem is resolved. Consider the long-term study of more than 11,000 children in Britain, published three years ago, also in Pediatrics. Mothers were asked about symptoms of sleep-disordered breathing in their infants when they were six months old. Then, when the children were four and seven years old, the mothers completed a behavioral questionnaire to gauge their children’s levels of inattention, hyperactivity, anxiety, depression, and problems with peers, conduct, and social skills.
The study found that children who suffered from sleep-disordered breathing in infancy were more likely to have behavioral difficulties later in life — 20 to 60 percent more likely to have behavioral problems at age four, and 40 to 100 percent more likely to have such problems at age seven. These problems occurred even if the disordered breathing had abated, implying that an infant’s breathing problem might cause some kind of potentially irreversible neurological injury. There is more going on in the nocturnal lives of our children than any of us have realized. Typically, we see and diagnose only their downstream, daytime symptoms.