Attention deficit hyperactivity disorder (ADHD) is a neurological disorder that impacts the parts of the brain that help us plan, focus on, and execute tasks. While there are multiple views on this disorder regarding its causal factors, there has generally been limited treatment options beyond medication and behaviour therapy until now. Neurofeedback and a new technology in the US called monarch TNS are two options showing promising results that should be explored. Could understanding the role that sleep plays in ADHD and other mental health concerns hold the key to improved and more specific treatment and thus better outcomes?

 

ADHD is a condition that I have worked with in clinical practice now for many years and one that I had always felt lacked any real understanding and treatment ‘positivity’ by clients and parents alike. Most of my clients would always report their disappointment in the medications prescribed, observing that they either did not work, made their child’s behaviour or anxiety worse, or worked for a a year or two and then seemed to stop. The side effects of the typical stimulant medications prescribed have also been of growing concern to many and rightly so. There is even research now that shows the effects of psychostimulant medication losing effectiveness over time as the brain adapts to compensate for the effects.

 

Parents feedback around behaviour therapy and parenting support, although more neutral, was also met with ‘there must be more than this’- often feeling like this treatment focus was blaming the condition on them.

 

Now there is a lot one can write about when it comes to ADHD. For the sake of keeping this to point, I wanted to consider only the role of sleep as the relationship between sleep and ADHD has been of interest to me for some time now in considering what appears to be a significant over diagnosis and likely misdiagnosis of ADHD. In both adults and children with ADHD, sleep problems are very common—often significantly more common than in the general population. What’s more, the symptoms of sleeplessness and the symptoms of ADHD, including difficulty with focus, mood swings, and hyperactivity, are often very similar—so similar that it can be difficult to distinguish between the two.   Sleep deprivation and ADHD have long been recognized as having a relationship. But they also have tended to be viewed as either two distinctly seperate conditions or, like with conditions like Depression, a result of the condition itself. This conclusion made, despite no actaul cause-effect evidence.

 

In relation to Depression, there is evidence that supports the directionality in that sleep isses predict depression more than depression predicts sleep. This has been raising further questions around the possibility of stress, impairing sleep, and leading to depressed mood through inflammatory processes and/ or neurotransmitter deficits from non-restorative sleep.

 

Likewise, a new theory is emerging that suggests that sleep and ADHD may be more related than originally thought.

 

As a Neurofeedback practitioner, within this community it has not been a surprise to most as both clinically obseved, and reasearch within this EEG biofeedback field supported, a large majority of ADHD clients showing ‘slow wave’ disorders within the brain has been evident. Simply put, one can observe either ‘Theta’ brain waves or ‘Alpha’ brain waves at levels not expected while awake and more similiar to sleep. It would appear as though the brian is frequently entering into stage 1/ stage 2 sleep and hence the client is experiencing a loss of vigilance or innattention.

 

The consequences of sleep deprivation have long been reported on showing short-term consequences such as fatigue, memory and attention difficulties, and more significant long term consequences such as increased risk of cancer, dementia, various physical and psychological health concerns and the scary list goes.

 

It is known that people who are sleep deprived are likely to experience ‘microsleeps’ during the day that they are not even aware of as the entire brain nods off so briefly that we often don’t notice it. The research shows that individual neurons in the brain can slumber, too, especially when we are sleep-deprived. Is this what is happening in those with ADHD?

 

In children with ADHD, there is a vast amount of literature on the increased prevalence of various sleep disorders and sleep problems, including delayed sleep–wake disorder, insomnia, sleep-disordered breathing, increased nocturnal motor activity, restless legs, and parasomnias such as sleep anxiety and teeth clenching (Van der Heijden et al. 2005a, b; Tsai et al. 2016; Mota-Veloso et al. 2017; Melegari et al. 2016)

 

In the paper by Arns, M., & Vollebregt, M. A. (2019). see editorial here , Attention-deficit/hyperactivity disorder (ADHD) is concluded to be highly associated with the delayed sleep phase disorder, a circadian rhythm sleep–wake disorder, which is prevalent in more global research in 73–78% of children and adults with ADHD. Besides the delayed sleep phase disorder, various other sleep disorders accompany ADHD, both in children and in adults such as sleep apnoea and restless legs syndrome.

 

In adults with ADHD, sleep is also affected: 78% of them have a delayed circadian rhythm and an increased prevalence of short sleep as compared to healthy controls.*

 

In summary, these researchers suggest a redefinition of part of the ADHD symptoms as the result of a chronic sleep disorder and cite other reasons such as:

1. Sleep restriction studies and cross-sectional studies show that shorter sleep is associated with impaired sustained attention and executive functioning.

2. Genetic associations between ADHD and a delayed circadian rhythm

3. A higher ADHD prevalence in countries and geographical areas with lower solar intensities and thus less entrainment to the day and night by the central biological clock.

4. Possible indications of a lower functioning of photosensitive retinal cells that are key for optimal entrainment of the circadian rhythm to the natural day and night cycle

5. Indications of an effect of light therapy both on a phase advance of the circadian rhythm and on the symptoms of ADHD.

6. The central role of dopamine in ADHD, sleep, and retinal circadian alignment.

7. First indications of the short- and long-term effects of sleep improvement (by sleep hygiene measures, melatonin, light therapy, and SMR neurofeedback in delayed sleep; adenotonsillectomy in sleep apnea, and drug treatment in restless legs syndrome).

 

It does appear to me clinically, that sleep is not always an issue in ADHD and that more research is needed to build on this already impressive body of literature to truly clarify the link. However, for now it seems compelling that sleep should always be of primary focus in treating any health condition, including if one is seeking to sustainably function at their peak or address mood, attention, performance and behaviour issues as in itself, can drive these issues.

 

So where does one begin?

Simply put, sleep is primarily regulated through two processes. Process-S and Process-C.

Process-S relates to the pressure that needs to build up over the day, driven through the adenosine system, beginning when you wake up and helps us feel sleepy at night. Exercise, early morning and daylight exposure and diet supports this process, whereas stimulants like caffeine, or stimulant medications, or taking naps throughout the day may impair the build up of this sleep pressure making it harder to fall asleep.

Process -C relates to the 24 hour biological sleep clock known as the circadian rhythm that, although covering a 24 hour period, is known more as the process governing the stages of sleep, through electrical brain activity, neurotransmitters and hormones such as melatonin until we awake the next morning.

Both play a crucial role in sleep–wake regulation and optimal vigilance (i.e., alertness) regulation and must be considered in addressing any sleep concerns. If sleep is disrupted, then it is likely that the person will experience a loss of vigilance throughout the day, often seen as slow wave eeg activity during the day -or frequent loss of focus and attention.

Among other factors, the important one for me is that both are in part regulated/entrained by sunlight (bluelight) in the morning and (lack of) at night.

We ultimately fall asleep due to the role of the pineal gland, a small ant-sized lobe near the middle of our skull in the interbrain. Following our circadian rhythm, the pineal gland secretes a neurotransmitter and hormone called melatonin. Melatonin suppresses the activity of other neurotransmitters and helps to ‘calm’ the brain (in part by countering the stress hormone cortisol from our adrenal gland). And as we become drowsier, the brain slowly begins to turn off our voluntary skeletal muscle functions, so we don’t move around too much and try to act out our dreams or disrupt the body’s internal revitalization work.

 

For ideal sleep, melatonin should be rising steadily and cortisol should be rock-bottom low at bedtime. But there’s a catch: the pineal gland secretes melatonin by and large in response to darkness. And our evening cortisol levels are lowest in environments with low noise. Melatonin supplementation is a commonly used support for children and adults struggling with ADHD. Dosage is a real problem as recent evidence shows the typically prescribed higher dosages over 1mg can lead to habituation within 6 months- with no further real benefit. Timing and lower than 1mg dosages around 7-8om may be more useful and longer lasting when done in conjuction with the below strategies.

 

A topic well covered is the impact that technology is having on our sleep, with our addictions to TV, video games, mobile phones and email in the evening. These devices mostly display full-spectrum light which can confuse the brain about whether it’s night-time or not. We also often are stimulated by the content of what we watch, driving our cortisol level higher instead of supporting it to decline.

Research in 2018 in the Journal of sleep medicine (Becker&Lienesch) looked at Nighttime media use in adolescents with ADHD: links to sleep problems and internalizing symptoms and concluded:

Adolescents with ADHD spend more than 5 h after 9:00PM across media uses.

Adolescents with ADHD with insufficient sleep have more nighttime media use.

Greater media use is associated with shorter sleep duration and more sleep problems.

Greater media use is associated with greater anxiety and depressive symptoms.

What can you do to improve sleep and circadian rhythms:

 

1) Work to Set your sleep in the morning.

Setting your sleep means getting up within the hour after the sun has risen and ensuring that your eyes receive as much sunlight as possible without directly staring into the sun.

On low light days, try and get outside if you can to exercise.

Get plenty of exercise: Plenty of physical activity can help reduce restlessness and hyperactivity, and other behavioral symptoms associated with ADHD, as well as enhance and protect brain function. And exercise gives a terrific boost to sleep by assisting with Process-S as discussed above. Regular physical activity can help both children and adults with ADHD. Try avoid vigorous exercise within 4 hours of bedtime.

Avoid wearing sunglasses-at least for an hour or so after waking to allow enough light exposure.

Ensure you get outside regularly in the day, ideally while exercising.

Use light therapy. Research shows that in adults, morning light therapy improves symptoms of ADHD and shifts sleep toward an earlier circadian timing. Light therapy is commonly used to treat circadian rhythm sleep disorders, jet-lag and those suffering the ‘winter SADs’. Bright light exposure early in the day can help “re-set” the body’s circadian clock. It is recommended that you consult a specialist in this area when using to ensure that you consume light at the right times and for the right durations, to support sleep and strengthen circadian rhythms. Wearable Blue Light Therapy devices that you can wear for 20-30 minutes in the morning are becoming more available and will not stop your morning routine. This can be a fantastic device to help re-set your sleep. 

2) Protect your sleep at night:

Most with ADHD struggle to ‘power down’ at night time. It is important to focus on the 2 to 3 hours before bedtimes with a focus on powering down.

Sources of artificial bluelight are everywhere. Most modern devices now days are producing light within the bluelight spectrum even if it is not noticeably blue.

The most common sources are LED lights, house and office lighting, mobile phones, Ipads/tablets, computer screens, laptops, and even the fridge light. TV can also be a source but the main concern with the other devices is often their close proximity to your eyes.

Blocking these sources becomes vital as we need darkness to produce melatonin in order to sleep and stay asleep. Even with blue light block activated on devices, a substantial amount is still getting through and being registered by your eyes.

The best way is to wear Blue Light Blocking glasses that are in the Orange/Amber range.

Helping your brain wind down and relax can also help to increase Melatonin through reducing cortisol-Meditation has been shown to be very beneficial. However, many, including kids, find this a tough practice. Muse is a very clever brain-sensing headband that can be used as an eeg biofeedback device to give you realtime feedback on how your brain is doing and if you are achieving the right ‘zone’. This more interactive device is novel and interesting and can help to keep the night time practice ongoing.

Other strategies include:

Keeping sleep-wake routines consistent. Circadian rhythms, and sleep patterns, can be reinforced by consistency—or undermined by irregularity. For both children and adults with ADHD, regular bed and wake times can help strengthen sleep and the underlying circadian rhythms that support sleep.  

 Avoid stimulants. For adults, avoiding caffeine after the morning, as well as steering clear of stimulants like nicotine and alcohol, can help avoid excessive alertness in the evenings, as well as the restlessness and anxiety associated with ADHD. Children with ADHD can benefit from avoiding sugar and caffeine, which might exacerbate both behavior symptoms of ADHD and sleep problems.

Diet and Supplements have been proven to assist sleep and ADHD. Best to gain medical advice around this topic of which I will write more on later as their is a lot to cover off. However, this is an area that should not be ignored for example Omega 3s have been shown to boost sleep quality, make falling asleep easier, and increase melatonin. In one study, children who received supplemental omega 3s slept an average of an additional hour a night, and woke up much less frequently throughout the night. omega 3s may help improve many of the symptoms of ADHD, including:

Inattention

Impulsiveness

Restlessness

Aggression

Difficulty completing tasks

Trouble with cooperation

Reduced academic performance

 

I hope this article has helped you consider some alternatives in the battle to fight ADHD. It is best to seek professional support and advice when trying to deal with such conditions and just because you read something, like this blog, you should never just stop your medication.