Sleep Deprivation and ADHD

In anger I threw my pager across the on-call room, slamming it against the wall. I don't anger easily or often, but I was a pediatric resident who had been awake for 36 hours. The pager had gone off one time too many. Sleep deprivation had changed me from a calm, caring person into an irritable, impulsive mess.

As if it shouldn’t have been obvious, research has shown that the sleep deprivation associated with medical residents’ on-call schedules brings about significant “impairment of physician mood” as the sleep deprivation increases.

The latest research shows that partial, or low-level, sleep deprivation has just as big of a negative effect on behavior, mood, and impulsivity as both the short or long-term complete sleep deprivation experienced by medical residents. Until recently, the effects of partial sleep deprivation have been seriously underestimated.

Sleep Deprivation and Kids

We know, based on common sense, that inadequate sleep makes kids more moody, more impulsive, and less able to concentrate. We’ve known for more than 20 years that sleep deprivation makes it difficult to learn.

Recent research has verified that chronic poor sleep results in daytime tiredness, difficulties with focused attention, low threshold to express negative emotion (irritability and easy frustration), and difficulty modulating impulses and emotions. These are the same symptoms that can earn kids the diagnosis of attention deficit hyperactivity disorder (ADHD, also popularly known as ADD).

ADHD is an important problem in its own right, but research in sleep laboratories has shown that some (and perhaps a great many) kids are mislabeled with ADHD when the real problem is chronic, partial sleep deprivation.

When children are identified with symptoms of ADHD, often no one thinks to explore the child’s sleeping habits, and whether those might be responsible for the symptoms. (People also forget to consider childhood depression as a possible cause for these symptoms — but that is another story.)

Symptoms of Sleep Deprivation in Kids

Sometimes it is obvious to parents that their children are not sleeping well — but not always!

Any child who snores may not be getting adequate sleep. Obstructive sleep apnea is a common medical condition that is now being identified in more and more children. The peak age for this is 2 to 5 years old, but it can occur at any age. Not all kids who snore have sleep apnea. Classically, those with sleep apnea snore quite loudly for a bit, then are silent, then snort briefly, move about, and resume snoring. If snoring is accompanied by nighttime breathing difficulty and pauses in breathing, then it may well be sleep apnea. This should be brought to the attention of your pediatrician. You might want to take a quick video of your child’s sleep noises and movements to bring with you.

Children with sleep apnea do not get sound sleep. They may also get suboptimal oxygen to the brain at night. Obstructive sleep apnea can have a serious negative impact on a child’s intellect and behavior. The common symptoms of sleep apnea are difficulty paying attention during the day, decreased academic performance, oppositional behavior, and restlessness. Not all kids with sleep apnea snore. Even when they do, sleep apnea is often overlooked. Instead, the child is diagnosed with a behavioral disorder — most commonly ADHD.

Children with sleepwalking, restless leg syndrome, narcolepsy, insomnia, or other sleep problems may also be misdiagnosed with ADHD.

Is it ADHD or Sleep Deprivation?

When parents of children with ADHD are interviewed, they usually identify their kids as poor or restless sleepers. Kids who have been diagnosed with ADHD do wake up more often at night than their peers. Poor sleep is a common feature of ADHD — a problem that can be made worse by the use of stimulant medications such as Ritalin or Dexedrine. In fact, recent studies have reported sleep problems in almost 75% of children and adolescents with ADHD.

In an individual child, it can be very difficult to tease apart whether interrupted sleep is the cause or the result of ADHD. ADHD is a 24-hour disorder and the disorder in itself can cause poor sleep.  The good news is that even when ADHD is the correct diagnosis, addressing the sleep issues can dramatically improve the behavior of the child. In fact, a sleep evaluation is now part of the standard workup for children when a diagnosis of ADHD is being considered.

A 10-year-old girl in Pittsburgh, Pennsylvania who had true ADHD also had significant sleep difficulties. She had long delays before falling asleep. She would often wake up at night and have difficulty falling back asleep. She received professional help for her sleep problem (chronotherapy combined with a behavior modification program), which resulted in an increase of sleep from 7.2 to 9.2 hours per night. There was significant, measurable improvement in her schoolwork, teacher evaluations, and behavior. These changes were observed by teachers and peers who were not aware of her treatment.

What Should You Do If Your Child has ADHD Symptoms?

If your child has ADHD or other behavior problems, he or she should be carefully assessed for sleep problems. If sleep disturbances are present, they need to be addressed, regardless of whether or not they are the root cause. If your child is not getting sound, uninterrupted sleep, discuss this with your pediatrician. You may also want to contact the National Sleep Foundation or the  American Sleep Association for information or referrals. There are now more than 3,000 Sleep Disorders Centers that can provide the kind of help the little girl from Pittsburgh received. Another great resource is Helping Your Child Sleep Through the Night, by Joanne Cuthbertson and Susie Schevill.

It is also important to follow good sleep hygiene for yourself and your child in order to help them function at their best during the day.  These recommendations include a healthy diet, daily physical activity, avoiding screens before bedtime, and having a consistent bedtime and wake-up schedule.

How do we know how much sleep our children need? First and foremost, every child is different. In general, toddlers and preschoolers sleep approximately 12 hours per day with one nap. School-age children need less, about 10 hours per day. Most preteens and teens need around 9 hours of sleep per day – though we all know that many teens get much less!

These are just averages! Some children need much more sleep than these numbers, others much less. Many sleep experts recommend asking yourself some questions to determine if your child is getting too little sleep.

These include:

  • Does your child seem sleepy or irritable during the day?
  • Does your child have difficulty staying awake when sitting still?
  • Does your child have trouble paying attention at school or at home?
  • Does your child seem to perform below his or her potential?
  • Does your child have emotional outbursts?

As parents, we all know what it feels like to be grumpy, contrary, and “not at our best” from lack of sleep. If our kids often feel this way, we owe it to them to find solutions to this problem.

References and Resources

Alhola P, Polo-Kantola P. Sleep deprivation: Impact on cognitive performance. Neuropsychiatr Dis Treat. 2007;3(5):553-567.

Howard SK. Sleep deprivation and physician performance: why should I care?. Proc (Bayl Univ Med Cent). 2005;18(2):108-113. 

Ingvild Saksvik-Lehouillier, et al, Mild to moderate partial sleep deprivation is associated with increased impulsivity and decreased positive affect in young adults, Sleep 2020; 43 (10)): Issue 10

Owens JA. A clinical overview of sleep and attention-deficit/hyperactivity disorder in children and adolescents. J Can Acad Child Adolesc Psychiatry 2009;18(2):92-102.Tsai, M., Hsu, J. & Huang, Y. Sleep Problems in Children with Attention Deficit/Hyperactivity Disorder: Current Status of Knowledge and Appropriate Management. Curr Psychiatry Rep 2016;18:76.

Last medical review on: January 09, 2021
About the Author
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Dr. Greene is a practicing physician, author, national and international TEDx speaker, and global health advocate. He is a graduate of Princeton University and University of California San Francisco.
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