ADHD Sleep Problems Linked to Gender, Mental Health: Study

November 5, 2024

Sleep problems are highly prevalent among adults with ADHD. Individuals who have ADHD and one or more psychiatric comorbidities face an increased risk for disordered sleep, according to a study published in the Journal of Attention Disorders.¹

The study followed a large sample of adults with ADHD in the Netherlands after they were referred to an outpatient mental health clinic. Nearly two-thirds of these patients screened positive for a sleep problem. Most screened positive for delayed sleep phase syndrome (35.8%), followed by insomnia (30.6%) and restless leg syndrome (28.8%).

Women with ADHD were more likely to report more types of sleep problems compared to men with ADHD. Women more often reported insomnia, hypersomnia, and parasomnia, while men more often reported sleep-related breathing disorders (SBD).

Adults with ADHD and mental health conditions faced a higher likelihood of having any type of sleep problem and of having more than one sleep problem than did those with ADHD alone. The risk of sleep problems was highest in adults with PTSD (OR=3.21), followed by:

• Substance use disorder (OR=1.76)
• Depression (OR=1.73)
• Anxiety (OR=1.51)
• Personality disorders (OR=1.54)

Why Do Adults with ADHD Struggle with Sleep?

Sleep disorders impact around 50 million Americans or 15% of the U.S. population.² This percentage is significantly higher in ADHD populations, as shown in the current study. According to data cited by the authors, disordered sleep affects an estimated 40% to 80% of adults with ADHD.^{3, 4} The most common sleep disorders are similar for both groups and include insomnia, restless legs syndrome (RLS), narcolepsy, and sleep apnea.^{5, 6}

ADHD and sleep go hand in hand, and the impact of one disorder can worsen the symptoms of the other. For example, the American Academy of Neurology found that people with ADHD and RLS experience more severe RLS symptoms than do those without ADHD.⁷

Many sleep problems are biological, but they can also be behaviorally motivated. A study cited by the authors shows that cognitive behavioral symptoms such as bedtime procrastination can delay sleep onset and potentially disrupt melatonin production.⁸

“Symptoms of ADHD exacerbate the things that make sleep hard for all of us,” said Joel Nigg, Ph.D., in his 2018 webinar with ADDitude, “Sleep and the ADHD Brain: Why It’s Critical and How to Get More.”

“Your body reacts more strongly to stimulation,” Nigg said. “You’re more hyper-aroused by things that happen during the day. It’s harder to turn your brain off. It’s a natural side effect of what ADHD is. Sleep requires the opposite of the energy that ADHD provokes, [making sleep] naturally difficult. That’s why it takes the kind of deliberate attention, behavioral strategy, or kind of tackling of this so often for those with ADHD.”

What Are the Consequences of Untreated Sleep Problems?

The impact of misdiagnosing symptoms of disordered sleep can have long-term consequences, leading to “poor treatment, and persistence and aggravation of symptoms,” the authors wrote.

Symptoms of poor sleep can look like ADHD and vice versa, making them somewhat difficult to differentiate. Left untreated, disordered sleep can worsen with age and cause a ripple effect from caregivers to their children.⁹

“Sung did a study [in 2008], which found that moderate or severe sleep problems in children with ADHD were strongly associated with the mental health of their primary caregivers and with those caregivers’ work attendance and overall family functioning,” said Roberto Olivardia, Ph.D., during his 2019 webinar with ADDitude, “Time for Bed! Sleep Solutions for the ADHD Brain.”

The good news is that “treatments for specific sleep problems are available, relatively accessible to implement in ADHD patients, and can improve ADHD treatment results substantially,” the authors wrote. Cognitive behavioral therapy (CBT) and lifestyle changes are first-line treatments for many sleep disorders and can be more effective than sleep medicine.¹⁰

Limitations, Strengths, and Future Research

The study followed 3,691 adults diagnosed with ADHD from 2018 to 2020. Data was assessed via electronic patient files and included an even male-to-female ratio. Adults with ADHD were referred to one of 46 specialized outpatient clinics in the Netherlands by their general practitioner or mental health counselor. The Holland Sleep Disorder Questionnaire (HSDQ) was used to assess sleep disorders, though it was used as a screening tool and not to diagnose. The DIVA-5 was used to test for ADHD, and the M.I.N.I was used to screen for psychiatric comorbidities.

Limitations of the study include a lack of control group. And although some patients had been diagnosed with a sleep disorder before being referred to an outpatient clinic, the HSDQ was only able to screen for sleep problems. Some data, such as BMI and treatment status, was not accounted for as it was not systematically recorded in patient files. Given each patient received a clinical referral, the severity of symptoms experienced by patients should be considered when interpreting results.

Future studies would benefit by measuring causal factors contributing to sleep problems in adults with ADHD. These studies should also include subjective sleep parameters, such as actigraphy and polysomnography, which were not included here. Insomnia has been widely studied in sleep research; more research is needed on other sleep disorders, including periodic limb movement disorder (PLMD), RLS, DSPS, and SBD.

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