Abstract
Introduction
Sleep disorders are common yet often underdiagnosed in children with attention deficit/hyperactivity disorder (ADHD). These disturbances can exacerbate ADHD symptoms and negatively affect cognitive, emotional, and behavioral functioning. This study aimed to describe the prevalence of obstructive sleep apnea (OSA) and other sleep disorders in children with ADHD using standardized diagnostic criteria and to identify associated clinical and behavioral factors.
Methods
A cross-sectional study was conducted on 629 children aged 6–12 years (mean age: 7.8 ± 1.5 years) who were diagnosed with ADHD. Sleep disturbances were assessed using the Children’s Sleep Habits Questionnaire (CSHQ), the Pediatric Sleep Questionnaire (PSQ), and respiratory polygraphy. Sleep disorders were classified on the basis of the International Classification of Sleep Disorders, Third Edition (ICSD-3). Multivariate logistic regression was used to identify associated risk factors.
Results
Sleep disorders were diagnosed in 70.0% of children with ADHD. The most common disorders were insomnia (40.2%), OSA (23.4%), parasomnias (27.8%), restless legs syndrome (10.5%), and delayed sleep–wake phase disorder (4.8%). The inattentive ADHD subtype, psychiatric comorbidities, tonsil and adenoid hypertrophy, iron-deficiency anemia, and sleep-related behaviors in children with ADHD were significantly associated with sleep disturbances.
Conclusions
Sleep disorders are highly prevalent and diverse in children with ADHD. Early identification and targeted management of sleep disturbances, particularly OSA and insomnia, are essential to improving sleep quality and optimizing ADHD outcomes. Routine sleep screening should be integrated into clinical ADHD evaluations.
Graphical abstract available for this article.
Graphical Abstract
Keywords: Attention deficit hyperactivity disorder, Sleep disorder, Obstructive sleep apnea, ICSD-3, Children
Key Summary Points
| Why carry out this study? |
| Sleep disorders are common yet frequently underdiagnosed in children with attention deficit hyperactivity disorder (ADHD), contributing to worsened cognitive, emotional, and behavioral outcomes. |
| There is a lack of comprehensive epidemiological data on the full spectrum of sleep disorders in children with ADHD in Vietnam, highlighting an important unmet clinical need. |
| This study aimed to determine the prevalence of obstructive sleep apnea (OSA) and other sleep disorders on the basis of the International Classification of Sleep Disorders, Third Edition (ICSD-3) criteria and to identify clinical and behavioral factors associated with sleep disturbances in children with ADHD. |
| What was learned from the study? |
| Sleep disorders were diagnosed in 70.0% of children with ADHD. Insomnia (40.2%), OSA (23.4%), and parasomnias (27.8%) were the most common disorders. Sleep disturbances were significantly associated with the inattentive ADHD subtype, psychiatric comorbidities, tonsil/adenoid hypertrophy, iron-deficiency anemia, and various adverse sleep behaviors. |
| Routine sleep screening, using both behavioral questionnaires and objective diagnostic tools, is essential for children with ADHD to enable early detection and intervention. |
| Specific clinical factors such as psychiatric comorbidities and physical abnormalities may help clinicians identify children at higher risk for sleep disorders, enabling more targeted and effective management strategies. |
Digital Features
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Introduction
Attention deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders in children, affecting approximately 5–7% of children worldwide [1, 2]. The condition is characterized by symptoms of inattention, hyperactivity, and impulsivity, which significantly impact a child’s academic performance, social interactions, and overall quality of life [3]. ADHD is often associated with various comorbidities, with sleep disorders being one of the most frequently reported. Studies indicate that up to two thirds of children with ADHD have at least one sleep disorder, which can exacerbate ADHD symptoms, complicate treatment, and negatively affect daily functioning [4, 5].
Among the different types of sleep disorders, obstructive sleep apnea (OSA) has been increasingly recognized in children with ADHD. OSA is a sleep-related breathing disorder characterized by partial or complete upper airway obstruction during sleep, leading to disrupted sleep, intermittent hypoxia, and excessive daytime sleepiness [6]. The prevalence of OSA in children with ADHD varies widely across studies, with estimates ranging from 20% to 30% [7, 8].
Research suggests that sleep fragmentation and oxygen desaturation caused by OSA may contribute to cognitive deficits, emotional dysregulation, and behavioral symptoms similar to ADHD, making accurate diagnosis and management of sleep disorders crucial for this population [9]. Other sleep disorders frequently observed in children with ADHD include insomnia, restless legs syndrome (RLS), periodic limb movement disorder (PLMD), circadian rhythm sleep disorders, and parasomnias [11]. These disorders can further impair attention, emotional regulation, and executive functioning, thereby worsening the clinical presentation of ADHD [10]. Despite the high prevalence and significant impact of sleep disorders in ADHD, they often remain underdiagnosed and undertreated, particularly in developing countries such as Vietnam, where awareness and screening for sleep disorders in children with ADHD remain limited. [11]
The International Classification of Sleep Disorders, Third Edition (ICSD-3) provides a standardized framework for diagnosing sleep disorders and classifies them into distinct categories such as insomnia disorders, sleep-related breathing disorders (including OSA), hypersomnolence disorders, circadian rhythm sleep–wake disorders, parasomnias, and sleep-related movement disorders [12]. However, few studies have applied this classification to assess the prevalence of specific sleep disorders in children with ADHD.
In Vietnam, there is a lack of epidemiological data regarding the prevalence of OSA and other sleep disorders in children with ADHD, as well as limited research on the factors associated with sleep disturbances in this population. Given the significant implications of sleep disorders on ADHD symptoms and overall quality of life, a comprehensive assessment of their prevalence and associated factors is essential for improving clinical management [6]. A previous publication from our research group focused on the prevalence and severity of OSA in children with ADHD using respiratory polygraphy in a sample of 524 participants [13]. Building on this, the present study expands the sample to 629 children and provides a broader assessment of sleep disorders using the ICSD-3 classification, aiming to explore the full spectrum of sleep disturbances and their associated factors in this population. Therefore, the aims of this study were to (1) determine the prevalence of obstructive sleep apnea (OSA) and other sleep disorders among children with attention deficit hyperactivity disorder (ADHD) using standardized diagnostic criteria based on the International Classification of Sleep Disorders, Third Edition (ICSD-3); and (2) identify clinical and behavioral factors associated with the presence of sleep disorders in this population.
Methods
Study Participants
This study included a total of 629 children aged 6–12 years who were diagnosed with ADHD according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [14]. The diagnoses were confirmed by pediatric psychiatrists at the Vietnam National Children’s Hospital between October 2022 and September 2024.
To minimize potential confounding factors, children who were using medications that could affect sleep or had acute and malignant medical conditions were excluded from the study, as these conditions could influence the prevalence estimates of sleep disorders in this population.
Measurements and Procedures
This study employed a comprehensive approach to assess sleep disorders in children with ADHD using both subjective and objective methods, guided by the ICSD-3 [12]. Given the high prevalence and diverse manifestations of sleep disorders in children with ADHD, ICSD-3 provides standardized diagnostic criteria that allow for accurate classification. In addition, owing to the large sample size, the extensive use of polysomnography was impractical; instead, validated sleep questionnaires, respiratory polygraphy (RPG) [15], and sleep diaries were used to diagnose sleep disorders.
To screen for general sleep disturbances, caregivers completed the Children’s Sleep Habits Questionnaire (CSHQ), a widely used tool designed for children aged 4–12 years. [16] The CSHQ consists of 33 items categorized into eight sleep domains, including bedtime resistance, sleep onset delay, sleep duration, night wakings, parasomnias, sleep-disordered breathing, and daytime sleepiness. A total CSHQ score ≥ 41 indicated clinically significant sleep disturbances. [16]
For the screening of OSA, caregivers also completed the Pediatric Sleep Questionnaire (PSQ), a validated tool for children aged 2–18 years. [17] The PSQ comprises 22 questions divided into three groups: seven questions related to sleep disorders, nine related to snoring, and six assessing hyperactivity and inattention. Each question was answered as “yes,” “no,” or “don’t know,” and OSA was suspected if seven or more questions were answered with “yes.” [17]
The CSHQ was used with permission obtained from its original author, Dr. Judith A. Owens. The PSQ was culturally adapted and officially endorsed for use in Vietnam by the Vietnam Society of Sleep Medicine. Both instruments were utilized with appropriate permission and cultural adaptation for Vietnamese children.
To confirm OSA diagnosis, RPG was performed using the ApneaLink Air device (ResMed, USA). The recording lasted for a minimum of 4 continuous hours during the child’s nighttime sleep. The Apnea Hypopnea Index (AHI), with OSA diagnosed if AHI ≥ 1 event per hour, was used [12, 18].
Insomnia was diagnosed on the basis of ICSD-3 criteria, requiring the presence of difficulties initiating or maintaining sleep, resistance to bedtime, or dependency on a caregiver for sleep. These difficulties had to occur at least three times per week, persist for at least 3 months, and cause daytime impairments such as fatigue, mood disturbances, or reduced focus [12].
For delayed sleep–wake phase disorder (DSWPD), diagnosis required a chronic delay in sleep onset persisting for at least 3 months, with improved sleep quality when following a preferred schedule [12, 19]. This diagnosis was supported by sleep logs and actigraphy over at least 7 days, and a 2-week sleep diary was used to document bedtime routines, sleep duration, and wake behaviors [20].
Parasomnias were identified on the basis of ICSD-3 classifications, with non-rapid eye movement (NREM)-related parasomnias (e.g., sleepwalking, sleep terrors, and confusional arousals) distinguished from rapid eye movement (REM)-related parasomnias (e.g., nightmares) [12, 21].
For restless legs syndrome (RLS), diagnosis followed ICSD-3 and the International Restless Legs Syndrome Study Group (IRLSSG) pediatric criteria [21, 22]. RLS was defined by an urge to move the legs, typically accompanied by uncomfortable sensations that worsen during periods of rest and improve with movement. Symptoms had to be worse in the evening or at night and could not be explained by other conditions [22].
To gain a more detailed understanding of sleep patterns and behaviors, caregivers were asked to complete a sleep diary for 2 weeks, recording pre-sleep activities, nocturnal awakenings, and post-sleep behaviors [23]. This diary helped assess environmental factors, bedtime routines, and the impact of sleep disturbances on daily functioning [23].
By integrating questionnaires, RPG, and sleep diaries, this study aimed to accurately assess the prevalence and associated factors of sleep disorders in children with ADHD, facilitating early diagnosis and targeted interventions.
Statistical Analysis
Categorical variables were presented as frequencies and percentages, while continuous variables were expressed as means and standard deviations (SD). Differences between proportions were analyzed using the chi-squared test (χ2), while comparisons of mean values between groups were performed using the T-test for normally distributed data and the Mann–Whitney U test for non-normally distributed data. The Spearman correlation coefficient was used to assess relationships between quantitative variables.
To identify factors associated with sleep disorders in children with ADHD, a multivariate logistic regression analysis was conducted. Variables that showed a p-value < 0.05 in univariate analyses were included in the multivariate model. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were reported to determine the strength of associations.
All statistical analyses were conducted using SPSS version 22.0 (IBM Corp, Armonk, NY, USA), with a p-value < 0.05 considered statistically significant.
Ethical Approval
This study was approved by the Biomedical Research Ethics Board of Hanoi Medical University (approval no. 794/GCN-HDDDNCYSH-DHYHN). The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki of 1964 and its later amendments. The methodology strictly adhered to the ethical standards set forth by the approving institution. Participants were fully explained the objectives and procedures of the study. They agreed to participate by signing a consent form to participate in the study.
Results
Study Population Characteristics
A total of 629 children with ADHD were included in this study. Among them, 87.0% were boys, and the mean age was 7.8 ± 1.5 years. The majority of participants (87.4%) were in the 6–9-year age group, while 12.6% were aged 10–12 years. Regarding ADHD subtypes, the combined subtype was the most prevalent (62.2%), followed by the inattentive subtype (21.5%) and the hyperactive subtype (16.3%; Table 1).
Table 1.
Study population characteristics
| Study population characteristics | n = 629 | % | |
| Age groups | School-age (6–9 years) | 550 | 87.4 |
| Adolescents (10–12 years) | 79 | 12.6 | |
| Gender | Female | 82 | 13.0 |
| Male | 547 | 87.0 | |
| ADHD subtypes | Combined subtype | 391 | 62.2 |
| Inattentive subtype | 135 | 21.5 | |
| Hyperactive–impulsive subtype | 103 | 16.3 | |
| ADHD comorbidities | 421 | 66.9 | |
| Type of ADHD comorbidities | Learning disorder | 94 | 14.9 |
| Behavioral disorder | 49 | 7.8 | |
| Oppositional defiant disorder | 199 | 31.6 | |
| Anxiety–depression disorder | 72 | 11.4 | |
| Intellectual disability | 49 | 7.8 | |
| Tic disorder | 128 | 20.3 | |
| Autism spectrum disorder | 30 | 4.8 | |
| At least two ADHD comorbidities | 180 | 28.6 | |
ADHD attention deficit hyperactivity disorder
Comorbidities were highly prevalent, with 66.9% of children having at least one comorbid disorder. The most common conditions included oppositional defiant disorder (31.6%), tic disorder (20.3%), learning disorders (14.9%), and anxiety–depression disorder (11.4%). In addition, 28.6% of children had at least two comorbid conditions, reflecting the complexity of ADHD and its associated challenges.
Sleep disturbances were also common in this population. Screening with the Children’s Sleep Habits Questionnaire (CSHQ) revealed that 588 children (93.5%) had clinically significant sleep problems. The Pediatric Sleep Questionnaire (PSQ) identified 293 children (46.6%) as having suspected obstructive sleep apnea (OSA; PSQ > 7). These 293 children were measured for RPG. RPG confirmed OSA (AHI ≥ 1 event/h) in 23.4% of children, underscoring the high prevalence of sleep-disordered breathing in this population.
These findings highlight the strong association between ADHD and sleep disturbances, underscoring the need for early screening and intervention to improve clinical outcomes.
Prevalence of OSA and Other Sleep Disorders in Children with ADHD
Of the 629 children with ADHD, 440 (70.0%) met the diagnostic criteria for at least one sleep disorder according to the ICSD-3. The most common sleep disorders identified were insomnia (40.2%); OSA (23.4%); RLS (10.5%); DSWPD (4.8%); and parasomnias (27.8%; Fig. 1). In addition, 124 children (19.7%) had two co-occurring sleep disorders, while 55 (8.7%) had three or more.
Fig. 1.
Prevalence of sleep disorders in children with ADHD; ICSD-3 International Classification of Sleep Disorders, Third Edition; ADHD attention deficit hyperactivity disorder
Prevalence of OSA and sleep disorders by age and gender: the prevalence of sleep disorders varied by age group, with DSWPD more frequently diagnosed in adolescents (10–12 years). However, no significant gender differences in sleep disorders were observed (Table 2).
Table 2.
Prevalence of sleep disorders by age groups and gender groups
| Age (years), n (%) | P-value | Gender, n (%) | P-value | |||||
|---|---|---|---|---|---|---|---|---|
| 6–9 years old (n = 550) |
10–12 years old (n = 79) |
Female (n = 82) |
Male (n = 547) |
|||||
| Sleep disorder | 376 (68.4) | 64 (81.0) | 0.02 | 59 (72.0) | 381 (69.7) | 0.67 | ||
| Type of sleep disorders | Insomnia | 218 (39.6) | 35 (44.3) | 0.43 | 35 (42.7) | 218 (39.9) | 0.63 | |
| Delayed sleep–wake phase disorder | 12 (2.2) | 18 (22.8) | 0.00 | 2 (2.4) | 28 (5.1) | 0.41 | ||
| Obstructive sleep apnea | 129 (23.5) | 18 (22.8) | 0.89 | 15 (18.3) | 132 (24.1) | 0.24 | ||
| Restless legs syndrome | 60 (10.9) | 6 (7.6) | 0,37 | 9 (11.0) | 57 (10.4) | 0.88 | ||
| Parasomnia | 155 (28.2) | 20 (25.3) | 0.59 | 27 (32.9) | 148 (27.1) | 0.27 | ||
| Type of parasomnias | Sleep terrors | 58 (10.5) | 7 (8.9) | 0.65 | 11 (13.4) | 54 (9.9) | 0.33 | |
| Nightmares | 44 (8.0) | 8 (10.1) | 0.52 | 8 (9.8) | 44 (8.0) | 0.60 | ||
| Sleepwalking | 35 (6.4) | 4 (5.1) | 0.81 | 8 (9.8) | 31 (5.7) | 0.15 | ||
| Confusional arousals | 113 (20.5) | 12 (15.2) | 0.27 | 19 (23.3) | 106 (19.4) | 0.42 | ||
Prevalence of OSA and sleep disorders by ADHD subtypes: sleep disorders were more frequently diagnosed in children with the inattentive ADHD subtype compared with other subtypes. Specifically, OSA and DSWPD were more prevalent in the inattentive subtype, whereas RLS was more commonly observed in children with the hyperactive–impulsive subtype (Table 3).
Table 3.
Prevalence of sleep disorders by ADHD subtypes and ADHD comorbidities
| ADHD subtypes, n (%) | P-value | ADHD comorbidities, n (%) | P-value | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Combined subtype (n = 391) |
Inattentive subtype (n = 135) |
Hyperactive–impulsive subtype (n = 103) |
No (n = 208) |
Yes (n = 421) |
|||||
| Sleep disorder | 259 (66.2) | 110 (81.5) | 71 (68.9) | 0.00 | 95 (45.7) | 345 (81.9) | 0.00 | ||
| Type of sleep disorders | Insomnia | 155 (39.6) | 58 (43.0) | 40 (38.8) | 0.76 | 51 (24.5) | 202 (48.0) | 0.00 | |
| Delayed sleep–wake phase disorder | 13 (3.3) | 16 (11.9) | 1 (1.0) | 0.00 | 10 (4.8) | 20 (4.8) | 0.97 | ||
| Obstructive sleep apnea | 85 (21.7) | 44 (32.6) | 18 (17,5) | 0.01 | 37 (17.8) | 110 (26.1) | 0.02 | ||
| Restless legs syndrome | 38 (9.7) | 3 (2.2) | 25 (24.3) | 0.00 | 15 (7.2) | 51 (12.1) | 0.06 | ||
| Parasomnia | 108 (27.6) | 39 (28.9) | 28 (27.2) | 0.95 | 24 (11.5) | 151 (35.9) | 0.00 | ||
| Type of parasomnias | Sleep terrors | 34 (8.7) | 20 (14.8) | 11 (10.7) | 0.13 | 7 (3.4) | 58 (13.8) | 0.00 | |
| Nightmares | 30 (7.7) | 12 (8.9) | 10 (9.7) | 0.77 | 2 (1.0) | 50 (11.9) | 0.00 | ||
| Sleepwalking | 22 (5.6) | 7 (5.2) | 10 (9.7) | 0.27 | 6 (2.9) | 33 (7.8) | 0.02 | ||
| Confusional arousals | 80 (20.5) | 26 (19.3) | 19 (18.4) | 0.88 | 19 (9.1) | 106 (25.2) | 0.00 | ||
ADHD attention deficit hyperactivity disorder
Prevalence of OSA and sleep disorders by ADHD comorbidities: children with ADHD comorbidities had a higher prevalence of sleep disorders than those without comorbidities (Table 3). Insomnia was the most frequently reported sleep disorder, particularly among children with autism spectrum disorder (77.4%) and tic disorder (52.7%). Parasomnias were also common, especially in children with anxiety–depression disorder (51.4%). Meanwhile, OSA and RLS showed moderate prevalence, and DSWPD was the least frequently diagnosed sleep disorder (Fig. 2).
Fig. 2.
Prevalence of sleep disorders across comorbid disorders in children with ADHD; OSA obstructive sleep apnea, RLS restless legs syndrome, DSWPD delayed sleep–wake phase disorder, ICSD-3 International Classification of Sleep Disorders, Third Edition
These findings highlight the strong association between ADHD and sleep disturbances, particularly OSA and other sleep disorders, emphasizing the importance of early detection and targeted management strategies for children with ADHD.
Factors Associated with Sleep Disorders in Children with ADHD
Multivariate analysis identified several independent risk factors for sleep disorders in children with ADHD. Among ADHD subtypes, the inattentive subtype showed a significantly higher association with sleep disorders (OR = 5.40, 95% CI: 2.12–13.72, p < 0.001). Children with at least one comorbid disorder were more likely to have sleep disturbances (OR = 2.76, 95% CI: 1.31–5.85, p < 0.001), and the risk increased further in those with two or more comorbidities (OR = 3.76, 95% CI: 2.12–6.64, p < 0.001; Table 4).
Table 4.
Factors associated with sleep disorders in children with ADHD
| Associated factors | Sleep disorder, n (%) | Univariate analysis | Multivariate analysis | |||
|---|---|---|---|---|---|---|
| No (n = 189) |
Yes (n = 440) |
p-value | OR | 95% CI | ||
| Age group | ||||||
| School-age (6–9 years) (n = 550) | 174 (92.1) | 376 (85.5) | 0.02 | 1.48 | 0.61–3.56 | |
| Adolescents (10–12 years) (n = 79) | 15 (7.9) | 64 (14.5) | ||||
| ADHD subtypes | ||||||
| Hyperactive–impulsive subtype (n = 103) | 32 (16.9) | 71 (16.1) | 0.81 | – | – | |
| Inattentive subtype (n = 135) | 25 (13.2) | 110 (25.0) | 0.00 | 5.40 | 2.12–13.72 | |
| Combined subtype (n = 391) | 132 (69.8) | 259 (58.9) | 0.01 | 1.45 | 0.68–3.10 | |
| Comorbid mental disorders | ||||||
| At least 1 comorbid disorder (n = 421) | 76 (40.2) | 345 (78.4) | 0.00 | 2.76 | 1.31–5.85 | |
| At least 2 comorbid disorders (n = 180) | 15 (7.9) | 165 (37.5) | 0.00 | 3.76 | 2.12–6.64 | |
| Physical conditions | ||||||
| Overweight–obesity (n = 142) | 32 (16.9) | 110 (25.0) | 0.03 | 1.26 | 0.66–2.40 | |
| Malnutrition (n = 115) | 26 (13.8) | 89 (20.2) | 0.05 | – | – | |
| Tonsil/adenoid hypertrophy (n = 159) | 26 (13.8) | 133 (30.2) | 0.00 | 2.71 | 1.45–5.04 | |
| Asthma (n = 57) | 10 (5.3) | 47 (10.7) | 0.03 | 2.54 | 0.95–6.81 | |
| Allergic rhinitis (n = 143) | 26 (13.8) | 117 (26.6) | 0.00 | 1.56 | 0.81–3.02 | |
| Gastrointestinal disorders (n = 157) | 31 (16.4) | 126 (28.6) | 0.00 | 1.02 | 0.56–1.87 | |
| Iron-deficiency anemia (n = 57) | 3 (1.6) | 54 (12.3) | 0.00 | 7.86 | 1.85–33.29 | |
| Pre-sleep behavior | ||||||
| Irregular sleep schedule (n = 429) | 141 (74.6) | 288 (65.5) | 0.02 | 1.62 | 1.04–4.89 | |
| Noisy sleep environment (n = 26) | 2 (1.1) | 24 (5.5) | 0.01 | 2.37 | 0.95–5.88 | |
| Sleep onset delay (n = 361) | 80 (42.3) | 281 (63.9) | 0.00 | 2.04 | 1.19–3.51 | |
| Screen exposure > 2 h before sleep (n = 485) | 132 (69.8) | 353 (80.2) | 0.00 | 1.39 | 0.78–2.48 | |
| Eating before bedtime (n = 333) | 95 (50.3) | 238 (54.1) | 0.38 | – | – | |
| Needing a caregiver at bedtime (n = 258) | 54 (28.6) | 204 (46.4) | 0.00 | 1.73 | 1.03–3.01 | |
| Requiring night light (n = 87) | 12 (6.3) | 75 (17.0) | 0.00 | 2.37 | 1.01–5.11 | |
| During-sleep behavior | ||||||
| Bruxism (n = 207) | 36 (19.0) | 171 (38.9) | 0.00 | 1.91 | 1.03–3.52 | |
| Nocturnal enuresis (n = 124) | 22 (11.6) | 102 (23.3) | 0.00 | 1.15 | 0.56–2.35 | |
| Sleep talking (n = 274) | 37 (19.6) | 237 (53.9) | 0.00 | 3.57 | 2.03–6.29 | |
| Night awakenings (n = 240) | 23 (12.2) | 217 (49.3) | 0.00 | 4.55 | 2.40–8.63 | |
| Post-sleep behavior | ||||||
| Morning awakenings difficulty (n = 383) | 93 (49.2) | 290 (65.9) | 0.00 | 1.09 | 1.01–2.83 | |
| Daytime sleepiness (n = 140) | 3 (1.6) | 137 (31.3) | 0.00 | 26.04 | 7.30–92.79 | |
| Difficulty napping (n = 316) | 82 (43.4) | 234 (53.2) | 0.02 | 0.38 | 0.214–1.66 | |
ADHD attention deficit hyperactivity disorder
Among physical conditions, tonsil and adenoid hypertrophy was significantly associated with sleep disorders (OR = 2.71, 95% CI: 1.45–5.04, p = 0.002), as was iron-deficiency anemia (OR = 7.86, 95% CI: 1.85–33.29, p = 0.005; Table 4).
Pre-sleep behaviors such as an irregular sleep schedule (OR = 1.62, p = 0.02); needing a caregiver at bedtime (OR = 1.73, p = 0.01); and requiring a night light (OR = 2.37, p = 0.04) were also significantly associated with sleep disorders (Table 4).
During-sleep behaviors, including bruxism (OR = 1.91, p = 0.04), sleep talking (OR = 3.57, p < 0.001), and night awakenings (OR = 4.55, p < 0.001), were strong predictors of sleep disturbances (Table 4).
Among post-sleep behaviors, morning awakening difficulty (OR = 1.09, p = 0.04) and daytime sleepiness (OR = 26.04, p < 0.001) were highly associated with sleep disorders, emphasizing the impact of poor sleep on daytime functioning (Table 4).
These findings highlight the complex interplay between ADHD subtypes, comorbidities, physical conditions, and sleep-related behaviors, reinforcing the need for comprehensive sleep assessments and tailored interventions in children with ADHD.
Discussion
Prevalence of OSA and Sleep Disorders in Children with ADHD
The results of the present study suggest a high frequency of sleep disorders in children with ADHD, with 70% satisfying the ICSD-3 diagnostic criteria. This percentage was considerably higher than the estimated prevalence of sleep disorders among children in general, which has ranged from 25% to 50% in published studies [24]. Our prevalence estimate is consistent with most reports that have examined the prevalence of sleep disorders in children with ADHD, which have found prevalence rates ranging from 50% to 80% [24–26]. Previous studies have shown that sleep disorders can exacerbate the symptoms of ADHD [27, 28], or are a consequence of primary sleep disorders such as OSA and RLS, which may be misdiagnosed, highlighting the importance of addressing sleep disorders in children with ADHD [6, 29]. Furthermore, a significant proportion of children with ADHD in our study experienced multiple sleep disorders, with 19.7% having two co-occurring sleep disorders and 8.7% having three or more. This underscores the complexity of managing sleep issues in this population and the need for comprehensive diagnostic approaches. This further demonstrates that the clinical manifestations of sleep disorders in children with ADHD are highly diverse and complex.
Sleep-related breathing disorders are most commonly described in children as OSA, which is caused by an anatomical or functional narrowing of the upper airway [30]. OSA occurred in approximately one quarter of the children with ADHD in our study, most frequently among those with the inattentive subtype. This prevalence estimate is consistent with the findings from other studies, which have noted OSA rates ranging from 25% to 30% in children with ADHD, with a significantly higher risk of OSA in children with ADHD compared with controls. [31]
The strong association between RLS and ADHD has been demonstrated in numerous studies, with children with ADHD at considerably greater risk for meeting the diagnostic criteria for RLS [32, 33]. The prevalence of RLS in children with ADHD has ranged from 13% to 43% [22, 34]. Our study’s prevalence of RLS at 10.5% was lower than previous reports in children with ADHD but significantly higher than the general prevalence of RLS in children (2–4%) [22, 35]. In current clinical practice in Vietnam, RLS in children is often misdiagnosed or overlooked owing to the intermittent nature of clinical symptoms, and young children often have difficulty describing the discomfort in their hands and/or legs. Clinically, children who meet the diagnostic criteria for RLS should undergo polysomnography to diagnose this possible limb movement disorder.
We categorized parasomnias into NREM-related types such as sleep terrors, sleepwalking, and confusional arousals and REM-related types such as nightmares. Our findings, consistent with the results of previous research, indicated varying prevalence rates of these disorders among children with ADHD who were reported by parents to frequently experience sleepwalking (11%) and sleep terrors (13%) [36]. In another study, confusional arousals were noted in nearly half of children aged 8–9 years with ADHD [9]. These differences in the frequency estimates of parasomnias may be due to these studies not having employed ICSD-3 standards for making the diagnosis, relying instead on survey questionnaires and nocturnal video-polysomnography. A study involving 46 children with ADHD aged 6–13 years indicated that one in every five of these children with ADHD met ICSD-3 criteria for nightmares and that nightmares were more common among children with ADHD comorbidities [37].
Factors Associated with Sleep Disorders in Children with ADHD
The multivariate analysis of factors associated with sleep disorders in children with ADHD demonstrated findings that highlight several key demographic, clinical, and behavioral risk factors that significantly contribute to sleep disturbances in this population.
ADHD Subtypes and Comorbidities
Children with the inattentive ADHD subtype had a significantly higher risk of developing sleep disorders (OR = 5.40, 95% CI: 2.12–13.72, p < 0.001), supporting prior research linking inattention to greater sleep onset difficulties and disrupted sleep cycles [38]. In addition, children with at least one comorbid mental disorder were more likely to experience sleep disturbances (OR = 2.76, 95% CI: 1.31–5.85, p < 0.001), with the risk increasing in those with two or more comorbid conditions (OR = 3.76, 95% CI: 2.12–6.64, p < 0.001). These findings emphasize the complex interplay between ADHD, psychiatric comorbidities, and sleep dysfunction, reinforcing the need for comprehensive clinical evaluations. [8]
Physical Conditions
Among physical health factors, tonsil and adenoid hypertrophy was significantly associated with sleep disorders (OR = 2.71, 95% CI: 1.45–5.04, p = 0.002), consistent with its well-established role in OSA in children [39]. In addition, iron-deficiency anemia was strongly linked to sleep disturbances (OR = 7.86, 95% CI: 1.85–33.29, p = 0.005), supporting previous studies that suggest low iron levels may contribute to restless legs syndrome (RLS) and fragmented sleep [40].
Sleep-Related Behaviors in Children with ADHD
In addition to diagnosed sleep disorders, our study also identified several behavioral patterns before, during, and after sleep that were strongly associated with sleep disturbances in children with ADHD. These behaviors may not meet full diagnostic criteria for sleep disorders but significantly disrupt sleep quality and contribute to daytime impairment.
Pre-Sleep Behaviors
Irregular sleep schedules, delayed sleep onset, and dependence on caregivers at bedtime were highly prevalent among children with ADHD. Multivariate analysis revealed that irregular sleep routines (OR = 1.62) and needing a caregiver to fall asleep (OR = 1.73) were significant predictors of sleep problems. These findings are consistent with prior research showing that children with ADHD often struggle with sleep initiation due to cognitive hyperarousal, poor bedtime routines, and emotional dysregulation [44]. The use of night lights (OR = 2.37) also emerged as a risk factor, possibly reflecting bedtime anxiety or sensory sensitivity, both common in children with neurodevelopmental disorders. Sleep onset delay (OR = 2.04), often exacerbated by screen exposure and overstimulation, is also linked to circadian misalignment and reduced melatonin secretion, especially in the inattentive ADHD subtype. [43]
During-Sleep Behaviors
Behaviors such as bruxism (OR = 1.91), sleep talking (OR = 3.57), and night awakenings (OR = 4.55) were significantly associated with sleep disruption. These may reflect underlying fragmented sleep architecture or increased arousal threshold, which are frequently observed in children with ADHD on polysomnography [9]. Night awakenings, in particular, have been associated with poor sleep consolidation and increased parental sleep disturbance, which can affect the child’s behavioral management the next day [16]. Although nocturnal enuresis was not a significant factor in multivariate analysis, its presence in 23.3% of children reflects the need to assess for immature sleep–wake control mechanisms in this population.
Post-Sleep Behaviors
Morning awakening difficulties (OR = 1.09) and especially daytime sleepiness (OR = 26.04) were among the strongest post-sleep correlates of poor sleep. Daytime sleepiness is not only a symptom of insufficient or nonrestorative sleep but also mimics or exacerbates core ADHD symptoms such as inattention, irritability, and reduced academic performance [44]. These overlaps may lead to misdiagnosis or overestimation of ADHD severity if sleep disturbances are not properly evaluated. Notably, difficulty napping was inversely associated with sleep problems (OR = 0.38), which may reflect a compensatory mechanism in children with better nighttime sleep quality or possibly hyperarousal in those unable to nap despite sleep deprivation.
Comparison with Previous Study
This study expands upon our previous work, which primarily examined OSA in children with ADHD [13]. While the earlier study focused specifically on OSA prevalence using RPG in 524 participants, the current research analyzes a larger dataset of 629 children and evaluates a broader range of sleep disorders as classified by ICSD-3. It also includes additional tools such as sleep diaries and performs multivariate logistic regression to identify behavioral, physical, and psychiatric risk factors. These methodological enhancements allow for a more comprehensive understanding of the sleep profiles in children with ADHD and their clinical implications.
Study Strengths and Limitations
This study has several notable strengths. It is one of the first to comprehensively assess the prevalence and associated factors of sleep disorders among children with ADHD in Vietnam, using standardized diagnostic criteria based on the International Classification of Sleep Disorders, Third Edition (ICSD-3). The study benefits from a large sample size and the use of validated tools, including the Children’s Sleep Habits Questionnaire (CSHQ), the Pediatric Sleep Questionnaire (PSQ), and respiratory polygraphy (RPG), enhancing the robustness and clinical relevance of the findings.
However, several limitations must be acknowledged. First, the study was conducted at a single institution, which may limit the generalizability of the results to other healthcare settings. Nevertheless, the Vietnam National Children’s Hospital is the leading tertiary pediatric center in northern Vietnam, attracting a diverse range of patients from across the region and offering high-quality specialized care, thereby providing a partially representative sample within the regional context. Second, the absence of a non-ADHD control group limits our ability to directly compare the prevalence of sleep disorders with the general pediatric population; future research incorporating matched control groups is warranted. Third, although respiratory polygraphy was used to confirm diagnoses of obstructive sleep apnea (OSA), the lack of full polysomnography may have reduced the sensitivity for detecting other sleep disorders, such as periodic limb movement disorder or specific parasomnias. Finally, much of the sleep behavior data were based on caregiver-reported questionnaires, which may introduce recall bias and subjective interpretation. Although this approach is commonly employed in pediatric sleep studies, future investigations should integrate objective measures such as actigraphy or full polysomnography to enhance diagnostic accuracy.
Conclusions
Sleep disorders are common in children with ADHD, with 70% meeting ICSD-3 criteria. Insomnia, OSA, and parasomnias were most prevalent. Factors such as ADHD subtype, comorbidities, physical conditions, and sleep-related behaviors were significantly associated with sleep problems. Early screening and targeted interventions are essential to improve outcomes in this population.
Acknowledgements
We extend our sincere gratitude to the Psychiatry Department at the Vietnam National Children’s Hospital for their invaluable support and collaboration in conducting this study. We also thank the Sleep Lab Center of the Vietnam Society of Sleep Medicine in Dalat, Vietnam, for their assistance and support. We express our deep appreciation to all the participants and their families for their willingness to contribute to this research. In addition, this study received training support from the “Training Program for Strengthening Research Capacity in Non-Communicable Diseases in Vietnam (TSORC-NCDs-VN)” [D43 TW012188], funded by the Fogarty International Center of the US National Institutes of Health. The program provided research skills development support to the investigators.
Medical Writing/Editorial Assistance
No medical writing assistance, editorial support, or AI tools were utilized in the writing of this article.
Author Contributions
Mai Nguyen-Thi-Phuong, Sy Duong-Quy, and Mai Nguyen-Thi-Thanh—contributed to the conceptualization and validation of the study; played key roles in drafting the original manuscript and conducting the review and editing process; and were responsible for developing the methodology and performing formal analysis. Robert Joel Goldberg, Hoa Lan Nguyen, and An Dao-Thi-Minh—contributed to the conceptualization, validation, and data analysis; and reviewed and provided critical feedback on the manuscript during its preparation. All authors—reviewed and approved the final version of the manuscript and agree to take responsibility for the accuracy and integrity of the study.
Funding
No funding or sponsorship was received for the publication of this article.
Data Availability
The data supporting the findings of this study are available from the corresponding author upon reasonable request. However, the data are not publicly accessible owing to privacy and ethical restrictions.
Declarations
Conflicts of Interest
Mai Nguyen-Thi-Phuong, Mai Nguyen-Thi-Thanh, Robert Joel Goldberg, Hoa L. Nguyen, An Dao-Thi-Minh, and Sy Duong-Quy declare that they have no competing interests. The authors confirm that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Sy Duong-Quy is a member of the Editorial Board of Pulmonary Therapy. He was not involved in the selection of peer reviewers for this manuscript nor in any of the subsequent editorial decisions.
Ethical Approval
This study was approved by the Biomedical Research Ethics Board of Hanoi Medical University (approval no. 794/GCN-HDDDNCYSH-DHYHN). The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki of 1964 and its later amendments. The methodology strictly adhered to the ethical standards set forth by the approving institution. Participants were fully explained the objectives and procedures of the study. They agreed to participate by signing a consent form to participate in the study.
Footnotes
Prior presentation: part of a broader research project. Related prior publication: Nguyen-Thi-Phuong M, et al. Pulmonary therapy. 2025;11(1):69–80. doi:10.1007/s41030-024-00286-8.
Mai Nguyen-Thi-Phuong and Mai Nguyen-Thi-Thanh contributed equally to this work as co-first authors.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data supporting the findings of this study are available from the corresponding author upon reasonable request. However, the data are not publicly accessible owing to privacy and ethical restrictions.