Tonsils, Sleep, and ADHD

Some years ago, when I was first learning about conditions such as hyperactivity and attention deficit disorder (now merged into attention deficit hyperactivity disorder or ADHD), the diagnostic instructions used to be that one should not diagnose ADHD until one had ruled out other potential causes of the behaviors and symptoms, which might include depression or anxiety, a stressful or chaotic home environment, or even a physical issues such as allergies. Somewhere along the way, this part of the diagnostic criteria became blurred and then almost forgotten. The current DSM-IV-TR criteria do include the caution

E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorders, or a Personality Disorder). 

However, this esentially instructs the clinician to look for another “mental disorder” as the culprit. It does not warn the clinician to consider other life factors.

Today, I found this story:

Tonsillectomy may help some kids’ ADHD symptoms

Tue Apr 4, 2006

By Amy Norton

NEW YORK (Reuters Health) – Children’s behavioral problems, including symptoms of attention-deficit hyperactivity disorder (ADHD), sometimes improve after they have their tonsils removed, a new study has found. 

The findings, published in the journal Pediatrics, support the theory that nighttime breathing problems — and consequently poor sleep — contribute to some children’s behavioral difficulties during the day.

When the tonsils at the back of the throat become enlarged, they can obstruct the breathing passages. Chronic breathing problems are a chief reason tonsillectomy is performed in children.

The new study followed 78 children, ages 5 to 13, who were scheduled to undergo tonsillectomy, most often due to suspected nighttime breathing problems.

Overnight sleep tests performed before surgery confirmed that half had obstructive sleep apnea, a disorder in which breathing stops and starts repeatedly during the night – typically causing loud snoring and, often, daytime sleepiness.

The children also happened to have a high rate of behavioral problems, as measured from parents’ reports and clinical assessments. A full 28 percent were diagnosed with ADHD, compared with only 2 percent of 27 children who served as a comparison group.

One year after the surgery, however, the children’s behavioral and sleep problems were no greater than those of their peers. The rate of sleep apnea fell from 50 percent to 12 percent, and symptoms of sleepiness improved.

The particularly striking finding, according to the researchers, was that half of the children who had been diagnosed with ADHD before surgery no longer had the disorder one year later.

This doesn’t mean that tonsillectomy is a “magic pill” for ADHD, Dr. Ronald Chervin, the study’s lead author, told Reuters Health.

But parents and doctors may want to consider the possibility of a sleep disorder when a child is either hyperactive or excessively sleepy during the day, according to Chervin, who directs the sleep disorders center at the University of Michigan in Ann Arbor.


Clinicians and students should take heed: Diagnosis is not a cookbook science and the essence of good diagnosis is differential diagnosis – and that should always include looking at the whole person, not just the collection of symptoms.

Related Story

attention deficit hyperactivity disorder, ADHD, sleep, medicine, child psychology, diagnosis, differential diagnosis

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