Does Sleep Deprivation Cause ADD, ADHD in Children?

Adult snoring and obstruction during sleep is relatively complicated. Children are less complicated, with the exception that when they don’t get good quality sleep, they don’t show it the same way adults do. That is, adults with poor sleep will be sleepy, ready for a nap. Kids with poor sleep will be cranky, “bouncing off the walls,” and unable to focus – all the symptoms of ADD or ADHD. Sound like your kid? Read more for what to do …

Snoring

It is estimated that somewhere around 10-12% of children snore.

So what?

Well, let’s examine what that sound means: snoring is the sound that air makes when it is forced through a partial obstruction.

So there it is: if your child is snoring, their airway is at least partially obstructed.

Doesn’t sound good, does it? You’re right: probably not good. What is the potential problem?

Obstructive Sleep Apnea (OSA)

OSA is the condition where collapse of the airway (obstruction) creates pauses in breathing (apnea) during sleep.

In children, even before complete obstruction and apnea occurs, there are commonly periods of reduced breathing – hypoventilation – resulting in reduced levels of oxygen circulating in the blood (hypoxemia). This condition, short of true and complete apnea, is often referred to as Sleep Disordered Breathing (SDB).

Of those 10-12% of children who snore, it is estimated that perhaps as many as one-third of them have OSA (and many more have SDB), or somewhere around 2-4% of all children in the US. In total, there may be 18 Million Americans with OSA, yet up to 95% of them go undiagnosed, and untreated.

Studies warn us that people with OSA are at risk for:

  • High blood pressure
  • Heart disease
  • Stroke
  • Diabetes
  • Depression

And, they have a higher incidence of death from all causes, compared to age-matched controls.

So, it makes sense to figure this out, right?

The question is: does your child have obstructive sleep apnea? How can you tell?

The short answer is: you can’t tell. At least not without some pretty sophisticated testing called a polysomnogram, or “sleep study.”

What are the signs and symptoms of OSA in children?

  • Snoring – usually loud or irregular
  • Morning headaches
  • Hyperactivity during the day
  • Irritability
  • Poor school performance
  • Frequent leg cramps (“growing pains”)
  • Restless sleep – thrashing about, kicking covers off, falling on floor during night
  • Nightmares, sleep-talking, sleep-walking
  • Frequent night sweats – parents often report that these children are “drenched with sweat when they sleep”
  • Bed-wetting (enuresis)
  • Frequent nighttime urination

The majority of these symptoms reflect reduced circulating oxygen levels, and the abnormal autonomic nervous activity resulting from a brain that is responding to hypoventilation and reduced oxygen levels.

Do these describe your child?

If so, what to do?

Your first step should be to visit your child’s pediatrician. You can’t predict whether your pediatrician will be among those who are sensitive to the possibility of OSA in your child, or if they are aware of the signs and symptoms.

They may refer your child to a sleep expert. On the other hand, if your child has sleep disturbance and also has enormous tonsils, they may simply refer you to an ENT for tonsillectomy.

The Good News

In children, the majority of OSA is due to enlarged tonsils and adenoid tissue.

The Bad News

The solution may be adenoidectomy & tonsillectomy. (The situation in adults is more complicated).

Whereas I advocate surgery only as a last resort, OSA is a convincing reason for me to recommend a tonsillectomy/adenoidectomy, and it usually provides the cure.

Clinical Study: A report from the Stanford University Sleep Disorders Clinic in the journal Sleep Medicine (vol 8: pgs 18-30; 2007) suggests that children with a diagnosis of ADHD (and who were on Ritalin), had significant improvement in their ADHD scores after tonsillectomy.

ADD & ADHD

Attention Deficit Disorder & Attention Deficit Hyperactivity Disorder. Statistics in the US show a huge increase in children under age 7 years being diagnosed and treated for ADD/ADHD. In the US alone, the number of children ages 3 to 17 years diagnosed with ADHD has risen steeply, particularly in the last three years. That number now exceeds 10,000,000!!! Yes – 10 Million!

Do those 10 Million children REALLY have ADHD? Do we really need 10 Million of our children on Ritalin?? Really?

Maybe not: It is estimated that as many as 40% of them, or 4 Million, are mis-diagnosed with ADHD.

The Question:

What is the #1 cause of inattention, impulsivity, poor concentration, and aggressive behavior in children who are mis-diagnosed with ADHD?

You already know the answer.

Think about how your children act when they are super tired. Unlike adults – who are looking for a place to take a nap – children who are fatigued are bouncing off the walls!

When MY kids are tired, they behave like wild chimpanzees!

chimpanzee

Image: chimpanzee

The answer to the question:

OSA and SDB – obstructive sleep apnea and sleep disordered breathing – can cause behaviors that are indistinguishable from ADHD.

Incidence of OSA in Children

In the general population of children – the “control group” – about 4% have OSA. In a group of 78 children diagnosed with ADHD, over half of them were found to have OSA!!

What to DO?

So how do you know whether your child, who may be diagnosed with ADD/ADHD, is merely showing behaviors of sleep problems?

First, go back to the list above. Do those sound like your child? Do they have those signs and symptoms?

Next, try to get a sense of how they are sleeping. Pull a chair into their room. After they are sound asleep, sit awhile and listen. Watch them breathe. Are they breathing quietly, smoothly? Or are they struggling?

Consider using your smart phone to record a video of them sleeping, or at least record the sound.

Just in case I was not clear about this:

It is NOT NORMAL for children to snore. That sound represents a partial airway obstruction.

Now, armed with your new education on ADD/ADHD and sleep deprivation, visit your child’s pediatrician. Take your video or audio recording of your child’s sleep with you. Take some print outs of clinical studies, especially the one from the journal, Pediatrics (#3 in Resources, below).

Stay informed. Stay healthy.

Get some answers. Your child just may NOT need to live on Ritalin!

_______________________________________

Hi, I’m Russell Faust, author of this medical education blog.

Russell Faust, PhD, MD boogordoctor

Dr. Faust and friend

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_______________________________________

Resources:

Image Credit: Chimpanzee from wikimedia, used under Creative Commons License: http://commons.wikimedia.org/wiki/File:Chimpanzee.jpg

  1. Sleep Problems in Children with Developmental Disorders. J Royal Society of Medicine 94: 177-179; 2001
  2. Dr. Steven Park blog: ADHD & Sleep Apnea: The Controversial Connection, 2010
  3. Sleep-Disordered Breathing, Behavior, and Cognition in Children Before and After Adenotonsillectomy. Chervin et al. Pediatrics. Vol 117: pg e769-e778; 2006
  4. Is it ADHD or Obstructive Sleep Apnea? http://www.spsk12.net/files/2012/03/Is-it-ADHD-or-Obstructive-Sleep-Apnea_Hot-Topic_February-2012.pdf

 

Comments

  1. My son was diagnosed with sleep apnea a few years ago. In addition to snoring, he was also very anxious. After being treated with Nasonex, we could see his anxiety levels go down. His second sleep study showed no sleep apnea. Anxiety is also a problem for my husband who has sleep apnea.

  2. Excellent article on the newly established/evidence-based link between Sleep Disordered Breathing/Obstructive Sleep Apnea Syndrome (SDB/OSAS). I think it’s also important to point out that, although tonsil and adenoidectomy (T&A) surgery is indeed the treatment of choice when deemed necessary per existence of enlarged tonsils and adenoids in a snoring and/or open-mouth sleep breathing child, early orthodontic expansion of a child’s jaws should also be considered as an effective adjunctive approach to maximizing effectiveness of T&A surgery…or maybe even precluding the need for T&A surgery in some cases, and also minimizing possibility of post-surgical regrowth of the adenoids in later childhood/adolescence. There are many risk factors that can be identified by dentists (and pediatricians, parents, teachers) in very early childhood just by looking at the face and the inside of a child’s mouth: excessive wear on molars from grinding of teeth at night (bruxism), dark skin under eyes (allergic shiners) , narrow/deep roof of mouth (high- vaulted palate), difficulty keeping lips closed (open-mouth posture) during waking and/or sleeping hours, deep overbites, anterior open-bites, underbites (anterior cross-bites), posterior cross-bites, scalloped lateral borders of tongue, inability to see the uvula when child opens mouth (increased Mallampati score), crowded/crooked teeth, tongue thrusting, etc.. All of the afore-mentioned oro-facial characteristics are scientifically supported (evidence based) as being legitimate risk indicators for SDB/OSA that tend to cluster around already established physical (snoring, restless legs, head banging against pillow, etc.) and behavioral (bedwetting), risk factors for SDB/OSA, and thus, are also indirect risk indicators for ADD/ADHD.

    Dentists and orthodontists who treat very young (2-5 y.o.) children are on the front line for early recognition of SDB/OSAS and ADD/ADHD risk; pediatricians, ENT’s, family physicians, sleep medicine physicians …and pre-school teachers (who might inform parents of their snoring child during pre-school naptime) must collaborate with one another, along with dental professionals, in order to establish the most effective ways for preventing, reversing and/or managing health problems associated with poor pediatric sleep hygiene.

    Anf finally, all children should have their first dental visit by age one according to the American Academy of Pediatric Dentistry and the American Academy of Pediatrics.

    • Russell A. Faust, PhD, MD says:

      Dear Dr. Boyd, (http://dentistry4children.net/)
      Thank you so much for sharing your expertise here!
      It is my experience that the “newer” generations of dentists and oral surgeons are very sensitive to the issue of OSA, as it is manifest in dental arch pathology and bruxism. In fact, there are a group of dentists and oral surgeons who regularly refer patients to me on this basis, actually refusing to correct occlusion problems without having the “airway optimized” first.
      Thanks again for visiting and sharing!!
      RF

  3. Dear Dr. Faust

    Thank you for your response.

    I am indeed encouraged by your mention of the group of dentists and oral surgeons who are ‘airway-centric’ in their approach to optimizing occlusion; and I am also encouraged that you optimistic about a “newer” generation of dentists and oral surgeons who have increased sensitivity to to SDB/OSA issues….this is all good news. What I think needs to happen now is a generalized raising of awareness about how dentists who treat very young (2-5 y.o.) children are actually in an ideal position to (not only) ‘prevent’ SDB/OSA in kids identified as being at increased risk per recognition of craniofacial/dentofacial risk indicators (e.g., narrow/deep palates, cross-bites, dental crowding, open mouth posture, etc.) and aggressive history taking (e.g., does your child wet the bed, snore, grind their teeth while sleeping, etc.), but also to sometimes ‘reverse’ existing airway-related disease if first recognized in the very young patient and then appropriately treated (with non-surgical orthodontic/orthotropic palatal expansion/maxillo-mandibular advancement, tongue training excercizes/Orofacial Myofunctional Therapy, etc.).

    The American Association of Physiological Medicine and Dentistry (aapmd.org) is conducting a symposium this Saturday in Chicago addressing these very issues (http://www.gelbcenter.com/images/breathing-airway%20blockage%20issues%20events%20seminars.pdf); please consider participating as an honored guest should your schedule allow on such short notice.

    • Russell A. Faust, PhD, MD says:

      Hi Dr. Boyd,
      Thank you for that generous invitation. Unfortunately, I am traveling this weekend and will not be able to attend. If you are attending, please provide updates.
      I agree that dentists and oral surgeons are really the “front lines” for recognizing the possibility of sleep disorders in children. I am disappointed by the number of parents and pediatricians who dismiss signs of severe sleep disorders. It is NOT normal for children to snore!
      Thanks for visiting and sharing.
      RF

  4. Excellent article. To add to Dr. Boyd’s announcement about the AAPMD event on Saturday, please know that there will be a Free Health Screening Event for Risk Factors of Poor Child Facial Development and
    Adult and Child Sleep Breathing Disorders, which will be help on March 8. Members of the public may sign up for this screening at:

    http://aapmd.org/aapmd-events/free-health-screening.html

    March 8, 2013
    Loyola University – Kasbeer Hall
    25 E. Pearson, Chicago, IL
    10:00 am – 2:00 pm

    Thank you!

    • Russell A. Faust, PhD, MD says:

      Dr. Gelb,
      Thank you for visiting, and for sharing that link.
      I was just reading over the agenda for your conference – outstanding!!
      Please consider adding a Pediatric ENT to your conference faculty for next year (I happen to know one :))
      Thanks again for visiting, and for your advocacy for children’s health.
      Please link back to this site at every opportunity.
      Thanks,
      RF

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