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Association between Attention Deficit Hyperactivity Disorder and Obstructive Sleep Apnea in Children: A Systematic Review and Meta-Analysis

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Title: Association between Attention Deficit Hyperactivity Disorder and Obstructive Sleep Apnea in Children: A Systematic Review and Meta-Analysis
Language: English
Authors: Bryan Hao Wei Leow, Claire Jing-Wen Tan (ORCID 0000-0003-4529-2978), Brian Sheng Yep Yeo, Noelle Na En Ng, Seraphina Cheng Yong Low, Adele Chin Wei Ng, Oon Hoe Teoh, Song Tar Toh, Ellen Ghim Hoon Tay
Source: Journal of Attention Disorders. 2026 30(6):822-832.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
Peer Reviewed: Y
Page Count: 11
Publication Date: 2026
Document Type: Journal Articles
Information Analyses
Descriptors: Attention Deficit Hyperactivity Disorder, Sleep, Children, Symptoms (Individual Disorders), Intervention, Child Health, Correlation, Surgery, Drug Therapy, Comorbidity, Equipment
DOI: 10.1177/10870547261426094
ISSN: 1087-0547
1557-1246
Abstract: Background: Obstructive Sleep Apnea (OSA) and Attention Deficit Hyperactivity Disorder (ADHD) are two relatively common conditions in the pediatric population, with multiple studies demonstrating a strong association between the two. Hypoxia and sleep fragmentation caused by OSA has been shown to exacerbate ADHD symptoms, while treatment for OSA, such as with continuous positive airway pressure or adenotonsillectomy, may improve ADHD symptoms. We aim to provide an updated systematic review and meta-analysis on the complex relationship between OSA and ADHD in children. Methods: PubMed, Embase, and SCOPUS were searched from inception to 1 December 2024 for longitudinal studies investigating the association between OSA and ADHD in children. Two independent authors selected relevant articles, extracted data, assessed bias using the Newcastle-Ottawa Scale and evaluated quality of evidence following the Grading of Recommendations, Assessment, Development and Evaluations framework. Random-effects meta-analysis was performed to synthesize pooled prevalence, while descriptive reviews were performed for all other outcomes. Results: This systematic review and meta-analysis of 11 studies and 903 children formally diagnosed with OSA or ADHD found that the pooled prevalence of OSA in children with ADHD was 44% ( 95% CI[2%,56%]). Descriptive analysis found that adenotonsillectomy for OSA consistently led to significant improvements in both OSA and ADHD symptoms, suggesting its potential in complementing existing pharmacological therapy in improving ADHD symptoms. Conclusion: OSA and ADHD are closely related comorbid conditions. Physicians should be cognizant of this association and consider concurrent evaluation for OSA in children with ADHD symptoms, which can effectively guide treatment strategies and potentially reduce the need for long-term pharmacological treatment.
Abstractor: As Provided
Entry Date: 2026
Accession Number: EJ1504201
Database: ERIC
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  Value: <anid>AN0193250483;gs001jun.26;2026Apr28.02:16;v2.2.500</anid> <title id="AN0193250483-1">Association between Attention Deficit Hyperactivity Disorder and Obstructive Sleep Apnea in Children: A Systematic Review and Meta-Analysis </title> <p>Background: Obstructive Sleep Apnea (OSA) and Attention Deficit Hyperactivity Disorder (ADHD) are two relatively common conditions in the pediatric population, with multiple studies demonstrating a strong association between the two. Hypoxia and sleep fragmentation caused by OSA has been shown to exacerbate ADHD symptoms, while treatment for OSA, such as with continuous positive airway pressure or adenotonsillectomy, may improve ADHD symptoms. We aim to provide an updated systematic review and meta-analysis on the complex relationship between OSA and ADHD in children. Methods: PubMed, Embase, and SCOPUS were searched from inception to 1 December 2024 for longitudinal studies investigating the association between OSA and ADHD in children. Two independent authors selected relevant articles, extracted data, assessed bias using the Newcastle-Ottawa Scale and evaluated quality of evidence following the Grading of Recommendations, Assessment, Development and Evaluations framework. Random-effects meta-analysis was performed to synthesize pooled prevalence, while descriptive reviews were performed for all other outcomes. Results: This systematic review and meta-analysis of 11 studies and 903 children formally diagnosed with OSA or ADHD found that the pooled prevalence of OSA in children with ADHD was 44% (95% CI [2%, 56%]). Descriptive analysis found that adenotonsillectomy for OSA consistently led to significant improvements in both OSA and ADHD symptoms, suggesting its potential in complementing existing pharmacological therapy in improving ADHD symptoms. Conclusion: OSA and ADHD are closely related comorbid conditions. Physicians should be cognizant of this association and consider concurrent evaluation for OSA in children with ADHD symptoms, which can effectively guide treatment strategies and potentially reduce the need for long-term pharmacological treatment.</p> <p>Keywords: obstructive sleep apnea; attention deficit hyperactivity disorder; inattention; hyperactivity; adenotonsillectomy; children; pediatrics</p> <hd id="AN0193250483-2">Introduction</hd> <p>Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by patterns of inattention, hyperactivity, and impulsivity that interfere with daily functioning or development. It is usually diagnosed in childhood, though it may persist into adolescence and adulthood. ADHD is diagnosed clinically in accordance with the Diagnostic and Statistical Manual for Mental Disorders-5 (DSM-5; [<reflink idref="bib32" id="ref1">32</reflink>]).</p> <p>Obstructive Sleep Apnea (OSA) is a form of sleep-related disordered breathing characterized by recurrent episodes of partial or complete obstruction of the upper airway during sleep, leading to intermittent cessation of airflow and sleep arousal. The underlying causes of OSA in children can be multifactorial, with major risk factors being adenotonsillar hypertrophy and obesity, and other risk factors being prematurity, asthma, allergic rhinitis, craniofacial abnormalities, neuromuscular disorders and a family history of OSA ([<reflink idref="bib14" id="ref2">14</reflink>]). Clinically, OSA severity is categorized by the Apnea-Hypopnea Index (AHI). It can be challenging to diagnose OSA in children as presentation may be distinct from that in adults. Children with OSA usually present with snoring, night awakenings, unusual sleep positions and sometimes nocturnal enuresis. In children, the sleep disruption may also lead to behavioral issues including hyperactivity, irritability, and even aggression. Adenotonsillectomy is the most common treatment for pediatric OSA ([<reflink idref="bib2" id="ref3">2</reflink>]).</p> <p>Several studies have shown that OSA and ADHD in children may be closely linked. Chronic sleep disruption caused by OSA can exacerbate the core symptoms of ADHD, leading to a cycle of worsening sleep disturbances and behavioral difficulties. Conversely, the hyperactive and impulsive behaviors commonly associated with ADHD may mask the presence of OSA in affected children, and lead to complications such as developmental delays, behavioral issues, cardiovascular problems, and impaired cognitive function ([<reflink idref="bib40" id="ref4">40</reflink>]).</p> <p>Of note, a previous systematic review and meta-analysis by Urbano et al. found that adenotonsillectomy in children with OSA was effective in the short-term treatment of ADHD symptoms. However, the success of other treatment options including Continuous Positive Airway Pressure (CPAP) therapy was not established ([<reflink idref="bib35" id="ref5">35</reflink>]). Another meta-analysis by Sedky et al. demonstrated that ADHD symptoms are related to OSA and improve after adenotonsillectomy, reducing the need for reliance on pharmacological intervention for control of ADHD. As such, it would be worthwhile to examine the association between these two comorbid conditions to guide clinical management ([<reflink idref="bib31" id="ref6">31</reflink>]).</p> <p>We aim to perform an updated systematic review and meta-analysis to summarize the latest literature and provide deeper insights on the relationship between OSA and ADHD in children.</p> <hd id="AN0193250483-3">Materials and Methods</hd> <p>According to a pre-registered protocol on PROSPERO (CRD42025645881), this systematic review and meta-analysis was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations ([<reflink idref="bib28" id="ref7">28</reflink>]). The PRISMA checklist can be found in Supplemental Table S1.</p> <hd id="AN0193250483-4">Search Strategy</hd> <p>PubMed, Embase and Cochrane Library were searched from inception to 1 December 2024, using search terms pertaining to OSA and ADHD, treatment methods and their relevant synonyms.</p> <hd id="AN0193250483-5">Study Selection</hd> <p>The selection of eligible articles by titles and abstracts, followed by full texts, was performed by three independent authors (CJWT, NNEN, SCYL), with disagreements resolved through the consensus of another independent author (BHWL). Based on the Population, Intervention, Comparators, Outcomes (PICO) framework, we selected studies that met the following inclusion criteria: randomized controlled trials or observational studies (cohort, cross-sectional) published as full-length articles in peer-reviewed journals studying the associations between OSA and ADHD in children. We included peer-reviewed observational studies that were published as full-length articles in English and utilized formal methods of diagnosis of OSA and ADHD. We utilized an AHI cut-off of ≥1 event per hour for the diagnosis of pediatric OSA, in accordance with the American Academy of Pediatrics guidelines ([<reflink idref="bib23" id="ref8">23</reflink>]). We excluded studies that did not meet the inclusion criteria, duplicate studies, case reports, case series, reviews, meta-analyses, letters, conference abstracts, and studies with incomplete data.</p> <hd id="AN0193250483-6">Data Extraction</hd> <p>We extracted data from each included article into a standardized extraction template. The data extraction process was performed by two independent authors (CJWT, BHWL). We extracted the following information: first author, year of publication, study design, country, follow-up duration, total number of participants, age, gender, prevalence of OSA in ADHD patients and vice versa, severity of OSA by AHI, intervention for OSA and ADHD respectively, subjective and objective outcomes following treatment, covariates, statistical methods and key findings.</p> <hd id="AN0193250483-7">Risk of Bias Assessment</hd> <p>The risk of bias of observational studies was appraised by four independent authors (CJWT, BHWL, NC, SL) using the Newcastle-Ottawa Scale (NOS; [<reflink idref="bib38" id="ref9">38</reflink>]) acknowledged by the Cochrane Collaboration ([<reflink idref="bib15" id="ref10">15</reflink>]), for interventional and observational studies respectively. The NOS is a nine-point grading system derived from an eight-item checklist, designed to evaluate the extent of selection, information, and confounding biases, in determining the risk of bias in non-randomized studies. As per the NOS grading in past reviews, we graded the studies as having a high (<5 stars), moderate (5–7 stars) or low risk of bias (≥8 stars; [<reflink idref="bib38" id="ref11">38</reflink>]). Risk of bias assessment via the Newcastle-Ottawa scale is demonstrated in Supplemental Table S2.</p> <hd id="AN0193250483-8">Statistical Analysis</hd> <p>We conducted all statistical analyses on RevMan (version 5.4), in accordance with statistical approaches laid out by the Cochrane handbook ([<reflink idref="bib15" id="ref12">15</reflink>]). Unless otherwise specified, a <emph>p</emph>-value of ≤.05 was considered statistically significant.</p> <p>When two or more studies were available, we proceeded with our planned meta-analyzes. Using a random-effects model, maximally covariate-adjusted ratios were pooled from each study. We assessed for between-study heterogeneity using Thompson's <emph>I</emph><sups>2</sups> values and the Cochran Q Test, where an <emph>I</emph><sups>2</sups> value of 25%, 50% and 75% represented low, moderate, and high degree of heterogeneity respectively and a τ<sups>2</sups><emph>p</emph>-value of ≤.10 was considered significant for heterogeneity. To assess for publication bias, we qualitatively examined funnel plots for asymmetry and imputed potentially missing studies using the trim-and-fill method.</p> <p>For all other outcomes in which there were insufficient data for a meta-analysis, descriptive analysis was performed.</p> <hd id="AN0193250483-9">Results</hd> <p>The PRISMA flowchart demonstrating the study selection process is presented in Figure 1. Literature search of the 4 databases (PubMed, Embase, Scopus and Cochrane Library) retrieved 825 results. 292 duplicates were removed. Title and abstract screening further excluded 498 articles. Full text screening excluded 24 articles. 11 articles were included in the final analysis ([<reflink idref="bib8" id="ref13">8</reflink>]; [<reflink idref="bib9" id="ref14">9</reflink>]; [<reflink idref="bib12" id="ref15">12</reflink>]; [<reflink idref="bib13" id="ref16">13</reflink>]; [<reflink idref="bib18" id="ref17">18</reflink>], [<reflink idref="bib19" id="ref18">19</reflink>]; [<reflink idref="bib22" id="ref19">22</reflink>]; [<reflink idref="bib26" id="ref20">26</reflink>]; [<reflink idref="bib27" id="ref21">27</reflink>]; [<reflink idref="bib34" id="ref22">34</reflink>]; [<reflink idref="bib39" id="ref23">39</reflink>]).</p> <p>Graph: Figure 1. PRISMA flow chart.</p> <hd id="AN0193250483-10">Study Characteristics</hd> <p>Baseline study characteristics of the included studies are summarized in Table 1. Briefly, of the 11 included studies, eight cohort studies, two case-control studies and one cross-sectional study. The proportion of males in the included studies ranged from 51.9% to 90%, while mean age ranged from 7.8 to 10.7 years. Six studies had low risk of bias while five studies had moderate risk of bias as per the Newcastle-Ottawa Scale in Supplemental Table S2.</p> <p>Table 1. Baseline Study Characteristics of Included Studies.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left">Study</th><th align="center">Country</th><th align="center">Study design</th><th align="center">Mean follow-up duration (months)</th><th align="center">Total participants</th><th align="center">No. of OSA participants</th><th align="center">No. of ADHD participants</th><th align="center">Mean age (years)</th><th align="center">Mean BMI</th><th align="center">% of males</th><th align="center">Treatment/intervention studied</th></tr></thead><tbody><tr><td>Nguyen-Ngoc-Quynh et al. (2022)</td><td>Vietnam</td><td>Cross sectional study</td><td>12</td><td>96</td><td>58</td><td>32</td><td>8.4 ± 2.4</td><td>17.1 ± 2.2</td><td>60.4</td><td>Clinical characteristics of patients with OSA and ADHD</td></tr><tr><td>Wu et al. (2023)</td><td>China</td><td>Prospective observational study</td><td>3</td><td>228</td><td>133</td><td>NA</td><td>7.8 ± 1.6</td><td>17.1 ± 4.0</td><td>62.3</td><td>Clinical characteristics of patients with OSA and ADHD</td></tr><tr><td>Galland et al. (2011)</td><td>New Zealand</td><td>Matched case control study</td><td>NR</td><td>56</td><td>NR, unable to tell how many participants have OSA as only mean AHI is reported</td><td>28</td><td>10.1 ± 1.8</td><td>18.7 ± 3.9</td><td>78.6</td><td>Treatment effects of methylphenidate on ADHD participants, evaluation of change in PSG parameters with use of methylphenidate</td></tr><tr><td><xref ref-type="bibr" rid="bibr18">Huang et al. (2004)</xref></td><td>Taiwan</td><td>Cross sectional case controlled study</td><td>6</td><td>102</td><td>67 of the ADHD patients had AHI >1</td><td>88</td><td>8.4 ± 1.8</td><td>18.2 ± 3.6</td><td>88.2</td><td>Clinical characteristics of patients with OSA and ADHD</td></tr><tr><td><xref ref-type="bibr" rid="bibr19">Huang et al. (2007)</xref></td><td>Taiwan</td><td>Prospective observational study</td><td>6</td><td>86</td><td>All 66 ADHD patients had AHI >1</td><td>66</td><td>8.1 ± 1.2</td><td>18.5 ± 1.2</td><td>87.2</td><td>Treatment effects of adenotonsillectomy and methylphenidate on OSA and ADHD symptoms</td></tr><tr><td><xref ref-type="bibr" rid="bibr13">Goraya et al. (2009)</xref></td><td>USA</td><td>Retrospective cohort study</td><td>12</td><td>33</td><td>8 of the ADHD participants had AHI >1</td><td>33</td><td>9.0 ± 1.4</td><td>21 ± 1.7</td><td>79.0</td><td>Clinical characteristics of patients with OSA and ADHD</td></tr><tr><td><xref ref-type="bibr" rid="bibr27">Pagel et al. (2004)</xref></td><td>Germany</td><td>Prospective observational study</td><td>NR</td><td>74</td><td>74:29 (AHI cut off >5), 45 participants had AHI <5</td><td>NR</td><td>10.7 ± 1.5</td><td>21.8 ± 2.2</td><td>58.6</td><td>Clinical characteristics of patients with OSA and ADHD</td></tr><tr><td><xref ref-type="bibr" rid="bibr9">Dillon et al. (2007)</xref></td><td>USA</td><td>Prospective cohort study</td><td>13</td><td>106</td><td>40</td><td>22</td><td>8.1 ± 1.8</td><td>NR</td><td>51.9</td><td>Treatment effects of adenotonsillectomy on OSA and ADHD symptoms</td></tr><tr><td><xref ref-type="bibr" rid="bibr8">Chin et al. (2018)</xref></td><td>Taiwan</td><td>Prospective cohort study</td><td>6</td><td>101</td><td>NR, unable to tell how many participants have OSA as only mean AHI is reported</td><td>71</td><td>8.8 ± 1.9</td><td>18.8 ± 3.9</td><td>76.0</td><td>Treatment effects of methylphenidate use on OSA and ADHD symptoms</td></tr><tr><td><xref ref-type="bibr" rid="bibr22">Li et al. (2006)</xref></td><td>Taiwan</td><td>Prospective cohort study</td><td>6</td><td>40</td><td>40:24 had SDB alone, 16 had SDB + ADHD</td><td>16</td><td>8.4 ± 1.6</td><td>18.6 ± 4.2</td><td>90.0</td><td>Treatment effects of adenotonsillectomy on OSA and ADHD symptoms</td></tr><tr><td>Tsai et al. (2012)</td><td>Taiwan</td><td>Case control study</td><td>12</td><td>256</td><td>2 of the ADHD participants had AHI >1</td><td>64</td><td>9.9 ± 2.5</td><td>NR</td><td>60.9</td><td>Clinical characteristics of patients with OSA and ADHD</td></tr></tbody></table> </ephtml> </p> <hd id="AN0193250483-11">Meta-Analysis</hd> <p>Four studies reported the prevalence of OSA in ADHD patients ([<reflink idref="bib13" id="ref24">13</reflink>]; [<reflink idref="bib18" id="ref25">18</reflink>]; [<reflink idref="bib27" id="ref26">27</reflink>]; [<reflink idref="bib34" id="ref27">34</reflink>]). The pooled prevalence of OSA in children with ADHD was 44% (95% CI [32%, 56%], <emph>I</emph><sups>2</sups> = 72.2%; Figure 2).</p> <p>Graph: Figure 2. Prevalence of OSA in children with ADHD. Note. Black diamonds are the estimated pooled prevalence for each random-effects meta-analysis; red box sizes reflect the relative weight apportioned to studies in the meta-analysis.</p> <hd id="AN0193250483-12">Systematic Review</hd> <p></p> <hd id="AN0193250483-13">Association Between OSA and ADHD</hd> <p>Two studies investigated the prevalence of ADHD in children with OSA. Nguyen et al. found that the prevalence of ADHD in children with OSA is 43.1% (25 events out of 58 subjects), while Dillon et al. found that the same prevalence is 27.8% (22 events out of 79 subjects; [<reflink idref="bib9" id="ref28">9</reflink>]; [<reflink idref="bib26" id="ref29">26</reflink>]).</p> <p>Three studies investigated the association between AHI and ADHD. Wu et al. demonstrated that attention deficit and hyperactive impulsivity scores graded by an 18-item ADHD rating scale were independently associated with the obstructive AHI (<emph>p</emph> <.001; [<reflink idref="bib39" id="ref30">39</reflink>]). Similarly, Chin et al. found that children with ADHD had significantly higher AHI (<emph>p</emph> =.002), hypopnea counts (<emph>p</emph> =.003) and lower slow-wave sleep percentages (<emph>p</emph> =.006) on polysomnography ([<reflink idref="bib8" id="ref31">8</reflink>]). Conversely, categorical analyses performed by Galland et al. in a small study population did not show any significant difference in AHI between children with and without ADHD ([<reflink idref="bib12" id="ref32">12</reflink>]).</p> <hd id="AN0193250483-14">Adenotonsillectomy</hd> <p></p> <hd id="AN0193250483-15">ADHD Parameters</hd> <p>Dillon et al. demonstrated that following adenotonsillectomy for the clinical indication of obstructed breathing while awake, obstructed breathing while asleep and recurrent tonsillitis, the overall prevalence of ADHD declined modestly from 27.8% to 20.5%. Among the 22 children diagnosed with ADHD at baseline, 50% remitted and no longer fulfilled DSM-IV criteria for ADHD, while the remaining 50% continued to have ADHD. The follow up prevalence remained high at 20.5% despite the 50% remission of ADHD because five children were newly diagnosed with ADHD at follow up ([<reflink idref="bib9" id="ref33">9</reflink>]).</p> <p>Two studies examined changes after adenotonsillectomy on the Disruptive Behavior Disorder Rating cale (DBDRS). Dillon et al. found that among the children whose ADHD remitted after adenotonsillectomy, rating changes on DBDRS corresponding to preoperative diagnosis changed by an average of 51.1%, with a mean decrease in DBDRS inattentive, hyperactivity and combined scores by 8.4, 6.0 and 18.0 respectively ([<reflink idref="bib9" id="ref34">9</reflink>]). [<reflink idref="bib19" id="ref35">19</reflink>] also demonstrated statistically significant changes in the overall DBDRS scores and hyperactivity/impulsivity sub scores post-adenotonsillectomy (<emph>p</emph> =.007 and <emph>p</emph> =.002 respectively; [<reflink idref="bib19" id="ref36">19</reflink>]).</p> <p>Similarly, two studies utilized the Child Behavior Checklist (CBCL). [<reflink idref="bib19" id="ref37">19</reflink>] found that multiple parameters in the CBCL rating scale showed statistically significant changes post-adenotonsillectomy, namely for 'thought/obsessive', 'somatic complaint', 'social withdraw', 'delinquent' and 'internalizing' (<emph>p</emph> <.05; [<reflink idref="bib19" id="ref38">19</reflink>]). Similarly, in different study, Li et al. found that all parameters in the CBCL rating scale showed significant changes post-adenotonsillectomy, with greatest change in 'depression/anxiety', 'thought/obsessive' and 'internalizing' (<emph>p</emph> =.001; [<reflink idref="bib22" id="ref39">22</reflink>]).</p> <p>The same two studies also utilized the Test of Variables of Attention (TOVA). Both [<reflink idref="bib19" id="ref40">19</reflink>] and Li et al. found that the change in response time post-adenotonsillectomy were statistically significant, from −0.83 ± 1.22 to −0.32 ± 0.94 and −0.79 ± 1.14 to −0.28 ± 0.93 respectively (<emph>p</emph> =.0006 for both; [<reflink idref="bib19" id="ref41">19</reflink>]; [<reflink idref="bib22" id="ref42">22</reflink>]). Overall ADHD scores post-adenotonsillectomy also showed statistically significant changes in both studies (<emph>p</emph> <.001).</p> <p>Lastly, [<reflink idref="bib19" id="ref43">19</reflink>] also analyzed changes in the ADHD rating scale (ADHD-RS) and found that children treated with adenotonsillectomy for OSA had an ADHD total score of 21.16 ± 7.13 on the ADHD-RS post-surgery compared to 31.52 ± 7.01 pre-surgery (<emph>p</emph> =.0001). Moreover, the attention and hyperactivity subscales were also significantly lower (<emph>p</emph> <.0001) in this group of children post-operatively ([<reflink idref="bib19" id="ref44">19</reflink>]).</p> <hd id="AN0193250483-16">Sleep Parameters</hd> <p>Two studies examined changes in sleep parameters following adenotonsillectomy for OSA.</p> <p>Two studies evaluated changes in PSG parameters. [<reflink idref="bib19" id="ref45">19</reflink>] demonstrated statistically significant changes to AHI following adenotonsillectomy in children diagnosed with ADHD, from pre-surgery AHI of 3.32 ± 1.11 to post-surgery AHI of 0.89 ± 0.63 (<emph>p</emph> <.001). The same study also noted statistically significant changes in snoring index, arousal index and total sleep time (<emph>p</emph> <.05 for all three parameters; [<reflink idref="bib19" id="ref46">19</reflink>]). In addition, Li et al. saw comparable changes to pre and post adenotonsillectomy AHI, from 10.6 ± 11.1 to 1.7 ± 2.1 (<emph>p</emph> <.001). However, the change in AHI did not correlate negatively with the TOVA score, suggesting that the TOVA score improvement from adenotonsillectomy may not be directly due to the reduction of sleep apnea or hypopnea events. The study also noted statistically significant changes post adenotonsillectomy for the snoring index and mean arterial oxygen saturation (<emph>p</emph> =.014 and <emph>p</emph> =.018 respectively; [<reflink idref="bib22" id="ref47">22</reflink>]).</p> <p>One study utilized the OSA-18 Quality of Life (QOL) rating scale in children with OSA and ADHD. [<reflink idref="bib19" id="ref48">19</reflink>] showed statistically significant changes to sleep disturbances and overall QOL parameters following adenotonsillectomy (<emph>p</emph> <.001 and <emph>p</emph> <.05 respectively; [<reflink idref="bib19" id="ref49">19</reflink>].</p> <hd id="AN0193250483-17">Pharmacological Treatment With Methylphenidate</hd> <p></p> <hd id="AN0193250483-18">ADHD Parameters</hd> <p>Two studies examined changes in ADHD parameters following methylphenidate use.</p> <p>[<reflink idref="bib19" id="ref50">19</reflink>] showed demonstrated a statistically significant change only in inattention sub scores (<emph>p</emph> <.01), but not for hyperactive sub scores or total score on the ADHD-RS after 6 months of methylphenidate use. However, there were no statistically significant changes in any of the eight subscales on the CBCL with methylphenidate use over the same time period ([<reflink idref="bib19" id="ref51">19</reflink>]).</p> <p>Separately, Chin et al. found that there was a statistically significant change in both inattention and hyperactive sub scores and total scores on the ADHD-RS after 6 months of methylphenidate use in children with ADHD (<emph>p</emph> <.05). Findings on the CBCL were dissimilar as only externalizing behavior, anxiety, obsession/compulsion and aggression subscales showed statistically significant change with methylphenidate use (<emph>p</emph> <.05) while the rest of the subscales had no significant change with methylphenidate use ([<reflink idref="bib8" id="ref52">8</reflink>]).</p> <hd id="AN0193250483-19">Sleep Parameters</hd> <p>Two studies examined changes in sleep parameters following methylphenidate use.</p> <p>In children with OSA, Huang et al. demonstrated a non-significant change in AHI from 2.24 ± 1.44 to 2.50 ± 2.95 with methylphenidate use after 6 months. In children who were not on methylphenidate, there was a change in AHI from 2.56 ± 1.46 to 2.31 ± 2.19 over the same duration. There was also no statistically significant change in other sleep parameters measured in the PSG, especially for snoring index, arousal index and total sleep time which showed significant changes post-adenotonsillectomy in the same study. Similarly, there was no significant change in OSA-18 QOL scoring for methylphenidate use, in comparison to adenotonsillectomy ([<reflink idref="bib19" id="ref53">19</reflink>]).</p> <p>Similarly, Galland et al. showed that in case-matched paired analysis done between 28 pairs of ADHD children and controls, only total sleep time showed statistically significant change on the medication night in children with ADHD (<emph>p</emph> <.01),and showed that methylphenidate use had no significant effect on AHI, desaturation events or snoring percentage ([<reflink idref="bib12" id="ref54">12</reflink>]).</p> <p>Chin et al. found a statistically significant increase in AHI from a mean of 1.20 ± 1.22 from 1.98 ± 2.78 (<emph>p</emph> =.012) following treatment with methylphenidate for 6 months. However, polysomnography findings showed significantly increased total sleep time and reduced periodic limb movement index, while the pediatric sleep questionnaire findings showed significant reduction in snoring. This suggests that while methylphenidate treatment may improve certain non-respiratory aspects of sleep in children with ADHD, it does not have a positive effect on sleep disordered breathing ([<reflink idref="bib8" id="ref55">8</reflink>]).</p> <hd id="AN0193250483-20">Discussion</hd> <p>Our systematic review and meta-analysis of 11 studies and found that close to half of children with ADHD have concomitant OSA, suggestive of a strong association between the two conditions. Descriptive analysis demonstrated that adenotonsillectomy consistently leads to improvement in both OSA and ADHD symptoms, and may be considered as an option before methylphenidate or as a complement to existing pharmacological therapy in improving ADHD symptoms in children with both conditions.</p> <p>In establishing the relationship between OSA and ADHD, it has been hypothesized that OSA is one of the five sleep phenotypes associated with ADHD, with the other phenotypes comprising delayed sleep onset insomnia, restless legs syndrome, narcoleptic and sleep EEG epileptiform discharges ([<reflink idref="bib25" id="ref56">25</reflink>]). With regards to biochemical changes, a previous study found that the systemic inflammatory response caused by OSA led to increased levels of inflammatory mediators like C-reactive protein and interleukin-6, which correlate with sleep disruption and hypoxia ([<reflink idref="bib33" id="ref57">33</reflink>]). Children with OSA also demonstrated evidence of decreased arterial blood oxygen saturation and brain hypoxemia ([<reflink idref="bib21" id="ref58">21</reflink>]). Such a phenomenon then limits the restorative benefits of sleep, disrupting cellular and chemical balances, eventually leading to prefrontal cortical dysfunction which may manifest as features of overactivity and impulsivity ([<reflink idref="bib4" id="ref59">4</reflink>]). Furthermore, sleep deprivation and fragmented sleep due to OSA can result in exacerbation of ADHD symptoms. This may explain why OSA and ADHD are strongly linked and may present concurrently in childhood.</p> <p>Nonetheless, we acknowledge that there exists heterogeneity in our analysis of the prevalence rates of ADHD in children with OSA. Notably, Nguyen et al. reported a high prevalence of 43.1% of ADHD in children with OSA. Current epidemiological literature suggests a prevalence of 20% to 30% of ADHD in children with OSA ([<reflink idref="bib26" id="ref60">26</reflink>]; [<reflink idref="bib35" id="ref61">35</reflink>]), which is similar to figures provided by Dillon et al. This may be attributed the fact that Nguyen et al. recruited subjects who were all diagnosed with asthma, regardless of whether they had OSA. A previous systematic review and meta-analysis by Kaas et al. demonstrated a positive association between asthma and ADHD after adjusting for relevant confounders ([<reflink idref="bib20" id="ref62">20</reflink>]). A large-scale genome-wide cross-trait analysis by Zhu et al. also found a significant genetic correlation between ADHD and asthma with seven jointly associated loci ([<reflink idref="bib41" id="ref63">41</reflink>]). Since children with asthma are more likely to have ADHD, this could have led to significant confounding and hence a higher prevalence of ADHD among the children with OSA in this study.</p> <p>Adenotonsillectomy may improve ADHD symptoms in children by improving overall sleep architecture and providing better quality of sleep which is critical in promoting optimal neurocognitive development in early adolescence, in areas including attention, reward, emotional processing and regulation, memory, and executive control ([<reflink idref="bib7" id="ref64">7</reflink>]). In fact, children with habitual snoring but without clinically significant hypoxia as measured by pulse oximetry have been shown to have poorer academic performance than those who do not snore ([<reflink idref="bib6" id="ref65">6</reflink>]). A prospective, nonrandomized study by Wei et al. showed that in 117 children with sleep disordered breathing who underwent adenotonsillectomy, correlations between sleep and behavior scores were statistically significant before and after surgery. Not only did both behavior and sleep improve independently before and after adenotonsillectomy for sleep disordered breathing in this group of patients, they also improved in correlation with each other ([<reflink idref="bib37" id="ref66">37</reflink>]). As such, the associations between poor sleep and neurocognitive, behavioral issues in children are evident, and adenotonsillectomy aims to restore proper sleep quality.</p> <p>Our findings are consistent with the Childhood Adenotonsillectomy Trial (CHAT) in 2013. The CHAT trial was a multicenter, single-blind, randomized study investigating the on neurocognitive and behavioral outcomes in children aged 5 to 9 years old with OSA who were subjected to early adenotonsillectomy versus watchful waiting. The study demonstrated significantly greater behavioral improvements post-surgery, as reported by caregivers and teachers using the Conners' Rating Scale. In addition, modest improvement for the adenotonsillectomy group was noted compared to the watchful waiting group in the attention and executive-function score on the Developmental Neuropsychological Assessment (<emph>p</emph> =.06; [<reflink idref="bib30" id="ref67">30</reflink>]). For the purposes of our study, the CHAT trial was excluded as participants did not have a formal diagnosis of ADHD; instead, general cognitive and behavioral outcomes were analyzed.</p> <p>Furthermore, several studies examining children with sleep-disordered breathing and ADHD have similarly shown substantial improvement in ADHD symptoms following adenotonsillectomy. Ahmadi et al. demonstrated that in 59 children with ADHD, adenotonsillectomy led to statistically significant change in ADHD rating scale score in both domains, in 1 month and 3 months follow-up period (<emph>p</emph> =.001; [<reflink idref="bib1" id="ref68">1</reflink>]). Another study by Amiri et al. showed similar findings with adenotonsillectomy leading to significant reduction in the severity of ADHD symptoms (oppositional behavior, cognitive disorders, inattention, hyperactivity and ADHD index) at 3- and 6-month postoperative intervals ([<reflink idref="bib3" id="ref69">3</reflink>]). These studies were not included in our current systematic review and meta-analysis as children did not have a formal diagnosis of pediatric OSA. Nonetheless, it is evident from current literature that adenotonsillectomy improves sleep quality which leads to enhanced cognitive function, reduced hyperactive behaviors and improved attention consistent across different rating scales.</p> <p>It is interesting to note that adenotonsillectomy may potentially give rise to greater improvement in ADHD symptoms than methylphenidate. While both interventions can ameliorate inattentiveness, hyperactivity, and impulsivity, they target distinct underlying mechanisms: methylphenidate addresses neurochemical dysregulation within dopaminergic and noradrenergic pathways and modulates attention networks, whereas adenotonsillectomy alleviates airway obstruction during sleep, a potentially reversible cause of neurobehavioral dysfunction. It is known that OSA can cause ADHD-like symptoms or worsen ADHD symptoms ([<reflink idref="bib40" id="ref70">40</reflink>]). This overlap in behavioral manifestations between OSA-related sleep fragmentation and ADHD often leads to diagnostic ambiguity. The symptoms of children initially identified to have ADHD may be secondary to underlying OSA, which could explain the substantial improvement in ADHD symptoms following adenotonsillectomy. As such, physicians should consider sleep evaluation concurrently with ADHD work-up in this group, especially in the presence of other supporting symptoms, which can help to reduce unnecessary long-term stimulant use and yield more sustained cognitive and behavioral benefits. Future studies providing a direct, head-to-head comparison between the two therapeutic modalities would be valuable and help to pave the way in formulating individualized, pathophysiology-driven treatment approaches for ADHD symptoms.</p> <p>While our study has found that adenotonsillectomy improves ADHD symptoms, it would be worthwhile to evaluate if the degree of adenotonsillar hypertrophy affects subsequent outcomes. In Huang et al. 56% of study participants who underwent adenotonsillectomy had grade 1 or 2 tonsils, and 20% did not have adenoid enlargement as evaluated on naso endoscopy and lateral neck radiographs. All other studies did not report data on the degree of adenotonsillar hypertrophy and did not conduct any subgroup analysis to adjust for the above.</p> <p>The strong association between the two conditions in the pediatric population should prompt physicians to assess and evaluate for OSA in ADHD, which can then guide subsequent treatment strategies. Both OSA and ADHD in children are associated with long-term health consequences, including metabolic syndrome, cardiovascular morbidity, neurocognitive deficits and depression in OSA, ([<reflink idref="bib5" id="ref71">5</reflink>]) as well poor somatic and psychiatric outcomes in ADHD ([<reflink idref="bib11" id="ref72">11</reflink>]). While central nervous system stimulants are typically considered to be first line treatment of ADHD, it is meaningful to appreciate that adenotonsillectomy may improve ADHD symptoms when co-diagnosed with OSA together. Moreover, it is widely known that methylphenidate can be associated with side-effects including insomnia, irritability and anxiety, reduced appetite, hypertension, tachycardia, tics, growth retardation and even suicidal ideation ([<reflink idref="bib36" id="ref73">36</reflink>]). As such, the potential of adenotonsillectomy in improving ADHD symptoms may shape the future of ADHD treatment for children with co-occurring OSA.</p> <hd id="AN0193250483-21">Strengths and Limitations</hd> <p>To our knowledge, this study is the first systematic review and meta-analysis that describes the bidirectional relationship of PSG-diagnosed OSA and ADHD diagnosed in the same setting in a pediatric population. While a previous systematic review by Urbano et. al similarly studied the association between sleep-disordered breathing and ADHD, our study differs in evaluating the bidirectional relationship of pediatric OSA and ADHD specifically with objective clinical diagnosis via polysomnography and DSM criteria respectively. It is widely known that children with sleep disturbances often display behavioral patterns that resemble some features of ADHD, ([<reflink idref="bib17" id="ref74">17</reflink>]) but may not fulfill its full criteria, limiting the strength of conclusions drawn from previous review papers.</p> <p>Another strength of our study includes the use of a rigorous protocol and structured methodology to systematically search and grade the included studies based on international guidelines. All included studies were of good quality and had a sizeable sample size, and the longitudinal studies had sufficient follow-up duration. Additionally, none of our included studies had high risk of bias. Moreover, we adopted a well-defined scope of analysis and only included studies which utilized gold standard, validated means of objective diagnosis for OSA and ADHD. We intentionally excluded papers examining general sleep-disordered breathing disorders, which may encompass central sleep apnea, complex sleep apnea and hypoventilation syndromes with different underlying pathophysiology, as well as primary snoring disorders. As such, our study presents a focused and precise analysis on the complex relationship of OSA and ADHD while avoiding confounding factors.</p> <p>Nonetheless, our study must be interpreted in the context of known and potential limitations. Firstly, there were relatively few studies investigating pediatric OSA and ADHD. Only a handful of studies used formal polysomnography to diagnose pediatric OSA, likely due to its time-consuming and cost ineffective nature, as well as difficulty in administering the test on young children. Instead, majority of studies relied on parent questionnaires or screening tools for OSA symptoms alone, such as use of the Pediatric Sleep Questionnaire, which can be subjective. Owing to limited number of studies, we were unable to adjust for confounders including obesity, allergic rhinitis, asthma, depression, learning disabilities, all of which can affect both OSA and ADHD in children ([<reflink idref="bib26" id="ref75">26</reflink>]; [<reflink idref="bib29" id="ref76">29</reflink>]). Furthermore, there was heterogeneity among studies related to baseline demographic characteristics of participants and clinical subtype of ADHD (inattentive vs. hyperactive vs. combined). Different studies also used various clinical checklists and rating scales for assessment of ADHD. Inclusion of a greater number of studies would allow us to perform additional analyses to adjust for these confounders and draw more robust conclusions on the relationship and optimal treatment approaches for both OSA and ADHD.</p> <p>Moreover, while majority of studies have demonstrated clear short-term benefits of adenotonsillectomy on ADHD symptoms in pediatric OSA patients, few have evaluated the long-term benefits of adenotonsillectomy. As OSA has been known to recur in some children post-adenotonsillectomy, it would be useful to determine the long-term behavioral changes in this group of children.</p> <hd id="AN0193250483-22">Future Studies</hd> <p>Future studies should focus on addressing current gaps in understanding causality, mechanisms, and treatment outcomes. Longitudinal cohort studies with longer follow-up durations would be helpful in determining whether early identification and treatment of OSA can reduce the onset or severity of ADHD symptoms over time. Neuroimaging and biomarker-based research may help uncover shared neurobiological pathways, such as dysregulation in dopamine or inflammatory markers. This can lead to development of novel pharmacological therapies. For example, Meliante et al. previously studied the potential role of antioxidant therapy with vitamin C or N-acetylcysteine in reducing oxidative stress produced during episodes of intermittent hypoxia in OSA ([<reflink idref="bib24" id="ref77">24</reflink>]).</p> <p>It would also be interesting to explore how different ADHD subtypes can possibly relate to specific patterns of sleep disruption such as arousals or rapid eye movement (REM) suppression. This is especially in light of promising developments in wearable sleep technology in the consumer market today, allowing for convenient yet accurate means for diagnosis.</p> <p>Lastly, future studies should investigate if other OSA treatment including CPAP therapy and orthodontic devices can improve ADHD symptoms in children. Hobzova et al. found that in the adult population, CPAP therapy demonstrated significant improvement in attention, working memory, and depressive symptoms in OSA patients, ([<reflink idref="bib16" id="ref78">16</reflink>]) while Escobar et al. previously hypothesized the use of oral appliance therapy for OSA treatment may reduce the symptoms of ADHD ([<reflink idref="bib10" id="ref79">10</reflink>]).</p> <hd id="AN0193250483-23">Conclusion</hd> <p>OSA and ADHD are closely related conditions of childhood with overlapping symptomatology. Adenotonsillectomy consistently leads to statistically significant improvement in both ADHD and OSA symptoms and may be considered as an option before or as complementary therapy to methylphenidate in improving symptoms of inattention and hyperactivity in children with both conditions. Moreover, children with ADHD symptoms would benefit from sleep evaluation concurrent with ADHD work-up. A greater number of large-scale, robust studies are required to further evaluate the treatment outcomes between OSA and ADHD.</p> <hd id="AN0193250483-24">Supplemental Material</hd> <p>Graph: Supplemental material, sj-docx-1-jad-10.1177_10870547261426094 for Association between Attention Deficit Hyperactivity Disorder and Obstructive Sleep Apnea in Children: A Systematic Review and Meta-Analysis by Bryan Hao Wei Leow, Claire Jing-Wen Tan, Brian Sheng Yep Yeo, Noelle Na En Ng, Seraphina Cheng Yong Low, Adele Chin Wei Ng, Oon Hoe Teoh, Song Tar Toh and Ellen Ghim Hoon Tay in Journal of Attention Disorders</p> <ref id="AN0193250483-25"> <title> References </title> <blist> <bibl id="bib1" idref="ref68" type="bt">1</bibl> <bibtext> Ahmadi M. S., Poorolajal J., Masoomi F. S., Haghighi M. (2016). Effect of adenotonsillectomy on attention deficit-hyperactivity disorder in children with adenotonsillar hypertrophy: A prospective cohort study. 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This work has not been submitted, in whole or in part, for publication or academic credit elsewhere.</bibtext> </blist> <blist> <bibtext> Not applicable as no study participants are involved in this study.</bibtext> </blist> <blist> <bibtext> BLHW, CJWT, BYSY, ANCW, TOH, TST, and ETGH designed the study and developed the study protocol and tools. BLHW, CJWT, NNNE and SLCY were responsible for data collection. BLHW, CJWT and BYSY analyzed data and wrote the manuscript. All authors read and approved the final manuscript.</bibtext> </blist> <blist> <bibtext> The authors received no financial support for the research, authorship, and/or publication of this article.</bibtext> </blist> <blist> <bibtext> The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.</bibtext> </blist> <blist> <bibtext> Data used for this study can be accessed upon request from the Principal Investigator (Dr. Ellen Tay Ghim Hoon) at ellen.tay.g.h@singhealth.com.sg.</bibtext> </blist> <blist> <bibtext> Supplemental material for this article is available online.</bibtext> </blist> </ref> <aug> <p>By Bryan Hao Wei Leow; Claire Jing-Wen Tan; Brian Sheng Yep Yeo; Noelle Na En Ng; Seraphina Cheng Yong Low; Adele Chin Wei Ng; Oon Hoe Teoh; Song Tar Toh and Ellen Ghim Hoon Tay</p> <p>Reported by Author; Author; Author; Author; Author; Author; Author; Author; Author</p> <p></p> <p>Bryan Hao Wei Leow is a Medical Officer in Singapore General Hospital Otolaryngology Department.</p> <p>Claire Jing-Wen Tan is a Junior Resident in Singapore General Hospital Otolaryngology Department.</p> <p>Brian Sheng Yep Yeo is a House Officer in Singapore General Hospital Otolaryngology Department.</p> <p>Noelle Na En Ng is a medical student in National University of Singapore.</p> <p>Seraphina Cheng Yong Low is a medical student in National University of Singapore.</p> <p>Adele Chin Wei Ng is an Associate Consultant Otorhinolaryngologist at Singapore General Hospital and Singhealth Duke-NUS Sleep Centre, with special interest in treatment of snoring and obstructive sleep apnea related conditions.</p> <p>Song Tar Toh is a Senior Consultant Otorhinolaryngologist at Singapore General Hospital and Singhealth Duke-NUS Sleep Centre, with special interest in treatment of snoring and obstructive sleep apnea related conditions. He has extensive experience in transoral robotic surgery and hypoglossal nerve stimulation implant surgery.</p> <p>Dr Ellen Ghim Hoon Tay is a Senior Consultant in the Department of Child Development at KK Women's and Children's Hospital (KKH), with an interest in caring for children with developmental, behavioural, and learning needs.</p> </aug> <nolink nlid="nl1" bibid="bib32" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib14" firstref="ref2"></nolink> <nolink nlid="nl3" bibid="bib40" firstref="ref4"></nolink> <nolink nlid="nl4" bibid="bib35" firstref="ref5"></nolink> <nolink nlid="nl5" bibid="bib31" firstref="ref6"></nolink> <nolink nlid="nl6" bibid="bib28" firstref="ref7"></nolink> <nolink nlid="nl7" bibid="bib23" firstref="ref8"></nolink> <nolink nlid="nl8" bibid="bib38" firstref="ref9"></nolink> <nolink nlid="nl9" bibid="bib15" firstref="ref10"></nolink> <nolink nlid="nl10" bibid="bib12" firstref="ref15"></nolink> <nolink nlid="nl11" bibid="bib13" firstref="ref16"></nolink> <nolink nlid="nl12" bibid="bib18" firstref="ref17"></nolink> <nolink nlid="nl13" bibid="bib19" firstref="ref18"></nolink> <nolink nlid="nl14" bibid="bib22" firstref="ref19"></nolink> <nolink nlid="nl15" bibid="bib26" firstref="ref20"></nolink> <nolink nlid="nl16" bibid="bib27" firstref="ref21"></nolink> <nolink nlid="nl17" bibid="bib34" firstref="ref22"></nolink> <nolink nlid="nl18" bibid="bib39" firstref="ref23"></nolink> <nolink nlid="nl19" bibid="bib25" firstref="ref56"></nolink> <nolink nlid="nl20" bibid="bib33" firstref="ref57"></nolink> <nolink nlid="nl21" bibid="bib21" firstref="ref58"></nolink> <nolink nlid="nl22" bibid="bib20" firstref="ref62"></nolink> <nolink nlid="nl23" bibid="bib41" firstref="ref63"></nolink> <nolink nlid="nl24" bibid="bib37" firstref="ref66"></nolink> <nolink nlid="nl25" bibid="bib30" firstref="ref67"></nolink> <nolink nlid="nl26" bibid="bib11" firstref="ref72"></nolink> <nolink nlid="nl27" bibid="bib36" firstref="ref73"></nolink> <nolink nlid="nl28" bibid="bib17" firstref="ref74"></nolink> <nolink nlid="nl29" bibid="bib29" firstref="ref76"></nolink> <nolink nlid="nl30" bibid="bib24" firstref="ref77"></nolink> <nolink nlid="nl31" bibid="bib16" firstref="ref78"></nolink> <nolink nlid="nl32" bibid="bib10" firstref="ref79"></nolink>
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  Data: Association between Attention Deficit Hyperactivity Disorder and Obstructive Sleep Apnea in Children: A Systematic Review and Meta-Analysis
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  Data: English
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  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Bryan+Hao+Wei+Leow%22">Bryan Hao Wei Leow</searchLink><br /><searchLink fieldCode="AR" term="%22Claire+Jing-Wen+Tan%22">Claire Jing-Wen Tan</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-4529-2978">0000-0003-4529-2978</externalLink>)<br /><searchLink fieldCode="AR" term="%22Brian+Sheng+Yep+Yeo%22">Brian Sheng Yep Yeo</searchLink><br /><searchLink fieldCode="AR" term="%22Noelle+Na+En+Ng%22">Noelle Na En Ng</searchLink><br /><searchLink fieldCode="AR" term="%22Seraphina+Cheng+Yong+Low%22">Seraphina Cheng Yong Low</searchLink><br /><searchLink fieldCode="AR" term="%22Adele+Chin+Wei+Ng%22">Adele Chin Wei Ng</searchLink><br /><searchLink fieldCode="AR" term="%22Oon+Hoe+Teoh%22">Oon Hoe Teoh</searchLink><br /><searchLink fieldCode="AR" term="%22Song+Tar+Toh%22">Song Tar Toh</searchLink><br /><searchLink fieldCode="AR" term="%22Ellen+Ghim+Hoon+Tay%22">Ellen Ghim Hoon Tay</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Attention+Disorders%22"><i>Journal of Attention Disorders</i></searchLink>. 2026 30(6):822-832.
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  Data: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
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  Data: 11
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  Data: 2026
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  Label: Document Type
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  Data: Journal Articles<br />Information Analyses
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Attention+Deficit+Hyperactivity+Disorder%22">Attention Deficit Hyperactivity Disorder</searchLink><br /><searchLink fieldCode="DE" term="%22Sleep%22">Sleep</searchLink><br /><searchLink fieldCode="DE" term="%22Children%22">Children</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Child+Health%22">Child Health</searchLink><br /><searchLink fieldCode="DE" term="%22Correlation%22">Correlation</searchLink><br /><searchLink fieldCode="DE" term="%22Surgery%22">Surgery</searchLink><br /><searchLink fieldCode="DE" term="%22Drug+Therapy%22">Drug Therapy</searchLink><br /><searchLink fieldCode="DE" term="%22Comorbidity%22">Comorbidity</searchLink><br /><searchLink fieldCode="DE" term="%22Equipment%22">Equipment</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1177/10870547261426094
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1087-0547<br />1557-1246
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Background: Obstructive Sleep Apnea (OSA) and Attention Deficit Hyperactivity Disorder (ADHD) are two relatively common conditions in the pediatric population, with multiple studies demonstrating a strong association between the two. Hypoxia and sleep fragmentation caused by OSA has been shown to exacerbate ADHD symptoms, while treatment for OSA, such as with continuous positive airway pressure or adenotonsillectomy, may improve ADHD symptoms. We aim to provide an updated systematic review and meta-analysis on the complex relationship between OSA and ADHD in children. Methods: PubMed, Embase, and SCOPUS were searched from inception to 1 December 2024 for longitudinal studies investigating the association between OSA and ADHD in children. Two independent authors selected relevant articles, extracted data, assessed bias using the Newcastle-Ottawa Scale and evaluated quality of evidence following the Grading of Recommendations, Assessment, Development and Evaluations framework. Random-effects meta-analysis was performed to synthesize pooled prevalence, while descriptive reviews were performed for all other outcomes. Results: This systematic review and meta-analysis of 11 studies and 903 children formally diagnosed with OSA or ADHD found that the pooled prevalence of OSA in children with ADHD was 44% ( 95% CI[2%,56%]). Descriptive analysis found that adenotonsillectomy for OSA consistently led to significant improvements in both OSA and ADHD symptoms, suggesting its potential in complementing existing pharmacological therapy in improving ADHD symptoms. Conclusion: OSA and ADHD are closely related comorbid conditions. Physicians should be cognizant of this association and consider concurrent evaluation for OSA in children with ADHD symptoms, which can effectively guide treatment strategies and potentially reduce the need for long-term pharmacological treatment.
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  Data: 2026
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  Data: EJ1504201
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