Sleep
Sleep issues are incredibly common in children with neurodevelopmental disorders and/or mental health conditions and can have a huge impact on functioning.
Many parents can relate to the child who is quite “off”, inattentive, and daydreaming during the day … but come 10 pm is WIDE AWAKE and wanting to discuss climate change, capital cities of the world or life on alternate planets. Alternatively, you may have one of those kids who are “on” all day to the point where everyone is exhausted, but, come bedtime, will not GO TO SLEEP. Finally, there are the kids who become very anxious at night and may want to discuss all their fears before they can get to sleep (with the light on, after a head pat, a drink of water, and three snacks, of course).
Sleep is known to be impacted in ALL neurodevelopmental and psychiatric disorders (Mathew Walker’s book – Why We Sleep: The New Science of Sleep and Dreams” is a great read for anyone wanting to dive deeper). The underlying causative mechanisms of sleep disturbance are complex involving genetics, neurotransmitter systems, disrupted circadian rhythms, obstructive sleep apnoea, anxiety, and other medical disorders. Most studies are correlational, and it seems unlikely that there is a single causative factor underlying sleep difficulties.
Children (and adults) with ADHD/autism have real difficulties getting to sleep. Sleep difficulties include resisting bedtime, insomnia (a big one in my house), delayed sleep onset, night wakings, and daytime sleepiness. There is a huge academic literature covering sleep and ADHD/autism. A quick PubMed search brings up thousands of research articles. A recent meta-analysis of 13 studies (a total of 2,465 adolescents and 18,417 controls) found that teens with ADHD report significantly more sleep problems than their peers (Marten et al., 2023). The authors suggest including an assessment of sleep problems in the diagnostic process. Interestingly, ‘restless sleep’ was considered a symptom for diagnosing ADHD in the DSM-III (it was removed in 1987). Sleep is similarly impacted in autism. A 2006 study that included 167 autistic children found that 86% had at least one sleep problem, most commonly insomnia (Liu et al., 2006).
While the effects of insomnia may be compounded by the stimulant medications used to treat ADHD, many parents report that sleep disturbances were present from early infancy and childhood, before their child began the medication. A large-scale epidemiological study in 2019 found that almost half of 2-to-5-year-old children who had autism or a neurodevelopmental disorder with similar features have significant difficulties with sleep (Reynolds et al., 2019).
Sleep problems do not only affect the child – they affect the entire family. I have written in the past about co-regulation and the way that stress affects the dynamics of emotion regulation within the family see HERE. A common scenario in many of the families I work with is “end-of-the-day chaos”. As parents, we are tired, overwhelmed, busy, and (possibly) irritable. At precisely the time when we most need quiet and calm (and want to watch Netflix), we have a child who cannot sleep and may be very distressed. It can become a vicious, stressful cycle and it has an impact. Research shows that parents of children with ADHD/autism and co-occurring sleep difficulties report more mental health challenges and higher parenting stress (Martin et al., 2019).
Poor sleep will affect children the next day. Lack of sleep affects all cognitive skills including executive functioning. Given executive functions can lag 3-5 years in kids with neurodevelopmental disorders, a poor night’s sleep packs a double whammy. Sleep disturbances in children ages 7-9 are significantly correlated with decreases in executive function skills, in particular inhibitory control and working memory. Both skills are vital in the classroom and in navigating friendships (Chen et al., 2021).
Sleep difficulties affect learning as sleep plays an important role in the consolidation of procedural memories. A recent study showed that kids with ADHD performed similarly to peers on the initial learning of a task but did not improve in the same way as neurotypicals following a sleep interval (Ballan et al., 2022). This study was the first to show that sleep does not produce skill memory benefits in ADHD in the same way it does for kids without ADHD. Procedural memory is our implicit (unconscious learning) of new tasks, e.g., riding a bike, tying shoe laces, playing an instrument, writing etc. This is important as we know that neurodevelopmental disorders are dynamic. Many parents I work with notice that some days their child is on top of their game and able to complete daily activities with ease. On other days, it is like these same skills have disappeared into thin air. This can be really frustrating for both child and parent. My hunch is that sleep difficulties are strongly tied to the dynamic nature of these skills in neurodiverse children.
We sleep to “learn and remember”. As we sleep the hippocampus sends information that it has stored during the day to the cerebral cortex where it can be consolidated so that we can recall it later. During rapid eye movement (REM) sleep, we dream, and our brain replays “memories” and creates connections between cortical regions. REM sleep is considered “paradoxical sleep” as patterns of brain activity measured by EEG look almost identical to when we are awake. In contrast, nonREM sleep (where we do not dream) is associated with weeding out unnecessary connections. Deep, restorative slow-wave sleep is generated by (you guessed it) – the frontal lobes and we know that a lack of sleep has a profound impact on emotion regulation and cognitive processing. Even a single night of sleep deprivation will result in an immediate decrease in working memory capabilities (e.g., Kopasz et al., 2010).
A systematic review of world literature shows us that over the last 103 years, there have been consistent rapid declines in the sleep duration of children and adolescents (equalling around an hour a night) (Cook et al., 2020). With the invention of light – came the disruption of sleep. Electric light tricks our brain into thinking the sun has not set and fools the regions of the brain that produce melatonin.
Melatonin usually has our 9-year-olds asleep by 9 pm. The teenage years are associated with massive neurodevelopmental changes (particularly in the frontal lobe and executive functions). However, during the teenage years – melatonin levels do not rise until FAR later and teens are not ready to sleep until close to midnight (this does normalise in early adulthood). For any parent trying to get a teen to bed at night or up in the morning – you are not alone! Early school times are NOT designed for the teenage brain and teenagers tend to be incredibly sleep-deprived at a key time in their development.
Sleep is a modifiable factor that has a powerful contribution to mental health and well-being. Poor sleep is linked to mental health problems later in childhood and children who have persistent sleep problems report more internalising and externalising problems in middle childhood (ages 10-11 years) (Williamson et al., 2019)
An Australian study that assessed 934 school students in 2020 found that only 2% of school children were meeting criteria for sleep, physical exercise, and screentime (Howie et al., 2020). A recent paper by the MATILDA Centre investigated the association between modifiable behaviours (things we can change) and mental health among 6,640 Australian students in year 7 (median age 12.7 years) (Smout et al., 2022). Children who had the worst mental health scores:
Got less than 9 hours of sleep a night.
Did not eat regular servings of fruit and vegetables.
Regularly consumed sugar-sweetened beverages.
Did not exercise frequently.
Spent a lot of time on screens (14% were spending over 8 hours a day online).
Australian research has found that children who were not meeting minimum guidelines for sleep were more likely to have symptoms of poor mental health and have internet access in the bedroom or spend more time online (Evans-Whipp et al., 2018). Spending multiple hours per day on a screen is associated with shorter sleep duration for children of all ages (Twenge et al., 2019). There are many good reasons to keep screens out of the bedroom and you can see how factors such as lack of exercise, poor diet, excess screen time, and poor sleep have a cumulative contribution to poor mental health.
It is worth taking note of a few other things that, in my experience, may be linked. For example, many parents I have spoken with report that their child is sensitive to light (this may be related to stimulant medications). Another thing that is frequently mentioned is migraine (which can be debilitating). The association between migraine and ADHD has been confirmed in the literature (Salem et al., 2017). It is worth tracking symptoms such as sleep patterns, light sensitivity, and migraine and discussing them with your paediatrician.
Finally, a few tips to help your child (and you!) get a better night’s sleep:
No screens an hour or two before bed. Blue light from iPads/screens suppresses melatonin and the addictive nature of screens and the continuous scroll can be over-stimulating thanks to constant rewarding dopamine hits and the power of intermittent reinforcement. Screens in the bedroom have been consistently linked to poor sleep.
Avoid strong LED lights in the evening and dim lights in the bedroom before bedtime.
Ensure your child has as much outdoor time, exposure to natural light, and exercise in the day as possible. Exercise boosts sleep (just not too close to bedtime).
Avoid sleeping in a room that is too warm. To fall asleep, we need to decrease our body temperature by 1 degree. A shower before bed warms us up and then rapidly cools us down which can help promote sleep.
Regular sleep/wake times and a consistent routine before bed are often helpful. Despite protests about bedtime, kids love the safe predictability of routine.
Be aware of the time of day your child last took medication (or had a drink that contained high levels of sugar or caffeine).
If your child does not like reading before bed, try some other form of quiet time in bed such as drawing or sorting Pokémon cards.
Ensure time for connection just before sleep. This works well in my house and my favourite chats with my boys are often just before they fall asleep.
Melatonin can be beneficial, however, please discuss this with your paediatrician or doctor. Melatonin is not sold over the counter in Australia for children/young adults and should not be bought online without careful discussion with a doctor (who may prescribe it).
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References
Ballan, R. et al. (2022). A failure of sleep-dependent consolidation of visuoperceptual procedural learning in young adults with ADHD. Translational Psychiatry, 12, 499.
Chen, Y. et al. (2021). Self-Reported Sleep and Executive Function in Early Primary School Children. Frontiers in Psychology, 12: 793000.
Cook, F., et al. (2020). Infant sleep and child mental health: a longitudinal investigation. Archives of Disease in Childhood, 105(7): p. 655-660.
Evans-Whipp, T. & C. Gasser, C. Are children and adolescents getting enough sleep? In G. Daraganova and N. Joss (Eds.), Growing Up In Australia – The Longitudinal Study of Australian Children, Annual Statistical Report 2018. Melbourne; Australian Institute of Family Studies. 2018.
Howie, E.K., et al. (2020). Associations between meeting sleep, physical activity or screen time behaviour guidelines and academic performance in Australian school children. BMC Public Health, 20: p. 1-10.
Kopasz, M. et al. (2010). Sleep and memory in healthy children and adolescents – a critical review. Sleep Medicine Reviews, 14(3):167-77.
Liu, X. et al. (2006). Sleep disturbances and correlates of children with autism spectrum disorders. Child Psychiatry & Human Development, 7(2):179–91.
Marten, F., et al. (2023). Sleep parameters and problems in adolescents with and without ADHD: A systematic review and meta‐analysis. JCPP Advances, 2023: p. e12151.
Martin, C.A., et al. (2019). Associations between parenting stress, parent mental health and child sleep problems for children with ADHD and ASD: Systematic review. Research in developmental disabilities, 93: p. 103463.
Reynolds, A. et al. (2019). Sleep problems in 2- to 5-year-olds with autism spectrum disorder and other developmental delays. Pediatrics, 143(3):e20180492.
Salem, H. et al. (2017). ADHD is associated with migraine: a systematic review and meta-analysis. European Child & Adolescent Psychiatry, 27, 267-277.
Smout, S., et al., Dose–response associations between modifiable lifestyle behaviours and anxiety, depression and psychological distress symptoms in early adolescence. Australian and New Zealand Journal of Public Health, 2022. 47(100010): p. 1-12.
Twenge, J.M. et al. (2019). Associations between screen time and sleep duration are primarily driven by portable electronic devices: Evidence from a population-based study of US children ages 0–17. Sleep Medicine, 56: p. 211-218.
Williamson, A.A., et al. (2019). Sleep problem trajectories and cumulative socio-ecological risks: birth to school-age. The Journal of Pediatrics, 215: p. 229-237.