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National Sleep Awareness Month: Rule out sleep disorders first before diagnosing kids with ADHD

March 21, 2018 0 Comments

adhd sleep apnea kids national sleep awareness month


MARCH IS NATIONAL SLEEP AWARENESS MONTH 

[by Tamara Sellman RPSGT CCSH for Advanced Cardiovascular Sleep Disorders Center]


It might be surprising to learn that children have sleep disorders (beyond the common resistance to bedtime).

However, school-aged kids can experience a wide range of sleep disorders, from obstructive sleep apnea (OSA) to insomnia to narcolepsy to parasomnias like sleepwalking and night terrors.

If your child’s pediatrician routinely asks about their sleep health, congratulations! That’s a great doctor!

Yet, there are still many doctors who do not think to ask about sleep health or problems, and may wait for parents to bring them up.

This is problematic because parents don’t always remember to raise these issues at appointments. It’s also problematic because certain sleep disorders may become misdiagnosed.

For instance, many children with sleep challenges may be misdiagnosed with attention deficit hyperactivity disorder (ADHD).

How the symptoms of poor sleep can mimic ADHD

Many of the symptoms of untreated sleep problems mimic those routinely seen as indicators of attention deficit.

  • Irritability and mood swings
  • Energy swings (hyperactive one moment, fatigued the next)
  • Problems with concentration, attention, or focus
  • Emergent learning problems

For quite some time, it has been thought that behavior problems in children were related to brain development, but new research continues to show a link between behavior problems that are connected directly to poor sleep health.

In this 2002 study published in Pediatrics, researchers concluded that “Inattention and hyperactivity among general pediatric patients are associated with increased daytime sleepiness andespecially in young boyssnoring and other symptoms of SDB [sleep breathing disorders]. If sleepiness and SDB do influence daytime behavior, the current results suggest a major public health impact.”

According to data from the Stanford School of Medicine, around 10 percent of children snore, and the American Academy of Otolaryngology estimates that up to four percent of kids who snore have OSA. 

Unfortunately, research published 10 years later in Behavioral Sleep Medicine demonstrated that "Children with one type of sleep problem are not routinely evaluated and treated for the other. The findings suggest that pediatricians, respiratory specialists and sleep medicine specialists should work together whenever a sleep problem is suspected."

Even in 2018, many doctors—and parents—still don’t recognize that sleep disorders can lead to problems with daytime functioning, such as maintaining attention, managing mood, learning problems, and low energy. On top of all that, sleep disorders can lead to insulin resistance, obesity, and even high blood pressure.

While it's impossible to know how many children who snore or who have OSA have been misdiagnosed with ADHD, it's likely a high enough tnumber o warrant concern and raise awareness about this common discrepancy. After all, treatments for sleep disorders are quite different from those for attention deficit, and successful treatment of OSA, in particular, can stave off a long list of chronic problems as they grow up.

What are the risks of ignoring (or failing to identify) sleep disturbances in children?

Poor sleep in children, by any cause, can lead to sleep fragmentation. This describes patterns of broken sleep, which are counterproductive to development, as the body and brain are meant to experience consolidated periods of uninterrupted sleep at night.

Sleep fragmentation causes oxidative stress due to the continual release of stress hormones, night after night, especially in those with sleep apnea.

In the case of kids with sleep breathing disorders, their brains and bodies will struggle for oxygen—a major building block in physical development—creating an ongoing “fight or flight” struggle to breathe.

Over time, these kinds of stresses eventually lead to permanent changes in the nervous system and major organs, such as the pancreas, the heart, the vascular system, and the brain, opening the door to chronic concerns such as obesity, diabetes, hypertension, and mental health disorders.

How does a parent get to the root of these problems before they take hold and alter the course of their child’s development?

First, they should consider all the symptoms of sleep disorders that might also accompany behavior problems, such as: 

  • nocturnal enuresis
  • sleep terrors
  • depression
  • insomnia psychiatric problems

Parents who notice a collection of these symptoms should approach their child's healthcare team to take further action. 

Pediatrics is all about teamwork

What a doctor sees when observing a child is important for diagnosis and treatment, but they can’t always see everything.

Parents are the record-keepers of day-to-day observations about their children’s health and behavior.

A teamwork approach to addressing problems with behavior makes good use of feedback from both healthcare professionals and parents.

What pediatricians can do when behavior problems arise

  • Inquire into bedwetting, nighttime teeth grinding or clenching (bruxism), and nightmares
    • Nocturnal enuresis may be a symptom of untreated sleep apnea and not a behavioral concern​
    • Often the jaw will clench in order for the airway to remain open, leading to soreness in the temporomandibular joint or dental problems
  • Routinely screen for sleep disorders using widely available questionnaires
    • The Pediatric Sleep Questionnaire is one tool that can be used to help with a differential diagnosis; it focuses on a wide range of sleep concerns
  • Ask parents about snoring and mouth breathing
    • Snoring may indicate an underlying case of sleep apnea, as can mouth breathing.
  • Check out a child patient’s dietary choices
    • People of all ages with sleep disorders tend to crave and overeat high-fat, high-carbohydrate, high-calorie foods, due to a disruption in leptin and grehlin levels caused by poor sleep. Unusual weight gain can be a sign of an emergent sleep disorder
  • Certain other health concerns may require a sleep test
    • Craniofacial syndromes and neuromuscular disorders, in particular, are closely associated with sleep breathing disorders in kids
  • Get a family history of sleep disorders
    • Obstructive sleep apnea tends to run in families, and new research suggests this is true for insomnia or other sleep problems

What parents can do when behavior problems arise

  • Pay close attention to the way your child breathes, day and night
    • If junior seem congested all the time, breathes through the mouth, has a constant runny nose, or snores, these could indicate potential sleep breathing problems
  • Consider your child’s energy levels… are they normal for a kid of that age?
    • Hyperactivity and restlessness are not only symptoms of ADHD but also of sleep deprivation in children
    • Conversely, if your child seems overly sleepy, struggles to get out of bed in the morning, needs naps after preschool age, or has flagging energy during activities that they should be able to perform without effort, these could be signs of sleep loss caused by an undiagnosed sleep disorder
  • Don’t ignore bedwetting
    • It can be a normal behavior in younger children, but it can also be a sign of untreated sleep apnea
  • If your child has dental problems, share this information with their pediatrician
    • It could be from an over- or underbite, a high arched palate, or there could be evidence of teeth grinding or jaw cleaning; these are all associated with obstructive sleep apnea
  • Consider your own health histories
    • The health histories of both parents should be considered. Often, people don’t realize that some sleep disorders could have a familial link. Consider whether there are grandparents, aunts, uncles, or siblings with sleep problems, and share this information with your doctor
  • Ask for a sleep test if you suspect your child has a sleep disorder
    • Don’t wait for your pediatrician to suggest one… if you think your child might have a sleep problem, request a test to rule it out before accepting an ADHD diagnosis

SOURCES

"Comorbid Symptoms of Sleep-Disordered Breathing and Behavioral Sleep Problems From 18–57 Months of Age: A Population-Based Study." Moore M, Bonuck K.  Behavioral Sleep Medicine, 2012; 11(3):222-230.

"Inattention, Hyperactivity, and Symptoms of Sleep-Disordered Breathing." Chervin RD, Archbold KH, Dillon JE, Panahi P, Pituch KJ, Dahl RE, Guilleminault C. Pediatrics, 2002; 109(3):449-56. 

"Pediatric Sleep Questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems." Chervina RD, Hedger K, Dillon JE, Pituch KJ. Sleep Medicine, 2000 Feb 1;1(1):21-32.


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