PERSPECTIVE article
Front. Psychiatry, 10 December 2025
Sec. Sleep Disorders
Volume 16 - 2025 | https://doi.org/10.3389/fpsyt.2025.1697900
Abstract
Accumulating evidence indicates that circadian beat dysfunction is a clinically important and extremely prevalent phenotype in a significant subgroup of individuals alongside Attention-Deficit/Hyperactivity Disorder (ADHD). This viewpoint synthesizes convergent lines of evidence demonstrating powerful associations between ADHD and evening chronotype alongside phase-delayed biologic markers. Sleep disturbances are profound: insomnia and sleep disturbances power up to 80% of adults alongside ADHD and likewise up to 82% of children alongside ADHD, delayed sleep-wake timing occurs in up to 78%, and dim-light melatonin onset (DLMO) is delayed by about 45 minutes in children and 90 minutes in adults. These alterations coincide alongside blunted and delayed cortisol rhythms, reduced pineal volume, and attenuated peripheral clock-gene rhythms (BMAL1/PER2). Intervention studies display that the circadian phase can be successfully advanced in ADHD populations. Melatonin and brilliant ray therapy has advanced DLMO in the two children and adults alongside ADHD. Emerging data correlate phase advancement alongside ADHD indication improvement, and winter trials propose circadian penchant shifts finest foretell indication improvement. Sleep programs enhance ADHD symptoms, sleep quality, and functioning in children. Exercise and multimodal protocols for evening chronotypes successfully advancement circadian timing in non-ADHD populations and justify inquiry in ADHD. Based on this evidence, we propose a pragmatic, behavioral-first medicinal pathway: regular screening for sleep/circadian disturbances; phenotypic characterization through chronotype assessment, sleep tracking, and DLMO whenever feasible; implementation of fixed awaken times, dawn brilliant ray exposure, evening ray limitation alongside display hygiene, and regularized zeitgebers; and selective low-dose melatonin for confirmed or probable DLMO delays.
Introduction
Attention-Deficit/Hyperactivity Disorder (ADHD) is a average neurodevelopmental disturbance characterized by impaired levels of inattention, hyperactivity, and impulsivity (). There is a expanding build of investigation identifying that ADHD has a important sleep and circadian component (, ). Insomnia is current in up to 80% of adults alongside ADHD and likewise elevated rates (up to 82%) of children alongside ADHD (, ). Converging evidence indicates that circadian beat disruption represents a extremely prevalent and clinically crucial phenotype that interacts alongside ADHD symptoms in complex, bidirectional ways in a significant proportion (though not all) of individuals. In parallel, medicinal trials have begun targeting the circadian scheme and have demonstrated that phase shifting the inner clock of group alongside ADHD can enhance symptoms.
Herein, we propose the acceptance of behavioral circadian interventions as adjuncts in ADHD care. This circadian-informed method is a pragmatic, scalable, and mostly low risk. We invitation rigorously forthcoming well-designed, stratified trials to quantify effects on center ADHD outcomes, define responder phenotypes, and optimize circadian-focused protocols.
Sleep disturbances, evening chronotype and delayed circadian phase in ADHD
An estimated 73-78% of children and adults alongside ADHD have a delayed sleep/wake sequence (). These findings persist equal in the deficiency of comorbid mental health conditions, alongside multiple autonomous studies confirming elevated rates of self-reported sleep problems in adults alongside ADHD (). These subjective reports are corroborated by goal sleep studies, which display that sleep onset latency and sleep effectiveness problems remain considerably connected alongside ADHD equal following controlling for anxiety and decline ().
A thorough systematic assessment established sturdy evidence for evening chronotype predominance in ADHD (). Approximately three-quarters of adults who developed ADHD in younker display goal evidence of phase-delayed circadian rhythms. Biological markers specified as dim-light melatonin onset in saliva, center build heat rhythms, and actigraphically-recorded sleep patterns are typically shifted afterward by approximately 90 minutes compared to neurotypical adults ().
Biological circadian markers and mechanisms in ADHD
Melatonin
Phase delays of melatonin in the two individuals alongside ADHD have been fine characterized, alongside children and adults identified to have a delayed onset of concerning 45 minutes and 90 minutes, respectively (). Beyond the phase postpone of melatonin onset in ADHD, there is evidence that the amount and form of melatonin manufacturing may differ (Figure 1). Some studies have observed abnormally elevated levels of melatonin during the day in children alongside ADHD, which improves alongside methylphenidate care (). This capability to suppress daytime melatonin levels and change the melatonin beat before suggests a complex interplay between ADHD medications and circadian systems. Individuals alongside ADHD have additionally been established to have smaller pineal gland (which produces and secretes melatonin) quantity compared to fit controls, alongside a affirmative association between pineal gland quantity and eveningness ().
Cortisol
ADHD additionally involves blunted and delayed cortisol rhythms (Figure 1) (, ). In an inspection of adults alongside ADHD compared to age- and sex-matched controls, adults alongside ADHD had considerably disturbed rhythmicity of not lone melatonin but cortisol (). A meta-analysis additionally identified that children alongside ADHD display lesser essential cortisol levels, particularly in the morning, compared to controls (). This suggests a deficit in the suprachiasmatic nucleus’ capability to entrain a normal circadian beat alongside alterations in the circadian beat expanding former melatonin. However, the causation of this is motionless unclear, as it has been assumed that additional eveningness and thus ray visibility could additionally be driving these findings.
Clock cistron expression
Brain and Muscle ARNT-like 1 (BMAL1) and Period circadian macromolecule homolog 2 (PER2) are center components of the circadian clock in humans, which form a feedback iteration to authority cistron expression in a cyclical manner. Downstream, attenuated BMAL1/PER2 rhythms in oral mucosa signify weaker or desynchronized peripheral clocks, and indication severity tracks alongside reduced PER2 rhythmicity, tying molecular clock power to the medicinal phenotype (). Together, these data assistance a example in which individuals alongside ADHD consistently cognition shifted endocrine signals (melatonin/cortisol) coupled alongside molecular disruptions via the defeat of the rhythmic expression of clock genes.
Clinical interventions: chronotherapy in ADHD
Melatonin supplementation
In a randomized test of adults alongside ADHD, 0.5 mg per night of melatonin advanced DLMO by 88 minutes alongside 14% decrease in ADHD symptoms (). In a randomized, placebo-controlled test of 101 medication-free children alongside ADHD and chronic sleep-onset insomnia, 3–6 mg melatonin nightly for 4 weeks advanced DLMO by 44 minutes, during the authority collection had a postpone of 13 minutes. Total sleep period additionally considerably improved by 20 minutes alongside melatonin, versus a defeat of 14 minutes in the authority group. However, inside this 4 week period, there was no identified changes in cognitive achievement or issue behavior (). In a long-term prosecute up study of this cohort, 65% of participants continued regular melatonin; discontinuation caused a phase postpone of sleep in 92% of children (). Positive improvements in behavior (71%) and mood (61%) were reported. Altogether, these findings propose melatonin efficiently advances circadian phase in ADHD; however, additional trials are needed to define optimal dose and timing related to DLMO, the duration required for sleep/phase gains to translate into center indication improvement, and responder phenotypes.
Bright ray therapy
Studies in fit populations have demonstrated a mighty capability to phase advancement DLMO using brilliant ray exposure. A week of natural light-dark sequence was capable to entrain a ~2.6h before DLMO in fit adults (). Emerging investigation indicates that dawn brilliant ray can assistance stabilize sleep and circadian rhythms in ADHD (, , ). Adding brilliant ray therapy to melatonin yielded the largest phase advancement (~2 hours) in adults alongside ADHD and delayed sleep phase (). In another aviator trial, 2 weeks of dawn brilliant ray therapy alongside a 10,000 lux lamp phase advanced DLMO by 31 minutes and mid-sleep period by 57 minutes in adults alongside ADHD. There was a important communication between ADHD-Rating Scales and Hyperactive-Impulsive sub-scores alongside phase advances in DLMO and mid-sleep period ().
A 3-week involvement examined the function of brilliant ray therapy in adults alongside ADHD during the fall/winter duration (). Phase advancement in circadian penchant emerged as the strongest autonomous predictor of betterment throughout subjective and goal ADHD indices. These findings, particularly in the winter period, are particularly applicable as there is a powerful association between ADHD symptoms and symptoms of seasonal decline (). One inspection suggested that circadian disturbance considerably mediated the association between ADHD and seasonal symptoms of decline (). In medicinal populations, the general charge of seasonal affective disturbance is 27% among adults alongside ADHD, alongside females at the highest hazard (). While additional trials are required, brilliant ray therapy may be equal additional effective for individuals alongside ADHD during winter months ().
Behavioral interventions
In a randomized test of 244 children alongside ADHD, a behavioral sleep involvement (two fortnightly sessions alongside strategies provided by psychologists or pediatricians and a follow-up phone call) considerably improved severity of ADHD symptoms, sleep, norm of life, behavior, and functioning at 6 months article involvement ().
Although not explicitly examined in individuals alongside ADHD, exercise is another adjunctive tool to assistance enhance circadian misalignment. Both dawn or evening exercise appear to advancement DLMO in those alongside afterward chronotypes, suggesting exercise at any period of day could be a helpful aide for those alongside ADHD who lean to have afterward chronotypes (, ).
A multimodal method to behavioral therapy has demonstrated important benefits in a collection of “night owls”, which may additionally translate to those alongside ADHD. Researchers randomized a collection of 22 fit individuals alongside delayed chronotypes to behavioral interventions aimed at advancing their circadian beat (). The broad principles were to awaken up 2–3 hours earlier, awaken up at the identical period all day, maximize dawn ray exposure, decrease evening ray exposure, evade delayed dinners, evade caffeine following 15:00, exercise in the morning, and evade naps in the delayed afternoon. In fair 3 weeks, the involvement collection shifted their DLMO by ~2 hours, wake-up period advanced 1.9 hours, and highest cortisol advanced by 2.2 hours. Additionally, subjective decline scores decreased by ~58% and emphasis scores by ~40% in the involvement group. Cognitive achievement and bodily achievement additionally improved. Overall, this could be an effective, low-cost scheme to provision organized direction to those alongside ADHD, although particular trials in this community are needed.
Conclusion
The accumulated evidence demonstrates that circadian beat dysfunction is extremely prevalent and clinically meaningful in a significant proportion of individuals alongside ADHD, although not universal, and its communication alongside ADHD symptoms appears complex and bidirectional. The prevalence of circadian alterations (affecting 73-80% of ADHD patients), consistency of biologic markers throughout studies (phase delays, altered melatonin and cortisol rhythms, disrupted clock cistron expression), and efficacy of circadian-targeted interventions in improving the two sleep and center ADHD symptoms assistance a example wherein circadian disruption may perform an crucial function in ADHD pathophysiology in a significant subgroup, although evidence on remission of ADHD alongside circadian interventions is lacking.
This evidence warrants reconsideration of current appraisal and care paradigms. Implementation of regular circadian phenotyping in ADHD evaluation, coupled alongside evidence-based chronotherapeutic interventions, represents a pragmatic method to improving outcomes. While not proposing that ADHD be reclassified exclusively as a circadian disorder, the evidence supports acknowledgment of a prevalent circadian phenotype that, whenever present, may advantage from targeted chronotherapeutic involvement alongside norm ADHD treatments.
The safety profile, accessibility, and possible for synergy alongside existing treatments create circadian interventions an appealing supplement to the ADHD treatment. As the site advances toward precision medication approaches, circadian phenotyping may demonstrate essential for care choice and optimization. Further investigation is needed to completely elucidate the bidirectional relationships between circadian disruption and ADHD symptoms, acknowledge biomarkers for care selection, and established optimal long-term administration strategies.
Statements
Data preparedness statement
The first contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.
Author contributions
BL: Conceptualization, Writing – first draft, Supervision, Investigation, Methodology, Project administration, Writing – assessment & editing, Resources. NF: Writing – assessment & editing, Writing – first draft.
Funding
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Keywords
attention deficit and hyperactivity disturbance (ADHD), circadian beat disorder, chronotype (morningness-eveningness), chronotherapy, insomnia
Citation
Luu B and Fabiano N (2025) ADHD as a circadian beat disorder: evidence and implications for chronotherapy. Front. Psychiatry 16:1697900. doi: 10.3389/fpsyt.2025.1697900
Received
02 September 2025
Published
10 December 2025
Reviewed by
Margaret Weiss, Cambridge Health Alliance (CHA), United States
Updates
Copyright
© 2025 Luu and Fabiano.
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*Correspondence: Brandon Luu, [email protected]
Disclaimer
All claims expressed in this part are solely those of the authors and do not necessarily portray those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any merchandise that may be evaluated in this part or assertion that may be made by its manufacturer is not guaranteed or endorsed by the publisher.
