Jack is a ball of energy. Too much energy, maybe. He tap-tap-tap-taps his pencil on his desk. He bounces in his seat. He’d rather poke the kids near him—reveling in their shrieks and other classmates’ giggles—even if it means another trip to the principal’s office.
Is it ADHD? The school suggests as much to Jack’s parents. His pediatrician agrees. Sure enough, a trial of Ritalin improves the boy’s behavior.
“Everybody pats themselves on the back, ‘We solved that one,'” says Charlottesville, Virginia, neurologist W. Chris Winter of this hypothetical—though not uncommon—case. “But in reality, nobody got to the bottom of it.”
As many as 1 in 4 cases of attention-deficit hyperactivity disorder (ADHD) may actually be another, much different problem—one that, like ADHD, seems to be rising among young kids.
Maybe Jack has sleep-disordered breathing.
A sleep problem?!
If you’re thinking that a hyperactive child is the opposite of a drowsy one, consider this: Sleep-disordered breathing—particularly a type called obstructive sleep apnea—can make it physically impossible to get deep, restorative rest at night. Children with the condition compensate by developing all kinds of behaviors to keep themselves jacked up and awake.
Like fidgeting. Making mischief. Diverting their attention from boring things (like teachers talking) to livelier ones. On top of that, a sleep-deprived child may be forgetful and impulsive, lose things, throw tantrums, wake up grumpy, and need lots of reminders.
In other words, a sleep-deprived kid may behave a lot like one with ADHD.
Disordered sleep = disordered behavior
Even more troubling, research shows that sleep breathing problems may alter the growing brain itself, causing lasting problems with cognition. “There’s evidence for both short-term and long-term effects,” says neurologist Ronald Chervin, director of the Sleep Disorders Center at the University of Michigan and president of the American Academy of Sleep Medicine.
He co-authored a study of 11,000 children who were tracked beginning at 6 months, and at annual intervals thereafter. Those younger than age 4 with sleep-disordered breathing were from 40 to 100 percent more likely than normal breathers to show neurobehavioral problems at ages 4 and 7. They showed more anxiety and depression, more peer problems, more aggression and rule breaking, and—especially—much more inattention/hyperactivity.
The worst sleep symptoms were associated with the worst behaviors—as early as age 30 months.
Another study, also published in Pediatrics in 2012, showed that children who snored loudly at ages 2 or 3 or both had more behavior problems than those who didn’t snore. (Snoring is a key red flag for obstructive sleep apnea.)
“All brain development and growth in the first years of life are cumulative,” says epidemiologist Karen Bonuck, a professor of family and social medicine and of pediatrics at Albert Einstein College of Medicine. “Parents and pediatricians alike should be paying closer attention to sleep-disordered breathing in young children.”
Yes, as young as infancy and toddlerhood.
About 1 to 4 percent of children have sleep apnea, though it’s widely considered to be underdiagnosed, according to a Journal of Clinical Sleep Medicine report. Up to 95 percent of people with sleep apnea have attention deficits, a 2011 review of studies in the Annals of Clinical Psychiatry found.
Sleep apnea peaks between ages 2 and 8 but can occur in both younger and older children. Both ADHD and sleep apnea tend to begin to be diagnosed around the same time—ages 3 to 6.
Meanwhile, more than 1 in 10 kids were diagnosed with ADHD in 2011 (the latest count available and a rate that’s been increasing 5 percent a year since 2003). To be sure, not all ADHD can be explained as a sleep problem. Its exact cause is still unclear.
But experts increasingly believe that sleep issues should be ruled out before ADHD is diagnosed. Chervin’s data suggest that 15 to 25 percent of hyperactivity is actually due to sleep apnea.
Another related condition is also rising: More kids are overweight (now 1 in 3). You can be lean and have sleep apnea, but extra weight spikes your risk. More than a third of obese children develop obstructive sleep apnea.
“You could probably lay three graphs showing trends in ADHD, sleep apnea, and obesity over one another and they’d look similar,” says Winter, a sleep-medicine specialist and the author of The Sleep Solution.
What is this messed-up sleep, anyway?
When kids finally drift off to slumberland—after the books, the back rubs, the onemoredrinkofwaterplease—they (like us) spend the night breathing in through their nose and sometimes their mouth. The air travels down those airways to the lungs, then back out.
Or that’s how it’s supposed to happen. If something blocks (obstructs) that airflow, the lungs get no air. It’s like when you’re drinking a milkshake and a strawberry clogs your straw. Nothing can make it to your mouth. With obstructed breathing during sleep, the body stops getting oxygen. So the brain, as a survival mechanism, hits the panic button. It wakes the body in order to force it to take a breath. Otherwise the sleeper would suffocate.
Someone with obstructive sleep apnea can awaken dozens of times a night—so briefly that the conscious brain doesn’t register it. But it’s enough to interfere with sleep quality, oxygen flow, and the normal production of hormones that regulate all kinds of body functions.
Young children are especially vulnerable because their airways are small—and their tonsils are relatively massive, which can interfere with airflow.
As kids grow, the tonsils stay the same size, but the airways get bigger. (So some children outgrow sleep-disordered breathing.) Overweight kids are at added risk for apnea, in part because fat deposits in the neck and throat further narrow airways. In some kids, there may be a structural issue, like enlargement of the tonsils, adenoids (soft lymphoid tissue near the tonsils), or tongue.
But wait, what about the Ritalin?
Why would an ADHD prescription (like the one given to hypothetical Jack) make a child seem better if he didn’t have ADHD in the first place?
As a stimulant, the drug makes a sleep-deprived child more awake—which allows him to attend better, says Winter. “It’s a masking effect, like drinking coffee to help you stay up,” he told me.
“When a child is referred with attention problems, before jumping to ADHD, we should be thinking of all the things that may be problems,” Winter says. “Responding to a stimulant can be the beginning of a diagnostic pathway, not the end of it.”
He adds: “I don’t think any child should be diagnosed with ADHD without a sleep study.”
A sleep specialist’s bias? Consider this: Although it’s been drilled into laypeople to count nutrition and exercise as the pillars of health, a mounting body of research in the past couple of decades shows that sleep is every bit as influential. Maybe more. All kinds of health conditions—heart disease, diabetes, brain disorders, cancer—and even longevity are turning out to be hugely and directly impacted by sleep.
Poor sleep in kids is a rising concern linked with worse grades, more sports injuries, and poorer immunity. It can also double a child’s odds of becoming obese by age 15, a 2014 Bonuck-led study found.
And yet general physicians and pediatricians don’t get much training in sleep disorders. Neither do most ADHD specialists, according to Chervin. All the more reason a child with apnea symptoms may be too quickly marked for ADHD instead.
How can you tell?
Because early intervention (before possible brain changes can occur) is so important, parents need to be proactive, experts say.
Listen for snoring.
“Prominent, habitual snoring is not normal in a child,” Chervin says. Although snoring isn’t always problematic, it’s a bright red flag for sleep-disordered breathing—especially when snores are loud or accompanied by noisy breathing and can be heard three or four nights a week.
“Snoring is a better predictor of hyperactivity than a sleep study,” Bonuck told me. “Unfortunately, most parents don’t see it that way,” she adds. “Research shows close to half of parents think that snoring is a sign of healthy sleep—’He snores like a baby,’ they say.”
If your primary-care doctor brushes it off, she suggests recording your child sleeping. “Push it. Say, ‘Listen to this. What should I do?'”
Watch your child sleep.
Parents often don’t realize the extent of disturbed sleep until a family vacation that puts everyone in the same room, Winter says. That’s when they notice gaps in regular breathing, where the child seems to struggle to breathe—and yes, it can be really scary!
During those moments when the body wakens to breathe, a child might gasp, cough, snort, call out, talk, grind teeth, even sleepwalk or wet the bed—but not remember anything the next morning. They’re not aware they had a lousy night’s sleep.
In the morning, you might also notice a pillow wet with drool. Some kids with apnea wake up with headaches. They may breathe through the mouth during the day.
Pay attention to your child’s growth.
“Kids with disturbed sleep stop growing robustly,” Winter says. During sleep, the body makes growth hormones. That’s why deviating from the growth curve can be a red flag for disordered sleep.
Weight gain is also a clue. Sleep deprivation can interfere with the hormones that manage appetite, as well as cause the body to resist insulin. Or a child, even a hyperactive one, may be too tired to get enough exercise. All these things can lead to packing on pounds.
Notice behavior cues.
Typically, the first signs on a parent’s radar are behavioral. The catch is that these clues overlap with age-appropriate behaviors. By the time they’re problems, once a child is in school and dealing with other students and teachers, it’s relatively late, Winter says.
Or a teacher may raise the possibility of ADHD because of those things.
Look at the whole child.
You might also watch for groupings of symptoms—say, snoring + bed-wetting + inattention, or hyperactivity + short stature + noisy sleep. The American Academy of Pediatrics recommends an overnight sleep study when signs of obstructive sleep apnea (like the ones described above) are shown, although diagnosis is possible without one.
Ask your child’s doctor about an evaluation by an otolaryngologist (ear-nose-throat doctor) or a sleep specialist. This can be especially important if ADHD is being diagnosed or medication for inattention and hyperactivity is prescribed.
“I would conclude that a significant minority of the huge number of children with ADHD would stand to benefit if their sleep-disordered breathing were addressed,” Chervin says. “Still, it’s not on the radar of ADHD specialists—and it needs to be, especially because it is to a large extent treatable.”
The #1 solution: removing the tonsils
More than half a million tonsillectomies a year are done in the U.S.—80 percent of them to treat sleep apnea, according to the American Academy of Otolaryngology. (Thirty years ago, 90 percent were done to treat infection.) It’s an effective treatment for as many as 9 out of 10 thin children with sleep apnea, and about half of overweight kids.
As breathing problems clear up, often so do attention problems. A 2006 study found that half the children who’d been found to have ADHD before an adenotonsillectomy (removal of tonsils and adenoids together) no longer met the criteria for ADHD a year after the surgery.
Kids with apnea who were thriving before surgery seem to do even better. A 2016 study of high-achieving kids ages 3 to 12 with suspected apnea showed that they, too, showed improvements in attention, hyperactivity, and social behaviors after adenotonsillectomy.
A 2013 study in the New England Journal of Medicine found improvements in behavior, quality of life, and mood for 5- to 9-year-olds with sleep apnea seven months after surgery, compared to a non-surgery group who were just monitored, but found no differences in attention and executive function. One possibility, according to Bonuck and Chervin, is that the intervention came too late; some ADHD-like effects of sleep-disordered breathing may not be reversible.
One complication is that many surgeons are reluctant to remove tonsils before age 2 or 3, Chervin says. The second most common surgery requiring general anesthesia (after appendectomy), tonsillectomy can be performed as young as age 1.
In cases where symptoms are mild or the child is very young, “watchful waiting” is recommended instead of surgery for a year or so. Some, but not all, kids get better as they grow.
“Unfortunately, there’s not a crystal-clear message,” Chervin told me. “We can say there’s a bad sleep disorder with potentially lifelong effects—the problem is that we don’t know who falls into that category. We don’t know the trajectory of what’s reversible or not. We haven’t determined the best time to intervene.”
He’s hopeful that future research on younger children will shed more light on those puzzles. In general, though, “the earlier the better” for getting snoring and other symptoms checked.
Good morning, new (well rested) kid.
Getting to the right root problem—and treating it—can lead to more than improved behavior. Parents often see a ripple effect of changes in areas they never linked to their child’s sleep, experts say.
For many chronic bed-wetters, the problem, and the embarrassment, ends.
Kids start performing better in school.
They often shoot up in height.
They have more energy, lose weight if overweight, and have lower blood pressure (which means a lower risk of heart disease).