Fatigue and Low Energy in ADHD

Written by Dr Kaleem Baig, Consultant Psychiatrist at UMID Healthcare.

Living with Attention Deficit Hyperactivity Disorder (ADHD) often involves more than just dealing with the well-known symptoms of inattention, hyperactivity, and impulsiveness. Many people with ADHD also report experiencing significant levels of tiredness, fatigue, and low energy, which can be just as disruptive to their daily lives. Over the past decade, research has increasingly focused on understanding this relationship, uncovering key neurobiological factors, and exploring effective interventions. This article provides an overview of the latest research findings and offers practical advice for managing fatigue in ADHD.

The Link Between ADHD and Fatigue: What Does the Research Say?

Fatigue is a common, yet often under-recognised, issue in individuals with ADHD. Several studies have explored the various dimensions of fatigue in ADHD, including its prevalence, underlying neurobiological mechanisms, and potential interventions.

Prevalence of Fatigue in ADHD

Individuals with ADHD are more likely to experience fatigue and low energy levels compared to those without the condition. In a study of adults attending outpatient services, Rogers et al. (2017) found that 62% of adults with ADHD met the criteria for clinically significant fatigue, and that the ADHD group was significantly more fatigued than healthy adults. Disturbed sleep is one important reason. A review by Bijlenga et al. (2019) reports that delayed sleep phase disorder, in which the body clock runs late so that falling asleep and waking both happen later than usual, affects 73 to 78% of children and adults with ADHD. A review by Yoon et al. (2012) found symptoms of sleep disorders in about 30% of children and 60 to 80% of adults with ADHD. Tiredness during the day can therefore affect people with ADHD across the lifespan.

Neurobiological Factors Contributing to Fatigue in ADHD

Fatigue in ADHD is thought to be closely related to the neurobiological underpinnings of the disorder. Key factors include:

1. Dopaminergic and Noradrenergic Dysregulation:

ADHD is characterised by dysregulation in dopamine and norepinephrine pathways in the brain, particularly in areas involved in executive function and reward processing. This dysregulation is thought to contribute not only to the core symptoms of ADHD but also to feelings of tiredness and low energy. Dopamine plays a critical role in motivation and alertness. Volkow et al. (2011) found that lower motivation in adults with ADHD was linked to reduced function in the brain's dopamine reward pathway, and a lack of drive of this kind can be experienced as persistent tiredness.

1. Circadian Rhythm Disruptions:

Research suggests that individuals with ADHD often experience disruptions in their circadian rhythms, which can contribute to sleep disturbances and, subsequently, daytime fatigue. A review by Coogan et al. (2016) highlighted that sleep and circadian rhythm disturbances are common in ADHD, including a delayed sleep phase, characterised by delayed sleep onset and waking times. This misalignment of the body’s internal clock can lead to poor sleep quality and increased tiredness during the day.

1. Executive Functioning Deficits:

ADHD is associated with impairments in executive functions, such as attention, working memory, and cognitive flexibility. These deficits can lead to increased mental effort required to perform tasks, which can contribute to mental fatigue.

1. Emotional Dysregulation and Stress:

Emotional dysregulation is a common feature of ADHD, characterised by heightened sensitivity to emotional stimuli and difficulty regulating emotional responses. This can lead to increased stress and anxiety, which are known to contribute to feelings of fatigue. A review by Shaw et al. (2014) concluded that emotion dysregulation is common in ADHD throughout the lifespan and is a major contributor to impairment.

Interventions to Manage Fatigue in ADHD

Understanding the relationship between ADHD and fatigue is crucial for developing effective strategies to manage these symptoms. Most of the research on the approaches below measured ADHD symptoms or sleep rather than fatigue itself, so direct evidence on tiredness is still limited. One of the few trials to measure fatigue directly, by van der Ham et al. (2026), found that adding treatment for sleep problems to usual ADHD care improved both sleep quality and fatigue in adults, although the authors describe their findings as preliminary.

1. Pharmacological Interventions

Stimulant Medications:

Stimulant medications, such as methylphenidate and amphetamines, are the most commonly prescribed treatments for ADHD. These medications increase the availability of dopamine and norepinephrine in the brain, which can help improve attention and reduce hyperactivity, and many people also feel more alert while taking them. The World Federation of ADHD International Consensus Statement (Faraone et al., 2021), which draws on large studies and meta-analyses, concludes that stimulant medications are effective in reducing ADHD symptoms in both children and adults. Stimulants can, however, delay sleep, which can add to tiredness the next day, so the timing of doses is worth discussing with your prescriber if sleep is a problem.

Non-Stimulant Medications:

Non-stimulant medications like atomoxetine and guanfacine are also used to treat ADHD. They are less likely than stimulants to delay sleep. In a trial in children with ADHD, sleep onset was delayed by about 12 minutes on atomoxetine compared with about 39 minutes on methylphenidate, although methylphenidate reduced night-time waking more (Sangal et al., 2006). However, tiredness and sleepiness are among the most common side effects of both atomoxetine and guanfacine. In the UK product information for guanfacine, sleepiness is reported by around 4 in 10 people taking it and fatigue by nearly 1 in 5, mostly in the first weeks of treatment. If you are taking one of these medicines and feel more tired than before, it is worth raising this with your prescriber, because the dose or its timing can sometimes be adjusted.

2. Behavioural and Lifestyle Interventions

Sleep Hygiene Practices:

Improving sleep hygiene is a crucial strategy for managing fatigue in ADHD. This includes maintaining a regular sleep schedule, creating a restful sleeping environment, and avoiding stimulants like caffeine before bedtime. Cognitive behavioural therapy for insomnia (CBT-I) is the treatment of choice for insomnia, although evidence for it in ADHD is still limited. In a small pilot study at a specialist adult ADHD clinic, Jernelöv et al. (2019) found that a group treatment based on CBT-I reduced insomnia severity.

Physical Activity:

Regular physical activity has numerous benefits for individuals with ADHD and may help with tiredness, although studies have not yet measured its effect on fatigue directly. Exercise is thought to increase dopamine activity, and it can improve sleep quality and overall energy levels. A meta-analysis by Cerrillo-Urbina et al. (2015) found that short-term aerobic exercise had moderate to large effects on attention, hyperactivity and impulsivity, and on related difficulties such as anxiety, in children with ADHD.

Mindfulness and Relaxation Techniques:

Mindfulness-based interventions, such as mindfulness meditation and yoga, can help individuals with ADHD manage stress, which may in turn ease feelings of fatigue. In a small pilot trial, Mitchell et al. (2017) found that eight weeks of group mindfulness training improved self-reported ADHD symptoms, executive functioning and emotion dysregulation in adults with ADHD.

3. Cognitive and Psychological Interventions

Cognitive-Behavioural Therapy (CBT):

CBT is widely used to help individuals with ADHD develop coping strategies for managing their symptoms. In addition to targeting core ADHD symptoms, CBT can address issues related to fatigue by helping individuals develop effective routines, improve time management, and reduce stress. A review by Knouse and Safren (2010) concluded that CBT for adult ADHD is promising in producing significant symptom reduction, and that learning and practising specific compensatory strategies may be its critical active ingredient.

Psychoeducation and Support Groups:

Educating individuals with ADHD and their carers about the relationship between ADHD and fatigue can empower them to take proactive steps in managing these symptoms. Support groups and psychoeducation programs provide valuable resources and strategies for managing fatigue, enhancing social support, and reducing feelings of isolation.

Gender Differences in Fatigue and ADHD

There may be gender differences in how fatigue shows itself in ADHD, although this has not been studied directly. A review by Rucklidge (2010) found that males and females with ADHD are more similar than different, although rates of depression and anxiety may be higher in girls and women, who are also less likely to be referred for treatment. Because anxiety and depression both commonly cause tiredness, fatigue in women with ADHD deserves particular attention.

Conclusion: Practical Tips for Managing Fatigue in ADHD

Living with ADHD and managing fatigue can be challenging, but understanding the underlying mechanisms and effective interventions can make a significant difference. Here are some practical tips for patients and carers:

1. Establish a Routine: Maintain a consistent daily schedule, including regular sleep and wake times.
2. Prioritise Sleep Hygiene: Create a calming bedtime routine and optimise your sleep environment.
3. Stay Active: Incorporate regular physical activity into your daily routine to boost energy levels.
4. Consider Professional Help: Consult with healthcare providers about medication options and psychological interventions like CBT.
5. Seek Support: Engage with support groups and educational resources to share experiences and learn from others.

By taking a holistic approach to managing ADHD and fatigue, individuals and their carers can improve their quality of life and better manage the daily challenges associated with the condition.

References

1. Bijlenga, D., Vollebregt, M. A., Kooij, J. J. S., & Arns, M. (2019). The role of the circadian system in the etiology and pathophysiology of ADHD: Time to redefine ADHD? ADHD Attention Deficit and Hyperactivity Disorders, 11(1), 5-19.
2. Cerrillo-Urbina, A. J., García-Hermoso, A., Sánchez-López, M., Pardo-Guijarro, M. J., Santos Gómez, J. L., & Martínez-Vizcaíno, V. (2015). The effects of physical exercise in children with attention deficit hyperactivity disorder: A systematic review and meta-analysis of randomized control trials. Child: Care, Health and Development, 41(6), 779-788.
3. Coogan, A. N., Baird, A. L., Popa-Wagner, A., & Thome, J. (2016). Circadian rhythms and attention deficit hyperactivity disorder: The what, the when and the why. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 67, 74-81.
4. Faraone, S. V., Banaschewski, T., Coghill, D., Zheng, Y., Biederman, J., Bellgrove, M. A., … & Wang, Y. (2021). The World Federation of ADHD International Consensus Statement: 208 evidence-based conclusions about the disorder. Neuroscience & Biobehavioral Reviews, 128, 789-818.
5. Jernelöv, S., Larsson, Y., Llenas, M., Nasri, B., & Kaldo, V. (2019). Effects and clinical feasibility of a behavioral treatment for sleep problems in adult attention deficit hyperactivity disorder (ADHD): A pragmatic within-group pilot evaluation. BMC Psychiatry, 19, Article 226.
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7. Mitchell, J. T., McIntyre, E. M., English, J. S., Dennis, M. F., Beckham, J. C., & Kollins, S. H. (2017). A pilot trial of mindfulness meditation training for ADHD in adulthood: Impact on core symptoms, executive functioning, and emotion dysregulation. Journal of Attention Disorders, 21(13), 1105-1120.
8. Rogers, D. C., Dittner, A. J., Rimes, K. A., & Chalder, T. (2017). Fatigue in an adult attention deficit hyperactivity disorder population: A trans-diagnostic approach. British Journal of Clinical Psychology, 56(1), 33-52.
9. Rucklidge, J. J. (2010). Gender differences in attention-deficit/hyperactivity disorder. Psychiatric Clinics of North America, 33(2), 357-373.
10. Sangal, R. B., Owens, J., Allen, A. J., Sutton, V., Schuh, K., & Kelsey, D. (2006). Effects of atomoxetine and methylphenidate on sleep in children with ADHD. Sleep, 29(12), 1573-1585.
11. Shaw, P., Stringaris, A., Nigg, J., & Leibenluft, E. (2014). Emotion dysregulation in attention deficit hyperactivity disorder. American Journal of Psychiatry, 171(3), 276-293.
12. van der Ham, M., Bijlenga, D., Molenaar, N., Starreveld, D. E. J., Böhmer, M. N., Wettstein, R., Dumont, G., Beekman, A. T. F., & Kooij, S. (2026). The effects of sleep treatment on symptoms of ADHD, sleep quality, fatigue, and depressive symptoms in adults. Journal of Attention Disorders, 30(3), 354-369.
13. Volkow, N. D., Wang, G. J., Newcorn, J. H., Kollins, S. H., Wigal, T. L., Telang, F., … & Swanson, J. M. (2011). Motivation deficit in ADHD is associated with dysfunction of the dopamine reward pathway. Molecular Psychiatry, 16(11), 1147-1154.
14. Yoon, S. Y. R., Jain, U., & Shapiro, C. (2012). Sleep in attention-deficit/hyperactivity disorder in children and adults: Past, present, and future. Sleep Medicine Reviews, 16(4), 371-388.

ADHD assessment and treatment at UMID

UMID Healthcare provides ADHD assessment and treatment for children, young people and adults. To discuss an assessment, contact our team or book an appointment.

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