Sleep Problems in Teens with ADHD: Causes and Solutions
Sleeping problems in teens with ADHD are common — and exhausting. The negative outcomes of poor sleep are as plentiful as its root causes, if they are left unaddressed. To improve sleep, teens should adhere to healthy sleep practices and bedtime hygiene. Here is how.
Sleep problems commonly plague individuals with ADHD — particularly during the teen years, when sleep hygiene and patterns go haywire in even the most neurotypical brains and households. Studies estimate that up to 70 percent of children and adolescents with ADHD have problems with sleep that stem from reasons ranging from racing thoughts to coexisting conditions and even environmental factors that can impact sleep patterns.
No matter the underlying causes, persistent sleep problems can impact functioning and impair quality of life over time. Thoughtful interventions and practices, however, can significantly improve sleep quality — especially when implemented during the childhood and adolescent years.
Sleeping Problems in Teens with ADHD: Causes and Outcomes
Common sleep problems in teens with ADHD include:
- Insomnia, or difficulty falling asleep even when going to bed later. This often comes with early awakenings and an inability to fall back asleep.
- Sleep onset association, or when falling asleep is linked to an object or an event (like turning on the TV for “background noise” to sleep).
- Bedtime resistance, or refusing to go to bed or adhere to bedtime limits.
- Anxiety, which may be sleep related (feeling worried about darkness or other things in the sleep environment), or related to worries and stressors experienced throughout the day.
- Delayed sleep phase, which refers to falling asleep late and waking up late in a strong deviation from what would be expected of a typical circadian or developmental pattern. This is a common issue, as teens have to rise early for school on weekdays but delay their sleep drastically on weekends.
Some factors predict sleep problems in teens with ADHD:
- Biology – similar neurological pathways appear to be involved in the regulation of attention, arousal, and sleep.
- Comorbidities – internalizing (anxiety, mood disorders) and externalizing (aggression, oppositionality) comorbidities are strong predictors of sleep problems.
- Medication – all stimulants can produce sleep problems, with sleep onset latency (how long it takes to fall asleep) as the main disturbance. But these disturbances generally resolve and subside after some time on medication1. Furthermore, unmedicated children with ADHD will still have elevated sleep problems compared to children without ADHD. Sleep should be monitored for teens initiating or changing ADHD medication doses.
- Environmental factors like parental mental health, family and social dynamics, and difficulties with schoolwork or homework can contribute to sleep problems.
For some children and teens, these sleep problems will resolve on their own or through some intervention. But for a sizable subset, they will persist. Teens with ADHD, for example, are more likely than their neurotypical peers to get insufficient sleep on school nights, and more likely to report doing “all-nighters.”2 They also have more variable sleep behaviors compared to peers without ADHD (i.e. varied sleep duration, quality of sleep, etc.).3 4
Sleeping Problems: Outcomes
Sleep problems in youth with ADHD are associated with several negative outcomes. They impact functioning during the day, be it at school or at home, and they are associated with mental health problems over time. Sleep problems in adolescents with ADHD are tied to poorer quality of life and parent mental health5, as well as poor academic performance and lower grades6. They also contribute to an increase in mood disorder symptoms and oppositional behaviors among teens with ADHD, even when accounting for baseline levels.7
Shortened sleep duration is also a causal contributor to the affect and mood disturbances frequently experienced by adolescents with ADHD, according to recent research8 9. When subjected to a shortened sleep duration compared to extended sleep time, teens with ADHD in these studies experienced greater
- difficulty waking
- daytime sleepiness
- symptoms of inattention
- oppositional behaviors
- emotional dysregulation
- executive dysfunction
Notably, sleep restriction in this study was not associated with any effects on symptoms of anxiety or of hyperactivity and impulsivity in participants.
How to Improve Sleep in Teens with ADHD
Healthy sleep practices and behavioral interventions can effectively curb many sleeping problems and improve psychosocial and daytime functioning in youth with ADHD10 11 12. A comprehensive sleep assessment conducted by a sleep clinic can also reveal individual factors contributing to sleep problems, including those related to ADHD symptoms, medication, and comorbidities.13
Healthy Sleep Practices
Sleep hygiene is the foundation to a good night’s sleep, which is influenced by day and evening routines, health and nutrition, light exposure, and other habits. Gradually shifting habits will be more effective, in the long run, than is making sudden and drastic changes. Basic sleep practices include:
- Maintaining a steady sleep-wake schedule. A reasonable schedule allows for enough sleep (the recommended time for high school students is 8 to 10 hours). Teens, however, are known to get to bed at unpredictable hours. Fortunately, it’s the wake-up time that is most important, regardless of bedtime. Weekday wake-up times are largely determined by school, and teens should try to wake up as close as possible to this time on weekends — within one to two hours.
- Avoiding technology (TV, computers, tablets, phones, video games, etc.) within one hour of bedtime. Some teens may depend on TV noise, a podcast, or music to help them fall asleep, but it’s best to gradually remove these items to establish independent sleep.
- Engaging in daytime physical activity and exercise (but not too close to bedtime).
- Avoiding meals close to and after bedtime to avoid “waking up” the body.
- Avoiding naps, which can interfere with the sleep-wake schedule, making it difficult to fall asleep at an established bedtime and wake up feeling rested the next day.
- Following a calming bedtime routine to get the body in sleep mode.
- Using the bed only for sleep to instill a powerful bedtime cue.
Is Melatonin Safe? Does It Work?
Melatonin sold over the counter is an increasingly popular supplement used to aid sleep. It is frequently used as a hypnotic to reduce sleep onset latency (the time it takes to fall asleep), and several studies in children with ADHD suggest that it is effective14 15. Melatonin supplements, however, are not associated with improvement in other sleep domains or with ADHD symptoms.
In the U.S., melatonin is considered a dietary supplement; it is not regulated by the FDA for safety, purity, or efficacy. One study that analyzed melatonin supplements found that a significant number did not meet label claims, and some contained serotonin16. While melatonin is generally considered safe, teens and families should talk to clinicians about the supplement and whether it could help address their sleep problems.
Relaxation Exercises for Better Sleep
Racing thoughts and the inability to calm the body and mind for bedtime are common problems among teens with ADHD, especially if anxiety is also present. Mitigating these stressors can reduce their interference in sleep. Strategies include:
- Relaxation training:
- Breathing exercises
- mindfulness; thinking of pleasant imagery
- progressive muscle relaxation
- Cognitive behavioral therapy to address distorted thoughts, worries, and fears
Sleeping Problems in Teens with ADHD: Next Steps
- Q&A: How Can I Help My Teen Learn to Mute His ADHD Brain at Bedtime?
- Read: End the ‘I Can’t Sleep’ Cycle of Exhaustion
- Guide: How to Fall Asleep with a Rowdy, Racing ADHD Brain
The content for this article was derived from the ADDitude Expert Webinar “Why Am I Always So Tired?” The Latest Science on Improving Sleep in Children and Teens with ADHD” [Video Replay & Podcast #351] with Stephen Becker, Ph.D. which was broadcast live on April 21, 2021.
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1 Chen, M., Wardlaw, M., Stein, M., (2019). Chapter 6 – ADHD Medications and Sleep. Hiscock, H., Sciberras, E. (Eds.)., Sleep and ADHD (pp. 151-174). Academic Press. https://doi.org/10.1016/B978-0-12-814180-9.00005-3
2 Becker, S. P., Langberg, J. M., Eadeh, H. M., Isaacson, P. A., & Bourchtein, E. (2019). Sleep and daytime sleepiness in adolescents with and without ADHD: Differences across ratings, daily diary, and actigraphy. Journal of Child Psychology and Psychiatry, 60, 1021–1031. https://doi.org/10.1111/jcpp.13061
3 Becker, S. P., Sidol, C. A., Van Dyk, T. R., Epstein, J. N., & Beebe, D. W. (2017). Intraindividual variability of sleep/wake patterns in relation to child and adolescent functioning: A systematic review. Sleep medicine reviews, 34, 94–121. https://doi.org/10.1016/j.smrv.2016.07.004
4 Langberg, J.M., Breaux, R.P., Cusick, C.N., Green, C.D., Smith, Z.R., Molitor, S.J. and Becker, S.P. (2019), Intraindividual variability of sleep/wake patterns in adolescents with and without attention‐deficit/hyperactivity disorder. J Child Psychol Psychiatr, 60: 1219-1229. https://doi.org/10.1111/jcpp.13082
5 Sung, V., Hiscock, H., Sciberras, E., & Efron, D. (2008). Sleep problems in children with attention-deficit/hyperactivity disorder: prevalence and the effect on the child and family. Archives of pediatrics & adolescent medicine, 162(4), 336–342. https://doi.org/10.1001/archpedi.162.4.336
6 Langberg, J. M., Dvorsky, M. R., Marshall, S., & Evans, S. W. (2013). Clinical implications of daytime sleepiness for the academic performance of middle school-aged adolescents with attention deficit hyperactivity disorder. Journal of sleep research, 22(5), 542–548. https://doi.org/10.1111/jsr.12049
7 Becker, S. P., Langberg, J. M., & Evans, S. W. (2015). Sleep problems predict comorbid externalizing behaviors and depression in young adolescents with attention-deficit/hyperactivity disorder. European child & adolescent psychiatry, 24(8), 897–907. https://doi.org/10.1007/s00787-014-0636-6
8 Becker, S.P., Tamm, L., Epstein, J.N. and Beebe, D.W. (2020), Impact of sleep restriction on affective functioning in adolescents with attention‐deficit/hyperactivity disorder. J Child Psychol Psychiatr, 61: 1160-1168. https://doi.org/10.1111/jcpp.13235
9 Becker, S.P., Epstein, J., Tamm, L. et al (2019). Shortened sleep duration causes sleepiness, inattention, and oppositionality in adolescents with attention-deficit/hyperactivity disorder: Findings from a crossover sleep restriction/extension study. Journal of the American Academy of Child & Adolescent Psychiatry, 58(4), 433-442
10 Keshavarzi, Z., Bajoghli, H., Mohamadi, M. R., Salmanian, M., Kirov, R., Gerber, M., Holsboer-Trachsler, E., & Brand, S. (2014). In a randomized case-control trial with 10-years olds suffering from attention deficit/hyperactivity disorder (ADHD) sleep and psychological functioning improved during a 12-week sleep-training program. The world journal of biological psychiatry : the official journal of the World Federation of Societies of Biological Psychiatry, 15(8), 609–619. https://doi.org/10.3109/15622975.2014.922698
11 Hiscock, H., et al. (2015). Impact of a behavioural sleep intervention on symptoms and sleep in children with attention deficit hyperactivity disorder, and parental mental health: randomised controlled trial. BMJ, 2015;350:h68. doi: https://doi.org/10.1136/bmj.h68
12 Corkum, P., et al. (2016). Better Nights/Better Days—Distance Intervention for Insomnia in School-Aged Children With/Without ADHD: A Randomized Controlled Trial. Journal of Pediatric Psychology, 41(6), 701-713. https://doi.org/10.1093/jpepsy/jsw031
13 Corkum, P., et al. (2019). Chapter 5 – Healthy Sleep Practices (Sleep Hygiene) in Children With ADHD. Hiscock, H., Sciberras, E. (Eds.)., Sleep and ADHD (pp. 119-149). Academic Press. https://doi.org/10.1016/B978-0-12-814180-9.00005-3
14 Bendz, L. M., & Scates, A. C. (2010). Melatonin treatment for insomnia in pediatric patients with attention-deficit/hyperactivity disorder. The Annals of pharmacotherapy, 44(1), 185–191. https://doi.org/10.1345/aph.1M365
15 Masi, G., Fantozzi, P., Villafranca, A., Tacchi, A., Ricci, F., Ruglioni, L., Inguaggiato, E., Pfanner, C., & Cortese, S. (2019). Effects of melatonin in children with attention-deficit/hyperactivity disorder with sleep disorders after methylphenidate treatment. Neuropsychiatric disease and treatment, 15, 663–667. https://doi.org/10.2147/NDT.S193891
16Erland, L. A., & Saxena, P. K. (2017). Melatonin Natural Health Products and Supplements: Presence of Serotonin and Significant Variability of Melatonin Content. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 13(2), 275–281. https://doi.org/10.5664/jcsm.6462
Updated on June 25, 2021