ЕNT and SLEEP: Disruptive Behavior Disorders in Children before and After Adenotonsillectomy

By Dina Golbin, Med Student 3, RPSGT

Sleep-disordered breathing (SDB) has been linked to inattention, hyperactivity, and aggression. Although SDB is present in many children who undergo Adenotonsillectomy (AT), little is known about behavior problems they may have.  A group of researchers  previously reported disruptive behavior disorders (DBDs) in 20 of 45 children 5-12 years-old evaluated before scheduled adenotonsillectomy. Later, they expand these findings to include 77 subjects and 23 controls, and for the first time report diagnostic outcomes in 56 children rigorously assessed just before and one year after adenotonsillectomy.

The results demonstrated that disruptive behavior disorders were diagnosed in 38% of the children scheduled for adenotonsillectomy, significantly more than the 9% rate for control children. The frequency of these disorders dropped by 50% in one year after surgery. These findings suggest that sleep-disordered breathing may play an important role in the etiology and treatment of disruptive behavior disorders in some children.

ENT treatment including adenotonsillectomy might help breathing and improve behavior in afflicted children. ENT evaluation of children with disruptive behavior disorder for possible underlying breathing problems, especial in sleep, is important part of treatment.

Ref; Dillon JE Ruzicka D. Champine DJ, Fluent TE, Marriott DJ, Giordani B.  
Weahterl RA, Chervin RD (University of Michigan Medical School).
Sleep, Vol. 26, Abstract Supplement, 2003

Polysomnographic Analysis of Sleep Disrupted Autism Patients disturbance in the children. Previous studies have suggested on increased prevalence of Periodic Limb Movements in Sleep (PLMS) or REM Sleep Behavior Disorder (RBD) in children with autism.

Results: By history, the 8 autism children have difficulty initializing and maintaining sleep and all 8 children have a history of snoring. By history, sleep enuresis is present in 5 of the 8 children. Four of the 8 children have been previously diagnosed with Attention-Deficit-Hyperactivity Disorder (ADHD). One patient has a history compatible with Restless Legs Syndrome (RLS). The neurological and general physical examination was grossly normal in all patients. PSG study showed that there of the 8 children had an apnea index >1.0. Five out of 8 patients had sudden awakening of 10 seconds to a few minutes directly from slow wave sleep (stage III and IV). These events were associated with an increase in cardiac and respiratory rate on PSG and arm and leg movements as documented by video. In no case did any child leave the bed to walk during those episodes. A diagnosis of Confusional Arousal/Sleep Terrors could not definitely be made due to problems of determining the level of awareness in an autistic child. Only one patient had a significant PLMS index>5.0 (7.3) and that child also had ADHD. No child had evidence of RBD on either night of the Polysomnographic study. An arousal index > 10/hour occurred in 2 of the 8 patients (20 and 23.8). Sleep efficiencies were on average above 90%, but sleep times were sometimes shortened and bed times were later than at home due to laboratory schedule demands. The overall sleep architecture for the children as a whole was close to normal except that REM was lower (average 13.7% TST), perhaps due to the foreshortened sleep times.

Conclusions: A variety of sleep disturbances occur in children with autism and insomnia. The most frequent of these are sleep disordered breathing, enuresis, and polysomnographic findings compatible with confusional arousal/sleep terrors. All together, all 8 of the children with autism had historical evidence of sleep disordered breathing and all had either historical or polysomnographic evidence suggestive of at least one parasomnia.

Sun Y. Ming SX. Walters AS
(1) New Jersey Neuroscience Institute at JFK Medical Center, 65 James Street. Edison, NJ 08820. (2) UNDNJ New Jersey Medical School, Dept. of Neuroscience

Introduction: The parents of children with autism frequently complain of sleep Sleep, Vol. 26, Abstract Supplement, 2003

0300. G

Periodic Limb Movements in Sleep (PLMS) and Restless Leg Syndrome (RLS) in Children with “Growing Pains”

Rajaram S. Wahers A.S. Nizam F. Metha D.
(1) New Jersey Neuro Science Institute at JFK Medical Center, Edison, NJ (2) Albert Einstein School of Medicine, New York

Sun Y. Ming SX. Walters AS

(1) New Jersey Neuroscience Institute at JFK Medical Center, 65 James Street. Edison, NJ 08820. (2) UNDNJ New Jersey Medical School, Dept. of Neuroscience

Introduction: The parents of children with autism frequently complain of sleep Introduction: The purpose of the study is to determine if children with “growing pains” have RLS and PLMS. The next goal is t determine if “growing pains” respond to dopaminergic drugs. There have been no studies done to evaluate the prevalence of PLMS in children with “growing pains”. Many children with RLS have been misdiagnosed as “growing pains”. The prevalence of PLMS in children with RLS is not known. RLS and PLMS occur more commonly in children with ADHD.

Results: A total of 10 children with “growing pains” were evaluated. Nine of these 10 children met criteria for RLS. One of these 9 had pain in the arms predominantly in addition to the legs. The average PLMS of the 9 children with RLS was 4.9 per hour. The range was 0.3 to 27. Only 3 of these 9 children had PLMS index more than 5 per hour of sleep. The Apnea index average of these 9 children with RLS was 0.61 with a range of 0 to 2.65. Two children had apnea index more than 1. Four of these 9 children with RLS were started on L-Dopa treatment. Two of these children had an average pre-treatment RLS rating scale of 30.5 that went down to 11 in two months follow-up. The other 2 children on treatment need follow -up evaluation in 2 months. Preliminary results of the RLS rating scale after treatment showed significant improvement in the complaint of growing pains and RLS symptoms. Four children of 10 with “growing pains” have ADHD. RLS was misdiagnosed as “growing pains” in 9 of 10 children.

Conclusions: A PLMS index of more than 5 per hour seems to occur less frequently in children with RLS compared to adults, but further investigation is warranted. This study further confirms that RLS can be misdiagnosed as “growing pains”. As with other previous studies there seems to be a high correlation between ADHD and RLS/ PLMS. As in other previous limited studies, childhood RLS seems to respond well to L-Dopa therapy.

Sun Y. Ming SX. Walters AS

(1) New Jersey Neuroscience Institute at JFK Medical Center, 65 James Street. Edison, NJ 08820. (2) UNDNJ New Jersey Medical School, Dept. of Neuroscience

Introduction: The parents of children with autism frequently complain of sleep

Sun Y. Ming SX. Walters AS

(1) New Jersey Neuroscience Institute at JFK Medical Center, 65 James Street. Edison, NJ 08820. (2) UNDNJ New Jersey Medical School, Dept. of Neuroscience

Introduction: The parents of children with autism frequently complain of sleep


Hyperactivity Symptoms Are Related to Poor Sleep in Children with ADHD

Cohen-Zion M, Leslie LK Nathan D, Ancoli-Israel

SLEEP, Vol. 26, Abstract Supplement, 2003
(1) SDSU/UCSD Joint Doctoral Program in Clinical Psychology. (2) Child and Adolescent Services Research Center, San Diego Children’s Hospital, (3) Department of Pediatrics UCSD, (4) Department of Psychiatry, UCSD, (5) VASDHS

Introduction: ADHD is the most commonly diagnosed behavioral disorder of childhood. Subjective and objective reports have shown that children with ADHD have extensive sleep disturbances and age-inappropriate increases in daytime and nighttime activity levels. This study therefore, examined whether there is a relationship between objectively recorded sleep and severity of ADHD hyperactivity symptoms.

Conclusions: These data suggest a possible relationship between daytime hyperactivity levels in children with ADHD, number of nighttime awakenings, and time spent awake during the night. Children with ADHD are known to have extensive increase in arousal levels and daytime activity patterns, which may be extending into their nighttime period and thus affecting their nighttime sleep. We are continuing to collect data to further examine these possible relationships.

Research supported by NIMH MN 65793, Research Service of VASDHS

0314. G
Daytime Sleepiness And Sleeping Habits of High School Students
Kayumov LL, Tatourian I, __________M., Rahman F., Shapiro CM
(1) Runnymede Public School, JA McDonald Collegiate Institute, Sleep Research Laboratory, Toronto Western Hospital, Canada. (2)Department of Psychiatry, University of Toronto, Canada

Introduction: Poor sleep hygiene and sleep deprivation in adolescents have been linked to unintentional injuries, low grades and poor school performance, negative moods and increased likelihood of stimulant use. To date there is limited research information on the effects of sleep disturbance on adolescents. There is also lack of awareness of the problem of seep deprivation in adolescent students and daytime sleepiness or decreased alertness are still not recognized as significant obstacles to the education. However, the combination of late night social schedule, part time jobs, sport or other activities of high school students are significantly compressing the hours available for sleep, causing daytime sleepiness and lack of attention in the classroom. The purpose of this study was to investigate seeping habits in a group of randomly selected grade 11-12 students.

Conclusions: This study showed evidence of significant sleep deprivation and daytime sleepiness in high school students. Surprisingly the high proportion of students who reported difficulty initiating sleep despite chronic sleep deprivation implies disturbed circadian mechanisms regulating sleep/wake cycle in this population.

0315. G

Daytime Sleepiness in Children with Attention Deficit Hyperactive Disorder
Golan N, Suraya S. Pillar G
(1) Sleep Laboratory, (2) Department of Pediatrics A, Rambam Medical Center and Technion – Israel Institute of Technology, Haifa, Israel

Introduction: Children with attention deficit hyperactive disorder (ADHD), although hyperactive, benefit from stimulant treatment. We hypothesized that children with ADHD are in fact sleepy during the day and sought to test it objectively.

Methods: Thirty four children with a previous diagnosis of ADHD (age 12.4 ± 4.6) (mean ± STD) and 32 matched controls (age 12.0 ± 3.6 years) were studied. All underwent a full night polysomnographic study followed by a multiple sleep latency test (MSLT).

Results: During the night study, sleep latency, total sleep time and sleep efficiency were comparable between the groups. Yet, ADHD children were significantly sleepier than controls during the day (mean MSLT score of 21.9 ± 5.5min vs. 27.9 ± 2.0min, p<0.005). Eighteen of the ADHD children have been found to suffer from obstructive sleep apnea syndrome (50%) vs. 7 of the control group (22%, p<0.005). Five of the ADHD group had periodic limb movement of sleep (PLM, 15%) vs. However, surprisingly, within the ADHD group; children with OSA were not sleepier than children without OSA. Children without a noticeable primary sleep disorder had the lowest nocturnal sleep efficiency and total sleep time.

Conclusions: Children with ADHD demonstrate objective daytime somnolence, which can explain the beneficial effects of stimulant medications. Sleep disorders should be looked for in children with ADHD, as many of them (over 50% in this study) may suffer from a primary sleep disorder. ADHD children without a primary sleep disorder may have low sleep efficiencies and short total sleep time.