ADHD and the lack of quality sleep

As the new school year begins, it’s only natural that there’s more awareness about learning and behavior issues. One of the most controversial topics that came up frequently is ADHD, or Attention Deficit Hyperactivity Disorder. It’s thought that 2-4% of children have this condition, and a shocking 50% of children with this condition are on some form of prescription medication. Not only is it seen in children, but adults can have it as well. Symptoms include inability to focus or pay attention, being easily distracted, and various behavioral problems in the classroom.

There are a number of proposed explanations for why ADHD occurs, including brain biochemical imbalances, environmental and dietary toxins, and allergic conditions. One possible explanation that never receives very much attention is from lack of deep quality sleep.

Poor sleep can ruin your child’s brain health

It may be coincidence, but it’s estimated that about 2-4% of all children have obstructive sleep apnea. And we know from numerous studies that poor sleep, whether not enough sleep, or poor quality sleep, can adversely affect the brain in a number of different ways.

For one thing, lack of oxygen to the brain has been shown to cause lowered blood flow and metabolism in critical areas of the brain, including parts that involve memory and executive function.

There’s no doubt that hypoxia can cause significant alterations in the levels of neurotransmitters that regulate memory, focus, concentration, and other cognitive skills. If you pick any one out of dozens or hundreds of biochemical markers, you’ll find that there will be a deficiency or an elevation. Whether it’s dopamine, acetylcholine, or serotonin, if you look for abnormalities, you’ll find it. Not too surprisingly, the same can be said for depression, anxiety, and other mood disorders.

Admittedly, ADHD is a multifaceted condition. Sometimes, it’s mainly due to one condition, and in other cases, from a combination of different causes. Not breathing well at night while sleeping can present with the same clinical symptoms as toxic contamination such as lead poisoning. So it’s important to have the pediatrician or other health care professional to look at all possibilities before considering psychotherapy or prescription medications. Only after every treatable condition has been ruled out should the diagnosis of ADHD be given, since ultimately, it’s a diagnosis of exclusion.

First check for sleep apnea, then ADHD

One recent study found that 28% of children scheduled to undergo routine tonsillectomy had official ADHD. Once their tonsils were removed, the rate of ADHD dropped by about 50%. Since these children were selected from a pool of patients that are already predisposed to sleep-breathing problem, it’s only natural that sleep apnea is so common. In another contrasting study, there was no difference in the rate of obstructive sleep apnea between controls and children with ADHD.

One thing that’s for certain, many children with ADHD, even if they don’t officially have sleep apnea, will have major sleep breathing or sleep hygiene issues. This situation is similar to patients who don’t have obstructive sleep apnea but have upper airway resistance syndrome, where they still stop breathing multiple times during the night.

During the initial evaluation process, one of the first things to always consider is the possibility of a sleep-breathing problem. Snoring or breathing problems at night are always a good thing to look for, but you don’t have to snore to have significant obstructive sleep apnea. If your child has very large tonsils, or has frequent throat infections, then consider seeing an ENT surgeon. Chronic nasal congestion or a runny nose can suggest a problem with the upper breathing passageways as well. If one or both parents snore, then even more reason to suspect a possible sleep-breathing problem.

But before you take your child to see a sleep doctor or an ENT surgeon, first try these simple steps to improve their sleep quality.

1.  Take care of any allergies, whether food related or environmental. Allergies can cause inflammation of the upper air passageways that can cause swelling and further narrowing, leading to more obstructions and arousals. If conservative options fail, then see an allergist.

2.  Don’t eat or snack within 3-4 hours of bedtime. Eating close to bedtime allows more stomach juices to be suctioned up into the throat when you stop breathing.

3.  Deal with any nasal congestion. Having a stuffy nose for any reason causes a vacuum effect that allows your tongue to fall back easier when in deep sleep.

4.  Set a regular bedtime routine, with no media (TV, computers or phones) within one hour of going to bed.

5.  Make sure the bedroom is completely dark. Many bedroom appliances, clocks or other devices have exceptionally bright LED bulbs that can prevent proper sleep onset.

If you suspect that your child may have ADHD, the first thing to consider is to consider poor sleep quality as a major aggravator, if not the cause. Yes, you still need to address all the other issues that can aggravate ADHD, such as diet, stimulus control or allergies, but sleep should never be excluded from the list. Even if sleeping better doesn’t’ help with the ADHD, it can definitely help with various other health issues, such as obesity prevention, or lower incidence of asthma, depression, and anxiety. It could even help your child raise his or her test scores.

Steven Y. Park is Clinical Assistant Professor of Otolaryngology at the New York Eye & Ear Infirmary, and author of the book, Sleep, Interrupted: A Physician Reveals The #1 Reason Why So Many Of Us Are Sick And Tired.

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  • Rob Lindeman

    Steve, can we have a citation for the study showing loss of ADHD symptoms s/p T&A?  I wonder how many of these children stayed on meds post-op who no longer needed them.

  • Steven Park


    That study was by Chervin, et al in Pediatrics 117(4) e769-778. These particular children were not on any medications since they were screened from a general ENT population that were scheduled to undergo tonsillectomy, and were found to meet the criteria for ADHD. You could argue that if these children didn’t undergo tonsillectomy, some would have eventually gone on to get diagnosed with ADHD and be placed on a stimulant.

    • Rob Lindeman

      Thanks, Steve!

  • Matthew Toohey MD

    Excellent article.  The effect of good sleep on our health and behavior is constantly overlooked. From newborns all the way up to adults like me (who couldn’t turn off The Bourne Ultimatum last night) poor sleep can be devestating, not just the next day, but in regard to long term behavior (fussy infants, inattentive children, and distracted doctors who comment on blogs between patients).
    In regard to ADHD, I completely agree that it plays a part. Thanks for synopsis, Dr. Park.

  • Anonymous

    How is it shocking that 50% of kids get medication for their ADHD? GIven the penalties these days of a poor education, I think it’s shocking that 50% of them DON’T get medication. What are they supposed to do, borrow someone else’s forebrain? If you said that lots of these diagnoses were incorrect, that might be another story, but I doubt that’s true.
    If I had been medicated when I was in college, I might have graduated many years earlier and saved my Dad LOTS of tuition money, and myself a lot of pain. Instead, it took me an extra 10 years (not all actually in school). I’m sure similar scenarios occur all the time with kids who don’t get medicated.
    While it’s true that apnea and poor sleep can aggravate ADHD, it’s also true that ADHD can CAUSE poor sleep. If I want to sleep in, I do a lot better if I take a little bit of my medication and go back to sleep. I can get much closer to 8 hours of good sleep if I do this. A while back, I developed sleep apnea (or maybe it just got worse). I now use a CPAP machine with  fairly good results (only two yellow stripes in the road instead of 4), but I still have trouble with ADHD.

    It makes sense to check for other possible problems, as treating them will help. But whether it helps or not, these may be problems that are co-morbid with ADHD and not necessarily causes.

  • kristen stuppy

    Great article. Something I talk about routinely with parents at behavior visits.  My only question is how does a child with a 7:30-8pm bedtime NOT eat 3-4 hrs before sleep? Working parents aren’t home to fix dinner by 4pm. Family dinners are also important.  :-)

  • Heidi

    I’ve been “hyper” my whole life – had problems with falling asleep in class throughout high school and can generally fall asleep anytime, anywhere!  – in some ways this has helped me -  could go right back to sleep on call nights but unfortunately would fall asleep during exams or when driving more than 40 minutes or so- was diagnosed with ADHD during residency and narcolepsy only a few years back!
    It’s been cool working as a Pediatrician in the schools with kids referred for “ADHD” because I know there is much more that might be going on and stimulants often help but sleep, exercise, positive feedback etc. so important!

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