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Child Psychiatrist /Adult Psychiatrist

Sleep Disordered Breathing Likely Exacerbates ADHD Symptoms

Keypoint: Sleep disordered breathing and ADHD are highly cross-prevalent, particularly among children and adolescents.

ADHD Symptoms

A targeted review published in the Journal of Attention Disorders found that the relationship between sleep disordered breathing (SDB) and attention-deficit/hyperactivity disorder (ADHD) was well-supported. In particular, SDB may contribute to the development and worsening of ADHD symptoms.

Disordered sleep has been associated with impaired cognition and ADHD and SDB appears to be highly prevalent among children with ADHD. However, the relationship between ADHD and SDB may be under-recognized and relatively understudied. To provide a more comprehensive understanding of the effect of SDB on ADHD, investigators searched publication databases through September 2022 for studies of SDB and/or obstructive sleep apnea (OSA) in ADHD in their focused review.

In evaluating the prevalence and co-occurrence of SDB/OSA and ADHD, the investigators found that the existing evidence indicates a high cross-prevalence between sleep disorders and ADHD (or ADHD symptoms), particularly among children and adolescents. One study found that among 3019 children aged 5 years, 25% had SDB. The children with SDB had a higher prevalence of hyperactivity (odds ratio [OR], 2.5; 95% CI, 2.0-3.0), inattention (OR, 2.1; 95% CI, 1.7-2.6), and aggressiveness (OR, 2.1; 95% CI, 1.6-2.6) than the children without SDB. Similarly, a review found that children with OSA had a high rate of attentional deficits (95%), and up to 20% to 30% of children with ADHD had OSA. Furthermore, a meta-analysis reported that youth with SDB were at higher risk of presenting with ADHD and that ADHD symptoms improved after adenotonsillectomy.

The investigators found that several studies reported on the proposed mechanisms of the association between SDB and ADHD. Study authors posit that fluctuating levels of hypoxia and hypercapnia during sleep may affect brain function relating to working memory and attention. Another proposed mechanism is that SDB causes sleep fragmentation and micro-awakenings, which leads to fatigue, exhaustion, and excessive daytime sleepiness.

Based on the published evidence, the review authors found a preponderance of evidence that supported the relationship between SBD and physiological processes, such as the activation of stress hormones and immunological activities. The activation of stress hormones and immunologic responses that affect blood oxygenation during sleep affects the brain regions associated with attention and executive function. These effects can, in turn, cause cognitive deficits consistent with symptoms of ADHD.

The investigators stated, “Accumulating evidence on possible neurophysiological mechanisms that may link SDB to the development of ADHD-like symptoms further supports the recommendation that SDB should be considered in the initial assessment of young children exhibiting inattention, daytime fatigue and distractibility.” Review authors concluded, “While SDB and ADHD are not mutually exclusive, their comorbidity can influence the severity of each condition. Consequently, there is a need for more targeted assessment of possible sleep disturbances in children evaluated for ADHD.”

Note: This article originally appeared on Psychiatry Advisor

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