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Attention-deficit/hyperactivity disorder with obstructive sleep apnea: A treatment outcome study
Abstract
Background Children diagnosed with attention-deficit/hyperactivity disorder (ADHD), based on Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV) criteria, may also have obstructive sleep apnea (OSA), but it is unclear whether treating OSA has similar results as methylphenidate (MPH), a commonly used treatment for ADHD.Methods This study enrolled 66 school-age children, referred for and diagnosed with ADHD, and 20 healthy controls. Polysomnography (PSG) performed after ADHD diagnosis showed the presence of mild OSA. After otolaryngological evaluation, parents and referring physicians of the children could select treatment of ADHD with MPH, treatment of OSA with adenotonsillectomy or no treatment. Systematic follow-up was performed six months after initiation of treatment, or diagnosis if no treatment. All children had pre- and post-clinical interviews; pediatric, neurologic, psychiatric and neurocognitive evaluation; PSG; ADHD rating scale, child behavior checklist (CBCL) filled out by parents and teacher; test of variables of attention (TOVA); and the quality of life in children with obstructive sleep disorder questionnaire (OSA-18).Results ADHD children had an apnea-hypopnea index (AHI)>1<5 event/hour; 27 were treated with MPH, 25 had adenotonsillectomy, and 14 had no treatment. The surgical and MPH groups improved more than the non-treatment group. When comparing MPH to post-surgery, the PSG and questionnaire sleep variables, some daytime symptoms (including attention span) and TOVA subscales (impulse control, response time and total ADHD score) improved more in the surgical group than the MPH group. The surgical group had an ADHD total score of 21.16+/-7.13 on the ADHD rating scale (ADHD-RS) post-surgery compared to 31.52+/-7.01 pre-surgery (p=0.0001), and the inattention and hyperactivity subscales were also significantly lower (p=0.0001). Finally, the results were significantly different between surgically and MPH-treated groups (ADHD-RS p=0.007). The surgical group also had a TOVA ADHD score lower than -1.8 and close to those obtained in normal controls.Conclusion A low AHI score of >1 considered abnormal is detrimental to children with ADHD. Recognition and surgical treatment of underlying mild sleep-disordered breathing (SDB) in children with ADHD may prevent unnecessary long-term MPH usage and the potential side effects associated with drug intake.
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“In children with diagnoses of ADHD and OSA, two prospective studies have demonstrated significant improvements in ADHD symptoms, including hyperactivity, following adenotonsillectomy (Chervin et al. 2006; Huang et al. 2007).”
From Associations of sleep disturbance with ADHD: implications for treatment (2015) · cites this paper as Huang et al. 2007
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“Evidence for a potential causal link between SDB and ADHD comes from the finding that pharmacological/ surgical treatment of SDB and sleep apnea often improves symptoms of inattention and hyperactivity (Chervin et al. 2002; Huang et al. 2007).”
BackgroundIdentification of different clinical faces of obstructive sleep apnea in children
Wu, Y., Feng, G., Xu, Z., Li, X., Li, Z., Ge, W., & Ni, X. (2019) · International Journal of Pediatric Otorhinolaryngology · doi:10.1016/j.ijporl.2019.109621 · Cited by 20
Self-citationLin, C.-F. J., Ho, N., Hsu, W.-L., Lin, C.-H., Wang, Y., & Wang, Y. (2024) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.11310 · Cited by 22
Predicting poor school performance in children suspected for sleep-disordered breathing
BROCKMANN, P. E., V, Schlaud, M., Poets, C. F., & Urschitz, M. S. (2015) · Sleep Medicine · doi:10.1016/j.sleep.2015.03.021 · Cited by 19
“Sleep-disordered breathing (SDB), among other socioeconomic and biological factors, may be associated with neurocognitive impairment (NCI) as evidenced by poor school performance (PSP) [1,2], inattentive and hyperactive behavior [3,4], and other externalizing behavioral problems in children [5,6].”
BackgroundSomuk, B. T., Bozkurt, H., Göktaş, G., Demir, O., Gürbüzler, L., & Eyibilen, A. (2015) · American Journal of Otolaryngology · doi:10.1016/j.amjoto.2015.08.003 · Cited by 19
van Andel, E., Bijlenga, D., Vogel, S. W. N., Beekman, A. T. F., & Kooij, J. J. S. (2022) · Journal of Biological Rhythms · doi:10.1177/07487304221124659 · Cited by 23
“Several studies in children support this notion, as ADHD symptoms decreased after treatment of specific sleep disorders (Corkum et al., 2016; Huang et al., 2007; Walters et al., 2000).”
BackgroundAu, C. T., Chan, K. C. C., Lee, D. L. Y., Leung, N. M. W., Chow, S. M. W., Chow, J. S., Wing, Y. K., & Li, A. M. (2021) · Respirology · doi:10.1111/resp.14050 · Cited by 18
Unbiased Categorical Classification of Pediatric Sleep Disordered Breathing
Spruyt, K., Verleye, G., & Gozal, D. (2010) · SLEEP · doi:10.1093/sleep/33.10.1341 · Cited by 18
Prevalence of sleep problems in Smith‐Lemli‐Opitz syndrome
Żarowski, M., Vendrame, M., Irons, M., & Kothare, S. V. (2011) · American Journal of Medical Genetics Part A · doi:10.1002/ajmg.a.34021 · Cited by 17
“amelioration of ADHD symptoms has been observed after adequate OSA treatment [Huang et al., 2007].”
MethodAutism spectrum disorders, attention deficit/hyperactivity disorder, and sleep disorders
Ming, X., & Walters, A. S. (2009) · Current Opinion in Pulmonary Medicine · doi:10.1097/mcp.0b013e3283319a9a · Cited by 17
Effect of adenotonsillectomy on ADHD symptoms of children with adenotonsillar hypertrophy.
Dadgarnia, M. H., Baradaranfar, M., Fallah, R., Atighechi, S., Ahsani, A. H., & Baradaranfar, A. (2012) · PubMed · Cited by 16
Soylu, E., Soylu, N., Yıldırım, Y. S., Sakallıoğlu, Ö., Polat, C., & Orhan, İ. (2013) · International Journal of Pediatric Otorhinolaryngology · doi:10.1016/j.ijporl.2013.08.020 · Cited by 16
Severe Hypothyroidism Presenting as Obstructive Sleep Apnea
Rosen, D. (2010) · Clinical Pediatrics · doi:10.1177/0009922809351093 · Cited by 16
Current Trends in Pediatric Orthodontics: A Comprehensive Review
Koaban, A., Alharbi, S., Al-Shehri, A. Z., Al-Shamri, B. S., Aburazizah, M. F., Al-Qahtani, G. H., Alwusaybie, L. H., Alkhalifa, L., Al-Saad, M. M., Al-Nehab, A. A., et al. (2024) · Cureus · doi:10.7759/cureus.68537 · Cited by 18
“It may present as aggressive behaviors or contribute to symptoms of ADHD [146,147].”
BackgroundAndersson, H., & Sonnesen, L. (2018) · European Archives of Paediatric Dentistry · doi:10.1007/s40368-018-0330-3 · Cited by 16
“Consideration may be given to whether the differences found in sleepiness between the two groups were caused by ADHD or SDB/OSA and this may further emphasise the importance of the differential diagnosis between ADHD and SDB/OSA in children.”
BackgroundInfluentialKalaskar, R. R., Bhaje, P., Kalaskar, A., & Faye, A. (2021) · International Journal of Clinical Pediatric Dentistry · doi:10.5005/jp-journals-10005-1987 · Cited by 13
“The remaining 35 items were then grouped into eight subscales as following sleep domains: (1) Bedtime resistance, (2) sleep onset delay, (3) sleep duration, (4) sleep anxiety, (5) night wakings, (6) parasomnias, (7) sleepdisordered breathing, and (8) daytime sleepiness.”
Schoenfelder, E. N., Tran, N., Wholly, D., Kuhn, M., Stein, M. A., Mendoza, J. A., Ola, C., Sasser, T. R., & Tandon, P. S. (2023) · Journal of Attention Disorders · doi:10.1177/10870547231168332 · Cited by 12
“Prior studies demonstrate that treating sleep problems, which are commonplace for youth with ADHD (Yürümez & Kılıç, 2016), including through parent-focused sleep hygiene interventions, improves ADHD-related functioning (Huang et al., 2007; Sciberras et al., 2020; Weiss et al., 2006).”
BackgroundHolty, J.-E. C., & Guilleminault, C. (2012) · Seminars in Orthodontics · doi:10.1053/j.sodo.2011.10.014 · Cited by 12
Self-citationLundahl, A., & Nelson, T. D. (2014) · Journal of Health Psychology · doi:10.1177/1359105314544991 · Cited by 14
“However, treatment of disrupted sleep patterns results in significant improvements in both attention and hyperactivity and often leads to the discontinuation of ADHD stimulant medications (Fidan and Fidan, 2008; Guilleminault et al., 1981; Huang et al., 2007).”
Background
Metadata
- Authors
- Huang, Y.-S., Guilleminault, C., Li, H.-Y., Yang, C.-M., Wu, Y.-Y., & Chen, N.-H.
- Affiliations
- Chang Gung Memorial Hospital (TW)
- Stanford University (US)
- National Chengchi University (TW)
- Corresponding author
- Guilleminault, Christian
- Venue
- Sleep Medicine
- Publisher
- Elsevier BV
- Published
- 2007-01
- Volume
- 8
- Issue
- 1
- Pages
- 18-30
- ISSN
- 1389-9457 (ISSN-L)
- OpenAlex
- W2130844643
- Cited by
- 202
- References
- 51
- Citations by year
- 2026: 4 · 2025: 5 · 2024: 11 · 2023: 6 · 2022: 11 · 2021: 6 · 2020: 6 · 2019: 11 · 2018: 5 · 2017: 8 · 2016: 14 · 2015: 10 · 2014: 17 · 2013: 16 · 2012: 20
- FWCI
- 5.30
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Sleep Medicine (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Science Council
- Topics
- Health Sciences › Medicine › Physiology (medical) › Obstructive Sleep Apnea Research
- Health Sciences › Medicine › Psychiatry and Mental health › Attention Deficit Hyperactivity Disorder
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Keywords
- attention deficit hyperactivity disorder, obstructive sleep apnea, adenotonsillectomy, methylphenidate, sleep-disordered breathing, apnea-hypopnea index, children, treatment outcomes, inattention, hyperactivity, quality of life, polysomnography, Test of Variables of Attention, ADHD Rating Scale, Child Behavior Checklist, OSA-18
- MeSH terms
- Adenoidectomy, Adenoids, Central Nervous System Stimulants, Attention Deficit Disorder with Hyperactivity, Child, Female, Humans, Disruptive, Impulse Control, and Conduct Disorders, Male, Methylphenidate, Surveys and Questionnaires, Reaction Time, Severity of Illness Index, Sleep Apnea Syndromes, Tonsillectomy, Tonsillitis, Observer Variation, Polysomnography, Sleep Apnea, Obstructive, Diagnostic and Statistical Manual of Mental Disorders
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