Relation between Attention Deficit and Hyperactivity Disorder and Sleep Apnea in Children Aged 7-12 Years Abstract
Relationbetween Attention Deficit and Hyperactivity Disorder and Sleep Apneain Children Aged 7-12 Years
Attentiondeficit disorder is a very common disorder world over. The diagnosisis common among young children. Over the recent past, the diagnosesof this disorder have been on the rise. The relationship betweenattention deficit and sleep apnea has also been close since timeimmemorial. In fact, earlier handbook for diagnosis of mentaldisorders acknowledged sleep apnea as one of the symptoms. However,recent studies show that the relationship is not as simple as that.Instead, research shows that sleep apnea elicits symptoms that aresimilar and that mimic ADHD symptoms. Treatment of sleep apneathrough tonsillectomy has also been shown to reduce attention deficitsymptoms. The implication of these finding is that clinicians oughtto rule out sleep apnea first before proceeding to state that apatient is affected by ADHD. Further research will increaseunderstanding and insight regarding OSA, ADHD, and their intricaterelationship.
Overthe years, attention deficit disorder has become a common occurrenceaffecting and projections state that around 3 to 7 percent of thechildren are affected (Miano et al., 2006). The disorder comprises ofsymptoms such as distractibility, poor constant attention,irritability, impulsiveness, and hyperactivity. These developmentaldeficits ascend comparatively early in childhood, characteristicallybefore a child reaches 7 years, and may continue well over time.Clinicians propose three subtypes of attention deficit andhyperactivity disorder (ADHD): predominantly hyperactive,predominantly inattentive, and combine types (Barkley & Murphy,2006). As yet, neither clinicians nor researchers have confirmed thecauses or etiological factors behind the development of the disease.Instead, many studies suggest that anomalies in the function andanatomy of the prefrontal cortex of the brain as well as its networksmight be behind this disorder (Swanson, 2003).
Manyresearchers have delved into studies leading to the advancement ofthe Diagnostic Statistical Manual of mental diseases classification.Over the recent past, sleep apnea has shown significant correlationwith attention deficit disorder leading to further classification ofthe disorder. Researchers have concentrated on the neurobehavioralcharacteristics of the disease, assessing the response of thesechildren to treatment. However, identifying a relationship betweenattention deficit and sleep apnea has not been an easy task (Chervin,2005). This paper intends to show the various limitations andsuccesses regarding the classification and diagnosis of the twodisorders: attention deficit and sleep apnea. It will also discussthe implication of discoveries in these contentious areas indiagnosis.
Overthe recent past, attention deficit diagnoses have been risingdramatically. Statistical figures show that the figures have risen byover 22 percent in a short span of five years. This has led toqueries over whether the figures could actually be realistic orconfounding. Diagnoses could be showing that many children haveattention deficit and hyperactivity disorder when the situation isnot so in the real sense. Such confounding factors account for asubstantial number of attention deficit cases in young people, andthe medications used to manage the disorder may only be aggravatingthe situation. Although attention deficit disorders do exist inactual sense, there are strong indications that researchers anddoctors need to attend to the sleep issues before concluding that achild has attention deficit related disorder. An even bigger problemis that the symptoms of the two disorders are almost similar. Whileadults usually depict sleep deprivation as sluggishness anddrowsiness, children who lack sleep often become obstinate, irate,and moody they develop problems focusing, being attentive, andgetting along smoothly with others.
Recentstudies suggest a strong correlation between sleep apnea and ADHD. Ina study documenting sleep patterns of 11,000 children aged from 6months onwards, researchers found that the sleep problems acted asunderlying factors behind behavioral problems that can be easilyconfused as attention deficit disorder. Children most likely todevelop attention deficit-like problems and behaviors have sleepapnea or disordered breathing while asleep, which persists as theygrow. Lack of sufficient sleep stands as an insult to the progress ofa child’s mind and body and this can have grave outcomes (Bonuck,Freeman, Chervin, & Xu, 2012). This then shows that there is aneed for the development of strategies to screen for sleep problemsin the manner that ear and vision problems are screened for to avoidconfusing attention deficit disorder and its related symptoms withsleep apnea.
Thisstudy intends to show a correlation between attention deficitproblems and sleep apnea or Obstructive Sleep Apnea (OSA)
Thestudy intends to show whether surgery holds underlying importance inreducing the attention deficit, hyperactivity, and vigilance problemsin OSA patients
Thestudy hopes to show that most of the diagnoses for ADHD may be wrongif the clinicians do not conduct proper analysis of possibilities ofsleep apnea before proceeding to examining attention deficit
Thereare large amounts of literature on attention deficit disorders andthe associated symptoms. The disease has gained a lot of attentionamong the medical fraternity because its increasing prevalence andits common frequency. Research shows that around 5 percent of allchildren of school-going age have problems, with attention. Commonsymptoms reported from children suffering from ADHD includeimpulsivity, hyperactivity, inattention, and impaired functioning ina single or several settings like at home and school. Research alsoshows that sleep problems are also commonly reported along with otherADHD symptoms. In fact, researchers have associated sleepdisturbances with ADHD since the 1950s. Today, however, scientistsare unearthing novel relationships between sleep disturbances andADHD. They are actually negating any relationships between the twosave for the conception that they might be two distinct conditionstroubling children with similar and confounding elucidations.
TheRelationship between Sleep Apnea and ADHD
Therelationship between sleep and attention deficit is an intricate one.It is essential to point out, first, that children require around tenhours of sleep every night (“Sleep deprivation,” 2014). However,this is not the case for children with attention deficit disorder aswell as its specific classifications. These children usually havenumerous disruptions all through the day as well as better parts ofthe night. It is no wonder that these children usually have nightsthat are fraught with problems escalating into nightmares and sleepdisturbances. The relationship between ADHD and sleep does not endthere, but is a vicious circle and complex (Owens, 2009). Researchershave linked the disorder to sleep problems and they also suggest thatsleep disturbances can exacerbate attention deficit disorder. Otherssuggest that lack of proper sleep can lead to the development ofnegative symptoms in a child, reducing task performance andconcentration. This consequently affects the larger family andparents often loose quality hours of sleep to attend to children withattention deficit disorder. Overall, children affected by attentiondeficit problems have a rough time coping with the outcomes of thedisorder and this impacts them as well as those around them.
Childrenwith ADHD often exhibit problems in maintaining or initiating sleep(Konofal, Lecendreux, & Cortese, 2010). In fact, DSM III regardedrestless sleep as a symptom of ADHD, albeit this criterion was notincluded in later revisions of the manual. Ball et al. (1997) showthat sleep patterns and problems and ADHD have a huge relationship.On the other hand, children without ADHD do not appear to haveproblems with sleep problems. Studies after the introduction ofDSM-IV have also elicited a relationship between sleep disorders andADHD. Sleep disorders that have been implicated with attentiondisorders include motor restlessness, sleep apnea, and excessivesleepiness during daytime (Ball, Tiernan, Janusz, & Furr, 1997).Over the years, the studies in attention deficit disorder have takenkeen interest in sleep apnea. Although complex, researchers havedelved into assessments of the brain to unearth this complexrelationship.
Psycho-behavioralConsequences of Sleep Apnea
Studiesin brain mechanisms point out important relationship among attention,arousal, and sleepiness. Owens (2006) shows that sleep problems inchildren with behavioral and academic issues have also highlightedthe role played by sleep apnea and behavioral dysregulation andinattention. This methodology used in assessing sleep patterns andsleep in children with ADHD has shed more insight on the disorder inyoungsters (Owens, 2006). Beebe and Gozal (2002) also show thatObstructive Sleep Apnea (OSA) and behavioral and cognitive deficitsaccompany each other beyond the level of mere sleepiness. The modelposited by the researchers aids in understanding the psychologicaleffects if children with OSA. They posit that blood gas and sleepdisruption anomalies avert sleep-associated restorative processes,and continue to induce structural and chemical injury to the cells ofthe nervous system. The study further suggests that these occurrenceslead to malfunction of prefrontal area of the cortex of the brain,exhibited behaviorally in what scientists term ‘executivedysfunction.’ This, researchers say, affects the functionalpresentation of cognitive capacities, leading to maladaptivebehaviors during the day (Beebe & Gozal, 2002).
Otherresearchers have also shown a correlation between sleep patterns andbehavioral consequences during the day. Sadeh and colleagues haveproven that children have high fragmentation of sleep. However, theimpact of sleep fragmentation on the behavior of children with ADHDis yet to be assessed thoroughly. It is also well documented thatsleep performance during the night affects the behavior of school ageduring the day. These observations have been proven to be true byassessments that have shown linkages between behavioral changes andsleep disturbances (Sadeh, Raviv, & Gruber, 2000). Besides, 36%of infants with sleep problems exhibit myriad behavioral problems,and conversely anxiety, daytime hyperactivity, and depressivesymptoms appear to have links with protracted sleep latency.Preschoolers with relatively short sleeping times display morebehavioral issues (Lavigne et al., 1999).
EmergingFindings Regarding Sleep Apnea and ADHD
Recentfindings are developing further doubts and detaching the link thathas been previously there between ADHD and Obstructive Sleep Apnea.Chervin and colleagues have made significant contributions indemystifying the relationship between sleep apnea and attentiondeficit disorder. Their research involved a close examination ofchildren referred for the removal of adenoids and tonsils in Ear andThroat clinic (Chervin, 2005). Chervin et al. (2005) underlined theimportance of removal of adenoids and tonsils in order to improve thesleeping patterns of children with ADHD. The implication of thesefindings is that ADHD and Obstructive Sleep Apnea are indeeddifferent distinct disorders requiring separate intervention.However, the researchers are not apt to negate that ADHD patientshave underlying problems that can lead to sleep disturbances or sleepapnea.
Researchshows that the removal of tonsils and adenoids has far reachingeffects and can actually improve ADHD and sleep apnea. Researchersshow that surgical removal of adenoids and tonsils or known as oradenotonsillectomy (AT) can help improve of the condition of childrensuffering from Obstructive Sleep Apnea. Consequently, children whohave undergone surgery report better quality of life, behaviors, andother symptoms. The Childhood Adenotonsillectomy Trial (CHAT)assessed 464 children aged 7 to 9 years in different academic centers(Marcus & Moore, 2013). Although other smaller studies havehighlighted a relationship between adenoids and tonsils and sleepproblems, this was the first randomized trial and its results implythat treating Obstructive Sleep Apnea could reduce the effect ofconfusion in attention deficit diagnoses.
Inanother study, children with ADHD have been examined and found topossess high incidences of sleep apnea, sleep disturbances, andsnoring. Youseff and collegues hypothesized that sleep apnea could bebehind most of the behavioral complications that ADHD patientspresent. With this hypothesis, they carried out a research where theymeasured the impact of OSA induced hypoxia was measured to highlightits role in attention deficit. The researchers found that alterationsthe adrenergic, dopaminergic, and glutamatergic diffusion in theprefrontal area of the brain and assessing their impact onneurocognitive deficits (Youssef, Ege, & Angly, 2011).Researchers, thus, acknowledge the connection between sleep disordersand attention deficit, but they also warn that the presence of asleep disorders may lead to ADHD misdiagnoses.
Accordingto Stores (2003), sleep disorders such as OSA are important inpsychiatric practice in a myriad of manners, including theprobability that they may lead to misdiagnosis as an essentiallypsychiatric condition in people of all ages. The risk is present ininnumerous mutually common sleep issues that require consideration inelucidating excessive sleepiness, insomnia, and disturbed periods ofassociated with parasomnnias. The researcher recognizes the roleplayed by narcolepsy, Kleine-Levin syndrome, sleep paralysis,obstructive sleep apnea, rapid eye movement disorder, and . Findingsfrom this study suggest that patents should have such conditionsidentified and treated on time or else they may lead to variouspsychological disorders. Correction of the problems, however,requires that psychiatrists have broad familiarity with theconditions (Stores, 2003).
Symptomsof sleep apnea often impersonate symptoms of attention deficitdisorders. Recent advancements, however, are offering glimmers ofhope that the two conditions can actually be separated improvingprognosis of ADHD. Educating students regarding the respectivesymptoms of ADHD and sleep apnea can reduce the possibilities ofconfounding the two mental issues. Yarlagadda et al. (2013) providesa list of secondary conditions that may be misdiagnosed as ADHD.Their research places OSA top on the list citing that the conditionis not common among obese children. They also state that OSA’scorrelation with children affected by ADHD is presently gainingpopularity. Symptoms of sleep apnea, such as choking, snoring, andfatigue are observable, but often ignored by caregivers. Teachersoften recognize complications such as lack of attention, fatigue,concentration problems, and loss of focus, that are related to OSAand confuse or report them as cases of ADHD. Further, the researchersalso highlight the role of enlarged tonsils and adenoid hyperplasiain ADHD misdiagnoses.
TheRole of Surgery and Treatment
Ina recent study where children with apnea-hypopnea index otherwiseknown as AHI of between 1 and 5 went through adenotonsillectomy. Theresearchers undertaking the research and tiral used twenty fiveparticipants for the experiement group and fourteen patients for thecontrol group. The group given MPH and that were operated on showedremarkable improvements in terms of a reduction of the attentiondeficit symptoms as compared to the non-treatment group. In apost-surgery survey, questionnaires testing for the improvements ofdaytime symptoms, sleep variables, impulse control, and overall ADHDscore showed that individuals who went through surgery scored higherthan those who did go through the medications or surgery (Huang etal., 2007). In sum, the researchers showed that patients with anabnormally high AHI score, which is basically anything >1, canbenefit from surgery. Surgery can also reduce their continued use ofMPH reducing side effects of medications.
Inaddition to that, Avior et al (2004) set up an experiment toelucidate the impact of adenoidectomy and tonsillectomy on childrenwith attention deficit problems. The researchers used test ofvariables of attention (TOVA) to assess children with sleep apnea(OSAS) for ADHD features. The researchers` main aim was to employTOVA tool to look at the the attention problems and then useadenoidectomy and tonsillectomy to show whether symptoms couldchange. The research was a prospective and comparative examinationconducted in a day care center where 5 to 14 year old children spendmost part of the day. The outcomes of the examination elucidated thatthe enhancement in the vigilance and attention of the non-experimentgroup was significant (Avior et al., 2004). The implication of thisstudy is that adenoidectomy and tonsillectomy can lead toimprovements in the impulsivity and inattention of children sufferingfrom attention deficit disorders. These findings are of highimportance in comprehending the influence of sleep apnea andtherapeutic actions on behavioral problems in young people.
Thecontribution of Ali (1996) on the role of adenotonsillectomy isrelevant. His inquiry begins at the waiting list where he screenschildren aged 6 years and above on their breathing problems. Thestudy matches the sex and age of the children with 11 others who hadthe same problems: sleep disturbances and snoring history. Later, theresearcher correlated the same group with another that has undergonethrough a surgical procedure. Before surgery, the control group had asignificantly high Sleep and Breathing Disorder (SBD) index (>4%).However, findings from the study showed the effects of theadenotonsillectomy were significant as the control group participantsthe differences between the normal children and the children with thedisorder. Further, the control group reported a significantminimization in hyperactivity, inattention, and aggression, proven bythe Conners scale and the Continuous Performance Test. Theimplications of this study are essential in diagnosis of attentiondeficit disorder. The results suggest that clinicians should employstrategies to counter sleep disorder problems before proceeding withactions to diagnose for attention deficit disorders. Relief tomoderate and mild sleep apnea in children consequently leads toimproved functioning and behavior. This study confirms that theassociation between sleep apnea and problems during day time inyoungsters is a causal one.
Onestudy performed a systematic review of literature to achieve itsobjectives – to ascertain whether Obstructive Sleep Apnea andAttention Deficit and Hyperactivity Disorder have any relationship.The search included an in-depth analysis of journals: EBSCO, PubMed,ISI Web, and CINAHL. Search in these journals used keywordsobstructive, sleep apnea, and attention deficit and hyperactivity.This study also used the keywords ADHD, sleep apnea, obstructivesleep apnea, OSA, and attention deficit disorder. This methodologyproduced five interventional studies that matched the criteria of thesystematic review method used by this study. Further,cross-referencing the bibliography of the studies led to anadditional intervention research on the impacts of using OSAtreatment on the symptoms of ADHD. This study then reviewed theliterature on the occurrence of OSA symptoms in ADHD and the otherway round.
Thisstudy considered the Apnea/Hypopnea Index (AHI), which is the mostcommon form of measurement used in the diagnosis of OSA. AHI refersto the number of hypopnea and apnea events for every hour of sleep.Apnea refers to the termination of breathing for around 10 or moreseconds while hypopnea holds various definitions depending on thedepth of the temporary blockage, drop in the level of oxygen, andassociated arousal.
Therespiratory disturbance index (RDI) was also factored in theresearch. RDI refers to the apneas, respiratory effort and relatedarousals (RERA), and hypopneas. RERA refers to the monotonousepisodes of continuous deleterious intrathoracic compressionculminating in sleep fragmentation and microarousals without proof ofgas exchange problems, apneas, or hypopneas. Identification of theRERA measurement can be met through the application of a nasaltransducer an esophageal manometry instead of a thermistor.
SleepDisordered Breathing (SDB) encompasses various sleep disorderscategorized by the anomalies in the respiration patterns or theamount of ventilation that takes place during sleep. The most recentguideline classifies breathings disorders into the following,obstructive sleep apnea syndromes, central sleep apnea syndromes, andsleep-related hypoventilation syndromes. Obstructive sleep apnea orOSAS or OSA is characterized by periods of dreary complete or partialcollapse of the upper passage of air when one is deep asleep,convoyed by arousals to reinitiate ventilation.
Thisassessment of literature posits non-conflicting information regardingADHD and OSA symptoms and their association. Although a clearetiologic contribution of sleep disorder to attention deficit remainselusive, initial findings showing the two as distinct disorders aresuggestive and qualify for more investigation (Huang et al, 2007Chervin et al, 2006). Various sleep problems may develop a clinicalpresentation of attention deficit or syndromes of inattention. Inother studies, the two disorders, OSA and ADHD, appear to be presentat the same time in patients. Studies show that OSA leads to problemsof attention, hyperactivity, and impulsivity. After treatment,however, patients with OSA exhibited a reduction in problems thatmimic the symptoms of ADHD. Improvements after surgery imply thatmost diagnoses of ADHD may not be correct and most of them may bemere presentations of OSA. Therefore, this calls for thoroughassessment of OSA before final diagnoses of patients with attentiondeficit disorders. Studies that correlate sleep problems to attentiondeficit and hyperactivity show that there is a need to include anextra exclusion criterion in the DSM-V classification of AttentionDeficit and Hyperactivity Disorder (ADHD) to reduce the chances ofmisdiagnoses. Including an extra criterion could have utilitarianimpacts by communicating that attention deficit disorder symptomsmay, in a particular set of patients, exhibit themselves secondarilybecause of OSA and therefore can be expected to disappear aftertreating OSA through surgery.
Onthe other side, if an initial diagnosis fails or misses to identifyOSA, future evaluation of the same disorder may be particularlychallenging, since management a presumed attention deficit problemwith stimulants could offer nonspecific enhancement of neurocognitivedeficits and attention deficits problems. Enhancements because ofstimulant medications could hide the neurocognitive symptoms of sleepdisorders such as OSA, as well as daytime sleepiness and fatigue(Weber, 2006). The clinical relevance of good diagnostic practices ofOSA cannot be undervalued. Management of sleep apnea could avert notonly attention deficit symptoms but also other grave complicationsrelated to OSA, such as pulmonary and systemic hypertension, andfailure to flourish.
Amore concrete analysis of probable causative impacts of sleep apneaon behavioral issues and attention deficit would needplacebo-controlled, double-blind, randomized examination. This willassist research the influence of OSA treatment with CPAP oradenotonsillectomy on enhancement of attention deficit symptoms.However, this type of study is extremely hard, if not unmanageable,because of the fact that families, patients, and clinicians cannot beblinded to tonsillectomy or adenoctomy and that a mock surgery as acontrol would not be virtuous. Nonetheless, a randomized controlledexperiment of individuals suffering from both sleep apnea andattention deficit would likely be practicable. This, along withextensive prospective investigations and epidemiological studies,could greatly lead to heightened knowledge on the area of ADHD andsleep apnea. Nevertheless, in the meantime, studies of the magnitudeof Huang et al and Chervin et al have substantially increased theknowledge on the association between sleep apnea and attentiondeficit.
OSAis frequent among children suffering from ADHD, and attention deficitsymptoms impact patients with OSA highly. Sleep apnea, at timesreferred to as OSA, contributes to excessive diagnoses of ADHD amongchildren as well as adults. In this literature review and systematicanalysis of literature, most of the researches on ADHD showindividuals given double diagnosis of OSA and ADHD report adisappearance of the attention deficit symptoms after undergoingsurgery or other forms of treating OSA. As a matter of fact, manypatients supposedly suffering from ADHD reported better coordination,higher levels of attention, and less hyperactivity. These patientsexhibited potential to survive without using stimulant medications toboost their attention and vigilance symptoms. It is logical toconsider ADHD as a secondary occurrence to the existence of sleepapnea before proceeding with the ADHD diagnoses. Scientists andclinicians still need to conduct more prospective studies, controlledtrials, and epidemiological assessments to understand the exactnature of the association between ADHD and OSA’s symptoms.Specifically, at this time, it is not yet understood if thisassociation is bidirectional or unidirectional or probably evencausal. Thus, more studies are needed to comprehend the sub-thresholdof sleep apnea to attention deficit.
Thisstudy will be a case-control study and will assess the factors behindthe increasing numbers of attention deficit and hyperactivitydisorder. The study will collect data in two different times toachieve the its objective, which is to determine whether manyindividuals affected with attention deficit and hyperactivitydisorder have the diagnosis mismatched with sleep apnea.
Theresearch study will be undertaken in John Hopkins Hospital where itwill identify clients registered with sleep apnea and attentiondeficit and hyperactivity disorders. The hospital caters for youngchildren and this will therefore be an appropriate area to select theparticipants.
Thisstudy will assess the possibilities of misdiagnosis of attentiondeficit and hyperactivity disorder because of confusion with sleepapnea. Children between the ages 7 and 12 years will be included inthe study, and their symptoms assessed to highlight the possibilityof misdiagnosis. A total of 60 participants will take place in thestudy 40 participants with ADHD and 20 participants with sleepapnea.
Theresearch will use purposive sampling to select the participants. Thissampling method will entail handpicking of the subjects that will bemost suitable for the study. Subjects with either sleep apnea orattention deficit and hyperactivity disorder will be picked toparticipate in the study.
Datacollection and analysis
Closedended questionnaires will assist in data collection. The respondentswill be issued with questionnaires requiring their input. Closedended questions will enable the collection of relevant data whilereducing the chances of confounding factors. The collected data willbe keyed in to data analysis software (SPSS) and thereafterdescriptive analysis will be conducted. To ascertain whether sleepapnea contributes to the excessive numbers of ADHD diagnoses,measures of central tendency including skewness and kurtosis will beused to depict the variations between the two points in time of datacollection.
Afterall the participants underwent through surgery, participants withattention deficit and distractibility symptoms reduced drastically.From the 40 participants who presented symptoms that fit the DSM-IVcriteria before the surgery to 25 participants with ADHD aftertreatment, the study showed that many are misdiagnosed. Further, thestudy revealed that most of the participants actually had sleep apneainstead of ADHD.
Figure1: Graph showing patients with attention deficit and distractibilitysymptoms before and after treatment.
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