Lois Levine

“I hope to convince you, by the end of this talk, that children and adolescents with attention-deficit/hyperactivity disorder (ADHD) have a consistently higher prevalence of sleep disorders as compared to the general pediatric population," Grace Wang, MD, FAAP assistant professor of pediatrics at Penn State Health in Lancaster, Pennsylvania, told attendees of the virtual 2021 American Academy of Pediatrics National Conference & Exhibition. "There is evidence that shows that resolving the underlying sleep disorders can improve and in some cases, resolve, a patient’s ADHD diagnosis.”

“Sleep disorders are not listed in the differential diagnosis of ADHD in the DSM 5,” Wang continued. This, Wang believes, is why practitioners evaluating children for ADHD might not have it on their radar to screen for sleep disorders.

Wang shared several relevant case studies to illustrate her point. She described the case of a female aged 6 years with seasonal allergies and dysfunctional voiding patterns in the context of constipation. She was hyperactive and emotionally labile, threw frequent tantrums, had difficulty sustaining attention, and started to fall behind her peers at school. The child had no past surgical history, no family history of ADHD, and her family, preferring to avoid stimulants, asked if anything else can be done to support their child. 

Studies have shown that 25% of children with ADHD have OSAS, and 33% have snoring. Additionally, 25% to 64% of patients with ADHD have some sort of sleep-disordered breathing.

The patient presented as an alert girl with normal vital signs, normal intellect, and good eye contact; she was cooperative with the interview. Vanderbilt parent/teacher rating scales were implemented and the child was screened for ADHD, combined type. Psychometric testing revealed normal intellect with no learning disabilities. In recalling that sleep disorders can be seen in children with ADHD, the physician asked about snoring, and discovered the child does indeed snore, is a mouth breather, is restless throughout sleeping, and occasionally sleepwalks. Furthermore, she is exhausted after school, often falling asleep in the car on the drive home. This prompted a polysomnography, which showed she had sleep-related hyperventilation, and a mild/ borderline degree of obstructed sleep apnea syndrome (OSAS).

Wang interjected, “Studies have shown that 25% of children with ADHD have OSAS, and 33% have snoring. Additionally, 25% to 64% of patients with ADHD have some sort of sleep-disordered breathing.” The million-dollar question then becomes, Wang noted: “Can you expect improvement of ADHD symptoms after addressing sleep disorders? Literature shows that adenotonsillectomy in treating sleep disorders improves ADHD symptoms and may even resolve the diagnosis.” She noted this evidence in studies such as the Childhood Adenotonsillectomy Trial, which showed improved quality of life and behavior ratings by parents and teachers. Wang also pointed to a remarkable study of children aged 5 to 13 years, in which 28% were diagnosed with ADHD before an adenotonsillectomy. One year after the surgery, half of those children no longer met DSM criteria for ADHD. Similarly, ADHD scores were normalized in 69% of 40 children who had undergone the surgery 6 months prior.

In the aforementioned case, it was ultimately recommended that she get an adenotonsillectomy. Not only did her sleep improve after the surgery, but so did her attention span and behavioral issues.

Wang also discussed restless leg syndrome (RLS) in patients with ADHD, which can be treated with iron supplements, leg massages, compression devices, and lower body exercises.

In concluding, Wang  shared a few reminders with attendees: Keep that high index of suspicion for both sleep disorders and RLS in children with ADHD, as RLS runs in families. Ask about RLS in the biological parents and siblings. And, as iron deficiency is a risk with RLS, be sure to check on that as well. Because sleep deprivation and RLS can mimic symptoms of ADHD, have a high index of suspicion when examining and screening a patient for these conditions.



A version of this article originally appeared on 

1. Wang G. My child won’t sit still! Is it ADHD, or an underlying sleep disorder? 

American Academy of Pediatrics 2021 National Conference & Exhibition

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