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"My husband insists he's going to bed at 10 each night," says Christine, "but that's actually when he starts thinking about it. It's midnight or later before Jake is in bed, and we must be up at 5 in the morning." Christine is sleep-deprived, too, because of Jake's disruptive restlessness.
Mari doesn't dawdle getting to bed, but she doesn't know when to go. "Activities don't have a natural ending for me," she explains. "Whether it's watching TV or chatting on the phone, I keep going until some external force stops me." She relies on her husband to provide the bedtime cue, but shuteye doesn't come easily. "Lately," she says, "I've been dozing off in the middle of playing Angry Birds on my iPhone in bed. I play it under the covers, so my husband doesn't see and ask, 'Babe, are you still awake?'"
Based on appearances alone, sleep specialists might insist that Jake and Mari don't have ADHD, despite professional diagnoses and vastly improved daytime functioning, thanks to stimulant medication. Instead, these experts might advise Jake to make a better effort to get in bed by 10 and Mari to refrain from taking her iPhone under the sheets. That way, both could have more sleep and enjoy improved cognitive ability during the day. Voila! ADHD cured!
When it comes to ADHD, however, appearances can deceive. Jake's poor sense of timing is a lifelong trait; he is the poster boy for ADHD's two kinds of time: now and not now. Mari has battled "brain chatter" when trying to fall asleep since she was a child. Playing iPhone games is not the cause of her delay in going to sleep; it's her latest strategy for dealing with boredom.
ADHD is Always Awake
Jake's and Mari's trouble with sleep remind us that ADHD neurobiology doesn't go off-duty when the day ends. ADHD works 24-7 to distract, delay, and disorder one's capacity to get restorative sleep. The result? ADHD symptoms get worse. Research during the last five years substantiates what ADHD experts have suspected for decades: ADHD carries with it intrinsic challenges to sleep. In fact, "restless sleep" was part of the 1980s-era diagnostic criteria for ADHD. It was dropped because specifics as to the causes were lacking.
Too Loud! Too Itchy! Too Much!
Today, terms such as delayed-onset sleep phase and sleep-disordered breathing (sleep apnea) crop up in studies done on ADHD populations. But just as ADHD symptoms vary among individuals who may also have co-existing conditions, such as anxiety, the nature of sleep disorders varies among individuals with ADHD. Generally speaking, though, up to 50 percent of children and 80 percent of adults with ADHD have problems going to sleep, staying asleep, getting restful sleep, and getting up the next morning.
Some sleep disturbances spring from core ADHD symptoms. What is more boring to the hyperactive person than lying in the dark waiting for nothing to happen? Other sleep problems, such as restless leg syndrome, are increasingly being linked to dopamine pathways. Research studies focusing solely on adults with ADHD are mostly small and preliminary, but they show higher-than-average rates for nocturnal motor activity and restless leg syndrome; periodic limb movement disorder; sleep disordered breathing (such as snoring or sleep apnea); and hypersomnia (sleepiness throughout the day that is not due to lack of sleep or interrupted sleep at night).
"It's important to remember that ADHD is a medical, physiological disorder," says ADHD expert and physician Patricia Quinn. Some adults with ADHD say, "I like to stay up late because it's quiet, and I can get a lot done." In other words, daytime distractibility and disorganization can lead to too-late bedtimes. But sleep deprivation with ADHD is not something you choose. "EEG studies done since the 1980s have found that people with ADHD have less REM sleep, don't enter stage-4 sleep, and have more arousals," she says.
Time to Go to Bed
What is the best way for sleep-deprived souls to get more and better rest? Sleep professionals' first line of advice is to practice good sleep hygiene — establishing a regular sleep/wake schedule, limiting caffeine, getting daytime exercise, keeping the bedroom dark and cool. So that's a good place to start. For many adults with ADHD, however, it won't be enough. If that's the case for you, try these ADHD-specific strategies.
Is It Adult ADHD?
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