THOMAS E. BROWNa AND WILLIAM J. MCMULLEN, JR.b
aClinic for Attention and Related Disorders, Yale University School of Medicine,
New Haven, Connecticut 06519, USA
bCalifornia Pacific Epilepsy Center, San Francisco, California 94115, USA
ABSTRACT: Many children, adolescents, and adults with Attention Deficit Disorders
report chronic difficulties with falling asleep, awakening and/or maintaining
adequate daytime alertness. These problems may be due to a variety of
factors, including environment, lifestyle, and psychiatric comorbidities.
Impairments in sleep/arousal may also be related more directly to the underlying
pathophysiology of ADD. This chapter describes clinical manifestations
of sleep/arousal problems often associated with ADD and reviews behavioral
and medication options for treatment.
KEYWORDS: ADD; ADHD; Sleep disturbances; Sleep disorders.
"Given the above, it is not surprising that a fair degree of overlap exists between
these two disorders, though the rates of sleep disturbance in children with attention
deficit/hyperactivity disorder (ADHD) is much higher than one would expect even
given the high prevalence of sleep problems in the general school-age cohort. Ball
9 have reported that more than 50% of children with ADHD have difficulty falling
asleep. Stein10 reported that moderate to severe sleep problems occurred at least
once a week in nearly 20% of children with ADHD compared to 13.3% of psychiatric
controls, and 6.2% of pediatric controls."
Adolescent and adult patients too may suffer from inadequate wind-down routines
to prepare for sleep or from ruminative worry, or from evening family conflicts.
Some report that they remain awake primarily due to becoming distracted by activity
that is inconsistent with sleep (reading, surfing the internet, socializing). For some it
is actually easier to concentrate in the evening when background environmental
stimulation may be reduced relative to the targeted activity. Attempts at daytime
attention to target material may be thwarted by frequent interruption by distracting
background activity, while evening activity is both more stimulating than sleep (e.g.,
it is the distractor), and less often interrupted by competing stimuli. These patients
sometimes are able to fall asleep when they so engage, but establish behavior patterns
over time that preclude adequate sleep. Others may attempt to self medicate
sleep disturbance by using over the counter sleep aids or alcohol. These attempts are
often less than effective because they may not work, they may contribute to exacerbation
of attention problems, and they may alter the quality of sleep attained.25,26
Attention to proper sleep hygiene (discussed later in this chapter) and avoidance of
potentially maladaptive behavior patterns may offer some relief from problems falling
asleep in these patients.
Other patients with ADD report a lifelong pattern of consistently becoming more
alert in the evening, feeling more energized and more ready to engage in work or
social activities after dark than in the daytime. These individuals often describe a
pattern of difficulty falling asleep until very late at night; as preschoolers they may
not have been able to settle and fall into sleep until 10 or 11 P.M. most nights. As
adolescents or adults they may chronically feel restless and unable to sleep until 2 or
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3 A.M. or later. Attention to proper sleep hygiene may help these patients, but they
may continue to experience delayed onset of sleep due to internal restlessness, even
in the absence of maladaptive behavioral patterns.
At present, it is not clear how these problems in getting to sleep are related to the
pathophysiology of ADD. Dahl has emphasized that there is a strong relationship
between the control of sleep and the regulation of mood and behavior in waking
states, yet he notes that “Our current knowledge of these complex relationships
between sleep, development and psychiatric well-being is at an embryonic state.”17
These issues are discussed later in this chapter