Sleep apnea vs ADHD: how breathing problems at night can look like attention problems

Sleep apnea and ADHD can look surprisingly alike during the day. A child who sleeps badly because their airway keeps narrowing at night may be restless, impulsive and hard to keep on task, and an adult with untreated sleep apnea may struggle to focus. The two can also happen together. The useful thing to know is that a breathing problem at night is something a doctor can check for and treat.

This article explains how the symptoms overlap, what the research shows in children and adults, and what to ask your doctor. It isn't medical advice, and only a clinician can sort out which condition, or which combination, is behind the symptoms.

How can sleep apnea look like ADHD?

Sleep apnea can look like ADHD because poor-quality sleep shows up as daytime behavior and attention problems. NHLBI lists being overactive or aggressive and having trouble paying attention at school among the daytime symptoms of sleep apnea in children, which overlap closely with how ADHD is often described.

The difference is in the night. In obstructive sleep apnea, the airway narrows or closes repeatedly during sleep, so sleep is broken up even if nobody wakes fully. NHLBI lists the night-time signs in children as snoring, mouth breathing, breathing that starts and stops, waking up often and bedwetting. In the morning, a child may have a dry mouth or a headache.

In adults, the overlap tends to look more like tiredness than hyperactivity. NHLBI says daytime sleepiness and tiredness from sleep apnea can lead to problems with learning, focusing and reacting.

What does the research say about sleep apnea and ADHD in children?

Research in children shows a real link between sleep-disordered breathing and ADHD symptoms. Sleep-disordered breathing is the umbrella term for snoring, sleep apnea and the breathing problems in between. A 2014 meta-analysis in Sleep Medicine Reviews pooled 18 studies and found a medium-sized relationship between sleep-disordered breathing and ADHD symptoms in children and teens.

The same meta-analysis looked at 12 studies that measured ADHD symptoms before and after adenotonsillectomy, the surgery that removes the tonsils and adenoids. ADHD symptoms were lower 2 to 13 months after surgery, again with a medium-sized effect. The authors concluded that children with ADHD symptoms should be screened for sleep-disordered breathing, and that treating it should be considered before medicating the ADHD symptoms when both are present.

The American Academy of Pediatrics reached a similar view in its 2012 technical report on childhood sleep apnea. It found that sleep apnea was associated with neurobehavioral problems, and that treating it resulted in improvements in behavior and attention, and likely in cognitive abilities.

What happened in the big surgery trial?

The strongest single study is the Childhood Adenotonsillectomy Trial, published in the New England Journal of Medicine in 2013. Researchers randomly assigned 464 children aged 5 to 9 with sleep apnea to early surgery or to watchful waiting with supportive care, then checked them 7 months later.

The results were mixed in an instructive way. Scores on formal tests of attention and executive function, the trial's main measure, improved in both groups and didn't differ significantly between them. But the surgery group had greater improvements in behavior, quality of life and sleep study results, and a bigger reduction in symptoms. Sleep study results returned to normal in 79% of the surgery group compared with 46% of the watchful-waiting group.

So surgery helped behavior and how children felt, even though it didn't move their scores on attention tests. Parents and teachers notice behavior, which is part of why sleep apnea can be mistaken for ADHD in the first place.

What does the American Academy of Pediatrics recommend?

The American Academy of Pediatrics recommends that all children and adolescents be screened for snoring. Its 2012 clinical practice guideline, written for primary care clinicians, covers children whose sleep apnea is linked to large tonsils and adenoids or to obesity.

The guideline's main recommendations are:

• A sleep study (polysomnography) for children who snore and have symptoms or signs of sleep apnea, or referral to a specialist if a sleep study isn't available.
• Adenotonsillectomy as the first-line treatment for children with enlarged tonsils and adenoids.
• Checking children again after surgery to see whether they need more treatment.
• CPAP if surgery isn't done or sleep apnea persists after it.
• Weight loss alongside other treatment for children who are overweight.
• Nasal steroid sprays as an option for mild sleep apnea in certain cases.

The technical report behind the guideline adds a useful caution: sleep apnea remained after surgery in 13% to 29% of lower-risk children, and in more children when obesity was involved. That's why follow-up matters. Our guide to snoring in children covers what's normal and what isn't.

How do the symptoms compare?

The symptoms of sleep apnea and ADHD overlap during the day but differ at night. This checklist, based on NHLBI's lists of sleep apnea symptoms, can help you decide what to mention to a doctor. It's a prompt for a conversation, not a way to diagnose either condition.

If several of the night-time signs are present, a sleep evaluation can rule sleep apnea in or out. That's a simpler question to answer than it might seem, and the answer changes what treatment makes sense.

Is sleep apnea linked to ADHD in adults?

In adults, the link between sleep apnea and ADHD is less clear than in children. A 2011 review in Annals of Clinical Psychiatry reported that attention deficits had been described in up to 95% of people with sleep apnea, and that sleep apnea had been found in 20% to 30% of people with ADHD. All six treatment studies it found reported improvements in behavior, inattention or overall ADHD symptoms after sleep apnea was treated, though the authors said controlled trials were still needed.

Newer studies disagree with each other:

• A 2019 study in Cureus gave 194 adults referred to a sleep center an ADHD screening questionnaire and a sleep study. Sleep apnea was found in 83% of them, and 19% screened positive for ADHD. There was no link between how severe the sleep apnea was and ADHD symptoms, but people who screened positive were sleepier during the day.
• A 2013 study of 81 adults with untreated sleep apnea and 32 controls found adult ADHD in 7.4% of the sleep apnea group and 6.3% of the controls, which was not a meaningful difference. Those who had both conditions reported more anxiety and daytime sleepiness and a poorer quality of life.

The fair summary is that adults with sleep apnea often have trouble concentrating, and some will also have ADHD. Sleepiness seems to be a common thread. If you're an adult who snores loudly, wakes unrefreshed and struggles to focus, it's worth getting your sleep checked as well as discussing attention with your doctor. Our list of sleep apnea warning signs is a good place to start.

How is sleep apnea checked?

Sleep apnea is checked with a sleep study, which records breathing, oxygen levels and sleep overnight. For children, NHLBI says a provider will also look in the nose and mouth for large tonsils or other structures that could be blocking the airway, and may measure blood oxygen overnight.

For adults, some people can do a test at home. Our guide to the home sleep apnea test explains who it suits, and what AHI means explains the number you'll get back.

Questions to bring to the appointment

• Could poor sleep or a breathing problem be contributing to these attention or behavior symptoms?
• Do the tonsils or adenoids look enlarged? (for a child)
• Would a sleep study help, and should it come before or alongside an ADHD assessment?
• If sleep apnea is found, what are the treatment options, and how will we know whether it's worked?

What are the treatment options?

Treatment depends on the cause. For children, NHLBI lists surgery to remove the tonsils and adenoids, PAP machines such as CPAP, nasal steroid sprays, a specific asthma medicine, oral devices or orthodontic treatment, mouth and facial muscle exercises, and support with weight loss where that's a factor. For adults, our overview of sleep apnea treatment options covers CPAP, oral appliances, positional therapy and surgery.

If ADHD is also diagnosed, it's treated in its own right. Sorting out sleep first can make it clearer which symptoms belong to which condition.

Can mouth tape help with sleep apnea or mouth breathing in kids?

Mouth tape is not a treatment for sleep apnea, and it isn't for children. We don't recommend mouth tape for children. Sleep Foundation says mouth taping in children has not been studied and should not be tried, and that mouth breathing may slow growth in children, so it may need medical attention. Mouth breathing in a child is often a sign that something, such as large adenoids, is blocking the nose, which is exactly what a doctor should look at. Our guides to mouth breathing in children and mouth tape for kids go into more detail.

For adults, Sleep Foundation says anyone with signs of sleep apnea, such as loud snoring, choking or gasping during sleep, or heavy daytime tiredness, should see a healthcare provider before trying mouth tape.

When should you see a doctor?

See a doctor if attention or behavior problems come with snoring, mouth breathing, pauses in breathing, restless sleep or bedwetting in a child, or with loud snoring and daytime sleepiness in an adult. NHLBI also lists learning problems, impaired growth and poor academic performance among the risks of untreated sleep apnea in children, so it's worth acting on rather than waiting.

Read next

• Snoring in children: what's normal and when to see a doctor
• Mouth breathing in children: signs to watch for
• Snoring vs sleep apnea: how to tell the difference

* This content is for informational and educational purposes only and is not medical advice. It is not intended to diagnose, treat, cure or prevent any disease or health condition. Talk to a qualified healthcare provider about your health.