For many adults and children with attention deficit disorder, the thought of falling asleep easily, staying asleep through the night, and then waking up easily — and refreshed — seems but a dream.
ADHD adults know that their sleep can be disturbed by mental and physical restlessness, and that it can impact a person's ADHD treatment. But, as with most of our knowledge about adult ADHD, we're only beginning to understand a stronger ADHD-sleep link, resulting in difficulties falling asleep, staying asleep, and waking up.
Sleep disturbances caused by ADHD have been overlooked for a number of reasons. Sleep problems did not fit neatly into the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) requirement that all ADHD symptoms must be present by age 7. Sleep disturbances associated with ADHD generally appear later in life, at around age 12 ½, on average. Consequently, the arbitrary age cutoff has prevented recognition of sleep disturbances in ADHD until recently, when studies of adults have become more common. Just as ADHD does not go away at adolescence, it does not go away at night either. It continues to impair life functioning 24 hours a day.
In early attempts to define the syndrome, sleep disturbances were briefly considered a criterion for ADHD, but were dropped from the symptoms list because evidence of them was thought to be too nonspecific. As research has expanded to include adults with ADHD, the causes and effects of sleeping disturbances have become clearer.
Many researchers expect them to return as a diagnostic criterion when the criteria for adult ADHD appear in the DSM V in 2010. For now, sleep problems tend either to be overlooked or to be viewed as coexisting problems with an unclear relationship to ADHD itself. Sleep disturbances have been incorrectly attributed to the stimulant-class medications that are often the first to be used to treat ADHD.
The four big sleep issues
No scientific literature on insomnia lists ADHD as a prominent cause of sleep disturbances. Most articles focus on sleep disturbance due to stimulant-class medications, rather than looking at ADHD as the cause. Yet adults with ADHD know that the connection between their condition and sleep problems is real. Sufferers often call it "perverse sleep"—when they want to be asleep, they are awake; when they want to be awake, they are asleep.
The four most common sleep disturbances associated with ADHD are:
1. Initiation Insomnia
About three-fourths of all adults with ADHD report inability to "shut off my mind so I can fall asleep at night." Many describe themselves as "night owls" who get a burst of energy when the sun goes down. Others report that they feel tired throughout the day, but as soon as the head hits the pillow, the mind clicks on. Their thoughts jump or bounce from one worry to another. Unfortunately, many of these adults describe their thoughts as "racing," prompting a misdiagnosis of bipolar mood disorder, when this is nothing more than the mental restlessness of ADHD.
Prior to puberty, 10 to 15 percent of children with ADHD have trouble getting to sleep. This is twice the rate found in children and adolescents who do not have ADHD. This number dramatically increases with age: 50 percent of children with ADHD have difficulty falling asleep almost every night by age 12 ½ by age 30, more than 70 percent of adults with ADHD report that they spend more than one hour trying to fall asleep at night.
2. Restless Sleep
When individuals with ADHD finally fall asleep, their sleep is restless. They toss and turn. They awaken at any noise in the house. They are so fitful that bed partners often choose to sleep in another bed. They often awake to find the bed torn apart and covers kicked onto the floor. Sleep is not refreshing and they awaken as tired as when they went to bed.
3. Difficulty Waking
More than 80 percent of adults with ADHD in my practice report multiple awakenings until about 4 a.m. Then they fall into "the sleep of the dead," from which they have extreme difficulty rousing themselves.
They sleep through two or three alarms, as well as the attempts of family members to get them out of bed. ADHD sleepers are commonly irritable, even combative, when roused before they are ready. Many of them say they are not fully alert until noon.
4. Intrusive Sleep
Paul Wender, M.D., a 30-year veteran ADHD researcher, relates ADHD to interest-based performance. As long as persons with ADHD were interested in or challenged by what they were doing, they did not demonstrate symptoms of the disorder. (This phenomenon is called hyperfocus by some, and is often considered to be an ADHD pattern.) If, on the other hand, an individual with ADHD loses interest in an activity, his nervous system disengages, in search of something more interesting. Sometimes this disengagement is so abrupt as to induce sudden extreme drowsiness, even to the point of falling asleep.
Marian Sigurdson, Ph.D., an expert on electroencephalography (EEG) findings in ADHD, reports that brain wave tracings at this time show a sudden intrusion of theta waves into the alpha and beta rhythms of alertness. We all have seen "theta wave intrusion," in the student in the back of the classroom who suddenly crashes to the floor, having "fallen asleep." This was probably someone with ADHD who was losing consciousness due to boredom rather than falling asleep. This syndrome is life-threatening if it occurs while driving, and it is often induced by long-distance driving on straight, monotonous roads. Often this condition is misdiagnosed as "EEG negative narcolepsy." The extent of incidence of intrusive "sleep" is not known, because it occurs only under certain conditions that are hard to reproduce in a laboratory.