Sleep Issues for Adults with ADHD Robert Myers, PhD Clinical Psychologist Associate Clinical Professor, Psychiatry & Human Behavior
Sleep Disorders are Prevalent in ADHD 30% in children 60% to 80% in adults 2 Adult ADHD & Sleep Nov 2017
Three Questions about Sleep and ADHD Does ADHD cause sleep disorders? Are people with ADHD more likely to also have a sleep disorder in addition to ADHD (co-occurring)? Could the ADHD like symptoms actually be just a sleep disorder? Most likely all of these can be true. The answers need to be determined on an individual basis. 3 Adult ADHD & Sleep Nov 2017
Does ADHD cause sleep disorders? Problems settling down before bedtime. Engaging in video games before bedtime. Stimulants used to treat ADHD can contribute to sleep disorders. Restless or overly active when going to bed. 4 Adult ADHD & Sleep Nov 2017
Are people with ADHD more likely to also have a sleep disorder in addition to ADHD (co-occurring)? Co-existing conditions such as anxiety or depression may cause sleep disturbance. It is possible that some people with ADHD may be more genetically prone to develop sleep disorders. Restless Legs Syndrome (RLS) Characterized by an irresistible urge to move the legs to relieve uncomfortable sensations while the person is at rest. (Present in 2% of general population but up to 44% in the ADHD population) Sleep Disordered Breathing (SDB) Most common are obstructive sleep apnea or primary snoring. (Present in about 3% in the general population and 25-30% in ADHD population) 5 Adult ADHD & Sleep Nov 2017
Other sleep issues associated with ADHD include: insomnia early awakening sleep walking Snoring restless sleep Nightmares delayed sleep phase 6 Adult ADHD & Sleep Nov 2017
Could the ADHD like symptoms actually be just a sleep disorder? Sleep in attention-deficit/hyperactivity disorder in children and adults: Past, present, and future Sleep Medicine Reviews (2012) 1) Subjects who suffer from sleep disorders such as excessive daytime sleepiness, restless legs syndrome, periodic limb movement in sleep, sleep disordered breathing, and obstructive sleep apnea have been reported to exhibit symptoms of attention-deficit/hyperactivity disorder. 2) Alternatively, studies have shown that both children and adults with ADHD exhibit symptoms of periodic limb movements in sleep, and sleep disordered breathing. Also, children and adults with ADHD have been reported to suffer from initial and middle insomnia, fractured and/or shortened sleep, and altered sleep architecture. 7 Adult ADHD & Sleep Nov 2017
3) Although most studies have revealed sleep problems exist in ADHD, different studies have yielded different findings. As a result, determining the nature of the sleep disturbances in ADHD e and the relationship between sleep disorders and ADHD e has been difficult. 4) The similarity of symptoms in sleep disorders and ADHD suggests that: Misdiagnosis may be common Different forms of ADHD may exist 8 Adult ADHD & Sleep Nov 2017
Symptoms associated with sleep disorders in addition to ADHD symptoms: Loud snoring Dry mouth when waking Irritability and mood swings Feeling tired even after a full night of sleep 9 Adult ADHD & Sleep Nov 2017
Night and Day? Actigraphy Studies in Adult ADHD: a Baseline Comparison and the Effect of Methylphenidate Sleep Vol 30 No 4 2007 Our data suggest that sleep problems are inherent in adults with ADHD and that methylphenidate reduced total sleep time but improved sleep quality by consolidating sleep. 10 Adult ADHD & Sleep Nov 2017
If you are experiencing sleep issues: Discuss your sleep issues with your physician. Ask about a referral for a sleep study (polysomnogram) Melatonin: 1-3 milligrams at least one hour before bed time CBT-I (Cognitive Behavior Therapy for Insomnia) Relaxation Training Practice good sleep hygiene 11 Adult ADHD & Sleep Nov 2017
ADHD Tips for a Good Night s Sleep VeryWell.com (August 2017) 12 Adult ADHD & Sleep Nov 2017
Create a Bedtime Routine Have a Warm Shower or Bath: Sometimes, very simple things can be very effective. Having a bath or shower is relaxing and will help you to fall asleep. Aromatherapy: Some people found that using aromatherapy oil at bath time helped them sleep, particular scents like lavender, jasmine, and chamomile. A Warm Cup of Herbal Tea: Many people find that a cup of warm chamomile or sweet dreams tea helps promote a good night s sleep. Be sure to choose a tea that doesn't have caffeine. A Light Healthy Snack: Too much food before bedtime can make sleep more difficult, but many people find that a light snack is helpful. 13 Adult ADHD & Sleep Nov 2017
Quiet Time: Spending some quiet time before bed helps the brain wind down and prepare for sleep. Here are some options to try during your quiet time: Reading time Listening to relaxing music or soothing outdoor sounds like running water or crickets Deep relaxation and breathing exercises Visualization Meditation 14 Adult ADHD & Sleep Nov 2017
Think Positive Thoughts: Though it may take some time to readjust your thinking, try to think happy thoughts at bedtime. Set aside those worries and any negative thoughts and get into the habit of positive thinking at bedtime. One tactic is to think of a favorite place, such as the beach. You might even play ocean sounds. The happy thoughts and good feelings can make it easier to drift off to sleep. 15 Adult ADHD & Sleep Nov 2017
What to Avoid at Bedtime Don t Start a Hyperfocus Activity at Bedtime: Even though it can be hard, do not begin an activity that you will hyperfocus on as it can be very hard to disengage and go to bed. You can hyperfocus when they are using their computer or mobile phone. Removing the TV, computer, and mobile phone from the bedroom helps. Don t Drink Alcohol: Many people think of alcohol as a sedative. Indeed, it does appear to help induce sleep. However, your sleep will be less restful and more disrupted. Alcohol can increase the number of times you wake up throughout the night and it stops you from getting the deep sleep you need to feel rested in the morning. Alcohol is also a diuretic and can cause you to wake up several times during the night to urinate. 16 Adult ADHD & Sleep Nov 2017
Don t Drink Caffeine: Avoid caffeine for at least four hours before bedtime or even eliminate it completely. Caffeine is a diuretic, so you may be making several bathroom trips during the night if you ve consumed caffeine close to bedtime. Don t Smoke: Not only is smoking harmful to your lungs, but nicotine may also make it more difficult to fall asleep and can result in disrupted sleep during the night. Don t Eat Sugar: Avoid sugary foods and drinks late in the day. That extra initial energy boost from sugars can make it more difficult to fall asleep. All of the activities in the bedtime routine will help to prepare you for sleep. 17 Adult ADHD & Sleep Nov 2017
Here are some additional rituals that can help you fall asleep once you have climbed into bed. Listen to an Audio Book: A nice story can help children and adults wind down. Try listening in the dark with your eyes closed. Reading: Many people read a book or magazine to prepare for sleep. However, a really gripping book may backfire and keep you turning the pages for hours. A magazine might be a safer choice as the articles are much shorter, no matter how interesting. Stop Worrying: Once your head hits the pillow, problems of the day can start racing through your mind making sleep impossible. One way to stop this is to keep a pen and pad of paper by your bedside. Jot down your thoughts and worries. Sleep Environment: Make sure your sleep environment is conducive to sleep pillows and mattress are comfortable, lights are dim, the temperature is cool (not cold or too warm), and it is quiet. 18 Adult ADHD & Sleep Nov 2017
Healthy Habits Have a Regular Bedtime and Wake Up Time: Going to bed at a set time each night and waking up at a regular time each morning promotes better sleep. Your internal biological clock helps regulate your sleep and wake cycles. Consistency helps keep that clock set right and ensures you get the adequate sleep you need. Exercise: Exercise not only promotes good health and overall wellbeing, it also promotes good sleep. Vigorous exercise right before bed isn t recommended, but exercise during the day will make it easier to get to sleep and stay asleep at night. Be Patient With Changes: Sleep issues make take some time to resolve, so be patient. Stick with your routine and slowly but surely you will begin to experience the benefits of a good night s sleep. 19 Adult ADHD & Sleep Nov 2017
Supplements Melatonin: This naturally-occurring hormone is secreted by a part of the brain called the pineal gland. Melatonin helps regulate sleep. The dark stimulates the production of melatonin and light suppresses it. It can improve sleep onset and duration. It can also be helpful with those who work rotating shifts or are dealing with jet lag. Discuss using melatonin with your doctor as it may interact with other medications and supplements. L-Theanine: This is an amino acid found in green and black tea that seems to work against the effects of caffeine. It is used by some people to reduce stress and promote relaxation. However, you could get its benefits by drinking tea earlier in the day (avoid caffeine in the evening). Be sure to discuss any supplements with your doctor in case they may interact with medications. 20 Adult ADHD & Sleep Nov 2017
Visit Your Doctor Check Iron Levels: Some people with iron deficiency anemia experience restless leg syndrome (RLS) which can cause difficulty falling and staying asleep. Adjust Medication Times: An adjustment in your ADHD medication dosage or the time medication is taken may help make sleep a little easier. Speak with your doctor about this. If Sleep Problems Continue: Sleep disorders, such as sleep apnea, restless legs syndrome, narcolepsy, or other medical issues may be causing or contributing to sleep problems. If you continue to have concerns about sleep, consult your doctor. 21 Adult ADHD & Sleep Nov 2017
Good Sleep Ilygiene Handout The most common cause of insomnia is a change in your daily routine. (eating, exercise, leisure, etc'), and For example, traveling, change in work hours, disruption of other behaviors relationshlp conflicts can all cause sleep problems' do to maintain good sleep' Paying attention to good sleep hygiene is the most important thing you can Do: 1. Go to bed at the same time each day. 2. Getup from bed at the same time each day. Try to maintain a time close to this on weekends' is good evidence that regular exercise 3. Get regular exercise each day, preferably in the lorni-ng. There irrrprorr"jr"stful sleep. This includes stretching and aerobic exercise. afternoon. 4. Get regular exposure to outdoor or bright lights, especially in the late '".i; 5. Keep the temperatule in your bedroom comfortable' 6. Keep the bedroom quiet when sleeping. 7. Keep the bedroom dark enough to facilitate sleep' not with only for sleep and sexual activity. This will help you associate your bed with sleep, other activities like paying bills, talking on the phone, watching TV. g. Use your bed prior to bedtime may include a wafln bath or 9. Establish a regular, relaxing bedtime routine. Relaxing rituals shower, aromatherapy, reading, or listening to soothing music' relaxing imagery. Even 10. Use a relaxation exercise just before going to sleep or use this will allow your body to rest 11. Keep your feet and hands if you don't fall asleep, and feel relaxed' warn' Wear warm socks to bed' you write down problems & possible solutions, instead focus on the things that are gratelul for and positive things that happen in the day' 12. Designate another time to
Donrt: 1. Exercise just before going to bed. Try to keep it no closer than 3-4 hours before bed. 2.Engage in stimulating activity just before bed, such as playing a competitive game, watching an exciting program on television or movie, or having an important discussion with a loved one. 3. Have caffeine in the evening (coffee, many teas, chocolate, sodas, etc.) 4. Read or watch television in bed. 5. Use alcohol to help you sleep. It actually intemrpts your sleep cycle. 6. Go to bed too hungry or too full. 7. Take another person's sleeping pills. 8. Take over-the-counter sleeping pills, without your doctor's knowledge. Tolerance can develop rapidly these medications. 9. Take daytime naps. If you do, keep them to no more than20 minutes with and not close to bedtime. 10. Command yourself to go to sleep. This only makes your mind and body more alert. l2.liein bed awake for more than 20-30 minutes. Instead, get up, go to a different room (or different part of the bedroom), participate in a quiet activity (e.g. non-excitable reading), and then return to bed when you feel sleepy. Do not turn on lights or sit in front of a bright TV or computer, this will stimulate your brain to wake up. Stay in a dark, quiet place. Do this as many times during the night as needed. 13. Succumb to maladaptive thoughts like: "Oh no, look how late it is, I'11 never get to sleep" or "I must have eight hours of sleep each night, if I get less than eight hours of sleep I will get sick." Challenge your concerns and avoid catastrophizing. Remember that we cannot fully control our sleep process. Trying too hard to control it will make you more tense and more awake. 14. Change your daytime routine the next day are tired if you didn't sleep well. Even if you have a bad night sleep and it is important that you try to keep your daytime activities the same as you had planned. That is, don't avoid activities or stay in bed late because you feel tired. This can reinforce the insomnia. 15. Increase caffeine intakes the next day, this can keep you up again the following night. For more information feel free to call CWFL at (213) 821-0800 or visit www.usc.edu/worklife