Nearly half of children with ADHD also have obstructive sleep apnea, and removing their tonsils may help more than stimulants
STUDY: Leow BHW et al, J Atten Disord 2026;30(6)
STUDY TYPE: Systematic review and meta-analysis
FUNDING: Independent
Background
Obstructive sleep apnea causes fragmented sleep and intermittent oxygen drops that impair attention, impulse control, and behavior, symptoms that overlap closely with ADHD. Children with enlarged tonsils and adenoids are especially prone to both.
The Study
- 11 studies, 903 children with a formal diagnosis of obstructive sleep apnea or ADHD, or both
- Studies examined the prevalence of each condition in the other, and the effects of adenotonsillectomy and methylphenidate on ADHD and sleep symptoms
- Mean age ranged from 7.8 to 10.7 years across studies
44% of children with ADHD had obstructive sleep apnea. In the other direction, 28–43% of children with obstructive sleep apnea had ADHD.
Adenotonsillectomy consistently improved both conditions across multiple rating scales. On the ADHD Rating Scale (ADHD-RS), total scores dropped from 31.5 to 21.2 after surgery. Half of children with a formal ADHD diagnosis no longer met criteria one-year post-surgery. Apnea scores fell sharply as well, from an average index of 3.3 to 0.9.
Methylphenidate improved inattention but did not improve sleep-disordered breathing, and in one study actually worsened the apnea index slightly.
Rates in Adults
In adults, ADHD and sleep apnea overlap at about twice the rate in the general population. 20 to 30% of adults with ADHD have sleep apnea, and the rate is closer to 50% when broadened to include all types of sleep disordered breathing.
This doesn’t mean that ADHD will resolve with treatment of sleep apnea, as the relationship is bidirectional. ADHD increases the risk of sleep apnea (about 10%), and sleep apnea increases the risk of ADHD (about 25%). The two disorders share common genetic and pathophysiologic pathways, including neuroinflammation and immune-related mechanisms in deep gray matter brain regions
Practice Implications
- When a child comes in with ADHD, ask about snoring, restless sleep, and nighttime breathing. If any of those are present, consider a sleep study. Sleep apnea is also common in adult ADHD (20-30%, but studies are fewer here).
- Adenotonsillectomy may resolve ADHD symptoms entirely in some children.
- The Pediatric Sleep Questionnaire SRBD subscale is a validated, free tool for screening obstructive sleep apnea in kids, and it takes under five minutes to complete. For adults, start with the STOP-BANG questionnaire.
— Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
