Attention deficit hyperactivity disorder and sleep disordered breathing in pediatric populations: a meta-analysis.
Level 3 - non-randomized controlled study
Systematic review and meta-analysis of observational cross-sectional and uncontrolled pre-post surgical studies.
PubMed 24581717 · doi:10.1016/j.smrv.2013.12.003
What was done
Authors conducted a systematic review and meta-analysis across PubMed/Medline, PsycINFO, and Cochrane databases for English-language studies published through September 2012. The review investigated two questions in pediatric populations: the cross-sectional relationship between sleep-disordered breathing (SDB) and attention deficit hyperactivity disorder (ADHD) symptoms, and the change in ADHD symptoms before versus after adenotonsillectomy. Part 1 included 18 studies comprising 1,113 clinical subjects (874 diagnosed with SDB assessed for ADHD; 239 diagnosed with ADHD assessed for SDB) and 1,405 controls. Part 2 included 12 studies with 529 children assessed before and 2 to 13 months after adenotonsillectomy.
What was found
Part 1 demonstrated a moderate relationship between SDB and ADHD symptoms (Hedges' g = 0.57, 95% CI: 0.36 to 0.78; p = 0.000001). Higher apnea-hypopnea index (AHI) cutoff thresholds were associated with lower effect sizes, whereas higher study quality was associated with larger effect sizes. Age, gender, and body mass index did not moderate the relationship. Part 2 demonstrated a moderate reduction in ADHD symptoms following adenotonsillectomy (Hedges' g = 0.43, 95% CI: 0.30 to 0.55; p < 0.001) across 2 to 13 months of follow-up.
Why it matters
The findings support routine screening for sleep-disordered breathing in children presenting with ADHD symptoms. Identifying and surgically managing underlying SDB with adenotonsillectomy may reduce ADHD symptom severity, potentially altering the need for or dosing of psychostimulant medication.
Limits
The surgical analysis relied on pre- versus post-operative observational designs without randomized, non-surgical control groups, leaving findings vulnerable to regression to the mean, placebo effects, and natural maturation. Variation in AHI diagnostic cutoffs across included studies introduced heterogeneity. The search was restricted to English-language publications, and long-term outcomes beyond 13 months were not reported.
Cited by
- partial Children who mouth-breathe consistently have attention-deficit disorder (ADD) issues.