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Teens, ADHD and Sleep: A Complicated Mix

Sleep problems may play an under-recognized role in teen ADHD.

Source: iStock

Teenagers need about 8 to 10 hours of sleep every night to be at their best, but many fall short of getting that amount consistently. Lack of sleep can affect attention, mood and daily functioning in any teen. But the consequences may be magnified in teens with attention-deficit/hyperactivity disorder (ADHD).

Unfortunately, sleep problems are very common in this group. Prevalence estimates vary, but studies suggest that 30% to 75% of youth with ADHD don’t get enough sleep.

Yet sleep is often overlooked as a potential treatment target. “Right now, most interventions for ADHD are not targeting sleep in any way,” says Stephen Becker, Ph.D., an assistant professor of behavioral medicine and clinical psychology at Cincinnati Children’s Hospital Medical Center. Becker believes this might be a missed opportunity. He’s heading up an ongoing study that could change the way we look at the complex relationship between sleep and ADHD in teenagers.

Recently, I had a chance to chat with Becker about his research. Here’s what he told me.

How ADHD May Interfere with Sleep

According to Becker, sleep problems that are particularly common in teens with ADHD include:

  • Short sleep time
  • Trouble falling asleep
  • Daytime sleepiness

One likely reason is that young people with ADHD often have trouble managing their waking activities and schedules. This may lead to inconsistent bedtimes and too few hours available for snoozing. “Think about high schoolers who are taking five, six, seven different classes,” Becker says. “All of a sudden, they realize that have a report due the next day, so they stay up really late to do their work.”

It’s also possible that there are neurobiological mechanisms at play. For example, some researchers have explored a possible link between ADHD and circadian rhythm sleep disorder, in which people have trouble falling asleep and waking up at the desired clock time. Becker says, “There is some evidence showing that individuals with ADHD might have a later circadian rhythm and circadian preference than individuals without ADHD, so they may have a harder time going to bed when they should in order to get enough sleep.”

Stimulant medications, the most common pharmacologic therapy for ADHD, have been implicated as well. These medications may cause sleep disruption as a side effect. If that occurs, however, it can often be minimized by adjusting the dose or timing of the medication or by switching to a different drug. In addition, research by Becker and his colleagues in younger children suggests that medication may actually improve sleep in some kids with ADHD. “By and large, it doesn’t seem that medication is responsible for the majority of sleep problems associated with ADHD,” Becker says.

How Lack of Sleep May Exacerbate ADHD

The relationship between sleep and ADHD is a two-way street. While ADHD impairments may contribute to sleep problems, the reverse is also the case.

Difficulty staying mentally focused is a common manifestation of ADHD. “We know that sleep difficulties are associated with poorer attention, both in people with and without ADHD,” says Becker.

But the effects of getting too little sleep don’t end there. Research in teens with ADHD has shown that sleep problems are associated with increases in depressive symptoms and oppositional behavior over time. Plus, daytime sleepiness, in particular, has been linked to diminished academic performance.

In one study, Becker and his colleagues looked at the impact of daytime sleepiness on college students with ADHD. Self-reported daytime sleepiness predicted poor school adjustment, overall functional impairment and the number of D and F grades received, above and beyond what would be expected based on ADHD symptoms alone.

The bottom line: “Research by our group and other people has shown that sleep might be a pretty important aspect of understanding what’s going on with teens who have ADHD,” says Becker. “It may affect how they’re functioning in school and at home as well as in their relationships and emotional functioning.”

Even in teens without ADHD, lack of sleep can have a negative impact on attention, mood and functioning in daily life. So is it possible that some teens diagnosed with ADHD might actually just have poor sleep habits or a sleep disorder instead? “I think it’s possible, but it’s probably not the majority of cases,” Becker says.

What It Means for Parents and Teens

Becker believes it’s more common for sleep problems and ADHD to exist side by side, with each condition making the other harder to manage. Because sleep problems can magnify ADHD-related impairments, and vice versa, it’s important to address both in treatment. “Any time [treatment providers] are doing an ADHD assessment, they should include sleep as part of the assessment process,” says Becker.

In the future, Becker hopes his research will help develop ADHD interventions that better target sleep issues. He’s currently collaborating on a study with Joshua Langberg, Ph.D., of Virginia Commonwealth University, which will be “one of the largest studies to look at teens with and without ADHD across the transition from middle school to high school.” He expects the study to shed light on how sleep problems and ADHD interact throughout this critically important turning point in a teen’s life.

For now, teens with ADHD who also have sleep problems may find that getting ADHD under control with behavioral strategies and/or medication may improve their sleep as well. Becker also recommends making it a point to follow healthy sleep habits, such as sticking with a regular bedtime every night and avoiding staying up too late to play electronic games, use social media or watch TV.

But keep in mind: “Adolescents want to have some say in what they’re doing and when, so I think it’s helpful when parents can approach this as a dialogue,” Becker says. “The parent and teen may negotiate things such as when bedtime is going to be, whether the teen is allowed to watch TV before bedtime and where the teen’s cell phone is going to be after bedtime. The parent needs to be clear about what he or she thinks is ideal, but engaging the teen in the conversation is a good way to go.”

Linda Wasmer Andrews is a health and psychology writer. She is currently coauthoring a book about parenting adolescents with ADHD.

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