This past weekend, an article entitled, “Diagnosing the Wrong Deficit,” , a psychiatrist named Vatsal Thakkar writes about the relationship between sleep disorders and attention deficit hyperactivity disorder in both children and adults. This is a great article and I would recommend that you read the whole thing. I especially appreciate his sharing his own diagnosis of atypical narcolepsy as an adult.
I’ve written previously on the connections between ADHD and sleep disorders in children. To summarize, both inadequate and disrupted sleep (for example, in obstructive sleep apnea) can cause problems with attentiveness and behavior similar to that of attention deficit hyperactivity disorder. Dr. Thakkar opens his article with the story of a patient presenting at age 31 with “the classic symptoms: procrastination, forgetfulness, a propensity to lose things and, of course, the inability to pay attention consistently.” However, this patient’s symptoms began at age 31, which does not fit the classic profile of ADHD:
It turned out he first started having these problems the month he began his most recent job, one that required him to rise at 5 a.m., despite the fact that he was a night owl.
The patient didn’t have A.D.H.D., I realized, but a chronic sleep deficit. I suggested some techniques to help him fall asleep at night, like relaxing for 90 minutes before getting in bed at 10 p.m. If necessary, he could take a small amount of melatonin. When he returned to see me two weeks later, his symptoms were almost gone.
To me, this is the key point of the piece. So many children, teens, and adults are not getting enough sleep, and suffering as a result. In my practice, this is especially common in teenagers in whom high academic workloads and early school start times contribute to chronic structural sleep deprivation, which leads to (again) attentional problems, depression, lower test scores, and an increased risk of car accidents.
Clearly, children (and adults) with problems paying attention or performing at work or school should have a sleep evaluation. Some people will need a sleep study or evaluation by a specialist. However, EVERYONE will benefit from getting enough sleep at night. There’s a great article on the National Sleep Foundation website about how much sleep people need at various ages. Some rough rules of thumb for sleep at night:
- Preschoolers (age 3-5) need 11-13 hours of sleep
- Elementary school age children (5-10 years of age) need 10-11 hours of sleep
- Teenagers (age 11-17 years) need 8.25-9.5 hours of sleep
- Adults need 7-9 hours of sleep at night.
Very few of my patients (or their parents) would not benefit from more sleep. I think that small incremental changes are a good place to start. When I’m negotiating with teenagers around sleep schedules, I start with an extra 30 minutes of sleep a night. That is almost an extra half night of sleep/week. Chronic sleep deprivation adds up, but so do improvements in habit and routine. Lately, I’ve been trying to go to bed earlier and have noticed a lot of improvement in my mood and productivity.
Does your child get this much sleep at night? Do you? If not, how can you make this better?
I’m so glad to read your thoughts on Thakkar’s article. I’m not a medical professional, but I think I do have some perspective on some cultural phenomena underlying our collective sleep deficit (and subsequent ADHD-like behavior).
The first is the common attitude towards sleep these days as something for the weak and the lazy (a favorite coffee shop of mine even sold t-shirts that read “Sleep is for the weak”). When we speak of sleep deprivation as something noble, and express admiration for people who brag that they only need 4 hours (so they say), kids pick up on that. Even kids as young as 2 and 3.
Secondly, our culture of pill-taking is surely behind the explosion in ADHD diagnoses as well. Personally, I am grateful for all the pharmaceutical innovations that allow people to regulate their thyroids, keep their bi-polar disorder at bay, etc. But I think there’s this broad desire to view pills as simple problem solvers. Dr. Thakkar mentioned that some patients are reluctant to undergo sleep tests and just want pills to help alter their behavior. It reminded me of an article I read once about childhood incontinence, which can sometimes be caused by severe constipation (I guess the blocked colon presses on the bladder, causing it to leak). Anyway, one girl’s mother refused to accept constipation as a possibility and demanded a prescription instead, even though constipation is a non-chronic, easily correctable condition. To me, that diagnosis would’ve come as a relief! As would the possibility that ADHD-like symptoms could be alleviated with some alteration of my bedtime routine instead of a lifetime of (expensive) medication. But I also suppose it is very hard for doctors to convince patients to alter their behavior.
Finally–I do wonder about the pharmaceuticals used to treat ADHD in light of Thakkar’s hypothesis. If sleep deprivation is a huge underlying factor in ADHD-like behavior, then might administering a form of speed be undermining the treatment?
Lots of good points here. I think that yes, generally, post people would prefer to take a pill (perceived as easy and safe) rather than undergoing cumbersome night testing. There can also be significant pressures from the school to treat disruptive children which is partly a function of less school funding and a higher student to teacher ratio.
I especially like your point about the medications themselves disrupting sleep. Most prescribers of stimulants conscientiously monitor insomnia, which is a well know side effect of stimulants. Sometimes I have been in a position as a prescriber where you have to contemplate both a wakefulness and sleep promoting agent– I often push for stopping both agents if possible.