Sleep Problems in Children With ADHD: Refusing Bed, Sleeping Late

Nine o'clock. The child is not going to bed. Half past nine, still busy with a toy. Ten o'clock, the parent is exhausted and the child has only just warmed up.

Sleep problems are one of the most commonly described kinds of exhaustion in families of children with ADHD. And this is not only a matter of upbringing. For adults there is the article on ADHD and sleep; here we look at the child's side.

How common

The meta-analysis by Cortese and colleagues showed that sleep problems are seen more often in children with ADHD than in a control group. Hvolby's review also notes that this relationship appears in both subjective (parent report) and objective measurements, but that there are differences between studies.

An important note: a sleep problem can increase ADHD symptoms; a tired child is more inattentive, more impulsive, angrier. These two topics can feed each other.

Why sleep gets harder

Several factors can work together:

• A drifting body clock. In some children with ADHD the sleep-wake cycle drifts late; the child falls asleep late in the evening and has difficulty getting up early in the morning.
• High arousal. The brain has difficulty switching to "off" mode; screens, play and noise can make this transition even harder.
• Difficulty with transitions. When moving from activity to activity is already hard, going to bed, the last transition of the day, can be the hardest.
• Medication. Stimulant medications can keep acting into the evening hours in some children and delay falling asleep. The dose time can be discussed with the doctor.
• Co-occurring conditions. Anxiety, restless legs, sleep apnea and snoring look similar and are evaluated separately.

For this reason, if there is a sleep problem, it needs to be addressed separately when the ADHD diagnosis is made or treatment is planned. How this question figures in the diagnostic process: how ADHD is diagnosed in children.

A routine that works at home

Fixed hours. Keep the difference between bedtime and wake time on weekdays and weekends small. Irregularity shifts the body clock even further.

Slowing down before bed. An hour before sleep, reduce stimulation: dim the light, lower the sound, end the active play. A short routine done in the same order every evening (washing, brushing teeth, a book) signals "sleep time" to the brain.

Screens. Putting the screen down at least an hour before getting into bed and taking the device out of the bedroom is the most decisive step in most families. Details are in the article on screen time and ADHD in children.

Movement during the day. Plenty of movement during the day, especially outdoors, increases sleep pressure in the evening. The article on sports and movement gives details. Intense exercise right before bed should be avoided.

The bedroom. Cool, dark and calm. For some children a dim night light or white noise can help.

A visual plan before bed. A bedtime list with pictures reduces the question "what will I do" and the bargaining. It must be prepared together with the child.

Not prolonging the putting-to-sleep job. Staying beside the child for hours at night solves it in the short term but can create dependence in the long term. For methods such as gradual withdrawal you can consult your doctor.

Caffeine and mealtime

Even for children, caffeinated things like tea, cola and chocolate can delay sleep in the evening hours. A heavy dinner can also be disturbing. On this topic there is a separate article on nutrition myths: ADHD and nutrition in children.

On melatonin and medication

The study by Van der Heijden and colleagues reported that in children with ADHD and difficulty falling asleep, melatonin moved the time of falling asleep earlier. However, even if it is a supplement, melatonin behaves like a medication; dose, time and duration are the doctor's decision. Do not give it to your child on your own.

If medication is being used, changing its time or stopping it is also the doctor's decision. For worries about medication you can read the article on medication and growth in height.

When to see a doctor

• If there is snoring, pauses in breathing during sleep or mouth breathing
• If the child wakes up often and for a long time at night
• If the sleep problem lasts longer than a few weeks and disrupts school functioning
• If the child is excessively sleepy or very angry during the day
• If nightmares or night terrors are intense

This article is for information purposes; the decision for your child belongs to the doctor who evaluates them.