Sleep problems are particularly common in ADHD. Sources speak of about 75% of those affected, , vion 44.4% in adults with ADHD, others of 12.7% in children 7 to 11 years of age with ADHD. One study found no changes in sleep architecture in ADHD.
Sleep disturbances occur more frequently in ADHD sufferers than in their unaffected twin siblings. Sleep duration decreases with the intensity of ADHD symptoms. At the same time, sleep deprivation causes greater fatigue in ADHD sufferers than in non-affected individuals. ADHD sufferers are thus more sensitive to sleep deprivation than non-affected individuals.
It is open whether sleep problems occur more frequently in ADHD-C, or in ADHD-HI and ADHD-C than in ADHD-I , or whether hyperactive ADHD-HI suffer from sleep problems less frequently than predominantly inattentive ADHD-I sufferers.
Further research found no subtype differences, but found gender and comorbidity differences: 75% of girls and 53% of boys with ADHD had sleep problems. Anxiety symptoms clearly correlated with later bedtime and sleep anxiety; hyperactive-impulsive symptoms were associated with more frequent nighttime awakenings and more sleep behavior problems (parasomnia). ODD and depressive symptoms correlated with shorter sleep duration. Depression was clearly reflected in increased daytime sleepiness and general sleep problems. Gender did not moderate the correlation between comorbidities and sleep problems. A tendency toward increased daytime sleep problems was found in the predominantly hyperactive-impulsive ADHD-HI subtype. Another study found a correlation between unstable sleep and inattention in boys with ADHD.
One study found that sleep problems in ADHD occurred only in those with sensitivity problems (taste and smell sensitivity, hearing sensitivity, and sensation seeking) according to the Short Sensory Profile (SSP) questionnaire.
In adults with ADHD, higher ADHD severity and with medical or psychiatric comorbidities (especially depression, anxiety disorders, personality disorders, and any type of substance use disorder) further increased sleep problems.
CRH impairs deep sleep. Insofar, sleep problems can be a direct consequence of an overactivated HPA axis.
Sleep problems should be treated with special priority in ADHD because sleep problems and ADHD form a vicious circle: Sleep problems exacerbate ADHD symptoms, while ADHD symptoms may in turn cause sleep problems.
- Sleep reduces the stress hormone cortisol. in one study, 1 hour longer sleep reduced the cortisol awakening response by 21%.
- Sleep deprivation enhanced the stress response of the HPA axis. In sleep deprivation, the cortisol response to the TSST appears to be increased.
- More frequent awakenings the previous night worsened math skills and (somewhat) working memory, independent of ADHD.
- Sleep deprivation correlates with decreased mental health in children in relation to
- Emotion regulation
- Cognition
- Attention
- A study in which participants were allowed to sleep only 6 hours for 2 weeks found a decline in sustained attention and working memory equivalent to that of two nights of complete sleep deprivation. Unlike the participants who were completely deprived of sleep for 2 nights, those with 2 weeks a 6 hours of sleep were unaware of their cognitive deficits. Another study reported the same results after 5-7 days of sleep restriction.
The cognitive deficits, especially inattention, required more days of normal sleep to fully recover than the duration of the initial sleep restriction, more than 2 weeks.
Several other studies concur with these findings.
- Sleep deprivation causes increased omission errors, commission errors, reaction time, and reaction time variability in ADHD sufferers and nonaffected individuals alike. However, ADHD produced additional omission errors, commission errors, and greater reaction time variability. Moreover, sleep deprivation in ADHD particularly impaired the recognition of emotional facial expressions.
- Problems falling asleep and staying asleep are not exacerbating causes of executive problems, but daytime sleepiness is.
Nevertheless, sleep problems are not the (sole) cause of ADHD. However, sleep problems exacerbate existing ADHD symptoms. This is how sleep training has a positive effect on ADHD symptoms.
1. Sleep problems with ADHD¶
Adolescents with ADHD have higher per-person variability in sleep problems than adolescents without ADHD. These relate to bedtime, wake time, sleep duration, sleep onset latency, sleep quality, and nighttime wakefulness.
Sleep problems correlate with elevated levels of proinflammatory cytokines. Cytokines regulate sleep. Cytokines released by immune cells, particularly interleukin-1β and tumor necrosis factor-α, affect neuronal activity, behavior (including sleep), hormone release, and autonomic function by addressing neuroendocrine, autonomic, limbic, and cortical areas of the CNS. One study found elevated inflammatory markers only in women (not men) with sleep problems.
Sleep deprivation and disturbed sleep result in increased levels of IL-6, tumor necrosis factor (TNF) (men only), and C-reactive protein (CRP) compared with undisturbed sleep.
Sleep problems apparently increase IL-6 and soluble intercellular adhesion molecule (slCAM) even more than major depression.
Sleep deprivation correlates with increased IL-6 levels, although the stimulatory effect of catecholamines on Il6 secretion is reduced; this change may result from concomitant reduced cortisol-induced inhibition, which is omitted by deficient cortisol. The stress hormones norepinephrine and CRH also increase IL-6
Sleep problems in 5-13 year olds with ADHD correlated weakly but statistically significantly with maternal mental health problems.
1.1. Circadian rhythm¶
1.1.1. Circadian rhythm and ADHD¶
Circadian problems are associated with multiple mental disorders.
Some voices discuss whether ADHD - at least for a subgroup of affected persons - is primarily the result of a shifted chronorhythm.
For a subgroup, this may be true. Likewise, most ADHD sufferers with a chronobiorhythm that is shifted backwards would benefit greatly if the shift could be reduced or eliminated. However, it must be kept in mind that the chronorhythm is controlled to a good extent by life circumstances and habits.
in the Corona pandemic, a shift of the chronorhythm to the back was observed in 2/3 of the test persons in quarantine as well as in home office. The time of going to bed as well as the time of getting up were delayed. At the same time, sleep quality deteriorated. In a good 16 %, home office led to a complete deregulation of the chronobiorhythm.
There are several points of contact between the neurophysiological regulation of the circadian rhythm on the one hand and ADHD on the other.
1.1.1.1. Norepinephrine and circadian rhythm¶
Norepinephrine is thought to be a key synchronizer of circadian rhythms. Norepinephrine regulates nocturnal melatonin secretion and circadian gene expression.
1.1.1.2. Stress systems and circadian rhythm¶
Chronic stress (which we believe mediates its symptoms through very similar neurotransmitter shifts as ADHD) often leads to disruption of the circadian system. See more at ⇒ Changes in the circadian system caused by chronic stress In the article ⇒ Stress damage caused by early/long-term stress in the section ⇒ ADHD as a chronicized stress regulation disorder in the section ⇒ Stress.
1.1.1.3. Dopamine and circadian rhythm¶
A (non-drug) administration of stimulants can induce a circadian rhythm in rodents, the so-called methamphetamine-sensitive circadian oscillator (MASCO). This is apparently (also) related to the domapinergic controlled dopamine ultradian oscillator, DUO. It would be conceivable that the circadian sleep problems in ADHD are linked to the MASCO through dopaminergic connections.
1.1.2. Circadian sleep-wake rhythm disturbances¶
1.1.2.1. Difficulty falling asleep¶
ADHD sufferers often need much longer to fall asleep. Typical is the description of a circle of thoughts.
1.1.2.1.1. Sleep phase shift (later sleep rhythm)¶
ADHD often shows an altered sleep rhythm. Up to 75% of ADHD-affected children and adults suffer from a shifted chronobiorhythm.
ADHD sufferers with a pronounced later sleep rhythm (“eveningness”, owls) showed in a small study increased self-ratings of inattention and sleepiness during the day as well as slower reaction times than sufferers with an early day rhythm (“morningness”, larks). The severity of overall symptomatology did not differ.
Eveningness correlated in studies
- (other than problems falling asleep and insomnia) with shortened leukocyte telomeres, which actually correlates with older biological age.
- 2.4 times more likely to have an obesity-related BMI than Morningness (independent of ADHD). In addition, higher BMI levels correlated with increased levels of ODD and ADHD.
- With increased sleep problems and increased daytime sleepiness, regardless of the duration of nighttime sleep.
- With a birth at times of long brightness (June, July), with at the same time significantly reduced prevalence with a birth date in December or January. Together with other studies, this strongly suggests a clear imprinting in the first months of life.
- With little time spent outdoors. People who typically spend their day outdoors go to bed earlier and sleep longer than people who typically spend their day indoors.
- With the latitude of the place of living / growing up. In countries and geographical areas with lower sun intensity and thus lower adaptation to day and night by the central biological clock, a higher ADHD prevalence is shown
- There are contradictory results on the question of whether carriers of DRD4-7R, a gene variant of the dopamine D4 receptor gene, are more frequently affected by ADHD, especially if they were born in spring or summer. It is conceivable that the contradictions will be resolved if it is taken into account that people with a northern genetic background are less sensitive to variations in sunlight intensity.
1.1.2.1.2. Delayed evening melatonin rise¶
In ADHD sufferers, as in those with sleep problems, the evening rise in melatonin is often delayed. In children between 6 and 12 years of age with ADHD and sleep problems, sleep onset was delayed by 50 minutes compared with children with ADHD without sleep problems, which corresponded to the delay period of the melatonin rise. Otherwise, sleep did not differ significantly.
Since the start of school and consequently the time of getting up is the same for all children, this explains that ADHD sufferers with sleep problems get less sleep and therefore have additional difficulties in everyday life.
1.1.2.2. Sleep Through Disorder¶
Waking up during the night, often after 3 to 4 hours of sleep. Trouble sleeping through the night is one of the most common sleep disorders in ADHD.
1.1.2.3. Shortened sleep duration¶
A meta-study found a correlation of shortened sleep duration and ADHD symptoms, especially hyperactivity. Increasing sleep duration significantly improved inhibition in children with ADHD.
Interestingly, children’s sleep duration has steadily shortened in recent decades. The evening bedtime for three-year-olds was 19:08 Uh in 1974, 19:53 in 1979, and 20:07 in 1986.
10- to 15-year-old children slept 30 minutes more per night in 1985 than their peers in 2005, with earlier sleep times in 1985 at the same time.
A large analysis of 690,747 children showed that sleep duration decreased by 0.75 minutes per year from 1905 to 2008, for a total of 1:15 hours over the 100 years. Further, a metastudy of 20 studies showed that the likelihood of obesity in ADHD-HI correlated with shorter sleep duration in children.
1.2. Sleep related breathing disorders¶
Breathing pauses during sleep are often a cause of ADHD-like symptoms.
In chronic adenotonsillar hypertrophy, adenotonsillectomy improves any or putative ADHD symptoms.
High weight increases the likelihood of sleep apnea.
Sleep apnea appears to be associated with a higher likelihood of ADHD in adults.
A sleep study of 27 medication-naive children with ADHD found one or more sleep disorders in all of them:
- 11 cases of obstructive sleep apnea
- 6 cases of a movement disorder phenotype
- 6 cases of sleep-related epileptiform discharges
- 3 cases of difficulty in falling asleep
- 2 cases of narcolepsy-like phenotype
- 1 case of arousal disorder
A test for sleep apnea does not require an overnight stay in a sleep lab. Sleep physicians give sufferers a device to take home, wear it for one night and return it the next day. The recorded data reliably indicate breathing problems during sleep.
1.3. Sleep related movement disorders¶
Restless legs symptoms, insomnia, and frequent snoring appear to be significant predictors of subsequent ADHD-HI symptoms.
1.4. Central disorders of hypersomnolence (hypersomnia)¶
Narcolepsy is a common comorbidity of ADHD.
1.5. Severe daytime sleepiness¶
ADHD sufferers are sometimes observed to have problems with severe daytime sleepiness or increased sleepiness.
One study found a correlation of daytime sleepiness and cognitive problems in ADHD.
In this case, treatment with modafinil is obvious.
Further, the orexin level should be checked. More on this at⇒ Orexin/hypocretin Modafinil apparently increases orexin levels. This may be one of the pathways of action of modafinil in the treatment of narcolepsy.
The selective D1 receptor agonist SKF38393 was shown to improve excessive daytime sleepiness and restore REM sleep in animal studies.
1.6. Prolonged REM sleep¶
5 studies found prolonged REM sleep phases in ADHD sufferers, one study found shortened REM sleep.
1.7. Slow wave sleep increased¶
Some studies found an increased slow-wave sleep proportion in ADHD within and outside REM sleep phases.
1.8. EEG peculiarities during sleep in ADHD¶
There are reports of specific EEG peculiarities in ADHD.
1.8.1. Sleeping spindles¶
While more sleep spindles (higher sigma power) in the EEG correlated with higher IQ in non-affected individuals in the light sleep phase (sleep phase 2), fewer sleep spindles correlated with ADHD.
In contrast, another study found increased amplitude, duration, density, and activity of slow-wave sleep spindles in children with ADHD.
1.8.2. Gamma connectivity altered in light sleep in ADHD¶
Children with ADHD showed altered gamma phase delay index in light sleep.
1.8.3. Slow-waves in EEG reduced in non-REM deep sleep in ADHD¶
ADHD-HI-affected children and adolescents showed a reduction of over 20% in the EEG power of low-frequency waves from 1 to 4.5 Hz (SWA) in non-REM deep sleep throughout the brain compared with healthy controls. Regular use of stimulants eliminated this abnormality. Assuming that SWA reflects synaptic density, this is consistent with previous neuroimaging studies that found smaller gray matter volumes in ADHD-HI sufferers and their normalization with regular stimulant use.
1.9. Frequent snoring¶
Insomnia, RLS, and frequent snoring appear to be significant predictors of subsequent ADHD-HI symptoms.
1.10. Immunological consequences of sleep problems¶
One-time as well as chronic sleep fragmentation increased mRNA and protein levels of cytokines in body tissues in mice. Changes in inflammatory responses reflected activation of stress axes with increased corticosterone and norepinephrine. Treatment with 6-OHDA significantly reduced sleep fragmentation-induced inflammation. This suggests regulation of sleep fragmentation-induced inflammation in body tissues by the autonomic nervous system (sympathetic/parasympathetic).
Chronic sleep fragmentation showed more severe consequences than single (acute) sleep fragmentation. One-week recovery from sleep fragmentation sufficiently alleviated peripheral inflammatory responses but not noradrenergic responses.
2. Measures to improve sleep (sleep hygiene)¶
ADHD sufferers have poorer sleep hygiene than non-affected individuals, and poorer sleep hygiene leads to increased sleep problems in ADHD. Nevertheless, poor sleep hygiene is not the cause or of ADHD, nor would its remediation be suitable as a monotherapy for ADHD.
A meta-study of 15 studies found sleep hygiene can be helpful in children with ADHD in 14 studies.
2.1. Increase sleep pressure¶
- Getting up when lying awake in bed for more than 40 minutes
In ADHD, the otherwise commonly cited 20-minute period should be extended, as ADHD sufferers typically require longer periods to fall asleep than non-affected individuals
- Nap no more than thirty minutes and before 2 p.m
- Slept badly? Endure fatigue to sleep earlier and better in the evening.
2.2. Train a regular sleep rhythm¶
- Keep regular rising and going to bed times
- Nevertheless go to bed only when tired, get up regularly at the same time in the morning
- So if possible, do not combat sleep problems with extended sleep that night, but maintain rhythm
- Get through fatigue and sleep well the next night with gained bedtime energy
- Regular exercise, up to a maximum of three hours before bedtime
2.3. Sleep phase shifting (chronotherapy)¶
ADHD-HI sufferers have an above-average frequency of an individually deviating day-night profile that is shifted far back, so that they become tired later and awake later. The sleep rhythm is shifted backwards by up to several hours. This is attributed, among other things, to an altered melatonin balance, whereby melatonin, the body’s own “sleep signal,” is either not released sufficiently or at the wrong time (too late at night).
2.3.1. Shift daily rhythm to the light hours¶
2.3.2. Light therapy¶
Treatment with bright bluish light early in the morning, especially during the darker seasons of the year (in addition to avoiding bluish light after 7 pm, which is recommended anyway) can help support an early daily rhythm.
For treatment have proven effective:
- Lamps with 7,000 to 10,000 lux
- At a distance of 20 to 35 cm.
- Protective screen and UV filter are required
- Illumination from oblique above, so that it does not dazzle
Light therapy that succeeds in bringing sleep forward is likely to improve ADHD symptoms.
2.3.3. Melatonin treatment¶
Targeted treatment in the evening with melatonin. See above at ⇒ Delayed evening melatonin increase As well as below at ⇒ Melatonergic antidepressants as well as at ⇒ Melatonin in ADHD in the section ⇒ Appropriate medications for ADHD.
As an alternative to treatment, it is also conceivable to integrate the shifted sleep rhythm into everyday life by regularly going to bed later and getting up later. As always, a consistent rhythm is required throughout to ensure a sufficiently long sleep. However, this is likely to be socially compatible for only a few people and, moreover, does not solve the basic problem that the shifted circadian rhythm can have a negative influence on the regulatory capacity of the HPA axis.
2.3.4. Neurofeedback - SMR Training¶
SMR neurofeedback training (frequency band training 12 - 15 Hz) should help reduce circadian sheep phase shift.
SMR Training
- Improved the frequency of sleep spindles
- Reduced the delay in falling asleep
- Increased the total sleep time
2.3.5. Light hygiene - avoid melatonin suppression¶
- Do not make bright light before going to bed or when getting up in the night. Dimmed yellowish/reddish light avoids melatonin suppression, thus promotes melatonin release.
- Warm light has a color temperature of 2700 Kelvin, better still lower.
Most LED bulbs retain their color temperature when dimmed; halogen and incandescent bulbs lose color temperature when dimmed, so give an even warmer light with less blue components when dimmed.
- Bluish and bright light has an immediate effect on the melatonin balance and signals the body: it’s morning, wake up, get active.
3000 Kelvin is already perceived as daylight color in lamps. Optimal daytime working light has 5000 Kelvin.
Fluorescent tubes make cold, bluish bright light: good in the morning, unfavorable in the evening.
- Do not use bluish or bright light in the evening
- Bright bluish light suppresses melatonin
- Melatonin is sleep-inducing
- Avoid computers and smartphones 1 to 2 hours before sleep time
- Set screen color scheme (only for evenings!) reddish dark.
Apple introduced its own color schemes for its smartphones in 2016 for this reason, which give a more reddish light in the evening, and Windows 10 has enabled this since October 2017.
This can be set up on any computer and TV.
- There are so-called computer glasses that filter out the bluish light components. These help to avoid the suppression of melatonin formation by blue light components during evening screen work, watching TV or reading.
- Working light during the day bright, white, bluish
- Blue-enriched white light during the day at work improves alertness, performance and sleep quality by suppressing melatonin.
- Relevant seems to be the change of bluish bright light during the day to reddish darker light in the evening.
- In one study, people who were implanted with lenses that filtered out bluish light, i.e., who constantly received the same level of blue light components, were found to have no improvement but also no worsening of sleep.
- At least 30 minutes of bright daylight outdoors every day
- According to the basic principle that the alternation of bright blue light in the morning/midday and less bright reddish light in the evening stimulates sleep-promoting melatonin production, a daily walk around midday in bright light should be helpful - especially in the darker winter months. The light brightness outdoors is dimensions greater than in brightly lit indoor spaces, even in overcast weather.
- In addition, bright daylight (preferably direct sunlight around midday) helps vitamin D3 production. Vitamin D3 is only formed above a threshold value of 18 mj/cm² light exposure. Even the most transparent types of glass reduce the light energy below this value, so that indoors, even on the sunniest days, the threshold value of light energy at which D-3 vitamin production begins is not reached. In Germany, sufficient D-3 production is achieved outdoors during midday in June within about 15 minutes, and in September within about 30 minutes. In December, even with clear skies, this is not even achieved if one were to spend the entire day outdoors - precisely because solar radiation does not exceed the required threshold. While a maximum melatonin suppression during the day (correlating with subjective alertness) already reaches its maximum at a light level of 1000 lux and at 100 lux still 50% of the maximum, the optimum of the circadian rhythm influence by bluish light during the day is only reached at 9100 lux, whereby the 50% value is also already reached from 100 lux. Melatonin suppression or circadian effectiveness is not suppressed indoors in contrast to D3 formation, but it is halved. This should therefore be compensated by bright bluish working light.
10.000 lux is roughly equivalent to a 300-watt halogen lamp shining on a tabletop 45 cm away. That is already quite a bit above what is usual for normal lighting in workplaces.
- Light intensity in lux on average:
- Parking lot - 20-25 lux
- Living area - 50 to 200 lux
- Public rooms - 200 lux
- Desk - 500 lux (target)
- Sunlight in summer - up to 50,000 lux
- Color temperature in Kelvin:
- Daylight: from 3000 Kelvin and more. Optimal daylight lamps have up to 5000 Kelvin (the higher, the bluer/colder)
- Evening light: up to 2700 Kelvin and less (the less, the more yellowish/warm).
2.4. Regular sleeping hours¶
- Regular and fixed times to go to bed
2.5. Bed use¶
- Use bed exclusively for sleeping
- Never eat, read, watch TV, work in bed
- At the appropriate age, sex is a good sleeping pill - with or without a partner
2.6. Sleep rituals¶
- Find your own sleep ritual
the habit of a ritual helps to pave the way for the ritualized action after about 6 weeks
Examples of appropriate sleep rituals:
- Walk before bedtime
- Read fiction (not non-fiction/technical books that pertain to a personal passion)
- Listen to audiobooks (not non-fiction/technical books that relate to a personal passion)
- Drink warm herbal tea
- Warm milk (with honey if necessary) before bedtime
- Listen to binaural theta music (see below at ⇒ Binaural Theta Wave Music
2.7. Sleeping environment¶
- Alarm clock / Clock
- Alarm clock out of sight
- Do not look at alarm clock at night
- Mobile
- Cell phone is not in the room
- Cell phone does not serve as an alarm clock
Otherwise, all intermediate messages would be displayed when looking at the clock, as well as when waking up in the morning. There is hardly anything more harmful for relaxation and switching off.
- Dinner
- Take evening meal on time
- Dinner light hold
- Bedroom choice
- Quiet and secluded space
- Not facing the street or other sources of disturbance
- If not possible in this apartment: move!
A quiet bedroom is absolutely essential for ADHD!
- If possible, no use as a dining room/TV room/study
- If sleeping next to your partner is difficult, use a separate bedroom from your partner, if necessary, where you can retreat after a good-night cuddle
The partner will be able to weigh the increase in quality of life during the day against the separate night’s rest
- Choice of the bed
- If necessary separate mattresses / grate to sleeping companions
- Bed wide enough to sleep undisturbed
2.8. Eliminate external sources of interference¶
With ADHD, even the smallest disturbances that do not bother other people at all can lead to massive sleep problems due to the wide-open stimulus filter. Observe your own standards and do not fall into the “normal” trap. ADHD always includes high sensitivity.
- Temperature / Ventilation
- Pay attention to the special temperature sensitivity of ADHD sufferers
- Allow sufficient oxygen
- Light
- Tape off LED from electrical appliances
- Close shutter
- Lightproof interior curtains
- Consider sleep goggles
- Sounds
- Earplugs help a lot
We know sufferers who were able to sleep through the night without interruption for the first time after getting used to earplugs
- Acclimatization period a few days
- Try different types of earplugs
- Silicone earplugs
- Insulate very well
- Before first use lightly grease the skin, otherwise difficult to get out of the ear. From 2. use more problem-free
- Fit well to the shape of the ear
- Foam earplugs
- Hold in ear for 10 seconds
- Cotton Wax Earplugs
- Customized earplugs
- Precise shape closes even tighter than silicone earplugs if necessary
- You do not feel when you lie on it
2.9. Sleep techniques¶
Mindful breathing exercises that increase oxygen intake can help you fall asleep.
e.g.: 4-7-8 technique according to Weil.
2.10. Dealing with circles of thought¶
Many ADHD sufferers are familiar with the phenomenon of the head not stopping to roll thoughts - and the sleep-preventing effect of this symptom. There are a few ways to counter this.
- Get up again after 40 minutes. Leave bed and bedroom.
- Turn on dimmed light, but not bright light: candle or very dimmed and warm (reddish) light with little blue components.
- If you can’t get a certain topic out of your head: write down all arguments pro/contra on a sheet or in an Excel table. Most of the time, you will be amazed to find that it hardly takes more than half a sheet of A4 paper.
Important: note down all arguments / motives / aspects that come to mind.
What is once written away and on the paper / in the file can no longer be lost. This facilitates immensely and saves you from having to “hold” a thought in your head
- If necessary, place a dictation machine next to the bed so that thoughts can be stored away in the dark without getting up.
Paper and pen next to the bed also work, but are not quite as good because you have to make light for it.
If necessary, get a pen with a built-in light.
- Take in other thoughts - read book / newspaper (NO activating activities like TV, internet, cell phone or similar).
- Only go back to bed when you really feel tired
- If necessary, take mild sedative and/or anxiolytic medications
e.g.:
- Trimipramine
5 - 20 mg/drops 1 hour before bedtime
Trimipramine is an old tricyclic antidepressant and is known to promote sleep. Unlike many other antidepressants and sleep aids, it does not interfere with REM sleep.
⇒ Trimipramine for ADHD
- Trazodone
⇒ Trazodone for ADHD
- For some sufferers, a small dose of stimulants (1/3 to 1/2 of a daily single dose unretarded) helps them find inner peace and stop their mind spinning.
2.11. Diet / nutrition for sleep problems¶
2.11.1. Avoid food stimulants¶
Food stimulants means stimulants that may be contained in food or stimulants.
- No caffeine (teein) / guarana / mate / dark chocolate after 2 p.m
Caffeine binds antagonistically to adenosine A1 receptors, which regulate the need for sleep in the brain. Adenosine A1 receptors inhibit the enyzm adenylate cyclase, which is needed for the conversion of ATP into cAMP. This inhibition is prevented by caffeine, and cAMP levels remain high. This increases alertness
- Caffeine:
- Coffee
- Instant coffee: 39 mg / 100 ml
- Filter coffee: 55 mg / 100 ml
- Decaffeinated coffee: 2 mg / 100 ml
- Espresso: 133 mg / 100 ml
- Cola
- Cola with sugar 10 mg / 100 ml
- Cola light: 12 mg / 100 ml
- Energy drinks
- Red Bull, Effect: 32 mg / 100 ml
- Cocoa / Chocolate
Chocolate consumption in the afternoon or evening is rarely recognized as a cause of sleep problems, but it can trigger just that.
- Caffeine: the higher the cocoa content, the more caffeine
- From 10 mg / 100 g (35% cocoa mass)
- Up to 142 mg / 100 g (99 % cocoa mass)
- Theobromine: the higher the cocoa content, the more theobromine.
Like caffeine, theobromine is a methylxanthine. Although the CNS-stimulating effect is weaker than that of caffeine, cocoa contains significantly higher amounts
- From 120 mg / 100 g (35% cocoa mass)
- Up to 1200 mg / 100 g (99 % cocoa mass)
- Tea:
- Black tea: 20 mg / 100 ml
- Green tea: 19 mg / 100 ml
- Mate tea: 35 mg / 100 ml
- No alcohol after 5 pm
- No alcohol as a (sleep) aid
- Even if sleep is possible with alcohol, the following day shows significantly increased stress levels of the autonomic nervous system (measurable by decreased heart rate variability).
2.11.2. Eliminate food allergies/food intolerances¶
A diet that limited sugar and excluded caffeine, chocolate, food additives, artificial colors, glutamate, and, for each child individually, potentially allergenic foods (such as milk) produced significant behavioral improvement in 45% of the participating children, including improvement in sleep problems phenotypic of ADHD (including delay in falling asleep).
See more at ⇒ Nutrition and diet for ADHD In the section ⇒ Nonpharmacological treatment and therapy of ADHD in the section ⇒ Treatment and therapy.
2.11.3. Eat/drink little/no carbohydrates in the evening¶
An evening intake of carbohydrates leads to increased insulin secretion. Insulin slows down the rest and regeneration hormones and fat burning. Sleep is less restful.
2.12. Sleep disturbing effect of drugs¶
Sleep disorders can be caused in particular by
-
SSRI
SSRIs may exacerbate sleep problems in ADHD
- Hypnotics
- Beta-blocker
- Alpha agonists
- Alpha Blocker
- Theophylline
- Glucocorticoids (cortisol)
- Thyroid hormones
- Antidepressants
- A large study of antidepressants found very different effects on the risk of sleep problems:
Explanation:
- Antidepressant active ingredient
- Risk increase of sleep disturbances (odds ratio) by the respective drug
- Note: some of the drugs mentioned here have a sleep-inducing effect when taken at low doses
- Mechanism of action of the active ingredient
- Amoxapine
- Atomoxetine
- 6,6
- NRI (norepinephrine reuptake inhibitor)
ADHD drug
- Maprotiline
- Mianserin
- Phenelzine
- 5,0
-
Monoamine oxidase inhibitor
- Clomipramine
- Fluvoxamine
- Olanzapine/fluoxetine
- 3,8
- Atypical antipychotic / SSRI
- Esketamine
- 3,8
- Noncompetetive NMDA glutamate tretor antagonist
- Imipramine
- Mirtazapine
- Doxepin
- Escitalopram
- Desvenlafaxine
- Nortriptyline
- Paroxetine
- Venlafaxine
- Citalopram
- Vilazodon
- 3,0
- Serotonin modulator and stimulator
- Duloxetine
- Selegiline
- 2,8
-
Monoamine oxidase inhibitor
- Trazodone
- 2,8
- Serotonin antagonist and SRI
- Amitriptyline
- Tranylcypromine
- 2,7
-
Monoamine oxidase inhibitor
- Fluoxetine
- Sertraline
- Bupropion
- 2,2
-
Norepinephrine/dopamine reuptake inhibitors
-
ADHD drug of choice 5
- Milnacipran
- Vortioxetine
- 1,3
- Serotonin modulator and stimulator
- Levomilnacipran
2.13. Check underlying sleep disorders with doctor¶
Examples:
- Depression
- In case of melancholic depression (falling asleep well, waking up after midnight, shortened night sleep) consider a combined intake of GABA, glycine, taurine and possibly L-theanine 2 hours before the time of falling asleep. This may increase sleep-through quality. These are inhibitory neurotransmitters or substances that support them, all of which are freely available as dietary supplements. Nevertheless, they should not be taken without consulting a physician, and the agents should be taken one at a time, not all at once. GABA taken orally does not cross the blood-brain barrier and therefore acts only in the body. Drugs that increase GABA in the brain, on the other hand, quickly become addictive.
- Anxiety disorders
-
Chronic pain
- Rheumatic diseases
- Coronary heart disease
- Asthma
- COPD
- Sleep Apnea Syndrome
Suspended breathing can cause symptoms that resemble ADHD.
Breathing disorders during sleep in ADHD-HI could be due to dysregulation of the mesencephalic serotonin system.
- Restless Legs Syndrome
2.14. ADHD treatment during the day improves sleep¶
A combined treatment of medication and behavioral therapy proved more effective in improving sleep problems than treatment each with medication or therapy alone. There was no worsening of sleep with any type of treatment, not even with the usual treatment with methylphenidate.
3. Non-drug treatment of sleep problems in ADHD¶
3.1. Binaural Theta Wave Music¶
Before going to bed, listen to 1 (to 2) hours of binaural theta waves music through headphones. (Attention: not alpha, as this increases concentration and - listened to immediately before going to bed - would increase sleep problems!) Depending on the selected theta music (there are also pure sounds), you can read (fiction), watch TV or surf (set the screen darker and redder) at the same time.
For more details, see ⇒ Binaural music as therapy for ADHD and for sleep problems.
3.2. Brain-Tapping¶
Similar to binaural theta music, brain tapping uses the brain’s synchronization to predetermined rhythms. Brain tapping uses light alternating drumming/tapping on the thighs for about 4 minutes, slowing down over time. This is combined with slow breathing.
3.3. Sleep training¶
One study reported a halving of sleep problems with sleep training in ADHD-affected children between the ages of 5 and 8.
Sleep Training provides oral and written information on normal sleep, sleep cycles, sleep disorders, sleep hygiene, and common strategies for treating behavioral disorders. Among other topics, it covers the importance of sleep hygiene methods such as consistent sleep routines and media-free sleep, and references standard sleep intervention strategies recommended by the American Sleep Association.
3.4. Endurance sports¶
Individuals who exercised moderately to intensively for at least 150 min per week suffered less frequently from problems falling asleep and daytime sleepiness than less active comparison subjects. In older people, the number of daily steps correlated with sleep quality and a reduced time to fall asleep.
3.5. Weight blanket¶
A weighted blanket is a sleeping blanket with a weight of 7 to 12% of the body weight. Children must always be able to remove the blanket independently.
The increased body pressure is comfortable for most sufferers and can help eliminate anxiety, depression and sleep disturbances.
An immediate improvement of ADHD symptoms should not be expected primarily, even though one study suggests this, which also reports a normalized time to sleep. Improved sleep, however, is expected to result in reduced daytime sleepiness and thus increased daytime activity. These are likely to be associated with improved ADHD symptomatology,
A study of 120 sufferers of psychiatric disorders, including 13 ADHD sufferers, found significant improvements in sleep disturbances within 4 weeks for almost all disorder profiles, including ADHD. The subsequent open-label study over an additional 11 months showed a reduction in previously severe sleep problems to subthreshold sleep problems in more than 75% of sufferers. Anxiety and depression symptoms also improved.
A meta-review of 8 studies concluded that weighted blankets can be helpful for anxiety symptoms. With regard to sleep problems, the basis was too weak to form a positive judgment.
Weight blankets are said to be helpful in terms of anxiety with as little as a 20-minute brief intervention.
4. Medication for sleep problems in ADHD¶
4.1. Sleep aids / sleep medications suitable for ADHD¶
4.1.1. Melatonin¶
Melatonin is produced in the body from serotonin and is involved in the sleep-wake rhythm. Release is inhibited by light. Highest natural release 3 o’clock at night.
Melatonin is freely available in D up to 1 mg/dose; if more than 1 mg per dose is recommended, melatonin requires a prescription.
In Austria, capsules up to 5 mg of melatonin are available.
In the USA, melatonin-containing drugs are freely available as dietary supplements.
Trade name: Circadin (EU), sustained-release melatonin 2 mg.
In relation to the elderly (55 years and older), efficacy of slow-release (prolonged-release) melatonin has been quite well established:
- Sustainable reduction of the time it takes to fall asleep
- Improving the quality of sleep
- Improve morning alertness and daytime performance
- Simultaneous improvement of sleep quality and morning wakefulness in patients with insomnia
The helpful effect of melatonin on jet lag was confirmed in a Cochrane Review.
Unretarded melatonin appears to be more appropriate for sleep onset disorders, while retarded melatonin appears to be more successful for sleep maintenance disorders.
More on melatonin at ⇒ Melatonin in ADHD.
4.1.2. Agomelatine¶
Agomelatine (trade name: Valdoxan) is a melatonergic antidepressant
- Agomelatine has a chemical structure related to melatonin
- Affinity for MT1 and MT2 melatonin receptors
-
Antagonistic properties at the serotonin receptor 5-HT2c (different from melatonin)
- Sleeping pill, which is also mentioned as a possible ADHD drug
- Agomelatine was tested against methylphenidate in a randomized double-blind trial with n = 54 children. Both drugs performed comparably in parent and teacher ratings of the children. Naturally, children treated with agomelatine had fewer sleep disturbances.
- Agomelatine can cause liver problems. Therefore, liver values must be monitored closely.
- Effect seems to be very individual.
- Discussion of over 50 users (mostly depression sufferers) about the effects and side effects of agomelatine (both positive and negative) at psychiatrietogo.de.
- Our non-representative experience with agomelatine is rather negative. The sleep reported to us is flat and “cold”. One does not feel refreshed.
See also ⇒ Agomelatine for ADHD
4.1.3. Trimipramine¶
Trimipramine is a tricyclic antidepressant. In low dosage it is sleep-inducing.
- 10 to 30 mg (instead of 100 to 300 mg as antidepressant) 1/2 to 1 hour before bedtime. For first use, test with even lower dosage.
- Anxiety-relieving
- Deep, restful sleep
- REM phases are preserved (for trimipramine, different for other TZADs such as amitriptyline or doxepin)
- Much less addictive than benzodiazepines
- The experience with trimipramine reported to us is very positive. Sleep is very restful and dreaming is not reduced. At times - especially in the beginning - a hangover occurred.
4.1.4. Trazodone¶
Trazodone is a dual-serotonergic antidepressant and is recommended as a sleep aid for ADHD.
- Phenylpiperazine
-
Half-life 5 to 9 hours
- Strongly inhibits α1-receptors
- Weakly inhibits α2- and H1-receptors
- Low dose (up to 50 mg)
- 5HT2A receptor antagonist
- = Blockade of the 5HT2A receptors
- → leads to dopamine increase in the striatum due to glutamate reduction
- → enhances serotonergic neurotransmission via the 5-HT1A receptors
- Incidentally not serotonergic
- Higher doses
- Stronger serotonerg
- Antihistaminerg
- Sleep-inducing in ADHD when low-dosed (25 to 100 mg)
- No impairment of sexual functions
- No increase in body weight
- Attenuating effect on tremor
- Not contraindicated in glaucoma and prostate disorders
- No extrapyramidal effect (no motor restlessness)
- No potentiation of adrenergic transmission
- No anticholinergic activity, therefore does not have the typical side effects of tricyclic antidepressants
- Do not combine with MAO inhibitors or (especially if high-dose) with serotonergic medications
- Sleep promotion by trazodone could also be due to serotonergic effects.
- In hordes of rhesus monkeys, the animals that fall asleep the latest are those with the lowest levels of 5-HIAA in cerebrospinal fluid, a serotonin degrader.(Grawe (2004): Neuropsychotherapy, page 200))
4.1.5. Mirtazapine¶
Mirtazapine is a tetracyclic antidepressant.
One small study reported positive experience as a sleep aid in ADHD at low doses of 3.75 to 7.5 mg per hour of sleep. Another very small study found comparable results at a dose of 30 mg.
4.1.6. ADHD Stimulants¶
- Methylphenidate, amphetamine medication
- To test sleep-promoting effect individually
Although stimulants generally have a more activating effect, a low dose of MPH or amphetamine before bedtime actually helps some sufferers by curbing their mind’s wandering. The effect can be individually significantly better than sleeping pills.
For most, it is too stimulating, so medication should be reduced throughout the day toward evening and stopped in time.
- A number of people report sleeping better at night with amphetamine medication (during the day) than with methylphenidate medication
As a rule, stimulants are more likely to inhibit sleep. However, it is not just isolated cases that report that an evening dose of unretarded MPH, equivalent to about one-third to one-half of the usual single dose during the day, can help with falling asleep.
4.1.7. Caffeine, nicotine¶
As a rule, caffeine or nicotine tend to prevent sleep, since they are stimulants. However, paradoxical reactions are possible in ADHD patients, just as with stimulant medications, so that caffeine or nicotine can have a sleep-promoting effect. This must be tested on an individual basis..
4.1.8. L-Theanine¶
L-theanine (5-N-ethyl-L-glutamine) is a glutamate antagonist. It is credited with a possible reduction in the physical and psychological stress response.
According to the German Federal Institute for Risk Assessment, L-theanine has various pharmacological effects in animal studies:
- Blood pressure lowering
- Influences the concentration of various neurotransmitters in the brain
- Counteracts caffeine effects
- Therefore possibly calming and relaxing (sedative) effect
- Unknown,
- Whether other effects exist
- Whether responsiveness or attention is impaired
- Whether possible negative effects are intensified by the additional consumption of alcohol or medication.
- Toxicological data on L-theanine are incomplete so far
- Therefore, it remains to be seen whether and if so, in what quantities L-theanine is safe for health when consumed daily and used in isolation.
Regarding ADHD, a randomized and placebo-controlled study in boys found a sleep-promoting effect at 400 mg/day, another study at 200 mg before bedtime.
There do not appear to be any other studies. A meta-study found that the results for eszopiclone were even better than for l-theanine, but the sleeping pill eszopiclone was only approved in the U.S. because it was denied novelty status in the EU. Further, L-theanine is reported to improve sleep quality, but little on falling asleep time and sleep duration.
In contrast, there are several studies showing a positive effect of L-theanine in depression. which has been attributed to, among other things, a change in monoamine levels in the striatum, cortex, limbic system, pallidum, and thalamus.
An anxiolytic effect and enhancement of hippocampal activity were noted in rats.
4.1.9. Combined intake of GABA, glycine, taurine, L-theanine¶
A combined intake of GABA (750 mg), glycine (500 mg), taurine (500 mg), and possibly L-theanine 2 hours before bedtime may increase sleepiness (which may particularly counteract the backward shift in sleep patterns in some ADHD sufferers) and improve sleep quality.
GABA and glycine are inhibitory neurotransmitters; taurine increases GABA.
All substances are freely available as dietary supplements. Nevertheless, they should not be taken without consulting a physician and the agents should be dosed one after the other and not all at the same time. GABA taken orally does not cross the blood-brain barrier and therefore only acts in the body. Drugs that increase GABA in the brain, on the other hand, quickly become addictive. This danger does not exist with orally taken GABA.
4.1.10. Iron¶
One review found strong evidence of a correlation of iron deficiency and restless legs sleep problems, as well as possible evidence of correlations with sleep problems in ADHD.
4.1.11. Dopaminergic agents and sleep and wakefulness¶
D1 receptor agonists:
- SKF38393 was able to improve excessive daytime sleepiness and restore REM sleep in animal studies.
- SKF-82958 infusion effected for 2 hours:
- increased waking time depending on the dose
- suppressed REM sleep and slow-wave sleep
- slightly increased locomotion
- slightly increased time of grooming and eating
D2 receptor agonists have different effects on sleep and wakefulness:
- Bromocriptine, dosed to address only the autoreceptor, increased slow-wave sleep and decreased wakefulness in rats. In healthy humans, it did not shorten sleep latency.
- Quinpirole
- low dose: decreased wakefulness and promoted sleep in rats
- high doses: increased wakefulness and decreased sleep
- easily increased drinking and locomotion
- significantly increased chewing on inedible material, a behavior associated with arousal/stress.
- RO 41-9067 increased alertness in animals in a dose-dependent manner
- Cabergoline reduced the number of periodic leg movements in RLS during sleep
- Pramipexole (D3 and D2 agonist)
- at low doses (30 micrograms/kg), it increased slow wave sleep, REM sleep, and decreased wakefulness
- high dose (500 micrograms/kg) increased alertness
- Ropinirole shortened sleep latency and increased total sleep time in Parkinson’s disease, in RLS, and in healthy subjects
- Piribedil has a strong wakefulness-promoting effect. In Parkinson’s it sometimes triggered sleep attacks
D4 agonists:
- Ro 10-5824
- prolonged waking time and shortened non-Rem sleep
- delayed the onset of non rem sleep
- amplified the theta and gamma power in the EEG.
- A-412997
- prolonged waking time and shortened non-Rem sleep
- delayed the onset of non rem sleep
- influenced onset and duration of rem.sleep
- amplified the theta and gamma power in the EEG.
D4 antagonists:
- L-741,741, a highly selective D4 antagonist was explored in Wistar rats
- 1.5 mg/kg
- increased only the light slow wave sleep
- 3 mg/kg
- increased the episodes of quiet wakefulness
- reduced and shortened the episodes of active wakefulness
- 6 mg/kg
- decreased episodes and increased latency of deep slow wave sleep
- decreased episodes and duration of light slow wave sleep
- reduced the total sleep time
- increased the active waking state
- erhlhte the latency of REM sleep
4.2. Sleep aids / sleep medications NOT appropriate for ADHD¶
4.2.1. Avoid benzodiazepines for ADHD¶
- High risk of addiction to benzodiazepines (within 14 days)
Not recommended against the background of addiction affinity in ADHD due to the strong reward delay aversion in ADHD
- Benzodiazepines reduce the activity of the locus coeruleus and thus reduce the production and transport of norepinephrine to other parts of the brain. Therefore, they should rather be contraindicated in ADHD.
- Strong sleep effect
- Anxiety Relief
- Frequently used active ingredients
- Flurazepam
- Nitrazepam
- Temazepam
- Triazolam
4.2.2. Neuroleptics not indicated in pure ADHD¶
Neuroleptics are not recommended for (pure) ADHD.
Neuroleptics, like antidepressants, are not typical sleeping pills, but are used to treat mental disorders. However, due to their sedative-dampening effect, they can also help with sleep disorders, especially if these are caused by psychoses. In ADHD-HI, neuroleptics seem potentially useful only in the presence of specific comorbidities (e.g., from the autism spectrum).
4.2.2.1. Pipamperon¶
Pipamperone is a low-potency neuroleptic.
Pipamperone blocked (antagonized)
- Primarily serotonin receptors
- Low D2 receptors
- Low D4 receptors
- Low alpha1-adrenoceptors
Since in ADHD there is often already a reduced sensitivity of the D4 receptor, which is partly responsible for the overreactivity of the striatum due to the omission of the inhibitory D4 receptor effect (keyword: DRD4-7R), it seems doubtful to us whether an additional impairment of the D4 receptor is really useful.
4.2.3. SSRIs (Selective Serotonin Reuptake Inhibitors)¶
Antidepressants are generally suitable for remedying depression-induced sleep problems.
However, SSRIs can exacerbate sleep problems in ADHD.
SSRIs reduce REM sleep by 30%.
REM sleep:
- Is essential to restore neurotransmitter balance in the brain (degradation of adenosine, build-up of glycogen in astrocytes; especially in non-REM)
- Causes structural relief (serotonin raphe nuclei etc.)
- REM sleep is particularly important in the first years of life:
- Training of sensorimotor skills
- Training of otherwise unused behaviors
- Newborns sleep 16 to 18 hours, of which 50 % = 8 - 9 hours REM
- 10-year-old children still have 2 - 2.5 hours of REM sleep
4.3. More sleeping pills¶
For the following sleep medications, we do not (yet) have any specific information on whether they are particularly indicated or contraindicated in ADHD. The list is by far incomplete.
4.3.1. Non-benzodiazepine agonists¶
-
Different structure than benzodiazepines
-
Act at the same receptors as benzodiazepines
-
Active ingredients, among others:
-
Zaleplon
-
Zolpidem
-
Zopiclone
-
GABA receptor agonist in the brain = risk of addiction!
New generation sedative - Z-Drug
Trade names: Imovane (D, CH), Optidorm (D), Somnal (A), Somnosan (D), Ximovan (D), Zopiclodura (D), Zopitin (CZ), various generics, Lunesta (USA)
-
Lower risk of dependence than benzodiazepines (unlike at least zopiclone, which may be taken for a maximum of 2 weeks due to the risk of psychological and physical addiction)
However, there remains a risk of dependence, which is why we do not endorse non-benzodiazepine agonists as sleep aids in ADHD sufferers.
4.3.2. Barbiturates¶
- Only to be used if other sleeping pills do not work
- Strong side effects, overdose can be fatal
4.3.3. First generation antihistamines¶
- Besides alleviating allergy symptoms, also sedative
- Active ingredients, among others:
- Doxylamine
- Meclozine
- Promethazine
4.3.4. Orexin antagonists¶
Orexin A and orexin B are neuropeptides that bind to orexin-1 and orexin-2 receptors to promote wakefulness.
Orexin antagonists such as daridorexant inhibit orexin receptors.
Daridorexant (trade name: Quviviq®) binds with approximately equal affinity to orexin-1 and orexin-2 receptors and thus has a sleep-promoting effect without altering the relationship between sleep phases.
Whether orexin antagonists are particularly helpful in ADHD, or whether this might be subtype-specific, would need to be investigated. One study reports decreased basal orexin A levels orexin levels in ADHD-I (ADD). For more on this, see: Orexin
5. Sleep problems due to ADHD medication¶
ADHD medications can cause sleep problems as side effects. Often, but not always, these are a mere consequence of the dosage and disappear within a few weeks. Care should be taken to stop taking ADHD medication in good time, so that the effective time is over one hour before bedtime.
Sleep problems from ADHD medications are most commonly reported by:
- Mixed amphetamine salts (40-45%) (not permitted in Germany)
- Dasotraline (35-45%) (new drug under investigation)
- Lisdexamfetamine (10-19%) (Elvanse)
- Atomoxetine (10 - 17 %)
-
Retarded methylphenidate (11%)
Several sufferers report that a small dose of stimulants (unretarded MPH, about 1/3 of a single dose taken during the day) helps them to fall asleep by relaxing them and stopping the carousel of thoughts. One sufferer commented that he could only sleep at full stimulant dosage.
