Association between Attention Deficit Hyperactivity Disorder and Obstructive Sleep Apnea in Children: A Systematic Review and Meta-Analysis

BACKGROUND: Obstructive Sleep Apnea (OSA) and Attention Deficit Hyperactivity Disorder (ADHD) are two relatively common conditions in the pediatric population, with multiple studies demonstrating a strong association between the two. Hypoxia and sleep fragmentation caused by OSA has been shown to exacerbate ADHD symptoms, while treatment for OSA, such as with continuous positive airway pressure or adenotonsillectomy, may improve ADHD symptoms. We aim to provide an updated systematic review and meta-analysis on the complex relationship between OSA and ADHD in children. METHODS: PubMed, Embase, and SCOPUS were searched from inception to 1 December 2024 for longitudinal studies investigating the association between OSA and ADHD in children. Two independent authors selected relevant articles, extracted data, assessed bias using the Newcastle-Ottawa Scale and evaluated quality of evidence following the Grading of Recommendations, Assessment, Development and Evaluations framework. Random-effects meta-analysis was performed to synthesize pooled prevalence, while descriptive reviews were performed for all other outcomes. RESULTS: This systematic review and meta-analysis of 11 studies and 903 children formally diagnosed with OSA or ADHD found that the pooled prevalence of OSA in children with ADHD was 44% ( 95% CI [2%, 56%]). Descriptive analysis found that adenotonsillectomy for OSA consistently led to significant improvements in both OSA and ADHD symptoms, suggesting its potential in complementing existing pharmacological therapy in improving ADHD symptoms. CONCLUSION: OSA and ADHD are closely related comorbid conditions. Physicians should be cognizant of this association and consider concurrent evaluation for OSA in children with ADHD symptoms, which can effectively guide treatment strategies and potentially reduce the need for long-term pharmacological treatment.