There is an important part of ADHD symptoms that hasn’t been studied enough: How ADHD can cause issues with sleep. Neurofeedback is a potential remedy to these problems, but why do the problems exist in the first place? This two-part article will try to shine a light on how ADHD can adversely affect sleep. (Click here for Part 1)

Why Do People with ADHD Have Problems Sleeping?

There are several theories about the causes of sleep disturbance in people with ADHD, with a telling range of viewpoints. Physicians base their responses to their patients’ complaints of sleep problems on how they interpret the cause of the disturbances. A physician who looks first for disturbances resulting from disorganized life patterns will treat problems in a different way than a physician who thinks of them as a manifestation of ADHD.

Thomas Brown, Ph.D., a longtime researcher in ADHD and developer of the Brown Scales, was one of the first to give serious attention to the problem of sleep in children and adolescents with ADHD. He sees sleep disturbances as indicative of problems of arousal and alertness in ADHD itself. Two of the five symptom clusters that emerge from the Brown Scales involve activation and arousal:

• Organizing and activating to begin work activities.
• Sustaining alertness, energy, and effort.

Brown views problems with sleep as a developmentally-based impairment of management functions of the brain — particularly, an impairment of the ability to sustain and regulate arousal and alertness. Interestingly, he does not recommend treatments common to ADHD but rather recommends a two-pronged approach that stresses better sleep hygiene and the suppression of unwanted and inconvenient arousal states by using medications with sedative properties.

The simplest explanation is that sleep disturbances are direct manifestations of ADHD itself. True hyperactivity is extremely rare in women of any age. Most women experience the mental and physical restlessness of ADHD only when they are trying to shut down the arousal state of day-to-day functioning in order to fall asleep. At least 75 percent of adults of both genders report that their minds restlessly move from one concern to another for several hours until they finally fall asleep. Even then, they toss and turn, awaken frequently, and sometimes barely sleep at all.

The fact that 80 percent of adults with ADHD eventually fall into “the sleep of the dead” has led researchers to look for explanations. No single theory explains the severe impairment of the ability to rouse oneself into wakefulness. Some patients with ADHD report that they sleep well when they go camping or are out of doors for extended periods of time.

One hypothesis is that the lack of an accurate circadian clock may also account for the difficulty that many with ADHD have in judging the passage of time. Their internal clocks are not “set.” Consequently, they experience only two times: “now” and “not now.” Many of my adult patients do not wear watches. They experience time as an abstract concept, important to other people, but one which they don’t understand. It will take many more studies to establish the links between circadian rhythms and ADHD.

How to Get to Sleep with ADD

No matter how a doctor explains sleep problems, the remedy usually involves something called “sleep hygiene,” which considers all the things that foster the initiation and maintenance of sleep. This set of conditions is highly individualized. Some people need absolute silence. Others need white noise, such as a fan or radio, to mask disturbances to sleep. Some people need a snack before bed, while others can’t eat anything right before bedtime. A few rules of sleep hygiene are universal:

• Use the bed only for sleep or sex, not as a place to confront problems or argue.
• Have a set bedtime and a bedtime routine and stick to it — rigorously.
• Avoid naps during the day.

Two more elements of good sleep hygiene seem obvious, but they should be stressed for people with ADHD.

• Get in bed to go to sleep. Many people with ADHD are at their best at night. They are most energetic, thinking clearest, and most stable after the sun goes down. The house is quiet and distractions are low. This is their most productive time. Unfortunately, they have jobs and families to which they must attend the next morning, tasks made harder by inadequate sleep.
• Avoid caffeine late at night. Caffeine can cause a racing ADHD brain to grow more excitable and alert. Caffeine is also a diuretic, although not as potent as experts once thought, and may cause sleep disruptions brought on by needing to go to the bathroom. It is a good strategy to avoid consuming any liquids shortly before bedtime.

Problems Waking Up with ADHD

Problems in waking and feeling fully alert can be approached in two ways. The simpler is a two-alarm system. The patient sets the first dose of stimulant-class medication and a glass of water by the bedside. An alarm is set to go off one hour before the person actually plans to rise. When the alarm rings, the patient rouses himself enough to take the medication and goes back to sleep. When a second alarm goes off, an hour later, the medication is approaching peak blood level, giving the individual a fighting chance to get out of bed and start his day.

A second approach is more high-tech, based on evidence that difficulty waking in the morning is a circadian rhythm problem. Anecdotal evidence suggests that the use of sunset/sunrise-simulating lights can set the internal clocks of people with Delayed Sleep Phase Syndrome. As an added benefit, many people report that they sharpen their sense of time and time management once their internal clock is set properly. The lights, however, are experimental and expensive (about $400).

Disturbances of sleep in people with ADHD are common but are almost completely ignored by our current diagnostic system and in ADHD research. These patterns become progressively worse with age. Recognition of sleep disturbance in ADHD has been hampered by the misattribution of the difficulty falling asleep to the effects of stimulant-class medications. We now recognize that sleep difficulties are associated with ADHD itself and that stimulant-class medications are often the best treatment of sleep problems rather than the cause of them.

Here at Neurohealth Associates, we specialize in Neurofeedback treatments. Neurofeedback may be helpful if you have unwanted mood swings, problems sleeping, anger management issues, motivation, or poor self-esteem. The easy, noninvasive treatment can painlessly improve your mental health condition and outlook on life.

Schedule a consultation with NeuroHealth today and find out how we can help you.