ADHD and Coexisting Conditions: ADHD, Sleep and Sleep Disorders (WWK5D)
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WWK refers to the What We Know series of information sheets on ADHD. See the complete list. See the PDF version of this sheet.
Attention-deficit/hyperactivity disorder (ADHD) is a common neurobiological condition affecting 5-8 percent of school age children1,2,3,4,5,6,7 with symptoms persisting into adulthood in as many as 60 percent of cases (i.e. approximately 4% of adults).8,9
Of all children with ADHD, only about 30 percent of them have ADHD as their only diagnosis. Two-thirds of children with ADHD are reported to have at least one co-existing condition, and these conditions complicate the diagnosis and treatment of ADHD.10,11
Any disorder can co-exist with ADHD, but certain disorders seem to occur more commonly. These include: oppositional defiant and conduct disorders, anxiety, depression, tics and Tourette syndrome, substance abuse, sleep disorders and learning disabilities.12,13
The relationship between sleep and ADHD is not a new one. At one time, sleep disturbances were included in the diagnostic criteria for ADHD, but due to a lack of demonstrable evidence, sleep disturbances were removed from the Diagnostic and Statistical Manual of Mental Disorders, when its Third Revised Edition was published inre 1980.14
This What We Know sheet:
- describes ADHD and sleep problems
- discusses the diagnosis of sleep disorders in people with ADHD
- describes the most common sleep disorders among persons with ADHD
- provides information on causes of sleep problems in individuals with ADHD
- offers ideas on suggestions to deal with sleep problems.
For an introduction to the diagnosis and treatment of ADHD, see What We Know #1: The Disorder Named ADHD.
ADHD, Sleep and Sleep Problems
While sleep problems can affect anyone in the general population, there is a greater occurrence of these problems in people with ADHD. One quarter to one half of parents of children with ADHD report that their children suffer from a sleep problem, especially problems with falling asleep and staying asleep.15 Parental reports actually indicate a two to threefold higher instance of sleep problems in children with ADHD compared to control groups in research studies.16 In addition to having difficulty falling and staying asleep, these problems also include greater activity during sleep, restless legs/periodic leg movements during sleep (PLMS), unstable sleep patterns, and greater sleepiness than other children during the daytime.17,18,19,20,21,22,23,24 Although largely anecdotal, studies have shown that a substantial number of children with ADHD also have a primary sleep disorder that accounts for some portion of their behavioral difficulties.25 Researchers also speculate that ADHD is associated with hypoarousal (a state of increased sleepiness) rather than hyperarousal. This indicates that hyperactivity could be a coping mechanism to counteract the daytime sleepiness these children experience.26 While the evidence has not been found strong enough for a causal relationship, excessive daytime sleepiness is believed to worsen the symptoms of ADHD.27,28
In adults, there is the possibility of diagnostic confusion between narcolepsy, excessive daytime sleepiness of unknown origin (called idiopathic hypersomnia) and ADHD in self reporting questionnaires.29 The overlap between symptoms of sleep disorders and ADHD does lead to questions regarding the possible misdiagnosis of both conditions in adults and how closely they are related.30
Screening for possible sleep problems should be part of the evaluation of every person with behavioral and/or academic problems, especially ADHD. If a sleep problem is suspected, a thorough sleep history should be taken by the evaluating clinician. The history should include questions about the usual bedtime, time required to fall asleep, whether there are night awakenings, snoring, difficulty waking up, whether the person takes naps, and daytime drowsiness. Patients may be asked to fill out a sleep diary that records daily sleep behaviors for a number of weeks.
Not all people with ADHD suffer from sleep problems, but because such difficulties can cause distress in people with ADHD and their families, it is important to understand the nature of these problems and how they relate to ADHD. In addition, identifying underlying differences in sleep patterns between children with ADHD who suffer from sleep disorders and those who do not may help determine common causes of both sleep problems and ADHD in those affected.31
Diagnosis of Sleep Disorders in People with ADHD
When ADHD is diagnosed, the diagnosing clinician must rule out other conditions as the source of the ADHD symptoms, as well as determine whether there are any other psychiatric or neurological disorders present. Often, the same symptoms overlap in different disorders. The problem for the clinician is to discern whether a symptom belongs to ADHD, to a different disorder, or to both disorders at the same time. For some individuals, the overlapping of symptoms can indicate the presence of multiple disorders.
Sleep disorders provide an especially difficult challenge, as many of the symptoms of sleep disorders can mimic ADHD symptoms and may be exacerbated by ADHD symptoms and medications used to treat ADHD.32
By conducting a complete evaluation, a well-trained clinician familiar with ADHD and other disorders will be able to discern between ADHD and other possible conditions. Interviews and questionnaires are part of the diagnostic process used to obtain information from the patient, the patient's family, and his or her teachers to screen for these other disorders.
Because sleep disorder symptoms can mimic ADHD symptoms, such as difficulty with paying attention and concentrating, they can actually be misdiagnosed as ADHD. Clinicians should be aware of the co-existence of Sleep Disordered Breathing (SDB) and Obstructive Sleep Apnea (OSA) with ADHD when diagnosing and treating symptoms.33 Some believe that many of the concerns that ADHD is over diagnosed may be related to some parents and providers incorrectly attributing attention difficulties to ADHD rather than to underlying sleep disorders.34
Common Sleep Disorders among People with ADHD
Restless Legs Syndrome. One of the more frequent sleep disorders among individuals with ADHD is Restless Legs Syndrome (RLS). Up to 24 percent of people with ADHD may have RLS symptoms, and up to 26 percent of people suffering RLS may have ADHD or symptoms of ADHD. Daytime manifestations of RLS can mimic ADHD symptoms, such as restlessness and inattention.35 [For more information, see the National Institute of Neurological Disorders and Stroke (NINDS) fact sheet on RLS , or the Restless Legs Foundation.]
Sleep Disordered Breathing and Obstructive Sleep Apnea. SDB and OSA are two more sleep disorders that may affect people with ADHD.36 SDB and OSA are believed to be more significant37 in people with ADHD than in the general population, and the sleep difficulties associated with these disorders can lead to ADHD symptoms during the day. It is not clear if difficulties arising from SDB make existing ADHD symptoms worse in general, or only in a subset of people with ADHD.38
Causes of Sleep Problems in Individuals with ADHD
While there is a known and demonstrable link between ADHD and sleep disorders, questions remain as to whether people with ADHD have more intrinsic difficulties settling down at bedtime that are not related to outside factors, co-existing conditions or sleep disorders. In other words, ADHD itself may lead to difficulty sleeping.39
Most studies using objective measures such as actigraphy (in which a small wristwatch-like computer device measures body movements during sleep as well as sleep/wake periods and total duration of sleep)and infrared video cameras (which observe sleep behavior and record movements during sleep) have shown no significant differences in how sleep works between children with ADHD and control groups. But certain characteristics do seem common across different studies.40 Activity during sleep has been found to be higher in children with ADHD in terms of the frequency and duration of movements. The instability of sleep patterns in children with ADHD may indeed set them apart from control groups, according to one study, which suggested that this might reflect an impairment in arousal regulation in ADHD. The result is that children with ADHD might be sleepier than children without the disorder.41 This study has been supported by subsequent studies, which have found that children with ADHD exhibit excessive daytime sleepiness, high motor achievements in sleep, and significant Sleep Disordered Breathing. It was also found that there is no other significant difference in sleep patterns between children with ADHD and those without.42
The cause of sleep problems in people with ADHD is still largely unknown and further research into this area is needed to better understand the complex relationship between sleep and ADHD.
Here are some specific causes of sleep problems that can impede sleep in children or adults with ADHD.
Bedtime resistance. Children with ADHD may have a great deal of difficulty settling down in the evening. Interruptions during bedtime routines can be more challenging when the child has ADHD and parents often describe increased bedtime resistance and struggles.43
Stimulants. The caffeine found in coffee, tea, chocolate and many carbonated beverages has long been known to increase problems with sleep. In addition, the stimulant medications used to treat ADHD can contribute to sleep disorders in people with ADHD.44
Co-existing conditions. In addition to primary sleep disorders, sleep problems in persons with ADHD can also be the result of common co-existing conditions. Anxiety and depression disorders can lead to difficulties with sleeping, and are two conditions often found to exist with ADHD.45 Drug and alcohol abuse problems also have a negative impact on a person's ability to sleep properly.46
Dealing with Sleep Problems in Individuals with ADHD
While there is no one specific recommended treatment for sleep problems in children or adults with ADHD, the National Sleep Foundation (NSF) does offer tips to help adults and children sleep better. The following suggestions may help to accomplish a smoother transition from wakefulness to restful sleep.
- Practice good sleep habits. Maintain a regular bed and wake schedule, even on weekends; avoid all caffeine products after late afternoon; avoid nicotine and alcohol close to bedtime; use the bed for sleeping only and avoid having children watch television or videos before bedtime.47,48
- Set up a realistic time for bed and stick to that schedule. Behavioral techniques may be necessary to help children with ADHD stay in bed when the decided time has arrived. Children with ADHD do better with structure and knowing what to expect ahead of time.49
- Pay attention to room environment. Keep the bedroom dark, quiet, cool and comfortable for the best sleep. Minimize potential interruptions, such as outside noise - this can be done by using a fan or humidifier to create "white noise."50,51 Part of ensuring a sleep-friendly environment might also mean keeping televisions, computers, videogames and other electronic equipment out of the bedroom.
- Get plenty of exercise during the day. Exercise helps dissipate hyperactivity and feelings of restlessness in those with ADHD.52,53,54 However, exercising close to bedtime can make it more difficult to fall asleep, so exercise should be completed at least three hours before bedtime.55
- Monitor eating times. Eating heavily too close to bedtime can inhibit a good night's sleep.56 However, because some children with ADHD don't get enough calories throughout the day to maintain proper nutrition, a small snack close to bedtime can ease bedtime hunger pains and help maintain a healthy weight.
- Establish a routine. Adults benefit from a relaxing routine at the end of the day. This helps ease the transition from the activities of the day to the calm restfulness of sleep. This is also important for children, as they thrive on and need routines.57
- If taking either prescription or over the counter medication, consult with a physician. Different medications can have different effects on different people. Discuss any medication taken with a physician to determine if there are any side effects that could impact the quantity or quality of sleep.
1. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders: DSM IV (4th ed., text, revision), Washington, D.C.: American Psychiatric Association.
2. Mayo Clinic. (2002). How Common is Attention-Deficit/Hyperactivity Disorder? Archives of Pediatrics and Adolescent Medicine 156(3): 209-210.
3. Mayo Clinic (2001). Utilization and Costs of Medical Care for Children and Adolescents with and without Attention-Deficit/Hyperactivity Disorder. Journal of the American Medical Association 285(1): 60-66.
4. Surgeon General of the United States (1999). Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services.
5. American Academy of Pediatrics (2000). Clinical practice guidelines: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics, 105, 1158-1170.
6. Centers for Disease Control and Prevention (2003). Prevalence of diagnosis and medication treatment for attention-deficit/hyperactivity disorder. Morbidity and Mortality Weekly Report 54: 842-847.
7. Froehlich, T.E., Lanphear, B.P., Epstein, J.N., et al. Prevalence, recognition, and treatment of attention-deficit/hyperactivity disorder in a national sample of US children. Archives of Pediatric and Adolescent Medicine (2007), 161:857-864.
8. Faraone, S.V., Biederman, J., & Mick, E. (2006) The age-dependent decline of attention-deficit hyperactivity disorder: A meta-analysis of follow-up studies. Psychol Med (2006), 36: 159-65.
9. Kessler, R.C., Adler, L., Barkley, R., Biederman, J., et al. The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. Am Journal of Psychiatry (2006), 163:724-732.
10. Biederman, J., Faraone, S.V., & Lapey, K. (1992). Comorbidity of diagnosis in attention-deficit hyperactivity disorder. In G. Weiss (Ed.), Attention-deficit hyperactivity disorder, child & adolescent clinics of North America. Philadelphia: Sanders.
11. Bartholomew, K., & Owens, J, M.D., MPH (2006). Sleep and ADHD: A review. Medicine and Health Rhode Island, 89: 91-93.
12. Biederman, J., Newcomb, J., & Sprich, S. (1991). Comorbidity of ADHD with conduct, depressive, anxiety and other disorders. American Journal of Psychiatry, 148, 564-577.
13. Bartholomew, K., & Owens, J, M.D., MPH (2006). Sleep and ADHD: A review. Medicine and Health Rhode Island, 89: 91-93.
14. Phillipsen, Alexandra, Hornyak, M, & Riemann, D (2006). Sleep and sleep disorders in adults with attention deficit/hyperactivity disorder. Sleep Medicine Reviews, 10: 399-405.
15. Corkum, P.H., Tannock, R., & Moldofsy, H. (1998). Sleep disturbances in children with attention deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 37: 637-646.
16. Gruber, R., Ph.D., Grizenko, N, M.D., Schwartz, G., M.Sc., Amor, L.B., M.D., Gauthier, J., De Guzman, R., & Joober, R., M.D., Ph.D. (2006). Sleep and COMT Polymorphorism in ADHD children: preliminary actigraphic data. Journal of the American Academy of Child and Adolescent Psychiatry, 45: 982-989.
17. Dagan, Y.; Zeevi-Luria, S.; Sever, Y., Hallis, D., Yovel, I., Sadeh, A., & Dolev, E. (1997). Sleep quality in children with attention deficit hyperactivity disorder: an actigraphic study. Psychiatry and Clinical Neurosciences, 51: 383-386.
18. Cordum, P., Tannock, R., Moldofsky, H., Hogg-Johnson, S., & Humphries, T. (2001). Actigraphy and parental ratings of sleep in children with attention-deficit/hyperactivity disorder (ADHD). Sleep, 24: 303-312.
19. Konofal, E., Lecendreux, M., Bouvard, M.P., & Mouren-Simeoni, M.C. (2001). High levels of nocturnal activity in children with attention-deficit hyperactivity disorder: a video analysis. Psychiatry and Clinical Neurosciences, 55: 97-103.
20. Gruber, R., Sadeh, A., & Raviv, A. (2000). Instability of sleep patterns in children with attention-deficit hyperactivity disorder. Journal of American Academy of Child and Adolescent Psychiatry, 39: 495-501.
21. Gruber, R., & Sadeh, A. (2004). Sleep and neurobehavioral functioning in boys with attention-deficit/hyperactivity disorder and no reported breathing problems. Sleep, 27: 267-273.
22. Palm, L., Persson, E., Bjerre, I., Elmqvist, D., & Blennow, G. (1992). Sleep and wakefulness in preadolescent children with deficits in attention, motor control and perception. Acta Paediatr, 81: 618-624.
23. Lecendreux, M., Konfal, E., Bouvard, M., Falissard, B., & Mouren-Simeoni, M.C. (2000). Sleep and alertness in children with ADHD. Journal of Child Psychology and Psychiatry, 41: 803-812.
24. Gruber, R., Ph.D., Grizenko, N, M.D., Schwartz, G., M.Sc., Amor, L.B., M.D., Gauthier, J., De Guzman, R., & Joober, R., M.D., Ph.D. (2006). Sleep and COMT Polymorphorism in ADHD children: preliminary actigraphic data. Journal of the American Academy of Child and Adolescent Psychiatry, 45: 982-989.
25. Owens, Judith (2005). The ADHD and Sleep Conundrum: A Review. Developmental and Behavioral Pediatrics, 4: 312-322.
26. Bartholomew, K., & Owens, J., M.D., MPH (2006). Sleep and ADHD: A review. Medicine and Health Rhode Island, 89: 91-93.
27. Cortese, S., M.D., Konofal, E., M.D., Ph.D., Yateman, N, Ph.D., Mouren, M.C., M.D., Bernardina, B.D., M.D., & Lecendreux, M., M.D. (2005). Sleep disturbances in children with ADHD. The ADHD Report, June: 6-11.
28. Bartholemew, K & Owens, J., M.D., MPH (2006). Sleep and ADHD: A review. Medicine and Health Rhode Island, 89: 91-93.
29. Oosterloo, M., Lammers, G. J., Overeem, S., de Noord, I., & Kooij, J.J. (2006). Possible confusion between primary hypersomnia and adult attention-deficit/hyperactivity disorder. Psychiatric Research, 143: 293-297.
31. Cortese, S., M.D., Konofal, E., M.D., Ph.D., Yateman, N, Ph.D., Mouren, M.C., M.D., Bernardina, B.D., M.D., & Lecendreux, M., M.D. (2005). Sleep disturbances in children with ADHD. The ADHD Report, June: 6-11.
32. Owens, J. (2005). The ADHD and sleep conundrum: a review. Developmental and Behavioral Pediatrics, 4: 312-322.
33. Philipsen, A., Hornyak, M, & Riemann, D. (2006). Sleep and sleep disorders in adults with attention deficit/hyperactivity disorder. Sleep Medicine Reviews, 10: 399-405.
34. Owens, J. (2005). The ADHD and sleep conundrum: a review. Developmental and Behavioral Pediatrics, 4: 312-322.
36. Phillipsen, A., Hornyak, M., & Riemann, D. (2006). Sleep and sleep disorders in adults with attention deficit/hyperactivity disorder. Sleep Medicine Reviews, 10:399-405.
37. Bartholemew, K., & Owens, J., M.D., MPH (2006). Sleep and ADHD: A review. Medicine and Health Rhode Island, 89: 91-93.
38. Cortese, S., M.D., Konofal, E., M.D., Ph.D., Yateman, N, Ph.D., Mouren, M.C., M.D., Bernardina, B.D., M.D., & Lecendreux, M., M.D. (2005). Sleep disturbances in children with ADHD. The ADHD Report, June: 6-11.
39. Owens, J. (2005). The ADHD and Sleep Conundrum: A Review. Developmental and Behavioral Pediatrics, 4: 312-322
40. Bartholemew, K. & Owens, J., M.D., MPH (2006). Sleep and ADHD: a review. Medicine and Health Rhode Island, 89: 91-93.
42. Cortese, S., M.D., Konofal, E., M.D., Ph.D., Yateman, N, Ph.D., Mouren, M.C., M.D., Bernardina, B.D., M.D., & Lecendreux, M., M.D. (2005). Sleep disturbances in children with ADHD. The ADHD Report, June: 6-11.
43. Corkum P., Tannock R., Moldofsky H., Hogg-Johnson, S., & Humphries, T. (2001). Actigraphy and parental ratings of sleep in children with attention-deficit/hyperactivity disorder (ADHD). Sleep, 24(3): 303-312.
44. Corkum, P.H., Tannock, R., & Moldofsy, H. (1998). Sleep disturbances in children with attention deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 37: 637-646.
46. Phillipsen, A., Hornyak, M., & Riemann, D. (2006). Sleep and sleep disorders in adults with attention deficit/hyperactivity disorder. Sleep Medicine Reviews, 10:399-405.
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53. Allen, J.J. (1980). Jogging can modify disruptive behaviors. Teaching Exceptional Children. Winter 1980: 66-70.
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57. "Children and Sleep." National Sleep Foundation. July, 2007. NSF.
The information provided in this sheet was supported by Grant/Cooperative Agreement Number 1U38DD000335-01 from the Centers for Disease Control and Prevention (CDC). The contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC. This fact sheet was approved by CHADD's Professional Advisory Board in 2007.
© 2007 Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD).
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