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Sleep: The Missing Link in ADHD

Sleep disorders may contribute to rising diagnoses of ADHD in children

The old saying "boys will be boys" is a well-known phrase that to some degree explains rambunctious behavior in boys. These days, many of these "energetic" boys and girls are placed on medications to calm this type of behavior. These stimulant medications can work very well for attention deficit hyperactivity disorder, or ADHD.

ADHD is generally thought of as a psychological or neurological disorder.1 Various studies have shown possible abnormalities of brain function or metabolism. There appears to be a genetic component as well. Treatment involves psychotherapy with or without medication. Alarmingly, the rate of children (and now adults) being placed on medications is climbing rapidly.

According to the CDC, it was estimated that in 2011, 11%, or 6.4 million individuals aged 4 to 17 were diagnosed with ADHD. 55% of these children (or 6.1% of all children) were receiving medication for treatment.

If you review the 2001 American Academy of Pediatrics guidelines,2 the possibility of obstructive sleep apnea is buried deep in the guidelines, among dozens of other conditions to consider.

Sleep Disorders
Sleep disorders (especially sleep apnea) can be a major aggravator of ADHD symptoms. Lack of sleep or poor quality sleep has been shown to cause significant neurocognitive and behavioral problems. It's been estimated that about one quarter of all children with ADHD may have a treatable sleep-breathing disorder.3,4 Some estimates are even higher. Those with possible sleep disordered breathing were much more likely to have daytime sleepiness, behavior problems, hyperactivity, inattention and aggressiveness.

There are numerous studies showing that sleep disordered breathing during pregnancy and early childhood can significantly increase a child's risk of OSA. Bonuck and colleagues published a study in Pediatrics in 2012 showing that snoring in the first two years of life strongly predicted behavioral problems by age 7.5 Another study published in Pediatrics in 2006 showed that one year after adenotonsillectomy, 50% of children diagnosed before surgery with ADHD no longer had symptoms. This study recruited 78 children scheduled for adenotonsillectomy and 27 control children undergoing other procedures. Before surgery, 28% of children in the adenotonsillectomy group (22 children) were found to have ADHD by DSM4 criteria. After surgery, only 11 of these 22 children were found to have persistent ADHD.6 Premature delivery was found to be strongly associated with developing OSA later in childhood.7

Even if a child doesn't officially have sleep apnea, it's likely that a child with ADHD will have either fragmented sleep or poor sleep hygiene. One such condition that may affect behavior without manifesting as obstructive sleep apnea is called upper airway resistance syndrome, or UARS. Children can experience multiple partial obstructions and arousals from deep sleep, but without significant apneas or hypopneas.8

Technically speaking, this is a brain injury problem, since lack of oxygen or lack of good quality sleep can affect proper brain activity, as well as optimal neurotransmitter levels.

Not breathing well and not sleeping well can cause physiologic and brain neurotransmitter alterations that can manifest as symptoms of ADHD. The question more healthcare professionals need to ask is: Why do hyperactive children get calmer when they are given stimulant medications? Perhaps because they are sleepy. Poor sleep hygiene and insufficient sleep in children are known to be at epidemic proportions in this country.

Better Sleep
Many parents of children with ADHD will tell you that their children have sleep issues. Even if there are obvious issues with poor sleep hygiene, they can be a challenge to correct, especially if the children (or the parents) are firmly set in their ways.

Here are some steps that parents can take to improve their children's sleep quality:

1. Discourage eating or snacking within three to four hours of bedtime. For toddlers, the earlier they eat before bedtime, the better. Having extra stomach juices can predispose children to reflux, leading to more arousals and possibly more obstructed breathing episodes.

2. Make sure to have your children sleep the appropriate length of time on a regular basis. Infants need up to 14 hours spread throughout the day. Toddlers need 12 hours (including naps). Preschoolers need 11 hours. School-aged children need 10 to 11 hours. Tweens (ages 9 to 12) need 10 hours, and teens need nine hours. Try to keep them from catching up on sleep by sleeping late on weekends. Encourage them to go to bed and wake up at the same time every day.

3. Don't allow any form of media within one to two hours of bedtime. This includes any form of screen time, including computers and smart phones (Remember that the extra blue light in these screens lowers levels of melatonin, a natural hormone important to sleep cycles). Remove any screen from within the reach of your child's bed.

4. Make sure that the bedroom is completely dark. Many electronic devices have extra-bright lights and buttons, which are sometimes brighter than most night lights. Here's how to scope it out. Wait for your children's eyes to adjust to darkness after turning off the lights and stay in the room. Look for any excessively bright lights. Use black electrical tape to cover these areas.

5. If your children have nasal congestion or they snore, talk to your doctor. Sleep can be adversely affected by these conditions, and breathing pauses could be a sign of obstructive sleep apnea. In this case, it's important to see a sleep physician.

In our field (otorhinolaryngology) we routinely see children experience dramatic behavioral improvements and quality of life after a routine tonsillectomy. It's not uncommon to see children on ADHD medications that also snore heavily, are mouth breathers, and have 4+ obstructing tonsils. I'm not suggesting that all cases of ADHD are due to sleep disorders. Medications can be important tools in treating ADHD where they are needed. But even if only a fraction of all ADHD cases are related to sleep-disordered breathing, it makes sense to screen for OSA before considering intensive behavioral intervention or prescription medications.

Steven Y. Park is an assistant professor of Otorhinolaryngology at the Albert Einstein College of Medicine in the Bronx, N.Y. He is the author of the book, Sleep Interrupted: A physician reveals the No. 1 reason why so many of us are sick and tired. For more information about Park, visit doctorstevenpark.com.

References
1. Lewin DSD, Di Pinto MM. Sleep disorders and ADHD: shared and common phenotypes. Sleep. 2004;27(2):188-189.
2. Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management, Wolraich M, et al. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. PEDIATRICS. 2011;128(5):1007-1022. doi:10.1542/peds.2011-2654.
3. Gottlieb DJ, et al. Prospective study of obstructive sleep apnea and incident coronary heart disease and heart failure: the sleep heart health study. Circulation. 2010;122(4):352-360. doi:10.1161/CIRCULATIONAHA.109.901801.
4. Gottlieb DJ, et al. Symptoms of Sleep-Disordered Breathing in 5-Year-Old Children Are Associated With Sleepiness and Problem Behaviors. PEDIATRICS. 2003;112(4):870-877. doi:10.1542/peds.112.4.870.
5. Bonuck K, et al. Sleep-disordered breathing in a population-based cohort: behavioral outcomes at 4 and 7 years. PEDIATRICS. 2012;129(4):e857-65. doi:10.1542/peds.2011-1402.
6. Chervin RD, et al. Sleep-disordered breathing, behavior, and cognition in children before and after adenotonsillectomy. PEDIATRICS. 2006;117(4):e769-78. doi:10.1542/peds.2005-1837.
7. Raynes-Greenow CH, et al. Sleep apnea in early childhood associated with preterm birth but not small for gestational age: a population-based record linkage study. Sleep. 2012;35(11):1475-1480. doi:10.5665/sleep.2192.
8. Guilleminault C, et al. A cause of excessive daytime sleepiness. The upper airway resistance syndrome. CHEST. 1993;104(3):781-787.

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