ADHD and sleep: What’s the connection?

What the headlines say

ADHD is associated with a markedly increased incidence of behaviorally related sleep problems. That includes challenges like not wanting to go to bed or having behavior problems around bedtime, and as a result, not getting sufficient sleep.

The other kind of sleep problem we can call a primary sleep disorder this includes problems like sleep apnea and restless legs syndrome. The association of these primary sleep disorders and ADHD has been less clear due to a shortage of representative studies. Recently, we have seen some concern about sleep-wake phase offset disorder in ADHD – that is, when an individual’s body clock is not synchronized to day/night, so they aren’t sleepy at bedtime and aren’t wakeful in the morning.

Read more: a typical small study on the effect of adenotonsillectomy on ADHD symptoms of children with adenotonsillar hypertrophy and sleep-disordered breathing. 

Even more recently, attention has been called to mouth breathing and ADHD. Mouth breathing is a well-known form of sleep-disordered breathing that can occur in children and can also be associated with sleep apnea. When it occurs, it should be addressed – over time, it can lead to alterations in facial skeletal growth and may also increase behavioral problems due to disrupted sleep. Sleep-disordered breathing can be treated with adenotonsillectomy, and also with myofunctional therapy – a form of exercises to help correct the functioning of the oral-facial muscles.

What the science says

While it’s not clear that sleep-disordered breathing occurs more often in ADHD, when it does occur it may be a contributor to ADHD symptoms. The science community has known for decades that inadequate sleep can create some symptoms similar to ADHD.

Because ADHD creates behavioral interference with sleep, a vicious cycle can develop for kids with ADHD. In those instances, where there is a true sleep disorder (whether sleep-disordered breathing or another disorder), it can lead to a misdiagnosis of ADHD. In those cases, treatment of the primary sleep problem – including sleep-disordered breathing – may improve the ADHD symptoms as well as prevent other physical health problems.

Dr. Joel Nigg has written previously about the association of sleep problems and ADHD in his book, “Getting Ahead of ADHD.” He and Dr. Elizabeth Super will be giving a free webinar on sleep and ADHD in collaboration with ADDitude magazine on Nov. 29. Sign up here!

I recently participated in a symposium on ADHD in adolescents. Sleep is a particularly difficult challenge for adolescents in our culture in general, because normal development changes their body clocks to prefer later hours – conflicting with early school start times in our society.

One of my colleagues, Dr. Steve Becker from the University of Cincinnati, presented new evidence that loss of sleep is not just correlated but causal in ADHD symptoms. Interestingly, it did not cause hyperactivity. Rather, it caused inattention and sluggishness (lower activity, more inattention).

The bottom line

It’s always important to obtain a careful medical exam as part of any ADHD work-up. If sleep related problems are suspected, they should be investigated with a professional evaluation, if necessary with a pediatric sleep expert consultation and referral.

 

Joel Nigg, Ph.D.
Director, Division of Psychology
Professor of Psychiatry, Pediatrics and Behavioral Neuroscience
Oregon Health & Science University

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