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How to differentiate sleep disorders from ADHD

September 20, 2021

Editor's note:  For more coverage of the 2021 AAP National Conference & Exhibition, visit

When she was a pediatric resident, Grace Wang, M.D., was surprised by how frequently undiagnosed sleep disorders could mimic attention-deficit/hyperactivity disorder (ADHD), learning disorders, emotional lability and other concerns seen in primary care. So she sought out opportunities to gain exposure to sleep medicine.

“In doing so, I witnessed firsthand how improving a child’s sleep could yield benefits in almost every facet of life — mental health, behavior, academic performance, cardiovascular health, pulmonary health, control of seizures and migraines, social functioning, caregiver stress level, etc.,” said Dr. Wang, assistant professor of pediatrics and director of pediatric sleep medicine at Penn State Health Children’s Hospital.

Dr. Wang keys in on patients presenting to the pediatrician with symptoms of ADHD during the on-demand session “My Child Won’t Sit Still! Is It ADHD or an Underlying Sleep Disorder?” (OD0271).

Studies have shown that sleep disorders occur at a higher frequency in children with ADHD than in children without the disorder, Dr. Wang noted.

For instance, obstructive sleep apnea syndrome is estimated to affect about 1%-4% of the general pediatric population but about 25% of children with ADHD. Restless legs syndrome prevalence is estimated at about 2% in the general pediatric population but can be as prevalent as 50% in children with ADHD.

“These sleep disorders have shared pathophysiology with ADHD and contribute to its manifestation and morbidity,” Dr. Wang said.

Parents, however, often do not associate their child’s ADHD symptoms with sleep disturbances, Dr. Wang said.

She encourages viewers to maintain a high index of suspicion and use high-yield questions to screen for sleep disorders in every patient with symptoms of ADHD, even those who do not volunteer sleep complaints. She also provides some diagnostic pearls and discusses when pediatricians should refer to sleep medicine specialists. 

Dr. Wang acknowledges there are multiple barriers to identifying sleep disorders in children with ADHD in the primary care setting.

Commonly used parent/teacher screening tools for ADHD do not include questions on sleep. “Thus, sleep disorders can be easily omitted from the initial differential diagnosis, which is concerning given the high prevalence of sleep disorders in youth with ADHD,” she said.

In addition, guidelines on ADHD diagnosis and the Diagnostic and Statistical Manual of Mental Disorders (DSM) only briefly mention considering sleep disorders in the routine evaluation of ADHD.

“These systematic factors — combined with time constraints that pediatricians face in their practices, limited sleep training in most pediatric residency and medical school curriculums, and the often vague and potentially misleading presentations of sleep disorders — can, not surprisingly, result in delayed or missed diagnoses.”

Dr. Wang emphasized that identification and treatment of an underlying sleep disorder can improve — or even resolve — ADHD symptoms in some children and adolescents.

“Given the high prevalence of sleep disorders in children with ADHD, it is so important to screen these patients routinely, whether they are a new evaluation or an established patient,” she said. “Identifying underlying sleep disorders in children with ADHD can prevent delayed diagnosis and reduce individual and familial morbidity, medication adverse effects and encounters with the health care system.”

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