Sleepless in America

Sleep and Behavioral Problems

Obesity sometimes causes this kind of blockage, says Michael Anstead, M.D., assistant professor of pediatric pulmonology at the University of Kentucky in Lexington. When this is the case, OSAS is relatively easy to treat: While sleeping, the child wears a breathing mask, which pumps higher-pressure air through the nose to help keep the airway open. (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.

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 OSAS, 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 600 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. 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 OSAS, periodic limb movement disorder (PLMD), 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, or medication -- kids return to the clinic to determine if they need additional care.

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