Improving Sleep Quality in ADHD With Nutritional Strategies
Attention deficit hyperactivity disorder (ADHD) is a diverse neurological development pattern which is characterized by a delayed cortical maturation and reduced activity in the reward systems.1 This altered activity is believed to be caused by a combination of reduced release of dopamine and fewer dopamine receptors.2 This is often combined with decreased conversion of dopamine to norepinephrine and/or chronically low serotonin.3
The effects of these neurological complications are as varied as there are people with ADHD, but co-morbidities such as insomnia, anxiety, depression, and disrupted cortisol levels are common.4 Pharmaceutical stimulants effectively improve the levels of neurotransmitters at the synapses and will support overall executive function such as short-term memory, attention, task initiation, impulsivity control and prioritisation.5
However, most co-morbidities relate to an imbalance in the hypothalamus-pituitary-adrenal (HPA) axis,4 and as naturopathic practitioners, this is our bread and butter. One of the most common complaints in ADHD clients is dysregulated sleep patterns, ranging from severely delayed onset, nighttime waking, as well as early starts, with low morning energy or daytime fatigue regardless of time in bed.6
Initial Consultation
A 40-year-old female schoolteacher presented with severe insomnia after the initiation of a stimulant medication six months prior. She had always struggled to stay sleeping after 5 am, even as a child, but had before the initiation of stimulants been able to achieve sleep onset nightly at 8.30-9 pm and sleep until 3-3.30 am, albeit disrupted. On the weekends she was sometimes able to snooze until 7 am but did not achieve improved energy on those days. Her doctor had prescribed Catapres, a medication which reduces sympathetic outflow from the central nervous system and results in reduced heart rate and blood pressure, often used as a sleeping aid in ADHDers, but she reported little improvement.
Morning routine:
- Alarm set for 4.55 am.
- Plays on phone on wake up until alarm.
- No breakfast.
- Gym sessions every morning at 5.30 am.
- Reacts with hives if eats within 30 min of gym sessions.
Nighttime routine:
- Dinner 6.30 pm.
- Watch TV or read until 8.30-9 pm.
- Catapres at 9pm.
- Then a shower and read a book.
- Finish reading at 10 pm. By then the Catapres has worked or TV will save her if
the medication won’t work, has fallen asleep to the TV noise all her life.
- Achieving onset at 11 pm nightly, since initiation of stimulant medication.
Diet:
- Fasts between 6.30 pm dinner, and cup of tea at 8 am.
- Drinks can of coke at 11 am.
- Eats a packet of corn chips at 1 pm break.
- Dinner at 6 pm is the only proper meal any day, cooked by partner.
- Lots of hypersensitivity reactions to food, with hives. Potatoes and tomatoes are
the main culprits.
- Reduced feelings of hunger on waking until dinner.
Other Considerations:
- Low energy when coming home from work.
Morning energy 8-9/10
After work physically 4-5/10 and mentally 3/10.
- History of burnout, 2021 – 2023, 18 months. She was sleeping a lot more and
withdrew socially.
- History of iron deficiency.
- Weekly exercise schedule: 1-2 swim, 2 longer rides >10 km, 2 gym sessions.
Exercises 5 days per week, with double up days. Training keeps her “mentally
stable”.
- Digestion: Bristol Stool Chart 2-3, daily, no bloating or gas.
- Urination: avoids urinating at work (common with teachers), only drinks 500ml
of water per day. Drinks more when training, up to 2L.
Prescription
The aim was to rebalance her cortisol and regulate her circadian rhythm through a multipronged approach, targeting her lifestyle, dietary habits as well as supporting her biochemistry directly with nutritional supplements. She was not interested in stopping the stimulants, so treatments were designed to support her HPA axis, and enable sleep.
- Calming Magnesium Powder: 2 level scoops (12 g) twice daily mixed in 250 mL
water or juice and drink immediately. Take double dose for the first 2 weeks. At
nighttime, take an hour after dinner, to allow body to settle before bed;
containing:
magnesium citrate 1.86g (equiv magnesium 300 mg); to improve overall quality
of sleep8
potassium 100 mg; supports circadian rhythm9
glutamine 1.5g; calms nervous system through conversion to GABA10
taurine 1.5g; attenuates sleep by up to 50%11
ascorbic acid 250 mg; may improve sleep duration12
vitamin B5 50 mg; precursor to CoA, that is synthesised to acetylcholine, which
regulates REM sleep; and supports the sleep-wake cycle13
vitamin B6 50 mg; cofactor in neurotransmitter production, dopamine, serotonin,
noradrenaline, and melatonin14
zinc 15 mg; to modulate neuronal activity15
- NAC Powder: Add 1g morning and night, stirred into the magnesium drink;
containing:
N-acetylcysteine 1000 mg; to lower neuroinflammation16
- Zinc capsules: 1 capsule daily with food, for 2 weeks, then up the dose to 2
capsules per day, containing:
Zinc citrate 30 mg; to modulate neuronal activity,15 and support immune
system.17
Lifestyle instructions:
- Fasting raises cortisol which stimulates the breakdown of macromolecules and
counter-regulates insulin to maintain glucose homeostasis. Recent studies have
shown that cortisol starts to increase when the fast is broken, which leads to
cortisol peaking in the afternoon. This peak disrupts the circadian rhythm and is
likely responsible for the poor sleep patterns seen in this client.18 She needed to
include breakfast and lunch in her routines, and preferably eat before training in
the morning.
- Working all day whilst only fuelling herself with coke and corn chips was further
exacerbating the imbalance in the HPA axis, which was already impaired by the
dysregulation caused by her ADHD.4
Diet changes:
Due to client’s struggles with executive function and resultant reduced ability to change habits, dietary advice was kept simple. Priority was to establish a three meal per day routine, not to overwhelm her with “have to do’s”.
Protein and nutrient rich shake, instructions: 3 scoops (22 g) twice daily in 200 mL water, once for breakfast and once for lunch, to replace the coke and corn chips.
2 Week Follow-Up
Client reported good compliance to treatment and had successfully been adding shakes both in the morning and at lunchtime. Sleep had improved with the magnesium powder combined with two Catapres tablets at night. New pathology report showed continued low iron status. She reported struggling to drink the magnesium powder with added NAC in the morning due to “sweet flavour” and the amount of fluid as she avoids urinating at work. We decided to drop the morning dose but to continue with a double dose one hour after dinner.
Prescription:
- Continue previous prescription
- Compounded Powder: 4.7 g/day, in water at night, containing:
L-theanine 400 mg /day; L-theanine has been shown to reduce cortisol within 1-
3 hours of administration.19
Tryptophan 300 mg/day; as a precursor to serotonin, tryptophan supports
melatonin production.20
Histidine 1000 mg/day; to reduce reactivity to food and improve mental clarity
and attention.21
Glycine 3000 mg/day; to improve sleep quality.22
- Adenosine Tablet: 1 tablet dissolved under the tongue before bedtime;
containing:
Adenosine 100 mg; to regulate sleep wake cycle, by inducing sleep homeostasis
in the brain.23
- Iron Capsule: 1 capsule three times per week; containing:
Iron 24 mg; anaemia is commonly associated with insomnia.24
4 Week Follow-Up
The client felt much better, and could manage 6 to 8 hours of sleep per night, sometimes even 8.5 hours. She would still wake at 3 am but was able to return to sleep. She was still having 2 Catapres tablets at night, now with the compound. She reported reduced food reactions to both tomatoes and potatoes, even after exposure during a dinner party. Executive function was improved, and she was successfully bringing containers with the meal replacement powder to work and would drink a shake instead of coke and corn chips during her breaks. She had occasionally also made a smoothie before work and enjoyed the boosted higher energy from the improved food intake.
Prescription:
- Continue previous prescription
- Increased the adenosine to 2 tablets per night.
6 Week Follow-Up
A sudden break-up with her long-term partner had set her back in her routines of taking her supplements, however she was still achieving sleep which was better than at the initial appointment. The client reported much better emotional self-regulation. Food reactivity had continued to improve, and she had even tried some capsicum, which was otherwise avoided completely, with success. Energy also much improved after work, physically 7/10, mentally 8/10 after work. Felt that she was now able to lengthen the time between appointments and wanted to focus on dealing with her break-up through psychotherapy.
Prescription:
- Continuing script with no changes.
Final Follow Up- 36 Weeks
Whilst there were several follow-ups between, in the most recent appointment the client reported that sleep was continuing to improve, despite the relationship break-up, consequent increased financial stress, and substantial pressure at work. She has now reduced the Catapres and adenosine at nighttime and was only taking Catapres 2-3 times per week and alternating that with one tablet of adenosine on the other nights. She was still taking her stimulant medication daily as it helps her executive function, and the compounded nutritional powder continues to be an important part of her daily routine.
Clinical Thoughts
Insomnia is very common in ADHDers, but the root cause is not the neurological development; rather the stress which neurodivergent people experience when attempting to function in a world designed around neurotypical persons. This chronic stress will disrupt the HPA and drive cortisol to be dysregulated. This client reported 5 am waking times already in childhood, suggesting that her cortisol was already dysregulated early in life.
It is important to work with the person in front of you every time you see a client, and whilst an ADHD diagnosis will tell you a lot about that person’s brain chemistry, it does not dictate how you should treat each case. Whilst some clients with ADHD struggle to sleep, others have no problems at all. Some clients experience reduced sleep quality when taking stimulant medications, but it’s important to remember that stimulants increase dopamine and are intended to have a calming effect on ADHDers. Any resultant insomnia is likely a sign that something else isn’t regulating as it should or has been put further out of balance with the stimulants. A polymorphism in the catechol-O-methyltransferase (COMT) gene is often involved here, as is cortisol as seen in this case study.
The main aim of this treatment was to lower and rebalance the client’s cortisol and improve her sleep-wake cycle. Fasting is often touted as a one-size fits all dietary intervention, but it’s important to recognise the impact on cortisol and the circadian rhythm. Using targeted nutrients was ideal in this client as cost was not an issue. Her reduced executive function meant that every proposed change had to be easy to execute and within her scope of energy through the day, as to not cause more overwhelm and result in non-compliance.
References
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