This isn’t the first time sleep and its role as a factor in ADHD has been addressed. However, continued awareness and discussion on the topic often brings other related issues to the forefront – issues that some experts feel may need to be more thoroughly explored and understood.
An Ongoing Topic Deserving of More Attention
According to Thomas E. Brown, director of the Brown Clinic for Attention and Related Disorders in Manhattan Beach, California, and a consulting psychologist at Understood.org, a free online resource and community supporting parents of the 1 in 5 kids with learning and attention issues, “sleep and its association with ADHD is not a new issue.” However, he adds, “it is an important issue that deserves more attention than it gets.” Brown says that the point shouldn’t be so much wondering which came first – sleeplessness causing ADHD or ADHD causing sleeplessness – or even questioning whether people with ADHD really just have sleep issues. Instead, he says it’s important to focus on the need to better assess people’s sleep habits during the ADHD diagnosis process, to improve understanding of any associations between ADHD and sleep and to remain informed about sleep-related changes in diagnostic criteria outlined by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders – the DSM-5.
Asking about sleep habits and any challenges surrounding them should be a significant part of the ADHD evaluation process, Brown believes. Questions about the times a person typically goes to bed and wakes the next day, what time a person goes to bed with the intent to sleep and how long it takes before actually falling asleep are among some sleep-related questions that should be examined in detail and not minimized. For those with ADHD, he says it’s “often hard to shut their head off regardless of what’s going on,” whether it’s rehashing the day, being worried about something or thinking about what tomorrow will bring. This inability to fall asleep, however, isn’t so much a matter of constant worry, he explains, as it is due to the fact that someone with ADHD has executive functioning impairments, which “includes the inability to modulate levels of arousal, settle down and be able to wake up when they need to. The fact is, people with ADHD struggle a lot more,” he says.
It could be that a sleep study may benefit people with ADHD, says Dr. Elsie Taveras, chief of general pediatrics at Massachusetts General Hospital for Children who studies sleep and chronic diseases in children. She explains that while parents can explain when they put children to bed and wake them up, they aren’t privy to every sleep occurrence throughout the evening and morning. “A sleep study, on the other hand, can determine whether someone is getting high-quality sleep,” she says. “Sleep duration is one thing, but sleep quality is another.”
Reut Gruber, associate professor at the department of psychiatry at McGill University and the director of the Attention Behavior and Sleep Lab at Douglas Mental Health University Institute in Montreal, adds that when it comes to ADHD, “we know that there is quite a range of sleep disorders that are commonly reported.” For example, she says that restless leg syndrome, which can impede sleep, frequently occurs with ADHD and is thought to stem from shared physiology related to iron and dopamine deficits.
Gruber says that sleep-disordered breathing, especially sleep apnea, is also commonly experienced among people with ADHD. But she says that the “which came first” question continues to persist. Is this a sleep disorder on its own, or is sleep apnea occurring because of ADHD-related challenges that interfere with sleep? Sleep apnea brings about sleep disruptions, she explains, rather than prompting a child to wake up entirely and get out of bed. Still, chronic sleep interruption can “take a toll on the brain’s prefrontal cortex, which can resemble ADHD,” Reut says.
Regarding children, Taveras cites a study she was involved in, published in August in the journal Academic Pediatrics. It found that children who aren’t getting sufficient sleep early in life – preschool and earlier -–are more likely to have poor neurobehavioral functioning. When insufficient sleep was an issue at the ages of 3 and 7, she says, researchers found that at age 7, behavioral problems and executive function issues ensued.
Beyond Sleep: Many Parts to the Equation
Gruber says that there are many variables surrounding this topic. Diagnosable sleep disorders may coexist with ADHD, but sometimes, people who treat individuals with ADHD aren’t “necessarily educated about sleep and sleep disorders,” so associations may be missed. It’s here where she emphasizes the importance for pediatricians and other experts who are assessing and helping a person manage ADHD to make sleep “a part of the norm.” At the same time, when it comes to children, she says that sleep issues may simply be a matter of behavioral problems in which children don’t fall asleep at a reasonable time, which can worsen ADHD symptoms.
“Some children with ADHD are chronically oppositional and tend to resist directions to prepare for bed as much as they resist many other directions from their parents,” Brown writes in his book “Outside the Box: Rethinking ADD/ADHD in Children and Adults.” He adds that some children and adolescents may also find it challenging to resist the urge to respond to friend’s late-night text message or from engaging in technology despite being in bed with the intention of falling asleep.
Although the topic of sleep and ADHD often arises, Brown says that changes in DSM criteria regarding ADHD have occurred over time. The current manual, he explains, does not include sleep problems, whereas previous revisions did. A study published in 2013 in the Journal of Attention Disorders – in which both Brown and Gruber were involved – touches on this. “Given the multiple overlaps and interactions described in this review,” its summary states, “some might question whether sleep problems are best understood as a comorbidity commonly associated with ADHD or, perhaps, as a fundamental characteristic of ADHD itself as was assumed by Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM-III; American Psychiatric Association, 1980).”
Is ADHD Strictly a Sleep Problem?
So, do these experts think that a time will ever come when ADHD will be considered strictly a sleep issue? In a nutshell: No.
“There is some overlap,” Brown says, “but it’s not as though ADHD can be considered scientifically a problem of sleep.” He explains that ADHD also involves much more, including – but not limited to – sustaining effort even when not interested in a topic, individual response to ADHD medication and modulating emotion.
Gruber feels similarly. “One can make the other worse, that’s for sure,” she says of ADHD’s impact on sleep and vice versa. “It’s very complex, but I don’t think ADHD is an artifact of a sleep disorder. I don’t think it’ll get to the ‘all or none’ point.”
Still, it’s worth exploring, Taveras says. The issue is “screaming for a longitudinal study to disentangle which comes first,” she says. “Is sleep the antecedent of these manifestations or is it ADHD in isolation of these sleep issues?”