ADHD & children
- Dr Louise Oliver
- 4 days ago
- 4 min read
Updated: 6 hours ago
Below is a statement that has been submitted by a multidisciplinary team of health professionals to highlight the substantial and growing body of high-quality evidence linking sleep-disordered breathing with behavioural and cognitive impairments that overlap with diagnostic features of ADHD. The submission sets out four recommendations for consideration by the Independent review into mental health conditions, ADHD and autism: terms of reference.
We are sharing this publicly to help raise awareness and encourage the development of evidence-informed policies. The statement is below with access to a downloadable PDF. Please share far and wide.
Open Submission to the Independent Review into Mental Health conditions, ADHD and autism.
Subject: Sleep Disordered Breathing (SDB) and its Overlooked Role in ADHD Presentations
Dear Panel Members,
We respectfully draw the Review’s attention to a substantial and growing body of high-quality evidence demonstrating that sleep-disordered breathing (SDB) - including habitual snoring and obstructive sleep apnoea (OSA) - is significantly associated with behaviours and cognitive impairments that overlap with diagnostic features of Attention Deficit Hyperactivity Disorder (ADHD).
We wish to highlight to the panel that assessing for sleep disordered breathing is not a requirement in current ADHD diagnostic pathways and seek to explain why we believe it should be.
Clinical and Neurocognitive Evidence
A high-quality systematic review with meta-analysis concludes SDB has a detrimental impact on all domains of neurocognitive functioning in children including impairments in attention, executive function, memory, language, visual spatial skills and overall intelligence measures. These deficits occur across the full spectrum of sleep-disordered breathing, from primary snoring to clinically significant OSA.
Recent evidence links SDB with increased risk of ADHD-like symptoms through mechanisms including sleep fragmentation, intermittent hypoxia, inflammatory activation, and disruption of prefrontal cortical function - mechanisms known to affect cognitive control, behavioural regulation, and attentional processes.
Observational studies reveal high prevalence of sleep disorders in children with ADHD: for example, nearly half of children referred for ADHD screening show signs suggesting sleep pathology on validated questionnaires, with approximately one in four confirmed to have OSA on clinical testing.
Prevalence and Overlap
Population and clinical research consistently report that behavioural symptoms associated with disrupted sleep - including inattention, hyperactivity, impulsivity and emotional dysregulation - can co-occur with or mimic ADHD. Parent-reported SDB symptoms in infancy predict externalising behavioural problems, reinforcing the developmental impact of early sleep disruption.
A meta-analysis from 2012 encompassing multiple studies found a medium effect size linking SDB and ADHD symptoms, underscoring that this association has been robustly observed across decades of research.
Consequences of Non-Recognition
Misclassification of reversible sleep-related behavioural symptoms as primary ADHD;
Long-term stimulant prescribing where sleep intervention may reduce symptoms;
Persistent untreated airway pathology and associated cardiometabolic and neurodevelopmental consequences;
Avoidable long-term public expenditure within health, education and social care pathways.
Economic and Public Health Imperatives
Our modelling indicates that ADHD diagnoses incur significant lifetime costs to health and social systems. Even a conservative estimate of SDB contributing to 10% of ADHD presentations suggests millions in potentially avoidable expenditure, whereas structured screening and early intervention carry minimal cost relative to these downstream impacts.
Recommendations for Practice and Policy
Mandatory structured sleep screening during initial ADHD assessment, using brief questions on habitual snoring or witnessed breathing pauses during sleep.
Clear referral pathways from primary care to paediatric sleep assessment, dental and ENT services where indicated.
Commissioned research explicitly quantifying the prevalence and impact of SDB among children clinically diagnosed with ADHD.
Health economic evaluation comparing lifetime ADHD costs with early identification and treatment of sleep-related airway obstruction.
Concluding Statement
Sleep-disordered breathing is common, measurable, frequently treatable, and closely associated with behavioural and cognitive symptoms aligned with ADHD diagnostic criteria. Integrating structured sleep assessment into ADHD diagnostic pathways will strengthen diagnostic accuracy, reduce avoidable medicalisation and optimise public health value.
We stand ready to engage further with the Review to explore practical implementation steps and evidence translation.
Respectfully submitted,
Amberin Fur, Osteopath, DO, BSc Ost (Hons), WHOst, Paed Cert MSCCO
Dr Yasmin E George, Dentist, BDS FICD FCGDent
Dr William M Hang, Orthodontist, DDS, MSD
Dr David McIntosh, ENT Specialist, MBBS, FRACS, PhD
Dr Helen Jones, Orthodontist (Ret'd), BDS,LDS.RCS,MFGDP.UK, FICD, FPFA
Mr Yakubu Karagama MBBS, DLO, MSc, FRCS, PGcertMed.Consultant ENT surgeon
Dr Biju Krishnan. Dentist, BDS, FICD, FCGDent, FRSM
Dr Mike Mew, Orthodontics, BDS, MSC
Alexandra Moyle, Physiotherapist, MCSP
Dr Louise Oliver, NHS GP, MBChB, MRCGP, DCH, DRCOG, DFFP
Mr Amit Parmar, ENT Consultant, FRCS, FRCS otol
Prof Marisa Santos, lecture in orthodontics
Dr. Muhammad Usama, MD FACP DiplABOM, Sleep and Obesity Physician (USA)
Dr Suraj Vatish, Dentist, DDS M Imp Dent RCS(Ed)
Additional signatories post-submission
Dr. Ryan Chin Taw Cheong MSc FRCS(ORL-HNS) Consultant ENT and Sleep Surgeon
Charlotte Marsh Healthy Breathing Coach, Children's Author and Educator
Key References Supporting This Submission
High-Quality Systematic Reviews & Meta-Analyses
Menzies et al. (2022) — Neurocognitive outcomes of children with sleep disordered breathing: A systematic review with meta-analysis
Song et al. (2016) — Neurocognitive outcomes after pediatric adenotonsillectomy for obstructive sleep apnea: A systematic review and meta-analysis
Sedky et al. (2014) — Attention deficit hyperactivity disorder and sleep disordered breathing in pediatric populations: a meta-analysis
Longitudinal Evidence
Reynaud et al. (2018) — Association of night-waking and inattention/hyperactivity symptoms trajectories in preschool-aged children
Tamana et al. (2018) — Parent-Reported Symptoms of Sleep-Disordered Breathing Are Associated With Increased Behavioral Problems at 2 Years of Age: The Canadian Healthy Infant Longitudinal Development Birth Cohort Study
Focused Mechanistic Reviews & Prevalence Studies
Ivanov et al. (2024) — Sleep Disordered Breathing and Risk for ADHD: Review of Supportive Evidence and Proposed Underlying Mechanisms
Nguyen-Thi-Phuong et al. (2025) — Obstructive Sleep Apnea and Sleep Disorders in Children with Attention Deficit Hyperactivity Disorder
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