1. Obstructive Sleep Disorders in Breathing in Childhood- Behavioral and Developmental Problems Michael S. Blaiss, MD Clinical Professor of Pediatrics and Medicine University of Tennessee Health Science Center Memphis, Tennessee

2. Health Relationships HEALTH ExerciseNutrition Sleep

3. Common Sleep Disorders Insomnia: wants to sleep but cannot Sleep Deprivation: does not want to sleep but can; problem of sleep quantity Sleep apnea: sleepy during day, snores at night because of obstruction in throat and/or nose; problem of sleep quality Obstructive sleep disorders can have a major effect on the child’s behavior and development

4. Sleep Disturbances in Children Parents of 5 to 12-year-olds reported the following sleep problems: Bedtime resistance (27%) Problems waking up (17%) Fatigue (17%) Sleep-onset delays (11%) Night waking (6.5%)

5. Sleep Disturbances in Children Obstructive Sleep Apnea Pauses in breathing during sleep Momentary wakening/arousals may not allow entrance into deep NREM stages and may reduce REM Symptoms – Loud snoring, restless sleep, daytime sleepiness

6. Sleep Apnea is Common Children (age 2 - 8) Middle aged adults Older adults ( > 65)  2-3%  5-7%  >15% AJRCCM 2002 165:1217-39

7. Sleep Apnea in Children: Risk Factors Family history Obesity: 80 % of sleep apnea patients Allergic rhinitis Large tonsils / adenoids Male gender

8. Childhood Sleep Apnea A "pulling in" of the chest when breathing High rates of upper respiratory infections Confusion when awakened Frequent bedwetting Excessive sweating while asleep Failure to grow at normal rates Nightmares and night terrors Morning headaches Unusual "arched" sleeping positions. Developmental delays Learning difficulties Personality changes Hyperactivity and symptoms of ADHD

10. Methods One hundred thirty-six children aged 7–12 were studied. Routine overnight polysomnography (PSG) classified children into 4 groups: Primary snoring (PS) (n = 59), mild OSAS (n = 24), moderate/severe OSAS (n = 18), and controls (n = 35). Behavioral function and behavioral aspects of attention and executive function were assessed the Behavior Rating Inventory of Executive Function (BRIEF) the Child Behavior Checklist (CBCL)

11. BRIEF is a parent-rated, 86-item questionnaire which assesses children’s attentional and executive skills

13. The Child Behavior Check List (CBCL) is an empirically derived parent-rated questionnaire consisting of 118 problem items assessing psychopathology and social competence

14. Attention Deficit Hyperactivity Disorder AD(H)D: criteria Core symptoms of: Impulsivity (or Hyperactivity) Inattention Impairing home, school, social and self- concept (at least 2 settings) Some symptoms by age 7 years Chronic condition (at least 6 months) The most commonly-diagnosed behavioral disorder in children Estimates of prevalence 3-11%

15. Differential Diagnosis Vision and hearing problems Developmental or learning problems; language deficits Absence seizures Acute change in living situation, grief, family conflict, recent trauma Substance abuse; side effect of medications Stress Breathing impairment, e.g., sleep apnea; sleep problems

17. Methods Assessed sleep and assessed behavioral, cognitive, and psychiatric morbidity in 105 children 5.0 to 12.9 years old 78 were scheduled for clinically indicated adenotonsillectomy, usually for suspected sleep disordered breathing 27 for unrelated surgical care One year later, we repeated all assessments in 100 of these children.

20. SDB in Children Results AT group Higher scores for hyperactivity, inattention, Multiple Sleep Latency Test (MSLT), and ADHD at baseline and improved to control rate 1 yr after surgery Even with children with “primary snoring” (in the absence of frequent apneic events, arousals, or gas-exchange abnormalities) may still be at risk for significant neurobehavioral consequences. Chervin et al. Sleep disordered breathing, behavior, and cognition in children before and after adenotonsillectomy. Pediatrics. 117(4) 2006 e769-e778.

21. SLEEP 2009;32(3):343-350.

22. Study Design Overnight sleep recordings were conducted in 15 children diagnosed with ADHD (DSM-IV) without comorbid psychiatric problems and in 23 healthy controls aged 7 to 11 years. Children were on no medication, in good health and did not consume products containing caffeine ≥ 7 days prior to the polysomnography (PSG) study. PSG evaluation was performed at each child’s home; children slept in their regular beds and went to bed at their habitual bedtimes.

25. Conclusions Sleep disorder breathing was associated with behavioral problems, including hyperactivity, reduced attention, somatic complaints, and developmental disorders In all children with learning, behavioral, or ADHD problems, assessment of SDB is paramount