The Hidden Causes of Sleep Problems
Some cultural factors are clearly at work. Increasingly, though, doctors are finding that many childhood sleep problems are medically based -- and closely linked to behavioral problems. These problems can be serious: "Sleep deprivation affects a child's motor skills, creativity, problem-solving skills, and attention span, and it leads to hyperactivity and poor impulse control," says Dr. Owens. A common medical cause of poor sleep is obstructive sleep apnea (OSA), which affects 1% to 3% of kids, generally between the ages of 2 and 6. It's usually caused by large tonsils and adenoids, which block the throat and decrease the oxygen flow, leading to mini-disruptions in sleep. Being overweight or obese is an important risk factor as well.
OSA occurs in about 3 percent of children. The majority of the time it is due to enlarged tonsils or adenoids, says Michael Anstead, M.D., assistant professor of pediatric pulmonology at the University of Kentucky in Lexington. When this is the case, OSA is relatively easy to treat by removing their tonsiles and adenoids. (Masks can be used by any child with sleep apnea.) But when obesity is not a factor, many doctors miss the connection between sleep apnea and behavior problems. This was the case with 6-year-old Steven of Fenton, MI. When he started kindergarten last year, his mother, Mary (who did not want her family's last name used), noticed a change in his behavior. "He started yelling, talking back, and acting out of control, " she recalls. "His school called me almost every day." Eventually, she took her son to a child psychologist, who diagnosed him with ADHD and recommended medicating him with Ritalin. She couldn't do it. "I don't like the idea of medicating, and I had this gut feeling that he was just exhausted," she says.
Obesity can also cause sleep apnea by depositing fat in the airway and limiting airflow. This is an increasing problem in children due to the epidemic problem of obesity in the U.S. Children who are obese with sleep apnea may not completely benefit from having their tonsils and adenoids removed. "They may need to wear a special mask while sleeping called a CPAP instead of, or in addition to, having their tonsils removed. This mask pumps higher pressure air through their nose to help keep the airway open while the child is asleep," says Dr. Anstead. Recognizing and treating sleep apnea is very important in children because of its link to school performance and behavior problems. According to Dr. Anstead, children with OSA have poor quality sleep and either can't pay attention during school or fall asleep during the day. Sleep apnea in children is the link to poor school performance and behavior problems such as ADHD. "Any child with poor school performance or ADHD should be evaluated by their pediatrician. The child's doctor should do a thorough sleep history if problems are present such as snoring, nocturnal sweating or restless sleep. Further evaluation, including an overnight sleep study, may be indicated to determine if sleep apnea is present," advices Dr. Anstead.
Soon after, at a well-child visit with a colleague of Steven's pediatrician, a doctor determined that the boy's tonsils were unusually large. (Steven's own doctor hadn't believed it to be a problem.) When the doctor learned that Steven had been snoring since infancy, he was referred to a sleep lab, where he was monitored overnight. It turns out that his enlarged tonsils were causing OSA, which led him to briefly stop breathing and awaken many times during the night, drastically cutting back on his restorative sleep. Steven then had a tonsillectomy and his behavior changed almost immediately. "He was much more relaxed, learning more quickly, and not acting out," says Mary. The psychologist retracted Steven's ADHD diagnosis.
The most convincing evidence that sleep may be partly responsible for behavioral problems comes from studies conducted in pediatric sleep labs such as the one Steven visited. Of the roughly 1200 children seen annually at the Sleep Disorders Center at Arkansas Children's Hospital in Little Rock, a full 50% of them have behavioral problems, says May L. Griebel, M.D., the center's pediatric neurologist and professor at the University of Arkansas for Medical Sciences. They've been referred to the lab by a pediatrician (often at parents' urging) or a teacher who notices ongoing problems with a student's daytime behavior. Between 60% and 70% of children who visit the Sleep Disorders Center will end up being diagnosed with a sleep disorder, most commonly an obstructed breathing pattern or OSAS, often in association with obesity or enlarged tonsils and adenoids, says Dr. Griebel. They'll then be referred to the appropriate specialist, such as an ear, nose, and throat physician or a nutritionist. After the start of treatment -- which usually consists of surgery, a weight-loss regimen, intervention by a behavioral psychologist,or medication -- kids return to the clinic to determine if they need additional care. Some of the children need positive pressure breathing support while they sleep, or CPAP, and are enrolled in the center?s adherence program to improve use of the CPAP equipment.