Advertisement

Behavioral Morbidity in Pediatric Sleep-Disordered Breathing

  • Elise K. HodgesEmail author
  • Barbara True Felt
  • Bruno J. Giordani
  • Ronald D. Chervin
Chapter
Part of the Respiratory Medicine book series (RM)

Abstract

Pediatric sleep-disordered breathing (SDB) is associated with a wide range of emotional and behavioral symptoms. Despite high prevalence rates, symptoms of SDB and potential SDB contributions to behavioral difficulties are often over-looked. During the past several years, case series, cross-sectional studies, and meta-analyses have suggested higher frequencies of SDB in children who are also diagnosed with disruptive behavior disorders such as attention deficit hyperactivity disorder. Conversely, children with objectively defined SDB exhibit higher frequencies of these disorders or related symptoms. The precise neuroanatomic mechanisms of these associations are not clear; however, we here provide a neuroanatomic model that attempts to synthesize the links between sleep problems, associated neurophysiological disruption, and observed behavioral difficulties. We propose that repeated sleep fragmentation due to ­frequent respiratory-related arousals, as well as hypoxemia are likely to impede normal development of the frontal-subcortical circuits implicated in disruptive behavioral disorders. In addition, considerations for assessment and treatment are provided through a case example. Recommendations for future directions highlight the need to clarify optimal polysomnographic definitions for pediatric SDB and to develop more sensitive ­methods that better predict neurobehavioral consequences.

Keywords

Attention Deficit Hyperactivity Disorder Obstructive Sleep Apnea Oppositional Defiant Disorder Sleep Problem Attention Deficit Hyperactivity Disorder 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Chervin RD, Archbold KH, Panahi P, Pituch KJ. Sleep problems seldom addressed at two general pediatric clinics. Pediatrics. 2001;107(6):1375–80.PubMedCrossRefGoogle Scholar
  2. 2.
    Archbold KH, Pituch KJ, Panahi P, Chervin RD. Symptoms of sleep disturbances among children at two general pediatric clinics. J Pediatr. 2002;140(1): 97–102.PubMedCrossRefGoogle Scholar
  3. 3.
    Blunden S, Lushington K, Lorenzen B, Ooi T, Fung F, Kennedy D. Are sleep problems under-recognised in general practice? Arch Dis Child. 2004;89(8):708–12.PubMedCrossRefGoogle Scholar
  4. 4.
    Fallone G, Owens JA, Deane J. Sleepiness in children and adolescents: clinical implications. Sleep Med Rev. 2002;6(4):287–306.PubMedCrossRefGoogle Scholar
  5. 5.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorder—fourth edition text revision. Washington, DC: American Psychiatric Association; 2000.CrossRefGoogle Scholar
  6. 6.
    Chervin RD. Attention deficit, hyperactivity, and sleep disorders. In: Sheldon SH, Ferber R, Kryger Meir H, editors. Principles and practice of pediatric sleep medicine. 1st ed. Philadelphia: Elsevier Saunders; 2005. p. 161–9.Google Scholar
  7. 7.
    O’Brien LM, Chervin RD. Cognitive and behavioral consequences of childhood OSAS. In: Marcus CL, Loughlin G, Carroll J, Donnelly D, editors. Breathing during sleep in children. 2nd ed. New York: Informa Healthcare USA, Inc; 2008. p. 461–87.Google Scholar
  8. 8.
    O’Brien LM, Gozal D. Neurocognitive dysfunction and sleep in children: from human to rodent. Pediatr Clin North Am. 2004;51(1):187–202.PubMedCrossRefGoogle Scholar
  9. 9.
    Cichetti D. The emergence of developmental psychopathology. Child Dev. 1984;55(1):1–7.CrossRefGoogle Scholar
  10. 10.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders fourth edition. 4th ed. Washington, DC: American Psychiatric Association; 1994.Google Scholar
  11. 11.
    Barkley RA. Behavioral inhibition, sustained attention, and executive functions: constructing a unifying theory of ADHD. Psychol Bull. 1997;121(1):65–94.PubMedCrossRefGoogle Scholar
  12. 12.
    Faraone SV, Biederman J. Neurobiology of attention-deficit hyperactivity disorder. Biol Psychiatry. 1998;44(10):951–8.PubMedCrossRefGoogle Scholar
  13. 13.
    Halperin JM, Schulz KP. Revisiting the role of the prefrontal cortex in the pathophysiology of attention-deficit/hyperactivity disorder. Psychol Bull. 2006;132(4): 560–81.PubMedCrossRefGoogle Scholar
  14. 14.
    Willcutt EG, Doyle AE, Nigg JT, Faraone SV, Pennington BF. Validity of the executive function theory of attention-deficit/hyperactivity disorder: a meta-analytic review. Biol Psychiatry. 2005;57(11): 1336–46.PubMedCrossRefGoogle Scholar
  15. 15.
    Beebe DW. Neurobehavioral effects of obstructive sleep apnea: an overview and heuristic model. Curr Opin Pulm Med. 2005;11(6):494–500.PubMedCrossRefGoogle Scholar
  16. 16.
    Faraone SV, Perlis RH, Doyle AE, et al. Molecular genetics of attention-deficit/hyperactivity disorder. Biol Psychiatry. 2005;57(11):1313–23.PubMedCrossRefGoogle Scholar
  17. 17.
    Sonuga-Barke EJS. Categorical models of childhood disorder: a conceptual and empirical analysis. J Child Psychol Psychiatry. 1998;39(01):115–33.PubMedCrossRefGoogle Scholar
  18. 18.
    Nigg JT. Neuropsychologic theory and findings in attention-deficit/hyperactivity disorder: the state of the field and salient challenges for the coming decade. Biol Psychiatry. 2005;57(11):1424–35.PubMedCrossRefGoogle Scholar
  19. 19.
    Swanson JM, Flodman P, Kennedy J, et al. Dopamine genes and ADHD. Neurosci Biobehav Rev. 2000; 24(1):21–5.PubMedCrossRefGoogle Scholar
  20. 20.
    Tripp G, Wickens JR. Neurobiology of ADHD. Neuropharmacology. 2009;57(7–8):579–89.PubMedCrossRefGoogle Scholar
  21. 21.
    Conners C. Conners rating scales—Revised. Toronto: Multi-Health Systems; 1997.Google Scholar
  22. 22.
    Guilleminault C, Eldridge FL, Simmons FB. Dement. Sleep apnea in eight children. Pediatrics. 1976;58(5): 23–30.PubMedGoogle Scholar
  23. 23.
    Guilleminault C, Korobkin R, Winkle R. A review of 50 children with obstructive sleep apnea syndrome. Lung. 1981;159:275–87.PubMedCrossRefGoogle Scholar
  24. 24.
    Chervin RD, Weatherly R, Ruzicka DL, et al. Subjective sleepiness and polysomnographic correlates in children scheduled for adenotonsillectomy vs other surgical care. Sleep. 2006;29(4):495–503.PubMedGoogle Scholar
  25. 25.
    Gozal D, Wang M, Pope Jr DW. Objective sleepiness measures in pediatric obstructive sleep apnea. Pediatrics. 2001;108(3):693–7.PubMedCrossRefGoogle Scholar
  26. 26.
    Dillon J, Blunden S, Ruzicka D, et al. DSM-IV diagnoses and obstructive sleep apnea in children before and 1 year after adenotonsillectomy. J Am Acad Child Adolesc Psychiatry. 2007;46(11):1425–36.PubMedCrossRefGoogle Scholar
  27. 27.
    Sangal RB, Sangal JM. Rating scales for inattention and sleepiness are correlated in adults with symptoms of sleep disordered breathing syndrome, but not in adults with symptoms of attention-deficit/hyperactivity disorder. Sleep Med. 2004;5(2):133–5.PubMedCrossRefGoogle Scholar
  28. 28.
    Owens JA. The practice of pediatric sleep medicine: results of a community survey. Pediatrics. 2001; 108(3):e51.PubMedCrossRefGoogle Scholar
  29. 29.
    Chervin RD, Archbold KH. Hyperactivity and polysomnographic findings in children evaluated for sleep-disordered breathing. Sleep. 2001;24(3):313–20.PubMedGoogle Scholar
  30. 30.
    O’Brien LM, Ivanenko A, Crabtree V, et al. Sleep disturbances in children with attention deficit hyperactivity disorder [Article]. Pediatr Res. 2003;54(2):237–43.PubMedCrossRefGoogle Scholar
  31. 31.
    Owens JSA, McGuinn M, Nobile C. Sleep habits and sleep disturbance in school-aged children. J Dev Behav Pediatr. 2000;21:27–36.PubMedCrossRefGoogle Scholar
  32. 32.
    Owens J. The ADHD and sleep conundrum: a review. J Dev Behav Pediatr. 2005;26(4):312–22.PubMedCrossRefGoogle Scholar
  33. 33.
    Burke JD, Loeber R, Birmaher B. Oppositional defiant disorder and conduct disorder: a review of the past 10 years, part II. Focus. 2004;2(4):558–76.Google Scholar
  34. 34.
    Pliszka S. The psychobiology of oppositional defiant disorder and conduct disorder. In: Quay HD, HOgan AE, editors. Handbook of disruptive behavior disorders. New York: Kluwer; 1999. p. 371–95.CrossRefGoogle Scholar
  35. 35.
    Raine A. The role of prefrontal deficits, low autonomic arousal, and early health factors in the development of antisocial and aggressive behavior in children. Journal of Child Psychology and Psychiatry. 2002;43:417–34.PubMedCrossRefGoogle Scholar
  36. 36.
    Lyoo IK, Lee HK, Jung JH, Noam GG, Renshaw PF. White matter hyperintensities on magnetic resonance imaging of the brain in children with psychiatric disorders. Compr Psychiatry. 2002;43(5):361–8.PubMedCrossRefGoogle Scholar
  37. 37.
    van Goozen S, Matthys W, Cohen-Kettenis PT, Gispen-de Wied C, Wiegant VM, Engeland HV. Salivary cortisol and cardiovascular activity during stress in oppositional-defiant boys and normal controls. Biol Psychiatry. 1998;43:531–9.PubMedCrossRefGoogle Scholar
  38. 38.
    Mezzacappa E, Tremblay R, Kindlon D, et al. Anxiety, antisocial behavior, and heart rate regulation in adolescent males. J Child Psychol Psychiatry. 1998;38: 457–69.CrossRefGoogle Scholar
  39. 39.
    Mayes SD, Calhoun SL, Bixler EO, et al. ADHD subtypes and comorbid anxiety, depression, and oppositional-defiant disorder: differences in sleep problems. J Pediatr Psychol. 2009;34(3):328–37.PubMedCrossRefGoogle Scholar
  40. 40.
    Coulombe JA, Reid GJ, Boyle MH, Racine Y. Concurrent associations among sleep problems, indicators of inadequate sleep, psychopathology, and shared risk factors in a population-based sample of healthy Ontario children. J Pediatr Psychol. 2009;35(7):790–9.PubMedCrossRefGoogle Scholar
  41. 41.
    Coulombe JA, Reid GJ, Boyle MH, Racine Y. Sleep problems, tiredness, and psychological symptoms among healthy adolescents. J Pediatr Psychol. 2010;36(1):25–35.PubMedCrossRefGoogle Scholar
  42. 42.
    Reid GJ, Hong R, Wade T. The relation between common sleep problems and emotional and behavioral problems among 2- and 3-year-olds in the context of known risk factors for psychopathology. J Sleep Res. 2009;18:49–59.PubMedCrossRefGoogle Scholar
  43. 43.
    McBurnett K, Lahey BB, Rathouz PJ, Loeber R. Low salivary cortisol and persistent aggression in boys referred for disruptive behavior. Arch Gen Psychiatry. 2000;57(1):38–43.PubMedCrossRefGoogle Scholar
  44. 44.
    Siever LJ. Neurobiology of aggression and violence. Am J Psychiatry. 2008;165(4):429–42.PubMedCrossRefGoogle Scholar
  45. 45.
    Lindberg N, Tani P, Appelberg B, et al. Sleep among habitually violent offenders with antisocial personality disorder. Neuropsychobiology. 2003;47(4):198–205.PubMedCrossRefGoogle Scholar
  46. 46.
    Chervin RD, Dillon J, Archbold KH, Ruzicka DL. Conduct problems and symptoms of sleep disorders in children. J Am Acad Child Adolesc Psychiatry. 2003;42(2):201–8.PubMedCrossRefGoogle Scholar
  47. 47.
    Owens JA. Epidemiology of sleep disorders during childhood. In: Sheldon SH, Ferber R, Kryger Meir H, editors. Principles and practice of pediatric sleep medicine. Philadelphia: Elsevier Saunders; 2005. p. 27–33.CrossRefGoogle Scholar
  48. 48.
    Spillsbury JC, Drotar D, Rosen CL, Redline S. The Cleveland Adolescent Sleepiness Questionnaire: a new measure to assess excessive daytime sleepiness in adolescents. J Clin Sleep Med. 2007;3(6):603–12.Google Scholar
  49. 49.
    Montgomery-Downs HE, O’Brien LM, Holbrook CR, Gozal D. Snoring and sleep-disordered breathing in young children: subjective and objective correlates. Pediatrics. 2004;27:87–94.Google Scholar
  50. 50.
    Ali NJ, Pitson D, Stradling J. Snoring, sleep disturbance, and behaviour in 4–5 year olds. Arch Dis Child. 1993;68:360–6.PubMedCrossRefGoogle Scholar
  51. 51.
    Beebe D. Neurobehavioral morbidity associated with disordered breathing during sleep in children: a comprehensive review. Sleep. 2006;29(9):1115–34.PubMedGoogle Scholar
  52. 52.
    Hodges EK, Bloomfied E, Coulas T, Giordani B. Cognitive and behavioral change after adenotonsillectomy in children with sleep-disordered breathing: a review. Minerva Psichiatr. 2008;49(4):307–20.Google Scholar
  53. 53.
    Brouillette RT, Fernbach SK, Hunt CE. Obstructive sleep apnea in infants and children. Pediatrics. 1982;100(1):31–40.CrossRefGoogle Scholar
  54. 54.
    O’Brien LM, Tauman R, Gozal D. Sleep pressure correlates of cognitive and behavioral morbidity in snoring children. Sleep. 2004;27(2):279–82.PubMedGoogle Scholar
  55. 55.
    Mulvaney SA, Goodwin JL, Morgan WJ, Rosen GR, Quan SF, Kaemingk KL. Behavior problems associated with sleep disordered breathing in school-aged children—the Tucson Children’s Assessment of Sleep Apnea Study. J Pediatr Psychol. 2006;31(3):322–30.PubMedCrossRefGoogle Scholar
  56. 56.
    Sheldon S. Disorders of initiating and maintaining sleep. In: Sheldon SH, Ferber R, Kryger Meir H, editors. Principles and practice of pediatric sleep medicine. Philadelphia: Elsevier Saunders; 2005. p. 127–60.CrossRefGoogle Scholar
  57. 57.
    Zuckerman B, Stevenson J, Bailey V. Sleep problems in early childhood: continuities, predictive factors, and behavioral correlates. Pediatrics. 1987;80:664–71.PubMedGoogle Scholar
  58. 58.
    Chervin RD, Burns JW, Ruzicka DL. Electro­encephalographic changes during respiratory cycles predict sleepiness in sleep apnea. Am J Respir Crit Care Med. 2005;171(6):652–8.PubMedCrossRefGoogle Scholar
  59. 59.
    Row BW, Gozal D. Intermittent hypoxia during sleep as a model of environmental (nongenetic) contributions to attention deficit hyperactivity disorder. In: Gozal D, Molfese D, editors. Attention deficit hyperactivity disorder: from genes to patients. Totowa: Humana Press; 2005. p. 131–42.CrossRefGoogle Scholar
  60. 60.
    Decker MJ, Hue GE, Caudle WM, Miller GW, Keating GL, Rye DB. Episodic neonatal hypoxia evokes executive dysfunction and regionally specific alterations in markers of dopamine signaling. Neuroscience. 2003; 117(2):417–25.PubMedCrossRefGoogle Scholar
  61. 61.
    Giordani BJ, Hodges E, Guire KE, et al. Neuropsychological and behavioral functioning in children with and without obstructive sleep apnea referred for tonsillectomy. J Int Neuropsychol Soc. 2008;14(04):571–81.PubMedCrossRefGoogle Scholar
  62. 62.
    Mills P, Dimsdale J. Sleep apnea: a model for studying cytokines, sleep, and sleep disruption. Brain Behav Immun. 2004;18:298–303.PubMedCrossRefGoogle Scholar
  63. 63.
    Vgontzas AN, Zoumakis E, Bixler EO, et al. Adverse effects of modest sleep restriction on sleepiness, performance, and inflammatory cytokines. J Clin Endocrinol Metab. 2004;89(5):2119–26.PubMedCrossRefGoogle Scholar
  64. 64.
    Tauman R, Ivanenko A, O’Brien LM, Gozal D. Plasma C-reactive protein levels among children with sleep-disordered breathing. Pediatrics. 2004;113(6): e564–9.PubMedCrossRefGoogle Scholar
  65. 65.
    Gozal D, Serpero LD, Sans Capdevila O, Kheirandish-Gozal L. Systemic inflammation in non-obese children with obstructive sleep apnea. Sleep Med. 2008;9(3):254–9.PubMedCrossRefGoogle Scholar
  66. 66.
    Stein M, Mendelsohn J, Obermeyer WAJ, Benca R. Sleep and behavior problems in school-aged children. Pediatrics. 2001;107:e60.PubMedCrossRefGoogle Scholar
  67. 67.
    American Academy of Pediatrics. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002;109:704–12.CrossRefGoogle Scholar
  68. 68.
    Alfano C, Zakem A, Costa NM, Taylor L, Weems C. Sleep problems and their relation to cognitive factors, anxiety and depressive symptoms in children and adolescents. Depress Anxiety. 2009;26:503–12.PubMedGoogle Scholar
  69. 69.
    Cortese S, Faraone S, Konofal E, Lecendreux M. Sleep in children with attention-deficit/hyperactivity disorder: meta-analysis of subjective and objective studies. J Am Acad Child Adolesc Psychiatry. 2009;48:894–908.PubMedGoogle Scholar
  70. 70.
    Garetz SL, O’Brien LM, Chervin RD. Neurobehavioral morbidity in childhood sleep disorders. In: Yaremchuk K, Wardrop P, editors. Plural Publishing, Ind; 2010.Google Scholar
  71. 71.
    Hart C, Palermo T, Rosen CL. Health related quality of life among children presenting to pediatric sleep disorders clinic. Behav Sleep Med. 2005;3:4–17.PubMedCrossRefGoogle Scholar
  72. 72.
    Chervin RD, Hedger K, Dillon JE, Pituch K. Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Med. 2000;1(1): 21–32.PubMedCrossRefGoogle Scholar
  73. 73.
    Fallone G, Acebo C, Seifer R, Carskadon M. Experimental restriction of sleep opportunity in children: effects on teacher ratings. Sleep. 2005;28: 1561–7.PubMedGoogle Scholar
  74. 74.
    van der Heijden KB, Smits MG, Van Someren E, Ridderinkhof KF, Gunning W. Effect of melatonin on sleep, behavior, and cognition in ADHD and chronic sleep-onset insomnia. J Am Acad Child Adolesc Psychiatry. 2007;46:233–41.PubMedCrossRefGoogle Scholar
  75. 75.
    Mick E, Biederman J, Jetton J, Faraone SV. Sleep ­disturbances associated with attention deficit ­hyperactivity disorder: the impact of psychiatric comorbidity and pharmacotherapy. J Child Adolesc Psychopharmacol. 2000;10(3):223–31.PubMedCrossRefGoogle Scholar
  76. 76.
    Mitchell R, Kelly J. Behavioral changes in children with mild sleep-disordered breathing or obstructive sleep apnea after adenotonsillectomy. Laryngoscope. 2007;117:1685–8.PubMedCrossRefGoogle Scholar
  77. 77.
    Hoban TF, Chervin RD. Sleep-related breathing disorder of childhood: description and clinical picture, diagnosis, and treatment approaches. Sleep Med Clin. 2007;2(3):445–62.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  • Elise K. Hodges
    • 1
    Email author
  • Barbara True Felt
    • 2
  • Bruno J. Giordani
    • 3
  • Ronald D. Chervin
    • 4
  1. 1.Neuropsychology Section, Department of PsychiatryUniversity of Michigan Medical SchoolAnn ArborUSA
  2. 2.Department of Pediatrics and Communicable DiseasesC. S. Mott Children’s HospitalAnn ArborUSA
  3. 3.Departments of Psychiatry, Neurology, and PsychologyUniversity of MichiganAnn ArborUSA
  4. 4.Department of NeurologyUniversity of MichiganAnn ArborUSA

Personalised recommendations