BY HUMAIRA HASAN

INTRODUCTION

Does sleep have the potential and power to exacerbate the symptoms of ADHD? 

ADHD or Attention Deficit Hyperactivity Disorder is the most commonly diagnosed psychological disorder occurring in children. (“What is ADHD?”, n.d.) As the name suggests, ADHD impairs daily functioning bearing specific characteristics as mentioned by the DSM (Diagnostic Statistical Manual for mental health disorders). According to the DSM-5, the following symptoms are commonly found in individuals diagnosed with ADHD: Inattentiveness( failing to remember important activities, decreased attention span, disinclined to begin important tasks, etc), Hyperactivity( Overtalkative, restlessness that is difficult to control, squirming), Impulsivity( struggle with waiting, interruptions during conversations or activities), etc. Sleep is essential for proper functioning and boosting cognitive performance and reducing the rate of cognitive decline that is age-related. (Suni & Suni, 2023) Various studies have proven that sleep disturbances or disturbed sleep patterns can contribute to the worsening of ADHD symptoms. 

WHY IS SLEEP IMPORTANT?

Sleep problems are linked to lower academic performance. (Larsson et al., 2022) Recent studies highlight a link between sleep microstructures (sleep stage transitions, arousals during sleep cycle, etc) and brain development. (Mason et al., 2021) A study by Walker et al. explored how sleep affects learning by dividing participants into two groups: wake-control and sleep-experimental. The wake-control group practiced a motor task at 10 AM and was tested 12 hours later. The sleep group learned the task at 10 PM, slept, and was tested the next morning. The sleep group showed greater performance improvement, highlighting the role of sleep in enhancing various cognitive processes like problem-solving, language learning, and motor skills. (Walker et al., 2002) (Ellenbogen, 2005)

Lack of sleep also affects emotional functioning, although the impact differs across various aspects. This highlights the crucial role of sleep in maintaining emotional well-being. (Tomaso et al., 2020) Several systematic reviews have shown how sleep deprivation and disturbances are common in children with ADHD, often worsening symptoms such as inattention, hyperactivity, and impulsivity. Improving sleep patterns has been found to ease these symptoms, while sleep restriction tends to intensify them, indicating that sleep problems may contribute to the severity of ADHD symptoms. (Gruber, 2012)  

General Statistics on Sleep Disturbances

Individuals with ADHD have a significantly higher risk of being diagnosed with sleep disorders and prescribed sleep medications across all age groups, with the highest relative risk observed in adolescents compared to those without ADHD. (Ahlberg et al., 2023) Females with ADHD have a significantly higher risk of developing any sleep disorder compared to males, with an odds ratio of 11.21 relative to those without ADHD. (Ahlberg et al., 2023) Research suggests that among children with ADHD, up to 70% experience sleep problems, compared to 20-30% of their healthy peers. (Larsson et al., 2022) (Quach et al., 2012)

TYPES OF SLEEP DISTURBANCES IN ADHD

Insomnia

A commonly occurring sleep disorder where individuals with insomnia are likely to struggle with falling asleep or getting quality sleep. It might cause some individuals to wake up before the completion of their sleep cycle followed by them being unable to fall back asleep. (Mayo Clinic, n.d.)

Research shows that the prevalence of insomnia is 66.8% in adults with ADHD, compared to 28.8% in the general population. (Brevik et al., 2017) People with other comorbid conditions, such as mood disorders (42%), anxiety disorders (26.8%), personality disorders (39.3%), and substance use disorders (11.6%), are more likely to experience insomnia, with these conditions contributing to a higher prevalence of sleep problems. Therefore, insomnia is very common in adults with ADHD and is closely linked to more severe ADHD symptoms, as well as a higher number of psychiatric and medical comorbidities. (Fadeuilhe et al., 2021)

A recent study highlights that treating insomnia in adults with ADHD may play a crucial role in improving the outcomes of ADHD treatments by reducing the severity of symptoms. (Fadeuilhe et al., 2021)

Sleep Apnea

Sleep apnea is a sleep disorder where the person inflicted by it experiences pauses in breathing during sleep disrupting restful sleep. (Cleveland Clinic, 2024) Sleep-disordered breathing, including conditions like obstructive sleep apnea (OSA), affects an estimated 25% to 57% of children and adolescents with ADHD. (Sedky, Bennett, & Carvalho, 2013)  

Very few pieces of literature exist that explore the relationship between ADHD and Sleep Apnea. A Thai study found that children with ADHD are more likely to have a high risk of obstructive sleep apnea (OSA), which seriously affects their quality of life. The study also showed a strong connection between high-risk OSA and obesity in these children. (Prajsuchanai et al., 2022) Another study suggested that ADHD is more common in people with obstructive sleep apnea (OSA), but it does not show a link between the severity of OSA and the symptoms of ADHD.  (Hesselbacher et al., 2019) Research also suggests that treatment of sleep apnea can alleviate symptoms of ADHD. (Youssef, Ege, Angly, Strauss, & Marx, 2011)

IMPACT OF SLEEP DISTURBANCES

Cognitive and Attention Impairments

Social Cognition

Social cognition is how a person responds to or interprets social cues. A recent study found that sleep disturbances significantly affect social cognitive skills, as evidenced by the “Facial Pattern Recognition Test” (FPRT), but did not have a significant impact on the “Reading the Mind in the Eyes Test” (RMET). This suggests that sleep may influence certain aspects of social cognition, but not all. (Sedky, Bennett, & Carvalho, 2013)

Inhibition Performance 

Sleep problems affect inhibition performance in children, regardless of whether they have an ADHD diagnosis, and this impact goes beyond the severity of ADHD symptoms. This highlights concerns about the overdiagnosis of ADHD, as behavioral symptoms of sleep disorders may be mistaken for ADHD. (Şahin, Hoşoğlu, & Önal, 2021)

Attention

Children with ADHD often experience sleep deprivation and disturbances, which can make symptoms like inattention worse. (Gruber, 2012)

Behavioral Impairments

It has been suggested by some studies that emotional impulsiveness could be even considered as a key feature of ADHD that is considered in the diagnostic criteria.(Surman et al., 2011)

Research indicates that children and adolescents with ADHD exhibit higher levels of deficient emotional self-regulation (DESR) compared to healthy controls. Additionally, those with ADHD who are not undergoing pharmacological treatment show greater DESR than those receiving treatment.

REFERENCES

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