Sleep disturbances in children and adolescents with attention-deficit/hyperactivity disorder: A narrative review

Abstract

Sleep disturbances and disorders are commonly associated with attention-deficit/hyperactivity disorder (ADHD), with affected children frequently experiencing delayed sleep onset, frequent nighttime awakenings, morning fatigue, and excessive daytime sleepiness. A bidirectional relationship exists between ADHD and sleep disturbances: Sleep deprivation is linked to increased inattention and emotional dysregulation, while evening hyperactivity and impulsivity may contribute to difficulty falling asleep. Central nervous system stimulants remain the first-line treatment for managing ADHD symptoms; however, insomnia can be a common side effect. Notably, newer and long-acting stimulants formulations have demonstrated extended benefit into evening with limited impact on sleep in recent studies. This narrative review summarizes the various sleep disorders associated with ADHD, outlines clinical approaches for sleep assessment, and evaluates the impact of ADHD treatments on sleep. It also highlights both non-pharmacological and pharmacological interventions for managing sleep problems in children with ADHD. Finally, the review offers practical recommendations to help clinicians optimize both sleep and daytime functioning in patients with ADHD. ADHD should be conceptualized as a 24-hour disorder, requiring integrated treatment strategies that address both daytime symptoms and nighttime sleep challenges.

Key Words: Attention-deficit/hyperactivity disorder; Sleep disorders; Psychopharmacology; Sleep hygiene; Children and adolescents

Core Tip: Children with attention-deficit/hyperactivity disorder (ADHD) frequently experience sleep disturbances, and many primary sleep disorders can worsen attention, hyperactivity and emotion regulation. It is essential for clinicians to assess for underlying sleep issues in children referred for ADHD evaluation. Recognizing that ADHD can impact both daytime functioning and nighttime sleep supports a comprehensive treatment approach that combines behavioral strategies, medication adjustments, and targeted sleep interventions. This review offers practical guidance to help clinicians effectively manage both sleep and ADHD symptoms, ultimately improving clinical outcomes.

INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) is a chronic and pervasive neurodevelopmental disorder, with prevalence estimates around 6% among school-aged children[1]. ADHD is associated with significant functional, occupational, and educational impairments[1]. Although evidence-based treatments for ADHD are effective[2] and have been shown to improve long-term outcomes[3], yet they are only moderately impactful for improving functioning across various domains of life[4].

Central nervous system (CNS) stimulants are considered the first-line treatment for children with ADHD; however, one of their most commonly reported side effects is delayed sleep onset[5]. Furthermore, sleep problems are more prevalent among children with ADHD and contribute to significant impairments in overall well-being—not only for the individuals themselves but also for their caregivers[6,7]. Sleep disturbances in children with ADHD have been linked to poorer psychosocial quality of life, reduced daily functioning, and increased caregiver mental health concerns, including stress, anxiety, and depression[6]. In fact, primary caregivers of children with ADHD were found to be 2.7 times more likely to experience clinical levels of depression, stress, or anxiety[6]. Additionally, sleep difficulties in children with ADHD are associated with higher intake of fats, carbohydrates, and sugar[8], placing them at increased risk for obesity and other negative health outcomes[9].

This narrative literature review examines the prevalence and types of sleep disorders in youth with ADHD, the bidirectional relationship between sleep problems and ADHD symptoms, and the associated clinical implications. It explores a range of sleep disturbances commonly observed in this population and highlights their impact on daily functioning and quality of life. The review synthesizes findings from major databases, including PubMed and PsycINFO, through February 2025, using a comprehensive search strategy with keywords such as sleep, ADHD, sleep disorders, sleep scales, interventions, medications, behavioral therapies, stimulants, non-stimulants, children, and adolescents. References from retrieved articles were also reviewed to ensure inclusion of all relevant studies. This review provides insights into the prevalence of sleep disturbances in youth with ADHD, tools for sleep assessment, the interaction between sleep and ADHD treatments, and practical clinical guidance for managing sleep problems in this population.

PREVALENCE OF SLEEP PROBLEMS AND DISORDERS IN YOUTH WITH ADHD

Sleep problems are commonly associated with ADHD, with prevalence estimates ranging from 25% to 55% in children[10] and reported to be even higher in adolescents—up to 75%[11]. A meta-analysis by Cortese et al[12] and colleagues found significantly elevated rates of sleep problems in children with ADHD, including increased bedtime resistance, difficulty falling asleep, night awakenings, trouble with morning awakenings, sleep-disordered breathing, and excessive daytime sleepiness. Objective sleep assessments further revealed that children with ADHD experience longer sleep onset latency, reduced total sleep time, more frequent stage shifts per hour of sleep, higher apnea-hypopnea index, lower sleep efficiency, and shorter sleep latency on the Multiple Sleep Latency Test[12].

A recent Swedish registry-based study of individuals with ADHD aged 5 to 60 years (n = 145490) found that 7.5% had a diagnosed sleep disorder, and 47.5% had been prescribed sleep medications—representing an eightfold increase in sleep disorder diagnoses and a 14% increase in sleep medication use compared to individuals without ADHD[13]. The highest risk for sleep disorders was observed among adolescents, followed by young adults.

Parents commonly report concerns such as restless sleep, early morning awakenings, and difficulty initiating sleep in children with ADHD[14]. Interestingly, the prevalence of diagnosed sleep disorders in ADHD patients, as reported in the Swedish registry, is substantially lower than what research studies have found in adult ADHD populations[5,15] up to 44%-67% measured by using self-report, structured clinical interviews and chart reviews, suggesting that sleep disturbances may often go unrecognized or undiagnosed in clinical practice.

The prevalence of sleep disturbances may vary by ADHD presentation. Children with the combined type tend to exhibit higher overall rates of sleep problems, whereas those with the inattentive type more commonly experience shorter sleep duration, difficulty waking in the morning, and increased daytime sleepiness[16]. Additionally, the presence of psychiatric comorbidities in children with ADHD is associated with an elevated risk of sleep difficulties[17].

Sleep disturbances follow a distinct neurodevelopmental trajectory that varies with age across childhood and adolescence. Longitudinal studies have shown that children with mother-reported ADHD symptoms exhibit significantly more behavioral sleep problems, as well as poorer emotional and attentional regulation. These difficulties are evident as early as ages 2 to 3 and persist through ages 6 to 7[18]. Population-based studies indicate that, among adolescents, self-reported sleep disturbances—including reduced sleep duration, increased sleep onset latency, extended time in bed, and greater nocturnal wakefulness—are associated with elevated ADHD symptoms[19]. Additionally, prolonged sleep latency in early childhood has been found to predict ADHD symptoms at age 15[20].

RELATIONSHIP BETWEEN SLEEP AND ADHD

There is a complex, bidirectional relationship between sleep and ADHD, underpinned by shared neurobiological pathways involving cortical regions such as the dorsolateral prefrontal cortex, anterior cingulate cortex, and parietal cortex—areas that regulate arousal and affect[21,22]. In addition to cortical involvement, dopaminergic dysregulation—a core feature of ADHD—also plays a pivotal role in circadian rhythm regulation. Genetic variants in dopamine-related genes, including the dopamine D4 receptor gene, dopamine D5 receptor gene and dopamine transporter gene, have been associated with attentional deficits[23]. Abnormal dopamine signaling in the suprachiasmatic nucleus may further contribute to circadian misalignment[24].

Children with ADHD commonly exhibit delayed melatonin onset, blunted cortisol rhythms, and misaligned sleep-wake cycles—physiological indicators of circadian disruption. Genetic studies have also identified associations between ADHD and core circadian clock genes such as Brain and Muscle ARNT-Like 1 and Period Circadian Regulator 1[25] suggesting a heritable vulnerability to sleep dysregulation. These findings reinforce the need for an integrated clinical and neurobiological perspective when evaluating and treating ADHD-related sleep problems.

Inadequate sleep is associated not only with emotional dysregulation but also with impairments in executive functions which are known as core deficits in youth with ADHD[26,27]. Longitudinal studies have further suggested that childhood sleep problems predict attentional difficulties in young adulthood[28,29], as well as poorer neurocognitive outcomes in adolescents with ADHD[30].

Disturbed sleep may mimic ADHD symptoms or be an intrinsic component of the disorder, highlighting the importance of careful assessment of sleep in all patients with ADHD. Co-occurring inattention and hyperactivity, combined with insufficient sleep, have been shown to exacerbate neurocognitive deficits[31], while improvements in sleep have been associated with reductions in ADHD symptoms[32]. Additionally, technology use[33,34], and poor sleep hygiene[35] are common occurrences in adolescents with ADHD that can worsen sleep. Sleep disturbances also increase the risk for depression and conduct problems in this population[36].

Insomnia is a commonly reported side effect of stimulant medications[5]. Earlier perspectives often attributed sleep difficulties in ADHD to stimulant use alone; however, more recent research underscores the need to control for baseline sleep problems, as these are highly prevalent even before treatment. Approximately 20% of patients initiating stimulant therapy may experience insomnia as an acute side effect, but overall group-level data indicate that the majority show improvements in sleep. In fact, more patients tend to transition from poor to good sleepers with stimulant treatment across all age groups[37,38].

SLEEP ARCHITECTURE IN CHILDREN WITH ADHD

Polysomnography (PSG), the gold standard for objectively assessing sleep architecture and disturbances, has been widely used to examine sleep in children with ADHD. However, PSG studies have yielded mixed findings regarding objective sleep parameters in this population. A meta-analysis by Díaz-Román et al[39] found that children with ADHD spent significantly more time in NREM Stage 1 sleep compared to controls (pooled SMD = 0.32, 95%CI: 0.08–0.55), suggesting lighter and more fragmented sleep, although individual study results varied. In addition, persistence of slow-wave activity over central brain regions during NREM sleep in children with ADHD has been interpreted as a marker of neurodevelopmental delay.

Gruber et al[40] reported that children aged 7-12 years with ADHD had shorter durations of REM sleep, a smaller percentage of total sleep time spent in REM, reduced overall sleep duration, and higher scores on measures of insufficient sleep compared to typically developing controls. Other PSG studies have also noted longer sleep onset latency, reduced total sleep time, lower sleep efficiency, increased numbers of sleep spindles, and more frequent sleep cycles in children with ADHD[39,41].

Furthermore, increased theta wave activity during REM sleep has been observed in children with ADHD, a finding associated with delayed maturation, poorer cognitive performance, and impaired inhibitory control[42]. Notably, there is often a discrepancy between parent-reported sleep difficulties and objective PSG findings. This gap may be due to behavioral sleep problems—such as bedtime resistance—that occur before the child actually falls asleep and are not captured in standard PSG recordings[10,43]. Another study compared medication-free adolescents with ADHD to peers without psychiatric diagnoses and found that those with ADHD spent less time in deep slow-wave sleep and more time in lighter stage 2 sleep. These disruptions in slow-wave Electroencephalogram (EEG) activity, along with increased high-frequency EEG power during sleep, were associated with lower cognitive performance among adolescents with ADHD[30].

SLEEP ASSESSMENT IN CHILDREN WITH ADHD

Evaluating sleep disturbances should be an integral part of the comprehensive care of youth with ADHD. Many sleep disorders can mimic or exacerbate ADHD symptoms, making it essential for clinicians to assess for primary sleep disorders in children referred for ADHD treatment. A careful clinical history and targeted sleep assessment are fundamental components of this evaluation. Utilizing a thorough diagnostic interview, along with psychometrically validated parent- and child-report questionnaires and sleep diaries, can help identify a range of sleep disturbances. These tools support clinicians in determining whether additional sleep testing or referral to a sleep specialist is warranted.

Bears screening/clinical interview

Clinical screening of sleep disturbances is essential before and during the start of treatment with ADHD. BEARS is an acronym that identifies five pillars needing clinical review: Bedtime problems, Excessive daytime sleepiness, Awakenings and abnormal behaviors, Regularity and duration of sleep and Snoring. Regular screening of sleep using BEARS has led to detection of sleep problems by four-fold compared to usual care[44,45]. In the clinical interview, it is essential to review with parents and child about their subjective experiences of sleep. It is quite common that many parents put their children to sleep at early bedtime assuming they will sleep earlier or sleep longer which may not be true. On the contrary, if a child goes to sleep when tired, they may have higher chances of falling asleep quickly and more efficient sleep. Excessive daytime sleepiness includes subjective feelings of sleepiness, objectively observed by others as sleepy or displaying behaviors known as “masked sleepiness” where sleepiness is masked by opposite behaviors such as silliness, hyperactivity or impulsivity[46]. In such scenario, it is important to ask if child may have been nodding off for brief periods during daytime. Furthermore, hyperarousal in ADHD during daytime can make patients vulnerable for nighttime wakefulness which makes it imperative to ask for nighttime awakenings. Clinical assessment of sleep should include both the child and the parent as informants.

There may be biological and behavioral mechanisms linking the pathophysiology of ADHD and Circadian Rhythm Sleep Disorders[47]. Difficulties with impulse control may cause challenges with settling down resulting bedtime resistance and delayed sleep onset. Clinical interview should assess for regularity and duration of sleep to look for Delayed sleep phase disorders and late chronotype which are common in adolescents with ADHD[48].

Sleep apnea is common in children and adolescent who presents with snoring, breathing pauses, mouth breathing and nasal obstruction[49]. Studies have consistently identified significant relationship between snoring, obstructive sleep apnea (OSA) and ADHD[50] and improvement in symptoms of ADHD after adenotonsillectomy[51]. Ascertaining complete medical history and examination are crucial to assess for underlying medical conditions, adenoids, obesity, apneic episodes during sleep and snoring.

Sleep screening questionnaires/rating scales

Use of rating scales can be highly effective in identifying various sleep disturbances in the pediatric population. Although many sleep rating scales exist, only a limited number have been psychometrically validated and are commonly used in both clinical and research settings[52,53]. Table 1 presents a range of validated tools, including pediatric sleepiness questionnaires, comprehensive sleep questionnaires, and sleep hygiene assessment scales[54-63]. The table outlines key information such as age range, number of items, area of assessment, and availability or training requirements. These instruments serve as valuable tools for initial screening, and any concerns identified should be followed by further evaluation using objective standardized testing or referral for a sleep study when appropriate.

Table 1 Tools for assessing sleep disturbances in children and adolescents with attention-deficit/hyperactivity disorder.

	Questionnaire/scale	Age range	No. of items	Area of assessment	Availability/training
Pediatric sleepiness questionnaires	Pediatric daytime sleepiness scale[54]	11–15 years	8	Daytime sleepiness	Free to use/no training required
	Cleveland adolescent sleepiness questionnaire[55]	11–17 years	16	Daytime sleepiness	Free to use/no training required
	Epworth sleepiness scale for children[56]	2–18 years	8	Daytime sleepiness and nighttime alertness	Free to use/no training required
	Teacher’s daytime sleepiness questionnaire[57]	4–10 years	10	Daytime sleepiness by teachers	Free to use/no training required
Comprehensive sleep questionnaires	Sleep disturbance scale for children[58]	5–15 years	26	Sleep disorders	Free to use/requires no training
	Children sleep habits questionnaire[59]	4–10 years	45	Sleep disturbances and sleep disorders	Commercial use/requires no training
	Pediatric sleep questionnaire[60]	2–18 years	22	Sleep apnea and sleep disturbances	Free to use/requires no training
Sleep hygiene scales	Children’s sleep hygiene scale[61]	2–8 years	22	Children sleep hygiene	Free to use/requires no training
	Bedtime routine questionnaire[62]	2–8 years	31	Children sleep hygiene	Free to use/requires no training
	Adolescent sleep hygiene scale[63]	12–18 years	28	Adolescent sleep hygiene	Free to use/requires no training

Sleep diaries/sleep logs

Sleep diaries or sleep logs are considered as the gold standard for the subjective assessment of sleep and are commonly used to evaluate conditions such as insomnia, circadian rhythm sleep disorders (CRSD), and hypersomnia[49,64]. These logs provide a visual representation of sleep patterns over time and offer valuable insights into sleep onset latency, total sleep time, night awakenings, and other sleep-related characteristics. They can also serve as useful tools to monitor response to interventions, such as improvements in sleep hygiene. The most important sleep log items to track include time in bed, time asleep, wakefulness after sleep onset and time out of bed in the morning.

Mazza et al[65] examined children’s self-perception of sleep by comparing self-reported sleep diaries with actigraphy data and parental reports. The study found a good level of agreement between sleep diaries and actigraphy for measures such as bedtime and wake-up time. To better capture variability, it is recommended to analyze sleep patterns on school days and weekends separately.

Emerging research also supports the use of electronic or web-based sleep diaries, which offer advantages such as shorter completion time, improved accuracy, and automated scoring[66].

PSG

PSG is considered the gold standard for the objective assessment of sleep disorders. It is recommended when there are concerns for sleep disordered breathing, unexplained daytime sleepiness or periodic limb movements. It is typically conducted in a sleep laboratory and involves video monitoring alongside the simultaneous recording of multiple physiological parameters, including EEG, electromyography, electrooculography, electrocardiography, pulse oximetry, and respiratory monitoring (e.g., pneumography), with audiovisual recordings if needed. However, PSG has limitations in evaluating night-to-night variability and overall sleep regularity[12,67,68].

Meta-analyses of PSG studies have examined the relationship between ADHD and sleep disturbances using these objective parameters. For example, children with ADHD have been shown to have shorter REM sleep duration, a lower percentage of total sleep time spent in REM sleep, and overall reduced sleep duration[69]. However, PSG findings can be inconsistent across studies, partly due to intra-individual night-to-night variability and the potential influence of the unfamiliar sleep laboratory environment. These factors may affect sleep patterns during assessment and contribute to variability in results.

Actigraphy

Actigraphy involves the use of a small, portable, and lightweight sensor—typically worn on the wrist—to estimate sleep patterns over extended periods. These devices track activity data to calculate metrics such as total sleep time, sleep onset latency, and wakefulness after sleep onset. Actigraphy is particularly useful for evaluating sleep disorders such as insomnia, hypersomnia, CRSD, and restless legs syndrome (RLS).

It is often used as a complementary tool to PSG, especially when longitudinal, at-home data is needed. Actigraphy interprets movement as wakefulness and inactivity as sleep. While actigraphy demonstrates high sensitivity, its specificity is lower. Nevertheless, studies have shown moderate correlations (intraclass correlation > 0.61) between actigraphy and PSG results for sleep duration, sleep onset latency, and sleep efficiency[70]. A meta-analysis of 46 studies also supports its reliability compared to both sleep logs and PSG[71].

However, findings on actigraphy’s accuracy in measuring sleep latency, sleep efficiency, and total sleep time remain mixed[67,72,73]. In children with ADHD, actigraphy has revealed increased sleep fragmentation—based on movement during sleep[74] and greater night-to-night variability compared to typically developing peers[72]. Despite these limitations, actigraphy remains a widely used and valuable tool for assessing sleep–wake patterns in this population. A recent study also found that the Apple Watch performed well in identifying sleep–wake states and physiological parameters when compared with wrist-worn actigraphy[75].

Multiple sleep latency test

The multiple sleep latency test (MSLT) is an objective measure of excessive daytime sleepiness. It evaluates how quickly a person falls asleep during a series of scheduled daytime naps. MSLT is typically conducted following an overnight PSG and is commonly used to diagnose conditions such as narcolepsy and idiopathic hypersomnia. During the test, the patient is given five nap opportunities, each lasting up to 20 minutes and spaced two hours apart. If the patient does not fall asleep within the 20-minute window, the nap is terminated, and the individual remains awake until the next scheduled session.

In a meta-analysis, individuals with ADHD were found to have significantly shorter sleep latencies on the MSLT compared to controls, suggesting increased daytime sleepiness[12]. Additionally, ADHD patients demonstrated high variability in sleep latency across naps, which may indicate dysregulated arousal[76]. A study by Miano et al[41], which assessed 30 children with ADHD using PSG, MSLT, and actigraphy, reported both static and dynamic alterations in slow-wave activity. These findings were interpreted as evidence of maturational delay, potentially due to chronic sleep deprivation in children with ADHD.

SLEEP DISORDERS AND ADHD

An association between ADHD and various sleep disorders—including sleep-disordered breathing (SDB), CRSD, RLS, and behavioral insomnia of childhood—has been well established. Multiple studies have demonstrated that sleep disturbances can contribute to symptoms of inattention and hyperactivity[77,78]. Some research further suggests that treating insomnia may lead to improved focus and reduced reliance on stimulant medications in children with ADHD[79,80]. However, other studies have failed to show significant improvement in core ADHD symptoms following the treatment of comorbid sleep problems[81]. While poor sleep may exacerbate challenges with attention and behavioral regulation, improving sleep alone often may not fully resolve the core symptoms of ADHD.

Restless leg syndrome and periodic limb movement disorder

RLS and periodic limb movement disorder (PLMD) are common comorbid sleep disorders in children with ADHD. While the pediatric prevalence of RLS in the general population is approximately 1.9%, it has been reported in 11%–42.9% of children and adolescents with ADHD[82]. RLS is characterized by an irresistible urge to move the legs, typically worsening during periods of rest or at night, and is relieved by movement. Children may have difficulty articulating the sensations associated with RLS, so age-appropriate, descriptive questions—such as asking if they feel a “creepy, crawly” sensation—can help elicit relevant symptoms. A shared neurobiological mechanism between RLS and ADHD involves dopamine dysregulation in the nigrostriatal pathway[47]. Iron deficiency is also implicated in both conditions, as iron serves as a cofactor for tyrosine hydroxylase, the rate-limiting enzyme in dopamine synthesis[83]. In a study of 7072 adolescents, the presence of RLS symptoms was significantly associated with a subsequent ADHD diagnosis (OR = 1.47, 95%CI: 1.02-2.19)[84].

PLMD, often comorbid with RLS, is diagnosed when polysomnography detects at least five periodic limb movements per hour[85]. These movements—typically brief (0.5–10 seconds), repetitive flexions of the lower limbs—occur every 15–30 seconds during sleep[86]. They may involve toe curling, foot or ankle movement, or jerking of the legs. One study of 129 children aged 6–17 found that 91% of those with a PLMS index greater than five per hour were diagnosed with ADHD, a finding supported by subsequent studies[87,88]. Conversely, between 26% and 64% of children diagnosed with ADHD met criteria for PLMD[89]. Two separate meta-analyses further confirmed a significantly higher prevalence of PLMD in children with ADHD compared to controls[12,90]. The presence of RLS and PLMD may contribute not only to diurnal ADHD-like symptoms but also to bedtime resistance, which can be misinterpreted as oppositional behavior[10].

Sleep-disordered breathing and obstructive sleep apnea

SDB in children includes a range of conditions, from primary snoring to OSA, the most severe form. Numerous studies have consistently shown a link between SDB and neurocognitive or behavioral impairments, including symptoms that resemble ADHD[91,92,51]. The prevalence of OSA in children with ADHD is significantly higher—estimated between 25% and 30%—compared to approximately 3% in the general pediatric population[93]. In a longitudinal study of over 11000 children followed for six years, those with SDB were found to be 50% more likely to be diagnosed with and treated for ADHD[94].

A meta-analysis by Cortese et al[14] reported that children with ADHD had higher apnea-hypopnea index (AHI) scores than controls. Another meta-analysis of 18 studies involving 1113 children found a moderate association between SDB and ADHD symptoms (Hedges’ g = 0.57; 95%CI: 0.36–0.78). Importantly, the analysis also found that ADHD symptoms may improve following adenotonsillectomy, underscoring the clinical relevance of evaluating and treating SDB in children with ADHD[51].

Insomnia

Insomnia—characterized by difficulty initiating or maintaining sleep—is one of the most common sleep disturbances associated with ADHD, with prevalence estimates ranging from 25% to 55%[6]. In young children, the most common form is behavioral insomnia of childhood, which is further categorized into two subtypes: Sleep-onset association type and limit-setting type.

In the sleep-onset association type, the child requires specific conditions or the presence of a person—such as watching television or lying in a parent’s bed—to fall asleep or return to sleep after waking. These associations can become problematic and burdensome[45]. In contrast, the limit-setting type occurs when caregivers struggle to enforce consistent bedtime routines or boundaries, leading to delayed sleep onset. For example, sleep often improves when a parent consistently implements a structured routine, such as turning off the lights after one story, even if the child initially resists.

When clinically significant symptoms of insomnia are present, it is recommended that caregivers complete a two-week sleep diary to track patterns and behaviors over time. This step is particularly important given the significant night-to-night variability observed in children with ADHD[95]. A sleep study may also be warranted if symptoms suggest the presence of an underlying sleep disorder[45].

Circadian rhythm sleep disorders

CRSD involve a misalignment between an individual’s internal biological clock and external social or environmental demands, such as needing to fall asleep early to accommodate a school schedule. One of the most common forms, delayed sleep-wake phase disorder, is characterized by a preference for late bedtimes (eveningness) and difficulty waking in the morning[10].

Studies have shown that children with ADHD and chronic sleep-onset insomnia exhibit delayed melatonin secretion, as measured by the dim light melatonin onset marker, compared to healthy controls[96,97]. While preliminary findings suggest a potential link between CRSD and ADHD, further research is needed to clarify the nature and direction of this relationship.

IMPACT OF PSYCHIATRIC COMORBIDITIES ON SLEEP IN CHILDREN WITH ADHD

Various psychiatric disorders—including anxiety disorders, mood disorders, oppositional defiant disorder (ODD), conduct disorder, and autism spectrum disorder—are commonly comorbid with ADHD[98,99], and these comorbidities can further exacerbate sleep problems. Children with more severe ADHD symptoms and co-occurring internalizing (e.g., anxiety, depression) and externalizing (e.g., ODD, conduct problems) conditions are significantly more likely to experience moderate to severe sleep disturbances than children with ADHD alone[100-102].

Moreover, longitudinal research has shown that sleep problems predict the development of externalizing behaviors and depressive symptoms in youth with ADHD over a one-year period[103]. Sleep difficulties have also been shown to be both a predictor and a consequence of comorbid conditions such as ODD, generalized anxiety disorder, and depression, underscoring the importance of routine sleep screening in children with ADHD[104]. Addressing sleep problems may offer a valuable opportunity to reduce the overall burden of mental illness in early life.

PHARMACOLOGICAL INTERVENTIONS FOR ADHD AND THEIR IMPACT ON SLEEP

Pharmacological treatment of ADHD includes CNS stimulants and non-stimulants, both of which have demonstrated strong efficacy in managing core symptoms of the disorder[1,2]. While stimulants are highly effective, they can affect sleep in complex and variable ways. Children with preexisting sleep disorders or comorbid psychiatric conditions such as depression or anxiety are at greater risk for sleep-related side effects[79].

CNS stimulants

Initial and middle insomnia are reported in approximately 20% of children starting stimulant treatment, with incidence rates increasing with faster titration schedules and higher doses[105,106]. Stimulant medications are associated with increased difficulty in falling asleep, longer latency to sleep onset, and overall shorter duration of sleep, as demonstrated in numerous studies based on both subjective and objective measures[107,108]. A meta-analysis examining methylphenidate (MPH) found the greatest sleep-related risks including initial, middle and terminal insomnia and various sleep disorders are associated with longer-acting formulations, transdermal systems, and controlled-release versions[109]. Insomnia is more likely in children who are stimulant-naïve, on higher doses, or younger in age[5].

However, findings have been mixed. Several studies measuring sleep as a primary outcome reported no significant changes after initiating stimulant treatment[110,111]. Notably, the Multimodal Treatment Study of Children with ADHD, which followed 576 children aged 7-9 years, found that treatment with MPH and behavioral therapy led to fewer sleep problems compared to community care[112]. When sleep disturbances do occur, they often resolve spontaneously over time or with dose adjustments[113]. Group-level data suggest that sleep-related adverse effects may not be as pronounced as individual reports indicate. For example, a six-month open-label extension study found no differences in sleep outcomes between multi-layer extended-release MPH and placebo based on the Pittsburgh Sleep Quality Index[38].

To further investigate the impact of MPH on sleep, Corkum et al[108] employed both PSG and actigraphy. Actigraphy data revealed that MPH use was associated with a significant reduction in total sleep time by approximately 30 minutes and a significant increase in sleep onset latency by the same amount. Sleep efficiency remained unchanged. In contrast, PSG did not show statistically significant differences in these variables, although the trends in the data paralleled the actigraphy findings[108].

Clinical trials of long-acting stimulant formulations assessing sleep as an outcome have also reported improvement in sleep parameters including sleep efficiency, sleep onset latency, total sleep time and nighttime awakenings. These include studies of methylphenidate[114], extended-release dexmethylphenidate[38], lisdexamfetamine[115], OROS methylphenidate[116], transdermal methylphenidate[110], and serdexmethylphenidate/dexmethylphenidate[117]. These improvements were often maintained or enhanced during open-label follow-up periods[118,119].

Non-stimulants

Alpha-2 agonists such as clonidine, extended-release clonidine, and extended-release guanfacine are FDA-approved for ADHD either as monotherapy or as adjunctive treatments with stimulants. These agents are also commonly used off-label to manage sleep disturbances in children with ADHD. Systematic reviews have shown that bedtime clonidine improves sleep quality and reduces bedtime-related oppositional behaviors[120,121]. In contrast, extended-release guanfacine has been associated with reduced total sleep time and increased wakefulness after sleep onset. It also reduces REM, non-REM, and N3 (slow-wave) sleep, raising concerns about potential impacts on overall sleep quality and daytime functioning[122].

Atomoxetine and viloxazine extended release (VLX-ER) are both FDA-approved non-stimulant medications for the treatment of ADHD. Somnolence is a common side effect, particularly in the early phases of treatment or with rapid titration[123,124]. Nonetheless, both medications are generally well tolerated. A comparative study found that insomnia and increased sleep onset latency were more common with MPH (27%) than with atomoxetine (6%)[125]. While VLX-ER is associated with somnolence when used alone, this effect tends to subside when combined with psychostimulants. Conversely, the incidence of insomnia increases to 8% when VLX-ER is combined with a psychostimulant, compared to 4% when used alone[126].

MANAGEMENT OF SLEEP DISTURBANCES AND DISORDERS IN CHILDREN WITH ADHD

Optimizing outcomes in children with ADHD requires a comprehensive approach that addresses both core ADHD symptoms and co-occurring sleep disturbances, as each can independently contribute to functional impairment and reduced quality of life[127]. Current guidelines recommend that sleep be assessed in children and adolescents with suspected ADHD prior to initiating any treatments[128]. A comprehensive sleep assessment can help differentiate whether sleep disturbances are due to a primary sleep disorder or are secondary to medications used to treat ADHD or comorbid psychiatric conditions. Treatment should be multidisciplinary and individualized, addressing the specific sleep-related concerns and underlying conditions. Effective management typically incorporates both pharmacological and non-pharmacological interventions.

Non-pharmacological interventions

Non-pharmacological strategies play a critical role in managing sleep disturbances in children with ADHD. One foundational approach is sleep hygiene, or the implementation of healthy sleep practices. These include maintaining a consistent bedtime and wake-up schedule, limiting screen time before bed, avoiding caffeine, and creating a sleep-promoting environment—such as a quiet, dark room with minimal distractions[129,130]. Parents should be educated to monitor signs of inadequate sleep, such as difficulty falling asleep, late weekend bedtimes, morning fatigue, or excessive daytime sleepiness, particularly in adolescence. In addition, delaying bedtime by putting child to bed when they are actually tired could also improve sleep duration and efficiency. Once a child is sleeping consistently through the night, bedtime could be moved up if still tired in the day. Refer to Table 2 for healthy sleep practices[131].

Table 2 Health sleep habits[131].

Behavior	How to do it?
Schedule	Keep consistent schedule everyday with same wake up time to keep sleep wake cycle regulated
Bedtime routine	Establish regular relaxing routine before bedtime to prepare your body for sleep
Screen time	Turn off your electronics at least 30 minutes before bedtime
Sleep environment	Keep your bedroom dark quiet and - cool
Diet	Don’t eat large meals before bedtime. If hungry, eat small health snack
Drinks	Avoid any caffeinated drinks before bedtime
If you still can’t sleep	If you unable to fall asleep within 20 minutes, get out of the bed and engage in quite activity such as reading. Avoid using electronic during this time

Parental factors may influence the success of these interventions. ADHD is more prevalent among parents of children with ADHD[132], which can pose challenges to the implementation of consistent routines. One behavioral program, “Better Nights/Better Days”, provided parents of children with ADHD a five-session manual and weekly telephone coaching. The intervention group reported improvements in sleep onset and reduced bedtime resistance[133].

Behavioral sleep interventions—including sleep hygiene, faded bedtime with response cost, and graduated extinction—have demonstrated effectiveness in improving sleep duration and quality[134,135]. Faded bedtime with response cost involves gradually shifting bedtime earlier while incorporating response costs (e.g., briefly removing the child from bed if they cannot fall asleep). Graduated extinction promotes independent sleep by phasing out parental presence during night wakings. Studies employing these methods have consistently shown positive outcomes. For instance, Mehri et al[136] found that parent behavioral training significantly improved total sleep scores and reduced bedtime resistance in a randomized controlled trial. Similarly, Hiscock et al[137] demonstrated that a brief two-session intervention led to sustained improvements in sleep at 3- and 6-month follow-ups in 361 children with ADHD.

Despite clear evidence supporting these behavioral strategies, their use in primary care remains limited, often due to a lack of provider training. Implementation may also be difficult when caregivers themselves have ADHD or sleep disturbances—a common scenario in families of children with ADHD.

Other non-pharmacological interventions have shown promise as well. For example, the use of weighted blankets has been associated with increased total sleep time, improved sleep efficiency, and reduced night awakenings in children with ADHD[138], suggesting a potential adjunct or alternative to pharmacologic treatments.

A recent umbrella review and meta-analysis concluded that non-pharmacological approaches, such as parent training and psychoeducation, are effective in reducing bedtime resistance, night wakings, parasomnias, and sleep anxiety, as well as improving overall sleep quality, ADHD symptoms, and quality of life[139].

Finally, specialized cognitive-behavioral interventions have been developed for adolescents. One such example is the Transdiagnostic Sleep and Circadian Intervention for Youth (TranS-C-Youth)—a cognitive behavioral therapy -based program incorporating components from cognitive behavioral therapy for insomnia, interventions for delayed sleep phase disorder, and interpersonal/social rhythm therapy. In a pilot study involving 14 adolescents with ADHD and comorbid sleep problems, participants showed improvements in sleep, mental health symptoms, and executive functioning, with gains maintained at 3-month follow-up[140,141].

Pharmacological interventions

ADHD medications may negatively impact sleep, but these effects vary considerably among individuals. Existing literature has suggested that with appropriate assessment and careful titration, sleep may improve with increasing duration of use of stimulants to treat ADHD[5,79]

When non-pharmacological interventions are insufficient to manage sleep difficulties, it is crucial to evaluate whether ADHD medications are contributing to insomnia. This may involve adjusting the dose, timing, or formulation (e.g., switching between methylphenidate and amphetamine compounds). While clinicians often reduce evening doses to minimize sleep disruption, paradoxically, some children may benefit from extending the duration of CNS stimulant effects later in the day to prevent rebound irritability, which may itself lead to difficulty falling asleep. This strategy may be most effective when there is prominent oppositional behaviors or hyperactivity that preclude getting into bed on time or staying in bed before falling asleep. This may explain why long-acting stimulants have not consistently been associated with sleep problems in randomized controlled trials[45].

If insomnia persists, switching to a non-stimulant such as atomoxetine or an alpha-2 adrenergic agonist—or combining treatments—may be necessary. In a comparative study, children taking atomoxetine reported greater ease falling asleep, better morning wakefulness, and improved sleep quality compared to those on methylphenidate. Interestingly, methylphenidate was associated with fewer nighttime awakenings, suggesting that despite delayed sleep onset, it may promote more consolidated sleep[125]. As compared to Guanfacine ER, clonidine has showed better outcomes with improving sleep quality and decreasing oppositional behaviors at bed time[120]. Several newer medications have been approved for ADHD[142], and clinicians should remain vigilant about assessing the impact of these treatments on sleep and modifying regimens accordingly.

Although there are no FDA-approved sleep medications for children, melatonin in doses of 3 mg (< 40 kg) and 6 mg (> 40 kg) around 7PM has demonstrated efficacy in children with ADHD, particularly those on stimulant medications. Studies have shown that melatonin reduces sleep onset latency and increases total sleep time[81,143]. In one trial, children receiving sleep hygiene education followed by randomization to melatonin or placebo showed significant improvements with melatonin. A long-term follow-up of children on stimulant therapy indicated melatonin remained effective for sleep problems in 88% of cases and led to improvements in behavior and mood in 71% and 61%, respectively[144,145]. In adolescents with late-onset ADHD, treatment strategies addressing delayed circadian rhythms—such as melatonin and light therapy—may be more appropriate than traditional stimulant therapy[146].

In contrast, trials of other hypnotic agents have yielded negative results. A study evaluating zolpidem (0.25 mg/kg/day) in youth with ADHD-related insomnia failed to demonstrate efficacy over four weeks[147]. Similarly, eszopiclone (up to 3 mg) did not significantly reduce sleep latency over 12 weeks[148].

In clinical settings, off-label use of sleep agents such as mirtazapine, antihistamines, trazodone, and doxepin is common, although evidence supporting their use in children with ADHD is limited. Importantly, there are no published randomized controlled trials supporting the use of antipsychotics for insomnia, despite their frequent prescription in practice. Given the risk of metabolic side effects, antipsychotics should not be used solely as hypnotics unless clearly indicated[5,45]. Additionally, it is essential to assess whether other psychiatric medications—particularly SSRIs—may be contributing to sleep disturbances, as they can increase sleep latency and exacerbate conditions like restless legs syndrome[45]. When addressing ADHD, sleep issues, and psychiatric comorbidities, clinicians should prioritize treatment based on the most functionally impairing condition.

SPECIAL CONSIDERATIONS

In children with RLS, the American Academy of Sleep Medicine recommends the use of ferrous sulfate over no treatment in patients with confirmed low or borderline iron levels, as iron deficiency can contribute to or exacerbate RLS symptoms. Currently, there is no strong evidence supporting the use of medications commonly prescribed for adults such as dopamine agonist (Pramipexole, Ropinirole) with RLS in pediatric populations[88]. However, a few prospective studies have suggested that dopaminergic medications may improve RLS symptoms in children, although they have shown limited effectiveness in addressing comorbid ADHD symptoms[149,150].

In children with OSA and co-occurring ADHD, treating OSA can result in improvements in ADHD symptoms. While large randomized controlled trials have not consistently demonstrated statistically significant improvements in neurocognitive outcomes following adenotonsillectomy compared to watchful waiting across various age groups, the clinical relationship between adenotonsillar hypertrophy, OSA, and ADHD remains significant. Therefore, adenotonsillectomy should be considered in pediatric patients with both ADHD and OSA when warranted to address sleep-disordered breathing[151,152]. Clinicians should also be aware that certain psychotropic medications commonly used to aid sleep, such as benzodiazepines or mirtazapine, may worsen obstructive sleep apnea and should be prescribed with caution in this population[153].

CONCLUSION

The association between sleep and ADHD is complex and multifaceted, with sleep disturbances both contributing to and being exacerbated by ADHD symptoms. Sleep problems are common in children with ADHD and can significantly impact cognitive, emotional, and behavioral development, further affecting caregiver well-being. Routine screening for sleep-related issues is essential and can be conducted using tools such as the BEARS questionnaire or other validated measures. Children at risk for obstructive sleep apnea, periodic limb movement disorder, frequent awakenings, or treatment-resistant insomnia should be referred to a pediatric sleep center for further evaluation. Before initiating CNS stimulant, it is important to establish a baseline assessment of the child’s sleep to help distinguish pre-existing insomnia from treatment-emergent side effects. Recognizing ADHD as a 24-hour disorder allows clinicians to adopt a comprehensive approach that integrates behavioral strategies, medication adjustments, and targeted sleep interventions to optimize both sleep quality and ADHD symptom management. Emerging research is now systematically evaluating sleep both as a potential adverse event and as a primary outcome in clinical trials of new ADHD medications. To implement evidence-based ADHD care effectively, clinicians can benefit from enhanced training in behavioral sleep interventions—such as sleep hygiene and other non-pharmacological strategies—enabling them to confidently use these approaches as a first-line treatment before considering the addition of medications specifically for sleep.

ACKNOWLEDGEMENTS

The authors would like to thank Stephanie Roth, MLIS AHIP-D, Medical Librarian at ChristianaCare for assistance with initial search that supported the development of this manuscript.