Is it ADHD or an underlying sleep disorder?

Research shows that sleep problems should be addressed as part of ADHD treatment.


“I hope by the end of this talk I will convince you that children and adolescents with attention deficit / hyperactivity disorder (ADHD) have consistently higher of sleep disorders compared to the general pediatric population,” said Grace Wang, MD, The FAAP- Assistant Professor of Pediatrics at Penn State Health in Lancaster, Pennsylvania, told attendees at the American Academy of Pediatrics National Conference & Exhibition 2021 virtual virtual a patient’s diagnosis of ADHD. “

“Sleep disorders are not included in the differential diagnosis of ADHD in DSM 5,” Wang continued. This, Wang said, is why practitioners screening children for ADHD may not have on their radar checking for sleep disorders.

Wang shared several relevant case studies to illustrate her point. She described the case of a aged 6 years with seasonal allergies and dysfunctional urination patterns related to constipation. She was hyperactive and emotionally unstable, had frequent tantrums, had difficulty maintaining alertness, and fell behind her peers in school. The child had no previous surgical history, no family history of ADHD, and her family preferred to avoid stimulants and asked if anything could be done to support their child.

Studies have shown that 25% of children with ADHD have OSAS and 33% have snoring. In addition, 25 to 64% of patients with ADHD have some type of sleep-related breathing disorder.

The patient presented herself as an girl with normal vital functions, normal intellect and good eye contact; she was cooperative with the interview. Vanderbilt parent / teacher rating scales were implemented and the child was assessed for ADHD, combined type. Psychometric tests indicated normal intellect with no learning disabilities. Recalling that children with ADHD can experience insomnia, the doctor asked about their snoring and found that the child was actually snoring, mouth breathing, restless while sleeping, and occasionally sleepwalking. She is also exhausted after school and often falls asleep in the car on the drive home. This resulted in a polysomnography that showed sleep-related hyperventilation and mild / borderline obstructed sleep apnea syndrome (OSAS).

Wang interjected, “Studies have shown that 25% of children with ADHD have OSAS and 33% have snoring. In addition, 25 to 64% of people with ADHD have some type of sleep-related breathing disorder. “The million dollar question then, noted Wang, is,” Can you expect any improvement in ADHD symptoms after treating sleep disorders? The literature shows that adenotonsillectomy in the treatment of sleep disorders improves ADHD symptoms and can even resolve the diagnosis. ”She found this evidence in studies such as the Childhood Adenotonsillectomy Trial, which showed improved quality of life and behavioral assessments by parents and teachers. Wang also pointed to a notable study of children ages 5 to 13 in which 28% were diagnosed with ADHD prior to adenotonsillectomy. One year after the operation, half of these children no longer met the DSM criteria for ADHD. Similarly, ADHD scores were normalized in 69% of 40 children who had undergone surgery 6 months earlier.

In the above case, she was eventually recommended to have an adenotonsillectomy. After the operation, not only did her sleep improve, but also her attention span and behavior problems.

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

In closing, Wang shared some reminders with participants: Keep this high index of suspicion for sleep disorders and RLS in children with ADHD because RLS runs in families. Ask the birth parents and siblings about RLS. Since iron deficiency is a risk in RLS, you should check this out too. Because sleep deprivation and RLS can mimic symptoms of ADHD, there is a high index of suspicion when a patient is screened and screened for these conditions.

A version of this article originally appeared in Contemporary Pediatrics, a sister publication of the Psychiatric TimesTM.


1. Wang G. My child will not sit still! Is it ADHD or an underlying sleep disorder? American Academy of Pediatrics National Conference and Exhibition 2021; virtual. Retrieved October 9, 2021.

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