ADHD and insomnia in adults

A night some adults with ADHD know well: tired all evening, then wide awake at bedtime, mind running, finally falling asleep long after midnight, and dragging through the morning. Poor sleep then makes attention worse the next day. Insomnia and ADHD often occur together, and ADHD treatment itself can affect sleep. This page covers what research shows, how a clinician sorts out the causes, and what treatment guidelines recommend.

For a broader look at sleep problems in ADHD, including restless legs and sleep timing, see ADHD and sleep problems. Because sleep apnea can itself cause ADHD-like symptoms, ADHD or sleep apnea is also worth reading.

What counts as insomnia

The National Heart, Lung, and Blood Institute (NHLBI) describes insomnia as trouble falling asleep, staying asleep or getting good-quality sleep, even when you have the time and the right setting to sleep. Short-term insomnia can follow stress or schedule changes and last days or weeks. Chronic insomnia happens 3 or more nights a week, lasts more than 3 months, and cannot be fully explained by another health problem. NHLBI notes that insomnia can affect memory and concentration, which is exactly where ADHD already causes trouble.

How often insomnia and ADHD occur together

A 2017 review in Current Psychiatry Reports pulled together the adult research:

• Clinical and population studies found insomnia in 43% to 80% of adults with ADHD. The review notes insomnia is common in the general population too, with reported prevalence from 31% to 56% depending on definition.
• Evidence on whether childhood ADHD leads to insomnia later in life is mixed: one long-term study supported a link and another did not.
• The reasons are not fully understood, though both genetic and environmental factors may play a part.

One explanation has good support: a late-running body clock. In a 2010 study in Biological Psychiatry, adults with ADHD who had trouble falling asleep went to sleep and woke later and had a later rise in evening melatonin than both adults with ADHD without insomnia and healthy controls. The authors suggested that treatments aimed at shifting the body clock should be studied. That is a reason to track when you fall asleep and wake on free days, not only how many hours you sleep.

When the medication is part of the problem

ADHD medications can cause insomnia. In adult trials, insomnia is listed among the most common side effects on the prescribing information for:

NICE guideline NG87 advises monitoring changes in sleep pattern, for example with a sleep diary, and adjusting medication accordingly. What adjustment fits is a decision for the prescriber, made with your sleep record in hand. More detail is in ADHD medication and sleep.

Insomnia is not always a medication effect. The 2017 review describes insomnia as frequently comorbid with adult ADHD itself, so a record of your sleep before starting medication gives a useful baseline.

How the evaluation looks at sleep

NICE asks clinicians to build an ADHD treatment plan around how symptoms affect everyday life, and it names sleep specifically. NICE also says the diagnostic process should include an assessment of coexisting conditions and physical health. Dr. Shershow's adult ADHD evaluation covers current symptoms, childhood, school and work history, health, medications, sleep and substances, and other explanations for symptoms, including sleep problems, either instead of ADHD or alongside it.

Useful things to bring or track for a week or two:

• Bedtime, time you actually fall asleep, night awakenings and wake time, on workdays and free days.
• Caffeine, alcohol, nicotine and screen use in the evening.
• Snoring, gasping or pauses in breathing that a partner has noticed, and urges to move your legs at night.
• Every medication and supplement, with the time you take it.

NHLBI notes that clinicians often ask people with insomnia to keep a sleep diary, so this record serves both questions.

Questions worth asking your prescriber if sleep is a problem on ADHD medication:

• Could the timing of my dose be affecting my sleep?
• Is my sleep record pointing to the medication, to a late body clock, or to something else?
• Would a different formulation or a nonstimulant be worth discussing?
• Should a sleep evaluation or CBT-I be part of the plan?

What treatment for insomnia looks like

The 2017 review concludes that adults with ADHD should be assessed for insomnia and that both conditions should be treated. For the insomnia part, the guidance is clear:

• CBT-I first. The American Academy of Sleep Medicine's 2021 guideline makes a strong recommendation for multicomponent cognitive behavioral therapy for insomnia (CBT-I) in adults with chronic insomnia, with or without other conditions. NHLBI describes CBT-I as a 6 to 8 week program and the usual first treatment for long-term insomnia.
• What CBT-I includes. According to NHLBI, it combines cognitive therapy, relaxation, sleep education and sleep restriction, and it can be done in person, by phone or online.
• Habits that support it. NHLBI lists regular sleep and wake times, a cool, quiet and dark bedroom, avoiding screens at bedtime, and limiting caffeine, nicotine and alcohol close to bed.

CBT-I is delivered by a trained clinician such as a psychologist, therapist or sleep medicine program. Dr. Shershow's practice does not provide therapy, including CBT-I, but sleep is part of how ADHD treatment is planned and adjusted. If the evaluation suggests a separate sleep disorder, such as possible sleep apnea, a sleep medicine evaluation may be the next step.

When to talk to a clinician

If poor sleep has lasted months and comes with lifelong trouble with attention, organization or restlessness, it can be worth asking about both. Bring a sleep diary if you can. The adult ADHD self-test can help you describe attention symptoms before a visit; it is a screener, not a diagnosis. To arrange an ADHD evaluation, see ADHD testing in NYC or ADHD testing in New Jersey, or call the office. If you already take ADHD medication and sleep has worsened, tell your prescriber rather than changing the timing on your own.