Ashford University COM345: Media Writing for Communication
♫Maybe it's not o-only ADHD♫
Five year-old Corey came from an attention-deficit family. His father had ADD; his uncle had ADHD; his great-uncle had other attention problems. Corey’s ADHD diagnosis did not surprise his mother. Having helped raise the young ADHD uncle in her youth had given her more experience with the condition than she cared to recall. Corey’s psychologist explained that since the months of behavior and parenting clinics had been unsuccessful, the only remaining option was to medicate the boy.
What Corey’s mom most feared was the constant dosage adjustments associated with the various ADHD medications, a roller coaster she’d ridden with the boy’s young uncle a decade before. Assuming a genetic connection and desperate for some relief from her son’s behavior problems, Corey’s mother hesitantly agreed to medication.
When other problems began, Corey’s mother began to question the diagnosis. ADHD alone did not cause her child to kick the wall beside his bed in his sleep. It did not cause him to seemingly wake a half-dozen times during the night, screaming as if someone were stabbing him. It did not cause the haunting stroll around he took around the house at night and had no memory of in the morning. ADHD does not cause those things, and, according to a number of studies, it may not even cause a child’s ADHD symptoms! According to a Mitchell & Kelly study done in 2005, “Sleep disorders in children may cause behavioral problems and diminish neurocognitive skills” (p. 2051).
A study by the University of Michigan Medical Center as long ago as 1997 also suggests that attention-deficit symptoms may be caused by some sleep disorders (Chervin, Dillon, Bassetti, Ganoczy & Pituch). Some time after his sixth birthday, when Corey’s medication proved effective only some of the time and his nighttime issues had not improved, his psychologist ordered a polysomnography – sleep study. To his mother’s surprise, the sleep clinic diagnosed her son with sleep apnea – pauses, sometimes long ones, in breathing while sleeping – and referred him to an otolaryngologist – an Ear/Nose/Throat physician or ENT – for evaluation.
Apnea is one of a number of SDB – sleep-disordered breathing – problems common in childhood. When apnea occurs, most children partially wake in order to coax the body into breathing again. This disrupts their natural sleep pattern, which leads to “nonrestorative sleep… [which] may result in executive dysfunction with adverse daytime effects such as poor planning, disorganization, rigid thinking, difficulty in maintaining attention and motivation, emotional lability [– instability] , and overactivity [– hyperactivity]/impulsivity,” all symptoms of ADHD (Walters, Silvestri, Zucconi, Chandrashekariah, & Konofal, 2008, p. 596).
Corey’s ENT believed that the cause of his apnea was oversized asymmetrical tonsils and suggested removing them. Indeed, the Mitchell & Kelly study done in 2005 retains that inattention and hyperactivity improve within 5 months following an adenotonsillectomy – surgical removal of tonsils and adenoids. Consequently, a follow-up study done in 2009 confirms that ADHD symptoms tend to improve 6 to 12 months after (Wei, Bond, Mayo, Smith, Reese, & Weatherly).
“It doesn’t work in every child,” states Dr. Cecelia Helwig, ENT at Geisinger Medical Center in Danville , Pennsylvania
Studies performed in 2006 and 2008 concluded that this surgery leads to marked behavioral improvement. “These children had a compromise in daytime symptoms (including attention span) and in subscales for impulse control and response time that was reversed by surgical treatment of OSA [– obstructive sleep apnea, a member of the SDB family]” (Walters, Silvestri, Zucconi, Chandrashekariah, & Konofal, 2008, p. 597). Whether an adenotonsillectomy is a cure for ADHD remains to be seen. The study claims, “Further investigation will be needed to define the spectrum of ADHD (primary ADHD versus Sleep-Disordered Breathing ADHD)” (Li, Huang, Chen, Fang & Lee, 2006, p. 1142).
After reading about the subject and extensively questioning Dr. Helwig, Corey’s mom decided to go ahead with the suggested adenotonsillectomy. The surgery went well and Corey is back to his usual active self. It has only been two weeks, but his mother is already noticing great improvements in his sleep. Time and a return to school will tell if the surgery has any effect on his ADHD.
How can parents tell if their child has primary ADHD or SDB ADHD? Dr. Helwig had a few tips (C. Helwig, personal communication, May 28, 2010).
1. Talk to your child. The only way to know what is going on inside his/her head is to try to get it out. See what they remember and what they do not. Ask for their opinion on how to fix it.
2. Know your child’s medical condition. Talk to your psychologist, primary care, ENT, sleep lab tech, anybody who will listen. The medical professionals around you are a wealth of information if you ask the right questions.
3. Resist the urge to up the medication. If the ADHD is being caused by SDB, the higher medication will not help. In fact, you could be overmedicating your child.
4. Listen to your children when they sleep. Unless they have a cold or other upper respiratory issue, they should not be snoring. Chances are the snoring child has apnea. If there’s apnea, your child’s ADHD may be caused by it, and may therefore be reversible.
5. Ask for a polysomnography! Often, doctors won’t consider what’s going on in your child’s sleep. Ask and ask again if necessary, especially if s/he snores!
6. Be patient. It may take several months to several years to tell if your child’s ADHD symptoms are caused by a SDB problem rather than true ADHD.
References
Chervin, R., Dillon, J., Bassetti, C., Ganoczy, D., & Pituch, K. (1997) Symptoms of sleep disorders, inattention, and hyperactivity in children. Sleep, 20(12), 1185-1192.
Li, H., Huang, Y., Chen, N., Fang, T. & Lee, L. (2006) Impact of adenotonsillectomy on behavior in children with sleep-disordered breathing. Laryngoscope. 116(7), 1142-1147.
Mitchell, R.B. & Kelley, J. (2005) Child behavior after adenotonsillectomy for obstructive sleep apnea syndrome. Laryngoscope. 115(11), 2051-2055.
Walters, A.S., Silvestri, R., Zucconi, M., Chandrashekariah, R., & Konofal, E. (2008) 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. Journal of clinical sleep medicine. 4(6), 591-600.
Wei, J.L., Bond, J., Mayo, M.S., Smith, H., Reese, M., & Weatherly, R. (2009) Improved behavior and sleep after adenotonsillectomy in children with sleep-disordered breathing. Archives otolaryngology head and neck surgery, 135(7), 642-646.