The sleep apnea and ADHD connection: Our children bear the scars
Sleep apnea is not just an adult problem. Far from it. Between 1% and 3% of young children have sleep apnea/disordered breathing, and if untreated, can grow up with lasting scars. Habitual nighttime battles for adequate air can set a child up for ADHD symptomology and a lifetime of mental health problems that flow from this.
- Difficulty getting organized
- Reckless driving and traffic accidents
- Marital difficulties
- Extreme distractibility
- Poor listening skills
- Restlessness, difficulty relaxing
- Difficulty starting a task
- Chronic lateness
- Angry outbursts
- Prioritizing issues
So tonsils are connected with mental health?
Strong correlations have been established and causal relationships are beginning to emerge from the research, but aside from this, there is something very fundamental we know: breathing matters. Oxygen matters. Acute lack of oxygen is a death sentence, a chronic shortage of oxygen is going to lead to a suboptimal life, and the little throats of children have disproportionately large organs around which to negotiate the air they need. Here's something else we do know: 10% of children snore regularly, and it is estimated that 10% to 30% of these children have obstructive sleep apnea. (2,3,4,5)
But wait — it gets worse! Untold numbers of children suffer from other upper airway restrictions that mimic OSA but which are not considered a problem by many people in the medical community. In total, that is a lot of children to put at risk for permanent damage from dysfunctional breathing.
In children who have moderate to severe OSA, the airway is so compromised that the body is in continual "fight or flight" mode, as the primitive brain struggles for oxygen. A child will snore, repeatedly stop breathing, and then arouse to recover, only to fall back into the cycle. Not only is there an oxygen deficit, but the "fight or flight" mode causes surges of sympathetic system hormones (adrenaline and cortisol) to be delivered throughout the bloodstream. In the short term, the child will simply be exhausted, "fuzzy," distracted by day. Over time, however, as the barrage of hormones habitually attacks the nervous system and organs, permanent changes take place. Anxiety, depression, and other psychological disorders are among the consequences of this unremitting hormonal onslaught.
In fact, researchers are accruing evidence that much of the behavior we call ADHD is a result of chronic struggle for oxygen from obstructive sleep apnea, and a significant percentage of the time, this is something that can be resolved by tonsil removal. Multiple studies have demonstrated that ADHD symptoms subside substantially postsurgery, and some studies even indicate that 20% to 30% of the participants who were diagnosed with ADHD became completely asymptomatic for ADHD. (6) If OSA is caught and treated early, we can mitigate damage and the toll that living with ADHD takes on the psyche.
The "adenoidal face" reflects childhood struggle
Any dentist, orthodontist, or physician can recognize the characteristics of what is called "adenoid facie" — a face that has developed an abnormally long, narrow bone structure due to chronic mouth-breathing over the growth years. The "dumb look" may belie an intelligence that is often dwarfed or subverted by years of others' negative responses to a tired, forgetful, distracted demeanor. Loneliness, rejection, failure in others' eyes, eventually converts to anger — at self or others.
The brain is permanently damaged by the struggle with airway incompetence. An indelible mark is left. Generally, only the person's close relationships suffer from the damage, but sometimes a missed diagnosis may have had repercussions way beyond that small circle. While we will never know the etiology of Adam Lanza's tragic rampage, he exhibits the classic "adenoidal face," and one can't help but wonder if he wasn't, as a child, victim to his own nighttime battles for air, and what kind of impact that made on his mental state over time.
Spare the knife, risk the outcome
Tonsillectomies are still painful and still carry the attendant risks of major surgery. However, the risk of morbidity or misplaced trust in a surgeon are very low, and to let fear blind us to the enormous benefits children receive from relieved airways, improved oxygenation, peaceful sleep, and potential prevention of long-term mental health problems is far riskier.
What if my child snores or exhibits ADHD symptoms?
A one to two night polysomnic sleep test at a certified sleep laboratory will enable a sleep medicine professional to rule out sleep disordered breathing or recommend surgery (primary recommendation for children), CPAP, or oral device treatment.
Dr. Metz is a diplomate and board member of the American Association of Dental Sleep Medicine. Having treated more than 2,500 sleep disordered patients, his outreach to colleagues, physicians, and the public is part of his mission to raise health risk awareness and improve treatment for sufferers of TMD and OSA. He brings a soft-spoken style and visionary approach to educating others in "medistry" (a term he coined for medically-informed dentistry). Since shedding 100 pounds in 2004 and alleviating his own case of sleep apnea, Dr. Metz relates readily to those struggling with OSA, obesity, and their attendant health problems. For more information, visit www.themetzcenter.com.
Head and Neck Surgery website, 2013.
Newacheck PW. Am. J Public Health, 1992.
Rosen C. Sleep, Yale University School of Medicine, 1996.
Chang S, Chae K. J Pediatrics, Oct. 2010.
National Sleep Foundation website, 2013.
Oguzturk O. J Clin Psychological Medical Settings, 2012