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Is it ADHD or Sleep Apnea? How to know the difference in kids (Part I)

Bedtime Network's "First Lady of Sleep," Lisa Mercurio interviews sleep doc Dr. Daniel Barone of New York Presbyterian Hospital/Weill Cornell Medical College just in time for the beginning of a new school year.  Make sure that neither you nor your child are suffering with bedtime disruptions.  Here's how to know the warning signs that can lead to lack of success and productivity at school, at play and at home.  ADHD or Apnea?  

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The First Ladies of Sleep recently appeared at an event where we interacted with a number of women that were over the age of 50.  We set up a Bedtime Network informational display complete with our Bedtime Beats music and, as the women rolled through the expo, we encouraged them not only to join Bedtime Network but to tell us their stories.  We always want to know how you’re sleeping, and  how your loved ones are sleeping. 


Well, as it turned out, people were curious. We found that ten to one, no one is sleeping all that well. The predominant outcry would lead to no surprises:   “I’m 52, 54, or 56, and I go to bed just fine but I always wake up in the middle of the night.”  At BTN we hear that a lot so we asked them, “What’s your special time?”  And we heard 3, 3:30 am, 4 am, and while some get back to sleep, many do not. 


But then, there was a subset ---- and, this shocked us.  These women reported, “I have a 16-year old son, a 14-year old or a 25-year old son and he cannot sleep.  What should I do?”


So we asked a few more questions, after all, that’s the job of a First Lady of Sleep.  “Is he holding a good sleep schedule?”  “Is he on meds?”  “Is he anxious?” A few times, we were able to be helpful.  But mostly, we had to suggest that they see a sleep doctor.  Incidentally, no problems were reported amongst mothers of daughters, just mothers of young men. 


That said, we asked Dr. Dan Barone of New York’s Weill Cornell Sleep Center, what is going on here, for real?


DB:  I don’t think it’s a coincidence.  That generation, from 10 to 25 or so, is exposed to so much stimulation during the day that it is mind-blowing.  Computers.  Twitter.  Facebook.  Video games.  Television.  Reading is done on an iPad or Kindle…all these things combine and, on top of that, they are doing it in bed and all of these devices are emitting blue frequency light.  That kind of light can get your body’s system OFFLINE.  Our pineal gland, which sits the middle of our brain, secretes melatonin – and this function is shut off when exposed to sunlight or blue light.  If melatonin is shut off, particularly at nighttime, when the sleep process is beginning, then they can forget it.   They’re going to have trouble falling asleep.


LM: I believe that the overstimulation factor is a key component.  Talk a bit about the biological forces going on with that age group.


DB: I think it’s a societal problem because a teenager needs about 9-10 hours of sleep a night.  It’s not an insurmountable problem, but this is a problem that’s been plaguing our society, for the first time in our history with all of these devices that we spoke about leading to insomnia.


LM: So let’s add another layer to this.  We have the biological manifestations and the technological advancement killing kids and then, we have the onset of drug administration, and I believe some of this was covered recently in a prominent Wall Street Journal article.


DB: Interesting that you brought that up.  We have a situation where we have kids over-diagnosed with ADHD.  Kids who are sleep deprived from apnea or insomnia or whatever it is, and they don’t act the way adults do.  They are not sleepy necessarily the way adults would be – rather, they may develop behavioral issues and difficulty concentrating.  So what happens?  The children get put on Ritalin and the underlying issue which, may well be sleep apnea, is never properly diagnosed.

Essentially, some of these kids are being diagnosed as ADHD when they are really apnea patients. 


LM: Let’s speak about sleep apnea a bit, particularly in this generation, perceived as more obese and overweight.


DB: Let me explain a bit what it is: the upper airway is where the tongue and tonsils sit as well as that little piece of tissue that hangs in the back of the throat called the uvula. What occurs is that when we’re awake, our brain tells the tongue to stay forward and our upper airway remains open.  When we fall asleep, that signal is either lessened or goes away entirely.  If there’s any chance that the airway is a little small, it can lead to the airway closing off.  It can cause the uvula and soft palate to vibrate which is known as snoring.  In more severe cases, the airway is totally blocked off and causes repeated gasping.   When that occurs, the brain gets a message that says, “I’m being choked,” and it causes a mini-awakening. The heart rate and blood pressure go up, the person takes a big breath and perhaps falls back to sleep. But if this happens many times per hour this is known as sleep apnea and that’s when other bodily functions start to suffer and problems arise.  Apnea is not reserved to the obese child.  The upper airway can become obstructed from time to time anatomic issues: residual tonsils, a big, fat tongue or uvula; these things are structural and sometimes inherited.


LM: We wonder how many children with undiagnosed sleep apnea become adults with serious sleep apnea?


DB: Typically as we get older and there’s higher fat distribution in the neck area, our muscle strength goes down and it’s a perfect storm and the apnea prevalence goes up, particularly in post-menopausal women.


LM: There’s so much to look forward to! Are you seeing more kids coming into the sleep clinic in general?


DB: Yes – more than 30 percent of children in the US are overweight or obese.  Additionally, children may have enlarged tonsils. Between the ages of 2 and 8, a child’s tonsils are biggest in relation to their upper airway.  Sometimes, if we do a sleep study we see the presence of apnea.  If the tonsils are removed, the sleep may improve, and what was thought to be ADHD may go away.  Interestingly, I’ve seen this also when a child is not getting enough quality sleep, Delta Wave sleep when growth hormone is emitted, from sleep apnea - we correct the tonsils and suddenly these kids start to grow.


LM: Developmentally – when you are dealing with the growth factor as well, what happens in the brain?


DB: Behavioral issues arise.  Cognitive.  They’re not scoring well.  All these issues occur.  The sleep may not be seen as the problem, but then the child gets diagnoses as having a neuropsychological problem.


LM: What are the warning signs for a parent that has a kid that isn’t sleeping?  When should the bell go off?  You would think that a16-year old wouldn’t discuss the fact that he or she couldn’t sleep but a smaller child would be inclined to cry out for help.


DB:  Snoring is a predominant symptom.  Our perception of snoring has changed over the years.  While it might be seen as something cute in the past, it is the biggest thing I would ask about, and a potential harbinger.  Also important to ask: what is their bedtime and sleep routine?  Are they sleeping until noon on the weekends and then, Sunday night, they are unable to get to sleep?  The problem arises when the person cannot get back to a regular schedule.


LM: For an adult, snoring is not necessarily the clue?


DB: Nearly everyone with sleep apnea does snore but many snorers do not have sleep apnea.


LM:  It’s relative but if they hear some raucous snoring, who knows?


DB: Right. And I would hope that both doctors and parents would send their kids more frequently to a sleep center.

DB: If the medical community can come together: psychiatric, neurological, physiological etc and see the value of sleep the way they need to, perhaps there will be less administration of drugs.


(to be continued)