Children’s Sleep Issues And ADHD

Children’s Sleep Apnea

child on computer in bed
Does your child snore or show other signs of disturbed sleep like long pauses in breathing, tossing and turning, chronic mouth breathing, night sweats or excessive bed wetting? All of these, especially snoring, are possible signs of sleep apnea, which is more common in children than most people realize. It’s estimated that 1 to 4 percent of children suffer from sleep apnea, many of them between 2 and 8 years old.

Evidence is growing that untreated sleep disorders, including sleep apnea can cause serious health concerns. Studies have suggested that as many as 25 percent of children diagnosed with attention-deficit hyperactivity disorder (ADHD) may actually have symptoms of obstructive sleep apnea, and that much of their learning difficulty and behavior problems can be the consequence of chronic fragmented sleep. Bed-wetting, sleep-walking, retarded growth, other hormonal and metabolic problems, even failure to thrive and grow normally can be related to sleep apnea.

Studies also show a strong association between pediatric sleep disorders and childhood obesity. Some physicians believe that adequate quality sleep is as important as proper diet and exercise in preventing childhood obesity.

Making the Diagnosis

A hospital-based overnight sleep study is the only tool for diagnosing and assessing the severity of pediatric obstructive sleep apnea. The test must be conducted by technologists experienced in working with children and the data interpreted by a sleep medicine physician with pediatric experience. Our office can assist you in finding a pediatric sleep specialist.

When to treat

Currently there are no universally accepted guidelines as to when children’s OSA is severe enough to warrant treatment. Unlike adults, normal children rarely experience obstructive apnea events. Consequently, most pediatric sleep specialists regard an apnea index (AI) of more than 1 or an apnea hypopnea index (AHI) of 1.5 as abnormal and most recommend treatment of any child with an AI greater than 5. (An apnea index includes only respiratory events with an absence of airflow and does not include hypopneas, or respiratory events with reduced air flow). In the case of an AHI of 5 to10 (mild to moderate OSA) or more than 10 in a child who is 12 or younger, which indicates moderate to severe pediatric OSA, the decision to treat is usually straightforward.


Surgical removal of the adenoids and tonsils is the most common treatment for pediatric OSA. In uncomplicated cases, the operation results in complete elimination of OSA symptoms in 70 to 90 percent of the time.  Because of post-operative swelling, full resolution of the OSA symptoms may not occur for six to eight weeks.

If surgery is not indicated or if the surgery does not fully resolve the symptoms, orthodontic treatment to expand the upper jaw as well as treatment to develop the lower jaw properly should be considered as young as age 6 to make room for the tongue and develop the nasal cavity.

Weight management, including nutritional, exercise, and behavioral elements, should be strongly encouraged for all children with OSA who are overweight or obese. Adequate nightly sleep is an important component of weight management and long term health.

Other issues that need to be considered in individual cases include allergies, asthma and treatment for gastroesophageal reflux.

ADHD Misdiagnosis

adhd misdiagnosisMany theories are thrown around to explain the rise in the diagnosis and treatment of ADHD in children.  According to the Centers for Disease Control and Prevention, 11 percent of school-age children have now received a diagnosis of the condition. What if a substantial proportion of these cases are really sleep disorders in disguise?

For children, sleep deprivation does not necessarily show up as typical tiredness.  Instead they can become hyperactive and unfocused. Researchers and reporters are increasingly seeing connections between dysfunctional sleep and what looks like ADHD, but parents and physicians are not always aware of these new findings and may result in an unnecessary prescription for ADHD medication instead of a sleep study.

Sleep is even more crucial for children, who need delta sleep — the deep, rejuvenating, slow-wave kind — for proper growth and development. Yet today’s kids sleep about an hour less than they did a century ago. Nonstop 14-hour schedules and tech devices in the bedroom like TV’s, cell phones, laptops and e-readers often impair sleep. Maybe it’s a coincidence, but the proliferation of personal electronics began getting more extreme in the 1990s, the same decade as the explosion in ADHD diagnoses.

A number of studies have shown that a huge proportion of children with an ADHD diagnosis also have sleep-disordered breathing like sleep apnea or snoring, where delta sleep is frequently interrupted.

One study, published in 2004 in the journal Sleep, looked at 34 children with ADHD. Every one of them showed a deficit of delta sleep, compared with only a handful of the 32 control subjects.

A 2006 study in the journal Pediatrics showed something similar, from the perspective of a surgery clinic. This study included 105 children between ages 5 and 12. Seventy-eight of them were scheduled to have their tonsils removed because they had problems breathing in their sleep, while 27 children scheduled for other operations served as a control group. Researchers measured the participants’ sleep patterns and tested for hyperactivity and inattentiveness, consistent with standard protocols for validating an ADHD. diagnosis.

Of the 78 children getting the tonsillectomies, 28 percent were found to have ADHD, compared with only 7 percent of the control group.

Even more remarkable was what the study’s authors found a year after the surgeries, when they followed up with the children. Half of the original ADHD group who received tonsillectomies — 11 of 22 children — no longer met the criteria for the condition. In other words, what had appeared to be ADHD had been completely resolved by treating their sleep disordered breathing problem.

adhdTo be clear, it’s also possible that ADHD symptoms can remain even after a sleeping problem is resolved. Some children have both conditions.  A long-term study of more than 11,000 children in Britain was published recently in the journal Pediatrics. Mothers were asked about symptoms of sleep-disordered breathing in their infants when they were 6 months old. Then, when the children were 4 and 7 years old, the mothers completed a behavioral questionnaire to gauge their children’s levels of inattention, hyperactivity, anxiety, depression and problems with peers, conduct and social skills.

The study found that children who suffered from sleep-disordered breathing in infancy were more likely to have behavioral difficulties later in life — they were 20 to 60 percent more likely to have behavioral problems at age 4, and 40 to 100 percent more likely to have such problems at age 7. Interestingly, these problems occurred even if the child eventually “grew out of” the sleep breathing disorder, implying that an infant breathing problem might cause some kind of potentially irreversible neurological injury.

What would happen if physicians evaluated each child for sleep disordered breathing before diagnosing ADHD in their patients?  How many of those children would be diagnosed with sleep breathing issues instead? Parents may resist a referral for sleep testing, since everything they have read, often drug company consumer marketing, points to ADHD. Parents may not want to hear that their child may have something that can’t be fixed with a pill.  This often changes once patients see the results of the sleep study and the sometimes dramatic improvement once treatment starts.  If you have been told that your child has ADHD, you owe it to them to have an evaluation by a qualified sleep specialist or dentist properly trained in evaluating sleep apnea issues before you administer prescription drugs for a condition they may not even have.  If you have further questions, please call us at Sleep Solutions Northwest for a consultation.