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ADHD or Sleep Apnea?

Similar symptoms can lead to misdiagnosis

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Your child daydreams a lot, often forgets or misplaces things, fidgets, talks excessively, makes careless mistakes and doesn't get along well with others. He has difficulty sharing, often shows a lack of judgment, has mood alterations and a decrease in ability to learn and retain information. What could be the possible cause of all these sysmptoms? Attention Deficient Hyperactivity Disorder (ADHD) is a common neurobehavioral disorder and is often a diagnosis given to children with symptoms such as these. And ADHD diagnoses are on the rise in the U.S. Study results reveal that ADHD is diagnosed at a rate of 2.5% in 2001 and a 3.1% rate in 2010-a 24% increase.1 But ADHD may not be the only possible diagnosis.

Children's Sleep Health
Sleep in general is overlooked as a health issue, yet according to Paavonen et al (2009) ADHD and sleep apnea share numerous symptoms such as poor concentration, difficulty maintaining focus and poor school performance.2 Sleep affects the immune system, metabolism, memory, learning and other functions, which in turn affect overall health and wellness. Children with incidental sleep apnea are four to five times more likely to have behavioral problems while those with persistent sleep apnea are likely to experience six times more behavioral problems.3 The National Sleep Foundation recommends that children 5-10 years of age acquire 10-11 hours of sleep nightly while children 11-17 years of age get 8 ½ - 9 ½ hours of nightly sleep.4 Getting the right diagnosis and solving the sleep problem is key to a happier, healthier child.

Diagnosing ADHD
If your child is getting less than the recommended amount of sleep, many symptoms akin to ADHD could appear. The American Academy of Pediatrics (AAP) released clinical practice guidelines for the diagnosis and treatment of ADHD. The guidelines include recommendations, including5:

• The primary care clinician should initiate an evaluation for ADHD for any child 4 through 18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity.

• To make a diagnosis of ADHD, the primary care clinician should determine that diagnostic criteria have been met based on Diagnostic and Statistical Manual of Mental Disorders - Fifth edition (DSM-5). Making a diagnosis includes documenting that the child is impaired in more than 1 major setting (e.g., in school and at home). The primary care clinician should include reports from parents or guardians, teachers, and/or other school and mental health clinicians involved in the child's care. The primary care clinician should also rule out any other possible cause.

• When evaluating a child for ADHD, the primary care clinician should assess whether other conditions are present that might coexist with ADHD, including emotional or behavioral (e.g., anxiety, depression, oppositional defiant, and conduct disorders), developmental (e.g., learning and language disorders or other neurodevelopment disorders), and physical (e.g., tics, sleep apnea) conditions.

• The primary care clinician should recognize ADHD as a chronic condition and, therefore, consider children and adolescents with ADHD as children and youth with special healthcare needs. Care for such children and youth should follow the principles of the chronic care model and the medical home.2

Sleep Disturbances
Based on the AAP guidelines, a child being assessed for the presence of ADHD should be tested for sleep disturbances, mainly sleep apnea. A child should be specifically tested for sleep apnea if they experience such things as night terrors or extreme nightmares, sleepwalking, snoring and behavioral problems. The sleep testing will determine the presence of sleep disturbances which can be treated. Sleep has been proven to affect the hormones that are pivotal to childhood development-growth and appetite hormones.4 Primary treatments for obstructive sleep apnea in children include the removal of enlarged tonsils and/or adenoids and the use of Continuous Positive Airway Pressure (CPAP). Once the sleep disturbances are effectively addressed, the treatment for ADHD can be addressed so as not to commit children to a lifetime of costly ADHD treatment and medications. The CDC notes that in 2005 (using 5% prevalence) the annual cost of ADHD ranged from $36 to $52 billion dollars with an annual per child cost between $12,005 and $17, 458.6 In the U.S. in 2000, the total excess cost of ADHD was $3.1 billion, representing direct medical cost, family member costs, and work loss costs for parents of children with ADHD.6 With the increased diagnoses, the future potential economic burden of ADHD is huge. For many reasons, sleep testing is crucial for the overall health of children, their parents, and the nation as a whole.

With the rising diagnoses of ADHD, the concurrent increase of misdiagnoses, and the costs associated with treatment, we must become more aware of the similarity of symptoms between ADHD and sleep disturbances such as sleep apnea. The rising cost of healthcare (including copious and costly ADHD medications) and the desire to provide our children with appropriate treatment demand a closer look at our diagnosis and treatment practices of ADHD which includes sleep testing.

Some tips for parents to help their children sleep better include having a set bedtime to accommodate the recommended hours of sleep, no electronics in children's bedrooms and no caffeine/chocolate before bedtime. Parents can find more information on children and the importance of sleep on the National Sleep Foundation's website.

Andre' B. Green is a sleep expert with over 20 years' experience at Palmetto Health Richland Campus, Columbia, SC. She is currently completing her Master of Health Education degree.

References
1. Heffron T. Rate of ADHD diagnosis in children is rising. Sleep Education. 2003. http://www.sleepeducation.com/news/2013/01/22/rate-of-adhd-diagnosis-in-children-is-rising
2. Paavonen J (2009). Short sleep duration and behavioral symptoms of attention-deficit/hyperactivity disorder in healthy 7- to 8- year old children. PEDIATRICS, 2009;123(5): e857-e864. http://pediatrics.aappublications.org/content/123/5/e857.full.html
3. Celmer, Lynn (2013, February 1). Sleep Deprivation Disrupts Gene. Sleep Education; 2013. http://www.sleepeducation.com/news/2013/03/01/sleep-deprivation-disrupts-genes
4. National Sleep Foundation (2013). How Much Sleep Do We Really Need? 2013. http://www.sleepfoundation.org/article/how-sleep-works/how-much-sleep-do-we-really-need
5. Centers for Disease Control and Prevention. Attention-Deficit/Hyperactivity Disorder (ADHD) -Recommendations 2013. http://www.cdc.gov/ncbddd/adhd/guidelines.html
6. Center for Disease Control and Prevention. Attention-Deficit Hyperactivity Disorder (ADHD): Data and Statistics 2013. http://www.cdc.gov/ncbddd/adhd/data.html#cost
Center for Disease Control and Prevention. Attention-Deficit/ Hyperactivity Disorder (ADHD): Facts about ADHD 2013. http://www.cdc.gov/ncbddd/adhd/facts.html




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