Friday, March 09, 2007

Additude Magazine

Additude Magazine

by William Dodson, M.D.
Many adults don’t know that it is AD/HD that is keeping them up at night—or what’s keeping them from waking up in the morning. Find out how to get the rest you need.


There are several theories about the causes of sleep disturbance in people with AD/HD, with a telling range of viewpoints. Physicians base their responses to their patients’ complaints of sleep problems on how they interpret the cause of the disturbances. A physician who looks first for disturbances resulting from disorganized life patterns will treat problems in a different way than a physician who thinks of them as a manifestation of AD/HD.

Thomas Brown, Ph.D., longtime researcher in AD/HD and developer of the Brown Scales, was one of the first to give serious attention to the problem of sleep in children and adolescents with AD/HD. He sees sleep disturbances as indicative of problems of arousal and alertness in AD/HD itself. Two of the five symptom clusters that emerge from the Brown Scales involve activation and arousal:

* Organizing and activating to begin work activities.
* Sustaining alertness, energy, and effort.

Brown views problems with sleep as a developmentally-based impairment of management functions of the brain—particularly, an impairment of the ability to sustain and regulate arousal and alertness. Interestingly, he does not recommend treatments common to AD/HD, but rather recommends a two-pronged approach that stresses better sleep hygiene and the suppression of unwanted and inconvenient arousal states by using medications with sedative properties.

The simplest explanation is that sleep disturbances are direct manifestations of AD/HD itself. True hyperactivity is extremely rare in women of any age. Most women experience the mental and physical restlessness of AD/HD only when they are trying to shut down the arousal state of day-to-day functioning in order to fall asleep. At least 75 percent of adults of both genders report that their minds restlessly move from one concern to another for several hours until they finally fall asleep. Even then, they toss and turn, awaken frequently, and sometimes barely sleep at all.

The fact that 80 percent of adults with AD/HD eventually fall into “the sleep of the dead” has led researchers to look for explanations. No single theory explains the severe impairment of the ability to rouse oneself into wakefulness. Some AD/HD patients report that they sleep well when they go camping or are out of doors for extended periods of time. Baltimore-based psychiatrist Myron Brenner, M.D., noted the high incidence of AD/HD individuals among the research subjects in his study of Delayed Sleep Phase Syndrome (DSPS). People with DSPS report that they can experience a normal sleep phase—For example, get into bed, fall asleep quickly, sleep undisturbed for eight hours, and awake refreshed—but that their brains and bodies want that cycle from 4 a.m. until noon. This is a pattern reported by more than half of adults with AD/HD. Brenner hypothesizes that DSPS and the sleep patterns of AD/HD have the same underlying disturbance of circadian rhythms. Specifically, he believes that the signal which sets the internal circadian clock (the gradual changes in light caused by the sun’s setting and rising) is weak in people with AD/HD. As a result, their circadian clock is never truly set, and sleep drifts into to the 4 a.m.-to-noon pattern or disappears entirely, until the sufferer is exhausted.

One hypothesis is that the lack of an accurate circadian clock may also account for the difficulty that many with AD/HD have in judging the passage of time. Their internal clocks are not “set.” Consequently, they experience only two times: “now” and “not now.” Many of my adult patients do not wear watches. They experience time as an abstract concept, important to other people, but one which they don’t understand. It will take many more studies to establish the links between circadian rhythms and AD/HD.

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