Ever Elusive Sleep

Why people with ADHD struggle and what you can do about it!

Sleepy all day, but can’t sleep at bedtime?

Teens, especially those with ADHD, often struggle with sleep due to an overactive mind at night, anxiety, impulse control, and their circadian rhythm.

There’s a push in the US to rethink how we manage chronic conditions to use more “natural” therapies — as if physicians have only pushed drugs and not recommended these things before. We always recommend healthy nutrition, regular exercise, and sufficient sleep. These are important, but for many reasons are difficult to attain.

I wish I heard more realistic ways that we could do healthy habits, such as coverage for mental health therapy, better access to healthy foods, paid time off for physical and mental health benefits, later school start times and more, but I don’t.

I’m revisiting sleep today because poor sleep is so common and better sleep is so beneficial to our mental and physical health. Unfortunately, when people are told to get better sleep without direction, it is not helpful. Working with your physician or a mental health professional is even better than reading this, but I’ll put in many ways to get better sleep. Try several. If they’re not enough, talk to your doctor or therapist.

Why are teens so often sleep deprived?

There are many reasons teens don’t sleep. One of the biggest in my community is that school starts far too early. Sometimes kids are even expected to attend before school activities. We know the biology of their inner clock — the circadian rhythm — yet we aren’t doing anything to support their biology. Studies show it’s hard for them to fall to sleep before 11 pm, yet they have to get up for school at 5 or 6 much of the time. There’s no way for them to get the required 8+ hours of sleep this way.

All teens, but in particular those with ADHD, struggle with lack of impulse control and dopamine-seeking behaviors due to their developing brains. They are more likely to do things at bedtime that interfere with going to bed. One more video. Another game. One more chapter. Screen time activities are especially counter-productive for sleep because the light emitted from the screen suppresses melatonin, a hormone that prepares your brain for sleep and is released in response to darkness.

People with ADHD also struggle with the appreciation of time, often referred to as time blindness. It’s easy to lose track of time when doing preferred tasks, so they get lost in the moment of whatever they’re doing and don’t realize it’s past bedtime.

Many with ADHD have a delayed sleep-wake phase disorder, in which the internal body clock is off, and sleep and wake times are delayed by several hours compared to typical sleep/wake times. They’re not tired at the time they should feel tired, whether due to light sources (screens) inhibiting natural melatonin or an off-set circadian rhythm.

Anxiety is common among people with ADHD and bedtime is a great time to worry! Not that it’s an ideal time, but without the business of the day to occupy our mind, our brains can focus on all the worry thoughts when we’re supposed to be settling down to sleep. All this thinking keeps our brain active and not able to sleep.

There’s evidence that people with ADHD have lower levels of iron than the general population. Low iron may lead to Restless Legs Syndrome (RLS), a condition that causes an uncomfortable tingling or crawling feeling in the legs, making it hard to get to sleep.

Of course ADHD itself is associated with hyperactivity and racing thoughts. During the day if a stimulant is used to help with focus, the brain is calmer. Stimulant medications are worn off by bedtime, which allows the brain to think all the thoughts. Turning off the brain can be hard for those with ADHD.

Why does it matter?

Unfortunately, chronic sleep deprivation worsens focus, impulse control, emotional regulation, and more. This makes it more difficult to go to sleep, further exacerbating problems with ADHD and sleep. It can be an endless battle for many.

During periods of wakefulness, we use energy and make adenosine. The buildup of adenosine in the brain gradually makes us sleepier. During sleep we can clear away the adenosine, which is why if you don’t sleep long enough you wake still tired. Caffeine blocks adenosine, which is how it keeps us feeling less tired even when we need sleep. Of course, caffeine does nothing to help with all the benefits of sleep. We can’t just mask the need for sleep with any substance.

Sleep helps:

• the brain organize and store information from the day as well as gets rid of waste products. This helps with stress management, emotional regulation, memory, focus and attention, reaction time, and even to prevent injury.

• the body repair cells, restore energy, and release hormones. This is why sleep is needed even more during periods of growth and why we are sick less often when we get enough sleep. Sleep can help maintain a healthy weight and even lower the risk of stroke, hypertension, heart disease and type 2 diabetes.

Breaking the cycle to win the battle

There are many ways to help improve sleep. We often need to use multiple tools and they need to be used regularly. It’s not enough to say you tried it once or twice and it didn’t work.

Resetting your internal clock takes time, but it’s time that is so worth it!

Think about sleep all day, not just at night

Your sleep cycle is dependent on the full 24-hour day, not just bedtime. What you do during the day impacts your sleep, both in helpful and harmful ways.

Helpful:

• Exercise is healthy for your body. We all know that. But it also helps you sleep better. It’s best done early in the day most days of the week. Exercise should be fun. If you’re not into sports, find another way to move — walk with friends, dance to your favorite music, get active with VR games, go for a bike ride, do yard work or gardening. There are so many ways to get exercise: find what works best for you.

• Proper nutrition can help sleep too. Diets high in fiber with a variety of fruits and vegetables, low in saturated fat, and low in sugar are healthy for your sleep as well as physical health. Skip the simple carbohydrates and highly processed grains and go for whole grains, especially close to bedtime. Studies have also found that consuming too much or too little protein can negatively impact sleep. Acid reflux is more common after spicy foods, fried foods, high-fat foods, and junk foods, so avoid those for 2 hours prior to bedtime. In general, eating late at night (within 2 hours of sleep) may lead to less restful sleep. Irregular meal times may also impact sleep and are associated with higher rates of obesity, so stick to a routine with meal and snack times.

• Planning and organizing helps. By taking some time each day to plan when you’ll do all the things you need to do, you’ll have fewer times that you need to work on homework at bedtime (and beyond). This is easier said than done if one has executive function problems, but there are tips in the Time Management and Organization link below this post.

• Up and out! Getting outside in the morning for natural sunlight helps to reset the body’s internal clock.

Harmful:

• Stress and worries worsen sleep, so learn to manage these. Mindfulness can help push out worry thoughts whenever they happen. The more you practice mindfulness, the more successful it will be. Work on it for at least 5-10 minutes every day for best results. See the Mind Tricks link below this post to learn more about mindfulness. Talk to your doctor if you can’t control your worry thoughts.

• Avoid substances that inhibit sleep. Caffeine can be found in tea, coffee, soda, energy drinks, and chocolate and disrupts the onset of sleep and affects the sleep cycles. Alcohol is another sleep disruptor. Though it may help some people fall asleep faster, ultimately, alcohol can lead to lower quality sleep and more frequent overnight awakenings. People who smoke, vape, or use other tobacco products tend to take longer to fall asleep, wake up more often during the night, and sleep fewer hours. Nicotine also leads to more light sleep and less restorative sleep.

• Overscheduling. We’ve all been there. We’re busy and something else comes along and we agree to another commitment. There are only so many hours in the day, and when there’s too much to do, we tend to cut sleep times. This is not helpful in the long run.

Bedtime routines and more to get best sleep

Our brains respond to routine, and routine is especially helpful for sleep.

• Determine your best bedtime.

  • Teens need a minimum of 8 hours of sleep each night, more during periods of rapid growth, but many report far fewer hours.

  • Calculate your ideal bedtime by looking at your ideal wake-up time and subtracting 8 hours. That is your ideal sleep time.

  • Subtract another hour to find your ideal wind-down time. You need this hour to get ready for bed by preparing your brain for sleep. During this time you will do quiet activities off screens. (Remember screens inhibit melatonin, which is needed for sleep.)

  • Set a reminder for wind-down time to start and another when it’s time to get in bed.

    • Wind-down time activities can help you get in the mindset for sleep and may include any of the following:

      • Turn off devices and plug them in outside of your bedroom.

      • Journaling: write down your thoughts before bed, check off completed tasks and update your to-do list for the next day with incomplete tasks

      • Reading a paper book

      • Listening to music or an audiobook

      • Art

      • Puzzles

      • Shower

      • Reviewing your upcoming day and week

      • Brushing teeth

      • Put on PJs

      • Switch to music, a podcast or an audiobook to help get off other activities that use your device

      • Mindfulness activities - If you don’t know how to do this, check out your app store for meditation apps. I personally chose Balance because they offer a year-long free trial and I’ve enjoyed their foundations courses to teach me about mindfulness as I’m practicing. Smiling Mind is always free and gets good reviews. There are many popular apps — read reviews and pick one! Set reminders and notifications to use it. Even if it’s hard at first. It really does get easier with practice.

    • If you must be on a computer to finish homework, use a blue-light filtering app, such as f.lux.

• Create a sleep-friendly environment

  • Make your bedroom a comfortable, calming space. Keep the room cool, dark, and quiet to minimize disturbances.

  • A fan can help not only with air circulation, but also as background noise.

  • Invest in a comfortable mattress and pillows to support good posture and sleep quality.

  • Deep pressure calms the nervous system. Use a weighted blanket or compression sleep pod after talking with your physician or occupational therapist.

  • Keep screens out of the bedroom at bedtime. Charge your phone and computer in another room. If you use your phone as an alarm clock: buy an alarm clock — it’s worth the small investment! Watch tv with others in a shared space earlier in the day.

  • Use your bed only for sleep. If you do homework, doom scroll, or watch tv in bed, your brain doesn’t associate the bed with sleep. Do those activities elsewhere.

  • Some people find that light boxes or glasses help regulate sleep by making the room brighter before waking.

  • Find the sound that helps you relax. Make your own playlist or find one on a mindfulness app. Use a speaker in your room rather than your phone to listen! White noise, pink noise, sleep stories, and other sounds may help.

• Organizing bedtime and morning routine

  • Get your things ready for the morning before you go to bed. Put your things in your backpack and your shoes and backpack near the door. Choose your outfit and put it near your bed. Decide what you’ll have for breakfast so you don’t have to think about it in the morning. Do everything that can be done and leave only essentials for the morning. You’ll need to eat, get dressed, fix hair (and possibly makeup), use the toilet, and brush teeth. Those don’t take as long if everything else is already done and you don’t have to make any decisions.

  • Go to bed and wake up at the same time every day, even on weekends. This helps regulate your body's internal clock (the circadian rhythm). If you do stay up late, try to keep it within an hour or two of your regular bedtime. If you sleep in, try to keep it within an hour or two of your wake time.

  • Develop a calming wind-down routine as mentioned above and practice this for an hour before sleep time each night.

  • Avoid activities that overstimulate your mind before bed, such as playing video games or scrolling through social media.

  • Set your alarm for when you need to get up, not 30 minutes early to allow for snooze time. You’re missing out on those 30 minutes of sleep hitting the snooze!

  • Get outside in the morning for natural sunlight for at least 30 minutes. A morning walk or outdoor exercise for light exposure and exercise is ideal for resetting the circadian rhythm.

• Set priorities.

  • Learn to say “no” when needed. Our jam-packed schedules are the sworn enemies of sleep. We only get 24 hours in a day, but we act like we can squeeze in another activity by borrowing from our sleep time. It's a common habit, but spoiler alert: it backfires.

  • Skimping on sleep makes us even more tired, which slows us down, so everything drags on longer than it should. And because we get bored more easily when sleep deprived, we end up procrastinating by swapping important tasks for time-wasters (doom-scrolling, video games, and other dopamine boosting activities).

  • It’s time to get better at saying “no” to things we can’t fit in. If we really want to add something to our plates, we need to first give up something else to make room. That might mean cutting down on time-wasters like social media or gaming.

  • If scaling back screen time isn’t enough, it’s time for some serious reflection on what really matters. You can’t be in six AP classes, play on an elite soccer team year-round, join the school team during the season, and be in the band all at once. You can do anything, but not everything!

  • Prioritizing means giving your full attention to what you can manage — without sacrificing sleep or other self-cares.

• Manage stimulants

  • Caffeine is a stimulant with a long half-life, so it stays in your system a long time. Limit use for 8 hours before bedtime to help with sleep. That means a soda with dinner may keep you up or interrupt your sleep cycles even if you fall to sleep. Water or milk would be a better choice for your dinner drink for many reasons.

  • Nicotine is also a stimulant that affects sleep. Nicotine acts as a stimulant, much like caffeine. People who use nicotine spend more time falling asleep, have more sleep disturbances, and generally suffer from poorer sleep quality. If you smoke or vape nicotine products, avoid them for at least 4 hours before bedtime. Of course, the healthiest choice is to stop using nicotine. If you’re trying to quit nicotine, you may also notice sleep problems increase initially. If you’re using a patch, remove it for sleep. Nicotine increases the metabolism of caffeine, so you need more caffeine for the same effect when using nicotine, and if you stop nicotine, you’ll need to significantly cut back on caffeine - start with half of what you previously consumed and adjust as needed. The good news: free help is available to quit! People who use phone coaching and quit medications are twice as likely to successfully quit.

    • Call 1 (800) QUIT-NOW or Text QUIT to 47848.

    • Visit CEASE Tobacco: CEASE, the Clinical Effort Against Secondhand Smoke Exposure for online resources.

    • If you’re in Kansas:

      • The Kansas Tobacco Quitline is a free, 24/7 resource available to Kansas residents to help them quit tobacco. Individuals aged 18 and up may qualify for 4 weeks of free Nicotine Replacement Therapy. The Quitline can be reached by calling 1-800-QUIT-NOW (1-800-784-8669) or visiting https://kansas.quitlogix.org/en-US/

      • The Quitline program also has a program tailored specifically to Kansans aged 13-17. My Life, My Quit can provide free, confidential coaching sessions and provide developmentally appropriate education to teens who want to quit tobacco. Teens can enroll in the program by calling or texting 855-891-9989 or by visiting ks.mylifemyquit.org.

  • If you take ADHD stimulant medications, consult your healthcare provider about the timing and dosage. Taking these medications too late in the day may interfere with falling asleep or your sleep cycle. Consider adjusting the timing or switching to a different medication if sleep problems persist.

• Nap strategically

  • A brief nap when timed right can be refreshing and restorative, but the key is brief. Set an alarm and GET UP when it goes off.

  • Early afternoon (1-3 PM) is when most people experience a natural decline in energy and alertness and is the optimal time for a nap. This is why it can be possible for many teens to fall asleep after school, but they struggle to sleep at the ideal bedtime.

  • Try to nap at least 8 hours before ideal sleep time to avoid problems falling asleep for the night. (Yes, this is hard with school, work, and activity schedules!)

  • For most people, napping for 20 minutes or less will have the most beneficial effect. This allows the body to get some light sleep without entering deep sleep. If you wake up during deep sleep, you may find yourself feeling more tired than you were before the nap.

  • If you’re significantly sleep deprived and have the time, napping for 90 minutes is another option. This allows your body to cycle through the stages of sleep and avoids disrupting deep sleep. It is best done at 1 PM to not affect bedtime. For teens who feel the need to sleep in on weekends to catch up on sleep, it may be more helpful to get up at the same time as usual to promote a healthy sleep cycle but take a 90-minute nap in the early afternoon.

  • If you struggle waking from a nap, a cup of coffee might help. Drink a cup of coffee (without added sugar) right before laying down, then set an alarm for 15-20 minutes. Coffee is preferred over any sweetened caffeinated product because sugar can impact sleep negatively. If you find coffee is too bitter, add a pinch of salt to the coffee grounds before brewing or to your cup of black coffee. (Trust me.) A coffee nap is best taken between 1 and 3 in the afternoon, when there is a natural dip in the circadian rhythm. Caffeine can stay in your system 8 hours, so avoid it later in the afternoon. The nap should be no longer than 15 to 20 minutes to avoid deeper sleep stages. Waking from a deeper stage is more difficult. The short period of sleep will end as the caffeine begins to take effect, making it easier to listen to the alarm and get going.

• Limit sweets and treats

  • Eating sugary foods or foods high in saturated fats close to bedtime are linked to insomnia and poor sleep (in addition to acid reflux — which can further lead to poor quality sleep, obesity, diabetes, and other health complications).

• Restless legs

  • If your child or teen struggles with moving too much at bedtime or feels like there are things crawling in or under their skin, talk to their doctor.

  • Iron deficiency is associated with Restless Leg Syndrome and can be managed with supplements, but following levels of ferritin (an indicator of iron) can help to prevent too much iron from being given and make sure the levels rise as expected with supplementation.

• Exercise regularly

  • Regular physical activity can help reduce hyperactivity, anxiety, and stress, which are common sleep disruptors.

  • Exercise helps to decrease sleep onset (the time it takes to fall to sleep) and improves sleep quality.

  • Try to get some form of exercise, like walking, biking, dancing, or yoga, most days of the week. Find something you enjoy and ask a friend to do it with you to help you start a new habit and stick with it.

• Apps and gadgets

  • Sleep tracking apps or gadgets can provide insights into your sleep habits, but don't get too fixated on the data. It’s more important to focus on how you feel during the day than on perfecting your sleep scores.

  • Use calming apps or sound machines to block out distractions and help create a soothing atmosphere for sleep.

  • Mindful screen usage: Be aware of your screen time & minimize distractions by turning off unnecessary notifications. There are many apps to help schedule time for certain online activities and block them when you should be doing something else. ADHD makes resisting these really hard, so use tools to help!

  • Mindfulness apps can help teach you to calm your mind, which is useful to fall to sleep, even if not used at bedtime. Consistent daily practice can help you learn to have thoughts without judgement and stop the chatter in your mind, which is important at bedtime.

• Melatonin

  • Melatonin is made in a gland in your brain and helps set our circadian rhythm (sleep patterns). Levels increase with darkness, which is why it is necessary to turn off screens prior to bedtime to feel tired.

  • Tryptophan is a building block of melatonin and studies show when people do not take in enough tryptophan, they are more likely to have insomnia. High tryptophan foods include chicken, turkey, red meat, pork, tofu, fish, beans, milk, nuts, seeds, oatmeal, and eggs. Contrary to the common belief that turkey makes you tired, these foods do not make you feel tired but eating them allows you to produce sufficient amounts of melatonin.

  • Melatonin is available as a supplement. Consult with your healthcare professional before using melatonin or other sleep aids. Supplements are not regulated, so they may not contain what is listed on the label, potentially increasing risk. Other means to get to sleep are preferred.

• Practice mindfulness and stress management

  • Stress and anxiety can worsen sleep problems, so finding ways to manage these emotions is crucial.

  • Mindfulness meditation, journaling, or breathing exercises can help calm the mind.

  • Daily exercise has been shown to help stress management.

  • Set aside a "worry time" each day to write down concerns. Total brain dump time. Outside this time if you recognize worry thoughts, tell yourself it’s not time to worry. Knowing that you have time blocked out to worry can really help prevent racing thoughts at bedtime and anxiety during the day. It sounds crazy, but schedule worry time at a time that won’t affect your sleep.

  • Work with a therapist to learn cognitive behavioral therapy tools to help with stress management and anxiety. I teach a lot of these skills in my online workshops for teens (and children 8-12 years) if you feel uncomfortable talking with a therapist but are willing to do an online class.

• Avoid alcohol

  • Alcohol is not recommended for many reasons, but for the purpose of this post, it should be avoided because it interferes with sleep. Even though it can help some people feel tired and fall to sleep, it does not lead to feeling rested in the morning.

  • Alcohol suppresses REM sleep. REM is when our brain organizes and stores memories and is important for mood regulation.

  • Alcohol increases the likelihood of snoring and sleep apnea by relaxing the muscles in the throat, collapsing the upper airway. Sleep apnea causes breathing to repeatedly stop and restart during sleep, affecting the amount of oxygen your body gets. You may wake feeling tired, groggy and not well rested. If left untreated, chronic sleep apnea can lead to serious health concerns, such as weight gain and obesity, hypertension, stroke, memory impairment and heart failure.

  • When you drink alcohol, you are also more likely to need to get up to go to the bathroom during the night, which disrupts your sleep further.

What about CBD?

CBD products are becoming quite popular in the management of chronic pain, anxiety, and sleep.

It’s important to note that CBD isn’t FDA-approved. This means CBD products aren’t regulated by any federal standards or guidelines. Most of these products do not contain pure CBD and may contain other cannabinoids, including delta-9 THC,4 and contaminants, such as pesticides.

In addition to being an unregulated product, potential side effects of CBD include:

• Changes in a person’s ability to be alert

• Changes in a person’s mood

• Fatigue, drowsiness or sedation

• Stomach upset or gastrointestinal distress, such as diarrhea

• Liver damage

• Male reproductive toxicity

• Unknown effects on the developing brain

For more, see this document from SAMHSA: CANNABIDIOL (CBD) – POTENTIAL HARMS, SIDE EFFECTS, AND UNKNOWNS.

Looking for more?

If your teen needs help with sleep, you can and should talk to their physician.

I use a coaching-style approach in my online workshops to help motivate teens to practice healthy life-management skills. The online workshops for teens are offered in an on-demand fashion — you can request a time. Individual workshops last about an hour and cost $100. Groups of 3 or more may last 60-90 minutes, depending upon group participation and are $50 per person. For children 8-12 years of age, the TEACH Me ADHD course is offered several times a year. All the courses are fun and interactive to keep kids and teens engaged.

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