Unrested Minds: A Teen’s Journey Through ADHD and Sleep

Alison Bentley, guest · [07:10]That's quite a common thing, that, that, that you, that you do feel sleepy, but then it kind of goes away. So when we talk about sleep, and just, so I'm going to give you some info as we go along. So when we talk about sleep, we talk about that sleep and awake should be like binary, like computers, one, zero. There, there shouldn't be a one and a half anywhere. Okay. When they do collide, when you do fall asleep, there's this very clear sense that you have to switch off the accelerator, which is you being awake. Yes. You have to switch that off and put the brake on. Right. So that has to be, that has to happen. And very often what happens is that the accelerator stays on, and then you get that head. It just keeps running, and you go like, actually now I could do that project, because I'm like wide awake, but that's actually not what the, this time is for. This time is actually to be asleep. So there is that sense that you can get that, and a lot of people go, that's the meds, okay? That's the meds that's keeping me awake. Well, the bottom line is, if you have the crash, you can't, it can't be the meds anymore, right? Because they've gone. All of those meds, whether they're, they're, the long-acting medication, the long-acting stimulants, work for about eight hours, okay? There's one that works for about ten hours, but if you're taking it at six in the morning, it's gone by the time you go to bed, okay? So it's not the meds. So then you have to go, why am I having this problem with, with falling asleep? Like, why? And, and part of the problem is because sleep is an incredibly passive process. Falling asleep, you just gotta be sleepy, and you just have to let go. Abandon yourself to the forces of sleep, okay? And you have to do that, but if your head is running high, and you're thinking a lot, It's very difficult to do that. And so what you're, what you're describing is what most patients with insomnia describe is that sense of being sleepy, switching the light off, and if you don't fall asleep fast enough, like the whole system revs up, and then it's hard to go back to sleep. It's, you don't feel sleepy anymore, and your head is just running, and, and you're awake, awake. Okay. And then there is a sense that you're going to fall asleep a lot later. It's not the meds, that's the important thing.

Alison Bentley, guest · [09:33]Falling asleep is very clear that that can be a problem because your head can be running high. There's also a couple of things of real Sleep disorders that can stop you falling asleep as well. So one of those is restless leg syndrome. Yeah. Okay? Ever get a sense that you have an urge to move your legs, that you can't lie still, that you're uncomfortable? Yes,

Peter, guest · [09:50]yes.

Alison Bentley, guest · [09:50]When you try to fall asleep?

Peter, guest · [09:52]And I've, I've been like that all my life. my mom used to deal, deal with it when I was in bed. She called me a kicker. That was, that was her name for it. She would wake up with bruises on her legs.

Alison Bentley, guest · [10:01]Right. So the question is, how many people have asked you that question in your journey?

Peter, guest · [10:07]Just you, Dr. Bentley.

Alison Bentley, guest · [10:09]That's my problem, because that is a sleep disorder, and restless leg syndrome, you know that if you're lying there and you can't get comfortable, then you can't fall asleep, right? Okay, so restless legs is one of those things that is much more common in patients who have ADHD, like double the prevalence that it is in people who don't have ADHD. So it's one of those things that unless you ask about it specifically, you aren't going to tell anybody because you don't think it's related. More than that, if you've had it for as long as you can remember, you don't know it's abnormal.

Peter, guest · [10:41]Yeah, I just think it's normal. Yeah,

Alison Bentley, guest · [10:43]you do. And so, I mean, I've just come from a consult with a 17-year-old kid, same age as you, basically, who's got ADHD, who, again, I was the first person to ask him if he's got restless legs, and he does. And then his mom goes, oh, by the way, I also like do this with my feet when I fall asleep, kind of move them backwards and forwards. I thought that was just about, you know, soothing kind of thing. And I go, well, what happens if you stop moving them? And she goes, oh, no, no, no. That, that doesn't work, no. Don't ask me to do that, right? So that's restless leg syndrome, and restless leg syndrome will stop you falling asleep.

Alison Bentley, guest · [11:46]The other big disorder that can stop you falling asleep is what we call delayed sleep phase syndrome, which is the most common disorder in young men your age. Every young person your age gets a shift of about an hour, so it just becomes a little harder to fall asleep. And you see it in your classmates. So you go from classes where kids are awake in the morning and they come to school and they're super cheerful to like over the course of a year, they come into school, everyone's grumpy.

Peter, guest · [12:12]Yeah.

Alison Bentley, guest · [12:13]Okay? You seen this? You see, if kids go to school by car, they go from being talkative in the car to being like...

Peter, guest · [12:20]Completely dead.

Alison Bentley, guest · [12:21]Dead in the car, right? And then you come to school and then it's about first break, you suddenly go, oh, I feel a whole lot better,

Peter, guest · [12:28]right? Like I've woken up. You can also see it in, in the classmates around you. I mean, my friends as well are at school here. They're usually quite dead until about nine thirty in the morning and then everybody's up cooking eggs. Yes.

Alison Bentley, guest · [12:41]And the interesting thing is they haven't had any more sleep, right? So the sense is that you haven't had enough sleep. That is why you're sleepy. But they haven't had any more sleep, the half past nine, but they feel a whole lot better. And that's because of this little time zone shift. Like you just shift, like you're sleeping an hour into the Atlantic. Does that make sense? Like, that side, right? It can get much worse than that. So you do know that during school holidays, and I'm not going to ask you to confess it because I just know it happens anyway, is that during school holidays you kind of stay up late at night, because you can, because it's super easy for you guys to stay awake late. So you stay up late, and then your parents go, oh, shame, it's the holidays, like sleep in till ten, eleven in the morning, right? And that sounds like a great plan, but then when school starts again, there are a group of you guys who don't come back into the right time zone.

Peter, guest · [13:27]No, your schedule's all...

Alison Bentley, guest · [13:29]Schedule's all off, right? You messed

Peter, guest · [13:30]up. It's waking up on that first morning, especially in winter, and you're thinking, oh.

Alison Bentley, guest · [13:34]But what you'll find is that over that week of getting up early every morning, you'll get back into the right, going to sleep at the right time zone, except there's a bunch of your classmates who don't.

Peter, guest · [13:43]Yeah.

Alison Bentley, guest · [13:43]Okay, and you know them, that they can only fall asleep at one, two o'clock in the morning. Yes. And they're also only waking up in second break. They're super grumpy in the morning. They're not hungry. They're, they're hangry, very hangry.

Peter, guest · [13:55]No, no social interaction. You do not speak to them.

Alison Bentley, guest · [13:57]You just know not to Speak to them that they are the people that you speak to at one o'clock in the morning because they're still awake. And that's delayed sleep phase syndrome, and that's pushed them, they're now much closer to New York than they are to South African time. Okay? So they're sleeping on that kind of time. And so their sleep is really short. And so obviously if their, if their natural sleep has moved out into two o'clock in the morning, let's say that's where they, that can actually fall asleep, then trying to fall asleep at ten o'clock is four hours too early. So it's equivalent to if your normal sleep time is half past nine, which it is, you trying to fall asleep at half past five in the afternoon. Doesn't work. It's not going to work, ever.

Alison Bentley, guest · [24:57]This medication is different. So this medication is actually a medication for pain, but a specific type of pain. So there's two different types of pain. So you're going to learn all about pain tonight as well, even if you didn't want to. The pain we remember is the pain receptors, you know, that, and you take anti-inflammatories, and you take codeine, and you take those kind of things for that kind of pain. But there's a type of pain that gets created within the nervous system itself. So for example, if you slip a disc, and the disc comes out and hits the spinal cord like that, super painful. There's not a single pain receptor there except in the muscles, okay? But in the spinal cord and brain, there's no pain receptors. I'm sure you've seen those cool videos of people doing surgery on the brain when people are awake. So there are no pain receptors in the brain itself and in, or in the spinal cord. So if the brain is perceiving pain because the nerves are overactive, That's why the pain is being created. So it's not a pain receptor thing, doesn't respond to anti-inflammatories, doesn't respond to the usual pain stuff, but it responds to these particular compounds. These compounds are designed to take a hyperactive part of the nervous system and calm it down. It's not going to take normal and make it dull, it's just going to take hyperactive and make it normal. Pull the system down a bit. So it's getting it down to a state of normal, and so we use these medications, and these are aimed at the spinal cord, where the spinal cord is hyperactive, doing this little circuit, ping, ping, and say, shh, calm down. Okay. So it calms down, and so the legs stop. If the legs stop, your natural sleep can happen. Does that make sense? So you don't need to take something for sleep, because the natural sleep should be able to happen. You're doing everything right as far as the sleep hygiene is concerned, but if you have restless legs, color doesn't work. You cannot beat restless legs. I mean, if it's there, it's a neurological thing, you can't beat it. But if you treat it, then all the sleep hygiene stuff works.

Gershom Aitchison, host · [36:28]Let's say that Peter gets treated for the restless leg so that he is sleeping better. And what it feels like for him to have a good night's sleep and to be rested and attentive during the day, if that allows some of his meds to be reduced for the ADHD, because how much of the inattentiveness is he's legitimately got ADHD, but also to what degree is it, is it stimulated more because he is, he's sleep deprived, as it were. So it would be interesting to see if that, where that journey goes, and the good news is that Peter's old enough to start actually realizing what that looks and feels like, because he's articulating very well what's going on in his body, and it's, it's good to be able to do that.

Alison Bentley, guest · [37:09]Yeah, I'm certainly not disputing the fact that ADHD exists. I'm not. I'm not saying that every kid with ADHD has a sleep disorder. I'm not saying that, because ADHD is a thing, but what happens is the sleep disorder exaggerates the symptoms of ADHD during the day. And so I have a bunch of patients, adults as well, who are on a lot of ADHD medication during the day, and then when we look at their sleep and we go, actually, there's a sleep Problem here and we treat that, then there's less ADHD medication. Because I can tell you that if you are trying to treat a sleep disorder, the symptoms of a sleep disorder with the methylphenidates and the Ritalins, et cetera, you're going to lose, because the doses have to be really, really high to do that. Whereas if you treat that, then this becomes manageable. So it's not about taking away the ADHD completely. I mean, it would be great if we did that, but I'm just saying it's not, it's not necessarily about that. It's about taking away something that, that should be treated differently. Yes. And then using a smaller amount, because as you said, you kind of want to get off the meds, but even pulling back on the meds and you go, actually, now they work a whole lot better, and I feel more in control because there's not this crash at the end of the day. Because part of that crash, I think, is the fact that you've got the sleep pressure. You're in sleep debt when you start the day, you're not slept well. The concerta's hiding that for the day, and then it comes back with a vengeance.

Alison Bentley, guest · [46:16]In my young man today, we're going to just keep him going through the day. But usually when it's sitting in around two o'clock in the morning, we use melatonin to, to move them back by an hour at a time. So it's a relatively slow process. Takes a week or so. So if we, if it's two o'clock, then we go right, let's make bedtime at one. So if bedtime is at one, then we give melatonin an hour and a half beforehand, and quite a big dose, and chew it so that, because it's prolonged release, chew it so it's fast release, so we get a big punch of melatonin. Have a very strict wake-up time in the morning, and in the morning, lots of light. So we do that for a couple of days, and then we go, once you're there, then we move you another hour, and then we move you another hour, and it works extremely well. However, it's a really strict routine, and we know what teenage boys are like with strict routines. Like, we go, I really like that, and you have to do this. Like, you just have to get it done. Once you're in the right time zone, then we keep you on melatonin for a little bit longer, and hope you take it off, and ban use from staying up late at night, and then you need to keep it there. So it's treatable. It's tricky to get it right, and often we get it right, and then December holidays hit, and they're right there again, and we have to do it again. So we often have to do it a couple of times. The good news is that work or varsity generally keeps them in the time zone after that, and having children is a dead cert to, like, stop that drift. The problem with school is not the school. The school is keeping them on track. It's the holidays. That's the problem. They are adrift in the holidays, and then they've got to come back. So, you know, I don't want to say that you've got to wake up at four o'clock. I

Peter, guest · [47:46]didn't

Alison Bentley, guest · [47:47]know that was coming. It's not that. It's just don't let it go too far. So yes, sleep in in the holidays, but don't sleep till eleven every day. Sleep

Gershom Aitchison, host · [47:55]until seven.

Alison Bentley, guest · [47:56]Sleep till seven, or yes, do that. That's fine. So I think the message is to parents, like, I know you kind of want to let your kids have a good holiday, but there's a limit to sleeping in in the morning, because it can create a real problem, which then has to be treated deliberately. And if it's not, if you get stuck at two o'clock in the morning, it's not going to just kick itself back. You've got to treat it. I see patients in their thirties and forties where it's never been treated, and they still have it.

Alison Bentley, guest · [49:57]I think the important thing is that if you see somebody doing it and you're concerned about it, you say to them, stop doing it. Now what happens in your head? Because if it's just self-soothing, they go, no, it's just hard to fall asleep unless I do that. But if they have restless legs, they go, please let me move, like it, it feels awful, like I have to move, I have to move. That's different. So if it's that they have to move, then that fulfills what we call the diagnostic criteria for restless legs, which is an urge to move your legs. You have that urge. And you hide it because you move all the time. So if you move all the time, you don't feel it. And it becomes such a habit that you don't realize why you're doing it. So I also have patients who like jig their legs. You know how you just like bounce your, bounce your leg. And they go, but isn't that like a symptom of anxiety or a symptom of ADHD? So I go, well, stop jiggling now. Stop jiggling now. And they stop and I go, what's happening in your head? And they're going, please let me move. Please let me move. I go, that's not anxiety. That's not ADHD. That's restless legs. Okay, it's different. So it's, there's a different reason why you're doing it. And so that's what we would interrogate is exactly why that's happening. There's also circumstan, what I call circumstantial evidence for restless legs. So if you're not clear about it. So it is about that, are you, do you look for other sensations to try and be able to calm your legs down? So that pressure, that massage, that cold, that hot. What if I said to you, you're booked on an overnight flight and you're in the middle seat? Like, what goes through your head? And if you have restless legs, instant panic. Like, please don't make me do that. And I can tell you who has restless legs by being in a plane overnight, and I go, you, you, you all have restless legs. Why? Because you're walking around the plane at night. Why are you doing that? Why are you not sleeping? But I, they can't sit still, so they will always book an aisle seat so that they can get up and walk. Then there's things like sleeping with a pillow between your legs or sleeping with a duvet between your legs. Why? Because your legs are sensitive, and they're touching, them touching each other doesn't feel good. So we put something between the legs so that you can be able to fall asleep. Sleeping in strange positions. So kids sleep with their legs bent, their feet up the wall, like that, because it feels better. You know, so they sleep in strange positions. Being able to sleep on a, on a painkiller instead of a sleeping tablet. So a painkiller works better than a sleeping tablet, and that's codeine, which is in like the Gen Pain, Still Pain, so those kind of painkillers, works for restless legs. And so patients say, yeah, actually, if I take a gin pain, I sleep a whole lot better, whereas if I try and take a sleeping tablet, that doesn't work. So those are all kinds of go, that's not normal, is it? Right, to have those kind of things happen, but they can be seen to be normal because people have always done that. And you go, just because you've always done it doesn't mean it's normal.