Sleep problems should be treated with special priority in ADHD, as sleep problems and ADHD form a vicious circle: Sleep problems exacerbate ADHD symptoms, while ADHD symptoms can in turn cause sleep problems.
- Sleep reduces the stress hormone cortisol. in one study, sleeping 1 hour longer reduced the cortisol awakening response by 21 %.
- Sleep deprivation increased the stress response of the HPA axis. The cortisol response to the TSST appears to be increased during sleep deprivation.
- Waking up more frequently the previous night worsened math skills and (somewhat) working memory, and this was independent of ADHD.
- Lack of sleep correlates with reduced mental health in children
- Emotion regulation
- Cognition
- Attention
- A study in which participants were allowed to sleep for only 6 hours for 2 weeks found a decline in sustained attention and working memory equivalent to that of two nights of complete sleep deprivation. In contrast to the participants who were completely sleep deprived for 2 nights, the participants with 2 weeks of 6 hours of sleep were unaware of their cognitive deficits. Another study reported the same results after 5-7 days of sleep restriction.
The cognitive deficits, especially inattention, required more days of normal sleep to fully recover than the duration of the initial sleep restriction, i.e. over 2 weeks.
Several other studies agree with these results.
- Sleep deprivation causes increased omission errors, commission errors, reaction time, and reaction time variability in both persons with ADHD and non-affected persons. However, ADHD produced additional omission and commission errors and greater reaction time variability. Furthermore, sleep deprivation in ADHD particularly impaired the recognition of emotional facial expressions.
- Problems falling asleep and sleeping through the night are not an aggravating cause of executive problems, but daytime sleepiness is.
Nevertheless, sleep problems are not the (sole) cause of ADHD. However, sleep problems do exacerbate existing ADHD symptoms. Sleep training has a positive effect on ADHD symptoms.
Further information on sleep problems can be found here:
1. Measures to improve sleep (sleep hygiene)¶
People with ADHD have poorer sleep hygiene than people without ADHD and poorer sleep hygiene leads to increased sleep problems with ADHD. However, poor sleep hygiene is neither the cause or ADHD, nor would its correction be suitable as a monotherapy for ADHD.
A meta-analysis of 15 studies found sleep hygiene may be helpful for children with ADHD in 14 studies.
1.1. Increase sleep pressure¶
- Getting up after lying awake in bed for more than 40 minutes
In the case of ADHD, the usual 20-minute period should be extended, as people with ADHD typically need longer periods to fall asleep than people without ADHD
- Naps / power naps for a maximum of 30 minutes and before 2 pm
- Slept badly? Endure tiredness to be able to sleep earlier and better in the evening.
1.2. Train a regular sleep rhythm¶
- Adhere to regular times for getting up and going to bed
- Still only go to bed when tired, regularly get up at the same time in the morning
- So don’t try to combat sleep problems by sleeping longer that night, but instead maintain your rhythm
- Get through tiredness and sleep well the next evening with a newfound weight in bed
- Regular sports, up to three hours before bedtime at the latest
1.3. Sleep phase shift (chronotherapy)¶
People with ADHD-HI often have an individually deviating day-night profile that is shifted far back so that they become tired later and wake up later. The sleep rhythm is shifted back by up to several hours. This is attributed, among other things, to an altered melatonin balance, whereby melatonin, the body’s own “sleep signal”, is either not released sufficiently or is released at the wrong time (too late at night).
1.3.1. Shift the daily rhythm to the light hours¶
- Early start to the day
- Early sports in the sunlight
- Do not wear sunglasses
*
- One person with ADHD reported considerable improvement in his problems falling asleep and staying asleep by simply exercising outside for 20 to 30 minutes after sunrise. However, this person with ADHD was an early riser type (lark).
- Finish the day’s work around 5 to 6 p.m.((Wolf, Calabrese (2020): Stress medicine & stress psychology; page 206)
- End the day afterwards
- Avoid stress in the evening
- No evening sport
1.3.2. Light therapy¶
A treatment with bright bluish light early in the morning, especially during the darker seasons (in addition to the recommended avoidance of bluish light from 7 pm) can help to support an early circadian rhythm.
They have proven to be effective for treatment:
- Lamps with 7,000 to 10,000 lux
- At a distance of 20 to 35 cm.
- Protective screen and UV filter are required
- Lighting from above at an angle so that there is no glare
Light therapy that succeeds in bringing sleep forward is likely to improve ADHD symptoms.
1.3.3. Melatonin treatment¶
Targeted treatment in the evening with melatonin. See above at ⇒ Delayed increase in melatonin in the evening And below at ⇒ Melatonergic antidepressants and at ⇒ Melatonin in ADHD in the section ⇒ Suitable medication for ADHD.
As an alternative to treatment, it is also possible to integrate the shifted sleep rhythm into everyday life by regularly going to bed later and getting up later. As always, a consistent rhythm is required to ensure a sufficiently long sleep. However, this may only be possible for a small number of people in a socially acceptable way and does not solve the basic problem that the shifted circadian rhythm can have a negative impact on the regulatory ability of the HPA axis.
1.3.4. Neurofeedback - SMR training¶
SMR neurofeedback training (frequency band training 12 - 15 Hz) is intended to help reduce the circadian sleep phase shift.
SMR training
- Improved the frequency of sleep spindles
- Reduced the delay in falling asleep
- Increased the total sleep time
1.3.5. Light hygiene - avoid melatonin suppression¶
- Avoid bright light before going to bed or when getting up at night. Dimmed yellowish/reddish light avoids melatonin suppression, i.e. promotes melatonin secretion.
- Warm light has a color temperature of 2700 Kelvin, preferably even lower.
Most LED light sources retain their color temperature when dimmed; halogen and incandescent bulbs lose color temperature when dimmed and therefore emit an even warmer light with fewer blue components.
- Bluish and bright light has a direct effect on the melatonin balance and signals to the body: it’s morning, wake up, get active.
3000 Kelvin is already perceived as the color of daylight in lamps. Optimal daylight has 5000 Kelvin.
Fluorescent tubes produce cold, bluish, bright light: good in the morning, unfavorable in the evening.
- Do not use bluish or bright light in the evening
- Bright bluish light suppresses melatonin
- Avoid computers and smartphones 1 to 2 hours before bedtime
- Set the screen color scheme (only for evenings!) to reddish dark.
For this reason, Apple introduced its own color schemes for its smartphones in 2016, which provide a more reddish light in the evening; Windows 10 has made this possible since October 2017.
This can be set up on any computer or television.
- There are so-called computer glasses that filter out the bluish light components. These help to prevent the suppression of melatonin production by blue light components when working on a screen in the evening, watching TV or reading.
- Working light bright, white, bluish during the day
- Blue-enriched white light in the workplace during the day improves alertness, performance and sleep quality by suppressing melatonin.
- The change from bluish bright light during the day to reddish darker light in the evening seems relevant.
- In one study, people who were implanted with lenses that filter out bluish light, i.e. who constantly received the same level of blue light, showed no improvement, but also no deterioration in sleep.
- At least 30 minutes of bright daylight outdoors every day
- According to the basic principle that the alternation of bright blue light in the morning/midday and less bright reddish light in the evening stimulates sleep-promoting melatonin production, a daily walk around midday in bright light can be helpful - especially in the darker winter months. Even in overcast weather, the brightness of the light outdoors is far greater than in brightly lit indoor spaces.
- In addition, bright daylight (preferably direct sunlight around midday) helps with vitamin D3 production. Vitamin D3 is only formed from a threshold value of 18 mj/cm² light exposure. Even the most transparent types of glass reduce the light energy below this value, so that even on the sunniest days, the threshold value of light energy above which D-3 vitamin production begins is not reached indoors. In Germany, sufficient D-3 production is achieved outdoors in June at midday within approx. 15 minutes, in September within approx. 30 minutes. In December, even under a clear sky, this is not even achieved if you spend the whole day outdoors - precisely because the solar radiation does not exceed the required threshold value. While maximum melatonin suppression during the day (correlating with subjective alertness) already reaches its maximum at a light level of 1000 lux and 50% of the maximum at 100 lux, the optimum circadian rhythm influence by bluish light during the day is only reached at 9100 lux, whereby the 50% value is also already reached at 100 lux. In contrast to D3 formation, melatonin suppression or circadian effectiveness is not prevented indoors, but is halved. It should therefore be possible to compensate for this with bright, bluish working light.
10.000 lux is roughly equivalent to a 300-watt halogen lamp shining on a tabletop 45 cm away. This is already well above the level of normal workplace lighting.
- Average light intensity in lux:
- Parking lot - 20-25 lux
- Living area - 50 to 200 lux
- Public spaces - 200 lux
- Desk - 500 lux (target)
- Sunlight in summer - up to 50,000 lux
- Color temperature in Kelvin:
- Daylight: from 3000 Kelvin and more. Optimal daylight lamps have up to 5000 Kelvin (the higher, the bluer/cooler)
- Evening light: up to 2700 Kelvin and less (the less, the more yellowish/warm).
1.4. Regular sleeping times¶
- Regular and fixed bedtimes,
1.5. Bed use¶
- Use the bed exclusively for sleeping
- Never eat, read, watch TV or work in bed
- If you don’t have sleeping problems, you can do it. If you have sleeping problems, you should definitely avoid it.
- At the right age, sex is a good sleeping aid - with or without a partner
1.6. Quiet activity from 1.5 hours before sleep; bedtime rituals¶
- The last 1.5 hours before going to bed should be spent on relaxing activities: What is relaxing is to be determined individually for each person
- Find your own bedtime ritual
the habit of a ritual helps to pave the way for ritualized action after approx. 6 weeks
Examples of suitable sleep rituals:
- Walk before going to bed
- Read fiction (not non-fiction/technical books that relate to a personal passion)
- Listen to audiobooks (no non-fiction/technical books that relate to a personal passion)
- Drink warm herbal tea
- Warm milk (possibly with honey) before going to bed
- Listen to binaural theta music (see below at ⇒ Binaural theta wave music
1.7. Sleeping environment¶
- Alarm clock / clock
- Alarm clock out of sight
- Do not look at the alarm clock at night
- Cell phone
- Cell phone is not in the room
- Cell phone does not serve as an alarm clock
Otherwise, when you look at the clock, all the messages in between would be displayed, just like when you wake up in the morning. There is barely anything more harmful for relaxation and switching off.
- Dinner
- Eat your evening meal on time
- Keep dinner light
- Choice of bedroom
- Quiet and secluded room
- Not facing the street or other sources of disturbance
- If not possible in this apartment: move!
A quiet bedroom is absolutely essential for ADHD!
- Preferably not used as a dining/TV/study room
- If sleeping next to your partner is difficult, use a separate bedroom from your partner where you can retreat after a good night’s cuddle
The partner will be able to weigh up the increase in quality of life during the day against the separate night’s sleep
- Choice of bed
- If necessary, separate mattresses / slats for sleeping companions
- Bed wide enough to sleep undisturbed
1.8. Eliminate external sources of interference¶
With ADHD, even the smallest disorders that do not affect other people at all can lead to massive sleep problems due to the wide-open stimulus filter. Observe your own standards and don’t fall into the “normal” trap. ADHD involves increased sensitivity to some stimuli.
- Temperature / ventilation
- Be aware of the particular temperature sensitivity of people with ADHD
- Allow sufficient oxygen
- Light
- Masking LEDs from electrical appliances
- Close roller shutter
- Lightproof interior curtains
- Consider sleeping goggles
- Noises
-
ADHD is usually accompanied by hyperarousal
- Lack of filtering
- Internal stimuli
- External stimuli
- At night, acoustic disturbances in particular lead to a spontaneous increase in noradrenaline
- Noradrenaline is switched off during sleep
- Noradrenaline surge is a wake-up signal
- Earplugs help a lot
We know quite a few people with ADHD who were able to sleep through the night without interruption for the first time after getting used to earplugs
- Settling-in period of a few days
- Try out different types of earplugs
- Silicone earplugs
- Insulate very well
- Grease the skin lightly before first use, otherwise they are difficult to remove from the ear. More problem-free after 2nd use
- Adapt well to the shape of the ear
- Foam earplugs
- Hold in your ear for 10 seconds
- Cotton wax earplugs
- Customized earplugs
- Precisely fitting shape may close even tighter than silicone earplugs
- You can’t feel it when you lie on it
1.9. Dealing with circles of thought¶
Many people with ADHD are familiar with the phenomenon of having a head that won’t stop churning thoughts - and the sleep-impeding effect of this symptom. There are a few ways to counteract this.
- Get up again after 40 minutes. Leave the bed and bedroom.
- Turn on dimmed light, but no bright light: candle (fire-safe!!!) or very dimmed and warm (reddish) light with little blue components.
- If you can’t get a particular topic out of your head: write all the arguments for/against on a sheet of paper or in an Excel spreadsheet. In most cases, you will be amazed to find that you have barely more than half a sheet of A4 paper.
Important: note down all arguments / motives / aspects that come to mind.
Once something has been written down and is on paper / in the file, it can no longer be lost. This makes things much easier and prevents you from having to “hold” a thought in your head
- If necessary, place a dictaphone next to the bed so that you can record your thoughts in the dark without getting up.
Paper and pen next to the bed also work, but are not quite as good because you have to turn on the light.
If necessary, get a pen with a built-in light.
- Take in other thoughts - read a book / newspaper (NO activating activities such as television, internet, cell phone or similar).
- Only go back to bed when you feel really tired
- If necessary, take mildly sedative and/or anxiolytic medication
e.g.:
- Trimipramine
5 - 20 mg/drops 1 hour before going to bed
Trimipramine is an old tricyclic antidepressant and is known to promote sleep. Unlike many other antidepressants and sleeping pills, it does not impair REM sleep.
⇒ Trimipramine for ADHD
- Trazodone
⇒ Trazodone for ADHD
- For some people with ADHD, a small dose of stimulants (1/3 to 1/2 of an immediate release daily dose) helps them to find inner peace and stop their thoughts from circling.
1.10. Nutrition / diet for sleep problems¶
1.10.1. Avoid food stimulants¶
Food stimulants means stimulants that can be contained in food or stimulants.
- No caffeine (tea) / guarana / mate / dark chocolate after 2 pm
Caffeine binds antagonistically to adenosine A1 receptors, which regulate the need for sleep in the brain. Adenosine A1 receptors inhibit the enzyme adenylate cyclase, which is required for the conversion of ATP into cAMP. This inhibition is prevented by caffeine, the cAMP level remains high. This increases alertness
- Caffeine:
- Coffee
- Instant coffee: 39 mg / 100 ml
- Filter coffee: 55 mg / 100 ml
- Decaffeinated coffee: 2 mg / 100 ml
- Espresso: 133 mg / 100 ml
- Coke
- Cola with sugar 10 mg / 100 ml
- Cola light: 12 mg / 100 ml
- Energy drinks
- Red Bull, Effect: 32 mg / 100 ml
- Cocoa / chocolate
Chocolate consumption in the afternoon or evening is rarely recognized as a cause of sleep problems, but it can trigger exactly that.
- Caffeine: the higher the cocoa content, the more caffeine
- Of 10 mg / 100 g (35 % cocoa mass)
- Up to 142 mg / 100 g (99 % cocoa mass)
- Theobromine: the higher the cocoa content, the more theobromine.
Like caffeine, theobromine is a methylxanthine. Although the CNS-stimulating effect is weaker than that of caffeine, cocoa contains significantly higher amounts
- Of 120 mg / 100 g (35 % cocoa mass)
- Up to 1200 mg / 100 g (99 % cocoa mass)
- Tea:
- Black tea: 20 mg / 100 ml
- Green tea: 19 mg / 100 ml
- Mate tea: 35 mg / 100 ml
- No alcohol after 5 p.m
- No alcohol as a sleeping pill
- Even if sleep is possible with alcohol, significantly increased stress levels of the autonomic nervous system (measurable by reduced heart rate variability) can be seen the following day.
1.10.2. Eliminate food allergies/food intolerances¶
A diet that limited sugar and excluded caffeine, chocolate, food additives, artificial colors, glutamate and foods that could potentially trigger allergies (e.g. milk) in the individual children resulted in a significant improvement in behavior in 45% of the participating children, including an improvement in the sleep problems phenotypical of ADHD (including delayed falling asleep).
Find out more at ⇒ Nutrition and diet for ADHD In the section ⇒ Non-drug treatment and therapy for ADHD in the chapter ⇒ Treatment and therapy.
1.10.3. Eat/drink little/no carbohydrates in the evening¶
Eating carbohydrates in the evening leads to an increased release of insulin. Insulin slows down the rest and regeneration hormones and fat burning. Sleep is less restful.
1.11. Sleep-disrupting effect of medication¶
Sleep disorders can be caused in particular by
-
SSRI
SSRIs can increase sleep problems in ADHD
- Hypnotics
- Beta-blocker
- Alpha agonists
- Alpha blockers
- Theophylline
- Glucocorticoids (cortisol)
- Thyroid hormones
- Antipsychotics
- Antidepressants
- A large study of antidepressants found very different effects on the risk of sleep problems:
Explanation:
-
Antidepressant active ingredient
-
Risk increase of sleep disorders (odds ratio) due to the respective medication
-
note: some of the medications mentioned here have a sleep-promoting effect when taken in low doses
-
Mechanism of action of the active ingredient
- Amoxapine
- Atomoxetine
- 6,6
- NRI (noradrenaline reuptake inhibitor)
-
ADHD medication
- Our experience: taking it in the evening in particular can impair sleep
- Maprotiline
- Mianserin
- Phenelzine
- 5,0
-
Monoamine oxidase inhibitors
- Clomipramine
- Fluvoxamine
- Olanzapine/fluoxetine
- 3,8
- Atypical antipychotic / SSRI
- Esketamine
- 3,8
- Non-competitive NMDA glutamate retorantagonist
- Imipramine
- Mirtazapine
- 3,6
- Tetracyclic AD
- Our experience: low doses may promote sleep; high risk of hangover
- Doxepin
- Escitalopram
- Desvenlafaxine
- Nortriptyline
- Paroxetine
- Venlafaxine
- Citalopram
- Vilazodon
- 3,0
- Serotonin modulator and stimulator
- Duloxetine
- Selegiline
- 2,8
-
Monoamine oxidase inhibitors
- Trazodone
- 2,8
- Serotonin antagonist and SRI
- Our experience: low doses promote sleep (up to 100 mg); also Krause, Krause (2014)
- Amitriptyline
- 2,8
- Tricyclic AD
- Low-dose sleep-promoting
- Tranylcypromine
- 2,7
-
Monoamine oxidase inhibitors
- Fluoxetine
- Sertraline
- Bupropion
- 2,2
- Noradrenaline/dopamine reuptake inhibitors
-
ADHD drug of the 5th choice
- Milnacipran
- Vortioxetine
- 1,3
- Serotonin modulator and stimulator
- Levomilnacipran
1.12. Check underlying sleep-disrupting illnesses with a doctor¶
Examples:
- Depression
- In cases of melancholic depression (falling asleep easily, waking up after midnight, shortened night sleep), consider taking a combination of GABA, glycine, taurine and possibly L-theanine 2 hours before going to sleep. This can increase the quality of sleep. These are inhibitory neurotransmitters or substances that support them, all of which are freely available as food supplements. Nevertheless, they should not be taken without consulting a doctor and the substances should be taken one after the other and not all at the same time. GABA taken orally does not cross the blood-brain barrier and therefore only works in the body. Medications that increase GABA in the brain, on the other hand, quickly become addictive.
- Anxiety disorders
-
Chronic pain
- Rheumatic diseases
- Coronary heart disease
- Asthma
- COPD
- Sleep apnea syndrome
Breathing interruptions can cause symptoms that resemble ADHD.
Breathing disorders during sleep in ADHD-HI could be due to dysregulation of the mesencephalic serotonin system.
- Restless legs syndrome
1.13. ADHD treatment during the day improves sleep¶
A combined treatment of medication and behavioral therapy proved to be more effective in improving sleep problems than treatment with medication or therapy alone. There was no worsening of sleep with any type of treatment, not even with the usual treatment with methylphenidate.
2. Non-drug treatment of sleep problems with ADHD¶
2.1. Binaural theta wave music¶
Listen to 1 (to 2) hours of binaural theta wave music via headphones before going to bed. (Caution: not alpha, as this increases concentration and - listened to immediately before going to bed - would intensify sleep problems) Depending on the theta music you choose (there is also pure sound), you can read (fiction), watch TV or surf the web (make the screen darker and redder).
For more information, visit ⇒ Binaural music as therapy for ADHD and sleep problems.
2.2. Brain tapping¶
Similar to binaural theta music, brain tapping uses the synchronization of the brain to predetermined rhythms. Brain tapping uses light alternating drumming/tapping on the thighs for about 4 minutes, slowing down over time. This is combined with slow breathing.
2.3. Sleep training¶
One study reported a halving of sleep problems through sleep training in children with ADHD between the ages of 5 and 8.
Sleep Training provides verbal and written information about normal sleep, sleep cycles, sleep disorders, sleep hygiene, and common strategies for treating behavioral disorders. It includes the importance of sleep hygiene methods such as consistent sleep routines and media-free sleep and references the standard strategies for sleep interventions recommended by the American Sleep Association.
2.4. Endurance sport¶
People who practiced moderate to intensive sports for at least 150 minutes per week suffered less often from problems falling asleep and daytime sleepiness than less active comparison subjects. A study on adults with ADHD who took stimulants confirmed this, particularly in men, but less so in women. There was an improvement from 105 min of sports per week and became significant from 341 min of sports per week. From 1,250 min of sports per week, the increase in improvement leveled off
In older people, the number of daily steps correlated with sleep quality and a reduced time to fall asleep.
Sports promote sleep, but should not be done later in the evening and should not be done at a higher intensity from the afternoon onwards
2.5. Weighted blanket¶
A weighted blanket is a sleeping blanket with a weight of 7 to 12% of the body weight. Children must always be able to remove the blanket independently.
The increased body pressure is pleasant for most people with ADHD and can help to eliminate anxiety, depression and sleep disorders.
An immediate improvement in ADHD symptoms should not be the primary expectation, even if one study suggests this, which also reports a normalized sleep onset time. However, improved sleep is expected to result in reduced daytime sleepiness and thus increased daytime activity. These are likely to be associated with improved ADHD symptoms,
A study of 120 people with psychiatric disorders, including 13 people with ADHD, found significant improvements in sleep disturbances in almost all disorder profiles, including ADHD, within 4 weeks. The subsequent open study over a further 11 months showed a reduction in previously severe sleep problems to subthreshold sleep problems in more than 75% of the people with ADHD. Anxiety and depression symptoms also improved. A small study of 26 children with ADHD reported an improvement with weighted blankets. One study found an improvement in sleep duration in children with ADHD from 11 to 14 years and ADHD-I in general.
A meta-analysis of k = 8 studies and a meta-analysis with k = 9 and n = 553 participants (SMD 0.47) came to the conclusion that weighted blankets can be helpful for anxiety symptoms. With regard to sleep problems, there were k = 4 studies that reported positive effects on insomnia, total sleep time and latency to fall asleep.
Weight blankets are said to be helpful for anxiety even with a short 20-minute intervention.
2.6. 4-7-8 - Technique according to Weil¶
Mindful breathing exercises that increase oxygen intake can help you fall asleep.
e.g.: 4-7-8 technique according to Weil.
2.7. Other sleep-promoting techniques¶
- Progressive muscle relaxation according to Jakobsen
- Yoga
- Mindfulness exercises
- Autogenic training
- Body Scan
3. Medication for sleep problems with ADHD¶
3.1. Improved sleep through ADHD medication¶
3.1.1. ADHD stimulants¶
A distinction must be made between the effect of ADHD medication with stimulants (methylphenidate, amphetamine medication) during the day and acute administration of stimulants on sleep.
In principle, ADHD medication with stimulants improves the quality of sleep. Impairments can occur if the medication is administered too late or during the first few weeks of dosing.
In exceptional cases, a small dose of stimulants can improve sleep. This should be tested individually.
Although stimulants generally have a more activating effect, a low dose of MPH or amphetamine before going to bed actually helps some people with ADHD by curbing their racing thoughts. The individual effect can be significantly better than sleeping pills.
For most people, however, it is too stimulating, so the medication should be reduced during the day towards the evening and stopped in good time.
A number of adult people with ADHD report being able to sleep better at night with amphetamine medication (during the day) than with methylphenidate medication.
One study found a 39% decrease in sleep problems in medicated adults with ADHD (40.5% in non-medicated compared to 24.73% of medicated ADHD sufferers). With an ADHD medication duration of one year or more, the rate of people with ADHD with sleep problems fell further to 21.05%, so that 48% of ADHD sufferers with sleep problems showed an improvement as a result of ADHD medication.
A study of adolescents with ADHD found no significant differences in sleep, either between people with and without stimulant use, or between days with and without stimulant use in persons with ADHD
One study reported a shortened sleep onset latency with stimulants (26 minutes with stimulants compared to 106 minutes without). In adults with ADHD, a blanket (not individually adjusted) medication with 30 mg lisdexamfetamine caused a reduction in sleep onset latency, 50 mg left it almost unchanged, 70 mg increased it. Overall sleep disturbances were reduced to 0.6% of those taking stimulants compared to 3.2% of those not taking medication, daytime sleepiness to 0.3% compared to 3.2%
One study found a later bedtime, later falling asleep and shorter sleep duration among adults with ADHD-C on methylphenidate. The number and total duration of nocturnal awakenings decreased and the average duration of uninterrupted periods of sleep at night increased, suggesting more consolidated sleep. These were ADHD subjects who had never been medicated before starting the 3-week drug trial, so single-dose side effects may explain some of the effects. In addition, the last of the 4 or 5 single daily doses of immediate release MPH was not given until 20:00. In our opinion, the very late last MPH administration counteracts the purpose of the study, as this only just complies with the basic rule that the end of the effect of the last dose should be at least one hour before bedtime, with a typical duration of action of a single dose of immediate release MPH of up to 4 hours. The authors’ argument that this should serve to avoid rebound effects at bedtime is not tenable in our view. If anything, the opposite is likely to be the case. The average bedtime of the ADHD group of 00:16 h was delayed to 0:34 h under MPH. Moreover, MPH titration was not based on the optimal effect, but on the onset of side effects. In sum, this reads a bit like a guide to causing sleep problems when dosing with MPH.
A small study of adults with ADHD, where the last dose was given at 4pm, found no change in sleep onset latency, but stimulant-induced improved sleep.
A study of children with ADHD found that a third dose of immediate release MPH (10 or 15 mg) in the late afternoon (4 pm) significantly reduced ADHD symptoms without affecting sleep.
3.2. Sleeping pills / sleep medication suitable for ADHD¶
3.2.1. Melatonin¶
Melatonin is produced in the body from serotonin and is involved in the sleep-wake cycle. Its release is inhibited by light. The highest natural release is shortly after midnight.
Melatonin is freely available in Germany up to 1 mg / dose; if more than 1 mg per dose is recommended, melatonin is only available on prescription.
Capsules containing up to 5 mg melatonin are available in Austria.
In the USA, drugs containing melatonin are freely available as dietary supplements.
It should be taken 1 to 2 hours before going to bed.
Trade name: Circadin (EU), sustained release melatonin 2 mg.
In older people (aged 55 and over), the effectiveness of sustained release (prolonged release) melatonin has been well documented:
- Sustainable reduction in the time it takes to fall asleep
- Improving the quality of sleep
- Improvement in morning alertness and daily performance
- Simultaneous improvement in sleep quality and morning alertness in patients with insomnia
The helpful effect of melatonin on jet lag was confirmed in a Cochrane Review.
Immediate release melatonin appears to be more suitable for sleep onset disorders, while sustained release melatonin appears to be more successful for sleep onset disorders.
More about melatonin at ⇒ Melatonin for ADHD.
3.2.2. Agomelatine¶
Agomelatine (trade name: Valdoxan) is a melatonergic antidepressant
- Agomelatine has a chemical structure related to melatonin
- Affinity to the MT1 and MT2 melatonin receptors
-
Antagonistic properties at the serotonin receptor 5-HT2c (unlike melatonin)
- Sleeping pill, which is also mentioned as a possible ADHD medication
- Agomelatine was tested against methylphenidate in a randomized double-blind study with n = 54 children. Both drugs performed comparably in the parents’ and teachers’ assessments of the children. Naturally, the children treated with agomelatine had fewer sleep disturbances.
- Agomelatine can cause liver problems. The liver values must therefore be monitored closely.
- Effect seems to be very individual.
- Discussion of over 50 users (mostly people with ADHD) about the effects and side effects of agomelatine (positive and negative) at psychiatrietogo.de.
- Our non-representative experience with agomelatine is rather negative. The sleep reported to us is shallow and “cold”. You don’t feel refreshed.
See also ⇒ Agomelatine Agomelatine for ADHD
3.2.3. Trimipramine¶
Trimipramine is a tricyclic antidepressant. In low doses it promotes sleep. Critical: Ridinger.
- 10 to 30 mg (instead of 100 to 300 mg as an antidepressant) 1/2 to 1 hour before going to bed. When using for the first time, test with an even lower dosage.
- Anxiety-relieving
- Deep, restful sleep
- REM phases are preserved (with trimipramine, different with other TCADs such as amitriptyline or doxepin)
- Much less addictive than benzodiazepines
- The experience with trimipramine reported to us is very positive. Sleep is very restful and dreaming is not reduced. Occasionally - especially at the beginning - a hangover occurred.
3.2.4. Trazodone¶
Trazodone is a dual-serotonergic antidepressant and is recommended as a sleep aid for ADHD.
- Phenylpiperazine
-
Half-life 5 to 9 hours
- Strongly inhibits α1 receptors
- Weakly inhibits α2 and H1 receptors
- Low dose (up to 50 mg)
- 5HT2A receptor antagonist
- = Blockade of the 5HT2A receptors
- → leads to an increase in dopamine in the striatum due to glutamate reduction
- → enhances serotonergic neurotransmission via the 5-HT1A receptors
- Incidentally not serotonergic
- Higher dosage
- More serotonergic
- Antihistaminergic
- Sleep-promoting in ADHD, if low-dose (25 to 100 mg)
- No impairment of sexual functions
- No increase in body weight
- Attenuating effect on tremor
- Not contraindicated in glaucoma and prostate problems
- No extrapyramidal effect (no motor restlessness)
- No potentiation of adrenergic transmission
- No anticholinergic activity, therefore does not have the typical side effects of tricyclic antidepressants
- Do not combine with MAO inhibitors or (especially if high doses) with serotonergic medication
- Sleep promotion by trazodone could also be based on serotonergic effects.
- In herds of rhesus monkeys, the animals that fall asleep the latest are those with the lowest levels of 5-HIAA in the cerebrospinal fluid, a serotonin metaboliteGrawe (2004): Neuropsychotherapy, page 200))
3.2.5. Mirtazapine¶
Mirtazapine is a tetracyclic antidepressant.
One small study reported positive experiences as a sleep aid for ADHD at low doses of 3.75 to 7.5 mg per hour of sleep. Another very small study came to comparable results at a dose of 30 mg.
Critical: Ridinger.
3.2.6. Pregabalin¶
Pregabalin is a mood stabilizer and is said to be able to help improve falling asleep, staying asleep and deep sleep in ADHD. There is a risk of hangover.
3.2.7. Gabapentin¶
Gabapentin is a mood stabilizer and is said to be able to help improve falling asleep, staying asleep and deep sleep in ADHD. There is a risk of hangover.
3.2.8. L-theanine¶
L-theanine (5-N-ethyl-L-glutamine) is a glutamate antagonist. It is said to potentially reduce the physical and psychological stress response.
According to the Federal Institute for Risk Assessment, L-theanine has various pharmacological effects in animal experiments:
- Lowers blood pressure
- Influences the concentration of various messenger substances in the brain
- Counteracts caffeine effects
- Therefore possibly calming and relaxing (sedative) effect
- Unknown is,
- Whether further effects exist
- Whether responsiveness or attention are impaired
- Whether possible negative effects are intensified by the additional consumption of alcohol or medication.
- Toxicological data on L-theanine are so far incomplete
- It is therefore still unclear whether and if so in what quantities L-theanine is harmless to health when consumed daily and used in isolation.
With regard to ADHD, a randomized and placebo-controlled study in boys found a sleep-promoting effect at 400 mg / day, another study at 200 mg before bedtime.
There are apparently no further studies. A meta-study found that the results for eszopiclone were even better than for L-theanine, but the sleeping pill eszopiclone was only approved in the USA as it was denied novelty status in the EU. L-theanine is also said to improve the quality of sleep, but not the time it takes to fall asleep or the duration of sleep.
In contrast, there are several studies that show a positive effect of L-theanine on depression. which was attributed, among other things, to a change in monoamine levels in the striatum, cortex, limbic system, pallidum and thalamus.
An anxiolytic effect and an increase in hippocampal activity were observed in rats.
3.2.9. Combined intake of GABA, glycine, taurine, L-theanine¶
A combined intake of GABA (750 mg), glycine (500 mg), taurine (500 mg) and possibly L-theanine 2 hours before bedtime can increase sleepiness (which can particularly counteract the delayed sleep rhythm in some people with ADHD) and improve the quality of sleep.
GABA and glycine are inhibitory neurotransmitters, taurine increases GABA.
All substances are freely available as dietary supplements. Nevertheless, they should not be taken without consulting a doctor and the substances should be taken one after the other and not all at the same time. GABA taken orally does not cross the blood-brain barrier and therefore only has an effect in the body. Medications that increase GABA in the brain, on the other hand, quickly become addictive. This risk does not exist with orally ingested GABA.
3.2.10. Combined intake of amino acids that reduce tyrosine¶
Tyrosine can increase dopamine and noradrenaline. More on this under Tyrosine for ADHD
However, a lower noradrenaline level is helpful to calm down.
A combined intake of amino acids that compete with tyrosine and phenylalanine for the same transporters across the blood-brain barrier, such as
- Tryptophan
- L-methionine
- Histidine
- Threonine
- L-glycine
- L-lysine
- L-arginine
- L-leucine
- L-isoleucine
- L-valine
can help to reduce dopamine and noradrenaline.
Taking a combination of the amino acids mentioned (without tyrosine and phenylalanine) could therefore possibly help people with ADHD to calm down.
To avoid disadvantages during the day, this should be combined with a morning intake of tyrosine and phenylalanine.
Even if these substances are available over the counter, their use should always be discussed with a doctor in order to avoid adverse effects, e.g. on individual constellations. Long-term use should be avoided, as there may be other amino acids or other substances that enter the brain via the same transporters. Permanent occupation of the transporters with tyrosine/phenylalanine competitors at night and tyrosine/phenylalanine during the day entails the risk that deficiency symptoms may develop with regard to these other substances ,
3.2.11. Iron¶
One review found clear evidence of a correlation between iron deficiency and restless legs sleep problems, as well as possible evidence of correlations with sleep problems in ADHD.
3.2.12. Valerian¶
Valerian can be helpful for ADHD-related sleep problems.
3.2.13. Caffeine, nicotine (paradoxical effect)¶
As a rule, caffeine or nicotine tend to inhibit sleep, as they are stimulants. However, paradoxical reactions are possible in people with ADHD, just as with stimulant drugs, so that caffeine or nicotine can have a sleep-promoting effect. This must be tested individually.
One person with ADHD reported that nicotine makes him so tired that he has been using a single cigarette as a sleeping aid immediately before going to bed for decades. During the day, smoking made him uncomfortable due to the same fatigue-inducing effect.
3.2.13. Dopaminergic active ingredients and sleep and wakefulness¶
D1 receptor agonists:
- SKF38393 was able to improve excessive daytime sleepiness and restore REM sleep in animal studies.
- SKF-82958 infusion worked for 2 hours:
- dose-dependent increased waking time
- suppressed REM sleep and slow-wave sleep
- slightly increased locomotion
- slightly increased time for grooming and eating
D2 receptor agonists have different effects on sleep and wakefulness:
- Bromocriptine, dosed to address only the autoreceptor, increased slow wave sleep and decreased wakefulness in rats. In healthy humans, it did not shorten sleep latency.
- Quinpirole
- low dose: reduced wakefulness and promoted sleep in rats
- high doses: increased alertness and reduced sleep
- easily increased drinking and locomotion
- significantly increased chewing on inedible material, a behavior associated with arousal/stress.
- RO 41-9067 increased alertness in animals in a dose-dependent manner
- Cabergoline reduced the number of periodic leg movements in RLS during sleep
- Pramipexole (D3 and D2 agonist)
- at low doses (30 micrograms/kg) it increased slow wave sleep, REM sleep and reduced wakefulness
- high doses (500 micrograms/kg) increased alertness
- Ropinirole shortened sleep latency and increased total sleep time in Parkinson’s, RLS and healthy subjects
- Piribedil has a strong wakefulness-promoting effect. It sometimes triggers sleep attacks in Parkinson’s patients
D4 agonists:
- Ro 10-5824
- extended the waking time and shortened the non-Rem sleep
- delayed the onset of non-Rem sleep
- increased the theta and gamma power in the EEG.
- A-412997
- extended the waking time and shortened the non-Rem sleep
- delayed the onset of non-Rem sleep
- influenced the onset and duration of rem. sleep
- increased the theta and gamma power in the EEG.
D4 antagonists:
- L-741,741, a highly selective D4 antagonist was investigated in Wistar rats
- 1.5 mg/kg
- only increased the light slow wave sleep
- 3 mg/kg
- increased the episodes of quiet wakefulness
- reduced and shortened the episodes of active wakefulness
- 6 mg/kg
- reduced the episodes and increased the latency of deep slow wave sleep
- reduced episodes and duration of light slow wave sleep
- reduced the total sleep time
- increased the active waking state
- increased the latency of REM sleep
3.3. Drugs with an influence on the circadian rhythm¶
3.3.1. Bromocriptine QR¶
Bromocriptine QR could potentially help to normalize the circadian rhythm. This has been discussed in relation to the treatment of obesity, where the circadian rhythm is also disturbed.
3.3.2. Remdesivir alters circadian gene expression¶
Remdesivir alters circadian gene expression in primary human dermal fibroblast cultures. In subjects without a neuropsychiatric diagnosis who did not exhibit eveningness in the chronorhythm, remdesivir caused a slight phase shift in Clock, Per1 and Per2 and significantly altered expression of Bmal1 and Per3. The difference between chronotype and circadian gene expression of Bmal1, Cry1 and Per3 was significant. Remdesivir influenced the circadian function and shifted the chronotype towards eveningness, as is also known from ADHD.
3.4. Sleeping pills / sleep medication NOT suitable for ADHD¶
3.4.1. Avoid benzodiazepines for ADHD¶
- High risk of addiction to benzodiazepines (within 14 days)
Not recommended against the background of addictive affinity in ADHD due to the strong reward delay aversion in ADHD
- Benzodiazepines reduce the activity of the locus coeruleus and thus reduce the production and transport of noradrenaline to other parts of the brain. They should therefore be contraindicated in ADHD.
- Strong sleeping effect
- Anxiety-relieving
- Frequently used active ingredients
- Flurazepam
- Nitrazepam
- Temazepam
- Triazolam
3.4.2. Neuroleptics / antipsychotics not indicated for pure ADHD¶
Neuroleptics are not recommended for (pure) ADHD.
Neuroleptics, like antidepressants, are not typical sleeping pills but are used to treat mental disorders. However, they can also help with sleep disorders due to their sedative-dampening effect, especially if these are caused by psychoses. In ADHD-HI, neuroleptics only appear to be useful in the case of specific comorbidities (e.g. from the autism spectrum).
3.4.2.1. Pipamperon¶
Pipamperon is a low-potency neuroleptic.
Pipamperone blocked (antagonized):
- Primarily serotonin receptors
- Low D2 receptors
- Low D4 receptors
- Low alpha1-adrenoceptors
Since ADHD often already involves a reduced sensitivity of the D4 receptor, which is partly responsible for the overreactivity of the striatum due to the loss of the inhibitory D4 receptor effect (keyword: DRD4-7R), it seems doubtful to us whether an additional impairment of the D4 receptor really makes sense.
3.4.3. SSRIs (selective serotonin reuptake inhibitors)¶
Antidepressants are generally suitable for treating sleep problems caused by depression.
However, SSRIs can exacerbate sleep problems in ADHD.
SSRIs reduce REM sleep by 30 %.
REM sleep:
- Is essential to restore neurotransmitter balance in the brain (breakdown of adenosine, build-up of glycogen in astrocytes; especially in non-REM)
- Causes structural relief (raphe cores etc.)
- REM sleep is particularly important in the first years of life:
- Training sensorimotor skills
- Training of otherwise unused behaviors
- Newborns sleep 16 to 18 hours, of which 50% = 8 - 9 hours REM
- 10-year-old children still have 2 - 2.5 hours of REM sleep
3.4.4. First generation antihistamines¶
- Critical: Ridinger
- In addition to alleviating allergy symptoms, it also has a sedative effect
- Active ingredients including:
- Doxylamine
- Diphenhydramine
- Meclozine
- Promethazine
3.4.5. Non-benzodiazepine agonists¶
- Different structure than benzodiazepines
- Act on the same receptors as benzodiazepines
- Active ingredients including:
- Zaleplon
- Zolpidem
- Zopiclone
-
GABA receptor agonist in the brain = risk of addiction!
New generation sedative - Z-Drug
Trade names: Imovane (D, CH), Optidorm (D), Somnal (A), Somnosan (D), Ximovan (D), Zopiclodura (D), Zopitin (CZ), various generics, Lunesta (USA)
- Lower risk of dependence than benzodiazepines (unlike at least zopiclone, which may be taken for a maximum of 2 weeks due to the psychological and physical risk of addiction)
However, there remains a risk of dependence, which is why we do not advocate non-benzodiazepine agonists as sleep aids for people with ADHD.
- Critical: Ridinger
3.4.6. Barbiturates¶
- Only to be used if other sleeping pills are not effective
- Strong side effects, overdose can be fatal
3.5. Other sleeping pills¶
We do not (yet) have any specific information on the following sleeping pills as to whether they are particularly indicated or contraindicated in ADHD. The list is far from complete.
3.5.1. Orexin antagonists¶
Orexin A and orexin B are neuropeptides that bind to the orexin 1 and orexin 2 receptors and thus promote alertness.
Orexin antagonists such as daridorexant inhibit orexin receptors.
Daridorexant (trade name: Quviviq®) binds to orexin-1 and orexin-2 receptors with approximately the same affinity, thereby promoting sleep without altering the ratio of sleep phases. Daridorexant has been available in Germany and Switzerland since 2022.
Whether orexin antagonists are particularly helpful in ADHD, or whether this could be subtype-specific, would need to be investigated. One study reports reduced basal orexin A levels in ADHD-I (ADD). More on this in the article Orexin
4. Sleep problems due to ADHD medication¶
ADHD medication can cause sleep problems as side effects. Often, but not always, these are simply a consequence of the dosage and disappear within a few weeks. Care should be taken to stop taking ADHD medication in good time so that the effective period ends one hour before bedtime.
Sleep problems from ADHD medications are most commonly reported by:
- Mixed amphetamine salts (40-45 %) (not authorized in Germany)
- Dasotraline (35-45%) (new drug under investigation)
- Lisdexamfetamine (10-19%) (Vyvanse)
- Atomoxetine (10 - 17 %)
- Sustained release methylphenidate (11%)
A number of people with ADHD report that a small dose of stimulants (immediate release MPH, approx. 1/3 of a single dose taken during the day) helps them to fall asleep by relaxing them and stopping the carousel of thoughts. One person with ADHD reported that he can only sleep on a full dose of stimulants.
One study reports a significant improvement in sleep in children with ADHD between the ages of 6 and 12 with serdexmethylphenidate or dexmethylphenidate.
