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

Studies consistently show that individuals with ADHD are more likely to experience fatigue and low energy levels compared to those without the condition. A study by Bijlenga et al. (2017) found that more than 70% of adults with ADHD reported experiencing significant fatigue, which was substantially higher than in the general population. Similar findings have been reported in children and adolescents, indicating that fatigue can affect individuals 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, and deficiencies can lead to a lack of drive and persistent feelings of fatigue (Volkow et al., 2011).

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 study by Coogan et al. (2019) highlighted that people with ADHD are more likely to have delayed sleep phase syndrome, 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. A study by Skodzik et al. (2017) found that the cognitive load experienced by individuals with ADHD can result in greater mental exhaustion, even during routine activities.

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. Research by Shaw et al. (2014) demonstrated that emotional dysregulation in ADHD can lead to a cycle of heightened stress responses and subsequent fatigue.

Interventions to Manage Fatigue in ADHD: Evidence-Based Approaches

Understanding the relationship between ADHD and fatigue is crucial for developing effective strategies to manage these symptoms. Over the last decade, several evidence-based interventions have been identified to help mitigate tiredness and improve energy levels in individuals with ADHD.

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, reduce hyperactivity, and alleviate symptoms of fatigue. A meta-analysis by Faraone et al. (2020) confirmed that stimulant medications not only improve core ADHD symptoms but also have a positive impact on fatigue levels in both children and adults with ADHD.

Non-Stimulant Medications:

Non-stimulant medications like atomoxetine and guanfacine are also used to treat ADHD. While primarily targeting ADHD symptoms, these medications can indirectly improve energy levels by enhancing sleep quality and reducing anxiety. Atomoxetine, for example, has been shown to improve sleep disturbances in individuals with ADHD, which can reduce daytime fatigue (Michelson et al., 2001).

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. A study by Yoon et al. (2013) found that cognitive-behavioural therapy for insomnia (CBT-I) can be particularly effective for individuals with ADHD, helping to improve sleep quality and reduce daytime fatigue.

Physical Activity:

Regular physical activity has been shown to have numerous benefits for individuals with ADHD, including reducing symptoms of fatigue. Exercise increases dopamine levels, improves sleep quality, and enhances overall energy levels. Research by Cerrillo-Urbina et al. (2015) suggests that aerobic exercise can significantly reduce ADHD symptoms and improve mood, which can help combat fatigue.

Mindfulness and Relaxation Techniques:

Mindfulness-based interventions, such as mindfulness meditation and yoga, can help individuals with ADHD manage stress and reduce feelings of fatigue. A study by Mitchell et al. (2013) found that mindfulness training can improve emotional regulation, reduce stress, and enhance overall well-being in individuals with ADHD, potentially alleviating symptoms of tiredness.

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) highlights the benefits of CBT in improving functional outcomes and reducing fatigue-related symptoms in adults with ADHD.

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

Research suggests that there may be gender differences in how fatigue manifests in individuals with ADHD. Women with ADHD are more likely to report fatigue and tiredness than men, potentially due to higher rates of emotional dysregulation and internalising symptoms such as anxiety and depression. A study by Rucklidge (2010) found that women with ADHD often experience more severe fatigue, highlighting the need for gender-specific approaches in managing these symptoms.

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., & Arns, M. (2017). The role of the circadian system in the etiology and pathophysiology of ADHD: Time to redefine ADHD? Attention Deficit and Hyperactivity Disorders, 9(3), 205-214.
2. Volkow, N. D., Wang, G. J., Tomasi, D., & Baler, R. D. (2011). Unbalanced neuronal circuits in ADHD and their relationship to sleep. Journal of Neuroscience, 31(11), 4224-4231.
3. Coogan, A. N., Baird, A. L., Popa-Wagner, A., & Thome, J. (2019). Circadian rhythms and attention deficit hyperactivity disorder: The what, the when and the why. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 89, 104-110.
4. Faraone, S. V., Banaschewski, T., Coghill, D., Zheng, Y., Biederman, J., Bulik, C. M., … & Franke, B. (2020). The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder. Neuroscience & Biobehavioral Reviews, 112, 1-24.
5. Rucklidge, J. J. (2010). Gender differences in attention-deficit/hyperactivity disorder. Psychiatric Clinics of North America, 33(2),

ADHD assessment and treatment at UMID

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