ADD/ADHD & Pediatric Sleep-Disordered Breathing

Millions of US children have been diagnosed with ADHD

The estimated number of children aged 3–17 years ever diagnosed with ADHD, according to a national survey of parents is 6 million (9.8%) using data from 2016-2019. This number includes

• 3–5 years: 265,000 (2%)

• 6–11 years 2.4 million (10%)

• 12–17 years: 3.3 million (13%)

Boys (13%) are more likely to be diagnosed with ADHD than girls (6%).

Black, non-Hispanic children and White, non-Hispanic children are more often diagnosed with ADHD (12% and 10%, respectively), than Hispanic children (8%) or Asian, non-Hispanic children (3%).

What is also interesting is that estimates for ADHD vary widely by state, with ADHD diagnosis among children aged 3-17 years old vary from 6-16% and ADHD medicate state estimates vary from 38-81%. This is a discussion better fit a different post that specifically evaluates correlations and/or influencing factors such as environment, nutrition, culture, etc.

According to a national 2016 parent survey, 6 in 10 children with ADHD had at least one other mental, emotional, or behavioral disorder:

• About half of the children with ADHD had a behavior or conduct problem.

• About 3 in 10 children with ADHD had anxiety.

Other conditions affecting children with ADHD: depression, autism spectrum disorder, and Tourette syndrome.

Pediatric Sleep-Related Breathing Disorders & ADHD

Most Common Treatment

• 62% were taking ADHD medication

  • Ages 2–5: 18%

  • Ages 6–11: 69%

  • Ages 12–17: 62%

• 47% received behavior treatment

  • Ages 2–5: 60%

  • Ages 6–11: 51%

  • Ages 12–17: 42%

• Almost 9 out of 10 children had received school support, which includes school accommodations and help in the classroom.

• About 6 out of 10 children had received some type of behavioral treatment or skills training:

  • 3 out of 10 received parent-delivered behavior therapy.

  • 4 out of 10 received social skills training.

  • 3 out of 10 received peer interventions.

  • 2 out of 10 received cognitive behavior therapy.

Ummmm. Excuse me, there's something missing from this picture...

What is WILD about the above CDC summary report on the prevalence and most common treatment modalities for pediatric ADD and ADHD is that there is NO discussion on evaluation of sleep and breathing despite significant data to support correlations and associations between the symptoms of ADD/ADHD and sleep and breathing disorders.

Cognitive and behavioral consequences of sleep disordered breathing in children

• Highlight: There is now a plethora of evidence that children with sleep disordered breathing (SDB) show deficits in neurocognitive performance, behavioral impairments, and school performance.

• Reference: Trosman I, Trosman SJ. "Cognitive and Behavioral Consequences of Sleep Disordered Breathing in Children." Med Sci (Basel). 2017 Dec 1;5(4):30. doi: 10.3390/medsci5040030. PMID: 29194375; PMCID: PMC5753659.

Relationship between sleep problems and quality of life in children with ADHD

• Highlight: The results of this study, which controls for a number of possible confounders found in previous examinations of ADHD and sleep, support the results of a number of other studies that have found an increased overall prevalence of parent-reported sleep disturbances in children with ADHD compared with healthy control participants. As the ADHD group have more night wakings than the control group through the night, it is thought that night wakings that cause a partitioned sleep may be important signs seen in ADHD.... These results underscore the importance of screening all children who have a symptom constellation suggestive of ADHD for sleep problems that may either play a causative role or exacerbate the clinical appearance of ADHD in a given child. Correct evaluation and treatment of sleep problems increase the life quality of family and child and also decrease the severity of ADHD symptoms.

• Reference: Yürümez, E., & Kılıç, B. G. (2016). "Relationship Between Sleep Problems and Quality of Life in Children With ADHD." Journal of Attention Disorders, 20(1), 34–40. https://doi.org/10.1177/1087054713479666

Learning, attention/hyperactivity, and conduct problems as sequelae of excessive daytime sleepiness in general population study of young children

• Study Highlight: This study suggests that in a large general population sample of young children, parent-reported EDS (excessive daytime sleepiness) is associated with neurobehavioral (learning, attention/hyperactivity, conduct) problems and poorer performance in processing speed and working memory. Impairment due to EDS in daytime cognitive and behavioral functioning can have a significant impact on children's development.

• Reference: Calhoun SL, Fernandez-Mendoza J, Vgontzas AN, Mayes SD, Tsaoussoglou M, Rodriguez-Muñoz A, Bixler EO. "Learning, attention/hyperactivity, and conduct problems as sequelae of excessive daytime sleepiness in a general population study of young children." Sleep. 2012 May 1;35(5):627-32. doi: 10.5665/sleep.1818. PMID: 22547888; PMCID: PMC3321421.

Snoring During Early Childhood and Academic Performance at Ages Thirteen to Fourteen Years

• Study Highlight: Children with lower academic perfor- mance in middle school are more likely to have snored during early childhood and to require T&A for snoring compared with better performing schoolmates. These findings support the concept that SDB-associated neuro- cognitive morbidity may be only partially reversible or that a “learning debt” may develop with SDB during early childhood and hamper subsequent school performance.

• Reference: Gozal D, Pope DW Jr. Snoring during early childhood and academic performance at ages thirteen to fourteen years. Pediatrics. 2001 Jun;107(6):1394-9. doi: 10.1542/peds.107.6.1394. PMID: 11389263.

Sleep disturbances in children with psychiatric disorders

• Study Highlight: Sleep disturbances are highly prevalent among children with psychiatric disorders, making recognition and management of pediatric sleep disorders an important step in improving treatment outcome and preventing relapse of mental illness.

• Reference: Ivanenko A, Johnson K. "Sleep disturbances in children with psychiatric disorders." Semin Pediatr Neurol. 2008 Jun;15(2):70-8. doi: 10.1016/j.spen.2008.03.008. PMID: 18555193.

Sleep problems and daily functioning in children with ADHD: An investigation of the role of impairment, ADHD presentations, and psychiatric comorbidity

• Study Highlight: Sleep problems and impaired daily functioning were more common in children with ADHD, but the overall association between sleep problems and impaired daily functioning was similar in clinical and nonclinical children. Internalizing or autistic comorbid disorders added significantly to the sleep problems.

• Reference: Virring, A., Lambek, R., Jennum, P. J., Møller, L. R., & Thomsen, P. H. (2017). "Sleep Problems and Daily Functioning in Children With ADHD: An Investigation of the Role of Impairment, ADHD Presentations, and Psychiatric Comorbidity." Journal of Attention Disorders, 21(9), 731–740. https://doi.org/10.1177/1087054714542001

Review of the possible relationship and hypothetical links between ADHD and the simple sleep related movement disorders, parasomnias, hypersomnias, and circadian rhythm disorders

• Study Highlight: Since ADHD patients more frequently have symptoms of the various sleep disorders in question, we also recommend that patients with ADHD be queried about the sleep disorders in question. If these sleep disorders are present in patients with ADHD, they should be addressed. In addition, there remains the possibility that treatment of the associated sleep disorder may lead to adjunctive improvement of the ADHD symptoms in conjunction with stimulant therapy.

• Reference: Walters AS, Silvestri R, Zucconi M, Chandrashekariah R, Konofal E. "Review of the possible relationship and hypothetical links between attention deficit hyperactivity disorder (ADHD) and the simple sleep related movement disorders, parasomnias, hypersomnias, and circadian rhythm disorders." J Clin Sleep Med. 2008 Dec 15;4(6):591-600. PMID: 19110891; PMCID: PMC2603539.

Sleep disturbances in children with ADHD: Comparative study with healthy siblings

• Study Highlight: Sleep disturbances are more prevalent in pharmacologically treated ADHD, making it an important aspect of ADHD management.

• Reference: Vaidyanathan S, Shah H, Gayal T. "Sleep Disturbances in Children with Attention - Deficit/Hyperactivity Disorder (ADHD): Comparative Study with Healthy Siblings." J Can Acad Child Adolesc Psychiatry. 2016 Fall;25(3):145-151. Epub 2016 Nov 1. PMID: 27924144; PMCID: PMC5130087.

Inflammation, anxiety, and stress in ADHD

• Study Highlight: Evidence showing an interplay between stress, anxiety, and immune dysregulation in ADHD, and we discuss the implications of a potential disrupted neuroendocrine stress response in ADHD. Moreover, we highlight confounding factors and limitations of existing studies on this topic and critically debate multidirectional hypotheses that either suggest inflammation, stress, or anxiety as a cause in ADHD pathophysiology or inflammation as a consequence of this disease. Untangling these relationships will have diagnostic, therapeutic and prognostic implications for ADHD patients.

• Reference: Saccaro LF, Schilliger Z, Perroud N, Piguet C. "Inflammation, Anxiety, and Stress in Attention-Deficit/Hyperactivity Disorder." Biomedicines. 2021 Sep 24;9(10):1313. doi: 10.3390/biomedicines9101313. PMID: 34680430; PMCID: PMC8533349.

Prevalence Studies:

• A study published in Pediatrics demonstrated a significant association between sleep-disordered breathing (SDB) and behavior resembling ADHD. In a cohort of 5-year old children, the researchers found that those with SDB were more likely to exhibit behaviors associated with ADHD [5].

• In a longitudinal cohort study published in Sleep involving over 11,000 children, kids with sleep-disordered breathing were more likely to exhibit symptoms of ADHD by age 7 [6].

• A review published in Frontiers in Psychiatry showed a high prevalence of sleep disorders, including sleep-disordered breathing, among children with ADHD. The authors suggested that screening for sleep disorders should be a routine part of ADHD evaluation [7].

What is the pathophysiology of sleep and breathing disorders and ADHD and other neurocognitive conditions?

Sufficient, high quality sleep is critically important for optimal whole-body wellness. High quality sleep is that which a patient will spend the appropriate amount of time cycling through the various phases of sleep (REM and non-REM, N1, N2, N3) to complete all pertinent physiological processes without disruption. While some people may be in their bed or even sleep for 10+ hrs, that doesn't necessarily mean that are engaging in high quality sleep; if they are constantly being disrupted by various triggers (night terrors, bedwetting, abnormal movement, snoring, teeth grinding), then they are not able to cycle through those phases. Additionally, if the patient is breathing through their mouth, then their airflow is compromised significantly both in quality and quantity, another big reason why these sleep phases can be compromised.

Other Considerations

Narrow dental arches, poor tongue position, suboptimal jaw relationships, and dysfunctional oral and facial habits have been linked to unhealthy breathing and sleep. However, they may not be the only contributing variables to this suboptimal health. Sleep and breathing can be impaired by other anatomical defects such as a severely deviated septum and enlarged adenoids and tonsils; environments with significant allergens such as mold, dust, or poor airflow; and inflammatory diets. We evaluate these concerns in an effort to have a holistic review of the patients lifestyle and baseline health; in some cases, we recommend immediate referral to specialists such as an ENT, neurologist, sleep physician, or pediatrician for further testing and/or treatment as needed. In other instances, we recommend initiating intra-oral appliance therapy in conjunction with diet changes and environmental changes.

• A study published in The Journal of Pediatrics showed that surgical treatment of adenotonsillar hypertrophy (a common cause of SDB in children) led to improvements in ADHD symptoms in children with both conditions [8].

• A systematic review published in the European Journal of Pediatrics found evidence suggesting that certain food additives, refined sugars, and food allergens could exacerbate ADHD symptoms in susceptible children [9].

• A study in the Journal of Attention Disorders suggested that a 'Western-style' diet (high in saturated fats, refined sugars, and sodium) was associated with a greater likelihood of an ADHD diagnosis, whereas a healthier diet was associated with a lower likelihood [10].

• A study published in Pediatrics found that children with ADHD were more likely to have unhealthy dietary patterns, including a higher intake of sugar-sweetened beverages and a lower intake of fruits and vegetables [11].

• A review in the Journal of the American Academy of Child & Adolescent Psychiatry suggested that omega-3 fatty acid supplementation could have modest benefits for ADHD symptoms, likely due to their role in maintaining healthy brain function [12].

References:

1. "Data and Statistics about ADHD" from Centers for Disease Control and Prevention.

2. Bitsko RH, Claussen AH, Lichstein J, et al. Mental health surveillance among children—United States, 2013–2019. MMWR Suppl. 2022;71(2):1-48.

3. Danielson ML, Holbrook JR, Newsome K., Charania SN, McCord RF, Kogan MD, Blumberg SJ. State-level estimates of the prevalence of parent-reported ADHD diagnosis and treatment among U.S. children and adolescents, 2016–2019. Journal of Attention Disorders, published online May 22, 2022.

4. Visser, SN Danielson ML, Wolraich ML, Fox M, Grosse SD, Valle LA, Holbrook JR, Claussen AH, Peacock, P. Vital signs: National and state-specific patterns of attention deficit/hyperactivity disorder treatment among insured children aged 2–5 years — United States, 2008–2014. Morbidity and Mortality Weekly Report (MMWR); 2016,65, 443–450.

5. Chervin, R. D., Dillon, J. E., Bassetti, C., Ganoczy, D. A., & Pituch, K. J. (1997). Symptoms of sleep disorders, inattention, and hyperactivity in children. Pediatrics, 100(6), 922-932.

6. Bonuck K, Freeman K, Chervin RD, Xu L. Sleep-disordered breathing in a population-based cohort: Behavioral outcomes at 4 and 7 years. Sleep. 2012;35(4):459-465.

7. Sedky, K., Bennett, D. S., & Carvalho, K. S. (2014). Attention deficit hyperactivity disorder and sleep disordered breathing in pediatric populations: A meta-analysis. Sleep Medicine Reviews, 18(4), 349-356.

8. Mitchell, R. B., & Kelly, J. (2005). Behavior, neurocognition and quality-of-life in children with sleep-disordered breathing. International Journal of Pediatric Otorhinolaryngology, 69(3), 359-364.

9. Pelsser LM, Frankena K, Toorman J, et al. Effects of a restricted elimination diet on the behaviour of children with attention-deficit hyperactivity disorder (INCA study): a randomised controlled trial. Lancet. 2011;377(9764):494-503.

10. Howard AL, Robinson M, Smith GJ, et al. ADHD Is Associated With a "Western" Dietary Pattern in Adolescents. J Atten Disord. 2011;15(5):403-411.

11. Ptacek R, Kuzelova H, Stefano GB, et al. Disruptive patterns of eating behaviors and associated lifestyles in males with ADHD. Med Sci Monit. 2014;20:608-613.

12. Bloch MH, Qawasmi A. Omega-3 fatty acid supplementation for the treatment of children with attention-deficit/hyperactivity disorder symptomatology: systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry. 2011;50(10):991-1000.