I recently treated an eight-year-old patient who wasexperiencing loud snoring and difficulty waking in the mornings. He could notsit still and had recently been diagnosed with attention deficit hyperactivitydisorder (ADHD). I requested that his mom wait to start stimulant therapy untilafter we could perform a sleep study.


Given the patient’s symptoms, I suspectedhe had sleep-disordered breathing and/or possibly periodic limb movements ofsleep. Unlike adults, children have difficulty describing how theyfeel when they do not get enough sleep. But similar to adults, unrefreshingsleep may lead to prefrontal cortical dysfunction. In children this canmanifest as behavioral problems, difficulty controlling emotions and difficultywith attention and hyperactivity.

 

Children with ADHD are three times more likely to havehabitual snoring versus their non-ADHD counterparts and most of the childrenaffected are young boys, studies show. Many children with ADHD also perform poorly in school. One study thatinvolved 1,588 seventh and eighth graders, showed that those performing in thebottom quartile of their classes were two- to three-times more likely to havebeen loud snorers since as young as two years old.

 

Other sleep disorders that are often overlooked in childrenwith ADHD are restless leg syndrome and periodic limb movements of sleep. Inthe May 1999 issue of Sleep, a retrospectivestudy found that 117 of 129 children (91%) referred to a sleep center had confirmedperiodic limb movements of sleep and also met criteria for ADHD.

 

In the case of this eight-year-old patient, I diagnosed obstructivesleep apnea. He underwent a tonsillectomy and adenoidectomy, andhis symptoms greatly improved.

 

Remember to consider sleep abnormalities in children withbehavior problems, especially those diagnosed with ADHD. A polysomnogram andtreatment as needed could mean that a patient may not need to spend his or herchildhood on stimulant therapy.  

 

SharonM. O’Brien, MPAS, PA-C, works at Presbyterian Sleep Health inCharlotte, N.C. Her main interest is helping patients understand the importanceof sleep hygiene and the impact of sleep on health.

 

 

References

 

  1. Beebe DW, Gozal D. “Obstructive sleep apnea and the prefrontal cortex: Towards a comprehensive model linking nocturnal upper airway obstruction to daytime cognitive and behavioral deficits.” J. Sleep Res. 2002; 11:1-16
  2. Chervin RD, Archbold KH, Dillon JE et al. “Inattention, hyperactivity, and symptoms of sleep-disordered breathing.” Pediatrics. 2002;109:449-456.
  3. Picchietti DL, Walters AS. “Moderate to severe periodic limb movement disorder in childhood and adolescence.” Sleep.1999; 22(3):297-300.