My youngster will not sit nonetheless! Is it ADHD or an underlying sleep disorder?

“Sleep disorders may not be the primary focus of a child’s initial assessment of inattentiveness, hyperactivity, or behavioral disorders,” began Grace Wang, MD, FAAP, Assistant Professor of Pediatrics, Penn State , Lancaster. Pennsylvania, at the virtual 2021 American Academy of Pediatrics National Conference & Exhibition. “By the end of this talk, I hope to convince you that children and adolescents with attention deficit / hyperactivity disorder (ADHD) have a consistently higher prevalence of sleep disorders compared to the general pediatric population. There is evidence that eliminating the underlying sleep disturbance may improve a patient’s diagnosis of ADHD, and in some cases even resolve it. “

“Sleep disorders are not included in the differential diagnosis of ADHD in the 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 described several case , the first being a 6-year-old woman with seasonal allergies and dysfunctional urination patterns related to constipation; hyperactive and emotionally unstable; had frequent fits of anger; has difficulty maintaining alertness; and begins to lag behind their peers at school. She had no previous surgical history, no family history of ADHD, and the family would rather not start her on a stimulant and ask if there was anything else that could be done. She presented herself as an awake girl with normal vital functions, normal intellect, good eye contact and cooperative in interviews. Vanderbilt parent / teacher rating scales are implemented and the child screens for ADHD, combined type. Psychometric tests show a normal intellect with no learning disabilities. As a reminder that children with ADHD may experience difficulty sleeping, the doctor will inquire about their snoring and determine that the child is actually snoring, is mouth breathing, is restless while sleeping, and is occasionally sleepwalking. She is also exhausted after school and falls asleep in the car on the drive home. This leads to a polysomnography showing sleep-related hyperventilation and mild / borderline obstructed sleep apnea syndrome (OSAS).

At this point, Wang throws in, “ have shown that 25% of children with ADHD have OSAS and 33% have snoring. Additionally, 25 to 64% of people with ADHD have some type of sleep-related breathing disorder. ”The multi-million dollar question then, admits Wang, is,“ Can you expect any improvement in ADHD symptoms after treating sleep disorders? The literature shows that when treating sleep disorders, adenotonsillectomy can improve ADHD symptoms and even resolve the diagnosis, ”says Wang. She points to a remarkable study of 5 to 13 year old children 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.

Finally, to come back to the case study of the 6-year-old child diagnosed with a sleep disorder, she was recommended to have an adenotonsillectomy. After the operation, not only did her sleep improve, but also her attention span and behavior problems.

Another patient discussed at this session was a 15-year-old male with sleep-wake phase disorder, a condition in which children do not feel as sleepy as their peers at bedtime because of the release of melatonin. Treatments for this condition include consistent sleep schedules on weekdays and weekends; Avoidance of blue light in the evening; and expose the child to bright, natural light when they wake up. If these do not resolve the disorder, sleep medicine and behavior therapy are often recommended.

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

In conclusion, Wang concluded, “Maintain this high index of suspicion for both sleep disorders and RLS in children with ADHD; since RLS occurs in families, ask about RLS from birth parents and siblings; and since iron deficiency is a risk in RLS you should check this out as well. Because sleep deprivation and RLS can mimic symptoms of ADHD, she also said that when they examine and screen a patient for these conditions, they have high suspicions.


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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