How do you differentiate between Attention Deficit Hyperactivity Disorder (ADHD) and Sleep Disordered Breathing in a 3-9 year old child?

Differentiating ADHD from Sleep-Disordered Breathing in Children Ages 3-9 Years

The key to differentiation lies in the temporal pattern and setting-specificity of symptoms: ADHD symptoms must have onset before age 12, be present across multiple settings since early childhood, and persist regardless of sleep quality, whereas sleep-disordered breathing symptoms are directly tied to sleep quality and often improve dramatically with treatment of the underlying sleep disorder. 1

Core Diagnostic Distinctions

ADHD-Specific Features

• Symptoms must be documented in MORE than one major setting (home, school, social activities) with information from parents, teachers, and other observers 1
• Onset before age 12 is mandatory for ADHD diagnosis, with symptoms typically present since early childhood 1, 2
• Symptoms persist throughout the day regardless of sleep quality the previous night 1
• Best identified during sedentary tasks requiring sustained attention in structured classroom settings, particularly for ages 6-9 1

Sleep-Disordered Breathing-Specific Features

• Nocturnal symptoms are prominent: witnessed apneas, snoring, restless sleep, frequent arousals 1, 3
• Morning symptoms: early morning headaches, difficulty awakening, non-restorative sleep 1, 3
• Physical examination findings: tonsillar hypertrophy, adenoid hypertrophy, obesity, midface hypoplasia 3, 4
• Nocturnal enuresis in older children (≥10 years old) is a red flag for sleep-disordered breathing 1
• Symptoms often improve with treatment of the underlying sleep disorder (adenotonsillectomy, CPAP) 3

Overlapping Symptoms That Complicate Diagnosis

Daytime Behavioral Manifestations Present in BOTH Conditions

• Hyperactivity and impulsivity can occur in both ADHD and sleep-disordered breathing 5, 3, 6
• Inattention and poor concentration are common to both conditions 5, 3, 4
• Behavioral problems and irritability may be present in either disorder 5, 3, 6
• Poor academic performance can result from either condition 1, 3

Critical distinction: In sleep-disordered breathing, these symptoms are secondary to poor sleep quality and chronic sleep deprivation, whereas in ADHD they are primary neurodevelopmental symptoms 5, 6

Systematic Assessment Protocol

Step 1: Comprehensive Sleep History

• Ask specifically about snoring (present in 23-50% of children with sleep-disordered breathing) 3, 4
• Witnessed apneas or respiratory pauses during sleep 1, 3
• Restless sleep with frequent position changes 3, 6
• Mouth breathing during sleep 3
• Excessive daytime sleepiness (more common in sleep-disordered breathing than ADHD) 1, 5, 3
• Difficulty with morning awakenings and non-restorative sleep 1, 5

Step 2: Physical Examination Focused on Airway

• Tonsillar size grading (hypertrophy increases risk of sleep-disordered breathing) 3, 4
• Adenoid facies or midface hypoplasia 3
• Body mass index assessment (obesity is a risk factor for sleep-disordered breathing) 1, 3
• Nasal patency evaluation 3

Step 3: Multi-Informant Behavioral Assessment

• Obtain DSM-5-based ADHD rating scales from both parents and teachers with age- and gender-specific norms 1
• Document symptoms across multiple settings (home, school, extracurricular activities) 1
• Assess for temporal consistency - ADHD symptoms should be relatively consistent regardless of sleep quality 1

Step 4: Screen for Comorbidities

• Both conditions can coexist: 23-40% of children with ADHD may have comorbid sleep-disordered breathing 5, 4
• Screen for anxiety and depression (14% and 9% comorbidity with ADHD respectively) 1, 7
• Assess for learning disabilities and language disorders 1

When to Pursue Formal Sleep Study

The American Academy of Pediatrics recommends screening for sleep disorders as part of ADHD evaluation, but formal polysomnography is NOT routinely indicated for asymptomatic patients 1

Indications for Polysomnography in This Age Group:

• Habitual snoring (≥3 nights per week) with witnessed apneas 1, 3
• Tonsillar hypertrophy (grade 3-4) with sleep symptoms 3, 4
• Unexplained oxygen desaturation or hypoxemia 1
• Persistent nocturnal enuresis in children ≥6 years old 1
• ADHD symptoms that fail to respond to appropriate behavioral and pharmacological treatment 1, 5
• History of recurrent morning headaches 1

Clinical Decision Algorithm

If Sleep-Disordered Breathing Features Predominate:

1. Refer to otolaryngology for evaluation of adenotonsillar hypertrophy 3
2. Consider polysomnography if clinical suspicion is high 1, 3
3. Defer ADHD diagnosis until sleep disorder is treated and symptoms reassessed 5, 6
4. Re-evaluate in 3-6 months after treatment of sleep disorder 3

If ADHD Features Predominate:

1. Confirm DSM-5 criteria are met with multi-informant data 1
2. Still screen for sleep problems using validated questionnaires 1, 5
3. Implement behavioral interventions first for preschool-aged children (ages 4-5) 1
4. Consider medication for school-aged children (ages 6-9) if behavioral interventions insufficient 1

If Both Conditions Appear Present:

1. Treat the sleep disorder first as it may improve or resolve ADHD-like symptoms 5, 3, 6
2. Reassess ADHD symptoms 3-6 months after sleep disorder treatment 3, 6
3. If ADHD symptoms persist despite adequate sleep, proceed with ADHD treatment 5, 6
4. Monitor for medication effects on sleep if stimulants are initiated 5, 6

Common Pitfalls to Avoid

• Assuming hyperactivity always equals ADHD: Children with sleep-disordered breathing paradoxically present with hyperactivity rather than sleepiness 3, 6
• Overlooking physical examination: Tonsillar hypertrophy is easily missed but highly relevant 3, 4
• Failing to obtain teacher input: ADHD cannot be diagnosed based solely on home behavior 1
• Not reassessing after sleep treatment: Many "ADHD" symptoms resolve with adenotonsillectomy 3, 6
• Ignoring comorbidity: 70% of children with ADHD have at least one comorbid sleep disorder 4

Age-Specific Considerations

Preschool Children (Ages 3-5):

• ADHD diagnosis is more challenging due to developmentally normal high activity levels and limited structured settings 1
• Sleep-disordered breathing may be easier to identify through parental observation of sleep 3
• Behavioral parent training is first-line if ADHD is suspected, without requiring definitive diagnosis 1

Early School-Age Children (Ages 6-9):

• ADHD becomes more apparent in structured classroom settings requiring sustained attention 1
• Teacher reports become critical for diagnosis 1
• Academic impact of either condition becomes measurable 3, 4

1, 5, 3, 6, 4