As an Occupational Therapist, I am constantly learning and seeking out opportunities to grow. Yesterday I took a course through the Centre for ADHD Awareness Canada , in which we talked about Sleep and ADHD. The Centre for ADHD Awareness Canada (CADDAC) is a national, not for profit, organization that provides leadership and support dedicated to improving the lives of those living with ADHD through ADHD awareness, education and advocacy. Every once in a while, they will offer some free webinars for the general public, and I try to attend as many as I can. As a new occupational therapist, it is helpful for me to collect as much knowledge and information as I can in preparation for my future clients. I thought it might be helpful to write my reflection on this course and share some of the information.
Please note – This information is general and by no means diagnostic. Individuals with ADHD may share symptoms and struggles, but their experiences can all look very different depending on many different factors. If you or your child has ADHD and you are looking for answers, please connect with a health professional for individualized care.
According to the webinar, over 78% of children with ADHD have a sleep disorder – sleep disorders in this conversation include a variety of things including:
- Behavioural insomnia of childhood (“I don’t want to go to bed you can’t make me”)
- Anxiety related insomnia (being anxious in anticipation of sleep)
- Excessive daytime sleepiness
- Sleep onset latency, waking, total sleep time and efficiency of sleep
- Night to night variability (may be sleeping early one night, late another, waking up early one day and sleeping in the next day)
- Circadian Rhythm sleep disorders
- Obstructive sleep apnea
- Restless legs syndrome
- Periodic limb movement disorder
- Night terrors
Circadian Rhythm Sleep Wake Disorder (CRSWD) seems like a pretty intense title, but it is probably something that is quite relatable to individuals with ADHD. This is basically the misalignment of the sleep wake cycle. All of us have a certain sleep wake cycle which refers to our 24 hour sleep pattern, which usually consists of around 16 hours of daytime wakefulness and 8 hours of night time sleep. This is something that is studied quite a bit in terms of managing sleep, especially around shift work. Some people have their sleep wake cycles set to what society sees as “normal”, where they wake up in the morning around 7 or 8am, and go to sleep in the evening between 10-12am. Individuals that work night shifts may have their whole sleep schedule flipped around where they sleep all day and work at night, but that is what their bodies are used to and it’s a regular practice.
Sleep Wake disorder (CRSWD) in individuals with ADHD is a misalignment of the sleep wake cycle, in which they may experience night to night variability in their sleep schedules. Many teens already will experience this, where they stay up late at night and sleep in on the weekends and have to readjust their schedule for the week when they need to wake up to make it to school on time. Teens with ADHD may also experience a delay in the Dim light melatonin onset, which is the chemical that is released in our bodies to help us fall asleep. So while falling asleep may be problematic for the average individual for a variety of reasons including genetics, caffeine consumption, participation in evening activities and late night screen time, it can be exacerbated for individuals with ADHD.
Sleep in Children
Just like healthy eating and physical activity are important for children, sleep plays an active role in healthy development. Sleep affects brain maturation, information processing, memory, learning, executive function, health, and overall quality of life. In extension, lack of sleep can affect the caregiver’s tiredness and wellbeing, which can affect family dynamics.
However, sleep is often NOT discussed with a family physician, and in a study done by Owens (2001), only 50% of pediatricians reported being confident about sleep problems. If your child or teen is unable to sleep well, about half of average children and teens also experience this, so don’t feel hesitant about bringing this up with your doctor (or seeking out an occupational therapist if you can). It is also important to note that in this presentation, it was brought up that often children with ADHD don’t need to sleep as much as the average child, but you can see lack of sleep in their behaviour. Children might have a hard time staying awake or focusing during the day, but they also may be hyperactive – when we say that someone is overtired and that’s why they’re hyper… this is one situation this saying applies to. Your child might get to bed time and be running, jumping, playing trick etc, and this might be their way of telling you they’re tired.
Sleep in teens/young adults can also be a challenge, but now on top of the childhood challenges, they also have contextual challenges of wanting to stay up late to text friends, play video games and relax after a day full of school work and completing homework. The average teen experiences sleep problems while sleeping late and having to adjust to wake up early for school, and ADHD can increase this.
Sleep Training for ADHD
Parents are CONSTANTLY flooded with opposing and aggressive advice about how to “properly” raise their children. Your child is sleeping too little or too much, getting too much screen time, or eating the wrong foods. The biggest issue with all these advice points is that they do not consider the situation the family is in. And the most important thing about sleep interventions is that they are FAMILY BASED.
“Children “need” 9 hours of sleep” – the average child with ADHD is sleeping 6.5 hours
“Going to bed earlier increases sleep” – putting your child to bed earlier might have them in bed, but it might still take them a long time to fall asleep. Longer time in bed does not necessarily equal longer time asleep
“My child can’t be tired because they are so hyper” – an overtired child can become hyper!
As an occupational therapist, I could read every single peer reviewed article, every mom blog and recommendation from other health professionals, but I will always need to meet with the family before I make a recommendation. As with many other life changes that occupational therapists can help with, sleep interventions can be intensive and need to be individualized to the person and the people they live with. If the parents or caregivers are working certain hours, are struggling with their own sleep schedules, or don’t have the space for certain sleep training methods, no matter how much information they’re given, it just won’t work. It is also important to recognize that the functional outcome of the child is related to treatment of sleep AND their ADHD.
ADHD impairs sleep and if a child is not getting assistance for their ADHD in the daytime, it will probably be affecting them at night too. Sleep in an attention demanding activity, even though for many people it comes easily and is relaxing. Think about getting to sleep on a night that you are over excited, over caffinated, or over stressed. As someone with ADHD, lying in bed trying to wait for sleep can be boring, and you may have a lot of racing thoughts keeping you up. Counting sheep is not the easiest to sit still and do, and often times the phone might come out to scroll through and pass the time, or you might get fixated on something and have an even harder time falling asleep.
So what skills can we look at to help sleep come a bit more easily?
Sleep hygiene is a general term that often can look extremely different for each individual, which is why I recommend seeking out an occupational therapist or other health professional if there is a lot of struggle
Stick to a sleep schedule, even on weekends – consistency is key, adjusting back and forth to late nights and regular nights can be hard for the body. That being said, I recognize that realistically as a teen or adult this can be hard to keep. Start your child off with a similar bedtime every night (of course some nights this can’t happen)… as they age, they will have the routine of same bedtime each night and hopefully will be able to use strategies to readjust.
Other tips for Sleep Hygiene practices
- Practice a relaxing bedtime ritual (this could be a warm bath, story time, lighting a candle, quiet time playing with toys… whatever calms your child or you down)
- Exercise/move your body daily
- Check if your bedroom is dark enough at night, is quiet enough, and has a decent temperature at night
- Give yourself time before bed without any electronics/screens
^These tips are very vague, but can be individualized for each person to help their mind and body calm down for bed. Screen time and high energy activities before bed can make the body take longer to wind down for sleep, so creating bedtime rituals that make you sleepy can help! An occupational therapist may be able to work closely with you to put together a sleep hygiene routine and a sleep tracker to help trial different strategies.
Another topic that was mentioned in this webinar was the use of melatonin. Personally, I have used melatonin for the last two years to help fall asleep when my anxiety is high. I am an individual who is prone to having intense dreams, so I have experienced some heightened dreams with them occasionally, but otherwise I have found it helpful and not harmful. However, professionally, I don’t recommend medications or natural supplements to my clients and always recommend you chat with a medical professional with knowledge about these things before starting using them. I will however summarize what they shared in the webinar as it was presented publicly.
Melatonin is a hormone that regulates sleep, and is often used to decrease the time it takes to fall asleep and to help with the duration of sleep. Melatonin is not addictive, and it’s effects don’t wear off over time, so you can take it as much as you need. The webinar I attended shared that many children do take melatonin to help with sleep and that it is safe.
Many people with ADHD, children, teens and adults alike, experience challenges with their sleep. As ADHD is a 24 hour disorder, meaning it can affect you day and night, you must consider treatment of sleep as part of treatment of ADHD to see improvement in quality of life.
If you or your child are experiencing challenges with sleep and any of the words above connected with you, speak to your doctor about sleep, or seek out an Occupational therapist for assistance with sleep hygiene and sleep routines.
Feel free to share your experiences in the comments below to connect with myself or others!