Are Sleep Problems Linked to Inattention and Hyperactivity?

from The Brown University Child and Adolescent Psychopharmacology Update

Child and Adolescent Psychopharmacology 2002 - Volume 4, Number 4

A new cross-sectional survey has found that children who snore, appear sleepy, or show other symptoms of sleep-disordered breathing are more likely to be rated by their parents as having problems with inattention and hyperactivity. Sleep-disordered breathing (SBD) is a condition characterized by repeated apneic and hypopneic episodes during sleep.

The study, conducted by Ronald D. Chervin, M.D., M.S., of the University of Michigan, Ann Arbor, and colleagues, examined the prevalence SDB in a sample of 866 children ages 2 to 13 years recruited from two general pediatrics clinics. Parental ratings scales and a validated Pediatric Sleep Questionnaire (PSQ) were used as the study’s main outcome measures.The study revealed that 16 percent of subjects were habitual snorers (i.e., they snored during half of their sleep time) and that 13 percent of all subjects showed increased hyperactivity, as measured by the Connors’ Rating Scale, Hyperactivity Index (HI). A ratings score of greater than 60 on the HI is considered to represent hyperactivity.

Chervin and colleagues found a significant association between habitual snoring and hyperactive behavior. Among all children, habitual snoring was found to be associated with an increase in the likelihood of hyperactivity from 12 percent (nonhabitual snorers) to 22 percent (habitual snorers). Snoring, sleepiness and SBD scores were significantly associated with a high score on the HI, as well as with the Inattention/Hyperactivity scale (IHS), on which a mean item response was determined high if greater than 1.25 on a four-point Likert scale.

When the sample was stratified by age and sex, Chervin and colleagues found a substantially strong association between snoring and behavior in male subjects who were younger than eight years old. In these younger male subjects, the likelihood of hyperactivity jumped from 9 percent (nonhabitual snorers) to 30 percent (habitual snorers). The investigators noted that the strong association between snoring and behavior in young males could not be replicated in subjects outside of this group and may represent a sex-based vulnerability to any impact that SDB may have on behavior.

According to Chervin, the bottom line is that the “association of sleepiness with daytime behavioral problems occurred in all ages and sexes tested, whereas the association of snoring with these problems derived primarily from boys eight-years old or younger.”

Chervin concluded that the next step is to “better address the questions -- still unresolved -- of whether and to what extent sleep-disordered breathing may contribute to inattention and hyperactivity in children.

Sleep-Behavior Connection

In their study, Chervin and colleagues discuss the importance of understanding how SDB can influence behavior, citing the high prevalence of attention-deficit/hyperactivity disorder among school-aged children today. They state that in some children, an unrecognized medical disorder such as SDB may lead to problem behavior.

In an interview with The Brown University Child and Adolescent Psychopharmacology Update, Judy Owens, M.D., said that SDB often results in arousals or partial brief awakenings during sleep, and which, if frequent, can lead to poor quality sleep and therefore daytime sleepiness.

Owens, an associate professor of Pediatrics at Brown University and director of the Pediatric Sleep Disorders Clinic at Hasbro Children’s Hospital in Providence, R.I., further explained, “Daytime sleepiness in turn is associated with mood, cognitive and behavioral dysfunction. The dips in oxygen levels that also occur with SDB may also contribute to the neurocognitive impairment.”

Specifically, Owens said that sleep deprivation can result in mood changes, inattention, delayed reaction time and impaired vigilance, decreased motivation, hyperactivity, aggressive behavior and impulsivity -- symptoms that may overlap with those commonly associated with ADHD. Thus children with sleep disorders may appear as if they have ADHD during the daytime.

Treatment of childhood sleeping problems is highly diagnostically driven, according to Owens. Often, SDB is treated surgically (adenotonsillectomy), or with weight management if obesity is a factor, she said. Other medical sleep disorders like Periodic Limb Movement Disorder (PLMD) may respond to pharmacologic treatment.

“There are many effective behavior treatment strategies available for more behaviorally based sleep disorders; pharmacology as an adjunct is only occasionally needed,” Owens said.

Clinical Implications

Many mood and behavior problems in children may be partially caused by primary or co-morbid sleep disorders such as obstructive sleep apnea or PLMD, said Owens. “Clinicians should routinely screen for these sleep problems, and parents should be aware of their symptoms.”

Owens said that in her clinic, they use an algorithm referred to as BEARS to screen for sleep problems in general. The acronym stands for bedtime problems (“B”), excessive daytime sleepiness (“E”), awakenings at night (“A”), regularity and duration of sleep (“R”) and snoring (“S”). (See box on left.) Other specific screening questions include inquiries about breathing pauses, choking, gasping or snorting, restless sleep, sweating in sleep and mouth breathing during sleep.

Owens and colleagues also employ the Children’s Sleep Habits Questionnaire (CSHQ) to help identify behaviorally and medically based sleep problems in school-aged children. The CSHQ is a parental-and self-report screening instrument that inquires about sleep patterns, behavior and daytime sleepiness (Owens 2000).

Conclusion

While the association between sleepiness and hyperactive behavior was found in both boys and girls throughout childhood and early adolescence, it is the association between snoring and behavior among younger children — particularly among young boys — that appeared especially strong. Chervin and colleagues state that the high frequency of pediatric SDB, the possibility that most children with the disorder may be undiagnosed, and evidence that SDB can affect behavior “all combine to suggest that occult SDB may have an important impact among children with inattentive and hyperactive behavior.”

Chervin and colleagues conclude that if sleepiness and SDB do indeed influence daytime behavior, the results could constitute a major public health burden.

For more information on sleep and behavior, check out these web-based resources: www.sleepfoundation.org; www.kidzzzsleep.org

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