Adhd sleep problems

ADHD and Sleep Disorders - CHADD

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Many children and adults who have ADHD also have a sleep disorder—almost three out of four children and adolescents, and up to four out of five adults with ADHD. Not getting enough sleep, or needing to sleep at times that don’t mesh with school or work obligations, can have significant long-term effects. Those can include physical illness, behavioral issues, and mood changes.  While adults may seem obviously tired when they are behind on sleep, fatigue in children often looks like exaggerated ADHD symptoms: hyperactivity and impulsivity—sometimes even aggressiveness and acting out.


Causes of sleep problems  

Circadian rhythm disorders. Researchers have repeatedly found that sleep problems are common among people who have ADHD. They think that one reason is because ADHD can mess up what is considered to be a standard sleep-wake cycle, or circadian rhythm. If your circadian rhythm is off, you may have a hard time falling asleep at a standard bedtime, or your sleep may be regularly disrupted, with lots of wakeups throughout the night. Either of those can make it hard for you to wake when your alarm goes off or stay awake and think clearly at work or at school. In general, people with ADHD feel more alert in the evening than they do in the morning. That is the opposite of the way it is for people who do not have ADHD.

For young children with ADHD, it can be difficult to settle down at the end of the day. It may be the child who is wound up from the day’s events can’t stop reliving them and talking about them, or the child who gets so lost in a book or a puzzle doesn’t want to stop reading to brush her teeth and put on pajamas. Although these are not troubling behaviors, when they occur every night, they can frustrate both the child and his or her parents, and in turn further mess with sleep habits.

Caffeine and ADHD medications. Caffeine in soda, coffee, and chocolate, as well as stimulant medications, can also get in the way of a good night’s sleep. Yet even nonstimulant ADHD medications can affect sleep by making people sleepy after taking them—they may need a nap during the day.

Alcohol. Alcohol can make people fall asleep quickly but struggle to stay asleep.

Other conditions. Many conditions that commonly coexist with ADHD, such as anxiety or depression, can have a significant effect on sleep as well.

Electronics. For anyone, too much time on a smartphone, playing video games, or watching television in the evening can mess with the ability to fall asleep and stay asleep.

Common sleep disorders. A number of diagnosable sleep disorders are associated with ADHD.

Breathing disorders. Obstructive sleep apnea, snoring, and other sleep-related breathing disorders are common among children and adults who have been diagnosed with ADHD, though doctors aren’t really sure why. When kids with ADHD and sleep-related breathing disorders have their tonsils removed, they often see an improvement in symptoms of both.

Restless Legs Syndrome. Another common coexisting condition is Restless Legs Syndrome (RLS). People with RLS have an almost uncontrollable need to move their legs. It is especially noticeable in the evenings and when they are in bed. RLS is not common among the general population of children, but many children who have ADHD also have RLS. Researchers aren’t sure why yet. It may just be that the symptoms of the two conditions are very similar and it’s hard to tell them apart when a person is sleeping.

Also in this series:

  • ADHD and Sleep Disorders Diagnosis and Management


  • ADHD: A 24-Hour Disorder. Psychiatric Times, October 2018.
  • Becker SP & Lienesch JA. (November 2018). Nighttime media use in adolescents with ADHD: links to sleep problems and internalizing symptoms. Sleep Medicine 51:171-178.
  • Hvolby A. (2015). Associations of sleep disturbance with ADHD: implications for treatment. Attention Deficit and Hyperactivity Disorders 7(1): 1–18.
  • Sedky, Karim et al. (August 2014). Attention deficit hyperactivity disorder and sleep disordered breathing in pediatric populations: A meta-analysis. Sleep Medicine Reviews 18(4):349-356.
  • Tsai MH et al. (August 2016). Sleep Problems in Children with Attention Deficit/Hyperactivity Disorder: Current Status of Knowledge and Appropriate Management. Current Psychiatry Reports 18(8):76.
  • National Institute of Neurological Disorders and Stroke. (2018). Restless Legs Syndrome Fact Sheet.

ADHD and Sleep Problems: Why You're Always Tired

ADHD and Sleep Problems

Adults with ADHD rarely fall asleep easily, sleep soundly through the night, and then wake up feeling refreshed. More often, ADHD’s mental and physical restlessness disturbs a person’s sleep patterns — and the ensuing exhaustion hurts overall health and treatment. This is widely accepted as true. But, as with most of our knowledge about ADHD in adults, we’re only beginning to understand the stronger link between ADHD and sleep, that creates difficulties:

  • Falling asleep
  • Staying asleep
  • Waking up

Sleep disturbances caused by ADHD have been overlooked for a number of reasons. Sleep problems did not fit neatly into the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) requirement that all ADHD symptoms must be present by age 7. Sleep disturbances associated with ADHD generally appear later in life, at around age 12, on average. Consequently, the arbitrary age cutoff has prevented recognition of night owls and sleep disturbances in ADHD until recently, when studies of adults have become more common. Just as ADHD does not go away at adolescence, it does not go away at night either. It continues to impair life functioning 24 hours a day.

In early attempts to define the syndrome, sleep disturbances were briefly considered a criterion for ADHD, but were dropped from the symptoms list because evidence of them was thought to be too nonspecific. As research has expanded to include adults with ADHD, the causes and effects of sleeping disturbances have become clearer.

For now, sleeping problems tend either to be overlooked or to be viewed as coexisting problems with an unclear relationship to ADHD itself and to the mental fatigue so commonly reported by individuals with ADHD. Sleep disturbances have been incorrectly attributed to the stimulant-class medications that are often the first to be used to treat ADHD.

The Four Big ADHD Sleep Problems

No scientific literature on sleep lists ADHD as a prominent cause of sleep disturbances. Most articles focus on sleep disturbance due to stimulant-class medications, rather than looking at ADHD as the cause. Yet adults with ADHD know that the connection between their condition and sleep problems is real. Sufferers often call it “perverse sleep” — when they want to be asleep, they are awake; when they want to be awake, they are asleep.

[Watch This Video: 5 Fixes for “I Can’t Sleep”]

The four most common sleep disturbances associated with ADHD are:


Difficulty Falling Asleep with ADHD

About three-fourths of all adults with ADHD report inability to “shut off my mind so I can fall asleep at night.” Many describe themselves as “night owls” who get a burst of energy when the sun goes down. Others report that they feel tired throughout the day, but as soon as the head hits the pillow, the mind clicks on. Their thoughts jump or bounce from one worry to another. Unfortunately, many of these adults describe their thoughts as “racing,” prompting a misdiagnosis of a mood disorder, when this is nothing more than the mental restlessness of ADHD.

Prior to puberty, 10 to 15 percent of children with ADHD have trouble getting to sleep. This is twice the rate found in children and adolescents who do not have ADHD. This number dramatically increases with age: 50 percent of children with ADHD have difficulty falling asleep almost every night by age 12 ½ by age 30, more than 70 percent of adults with ADHD report that they spend more than one hour trying to fall asleep at night.

2. Restless Sleep with ADHD

When individuals with ADHD finally fall asleep, their sleep is restless. They toss and turn. They awaken at any noise in the house. They are so fitful that bed partners often choose to sleep in another bed. They often awake to find the bed torn apart and covers kicked onto the floor. Sleep is not refreshing and they awaken as tired as when they went to bed.

[How Sleep Deprivation Looks a Lot Like ADHD]

3. Difficulty Waking Up with ADHD

More than 80 percent of adults with ADHD in my practice report multiple awakenings until about 4 a.m. Then they fall into “the sleep of the dead,” from which they have extreme difficulty rousing themselves.

They sleep through two or three alarms, as well as the attempts of family members to get them out of bed. ADHD sleepers are commonly irritable, even combative, when roused before they are ready. Many of them say they are not fully alert until noon.

4. Intrusive Sleep with ADHD

Paul Wender, M. D., a 30-year veteran ADHD researcher, relates ADHD to interest-based performance. As long as persons with ADHD were interested in or challenged by what they were doing, they did not demonstrate symptoms of the disorder. (This phenomenon is called hyperfocus by some, and is often considered to be an ADHD pattern.) If, on the other hand, an individual with ADHD loses interest in an activity, his nervous system disengages, in search of something more interesting. Sometimes this disengagement is so abrupt as to induce sudden extreme drowsiness, even to the point of falling asleep.

Marian Sigurdson, Ph.D., an expert on electroencephalography (EEG) findings in ADHD, reports that brain wave tracings at this time show a sudden intrusion of theta waves into the alpha and beta rhythms of alertness. We all have seen “theta wave intrusion,” in the student in the back of the classroom who suddenly crashes to the floor, having “fallen asleep.” This was probably someone with ADHD who was losing consciousness due to boredom rather than falling asleep. This syndrome is life-threatening if it occurs while driving, and it is often induced by long-distance driving on straight, monotonous roads. Often this condition is misdiagnosed as “EEG negative narcolepsy.” The extent of incidence of intrusive “sleep” is not known, because it occurs only under certain conditions that are hard to reproduce in a laboratory.

Why Do People with ADHD Have Problems Sleeping?

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

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

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

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

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

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

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

[Read This Next: Tired of Feeling Tired? How to Solve Common Sleep Problems]

How to Get to Sleep with ADD

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

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

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

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

Treatment Options for ADHD-Related Sleep Problems

If the patient spends hours a night with thoughts bouncing and his body tossing, this is probably a manifestation of ADHD. The best treatment is a dose of stimulant-class medication 45 minutes before bedtime. This course of action, however, is a hard sell to patients who suffer from difficulty sleeping. Consequently, once they have determined their optimal dose of medication, I ask them to take a nap an hour after they have taken the second dose.

Generally, they find that the medication’s “paradoxical effect” of calming restlessness is sufficient to allow them to fall asleep. Most adults are so sleep-deprived that a nap is usually successful. Once people see for themselves, in a “no-risk” situation, that the medications can help them shut off their brains and bodies and fall asleep, they are more willing to try medications at bedtime. About two-thirds of my adult patients take a full dose of their ADHD medication every night to fall asleep.

What if the reverse clinical history is present? One-fourth of people with ADHD either don’t have a sleep disturbance or have ordinary difficulty falling asleep. Stimulant-class medications at bedtime are not helpful to them. Dr. Brown recommends Benadryl, 25 to 50 mg, about one hour before bed. Benadryl is an antihistamine sold without prescription and is not habit-forming. The downside is that it is long-acting, and can cause sleepiness for up to 60 hours in some individuals. About 10 percent of those with ADHD experience severe paradoxical agitation with Benadryl and never try it again.

Experts point out that sleep disturbances in people diagnosed with ADHD are not always due to ADHD-related causes. Sometimes patients have a co-morbid sleep disorder in addition to ADHD. Some professionals will order a sleep study for their patients to determine the cause of the sleep disturbance. Such tests as a Home Sleeping Test, Polysomnogram, or a Multiple Sleep Latency Test may be prescribed. If there are secondary sleep problems, doctors may use additional treatment options to manage sleep time challenges.

The next step up the treatment ladder is prescription medications. Most clinicians avoid sleeping pills because they are potentially habit-forming. People quickly develop tolerance to them and require ever-increasing doses. So, the next drugs of choice tend to be non-habit-forming, with significant sedation as a side effect. They are:

  • Melatonin. This naturally occurring peptide released by the brain in response to the setting of the sun has some function in setting the circadian clock. It is available without prescription at most pharmacies and health food stores. Typically the dosage sizes sold are too large. Almost all of the published research on Melatonin is on doses of 1 mg or less, but the doses available on the shelves are either 3 or 6 mg. Nothing is gained by using doses greater than one milligram. Melatonin may not be effective the first night, so several nights’ use may be necessary for effectiveness.
  • Periactin. The prescription antihistamine, cyproheptadine (Periactin), works like Benadryl but has the added advantages of suppressing dreams and reversing stimulant-induced appetite suppression.
  • Clonidine. Some practitioners recommend in a 0. 05 to 0.1 mg dose one hour before bedtime. This medication is used for high blood pressure, and it is the drug of choice for the hyperactivity component of ADHD. It exerts significant sedative effects for about four hours.
  • Antidepressant medications, such as trazodone (Desyrel), 50 to 100 mg, or mirtazapine (Remeron), 15 mg, used by some clinicians for their sedative side effects. Due to a complex mechanism of action, lower doses of mirtazapine are more sedative than higher ones. More is not better. Like Benadryl, these medications tend to produce sedation into the next day, and may make getting up the next morning harder than it was.

Problems Waking Up with ADHD

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

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

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

[ADHD Directory: Find an ADHD Specialist or Clinic Near You]

William Dodson, M.D., is a member of ADDitude’s ADHD Medical Review Panel.

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Features of sleep organization in children with attention deficit hyperactivity disorder

Features of sleep organization in children with attention deficit hyperactivity disorder

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contains materials intended exclusively for healthcare professionals. By closing this message, you confirm that you are a registered medical professional or student of a medical educational institution.

Kalashnikova T. P.

Perm State Medical University. acad. E.A. Wagner» of the Ministry of Health of Russia

Anisimov G.V.

The first medical and pedagogical center "Lingua Bona"

Features of sleep organization in children with attention deficit hyperactivity disorder


Kalashnikova T.P., Anisimov G.V.

More about the authors

Magazine: Journal of Neurology and Psychiatry. S.S. Korsakov. Special issues. 2021;121(4‑2): 55‑60

DOI: 10.17116/jnevro202112104255

How to quote:

Kalashnikova T.P., Anisimov G.V. Features of sleep organization in children with attention deficit hyperactivity disorder. Journal of Neurology and Psychiatry. S.S. Korsakov. Special issues. 2021;121(4‑2):55‑60.
Kalashnikova TP, Anisimov GV. Features of the organization of sleep in children with attention deficit hyperactivity disorder. Zhurnal Nevrologii i Psikhiatrii imeni S.S. Korsakova. 2021;121(4‑2):55‑60. (In Russ.).


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The article reflects modern ideas about the clinical features of sleep in children with attention deficit hyperactivity disorder (ADHD), the macrostructure of sleep, its cyclic organization and possible common links in the pathogenesis of sleep disorders and regulatory functions, the level of social exclusion of patients with ADHD. Typical for children with ADHD are difficulty going to sleep and prolonged falling asleep (resistance to sleep time), increased motor activity associated with sleep, including the association of ADHD with restless legs syndrome (RLS) and periodic leg movement syndrome during sleep (Periodic Leg Movement during Sleep—PLMS), daytime sleepiness. The presence of circadian desynchrony in children with ADHD explains the relationship between chronotype, circadian typology, and clinical manifestations of the syndrome. Multidirectional information about the representation of the phase of REM sleep - sleep with rapid eye movements (REM) according to nocturnal polysomnography in children with ADHD depends on age. However, the change in the proportion of REM sleep during the night is considered as a leading factor in the pathogenesis of ADHD manifestations. Common pathogenetic mechanisms for sleep disorders and ADHD are identified: various variants of melatonin, dopamine, serotonin metabolism disorders aggravated by "social jet lag", as well as changes in the concentration of iron and ferritin in the blood, which can explain the frequency of RLS and PLMS in children with ADHD. This group of patients showed a change in the number of sleep cycles during the night. Possible strategies for correcting sleep disorders in children with ADHD and their impact on the manifestation of ADHD are discussed.


preschool children

sleep disorders


polysomnography in children

R. E.M. sleep



Kalashnikova T.P.

Perm State Medical University. acad. E.A. Wagner» of the Ministry of Health of Russia

Anisimov G.V.

The first medical and pedagogical center "Lingua Bona"


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  47. Villano I, Messina A, Valenzano A, Moscatelli F, Esposito T, Monda V, Esposito M, Precenzano F, Carotenuto M, Viggiano A , Chieffi S, Cibelli G, Monda M, Messina G. Basal Forebrain Cholinergic System and Orexin Neurons: Effects on Attention. Front Behav Neurosci. 2017;31:11:10.
  48. Holvoet E, Gabriëls L. Disturbed sleep in children with ADHD: is there a place for melatonin as a treatment option? Tijdschr Psychiatr. 2013;55(5):349-357.
  49. Arns M, Kenemans JL. Neurofeedback in ADHD and insomnia: vigilance stabilization through sleep spindles and circadian networks. Neurosci Biobehav Rev. 2014;44:183-194.

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The reciprocal influence of sleep structure, emotional status and cognitive functions is well known. Each of the fundamental states of the brain — wakefulness, REM sleep — rapid eye movement (REM) sleep, and non-REM sleep — slow-wave sleep (NREM) — have their own neuroanatomical basis, neurophysiological, neurochemical characteristics, and functions [1]. A deeper understanding of the mechanisms involved in sleep-wake cycle disorders and deviant developmental variants may lead to new diagnostic and therapeutic strategies, including those at the early stages of ontogeny [2, 3].

Attention deficit hyperactivity disorder (ADHD) in recent decades has been considered as the most common cause of behavioral disorders, difficulties in school and social adaptation in children with normal intelligence. ADHD is heterogeneous, including several clinical variants, transforms in the process of growing up a child, has a high comorbidity with oppositional defiant behavior, anxiety and depression, tics, and obsessive-compulsive disorder. Multidirectional changes in sleep in children with ADHD may be associated with the heterogeneity of clinical cases [2, 4–6]. Sleep problems occur in 25–50% of children and adolescents with ADHD [7].

In early attempts to define diagnostic criteria for ADHD, sleep disorders were considered as one of the possible criteria for verification of the syndrome, as reflected in the Diagnostic and Statistical Manual of Mental Disorders (DSM) 3rd edition. However, these data were excluded from subsequent and current editions of the DSM and the International Classification of Diseases (ICD) because there was no convincing evidence that the presence of sleep disorders could be one of the criteria for diagnosing ADHD [8].

Difficulty going to sleep and prolonged falling asleep (Resistance bedtime, sleep resistance, resistance to sleep time) are the most common complaints in patients with ADHD [9]. Often, prolonged falling asleep in ADHD is regarded as the result of taking psychostimulants, and the syndrome itself is not considered as a direct cause of insomnia. However, at the present stage, this point of view is untenable [10, 11].

In the process of ontogeny, prolonged falling asleep in patients with ADHD undergoes evolution. At primary school age, 10-15% of children have difficulty getting themselves to sleep. This is 2 times more common than in healthy peers. By 12.5 years, 50% of children with ADHD have difficulty falling asleep, and by age 30, 7% of patients report spending more than 1 hour trying to fall asleep at night [12].

A significant increase in the “evening” activity type (eveningness type) was demonstrated in children with ADHD at the age of 7–12 years, which positively correlated with prolonged falling asleep and daytime sleepiness [13]. The results of 13 studies have shown that children and adolescents with a late chronotype are more likely to suffer from daytime disorders, in particular, they have a tendency to aggression [14].

Sleep initiation disorder, marked variability in sleep onset with frequent awakenings in children with ADHD belongs to the category of circadian rhythm disorder (CRSWD) and is detected in 70% of cases (compared to 20% in healthy peers). At the same time, cortical connections change and the perception of environmental signals necessary for the development of the rhythm of sleep and wakefulness is disturbed. This manifests itself in inadequate thalamic signals to the hypothalamus, the formation and aggravation of CRSWD [15, 16].

Many studies have shown that CRSWD is based on a change in the activity of the gene that regulates the circadian rhythm ( CLOCK ). There are few genetic studies reporting an association between CLOCK gene polymorphisms and ADHD symptoms. Polymorphism can lead to inversion of endogenous melatonin secretion, which reaches a maximum in the daytime [17, 18].

The late chronotype in children with ADHD is associated with a delay in changes in circadian phase markers, in particular melatonin synthesis, and, as a result, a delay in the onset of sleep [10, 19].

Although genetic and/or epigenetic abnormalities in circadian sleep regulation may predispose children to CRSWD, poor sleep hygiene, negative associations, and social jet lag contribute to maintaining sleep problems [20, 21].

Thus, circadian desynchrony is an important factor mediating the proposed relationship between chronotype, circadian typology, and ADHD [22].

The features of dreams in children with ADHD are demonstrated. The content of dreams in children with ADHD is more negatively toned, including more failures, threats, negative consequences and physical aggression, which may be associated with pronounced emotional problems [9].

Anxiety during sleep is the second topical aspect of dissomnic disorders in children with ADHD. Actigraphy indicates an increase in motor activity in patients with ADHD, which is most pronounced in the combined subtype and the type with a predominance of hyperactivity [23, 24].

Sleep disturbances in children associated with ADHD include restless legs syndrome (RLS) and periodic limb movement sleep syndrome (PLMS). There is evidence of a relationship between the severity of daytime hyperactivity and the severity of RLS [2]. RLS is detected in children with ADHD in 44% of cases with a tendency to decrease with age [10]. However, the presence of RLS and PLMS cannot be fully explained by the neurobiological mechanisms of ADHD. It was assumed that RLS and PLMS are based on dopamine deficiency in the nigrostriatal system. But this requires further study. Most likely, RLS and PLMS, including those associated with ADHD, are interrelated with impaired regulation of REM sleep [25].

The importance of iron deficiency in ADHD, PLMS and RLS as a common metabolic link is also discussed. Children with ADHD have low serum ferritin [26]. This is an independent risk factor for the formation of sleep-related movement disorders, including PLMS and RLS. The change in ferritin concentration is not specific in children with ADHD. Similar changes have been found in children with autism spectrum disorders [16].

A number of studies have demonstrated excessive daytime sleepiness (EDS) in children with ADHD [27]. However, the potential impact of daytime sleepiness on school performance in patients needs to be clarified. A number of studies have shown that daytime sleepiness was more correlated with emotional and behavioral problems at school than total sleep duration. However, it did not affect the average grade of students in subjects [28]. Children with a predominance of inattention have more pronounced hypersomnia and excessive daytime sleepiness than patients with other subtypes of ADHD [29].

The neurobiological mechanisms underlying ADHD and sleep regulation have much in common. Alterations in dopamine levels and norepinephrine deficiency are key neurochemical determinants of ADHD symptoms. Both neurotransmitters play a critical role in NREM-REM sleep alternation. Serotonin levels are also important. Serotonin plays a key role in switching sleep phases, and its deficiency is considered as an important neurochemical mechanism for the psychopathology of ADHD [30, 31].

In addition, there is a commonality of biochemical transformations of serotonin and melatonin. Melatonin is synthesized from the amino acid tryptophan, which is involved in the synthesis of serotonin, and it, in turn, under the influence of the enzyme serotonin-N-acetyltransferase, is converted into melatonin. Melatonin is an indole derivative of serotonin. Thus, a violation of serotonin metabolism can affect the synthesis of melatonin, and, as a result, indirectly on the quality of sleep [16].

Impaired melatonin metabolism is associated with impaired expression of a gene that affects the enzyme N-Acetylserotonin O-methyltransferase (ASMT), which catalyzes the final reaction in melatonin biosynthesis. However, the widespread use of mass media in combination with the bright screen of multimedia devices can contribute to changes in melatonin secretion [32].

Developmental disorders, including ADHD, are associated with many CYP1A2 gene polymorphisms that alter melatonin degradation. This may explain the lack of effectiveness in a number of situations when melatonin is used to correct circadian rhythms in patients [33].

Finally, orexin deficiency may also contribute to both the clinical manifestations of ADHD and sleep disturbance. Orexin neurons are "multi-tasking" neurons. There is evidence that the orexin/hypocretinergic system contributes to the maintenance of attention by increasing the release of cortical acetylcholine and modulating the activity of cortical neurons [34, 35]. Orexin neurons have connections to areas of the brain involved in cognition and mood regulation, including the hippocampus. Orexins enhance hippocampal neurogenesis and improve spatial learning and memory performance. Conversely, orexin deficiency leads to learning deficits and memory loss, as well as depression [34, 36].

The available data on the structure of sleep according to polysomnography (PSG) in patients with ADHD are rather contradictory, which may be due to various methodological factors (sample of the observation group, clinical identification of ADHD, the impact of drug therapy, the presence of comorbid conditions, adaptation to laboratory conditions and etc.).

Changes in REM sleep are among the most common PSG changes in ADHD. Nine (64%) of 14 polysomnography reports recorded changes in REM sleep in children with ADHD [37]. Given the fundamental properties of REM sleep, this deserves focused attention. Powerful endogenous brain activation during REM sleep plays a unique role, providing stimulation-dependent development of the child's CNS, and expression of genes associated with changes in plasticity in the cortical zones occurs [1].

Changes (increase and decrease) in REM sleep have a different focus and severity in different studies [26, 37].

A lower proportion of REM sleep in children with ADHD has been associated with higher rates of inattention, hyperactivity, and impulsivity, with impaired cognitive function, including language skills and working memory [29, 38, 39].

In studies that included children aged 8 to 15-16 years with the combined subtype of ADHD, an increase in REM sleep was observed, which was associated with high levels of inattention, hyperactivity, and impulsivity. In addition, sleep in patients with ADHD may be characterized by a disturbance in the alternation of NREM and REM sleep phases [2, 37].

It is emphasized that the proportion of REM sleep in children with ADHD depends on age. Patients younger than 9-10 years of age have a reduced proportion of REM sleep compared to healthy peers. On the contrary, in children older than 9–10 years, there is an increase in REM sleep during the night [5]. Overall, the results point to an opposite effect of REM sleep on neurobehavioral functioning [28].

The authors' own research based on nocturnal PSG (without adaptation night) revealed the following features of sleep in children with ADHD aged 5-9years: a decrease in total sleep time, an increase in the latency and duration of the drowsiness stage, an increase in the latent period of REM sleep with a decrease in its duration, an increase in wakefulness during sleep, an increase in the number of awakenings, including more than 3 minutes, a decrease in the sleep efficiency index. At the same time, the level of anxiety did not affect the structure of sleep [40].

Considering that hereditary factors are considered in the pathogenesis of ADHD, it would be important to highlight PSG patterns of genetic screening. However, such multilateral studies are lacking. There is one study comparing nighttime actigraphy scores and the presence of a single nucleotide polymorphism (SNP) for catechol-O-methyltransferase (COMT). The authors demonstrated that among children with ADHD with the Val-Val SNP gene, more stable sleep indicators were recorded [41].

There is evidence of a change in the cyclical organization of sleep in the group of children with ADHD compared with controls, manifested by a significant decrease in the total number of sleep cycles during the night in children with ADHD (up to 2.7 ± 0.6 cycles, compared with 6 cycles in healthy peers), with an increase in the duration of the first sleep cycle. Distortion of ultradian rhythms is more pronounced in boys and patients with the combined ADHD subtype [42].

However, studies by R. Kirov et al. [10, 25] found an increase in the number of sleep cycles in children with ADHD. It is hypothesized that a decrease in REM sleep latency may also contribute to an increase in the duration of absolute REM sleep and lead to a higher frequency of sleep cycles. Deformation of ultradian cycles may be associated with changes in brain monoamines, lead to inhibition of the development of the cerebral cortex and enhance the psychopathology of ADHD.

The results of sleep studies in ADHD indicate that appropriate treatment tactics are needed for such patients. Before starting pharmacological treatment, it is necessary to assess the sleep status of children with ADHD, since sleep problems may play a causative role or aggravate the clinical signs of the syndrome [11, 32]. In addition, sleep disturbances themselves can induce ADHD-like symptoms and form clinical phenocopies. For example, obstructive sleep apnea [30, 40].

The first step in correcting sleep problems in children with ADHD is good sleep hygiene and cognitive behavioral therapy [14]. The second direction of treatment is the issue of choosing and modifying the dose of drugs.

In a study by K. France et al. [43] discusses the rational combination of behavioral interventions and drug therapy with the gradual abandonment of the latter. There is evidence of the high efficiency of the multicomponent homeopathic preparation Homeostres (Boiron, France) for sleep disorders and anxiety disorders from the 3rd day of use [44, 45]. Clinical homeopathy in the Russian Federation has a legislative base, in particular the Order of the Ministry of Health of the Russian Federation No. 335 of 29.11.95 "On the use of the method of homeopathy in practical public health." The composition of the preparation includes plant substances (wrestler, celandine, licorice, viburnum, belladonna and calendula) in the sixth dilution according to Hahnemann (6 CH). According to the instructions for medical use, the drug Homeostres is over-the-counter, does not cause lethargy and addiction, it is prescribed for children from 3 years old, two tablets 3 times a day for 2 weeks.

Methylphenidate abroad is a specialized drug for the treatment of ADHD. The use of CNS stimulant drugs may exacerbate insomnia in children with ADHD and increase restlessness during sleep, as confirmed by actigraphic studies [46].

One study showed that continuous treatment for 6 months with methylphenidate did not further adversely affect sleep architecture in children with ADHD [47]. Studies have emerged demonstrating that methylphenidate facilitates sleep onset and shortens its duration, reduces the representation of REM sleep in children with ADHD [10]. It is substantiated that, along with the suppression of ADHD symptoms, methylphenidate and other stimulants improve regulatory functions and emotional state, including by optimizing the processing of emotionally significant information during sleep [31].

An important conclusion is the need for a differentiated approach in assessing the effect of methylphenidate on sleep. The effectiveness of methylphenidate in ADHD depends on sleep patterns. In children with sleep disorders and ADHD, sleep improved after the appointment of methylphenidate, and in patients with ADHD without initial somnological complaints, sleep worsened [22].

There are also conflicting results regarding the efficacy of melatonin in the treatment of ADHD. There is evidence that the use of melatonin in the treatment of insomnia in children with ADHD at a dose of 3-6 mg was effective [32]. E. Holvoet et al. [48] ​​in their study demonstrated an improvement in behavior and mood with long-term use of melatonin for 2–3 years. However, discontinuation of the drug led to a recurrence of insomnia. Melatonin therapy in children with ADHD has better results in persistent insomnia, especially when it is an apparent phase shift in the endogenous circadian rhythm.

A number of studies have evaluated the effectiveness of non-drug treatments for ADHD, with positive effects using biofeedback and phototherapy [49].

Thus, sleep disorders and behavioral dysfunctions have a mutual influence. The described sleep changes in ADHD are most often not specific and are generally associated with the maturation of sleep mechanisms. This reflects deep disturbances in the formation of the integrative functions of the brain, including the integrative mechanisms of sleep and chronobiological processes in ontogeny.

The study was carried out with the sponsorship and informational support of Boiron.

Sleep and ADHD

Sleep is the golden chain that binds health and body together.
Thomas Dekker.

Recent studies have shown that even mild but chronic sleep deprivation has a more negative effect than short-term or even long-term complete sleep deprivation (as, for example, in doctors in residency).

A healthy child without any ADHD, dyslexia or conduct disorder begins:

  • learning problems
  • chronic fatigue
  • attention maintenance problem
  • intemperance
  • irritability
  • frustration
  • Impulse and emotion control problems.

Alas, when a child has these signs, clearly reminiscent of the symptoms of Syndrome , then few people (including a doctor) will come up with a seemingly obvious question: “What if the child simply does not get enough sleep?”

The child may not sleep for the following reasons:

1. Cannot sleep.

2. Goes to bed late.

3. Has sleep problems, such as sleep apnea (stopping breathing during sleep).

4. Someone or something prevents him from sleeping properly: for example, the night vigils of drunk dad, morons in the yard, the light of a street lamp, a tree branch beating through the window.

Child cannot sleep

Problem: Fidget has difficulty falling asleep due to:

  • hyperactivity (want to move)
  • residual effects of psychostimulant action (although Ritalin helps some Fidgets to sleep)
  • environmental hypersensitivity (always alert)
  • emotionality (difficult to calm down)
  • swarming streams of thoughts (it is difficult to stop the process of thinking and jumping from one thought to another).


  • the child must be a child. He must run, climb, jump, somersault. Older children need to wear out sports. But you need to finish jumping, climbing or training a few hours before bedtime
  • give your child golden milk with turmeric at night (recipe in a few minutes) if not allergic/hypersensitive to milk
  • the room should be dark, quiet, cool and comfortable for sleeping
  • the bed must be hard
  • In addition to or instead of the pillow, you can use a neck roll pillow or wooden neck support
  • the child must feel that he is safe
  • no caffeine or strong tea in the afternoon
  • No computer or TV before bed. It can be agreed that, for example, after 8 pm no one in the house uses electronic devices.


  • no computer or outdoor games before bed
  • read calm literature to children at night, for example, fairy tales. For adult Fidgets there is a great thing "Childe Harold's Pilgrimage" by Byron or a reference book on UNIX OS commands.
  • teach a child / teach yourself meditation - it cuts off in a few minutes (I will talk about the simplest technique)
  • a good idea is to fill the house in the evening with calm, melodic, slightly loading music. For example, Chopin's nocturnes
  • if you watch TV yourself or work with a computer - you need to make sure that the sounds and light from the screen do not reach the child
  • Filling up before bed is the way to long sleep, nightmares and restless sleep. On the other hand, Fidgets often don't get enough vitamins during the day, so a light, healthy snack before bed, like a banana, can help ease stomach discomfort and give Fidget the missing vitamins.
  • an adult Fidget can write down thoughts before going to bed that do not allow him to calm down and / or which he is afraid to forget. In a little while we will discuss the How to Do Things organization system.

If your child has difficulty falling asleep in a comfortable, safe environment, see a doctor.

The child goes to bed late

In terms of sleep, the city is the worst place. Parents come home from work at 7 or 8 pm. They still need to do housework, then spend time with the child and relax themselves. So far, yes, it's already 11 o'clock in the evening.

If you're willing and able, one of the best lifestyle changes you can make is going to bed at 9pm and waking up at 5 or 6am .

This has an amazing effect on performance, mood and generally improves the quality of life.

Naturally, the clock change will destroy the regime 2 times a year, but it will destroy it in any case, whenever you go to bed.

Trouble sleeping? Time to take action!

Unfortunately, even parents don't always know if a child is getting quality sleep.

This is primarily due to lack of information. If a child snores, then one should not be touched, but sound the alarm, since snoring is typical for 90,003 sleep apnea 90,004 - stops breathing in a state of sleep for a period of several seconds to several minutes.

Here is a typical sleep apnea snoring pattern: snoring, quiet, snoring again, quiet again, etc.

You can make an audio recording of your child's sleep and have your pediatrician or sleep specialist listen to the snoring patterns.

Although sleep apnea peaks between 2 and 5 years of age, the condition can occur at any age and have negative consequences for those who suffer from it.

There are cases when sleep apnea is not accompanied by snoring.

With sleep apnea, the child not only does not get enough sleep, but his brain receives less oxygen.

Typical consequences:

  • attention problems
  • deterioration in academic performance
  • oppositional behavior
  • restlessness, restlessness.

One of the common causes of sleep apnea is enlarged adenoids or tonsils. In one of the experiments, 22 Fidget children with enlarged adenoids/glands were removed and a year later they were re-diagnosed for the presence of the Syndrome.

In 11 children, behavior, learning, mental state improved so much that it was possible to talk about curing of ADHD .

Children who have sleep apnea, somnambulism, restless leg syndrome, narcolepsy, insomnia, or other sleep disorder may be diagnosed as Fidget.

Accordingly, the causes of restless behavior are eliminated when sleep problems are eliminated.

There are not only medicines for this, but also special therapies, such as chronotherapy .

Even if the symptoms of the Syndrome are not caused by sleep disorders, then when the lack of sleep is eliminated, Fidget will still be a big winner.

Sleep problems are typical for Fidgets:

  • Fidget parents usually think that their children have restless sleep
  • Fidgets are more likely than Nerds to wake up in their sleep
  • Psychostimulants can not only interfere with falling asleep, but also prevent Fidget from sleeping.

According to statistics, from 25 to 50% of Fidget children and adolescents have problems sleeping! This is 2-3 times more than the Nerds.

Imagine how many children can be helped by eliminating their lack of sleep!

It's hard to say how much sleep you need, as there are so many individual variations. But, on average, the situation is as follows:

  • Preschoolers must sleep 12 hours plus daytime naps
  • primary school students - 10 hours
  • middle school students and teenagers - 9 hours.

Here are some questions a parent might ask themselves:

  • Does your child appear sleepy or irritable during the day?
  • Does the child have trouble staying awake while sitting still?
  • Does the child have an attention problem at home or at school?
  • Does the child seem to be functioning below his ability?
  • Does the child have emotional breakdowns?

Part of the information about sleep problems was taken from an article by Dr.

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