Attention-deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed neurodevelopmental disorders, affecting approximately 3-5% of children.1
In many cases it continues into adulthood.2 It is four times more common in males than in females, with a prevalence of 3.6% and 0.9%, respectively, in children aged between 5-15 years old.3
The symptoms of ADHD can be categorised into different types of behavioural problems:2
Symptoms like these can cause problems in a child’s life. For example, underachievement at school or poorer social interactions.2 Although presentation can be highly variable, typically, the core behaviours associated with ADHD emerge before the age of 7, with some researchers suggesting that the cut off for presentation of symptoms is 12 years.1 Over 65% of those with ADHD also have one or more comorbidity, including anxiety disorder, depression, autistic spectrum disorder, dyspraxia, epilepsy or sleep problems.2,3
Sleep disorders are particularly common in children with ADHD.1 These include problems falling or staying asleep meaning they experience shorter sleep time, which can impact the child’s mood, concentration, behaviour and physical health.1 It has been estimated that approximately 73% of children with ADHD experience insomnia.1
Researchers have identified associations between ADHD and a range of sleeping disorders, such as insomnia (characterised by difficulty falling or staying asleep).1 Prolonged sleep onset, delayed bedtime and frequent night awakenings are frequently seen in those with ADHD in particular.1
Unhealthy sleep practices and a lack of routines (‘poor sleep hygiene’), especially at bedtime, have been shown to be more common in individuals with ADHD and to have a significant negative impact on sleep initiation.1
‘Sleep hygiene’ is the term used to describe healthy habits that you can practice during the day to help you get a good night’s sleep. For example, sticking to a set pattern each night, and keeping the bedroom quiet, dark and at a comfortable temperature.4
The relationship between sleep and ADHD is complex and can be a vicious cycle; ADHD can lead to sleep problems and a lack of sleep can make the symptoms of ADHD worse. In a recent survey of patients and parents on the impact of ADHD and sleep, 8 out of 10 respondents reported a positive impact on ADHD behaviours or symptoms after a good night’s sleep.5
The most frequently reported sleep issues were difficulty falling asleep, feeling too alert at bedtime, feeling overtired in the morning, and having fewer hours of sleep each night than recommended.6 This delayed sleep onset or “night owl” behaviour can impede on time-sensitive activities such as school or work or leave patients lacking the duration of sleep that they really need.
Upon a child’s first consultation with a GP they will discuss symptoms, social and academic life and family history. If a GP suspects a child has ADHD they will refer them to a specialist for a formal assessment. This will normally be a CAMHS nurse, psychiatrist or a paediatrician depending on guidelines in the local area.2
Diagnoses are made by qualified healthcare professionals with training and expertise in ADHD (such as a Child and Adolescent Mental Health Services Nurse (CAMHS), Paediatrician, Psychiatrist or Clinical Psychologist). Assessments often involve taking a detailed developmental and psychosocial history, observation of the child and the use of standardised questionnaires, sometimes psychological or computer-based tests, and, wherever possible, consideration of the child/young person’s view of their symptoms and the impact of these on their daily life.
Sleep is also considered at the time of an ADHD diagnosis as lack of sleep can make ADHD symptoms worse. Because symptoms can look so similar, it’s important for clinicians to consider sleep disorders when diagnosing ADHD.7
There is a significant community services backlog within the UK. NHS England and NHS Improvement (NHSEI) data from January 2022 estimates that over 900,000 children and adults are waiting for services as part of a community services care backlog.8 For community children and young people’s services, the most significant waits are in neuro-developmental assessments for those with suspected autism and attention deficit hyperactive disorder.9
The current NHS pathway can mean long waits to find effective solutions for sleep problems and the pathway involves several stages.10 ADHD services across the nation have seen a steady increase in demand over recent decades.
Child and Adolescent Mental Health Services (CAMHS) have significant waiting lists meaning that children suspected of having ADHD often have to wait long periods of time before seeing psychiatrists. Between April 2020 and March 2021 CAMHS saw 420,000 children and half of these children waited longer than four weeks while a fifth had to wait for longer than 12 weeks.10
The demand for Child and Adolescent Mental Health Services from school-age children has undergone an “explosion” in the last three years, soaring by 76% since 2019.11
If one is trying to treat sleep issues, the solution usually involves a focus on sleep hygiene, which considers each of the factors that help to initiate and maintain a healthy sleeping pattern. Sleep hygiene recommendations have evolved with increased understanding of other behavioural factors that improve or worsen sleep.12
Recommendations for non-medical strategies and homely remedies to improve sleep include:13
If sleep hygiene strategies have proven ineffective, then it is recommended that you seek further advice from your GP. There are medications available to treat insomnia but these are likely to be prescribed for short-term use only.
For children with a diagnosis of ADHD, a lack of sleep can lead to an increase in symptoms of ADHD and impact on their ability to think and reason13. Lack of sleep can worsen ADHD symptoms, cause you to be more susceptible to illness and increase stress and anxiety.
Narenza Dhanasar, Nurse Prescriber in NHS Child and Adolescent Mental Health Services at East London NHS Foundation Trust comments: “Since COVID, we saw a 33% increase of people coming in to see us. The first approach we take for children and young people with sleep disorders and ADHD are non-drug techniques such as good ‘sleep hygiene’ which can include having a fixed bedtime, a relaxing routine and reducing screen time.
“A conducive sleep environment should be a darkened quiet room, a good temperature, comfortable bedding and no negative associations. Try to stick to the same bedtime routines with quiet activities.”
In summary, sleep problems in ADHD are common. Sleep is a vital component to good health, wellbeing and overall quality of life. Sleep can be seriously affected by the symptomology of ADHD and vice versa but there are ways that we can combat this and improve the quality of sleep overall.
