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ADHD sx and Sleep Apnea

Discussion in 'Psychiatry' started by Abby Normal, Apr 6, 2007.

  1. Abby Normal

    Abby Normal New Member 5+ Year Member

    Jun 10, 2006
    Currently doing an ENT rotation and saw a 4 y/o boy yesterday with sx of poor concentration, inability to follow directions, and irritability who generally made life miserable for the rest of his family and at daycare. He was otherwise healthy, with normal birthweight and growth patterns until 6 months of age, when he inexplicably fell off the growth curve despite normal nutrition. His pediatrician, reluctant to diagnose him with ADHD, began inquiring about his sleep habits and found that he had not been a "good sleeper."

    Since this kid was too irrascible to cooperate with a sleep study, Mom sat up one night with a tape recorder near his pillow at home and discovered frequent apneic periods to the tune of 44 in an hour and extensive snoring. He did not display behaviors consistent with daytime sleepiness, interestingly.

    He'll have his tonsils and adenoids removed, which should improve his disposition.

    Not getting adequate REM sleep, when growth hormone is released, is most likely the reason for being small for his age, my ENT preceptor explained. A kid who is chronically sleep deprived could certainly behave like a kid with ADHD, or possibly like a kid who might otherwise be diagnosed with bipolar disorder.

    This particular ENT sees this situation from time-to-time and he said the difference in these kids and their behavior is quite dramatic once their tonsils and adenoids are removed, as one might imagine.

    Yet, I don't recall having been taught or considered the possibility of sleep apnea, obstructive or central, in the differential diagnosis of behavior disorders in kids.

    It is interesting to consider the possibility that there is a sub-population of kids (or adults for that matter) diagnosed with ADHD who have sleep apnea.

    Anybody else seen cases like this?
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  3. slope

    slope Physician 10+ Year Member

    Oct 21, 2006
    It is, indeed, a differential diagnosis that is often overlooked. If you want to see more cases like the one described, spend some time in a sleep clinic that accepts pediatric patients in their department.

    What I actually want to tell you is that either you misunderstood your ENT doctor or he/she didn't teach you the right thing; you say: "Not getting adequate REM sleep, when growth hormone is released, is most likely the reason for being small for his age, my ENT preceptor explained."

    Wrong, as a matter of fact, growth hormone is released during SWS (aka delta sleep) and not in REM. Not having enough REM (which, in this case, we have no evidence of) might explain part of the child's symptoms (e.g., poor concentration), but not the size of the child.
  4. MBK2003

    MBK2003 Senior Member 7+ Year Member

    Oct 23, 2001
    Lobsta' Land
    Having done 8months of school-based peds psych, I can attest that we ALWAYS asked about sleep patterns and snoring, and in our obese kids (40%) we more thoroughly screened and instructed parents to stay up and listen for apneic episodes. We had a number of DBD NOS kids whose parents would report "snoring that wakes up the dead" and episodes of gasping for breath while sleeping, but very few had daytime sedation. In our clinic, I'm not aware that any of the kids that went to ENT for surgery still had DBD symptomatology after 4-6 months. One of the things I really really like about child psych is being able to pick up the reversible causes of behavior symptoms that impair with the kid's ability to perform in school. Very gratifying when the parent shows you the report card with no more F's for behavior/classroom conduct.

  5. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Physician Moderator Emeritus SDN Advisor 10+ Year Member

    Dec 2, 2004
    Left of Center
    My high point in child was a "ADHD/bipolar" 6 y/o girl who "needed a change in meds" because on lithium and a stimulant she was still spacing out in class and having behavioral outbursts. Teacher (EBD trained and should've known better!!!) reported that she just seemed to "tune out" and then if disturbed would lash out kicking and hitting. I sent her for a neuro eval & EEG---3 per second spike & wave. Changed the lithium to Depakote, seizures went away, so did the post-ictal outbursts and the ADHD and bipolar diagnoses.
  6. MBK2003

    MBK2003 Senior Member 7+ Year Member

    Oct 23, 2001
    Lobsta' Land
    Or my other favorite, CC: "the teacher says she's always touching and tripping over the other students, and she's not paying attention in class."

    Dx: Retinopathy of prematurity with correction of approx +20, never went back to peds ophtho following discharge from 5mo NICU stay (former 26 weeker), never addressed by pediatrician.

    Follow-up: Status post glasses= stays in seat, attends to tasks, socializing appropriately with peers, able to write her letters and name her colors.

    Ahhh child psychiatry, it's so simple, it only looks like it's magic. ;)


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