Childhood Sleep Disorderes, ADD, ADHD and other "Mental Disorders"

I was directed here from a childhood sleep forum after investigating the connection between sleep and ADHD and other mental illnesses from the book It's Not Mental and the blog on sleep being a causative factor.

I didn't know alternative devices to CPAP even existed, and have a family member who absolutely hates the CPAP and the parents will be very happy with the information you have provided.

Thank you!

Dr Shapira Response: Research is finding that sleep is involved in almost every physiologic and disease process to some extent. I believe that early intervention with young children willl make incredible changes in developing children. Research has shown that the speed of brain development is strongly affected by the quality of sleep (especially in the case of sleep apnea). Patients with undiagnosed and untreated sleep apnea have permanent changes in brain development.

Treatment of pediatric sleep apnea is often limited to removal of tonsils and adenoids and this can be a grave mistake. The developmental changes in the oral, nasal and pharyngeal tissues do not normalize after T&A surgery.

Orthopedic widening of the maxilla (and maybe mandible) is incredibly safe and effective in children should always be considered as part of the total treatment. It has also been suggested that Rapid Maxiallry Expmansion or RME be considered prior to removal of tonsils oradenois to reduce surgical risk and morbidity. I frequently build expansion into appliances that treat sleep apnea. The same bite changes that are considered problematic in some adults are actually beneficial to children wearing oral appliances.

Parents in the Midwest have access to Dr Alexander Golbin (http://chicagosbmi.com/about-us) who is a leading expert on children and sleep disorders. He wrote the book on Children's Sleep and was head of Child Psychiatry at cook County Hospital for 25 years. He is an excellent resource for parents of children with Autism, ADD, ADHD, and bedwetting and other developmental challenges.

I have an adult practice with the exception of children with sleep disordeers, TMJ disorders, TMD or chronic headaches. Chronic headaches in children and adolescents are almost always related to the stomtognathic sytem including teeth, jaws, jaw joints, jaw muscles, sinus regions and the all important Trigeminal Nerve.

I have thousands of visitors sent to my site from other health blogs and I thank you for listing my site on those blogs. We can improve the health and quality of life for patients

SLEEP APNEA IN CHILDREN IS FREQUENTLY TREATED WITH REMOVAL OF TONSILS AND/ OR ADENOIDS. ORTHOPEDIC APPLIANCES AND SLEEP APPLIANCES ALSO HAVE A ROLE.

Dawn: My 5yo daughter had T&A sx at 22mos which seemed to help her osa up until about 8months ago. She is now going to start using a cpap for severe osa. I now know she will need orthodontic and/or maxillofacial close monitoring. I am wondering if any of thes oral applianced are used with children this young also, and if there is anyone in the northern ******** area who is best trained for this.

Dr Shapira: Dear Dawn,

There is an excellent Sleep Apnea Dentist in your area Dr *********** I just talked to him and he would be happy to work with you and your daughter. If there are any questions during treatment we can discuss it as treatment pprogresses.

There would actully be two appliances involved a nightime appliance and a daytime appliance. This will allow the widening of the maxilla while using an appliance to prevent apnea...Dr ******* has a great deal of experience in treating sleep apnea.

This will not only treat the sleep apnea but begin treating the underlying orthopedic problem. You child will still need orthodontics (probably) in the future but the early orthopedic therapy will make future orthodontics easier.

MORE ON THIS TOPIC: SLEEP APNEA IN CHILDREN IS FREQUENTLY TREATED WITH REMOVAL OF TONSILS AND/ OR ADENOIDS. ORTHOPEDIC APPLIANCES AND SLEEP APPLIANCES ALSO HAVE A ROLE IN TREATING CHILDHOOD SLEEP APNEA TREATMENT.

There is a question whether tonsilectomy and adenoidectomy should occur before of after widening of the maxilla. Widening the maxilla will improve the airway and possibly lower post-op complications. If T&A is done prior to widening studies have shown that it does not correct the development orthopedic problems. All patients should be reevaluated for sleep apnea and for maxillary expansion.

Sleep Apnea Treatment in Children improves Performance and Behavior. Treacher-Collins syndrome is discussed in Cleft Palate Journal

I recently came across an older article on sleep apnea and Treacher-Collins syndrome. The article describes improvements in Behavior and performance after correction of micrognathia. What is startling is that the article was published almost 30 years ago long before most physicians worried about pediatric sleep apnea. We now know that 80% of ADD and ADHD children have sleep apnea. Scalloped tongues are indicative (80% predictive) of sleep apnea.

We now know that all snoring and even the mildest sleep apnea can never be ignored in children. It is a shame how many years were wasted with children waiting to outgrow tonsils or adenoids. If you read the story of my son on the main website I had to fight to have his airway corrected. Even seeking a sleep study was considered for Billy was considered crazy. Now it appears the literature supported treating airway obstructions in children several years prior to my experiences.

I have to wonder what other advances are being ignored or just unknown despite published literature.

I know that headache and pain treatment is currently grossly undertreated by neuromuscular dentistry despite the research and case studies. See http://www.ihateheadaches.org


Cleft Palate J. 1981 Jan;18(1):39-44.
Obstructive sleep apnea in Treacher-Collins syndrome.
Johnston C, Taussig LM, Koopmann C, Smith P, Bjelland J.

Abstract
Studies of the Treacher-Collins syndrome have emphasized hearing and surgical considerations. Although craniofacial anomalies have been associated with respiratory disorders in infancy, the presence of such problems in older children has not been emphasized. An eight-year-old with Treacher-Collins syndrome presented a history of recent behavioral problems at home, poor attention span and performance in school, daytime somnolence, and sleep apnea with relatively long periods of chest movement but no airflow. He also had abnormal sleep behavior consisting of rocking to and fro on his hands and knees, often to such an extent that his nose became abraded. ICU monitoring with observation and recording of sleep patterns and sounds, and fluoroscopy of his upper airway utilizing cineradiography while asleep confirmed the diagnosis of obstructive sleep apnea. The patient subsequently underwent an orthognathic surgery consisting of insertion of rib bone grafts after anterior advancement of his mandible. This procedure resulted in disappearance of the obstructive sleep apnea and associated symptoms. Because of micrognathia, patients with Treacher-Collins syndrome are at high risk for developing obstructive sleep apnea. Surgical correction of their deformities can result in improvement in cosmetic appearance as well as in resolution of the obstructive episodes with improvement in performance and behavior.

Look for Sleep Apnea Symptoms in Children

Although the majority of obstructive sleep apnea sufferers are men over age 50, women and even children can suffer from this potentially dangerous or deadly condition. If your child is restless, has trouble focusing in school or cannot remember lessons he may be suffering from Attention Deficit Disorder (ADD) or Attention Deficit Hyperactive Disorder (ADHD), or it may be the result of obstructive sleep apnea. In talking to your doctor about your child's behavior and learning problems, it is important to consider and discuss sleep apnea, which can often cause not just ADHD symptoms, but can lead to long-term health problems if not properly diagnosed and treated.

When children are diagnosed with ADHD, the typical treatment regimen is pharmacological, but ADHD drugs come with potentially serious side effects and a lifetime of dependence. Furthermore, if the root cause of the problem is sleep apnea, the drugs may not seem to work until the dosages are increased to very high levels. However, sleep apnea can be treated with much less invasive methods, including either continuous positive airway pressure (CPAP) or oral appliance therapy.

It is unknown how many children suffer from this condition, but it may be as much as 13% of children aged 3 to 6 and perhaps 8% in older children. As many as 30% of overweight teens may suffer from obstructive sleep apnea, and if a child has had a broken nose or has a deviated septum, he or she is at a high risk for sleep apnea.

If your child is having trouble in school, has difficulty focusing, or has consistent behavioral problems, he or she may be suffering from sleep apnea. To learn more about pediatric sleep apnea and how to treat it, please contact a local sleep dentist today.

SLEEP APNEA AND ANXIETY: A PUBMED SEARCH ON THOSE TERMS YIELDS 243 RESULTS.

THERE ARE MANY STUDIES THAT SUGGEST NEGATIVE HEALTH EFFECTS FROM POOR SLEEP. AN ARTICLE IN Behav Sleep Med. 2010 Jul;8(3):157-71. TITLED Sleepiness and health in midlife women: results of the National Sleep Foundation's 2007 Sleep in America poll CONCLDES THAT " sleep disruptions and daytime sleepiness negatively affect the daily life of midlife women."

ANOTHER ARTICLE IN J Adolesc Health. 2010 Feb;46(2):124-32. Epub 2009 Aug 3.
Sleep patterns and predictors of disturbed sleep in a large population of college students CONCLUDES THAT "insufficient sleep and irregular sleep-wake patterns, which have been extensively documented in younger adolescents, are also present at alarming levels in the college student population. Given the close relationships between sleep quality and physical and mental health, intervention programs for sleep disturbance in this population should be considered."

A THIRD ARTICLE IN Acta Otorrinolaringol Esp. 2009 Sep-Oct;60(5):325-31. Epub 2009 Aug 13.
[Neurocognitive and behavioural abnormalities in paediatric sleep-related breathing disorders] CONCLUDES THAT " A high prevalence of behavioural and neurocognitive abnormalities was observed in children with sleep-related breathing disorders compared to a control group of healthy children. The use of objective assessment such as psychological tests revealed more abnormalities than were expressed by parents in response to clinical interviews."

IT APPEARS THAT RGARDLESS OF AGE AND/OR HEALTH STATUS SLEEP DISORDERS WREAK HAVOC ON BOTH PHYSICAL AND EMOTIONAL WELL BEING.


Behav Sleep Med. 2010 Jul;8(3):157-71.
Sleepiness and health in midlife women: results of the National Sleep Foundation's 2007 Sleep in America poll.
Chasens ER, Twerski SR, Yang K, Umlauf MG.

School of Nursing, University of Pittsburgh, 3500 Victoria Street, Pittsburgh, PA 15261, USA. chasense@pitt.edu
Abstract
The 2007 Sleep in America poll, a random-sample telephone survey, provided data for this study of sleep in community-dwelling women aged 40 to 60 years. The majority of the respondents were post- or perimenopausal, overweight, married or living with someone, and reported good health. A subsample (20%) reported sleepiness that consistently interfered with daily life; the sleepy subsample reported more symptoms of insomnia, restless legs syndrome, obstructive sleep apnea, depression and anxiety, as well as more problems with health-promoting behaviors, drowsy driving, job performance, household duties, and personal relationships. Hierarchical regression showed that sleepiness along with depressive symptoms, medical comorbidities, obesity, and lower education were associated with poor self-rated health, whereas menopause status (pre-, peri- or post-) was not. These results suggest that sleep disruptions and daytime sleepiness negatively affect the daily life of midlife women.

PMID: 20582759 [PubMed - in process]

J Adolesc Health. 2010 Feb;46(2):124-32. Epub 2009 Aug 3.
Sleep patterns and predictors of disturbed sleep in a large population of college students.
Lund HG, Reider BD, Whiting AB, Prichard JR.

Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA.
Abstract
PURPOSE: To characterize sleep patterns and predictors of poor sleep quality in a large population of college students. This study extends the 2006 National Sleep Foundation examination of sleep in early adolescence by examining sleep in older adolescents.

METHOD: One thousand one hundred twenty-five students aged 17 to 24 years from an urban Midwestern university completed a cross-sectional online survey about sleep habits that included the Pittsburgh Sleep Quality Index (PSQI), the Epworth Sleepiness Scale, the Horne-Ostberg Morningness-Eveningness Scale, the Profile of Mood States, the Subjective Units of Distress Scale, and questions about academic performance, physical health, and psychoactive drug use.

RESULTS: Students reported disturbed sleep; over 60% were categorized as poor-quality sleepers by the PSQI, bedtimes and risetimes were delayed during weekends, and students reported frequently taking prescription, over the counter, and recreational psychoactive drugs to alter sleep/wakefulness. Students classified as poor-quality sleepers reported significantly more problems with physical and psychological health than did good-quality sleepers. Students overwhelmingly stated that emotional and academic stress negatively impacted sleep. Multiple regression analyses revealed that tension and stress accounted for 24% of the variance in the PSQI score, whereas exercise, alcohol and caffeine consumption, and consistency of sleep schedule were not significant predictors of sleep quality.

CONCLUSIONS: These results demonstrate that insufficient sleep and irregular sleep-wake patterns, which have been extensively documented in younger adolescents, are also present at alarming levels in the college student population. Given the close relationships between sleep quality and physical and mental health, intervention programs for sleep disturbance in this population should be considered.

PMID: 20113918 [PubMed - indexed for MEDLINE]

Acta Otorrinolaringol Esp. 2009 Sep-Oct;60(5):325-31. Epub 2009 Aug 13.
[Neurocognitive and behavioural abnormalities in paediatric sleep-related breathing disorders]
[Article in Spanish]

Esteller Moré E, Barceló Mongil M, Segarra Isern F, Piñeiro Aguín Z, Pujol Olmo A, Soler EM, Ademà Alcover JM.

Servicio de Otorrinolaringología, Hospital General de Catalunya, San Cugat del Vallès, Barcelona, España. esteller@abaforum.es
Abstract
INTRODUCTION: Behavioural and neurocognitive abnormalities in children may be a consequence of sleep-related breathing disorders. The effectiveness of assessments based on questioning parents is dubious and objective assessment tools are therefore required.

AIM: To ascertain the impact of these abnormalities in children with sleep-related breathing disorders and compare the reliability of questioning parents in relation to validated psychological tests.

METHOD: A prospective study was performed on 20 children with sleep-related breathing disorders and 20 healthy control children between 3 and 12 years of age. Both groups were subjected to a battery of validated psychological tests. The results of both groups were compared with each other and with the response to clinical questionnaires given to parents in the problem group.

RESULTS: More than 75% of the cases in the problem group presented abnormalities with regard to attention, anxiety, memory and spatial structuring. The percentage involvement in all concepts was higher in the problem group. Comparisons of attention (40% of children affected in the control group and 80% in the problem group), memory (50% and 84.2%), and spatial structuring (45% and 75%) were statistically significant. More abnormality was observed in the parameters assessed with psychological tests than the equivalent concept obtained from interviewing the parents. Comparison of abnormal concentration assessed from the questionnaires (40% of children affected) with attention during the psychological test (80%), memory (15% and 84.21%), and delayed language development (10%) compared to spatial structuring (75%) was statistically significant.

CONCLUSIONS: A high prevalence of behavioural and neurocognitive abnormalities was observed in children with sleep-related breathing disorders compared to a control group of healthy children. The use of objective assessment such as psychological tests revealed more abnormalities than were expressed by parents in response to clinical interviews.

PMID: 19814984 [PubMed - indexed for MEDLINE]Free Article

Dangerous Consequences of Pediatric Sleep Apnea: Diagnosing and treating sleep apnea is vital to lifetime quality of life.

Question from Sylvia: What are the most common symptoms in children with sleep apnea? Does it affect their brain if left untreated

Dr Shapira Response: Dear Sylvia,
Great Question! There are many short term and long term problems related to sleep apnea. 80% of all ADD and ADHD are related to apnea. There are studies that show both delayed development and permanent changes in brain devlopment.

There are also hormonal (endocrine) changes that affect growth and development.

It is vitally important to children of all ages to iagnose and treat sleep apnea ASAP. Children may never recover from damages that occur in their first few years of life. I have publishe just a few studies below. Recent studies have shown tonsilectomy and adenoid removal may be insufficient treatment and that palatal widening is usually indicated in these patients. Pediatric may be better treated by doing rapid maxillary expansion prior to T&A surgery to create a better post-op healing situation.

It is never to soon to treat sleep apnea. snoring and even minimal apnea AHI of 1 or more should never be ignored but rather taken as an ominus sign of future developmental problems that can be prevented.

I would like to offer my highest recommendation to Dr Alexander Golbin at Sleep and Behavioral Medicine for Chicago area patients. Dr Ira L Shapira

See Pub Med abstracts below:

Pediatr Pulmonol. 2009 May;44(5):417-22.
Neurocognitive and behavioral impact of sleep disordered breathing in children.
Owens JA.

Department of Ambulatory Pediatrics, Rhode Island Hospital, Providence, Rhode Island 02903, USA. owensleep@gmail.com
Abstract
The consequences of poor quality and/or inadequate sleep in children and adolescents have become a major public health concern, and one in which pediatric health care professionals have become increasingly involved. In particular, insufficient and/or fragmented sleep resulting from primary sleep disorders such as obstructive sleep apnea (OSA), often compounded by the presence of comorbid sleep disorders as well as by voluntary sleep curtailment related to lifestyle and environmental factors, has been implicated in a host of negative consequences. These range from metabolic dysfunction and increased cardiovascular morbidity to impairments in mood and academic performance. The following review will focus on what is currently known about the effects of sleep disordered breathing (SDB) specifically on neurobehavioral and neurocognitive function in children. Because of the scarcity of literature on the cognitive and behavioral impact of sleep disorders in infants and very young children, this review will target largely the preschool/school-aged child and adolescent populations. In addition, the focus will be on a review of the most recent literature, as a supplement to several excellent previous reviews on the topic.

Sleep Med. 2010 Aug;11(7):714-20.
Autonomic alterations and endothelial dysfunction in pediatric obstructive sleep apnea.
Kheirandish-Gozal L, Bhattacharjee R, Gozal D.

Department of Pediatrics and Comer Children's Hospital, Pritzker School of Medicine, The University of Chicago, IL 60637, USA. lgozal@peds.bsd.uchicago.edu
Abstract
The cardiovascular consequences of obstructive sleep apnea syndrome (OSAS) in children have started to emerge over the last decade. It is clear that the respiratory and sleep alterations that characterize this relatively prevalent condition induce substantial alterations in autonomic nervous system control, ultimately generating high sympathetic outflow and reactivity that reflect an imbalance between sympatho-excitatory and vagal inhibitory inputs. In addition to these important consequences, the constitutive elements of OSAS also elicit a rather extensive activation of systemic inflammatory pathways that in turn pose substantial risk to the integrity and functional homeostasis of the endothelial network. The complex interactions between the multiple injury-associated pathways recruited by OSAS are further compounded by the potential release of angiogenic factors and by the mobilization and homing of progenitor cells that have the potential to repair and restore the OSAS-disrupted vascular function. Improved characterization of the mechanisms involved in every one of these processes and identification of the determinants of susceptibility in pediatric populations along with the interactions with obesity will clearly modify our approaches to OSAS in the future.

PMID: 20620107 [PubMed - in process]

Clin Chest Med. 2010 Jun;31(2):221-34.
Pediatric obstructive sleep apnea syndrome.
Katz ES, D'Ambrosio CM.

Division of Respiratory Diseases, Department of Medicine, Children's Hospital, Mailstop 208, 300 Longwood Avenue, Boston, MA 02115, USA. eliot.katz@childrens.harvard.edu
Abstract
Obstructive sleep apnea syndrome (OSAS) is a common and serious cause of metabolic, cardiovascular, and neurocognitive morbidity in children. Children with OSAS have increased upper airway resistance during sleep due to a combination of soft tissue hypertrophy, craniofacial dysmorphology, neuromuscular weakness, or obesity. Consequently, children with OSAS encounter a combination of oxidative stress, inflammation, autonomic activation, and disruption of sleep homeostasis. The threshold amount of OSAS associated with adverse consequences varies widely among children, depending on genetic and environmental factors. The choice of therapy is predicated on the etiology, severity, and natural history of the increased upper airway resistance.

PMID: 20488283 [PubMed - in process]

Pediatr Ann. 2008 Jul;37(7):465-70.
The snoring child.
Perez IA, Ward SL.

Keck School of Medicine, University of Southern California, Division of Pediatric Pulmonology, Childrens Hospital Los Angeles, 90027-6062, USA.
Abstract
Snoring is a common manifestation of obstructive sleep apnea and represents one end of the spectrum of sleep-related breathing disorders. Children with primary snoring initially may develop OSAS later, so inquiring about symptoms of OSAS should be part of each visit. Obstructive sleep apnea can result in serious cardiovascular and metabolic consequences and neurocognitive deficits. Adenotonsillar hypertrophy remains the most common cause of OSA although the rising prevalence of obesity is of increasing importance. Polysomnography remains the gold standard in the diagnoses of OSAS and in assessing the risks associated with surgery. Most children with OSAS can be treated with adenotonsillectomy in the ambulatory surgery center. However, there are children at risk for severe OSAS and for postoperative complications, who will need PICU care. In addition to adenotonsillectomy, OSAS can be treated successfully in referral centers with other surgical approaches and by the use of positive airway pressure. Children with obesity-related OSAS often require CPAP or BPAP for control of OSAS.

PMID: 18710136 [PubMed - indexed for MEDLINE]

# year old with (OSA) Sleep Apnea. Are there alternatives to tonsil and adenoid removal

comments : my 3yr old grandaughter has been diagnosed with OSA, they are referring surgery to remove adenoids & tonsils. would like to know if there are any alternatives out there. we are going to try the oxygen therapy 1st. is there anythings else we can do

This is an interesting question for several reasons. The first is that they have discussed oxygen therapy, unfortunately oxygen therapy is not helpful for obstructive sleep apnea because the airway is obstructed and therefore the oxygen does not get to the lungs.

The second part of the question is there an alterrnative to tonsil and adenoid removal. Rapid maxillary expansion can open the airway in children and is often indicated IN ADDITION to removal of tonsils and/or adenoids. A Swedish researcher suggested at the Dental Sleep Meeting that doing maxillary expansion prior to surgery make reduce complications and create easier and/or faster healing. Another recent report has shown that even if tonsils and adenoids are removed there will remain orthopedic jaw problems that will still usually require widening of the palate.

The question which should be done first surgery or widening of the maxilla is still open.

What is not open is that pediatric patients with sleep apnea should be treated ASAP. ADD, ADHD and other learning and behavioral disorders have been linked to pediatric sleep apnea and time is of the essence.

Various studies have shown delayed brain development and/or permanent changes in brain development as a consequence to sleep apnea in children. Read the story in my profile about my sons sleep apnea and how treating it changed his life.