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How ADHD and sleep are linked

Attention Deficit Hyperactivity Disorder or ADHD for short, is a neurodevelopmental difference in the way the brain functions. There are three underlying sets of symptoms that people with ADHD experience, which are inattentiveness, hyperactivity and impulsivity. People with ADHD can experience some or all of these symptoms, which can be mild, moderate or severe (see ‘What is ADHD?’ for more information).

With core symptoms of inattentiveness, hyperactivity and impulsivity, it is not surprising that many people with ADHD experience difficulties with sleep. Studies have shown that sleep-related difficulties are very common in adults with ADHD, affecting an estimated 50–75% of individuals. These challenges can range from trouble falling asleep (insomnia) to more complex sleep-related conditions. People with ADHD are more likely to experience shorter time spent asleep, difficulty settling at night, and frequent awakenings during the night. In some cases, this can lead to the development of specific sleep disorders.

Problems with lack of sleep in duration and quality of sleep have been associated with problem in attention and focus during waking hours (see  'strategies for inattentiveness’ for more information). Difficulties with sleep have also been link to problems with low mood (see ‘managing low mood’ for more information).

Sleep patterns can vary depending on the type of ADHD a person has.

Those with predominantly inattentive characteristics may find themselves going to bed later than intended. In contrast, individuals with more hyperactive or impulsive features often struggle with falling or staying asleep. (see advice & guidance ‘managing impulsivity & hyperactivity’ for more information). People with a combined presentation frequently experience both delayed bedtimes and reduced sleep quality. Irrespective of subtypes, it is common for individuals with ADHD to feel tired during the day, struggling to sleep at night, then experiencing difficulties waking up or getting out of bed in the morning.

In addition, while sleep issues can be present in childhood, research suggests that they often become more pronounced during adolescence and may continue to worsen into adulthood. In fact, lack of adequate sleep-in individuals with ADHD can have a substantial impact on daily functioning, sometimes causing as much difficulty as core ADHD symptoms themselves.

How to improve sleep

Behavioural and Lifestyle approaches

Whatever the cause of your sleep difficulties, the techniques used by health care professionals are referred to as ‘sleep hygiene’, which is often a key part of managing sleep. This involves adopting new habits that support more consistent and restful sleep. Not every suggestion will suit everyone, by experimenting with different approaches can be helpful.

Daytime and night-time routine

What we do in the day, is as important as what we do in the night. Getting up on time, not sleeping during the day, exercising, eating healthy and staying hydrated can all effect out nighttime routine and sleep. Substances such as caffeine found in coffee and many soft drinks, alcohol in beers, wines and spirits, nicotine found in cigarettes, and recreational drugs have all been found to different degrees to have a negative impact on sleep. Consider reducing or stopping to improve your sleep. 

Building a Healthy Sleep Routine

Plan in advance what time you need to go to bed and work out the time your need to awake in the morning. Contrary to what you may have been told, there is no evidence that human beings can function 100% on less than 6 hours sleep, we need somewhere between 6 and 9 hours. At different times of our lives, we need more or less sleep. You’ll will need to find what works for you.

Getting up at the same time

For many people with ADHD setting an alarm and getting up at the same time each day is the easiest place to start. Place you alarm clock or mobile on the other side of the bedroom, so you have to get up to turn it off. Practise this for a week or two, before working on the next strategy, going to bed at the same time each night.

Going to bed at the same time

Over the course of a week, by getting up at the same time each day, then working backwards from that time, you will begin to find the correct amount of time you need to sleep, in order to feel refreshed in the morning. For example, if you function best on 8 hours sleep, and you need to get up for work at 7 am, then lights out will need to be before or at 11 pm each night. 

If you have been going to bed at 2 am in the morning, it is unrealistic to start to try and go to bed at 11 pm. If 11 pm bedtime is your target, move your bedtime back 15 minutes each night, e.g., Monday night lights out at 1:45 am and then Tuesday night lights out at 1:30 am. Continue until you arrive at 11 pm. If you have a bad night where you go back to 2 am, then just repeat the cycle again.

Wind-down routine

By removing any sleeping during the day, eating well and exercising, then getting up at the same time, and trying to go to bed at the same time. You may have achieve the sleep routine you require. Now the skill is the keep it up and make it a new habit. However, you may arrive at 11 pm feeling overtight where you can’t sleep and are still wide awake.

Then you’ll need to think about the last hour of the day, in this example from 10 pm to 11 pm. Develop a wind-down routine. This is where you shower or bath, if that’s your normal routine, change into your bed clothes and clean your teeth an hour before bedtime. An hour before bedtime stop using electronical devices, don’t start working on a new problems or task, avoiding any eating. In fact, last meal needs to be completed 3 hours before bedtime. Turn you attention to quieter activities, for example, reading, organised your bag for work, make your patch lunch or picking out clothes for the next day.

Try and avoid wind down activities in bed:

Do not complete wind-down activities in bed. Once we climb into bed, it will aid the settling process for sleep by learning to preparing our body for sleep over time. On the other hand, if we do other activities in bed, looking at our mobile phones, playing video games on a laptop, our brain may associate this with needing to be awake and active. Additionally, try to avoid technical devices in bed, due to the blue screen which can trick your brain into thing it is daytime and can interfere with a hormone produced with in your brain. The hormone, call melatonin, regulates our sleep, blue screen activities prior to bedtime can interrupt the natural cycle of melatonin production.

However, some people find reading in bed is helpful to aid sleep. Although they read without the use of electronic devices. It’s likely reading before bedtime has become part of the wind-down routine and the brain associates the activity with getting ready for sleep. 

The 20-minute rule

We suggest only going to bed when you genuinely feel sleepy. However, many people with ADHD have difficulties feeling sleepy. If your body is not ready to sleep, lying in bed may lead to frustration and restlessness. Many people with ADHD remain active late into the evening and expect to fall asleep immediately as a result. If you can wait until you feel tired, can help reduce time spent awake in bed and make it easier to settle.

Although if you’re working on your target bedtime of 11 pm, as an example, then try this strategy. At 10 pm start your wind-down routine and climb into bed and lights out at 11 pm. If after 20 minutes, your still awake, don’t continue to lay there, as your brain may associate being awake with lying in bed, which is the opposite of what you want to achieve. Instead get up out of bed, and for 20 minutes complete a physically light and boring activity, not involving electronical devices.

Importantly set a stopwatch, for 20 minutes. When the alarm goes off, go back to bed. When back in bed, attempt to sleep again. If you find after 20 minutes, your still not asleep, repeat another 20 minutes of boring activities, before returning to bed. Repeat until you fall asleep. On the first night of trying this, you may repeat the cycle 3-4 times before falling asleep. Essentially, you’re teaching your brain, bed is for sleep only. Over a week, you may begin to notice the 20-minute cycles will reduce until you fall asleep within the 20 minutes.

Professional support - medication for sleep

For some people with ADHD, sleep problems have been life long and the guidance may only partially work, or not at all. Therefore, if sleep problems persist despite improving your routines and habits, it is advisable to consult your GP. Short-term medication for insomnia may be offered where appropriate. In more complex cases, referral to a specialist sleep clinic may be recommended, as sleep difficulties can sometimes require more detailed assessment and tailored intervention.

Considering medication for ADHD

Difficulties with sleep may also be addressed with ADHD medication is one possible option, but it isn’t suitable for everyone. It’s important to think about how ADHD affects your wellbeing and daily life. If it seems appropriate, you will be offered an appointment to discuss medication in more detail. Responses to medication can differ from person to person. While stimulant medications used to treat ADHD can sometimes disrupt sleep, in other cases they may actually improve it by reducing restlessness and helping the mind settle. If sleep difficulties are linked to medication, alternative options, including non-stimulant treatments, may be considered.

Other Adult ADHD service support

CBT or Cognitive Behavioural Therapy, a type of psychotherapy can be used to help monitoring problems and then develop routine and new strategies to help with sleep. The adult ADHD service is able to offer or signpost you to this type of support if needed. 

The adult ADHD service will be offering a range evidence-based treatment you may want to consider:

• Adapt ADHD medication assessment (if not already prescribed).
• Adapted CBT for ADHD, available for those with depression and anxiety in your local NHS trust NELFT, which also include modules on sleep management.
•  ADHD coaching, for those who want to focus on practical problems due difficulties experienced. 
•  Occupational Therapy for developing strategies for work or education.

We have a range of professionals who form the multidisciplinary team who can support you. We offer support from ADHD coaches and specialist occupational therapists, to help with the practical difficulties throughout the diagnosis processes. We have medical staff such as specialist nurses, psychiatrists and pharmacist, who will support you with the diagnosis, and if you decided to take medication. Finally, we have psychology staff, which includes assistant psychologists, practitioner psychologists and cognitive behavioural psychotherapists, to help support you with your mental health needs. The multidisciplinary approach allows the service offer tailored support for your current needs, now and into the future.