By Michael Breus, PhD, ABSM
Millions of children and adults struggle with symptoms of Attention Deficit Hyperactivity Disorder (ADHD), a condition marked by problems with concentration, impulse control, organization, and memory. It can be a frustrating and difficult condition, stigmatizing and often isolating for those who suffer from it.
But what if some of those who’ve been diagnosed with ADHD are, in fact, suffering from another disorder altogether—a sleep disorder? That’s the provocative and important question posed in this commentary by a practicing psychiatrist with extensive experience treating patients with ADHD. Dr. Vatsal Thakkar, who is also a clinical assistant professor of psychiatry at NYU Langone Medical Center, makes a powerful argument for the need to consider sleep problems as a possible cause when evaluating patients for ADHD.
As Dr. Thakkar points out, many of the symptoms of ADHD are very often similar to symptoms of insufficient and disordered sleep, for both children and adults. In children, the symptoms of ADHD and sleep deprivation can be indistinguishable. A diagnosis of ADHD in children frequently comes about after a child exhibits some or all of behavioral symptoms such as these:
Lack of focus: difficulty paying attention, problems listening, forgetfulness, disorganization
Agitated, excitable, impulsive behavior: excessive talking, inability to sit still, difficulty playing quietly, tendency to interrupt, difficulty sharing or waiting for one’s turn
These behaviors associated with ADHD interfere with a child’s social and intellectual development, causing problems with relationships with peers and adults, at school and at home. But what if ADHD isn’t always the underlying cause of these symptoms? Signs of poor quality and insufficient sleep in children can look remarkably like symptoms of ADHD, as a number of recent studies show. There’s particularly strong evidence that children with sleep-disordered breathing exhibit many of the same symptoms—and suffer many of the same behavioral problems—as children who’ve been diagnosed with ADHD.
Sleep-disordered breathing in children has been an area of growing interest among sleep scientists—with good reason. I’ve written about the dangers of sleep-disordered breathing in children, which is linked to a range of developmental and behavioral problems—problems that often mirror those associated with ADHD:
- This study found that children with obstructive sleep apnea had higher rates of behavioral problems including difficulty paying attention, hyperactivity, communication problems, and aggressiveness. These children were also more likely to have learning difficulties and low academic performance than those without sleep-disordered breathing.
- This large-scale study of more than 11,000 children found that those with sleep-disordered breathing were significantly more likely to show signs of hyperactivity, trouble interacting with peers, and conduct issues including aggressiveness and inability to follow rules. The study examined the effects of sleep-disordered breathing on children as young as 6 months. Researchers found that very young children who experienced some form of sleep-disordered breathing were, by the age of 7, 40-100% more likely to have behavioral problems similar to those used to diagnose ADHD.
Many adults being treated for ADHD have symptoms that are difficult to distinguish from the effects of poor quality and insufficient sleep. Difficulty concentrating, trouble completing tasks, problems with organization, and memory lapses are all common struggles for adults who’ve received an ADHD diagnosis. These are also some of the most common problems for adults with sleep problems. I’ve written about the challenges that lack of sleep and disrupted sleep pose to cognitive function in adults, including problems with memory, learning and focus.
Given the similarities of symptoms between ADHD and poor sleep in children and adults, it’s not hard to see how misdiagnosis is possible, even likely. That risk increases when we consider the lack of regular screening that exists for sleep problems. We’ve made great scientific strides in our understanding of sleep in recent years. But we still struggle with a lack of attention paid to sleep problems by both physicians and patients. For both children and adults, sleep problems continue to be significantly under-diagnosed. This study of members of the American Academy of Pediatrics evaluated sleep-screening practices among pediatricians. Researchers found that fewer than 1 in 5 pediatricians surveyed had received any training in sleep disorders, and fewer than 1 in 6 felt confident about their ability to offer guidance to parents about children’s sleep. The study also revealed serious knowledge gaps among pediatricians about sleep, with most unable to answer correctly questions about sleep disorders in children.
The news isn’t any better for adults. An analysis of data from the 2005-2006 National Health and Nutrition Examination Survey found that sleep disorders such as insomnia and sleep apnea remain drastically under-diagnosed. What’s more, though nearly all of the more than 2,000 adults surveyed reported at least one complaint about their sleep, fewer than 1 in 4 of them had talked with physicians about their sleep problems.
More rigorous and effective screening for sleep problems starts with better training for physicians and medical professionals who must make diagnoses every day. As patients and as parents, we also need to be attentive to symptoms of poor sleep in ourselves and in our children. And we need to take these concerns—however mild they may appear—to our physicians.
Another thing we can do? Protect our sleep, and our children’s sleep, by setting sleep-friendly limits against the nonstop, perpetually wired, always “on” culture we live in today. As Dr. Thakkar points out, the escalation of ADHD cases in the 1990s and 2000s coincided with the rise of the digital age, and the widespread use of personal technology that now pervades our daily lives. These devices—our laptops and tablets and cell phones—that enable so much convenience and connection, also threaten the quality and quantity of sleep. The nighttime exposure to light they emit interferes with the body’s release of melatonin, disrupting sleep cycles and diminishing time spent in the deepest, most restorative phases of sleep. More than ever before in history, we must work to create the darkness that is so essential to sleep. Keeping our bedrooms, and our children’s bedrooms, gadget-free sanctuaries for sleep is one important way to guard against chronic sleep deprivation.
To raise the possibility that some cases of ADHD in children and adults may actually be un-diagnosed sleep disorders does not call into question the seriousness of ADHD, the difficulties it poses, and the importance of effective treatment for this very real disorder. Additional research is critical to determine whether, and how often, sleep disorders are being misdiagnosed as ADHD. The goal is to make the right diagnosis—whether ADHD or sleep problems—and pursue the most effective treatment. All patients, whatever their condition, deserve no less. Pursuing the question of a link between disrupted sleep and symptoms of ADHD is a matter of public health, one that deserves prompt and sustained attention.
Michael J. Breus, PhD
The Sleep Doctor™