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Article #69

SUMMARY

Referring to a theory that hyperactive children with attention deficit disorder suffer from an inadequate level of arousal causing their attention deficits, the authors speculate that sleep disorders could play a role in this problem. Some evidence from community survey and sleep clinic data exists to support this hypothesis, but little from other settings. The authors chose to investigate this in a pediatric psychiatry and a general pediatric clinic, where they administered questionnaires to parents about their children's symptoms of sleep disorders and attention deficit hyperactivity disorder. Their samples consisted of the parents of 70 children attending the Child and Adolescent Psychiatry Clinic and 73 attending the General Pediatrics Clinic. Included were children aged 2 to 18 years (averaging 9.0 years, 77 boys and 66 girls), without severe mental retardation. Five children from the General Pediatrics Clinic with known past diagnosis of ADHD were excluded. The parents completed two questionnaires. A pediatric sleep questionnaire (PSQ) consisted of 69 questions asking about snoring, restless legs, and sleepiness. The authors had established the reliability of this scale with a separate group of 48 children who received polysomnography. In that sample, the PSQ snoring score proved highly predictive of sleep-related breathing disorders, which were in turn predictive of higher sleepiness scores. The second questionnaire asked about 18 symptoms used to make the diagnosis of ADHD. Children at the Psychiatric Clinic who carried a diagnosis of ADHD were combined alternatively with two comparison groups expected to have lower scores--the non-ADHD children at the psychiatric clinic and the children at the general pediatrics clinic. Among these mixed groups, the authors looked for relationships between the sleep disorder scores and the inattention/hyperactivity score (IHS). Among the 70 psychiatric patients, 27 (39%) carried a diagnosis of ADHD. These known ADHD children had higher IHS scores (2.00 SD=+/- 0.71) than psychiatric patients without diagnoses of ADHD (1.19 SD=+/-0.74) or those at the pediatrics clinic (0.55 SD=+/-0.55). Habitual snoring occurred more often among children with known ADHD (33%) than among those psychiatric patients without ADHD (11%) or general pediatrics patients (9%). Although ADHD children were older (9.5 yrs SD=+/-3.7) than general pediatric patients (7.7 yr SD=+/-4.6) and more often male (96%) than either general pediatrics patients (40% male) or other psychiatry patients (51%), and more often used stimulants, statistical accounting for these factors did not alter the results. These statistics indicated that, among children who snore, 81% of ADHD cases might be eliminated by control of sleep-disordered breathing. Among children in general, where the prevalence of snoring is estimated at 8%, 25% of ADHD cases should be amenable to management via intervention with sleep disordered breathing. The authors were surprised that children diagnosed with ADHD did not have higher snoring scores than other children after adjustment for sex. They suggested that the adjustment may have been inappropriate where there was only one female in the ADHD group. They also noted the absence, so far, of polysomnographic findings of frequent sleep-disordered breathing in ADHD children. This may have resulted in part from a focus of researchers on sleep staging and architecture rather than breathing. Special equipment scoring may be needed for children, who tend to have subtle hypopneas or upper airway resistantce syndrome rather than frank apneas. They speculated that sleep disorders may be a cause of attention deficit/hyperactivity disorders, in which case treatment of the underlying sleep disorder might be preferable to stimulants.

COMMENTS

This may start out confusing readers unfamiliar with the idea that hyperactive children could be underaroused when, to casual inspection, they appear the opposite. It requires a conceptual leap, based on evidence not cited here, to understand that these children may rely on their hyperactivity to stimulate themselves and thereby boost their low arousal. Having accepted that, it is easier to see how they suffer from inattention which a stimulant drug might help. In fact, many of us adults with sleep apnea may have tried self-stimulating tactics to keep ourselves awake while driving: turning on the car radio, talking to a passenger, rolling down the window, etc. Those who have been able to exercise through our apneic symptoms may have noticed a stimulant effect, however brief. The fact that adults with sleep apnea don't generally become behaviorally disruptive like hyperactive kids may have to do with the restraints we have learned in growing up. Such rationales and the substantial body of evidence behind them have not, to my knowledge, gained universal acceptance for this theory, perhaps because it remains counterintuitive. Likewise, I found the type of data collected here to be less than completely convincing, based as it is so much on statistical analyses. What would do a lot more to convince me would be a report of previously undiagnosed/untreated children, selected by these snoring and hyperactivity scales from a population group like a school setting to identify those at increased risk of having either sleep-disordered breathing or ADHD, who would then be given polysomnography of a type the authors would accept as appropriate for children. Finding the predicted proportions of sleep-disordered breathing in these groups, followed by CPAP treatment and objective monitoring for improvement of symptoms of inattentiveness, would come close to proving the point. But the data offered in this study suffice only to raise possiblities enough to stimulate further investment of research efforts. Meanwhile, those of us known to have sleep apnea already have reason to watch for development of symptoms in our children, because of the established hereditary nature of the sleep disorder increasing their risk of sleep-disordered breathing. In these children, we may now have additional cause to attend not only to an obvious sign of sleep disorder like snoring, but also to symptoms we might have once thought unrelated, like hyperactivity and poor attention.

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