Clinician-to-Clinician Update Clinician-to-Clinician Update

Hyperactivity and Behavioral Problems Caused by Obstructive Sleep Apnea

December 2014

Approximately 6% of children in the United States have obstructive sleep apnea.1 The symptoms of sleep apnea do not always overlap those seen in adults and may manifest as hyperactivity, distractibility, behavioral problems, depression, learning deficits, or other developmental and/or neurocognitive disorders.2 The effective treatment of sleep disordered breathing can greatly improve or eliminate these problems, as can be seen in the following case study.


A 9-year-old male presented at our pediatric clinic for the evaluation of possible attention deficit/hyperactivity disorder (ADHD). His parents reported that he is generally very hyperactive and has difficulty concentrating at home. His teachers report that he has difficulty concentrating, performs poorly in academic work, and displays behavioral problems at school. When asked about sleep complaints, the parents reported that, most nights, the patient sleeps restlessly, adopts a sleeping position with his neck hyperextended, snores loudly, and has breathing pauses and gasping arousals. The family history is significant in that there are other family members who reportedly snore and the patient’s father uses continuous positive airway pressure (CPAP) during sleep for sleep apnea.


The physical exam revealed tonsillar hypertrophy and mouth breathing. The child’s BMI was in the 95th percentile. The patient was referred for an overnight polysomnography study that showed breathing pauses with thoracoabdominal effort consistent with obstructive sleep apnea (Figure 1). The apnea hyopnea index (AHI) was 30 events per hour. (Normal AHI is less than 1, and 10 or more is considered severe apnea.) Oxygen desaturation to 65% was noted. 

case study-443x253
— Figure 1. A polysomnogram from the patient with symptoms of ADHD. Note the episodes of obstructive sleep apnea as evidenced by continued respiratory efforts with absent airflow.
— Figure 2. A normal polysomnogram.


The patient was referred to otolaryngology and underwent an adenotonsillectomy. A subsequent sleep study showed an improvement in the patient’s obstructive sleep apnea and hypoxemia. The child’s parents and teachers reported significant improvement in hyperactivity, concentration, behavioral problems, and school achievement.


In the pediatric population, sleep disordered breathing is closely associated with disruptive behavior disorders and poor academic performance. In one population-based cohort study of 605 children, frequent snoring or other obstructive sleep apnea symptoms were associated with a twofold difference in the odds of an ADHD diagnosis or the presence of ADHD-like symptoms and a threefold to fourfold difference in the odds of a conduct disorder diagnosis.3 Another study found that the incidence of failing grades is significantly increased in children with obstructive sleep apnea.4 In children with obstructive sleep apnea and tonsillar hypertrophy, significant improvements in aggression, depression, and hyperactivity have been reported after adenotonsillectomy, and these improvements were maintained during an 18-month follow-up.5 We recommend, therefore, that clinicians should strongly consider inquiring about sleep-disordered breathing symptoms in children with disruptive behavior disorders and should keep sleep-disodered breathing in the differential diagnosis of children in whom ADHD is suspected.


1. Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130:e714-755.

2. Chang SJ, Chae KY. Obstructive sleep apnea syndrome in children: Epidemiology, pathophysiology, diagnosis and sequelae. Korean J Pediatr. 2010;53:863-871.

3. Constantin E, Low NC, Dugas E, Karp I, O’Loughlin J. Association between childhood sleep-disordered breathing and disruptive behavior disorders in childhood and adolescence. Behav Sleep Med. 2014;7:1-13.

4. de Carvalho LB, do Prado LB, Ferrreira VR, da Rocha Figueiredo MB, Jung A, de Morais JF, do Prado GF. Symptoms of sleep disorders and objective academic performance. Sleep Med. 2013;14:872-876.

5. Mitchell RB, Kelly J. Long-term changes in behavior after adenotonsillectomy for obstructive sleep apnea syndrome in children. Otolaryngology Head Neck Surg. 2006;134:374-378.

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