What Comes First: ADHD or Sleep Problems?
Insufficient sleep makes almost every psychological problem worse. This is particularly true for teens with ADHD, who often fall in to the trap of staying up late interacting with friends or doing homework. Treatment for ADD-related insomnia begins with a stimulant, however medication sometimes exacerbates the problem. Here, learn about warning signs and alternative strategies for achieving healthy sleep.
How Does Sleep Impact ADHD — and Vice Versa?
Few things impact mental health more than sleep. Poor or insufficient sleep makes almost every psychological problem worse. In extreme cases, it can be the cause of the problem. With attention deficit disorder (ADHD or ADD), that link is obvious and complicated, because there are several ways sleep and ADHD affect each other.
Poor sleep can lead to ADHD-like symptoms and complicate a diagnosis. A few years ago, some researchers joined the “ADHD Is a Myth” crowd and declared all people with ADHD to be victims of chronic insomnia. That’s an overreach, but their findings did support the idea that quality of sleep must be considered in making an ADHD diagnosis. This is why you should start your teen’s diagnostic journey at the door of a qualified professional, and why you should study your child’s sleep patterns to answer the provider’s questions.
Are Sleep Problems Misdiagnosed as ADHD?
In my experience, insomnia-induced ADHD isn’t common, but I have referred two dozen teens and young adults for sleep studies to avoid misdiagnosing them. Some were found to have sleep apnea, narcolepsy, or primary insomnia, and treatment improved sleep and reduced symptoms. But those teens also wound up being treated at our clinic for ADHD. Nevertheless, I believe that severe sleep deprivation can present with ADHD-like symptoms, but most of such cases should be screened out from an ADHD diagnosis with an evaluation.
Poor sleep can result from ADHD, complicating diagnosis. This condition is common but under-recognized. Both of my children have what I call “ADHD-related insomnia.” I made up this name for it because I saw it so often among my clients, whose active minds didn’t shut down just because it was 10:30 p.m. It’s hard to know if this condition describes your child because you can’t easily separate this kind of insomnia from the one previously described. Which comes first: the chicken or the egg? The best solution the prescriber at our clinic has found is to begin treatment with stimulant medication, and follow the case closely for a month. Some teens will sleep better after beginning stimulants. A few will have daytime sleepiness despite taking them. That generally proves the diagnosis, but it also suggests it’s time to try a different stimulant or to pursue a sleep study.
How Can You Treat ADHD-Related Sleep Problems?
Sleep problems sometimes improve by treating the ADHD. More often, the insomnia remains but doesn’t worsen on stimulants, just as it has for my kids. In such cases, the prescriber may consider sleep medication as an adjunct. This is a complex decision, but our experience has been that, even when ADHD symptoms are improved by stimulants, ADHD-related insomnia will limit the effectiveness of treatment unless it too is addressed.
How Does ADHD Medication Impact Sleep?
Poor sleep can result from taking ADHD medication, complicating treatment. The point of stimulant medication is to stimulate the part of the brain that focuses attention. That’s the opposite of what we need when it’s time to hit the hay. However, for some people with ADHD, stimulants help sleep. For many others, insomnia predates stimulant use, which is another reason to assess sleep problems before any medication is prescribed. Figuring this out is subject to the “Hawthorne Effect.” If one is warned that sleep may be impaired by a stimulant, one gets worried about sleep, and may notice it isn’t very good. That makes it easy to blame the stimulant, rather than a chronic sleep impairment. Many teens compensate for poor sleep by taking naps. After starting a stimulant, one may not be able to nap as easily or as deeply.
On the other hand, if the teen hasn’t had sleep problems before, hasn’t over-used napping, begins to lose sleep after starting on medication, and doesn’t revert to better sleep in two or three weeks, a decision must be made. A common strategy is to discontinue stimulants and/or switch to a non-stimulant for ADHD. If the stimulants are working, we prefer to tinker with their timing and release to improve sleep. We find the Daytrana patch helpful for those with stimulant-induced insomnia, because it’s the only medication that can be shut off early (by removing the patch). In other cases, we find that treating the sleep problem directly is a better long-term solution than eliminating the stimulant.
Poor sleep reflects an unregulated life. Poor sleep may be the result of a dysregulated sleep-wake cycle and poor sleep hygiene. The worst thing about bad sleep is that it is self-perpetuating. The worse a teen sleeps, the more out of rhythm he will become. When he tries to compensate, the sleep gets worse. Good sleep hygiene is important in treating the conditions I’ve described, and it’s also critical to understanding the ADHD-sleep conundrum. More than once, we’ve tried to help a client manage stimulants and sleep, only to learn that the client is staying up late and, in extreme cases, reversing the sleep-wake cycle. Those with ADHD hate a sleep routine because it feels like a restriction of their freedom. We suggest that they consider a good sleep-cycle more like sharpening a saw than restricting their free expression.
Wes Crenshaw, Ph.D., ABPP, is a licensed psychologist board certified in couples and family psychology by the American Board of Professional Psychology. He is the author of I Always Want to Be Where I’m Not: Successful Living with ADD and ADHD (#CommissionsEarned) and a member of the ADDitude ADHD Medical Review Panel.
How to Help Teens with ADHD Sleep Better
1. Make time for it. The worst and most common sleep mistake teens make is failing to set aside eight hours to get it done, plus about an hour of prep before going to bed. For those with ADHD, it’s easy to put off sleep or to avoid it altogether. What could possibly be more boring than sleeping, especially when the night world is so interesting? It takes discipline to go to bed and to get up, but few life changes will make a bigger difference than this one in managing ADHD.
2. Turn off screens. Everyone hates this advice, including adults, but think back to a time when gaming consoles were in the family room, not the bedroom. Bedrooms shouldn’t look like mission control, they should look like sleeping quarters, and all screen time should end about an hour before bedtime. Not only are games too stimulating for late-evening use, they generate too much light.
3. Say goodnight to the (artificial) sun. Light is crucial in regulating the sleep cycle. Get teens in the habit of minimizing or shutting down artificial light in the evening after study time is over. This signals to the body that the night cycle is coming, and that it should prepare for sleep. Artificial light does the opposite. Get shades for windows to black out exterior light.
4. Rise with the light. When fall arrives and mornings become dark, go online or to your favorite home improvement store and buy a 4 x 4 or 4 x 8 daylight LED light panel. Install an extension cord (many shop lights have them already), or have an electrician do it for about $20. The panel doesn’t weigh much, so you can easily hang it on the wall of your teen’s bedroom. Set a timer for 20 minutes before your teen is scheduled to wake. If you’re feeling inventive, hang it in the window and use an auto dimmer to have the lights become progressively brighter like a sunrise.
5. No napping. Researchers consider naps to be evidence of unhealthy sleep. The only exception is the “micro-nap,” a 10- to 15-minute siesta one grabs mid-afternoon. These may improve functioning and improve sleep. Naps are hard to resist, but the fewer naps teens take, the better they’ll sleep at night.
Wes Crenshaw, Ph.D., is a member of the ADDitude ADHD Medical Review Panel.
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Updated on October 9, 2020