Sleep should be simple. The sun goes down, your brain and body get sleepy, you go to bed and close your eyes, you drift into slumber. It doesn’t work that way for me, nor anyone I know with attention deficit disorder (ADHD or ADD). What I didn’t realize, until over a decade ago, was that sleep problems and ADHD are highly correlated. It made sense to me as I delved into the scientific literature. People with ADHD are prone to sleep problems (usually undiagnosed). Sleep problems — like sleep apnea, restless leg syndrome, or delayed sleep phase syndrome — exacerbate ADHD symptoms. Sometimes people are misdiagnosed as having ADHD when they actually have a sleep disorder.
ADD and Sleep Apnea: A Personal Story
Even as an infant, my sleep was irregular. I liked the nighttime. I wasn’t colicky or irritable. I wanted to start the party at midnight. I am the youngest of three children, and my mom had to be awake during the day for my siblings. (As genetics and karma had it, neither of my two children slept through the night until they were over a year old.)
In my childhood, I didn’t want the day to end. Even when I was exhausted, I felt there was more to squeeze out of the day. I didn’t feel tired at night, I felt energized. To surrender to sleep seemed wasteful. Procrastination played a role. When I put off doing things, I could get them done at night. I knew no one was going to interrupt me, and there was nothing good on TV.
My habit was to exhaust myself, so it would be easy to fall asleep when my head hit the pillow. If I wasn’t exhausted, I would lie in bed thinking. Sometimes I had anxious thoughts, other times I thought about the concert I was looking forward to, a great meal I had, the meaning of life.
I had problems staying awake and alert during boring activities — namely, school. For me, school days were a school daze. It is hard to explain to someone what this was like. Fatigue overwhelmed me, as if my brain were barreling into shutdown mode. Digging my pen into my leg until it hurt, even puncturing the skin a bit, seemed reasonable — a defibrillator, if you will.
I wanted to pay attention; I physically could not. This daytime “narcolepsy” still affects me, although I have more options as to the environments I place myself in. I could have benefited from fidget toys, stand-up desks, and one-minute breaks. In graduate school, I assigned a designated kicker to hit my leg when I got drowsy in lectures.
Could Sleep Apnea Be the Culprit?
Then came my sleep apnea diagnosis in 2006. I had always been a snorer. My brother said that I sounded like a chainsaw at age nine. He couldn’t believe that a sound like that could come from a short, skinny kid. I had never heard myself snore, and I never woke up gasping for breath. It was when I was treating a patient with ADHD, who had severe sleep apnea, that I decided to educate myself about it in order to help him. As I checked off the symptoms, some of them resonated with me — chronic, loud snoring, never feeling rested in the morning. Others did not: headaches, mood disorder, and impotence. I decided to get a sleep study done to see whether I had the condition. That decision was a lifesaver.
In the sleep lab, I was hooked up to so many wires I looked like something out of The Terminator. The staff told me they were assessing the number of hypopnea (abnormally shallow breathing events) or apnea (pauses in breathing of at least 10 seconds and decrease in blood oxygenation) events during my sleep. If I had more than 20 events in an hour, they would put me on a CPAP (Continuous Positive Airway Pressure) machine and see if that helped. I’d have to sleep for at least three hours to get a stable reading.
After what felt like 20 minutes, a technician came in my room, wheeling the CPAP machine. I was puzzled. “I thought you needed me to sleep for at least three hours? It’s only been 20 minutes.” She said, “Sir, you have been asleep for three hours.” They attached the CPAP to me and, the next thing I knew, I was awakened at 6:30 in the morning and discharged. I was told to meet with the sleep doctor in five weeks, after they went through my sleep data.
After a week, the doctor’s office called, saying she wanted to see me sooner. The doctor told me that I had a severe case of sleep apnea. Twenty events in an hour warranted the diagnosis. I had 98 events! She said that it was one of the highest scores she had seen. “I am an overachiever,” I joked.
How CPAP Can Be a “Med” for ADHD-Induced Sleep Problems
The doctor said I would need to sleep with a CPAP for the rest of my life. Apparently, I had a severely deviated septum, allowing only about 30 percent of my oxygen into my lungs. In addition, I had large tonsils, a tipped jaw, and a thick tongue. I got almost no air down my throat. She said my sleep was like breathing underwater with a straw.
“What if I lose weight?” I asked. For some people, sleep apnea is merely a result of being overweight. When they lose pounds, the sleep apnea clears up. This was not the case for me. “Losing some weight will help, but it will only lower the pressure setting on your CPAP. It won’t take away the fact that you need to use one.”
The doctor reviewed the data with me. In normal sleep you go through a cycle of 5 stages (stages 1-4 and REM sleep) every 90 minutes. Due to my severe apnea, I was stuck in stages 1 and 2 for three hours, never progressing to the deeper, restorative levels of sleep. This has major health implications. The deeper stages of sleep, especially REM sleep, are responsible for information consolidation, building up your immune system, and repairing any wear and tear from the day. Sleep is not passive.
For most of my life, I have operated on a half-full tank of gas to get me through the day. Combine that with an ADHD diagnosis, and it is no wonder some things have been so difficult for me. I wonder how much my sleep apnea has exacerbated my ADHD traits, including hyperactivity and impulsivity.
I hated using a CPAP machine to get to sleep every night. Then my doctor showed me the results that tracked my heart’s activity. “Your sleep apnea is so severe that it is like someone putting a pillow over your face, causing your heart to beat hard to keep you alive. This can damage your heart.” Many people suffer major health consequences that no one ever associates with sleep apnea.
“You need to see the CPAP as a lifesaving medication,” the doctor said. That’s all I needed to hear. I owed it to myself, and to my children and wife.
The positive impact of the CPAP was undeniable. I woke up feeling rested and somewhat refreshed for the first time in my life.
In addition to sleep apnea, my sleep study revealed that I had delayed sleep phase syndrome (DSPS). I become energized around 10 or 11 p.m. and my brain doesn’t send sleep signals until 2 a.m. This is not uncommon in those with ADHD. I have to work extra hard to get to sleep before 1 a.m. I alter my environment to tell my body that sleep will be happening soon. I dim lights, change into sleeping clothes, and avoid screens of any kind an hour before I turn in. To make sleep more inviting, I keep the room cool, with heavy comforters nearby. I need to trick my brain to surrender to sleep.
Getting to sleep will always be a challenge for me. The thing that comes so easy to millions of people takes a lot of effort. As with my ADHD, I have to do what works.
Common Sleep Disorders — and ADHD-Friendly Fixes
Sleep disorders often mimic ADHD symptoms, causing inattentiveness and restlessness in people who don’t have ADHD. At the same time, sleep disorders can exacerbate symptoms in people who do have ADHD. There are two types of sleep disorders:
- Primary sleep disorders are physical conditions that disrupt sleep. They include disturbances like obstructive sleep apnea, restless legs syndrome, and delayed sleep-wake phase disorder (more on that in a minute). While difficult to diagnose, these problems can be managed by non-invasive medical interventions.
- Behaviorally based sleep problems are often secondary to ADHD. They are common in children who cannot make the transition to bedtime without a commotion that ends up disrupting sleep, or in adults who follow habits that disrupt sleep. If you have sleep problems, the first step in solving them is to review your sleep behaviors. If that doesn’t help, consult an expert to find out if you have a primary sleep disorder.
To address sleep problems that might be behavioral, establish these basic rules:
- Remove all screens from the bedroom, and turn off all screens at least one or two hours before your sleep time.
- Go to bed at the same time every night.
- Get up at the same time every morning.
- Don’t do work in your bed and, if possible, avoid working in your bedroom. Reserve your bed for rest, sleep, and sex.
- Get regular exercise.
- Reduce your alcohol and caffeine intake. This is a tough one for people with ADHD because many people try to “self-medicate” with caffeine. Nonetheless, everyone metabolizes caffeine differently, and it can disturb your sleep hours later.
- Review your ADHD medications with your doctor in light of your sleep problems. A medication change may be helpful.
- Establish a “winding down” routine before bedtime — quiet music, dim lights, and gentle conversation. Avoid stress, bright light, or vigorous exercise for an hour or two before bed.
If you suspect a primary sleep disorder, here are some common ones to watch for, in addition to sleep apnea:
- Delayed sleep phase syndrome. Perhaps the most common disorder to occur with ADHD, this characterizes people who are not tired at night and not wakeful in the morning. Their biological clock is off-track. Treatments include behavioral modifications, morning light, melatonin, and others.
- Restless legs syndrome (RLS). Patients with RLS experience uncomfortable feelings in their legs minutes or hours before sleep onset, leading to sleeplessness. There is an urge to move the legs because the movement eases the discomfort. While asleep, the individual moves excessively, resulting in sleep disruption. Symptoms include fatigue and waking up with the bed in disarray. Treatment can be dietary (taking iron supplements) or medical.
Sleep problems are often overlooked in routine ADHD assessment. If you are tired and can’t concentrate, discuss your sleep patterns with your doctor.
—JOEL NIGG, Ph.D., and KYLE JOHNSON, Ph.D.