“As clinical psychologists who work with adults with ADHD, we are surprised by how often we see DSPS in our clients – and how many of them have never heard of it. Many have tried to seek help for their sleep-wake problems, only to be misdiagnosed and put on the wrong kind of strategies and treatment. Understandably, these clients continue to experience significant sleep problems that affect overall functioning.”
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Sleep disorders and related issues often appear alongside ADHD, but we have yet to “wake up” to the relationship between ADHD and delayed sleep phase syndrome (DSPS) – a type of circadian rhythm sleep disorder. In fact, DSPS is quite common in individuals with ADHD but is seldom recognized, often brushed off as poor sleep hygiene or another sleep disorder.
When DSPS goes unrecognized or misdiagnosed, it can wreak havoc on ADHD symptoms and seriously disrupt quality of life. Accurate identification of DSPS – a treatable condition – is essential, as conventional approaches to manage sleep problems are often inadequate or ineffective for this sleep disorder.
DSPS is characterized by significant difficulty falling asleep and waking up at socially conventional times. As a circadian rhythm sleep disorder, DSPS affects the internal body clock, causing individuals to naturally sleep and wake several hours later (usually more than two hours later) than most people.
According to the American Academy of Sleep Medicine2, DSPS symptoms and characteristics include the following:
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Many individuals with DSPS, feeling completely alert and energized during normal sleeping hours, will stay up very late engaging in various activities (and often getting a lot of artificial light exposure, which further affects circadian rhythm). They’ll often go to bed in the early hours of the morning, when sleepiness finally sets in.
Other individuals with DSPS will go to bed at socially conventional times, only to lie awake in the dark for hours, waiting to fall asleep. They are alert and restless not because of anxiety or a racing mind that can’t shut off; they are awake because their brain and body are physiologically unready for sleep.
No matter what nighttime looks like, the result for those with DSPS is often a short sleep window, as obligations like work and school await in the morning – at normal hours. That’s why waking up is extremely difficult for these individuals, who often have to force themselves awake with multiple alarms or even with the help of another person. Once up, these reluctant risers – sleep deprived and with their brain still half asleep – feel awful.
But when individuals with DSPS get a chance to sleep in on weekends and during vacations, they usually wake up feeling refreshed and ready to go. Some people with DSPS, whether they know they have this condition or not, will structure their lives around their later sleep cycle, which can work if they have a flexible study or work schedule. For the most part, though, a delayed sleep cycle leads to significant impairment. Individuals who adopt a completely reversed sleep cycle, sleeping during the day and staying awake all night, often have additional mental health problems and functional impairments.
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As clinical psychologists who work with adults with ADHD, we are surprised by how often we see DSPS in our clients – and how many of them have never heard of it. Many have tried to seek help for their sleep-wake problems, only to be misdiagnosed and put on the wrong kind of strategies and treatment (like sleeping pills). Understandably, these clients continue to experience significant sleep problems that affect overall functioning.
DSPS, we have found, is often mistaken for bedtime procrastination, or the deliberate delay of one’s bedtime in favor of other activities, like scrolling through social media, streaming a new television series, and other (often dopamine-boosting) activities that keep the brain alert. With ADHD’s dopamine- and self-regulation challenges, it’s easy to assume that bedtime procrastination is the sole reason for problems sleeping and waking up at normal times. Further complicating matters are time-management and organization challenges brought on by ADHD that can also make it difficult to get to bed and wake up at reasonable hours.
While DSPS can occur with bedtime procrastination, the key here is that those simply engaging in bedtime procrastination are likely able to fall asleep at socially conventional times, but resist doing so. They likely feel sleepy as they’re engaging in bedtime procrastination, or, if they’re not sleepy, they’ll readily fall asleep once the stimuli keeping them up is removed. Individuals with DSPS, on the other hand, are not able to sleep at socially conventional times, even under the best sleep conditions, because of circadian rhythm differences.
Due to superficial similarities, DSPS is frequently mislabeled as insomnia, a type of sleep disorder characterized by difficulty falling or staying asleep and/or poor sleep quality. Insomnia can co-occur with DSPS, and it’s often seen with ADHD, too.
Individuals experiencing insomnia will report trouble initiating sleep, while those with DSPS will have trouble initiating sleep at conventional, socially normal times. Falling asleep actually comes easily for those with DSPS when it aligns with their internal clock, even if that’s several hours later than what’s considered normal. Additionally, staying asleep isn’t an issue for those with DSPS, but it often is for those with insomnia.
Talk to your doctor or a sleep specialist if you suspect that your sleep problems are due to DSPS. A proper diagnosis is critical, as DSPS has its own distinct physiological component that needs to be treated directly. Managing DSPS requires knowledge of circadian physiology, as effective interventions for this sleep disorder target the internal clock.
Standard interventions for sleep difficulties (like those recommended for insomnia), such as sleep hygiene, sleep restriction, and stimulus control strategies, as well as sedative medication, are unlikely to be effective for individuals with DSPS.
Many bodily and behavioral processes – from sleepiness and alertness to core body temperature fluctuations – follow a predictable 24-hour cycle. Ideally, the body’s internal timekeeper is reset each morning with exposure to light. Without enough morning light, the sleep-wake cycle may gradually drift later and later each day, decoupling from the day-night cycle.
Darkness also influences circadian rhythm, as it triggers the secretion of melatonin, a hormone that facilitates a drop in core body temperature and prepares the body to sleep (and stay asleep). Bright light in the evening, even low levels, suppresses melatonin production, which has the effect of pushing off sleep and delaying circadian rhythm. Treating DSPS, therefore, centers heavily on careful timing of light and dark exposure.
Light therapy for DSPS involves increasing exposure to bright light after waking up and reducing light exposure as much as possible before bed — along with gradually shifting sleep-wake times — to regulate the internal clock.
Under this intervention, bright light exposure should occur within two hours of natural waking time*, and for at least 30 minutes. Exposure to unfiltered daylight is best; even light exposure on an overcast day is better than indoor lighting, which is rarely bright enough to get a circadian effect. A morning walk for light exposure is ideal for strengthening and calibrating the circadian rhythm, but light exposure devices, like wearable LED light visors (the modern-day equivalent of light boxes), are also helpful. Potential side effects of light therapy include eye strain and headaches.3
*An important note: If you wake up within six hours of falling asleep (either naturally or forced) you will need to delay light exposure to avoid delaying your body clock even more. This has to do with core body temperature, which reaches its lowest point about six hours after sleep onset. Light exposure after the six-hour point promotes earlier sleep onset and waking. Light exposure before this point does the opposite.
If you normally fall asleep at 3 a.m., for example, light exposure should not happen until after 9 a.m. But if rising before 9 a.m. is unavoidable, avoid sunlight (keep the curtains closed) and turn off or keep artificial light sources dim. If you must be outside before 9 a.m., wear sunglasses and a hat and try to avoid direct sunlight.
To augment light therapy, avoid light exposure before and during sleep to prevent melatonin suppression. Dim the lights and avoid looking at screens two hours before bedtime to assist natural melatonin production. If this is not feasible, install a blue light filter on your device, or don eyewear with orange lenses. Wear a sleep mask or install blackout curtains to make your sleep environment as dark as possible.
The final component of light therapy is gradually shifting bedtime and rise time 15 minutes earlier each day, with the goal of adjusting your internal clock to sleep and wake at normal times. It may take a couple of weeks to reach desired sleep-wake times; after this point, (relaxed) maintenance is key in the form of fairly consistent rise times and morning light exposure times on most days.
Talk to your doctor about taking melatonin to manage DSPS, as carefully timed melatonin administration can aid in shifting circadian rhythm.4 For optimal circadian shifting, take melatonin about six hours before your natural sleep onset. For example, if you typically fall asleep at around 3 a.m., take a 3 mg dose of melatonin at about 9 p.m. As your sleep phase shifts earlier, adjust the timing of melatonin intake accordingly. Once you’ve reached your desired sleep time, help maintain it by taking a lower dose (1-2 mg) of melatonin two hours before bedtime. Be sure to discuss any changes to your melatonin use with your health provider.
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1 Coogan, A. N., & McGowan, N. M. (2016). A systematic review of circadian function, chronotype, and chronotherapy in attention deficit hyperactivity disorder. ADHD Attention Deficit and Hyperactivity Disorders, 8(3), 129-147, DOI 10.1007/s12402-016-0214-5.
2 American Academy of Sleep Medicine. (2014). International Classification of Sleep Disorders – Third Edition (ICSD-3). Darien, IL: American Academy of Sleep Medicine.
3 Terman M, Terman JS. Light therapy for seasonal and nonseasonal depression: efficacy, protocol, safety, and side effects. CNS Spectr. 2005 Aug;10(8):647-63; quiz 672. doi: 10.1017/s1092852900019611. PMID: 16041296.
4 van Andel, E., Bijlenga, D., Vogel, S. W. N., Beekman, A. T. F., & Kooij, J. J. S. (2021). Effects of chronotherapy on circadian rhythm and ADHD symptoms in adults with attention-deficit/hyperactivity disorder and delayed sleep phase syndrome: a randomized clinical trial. Chronobiology International, 38(2), 260-269. doi:10.1080/07420528.2020.1835943
Tags: diagnosing adults, treating adults
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