Suneela Cherlopalle, M.D., Murali K. Kolikonda, M.D., Manasa Enja, M.D., Steven Lippmann, M.D.

You are in your office evaluating a child with hyperactivity and inattention. The parents want quick intervention;  the teacher suggests to “start medication” now. Under pressure, you are considering attention deficit hyperactivity disorder (ADHD), and the child appears to fit the criteria. However, sleep disordered breathing (SDB) and ADHD can present similarly, with hyperactivity and inattentiveness. So similarly, that mis-diagnoses can occur. Erroneous diagnosis leads to ineffective treatment and may make things worse.

Fortunately, office-based screening with a history from the parents about the child’s sleep can quickly help rule out sleep disordered breathing.Thus, SDB screening is recommended before prescribing pharmacotherapy for hyperactivity. Such screening is easy to obtain and may avoid mistakes without additional cost.

Question the parents about the child’s sleep-related behavior, seeking to establish whether or not sleep disordered breathing is present. Ask them about snoring, short periods of not breathing, awakenings accompanied by gasping, and daytime dysfunction. This is critical since sleep disorders are rarely considered during the evaluation of children.

History from the parents that suggest a possible diagnosis of SDB, prominently includes loud snoring or apneic spells during sleep. Obstructive sleep apnea (OSA) occurs in children with hyperactivity. The predominant etiology of OSA in children is adenotonsillar hypertrophy, and it appears between the ages of 2 – 8 years, which coincides with the onset of ADHD. Disorders of sleep result in behavioral disturbances, cognitive impairment, and inattentiveness. Research confirms that children with hyperactivity sometimes have sleep disordered breathing etiologically related to adenotonsillar hypertrophy. In those cases, the majority return to a more healthy state following adenotonsillectomy.
 
If screening indicates possible SDB, consider referral to a pediatrician for a physical examination or other studies, such as fiberoptic endoscopy, to rule out adenotonsillar hypertrophy. The definitive diagnostic test confirming a disorder of sleep is the nocturnal polysomnography, but it may not always be medically necessary. There are also pediatric sleep questionnaires available for screening that are listed in the table.

If adenotonsillar hypertrophy is confirmed, adenotonsillectomy may be curative of the breathing disorder. That diminishes hyperactivity or inattentiveness by improving sleep quality. Thus,  screening for sleep disordered breathing is important in children with hyperactivity.

Table- Questionnaires screening for sleep disordered breathing.
1.    Children sleep habit questionnaire (CSHQ)
2.    Pediatric sleep questionnaire (PSQ)
3.    Sleep disturbance scale for children (SDSC)
4.    Omnibus questionnaire