Bedtime Battles, Part 2
What's going on here?
There are several theories about the causes of sleep disturbance in people with ADHD, with a telling range of viewpoints. Physicians base their responses to their patients' complaints of sleep problems on how they interpret the cause of the disturbances. A physician who looks first for disturbances resulting from disorganized life patterns will treat problems in a different way than a physician who thinks of them as a manifestation of ADHD.
Thomas Brown, Ph.D., longtime researcher in ADHD and developer of the Brown Scales, was one of the first to give serious attention to the problem of sleep in children and adolescents with ADHD. He sees sleep disturbances as indicative of problems of arousal and alertness in ADHD itself. Two of the five symptom clusters that emerge from the Brown Scales involve activation and arousal:
- Organizing and activating to begin work activities.
- Sustaining alertness, energy, and effort.
Brown views problems with sleep as a developmentally-based impairment of management functions of the brain - particularly, an impairment of the ability to sustain and regulate arousal and alertness. Interestingly, he does not recommend treatments common to ADHD, but rather recommends a two-pronged approach that stresses better sleep hygiene and the suppression of unwanted and inconvenient arousal states by using medications with sedative properties.
The simplest explanation is that sleep disturbances are direct manifestations of ADHD itself. True hyperactivity is extremely rare in women of any age. Most women experience the mental and physical restlessness of ADHD only when they are trying to shut down the arousal state of day-to-day functioning in order to fall asleep. At least 75 percent of adults of both genders report that their minds restlessly move from one concern to another for several hours until they finally fall asleep. Even then, they toss and turn, awaken frequently, and sometimes barely sleep at all.
The fact that 80 percent of adults with ADHD eventually fall into "the sleep of the dead" has led researchers to look for explanations. No single theory explains the severe impairment of the ability to rouse oneself into wakefulness. Some ADHD patients report that they sleep well when they go camping or are out of doors for extended periods of time.
Baltimore-based psychiatrist Myron Brenner, M.D., noted the high incidence of ADHD individuals among the research subjects in his study of Delayed Sleep Phase Syndrome (DSPS). People with DSPS report that they can experience a normal sleep phase — for example, get into bed, fall asleep quickly, sleep undisturbed for eight hours, and awake refreshed — but that their brains and bodies want that cycle from 4 a.m. until noon. This is a pattern reported by more than half of adults with ADHD. Brenner hypothesizes that DSPS and the sleep patterns of ADHD have the same underlying disturbance of circadian rhythms. Specifically, he believes that the signal which sets the internal circadian clock (the gradual changes in light caused by the sun's setting and rising) is weak in people with ADHD. As a result, their circadian clock is never truly set, and sleep drifts into to the 4 a.m.-to-noon pattern or disappears entirely, until the sufferer is exhausted.
One hypothesis is that the lack of an accurate circadian clock may also account for the difficulty that many with ADHD have in judging the passage of time. Their internal clocks are not "set." Consequently, they experience only two times: "now" and "not now." Many of my adult patients do not wear watches. They experience time as an abstract concept, important to other people, but one which they don't understand. It will take many more studies to establish the links between circadian rhythms and ADHD.
How to get to sleep
No matter how a doctor explains sleep problems, the remedy usually involves something called "sleep hygiene," which considers all the things that foster the initiation and maintenance of sleep. This set of conditions is highly individualized. Some people need absolute silence. Others need white noise, such as a fan or radio, to mask disturbances to sleep. Some people need a snack before bed, while others can't eat anything right before bedtime. A few rules of sleep hygiene are universal:
- Use the bed only for sleep or sex, not as a place to confront problems or argue.
- Have a set bedtime and a bedtime routine and stick to it - rigorously.
- Avoid naps during the day.
Two more elements of good sleep hygiene seem obvious, but they should be stressed for people with ADHD.
- Get in bed to go to sleep. Many people with ADHD are at their best at night. They are most energetic, thinking clearest, and most stable after the sun goes down. The house is quiet and distractions are low. This is their most productive time. Unfortunately, they have jobs and families to which they must attend the next morning, tasks made harder by inadequate sleep.