Feeding better sleep in children with ADHD, ASD and related conditions – by Dr Alex Richardson

by | Mar 4, 2024 | ADHD, Autism, Behaviour, Diet, Neurodevelopment, Sleep, Supplements, Uncategorized, Wellbeing | 0 comments

Difficulties achieving sufficient sleep are particularly common in children with behaviour and learning difficulties – affecting up to 70% of children with autism spectrum disorders (ASD) and 50% of those with clinical-level ADHD,1 and adding to parent-reported difficulties in emotional self-regulation, behaviour and learning.2

This brief article considers the evidence that improving nutrition can benefit children’s sleep, and with it, their mood, behaviour, wellbeing and ability to learn. This topic is so broad and complex that only an outline is possible here, but references and further information are provided.

Why Sleep Matters

Persistent sleep problems have detrimental effects on almost all aspects of children’s general health, wellbeing and quality of life.3  With respect to brain function, lack of sleep disrupts emotional self-regulation, increasing anxiety and mood problems;4 reduces pro-social behaviour (across individuals and societies);5 and also impairs learning and memory, both in the short- and longer-term.6 What’s more, only during deep sleep is the ‘glymphatic’ system activated, which ‘flushes’ accumulated metabolic waste and toxins from the brain, helping to explain how poor sleep can contribute to almost all forms of mental and neurological disorder.7

The amount of sleep children need to prevent these kinds of difficulties declines with age. So for 1-2 year-olds, 11-14 hours (including naps) is recommended; and for 3-5 year-olds, 10-13 hours. This reduces to 9-12 hours’ sleep each night for children aged 6-12, and 8-10 hours for 13-18 year-olds. Individuals differ in how much sleep they need, however – and the quality of sleep not just the duration, is important.

Sleep Deprivation or Sleep Disorder?

Modern lifestyles, environments and habits make sleep deprivation extremely common, but true sleep disorders involve an inability to sleep well despite consistent attempts and opportunities to do so.  Behavioural approaches – often summarised as ‘good sleep hygiene’ – can help many children achieve better sleep. Basics include regular bedtimes and routines (including mealtimes) and regular daytime exercise, as this has major mental as well as physical health benefits. Light exposure – and its timing – remains the strongest environmental influence on our circadian rhythms or ‘body clocks’, so exposure to morning daylight, keeping the bedroom dark, cool and free from distractions, and avoiding screen use or bright light before bedtime are all key factors in maintaining a healthy sleep-wake cycle.

Sleep disorders can take many different forms, including difficulties getting to sleep, night-time or early morning wakening; disturbances or disruptions during sleep – e.g. from ‘restless legs syndrome’ or periodic limb movements; or nightmares, night terrors, sleepwalking or other ‘parasomnias’. Breathing problems are another common cause of impaired sleep, and excessive daytime sleepiness – e.g. from sleep apnoea, asthma or other allergies. Any combination can co-occur with ADHD and ASD, but delayed sleep onset, irregular sleep-wake cycles, restless sleep and parasomnias are particularly common.8

Management of Sleep problems – and Co-occurring Conditions

Medical assessment should always be sought for serious and persistent sleep problems, as many physical conditions can contribute to these, as can medication side-effects. Use of stimulants for ADHD symptoms is one obvious example (although careful attention to the form, dosage and timing can minimise sleep disruption), but many other medications also impact sleep. Importantly, although off-label use is common, the US FDA approves no medications for treating childhood insomnia;9 and while melatonin has had EU approval since 2018, uncertainty remains about benefits vs excess side-effects reported, especially for longer-term use.10

Obesity often contributes to sleep apnoea; and metabolic, hormonal, allergic or other immune disorders can all affect sleep, as can pain and other somatic symptoms. These kinds of conditions can also mimic or exacerbate ADHD or ASD symptoms, and they co-occur so frequently with neurodevelopmental difficulties that medical evaluation is warranted in any case.11,12

The co-occurrence of sleep disturbances with gut and digestive disorders is so high that it has been suggested sleep problems should be seen as a primary symptom of these.13  Gut and digestive problems are extremely common in children with ASD and ADHD, and are also strongly associated with anxiety and mood disorders.  Although causality here may work both ways, nutrition and diet have obvious relevance to managing gastrointestinal symptoms.

Learn more about gut and digestive system, and how when it goes wrong it can be a primary consideration in autistic type behaviours:

How Diet can affect Sleep (and vice versa)

Sleep itself and the circadian rhythms that govern our sleep-wake cycle reflect the actions of a highly complex orchestra of hormones, neurotransmitters and other signalling molecules, essentially involving every organ and system in the brain and body. In turn, all are regulated by different nutrients involved in their metabolic pathways.

Numerous aspects of nutrition and diet can therefore influence sleep – but the links work both ways, as lack of sleep also affects appetite and food choices. Even small reductions in sleep duration increase children’s intakes of unhealthy foods, particularly snacks high in fat, sugar and/or salt, i.e. ultra-processed foods (UPF) such as crisps, sweets, cakes, biscuits or ice-cream.14 Brain imaging studies have provided evidence helping to explain why sleep deprivation increase our cravings for ‘junk foods’.

In turn – and potentially creating a vicious spiral that is all too prevalent in modern societies – eating a diet high in fat, carbohydrate or both promotes daytime sleepiness; and similarly, systematic reviews show that high UPF consumption predicts both mental and physica ill-health – including sleep problems, with clear dose-response effects.15

Conversely, numerous studies show better sleep is associated with higher intakes of Mediterranean-type or other traditional diets, rich in whole and minimally processed foods such as vegetables and fruits, whole grains and small amounts of meat and dairy products, as well as fish, eggs and nuts, all of which are good dietary sources of melatonin (as well as other key brain nutrients).16 However, association studies alone cannot determine causal effects.

Clinical trials of dietary interventions are more limited, but show possible benefits for sleep quality from specific foods consumed before sleep, such as milk, tart cherry juice, kiwifruit or fatty fish.17 The main rationale here is provision of melatonin, its precursor serotonin, and/or the amino acid tryptophan from which serotonin is made. Likewise, healthy high-carb (and low protein) food before bedtime may help promote serotonin transport into the brain. However, relative to the effect of darkness, dietary influences on night-time melatonin levels appear fairly minimal.18  Most clinical trials assessing effects of diet on sleep have also involved healthy adults, so their relevance to children with neurodevelopmental difficulties is uncertain.

What Nutritional and Dietary changes might help?

 

Dietary interventions

Children with ADHD and ASD tend to crave and consume ultra-processed foods even more than typically developing children do – and as noted, lack of sleep increases those cravings, both by impairing emotional regulation and increasing sensitivity to the ‘rewarding’ features of ‘hyper-palatable’ snack foods high in fat, sugar and/or salt.19  However, taking steps to reduce children’s intake of UPF is likely to be the single most important thing parents can do to improve their nutrition, health and development – and break the vicious cycle between stress, sleep problems and cravings for junk food.

This is because UPF-rich diets are almost always ‘low quality’ in nutritional terms, providing excess sugar and refined carbohydrates, an unhealthy balance of fats, and numerous artificial additives; and lacking in brain-essential micronutrients and dietary fibre. All of these features can damage brain, gut and immune health via known mechanisms.20

Systematic reviews of clinical trials show good or promising evidence that various specific dietary or nutritional interventions can help reduce child and adolescent sleep problems.21,22 Importantly, some of these – such as ketogenic or elimination (few foods) diets – only benefit particular subgroups, and also require professional help to implement them safely and effectively. Nonetheless, longstanding and substantive evidence shows that well-designed elimination diets can help many children with ADHD-type difficulties, and improvements in sleep are among the reported benefits.23  Similarly, solid clinical trial evidence shows that elimination of artificial food colourings alone can reduce ADHD symptoms in both clinical and general populations;24 and adverse reactions to these non-essential additives include irritability, restlessness and sleep disturbance.25

Nutritional supplementation

Long-chain omega-3 EPA/DHA (found in fish oils) and vitamin D are two key nutrients needed for healthy brain development and function that many children lack, particularly those with ADHD or ASD. With respect to effects on sleep, both omega-3 and vitamin D regulate production of serotonin – needed to make melatonin; and their anti-inflammatory and anti-depressant properties may also help. Preliminary clinical trial evidence does suggest sleep may be improved by supplementation with either Vitamin D26 or omega-3,27 but further research is needed to confirm this.

Controlled trials also show supplementation with omega-3 EPA/DHA can reduce ADHD symptoms in both clinical and non-clinical populations;28 and preliminary evidence suggests possible benefits for some ASD symptoms.29  Similarly, preliminary evidence has shown Vitamin D supplementation alone may improve some core behavioural and cognitive symptoms of ADHD30 and ASD;31 and that omega-3 and Vitamin D combined may reduce core ASD symptoms.32 Definitive evidence awaits further trials, but meanwhile, deficiencies of both omega-3 and Vitamin D are widespread, and supplementation with these nutrients is safe and generally well tolerated.

Many vitamins and minerals have been studied in relation to sleep problems,33  but magnesium, zinc and iron stand out – and low dietary intakes and/or tissue levels are commonly reported in ASD, ADHD and related conditions.  All three also play key roles in emotional regulation, behaviour and cognition (as well as physical health) so ensuring adequate intakes of these (as well as all other essential nutrients) makes sense in any case.

For magnesium, systematic reviews confirm that low intakes and status relate to sleep problems, but clinical trial evidence that supplementation with magnesium alone improves sleep is limited.34 Likewise, low zinc levels are linked with child sleep problems, especially in adolescence,35 consistent with other evidence zinc helps modulate sleep.36 Again, clinical trial evidence is limited; and like magnesium, zinc has multiple synergistic interactions with other nutrients. A more effective approach may therefore involve broad-spectrum micronutrient supplementation, which has already shown promise in the management of both ADHD and ASD symptoms.

Lack of iron is well known to impair brain function, with deficiency symptoms including low energy and mood, attentional and learning difficulties, behaviour problems and poor motor coordination – as well as sleep problems. Low iron is particularly linked with ‘restless legs syndrome’ or periodic limb movements, both common in children with ADHD and related conditions; and clinical trials show iron supplementation can significantly reduce these kinds of sleep disturbances in children with or without ADHD.37 However, excess iron can be harmful (and sometimes supplementation itself can have negative side-effects, depending on the form and dosage), so medical assessment and professional guidance is always recommended.

Real food is the best source of all nutrients whenever possible, because nutrients work synergistically; and (as research into UPF is now showing) other aspects of food and diet – in addition to their technical nutrient and energy content – are also important for good health. Unfortunately, food allergies or intolerances, and/or the food preferences of many children with ASD, ADHD and related conditions can make it difficult for them to obtain adequate intakes of all essential nutrients from diet alone. If so, good quality supplements can help to provide these, increasing the chances of achieving better sleep, as well as better health and wellbeing.

We highly recommend getting support from a registered nutritionist before you start any new supplement regime:

Book an appointment with a nutritionist here

View our list of supplements that may support sleep issues:

Supplements to support sleep issues

References

  1. Al Lihabi A. A literature review of sleep problems and neurodevelopment disorders. Front Psychiatry. 2023;14.
  2. Harris U, Svedberg P, Aili K, Nygren JM, Larsson I. Parents’ Experiences of Direct and Indirect Implications of Sleep Quality on the Health of Children with ADHD: A Qualitative Study. Int J Environ Res Public Health. 2022;19(22).
  3. Paruthi S, Brooks LJ, D’Ambrosio C, et al. Consensus Statement of the American Academy of Sleep Medicine on the Recommended Amount of Sleep for Healthy Children: Methodology and Discussion. J Clin Sleep Med. 2016;12(11):1549-1561.
  4. Vandekerckhove M, Wang YL. Emotion, emotion regulation and sleep: An intimate relationship. AIMS Neurosci. 2017;5(1):1-17.
  5. Simon E Ben, Vallat R, Rossi A, Walker MP. Sleep loss leads to the withdrawal of human helping across individuals, groups, and large-scale societies. PLoS Biol. 2022;20(8).
  6. Abel T, Havekes R, Saletin JM, Walker MP. Sleep, plasticity and memory from molecules to whole-brain networks. Curr Biol. 2013;23(17).
  7. Xie L, Kang H, Xu Q, et al. Sleep drives metabolite clearance from the adult brain. Science. 2013;342(6156):373-377.
  8. Petti T, Gupta M, Fradkin Y, Gupta N. Management of sleep disorders in autism spectrum disorder with co-occurring attention-deficit hyperactivity disorder: update for clinicians. BJPsych Open. 2024;10(1):e11.
  9. Bruni O, Angriman M, Melegari MG, Ferri R. Pharmacotherapeutic management of sleep disorders in children with neurodevelopmental disorders. Expert Opin Pharmacother. 2019;20(18):2257-2271.
  10. Händel MN, Andersen HK, Ussing A, et al. The short-term and long-term adverse effects of melatonin treatment in children and adolescents: a systematic review and GRADE assessment. EClinicalMedicine. 2023;61:102083.
  11. Sadek J. Attention Deficit Hyperactivity Disorder Misdiagnosis: Why Medical Evaluation Should Be a Part of ADHD Assessment. Brain Sci. 2023;13(11):1522.
  12. Muskens JB, Velders FP, Staal WG. Medical comorbidities in children and adolescents with autism spectrum disorders and attention deficit hyperactivity disorders: a systematic review. Eur Child Adolesc Psychiatry. 2017;26(9):1093-1103.
  13. Vernia F, Di Ruscio M, Ciccone A, et al. Sleep disorders related to nutrition and digestive diseases: A neglected clinical condition. Int J Med Sci. 2021;18(3):593-603.
  14. Morrison S, Jackson R, Haszard JJ, et al. The effect of modest changes in sleep on dietary intake and eating behavior in children: secondary outcomes of a randomized crossover trial. Am J Clin Nutr. 2023;117(2):317-325.
  15. Lane MM, Gamage E, Du S, et al. Ultra-processed food exposure and adverse health outcomes: umbrella review of epidemiological meta-analyses. BMJ. 2024;384:e077310.
  16. Meng X, Li Y, Li S, et al. Dietary Sources and Bioactivities of Melatonin. Nutrients. 2017;9(4).
  17. St-Onge MP, Mikic A, Pietrolungo CE. Effects of diet on sleep quality. Adv Nutr. 2016;7(5):938-949.
  18. Peuhkuri K, Sihvola N, Korpela R. Dietary factors and fluctuating levels of melatonin. Food Nutr Res. 2012;56(1):17252.
  19. Greer SM, Goldstein AN, Walker MP. The impact of sleep deprivation on food desire in the human brain. Nat Commun. 2013;4.
  20. Contreras-Rodriguez O, Solanas M, Escorihuela RM. Dissecting ultra-processed foods and drinks: Do they have a potential to impact the brain? Rev Endocr Metab Disord. 2022;23(4):697-717.
  21. Innocenti A, Lentini G, Rapacchietta S, et al. The Role of Supplements and Over-the-Counter Products to Improve Sleep in Children: A Systematic Review. Int J Mol Sci. 2023;24(9).
  22. France KG, McLay LK, Hunter JE, France MLS. Empirical research evaluating the effects of non-traditional approaches to enhancing sleep in typical and clinical children and young people. Sleep Med Rev. 2018;39:69-81.
  23. Pelsser LM, Frankena K, Buitelaar JK, Rommelse NN. Effects of food on physical and sleep complaints in children with ADHD: A randomised controlled pilot study. Eur J Pediatr. 2010;169:1129-1138.
  24. Arnold LE, Lofthouse N, Hurt E. Artificial food colors and attention-deficit/hyperactivity symptoms: conclusions to dye for. Neurotherapeutics. 2012;9(3):599-609.
  25. Rowe KS, Rowe KJ. Synthetic food coloring and behavior: a dose response effect in a double-blind, placebo-controlled, repeated-measures study. J Pediatr. 1994;125(5 Pt 1):691-8.
  26. Abboud M. Vitamin D Supplementation and Sleep: A Systematic Review and Meta-Analysis of Intervention Studies. Nutrients. 2022;14(5).
  27. Dai Y, Liu J. Omega-3 long-chain polyunsaturated fatty acid and sleep: a systematic review and meta-analysis of randomized controlled trials and longitudinal studies. Nutr Rev. 2021;79(8):847-868.
  28. Chang JPC, Su KP, Mondelli V, Pariante CM. Omega-3 Polyunsaturated Fatty Acids in Youths with Attention Deficit Hyperactivity Disorder: a Systematic Review and Meta-Analysis of Clinical Trials and Biological Studies. Neuropsychopharmacology. 2018;43(3):534-545.
  29. Cheng YS, Tseng PT, Chen YW, et al. Supplementation of omega 3 fatty acids may improve hyperactivity, lethargy, and stereotypy in children with autism spectrum disorders: a meta-analysis of randomized controlled trials. Neuropsychiatr Dis Treat. 2017;Volume 13:2531-2543.
  30. Gan J, Galer P, Ma D, Chen C, Xiong T. The Effect of Vitamin D Supplementation on Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Child Adolesc Psychopharmacol. 2019;29(9):670-687.
  31. Li B, Xu Y, Zhang X, et al. The effect of vitamin D supplementation in treatment of children with autism spectrum disorder: a systematic review and meta-analysis of randomized controlled trials. Nutr Neurosci. 2022;25(4):835-845.
  32. Mazahery H, Conlon CA, Beck KL, et al. A Randomised-Controlled Trial of Vitamin D and Omega-3 Long Chain Polyunsaturated Fatty Acids in the Treatment of Core Symptoms of Autism Spectrum Disorder in Children. J Autism Dev Disord. 2019;49(5):1778-1794.
  33. Ji X, Grandner MA, Liu J. The relationship between micronutrient status and sleep patterns: a systematic review. Public Health Nutr. 2017;20(4):687-701. doi:10.1017/S1368980016002603
  34. Arab A, Rafie N, Amani R, Shirani F. The Role of Magnesium in Sleep Health: a Systematic Review of Available Literature. Biol Trace Elem Res. 2023;201(1):121-128.
  35. Ji X, Liu J. Associations between Blood Zinc Concentrations and Sleep Quality in Childhood: A Cohort Study. Nutrients. 2015;7(7):5684-5696. doi:10.3390/NU7075247
  36. Cherasse Y, Urade Y. Dietary zinc acts as a sleep modulator. Int J Mol Sci. 2017;18(11). doi:10.3390/ijms18112334
  37. Leung W, Singh I, McWilliams S, Stockler S, Ipsiroglu OS. Iron deficiency and sleep – a scoping review. Sleep Med Rev. 2020;51:101274. doi:10.1016/j.smrv.2020.101274

 

Disclaimer:  The views and opinions expressed in this blog post are those of the author and do not necessarily reflect the official policy or position of any professional organization or guidelines. The information provided is for educational and informational purposes only and is not intended as a substitute for professional advice, diagnosis, or treatment. Always seek the advice of your therapist or other qualified health provider with any questions you may have regarding a medical or mental health condition.