Sleep problems can mimic or worsen symptoms of attention-deficit/hyperactivity disorder (ADHD)1
At least 50% of children and adults with ADHD report substantial sleep problems, including delayed sleep phase syndrome and insomnia, leading to disrupted or insufficient sleep. Adults with ADHD have been shown to have high prevalence of restless leg syndrome (30%) and obstructive sleep apnea (20%–30%).1
Screening for sleep disturbances should be included during initial evaluation of ADHD
Validated tools such as the Sleep Disturbance Scale for Children, the Insomnia Severity Index, the Epworth Sleepiness Scale, the STOP-Bang Questionnaire for obstructive sleep apnea, and the single-question screen for restless leg syndrome can be used, depending on the patient’s sleep-related problems.2 Referral to a sleep medicine specialist is advised if a sleep disorder is suspected, but ADHD treatment should not be delayed.
Psychiatric comorbidities associated with ADHD contribute to sleep disturbances
Depression, anxiety disorders, and substance use disorders should be identified and treated concurrently with ADHD.1 Alcohol and cannabis can disrupt normal sleep architecture and contribute to nonrestorative sleep.3
Melatonin and light therapy are supported by international recommendations4
For delayed sleep-phase syndrome, immediate-release melatonin (0.5 mg) — taken 3 hours before habitual sleep onset and advanced by 1 hour earlier each week for 3–4 weeks — can improve circadian rhythm and ADHD symptoms. Thirty minutes of morning bright light therapy or exposure, gradual wake-time advancement, and limiting light exposure within 3 hours of bedtime may provide additional benefit. For primary insomnia, when optimizing sleep hygiene measures have been insufficient, 2–6 mg of immediate-release melatonin at bedtime may help, although evidence is limited.
Long-acting stimulants remain the first-line treatment for ADHD in patients with sleep disturbances5
If insomnia persists beyond initial adjustment to ADHD treatment, clinicians should consider dose adjustment before switching to shorter-acting formulations. Long-acting stimulants may prevent rebound symptoms and improve sleep.5 Clonidine, starting at 0.1 mg, taken 1 hour before bedtime can alleviate stimulant-related insomnia.6 Lastly, clinicians should consider nonstimulants and avoid sedative–hypnotics unless indicated. The effectiveness of dual orexin receptor antagonists in ADHD remains under investigation.
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Footnotes
Competing interests: Ayan Dey reports funding from the Temerty Faculty of Medicine at the University of Toronto. Thuy Linh Do reports advisory board participation with Elvium Life Sciences. Doron Almagor reports honoraria from Elvium Life Sciences, Janssen, Otsuka, Takeda, Kye Pharma, Biron, Knight Therapeutics, Pearson, and the Canadian ADHD Resource Alliance (CADDRA). Dr. Almagor is chair of the CADDRA Advisory Council. Atul Khullar reports honoraria from Abbvie, Bausch, Takeda, Elvium, Lundbeck, Otsuka, Eisai, and Idorsia. No other competing interests were declared.
This article has been peer reviewed.
References
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