Pediatric medicine's damaging oversight

In 1889, pediatric surgeon William Hill was removing the tonsils from children with obstructed airways to alleviate their struggles with breathing when he noticed unforeseen side effects of the procedure. The tonsillectomies unexpectedly cleared up the children’s chronic headaches and problems paying attention in school.

In the British Medical Journal, Dr. Hill noted that “children, the victims of nasal and pharyngeal obstructions ... frequently evince a marked inability to fix their attention on their lessons or work for any length of time.” His description of the symptoms are the same as the ones we now associate with attention deficit hyperactivity disorder (ADHD), a diagnosis that accelerated to epidemic proportions in the past two decades for unknown reasons.

The superabundance of ADHD diagnoses in children today may be caused by a damaging oversight: Undiagnosed sleep disorders, often linked to obesity in children, present identical symptoms. While the latest research has shown a direct connection between sleep deprivation and attention deficit behaviors, mainstream medical practice has yet to catch up. Attention deficit disorders are diagnosed based on behavior, overlooking the glaring fact that the children could have sleep disorders. If this red herring is not caught in a medical evaluation, the stimulant drugs prescribed to treat the mislabeled symptoms can exacerbate the sleep problem.

Sleep is broken into two phases: non-REM and REM. Non-REM, in which humans spend 75 percent of sleep time, consists of four stages. Stages one and two bring the sleeping person into a deeper state by regulating the heart rate, breathing and body temperature. Stages three and four are the most restorative. This is when tissue growth and cell repair occur. REM, which accounts for the remaining 25 percent of sleep time, supports daytime performance and is when dreaming occurs. 

The body cycles through all four stages multiple times throughout the night, ending in REM sleep about every 90 minutes. Obstructive sleep apnea (OSA)—difficulty breathing while sleeping due to an obstructed airway, which is related to obesity—has been shown to fragment these stages, detracting from restorative sleep.

“There’s another aspect of sleep, which doesn’t have anything to do with the total amount of sleep, and that’s the quality of sleep,” said Craig Heller, a professor of biology at Stanford University. “If sleep is fragmented, the total amount of sleep may not change, but the utility of that sleep in memory consolidation is very much damaged.”

Short-term memory is consolidated into long-term memory during sleep. Interruption of the sleep cycle results in a tremendous negative impact on cognitive performance and other functions, he said.

“What people experience in the normal, modern-day society world—cutting back sleep to five or six hours a night during the week and sleeping in on the weekend—has decided [negative] effects,” Heller said. “Those kinds of effects are not easily paid back by a weekend of sleeping in in the morning.”

The American Academy of Pediatrics recommends three options for the treatment of ADHD-related symptoms in adolescents, none of which include a focus on improving sleep or addressing sleep disorders. The treatment options outlined by the AAP are medication, behavior management and enhancing support for the child at school.

A February 2014 meta-analysis published online in the journal Sleep Medicine found that in a sample size of more than 1,100 children with sleep disorders, those who underwent a tonsillectomy had improved ADHD symptoms after the procedure. 

The authors concluded that children diagnosed with ADHD should be screened for sleep problems. However, between 2002–2010, prescriptions for ADHD medications increased 46 percent, according to a 2012 report published in the journal Pediatrics. This may suggest an alternate diagnosis is not being considered.

Pediatricians estimate that up to 30 percent of children may experience a sleep disorder at some point during childhood, according to the National Association of School Psychologists. A 2011 report from the U.S. Centers for Disease Control and Prevention found some 6.4 million children aged 4 to 17, or 11 percent, have been diagnosed with ADHD. The average age of diagnosis was 7, but more severe cases were reported at an earlier age. The reported rates of sleep disorders in children with developmental delays are even higher.

Sleep disorders can develop in children as young as 2 years old and lead to chronic sleep deprivation, which has a serious effect on cognition, memory consolidation and behavior.

A hypothetical child who complains of being overtired is diagnosed with ADHD and behavioral problems and is subsequently prescribed a stimulant drug like Ritalin. The child’s attention deficit and difficulty focusing may improve but his sleep quality suffers as a side effect of the medication. In all likelihood, there was no discussion of the child’s sleep habits during the consultation. The root cause is never addressed.

“If you’re not sleeping well, and you’re chronically fatigued but don’t really realize you’re chronically fatigued ... it probably shouldn’t surprise you that you could have issues with your behavior, your concentration, your academic ability,” said Dr. Jerome Hester, a surgeon at the California Sleep Institute in Palo Alto, California. He said throughout his career, he has consistently met parents who are unaware that there could be a connection.

Dr. Kirk Parsley, who this year gave a popular TED talk on the prevalence of sleep deprivation in America, said sleep deprivation is one of the country’s largest problems, and is often ignored.

“It’s actually a tragic thing,” Parsley said. “Knowing what we know about what happens [during] sleep, there’s no doubt this is affecting [children’s] cognitive development, their cognitive abilities, their emotional development, their emotional abilities.”

Meanwhile, a 2011 meta-analysis from the American Academy of Clinical Psychiatrists found up to 95 percent of patients diagnosed with OSA also had attention deficits. In children with ADHD, a high incidence of OSA occurs. Similar to Hill’s findings, the study notes treatment of the sleep disorder also alleviated ADHD symptoms.

An April 2012 study in the journal Pediatrics found that of 11,000 children followed over the course of six years, kids with OSA were 40–50 percent more likely to develop behavioral problems by age 7. Children with the most severe symptoms were 60 percent more likely to need special education by age 8.

“The sad part is, that’s not new data,” Hester said. “When you treat them for their sleep apnea, they do better. It’s a shame because you have a very high chance that a young person with that diagnosis has a contributing factor of sleep and specifically sleep apnea.”

 A lack of emphasis on sleep education for students of pediatric medicine has also been suggested as a compounding factor.

 “I always tell people if we do screening [electroencephalograms] on adults, the chance you’re going to pick up an abnormality is unbelievably low,” Hester said. “If you have something where you know the incidence is 40 percent, and it can be a major contributor to the problem you’re treating, why wouldn’t you at least ask a battery of questions to see if it’s appropriate to study that patient?”

 Parsley, who was diagnosed with ADD at 32 years old while still in medical school, said during the course of his evaluation and treatment, sleep habits were not used as a metric for diagnosis.

“I was working with this 75-year-old physician who’d been practicing medicine for many years, who was one of the professors at my school, and sleep deprivation was never discussed as a possible mechanism for this,” Parsley said. “I slept four to five hours per night for six to seven years through college and medical school, and interestingly, when I started sleeping adequate amounts, all of these ADHD symptoms went away, and the same thing’s been observed in kids.”

An April 2013 study published on the open access website BioMed Central surveyed pediatric residents from 10 countries around the world who reported that 23 percent of their residency programs provided no sleep education. The research indicated that for programs that did include sleep education, medical students received, on average, 4.4 hours.

Obesity results in fat deposits in the region surrounding the airway, making it the most significant risk factor to the development of OSA and, in turn, sleep disorders. 

In a study conducted between 2009–2010 by the American Heart Association, nearly 20 percent of children ages 6–11 were deemed overweight. A 20-year review of obesity-associated diseases among children ages 6–17 conducted by the CDC found a significant increase in hospital discharges for obesity-related medical conditions. Discharges for sleep apnea increased 436 percent in that time. OSA also has been linked to risk factors that lead to cardiovascular disease. 

Dr. Jonathan Freudman, medical director for NuSomnea—a medical technology company—said when an individual suffers from OSA, the body, sensing a drop in oxygen saturation in the blood, releases a surge of adrenaline as a defense mechanism. This adrenaline signals the muscles around the airway to become more rigid, allowing the airway to reopen. A side effect is the sporadic interruption of the sleep cycle, preventing the individual from sleeping as deeply. This makes sleep less restful and manifests as excessive daytime sleepiness and dozing off in adults. In children, it displays itself through “cognitive impairment and behavioral [problems],” Freudman said. “They can’t concentrate. They’re restless.”

According to Freudman, this surge of adrenaline is also associated with the fight-or-flight response the human body initiates in the face of a threat. Pulse and blood pressure rise, and an inflammatory response is elicited. These biochemical markers of stress add up, and in the long term, lead to an increased risk of heart disease, diabetes and stroke. 

If not properly treated, these problems can last a lifetime.

The Easy Peezy Pee Test, NuSomnea’s newly developed diagnostic test for OSA in children, has been shown to be 96.5 percent accurate in measuring proteins present in urine the night after an episode of disrupted sleep caused by sleep apnea. 

Michael Thomas, co-founder of NuSomnea, said monitoring the occurrence of OSA in children is difficult because not all sleep specialists and sleep labs are equipped to properly monitor them. When children are monitored in sleep labs, the experience is often traumatic, and they are unwilling to return even if the OSA recurs. However, research shows that 60 percent of kids who undergo a tonsillectomy have OSA recurrence in three to five years after surgery.

“There’s nowhere near the volume of facilities that are necessary or comfortable to look at all of these kids,” Thomas said. “Compound that with the fact that the research shows [tonsillectomies, which were] thought to be a cure, [are] in fact not. It’s coming back again. We still have to fix it, and no one is catching it." 

Dwindling face time between doctors and patients could also be a contributing factor to the lack of emphasis placed on treatments for sleep disorders that focus primarily on correcting sleep habits rather than medication. The childhood obesity epidemic likely contributes to the number of kids with undiagnosed sleep apnea, Thomas said.

“Some of the biological ramifications of sleep deprivation in young children present with early childhood obesity and diabetes, among the other problems with focus and high-risk behavior,” said Jenni June, a Los Angeles-based sleep hygienist.

Sleep hygienists manage the different environmental and behavioral factors vital to normal, quality nighttime sleep and full daytime alertness.

In young children, the brain is growing and developing at a rapid rate and requires the deep stages of restorative sleep. June said evaluating sleep hygiene should be the first step in diagnosing a sleep disorder because sleep deprivation and restriction can impact everything from behavior to performance in school.

Recent research shows a strong correlation between even a single hour less of sleep per night and the likelihood for high school-aged students to fail classes.

June said she has seen several cases in which children with poor sleep hygiene were hospitalized as a result. In one instance, a child chronically vomited until the age of 2. He learned that every time he would throw up, his parents would come running. The entire family was getting no sleep.

The nursery smelled so intensely of vomit that the family would place plastic over everything. The carpet had to be torn out, replaced multiple times, and the mother had to quit her teaching job to take care of her son. June said this is an extreme example of the “vicious cycle” that people need to break by becoming aware of this issue. Otherwise, for some children, it will never end. 

The same hypothetical child who was sleep-deprived but misdiagnosed will continue taking the prescription stimulant into elementary, middle and high school. As his sleep continues to deteriorate, so does his cognitive ability and his social and emotional functioning. If the sleep disorder is never addressed, the two competing ailments will never become disentangled.

Ultimately, cases like these are not a rarity, and children are oftentimes prescribed remedies for symptoms rather than the problem at hand. Children across the U.S. suffer from sleep-

related disorders that may look to physicians like the arguably overdiagnosed symptoms of attention deficit disorders. Yet the origin point of the symptoms and why these studies are going unnoticed remains in question.

“It’s amazing that this hasn’t become more mainstream in the people out there seeing these kids every day to have it be one of those things that they ask questions about,” Hester said. “I don’t want to say that there is no one out there who’s kind of doing it that way, but I do think there are a lot of [instances when] the question is not being asked.”

In 1889, pediatric surgeon William Hill was removing the tonsils from children with obstructed airways to alleviate their struggles with breathing when he noticed unforeseen side effects of the procedure. The tonsillectomies unexpectedly cleared up the children’s chronic headaches and problems paying attention in school.