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Shortage Of ADHD Medications Creates An Uproar

A recent New York Times article reports on the shortage of medications for people with ADHD, or attention deficit hyperactivity disorder. There’s a lot of speculation about why this is happening. One explanation that was put forth was that the FDA (Food and Drug Administration) is limiting the available supply, due to the high rates of possible abuse of these stimulant medications. My response was a little off-topic, but I just had to comment. Here’s a reprint of what I wrote:

“There’s no doubt that ADHD medications can be lifesaving for millions of Americans, but there’s another dimension to this issue that’s being ignored by the mainstream media and the general public, despite growing evidence in published studies. 

It’s a general consensus in sleep medicine that sleep deprived adults get drowsy, whereas children become fidgety and hyperactive. Not only are todays’ children sleep deprived (homework, TV, etc.), many are not able to breathe properly at night, due to narrowed airways.

In a study published in Pediatrics in 2006, 28% of children scheduled for tonsillectomy were found to have undiagnosed ADHD, compared to 7% in controls. After tonsillectomy, 50% of the ADHD group were cured. Another study showed that children with ADHD are more likely to snore, and that about 25% of children with ADHD could be treated effectively by treating their sleep apnea.

Notice all the typical findings in a child with sleep-breathing problems that are also found with ADHD: inability to sleep supine, snoring, nasal congestion, mouth breathing, snoring parents, unrefreshing sleep, frequent urination, inability to focus or concentrate, history of needing braces, and bottle-feeding. You don’t have to be obese or snore to have sleep apnea.

It’s clear that in some children with ADHD, stimulants like Ritalin or Adderall work because they’re sleepy. My feeling is that all children with ADHD should be screened for obstructive sleep apnea.“

Let me make it clear that I’m NOT saying that all children with ADHD have obstructive sleep apnea. But even if it’s only 25% (a very conservative number), the implications are huge. If you look at the CDC’s website on ADHD statistics, it’s frightening. 

• 9.5% or 5.4 million children 4-17 years of age have ever been diagnosed with ADHD, as of 2007
• Rates of ADHD diagnosis increased an average of 3% per year from 1997 to 2006 [Read article ] and an average of 5.5% per year from 2003 to 2007
• Prevalence of parent-reported ADHD diagnosis varied substantially by state, from a low of 5.6% in Nevada to a high of 15.6% in North Carolina
• As of 2007, 2.7 million youth ages 4-17 years (66.3% of those with a current diagnosis) were receiving medication treatment for the disorder
• Rates of medication treatment for ADHD varied by age and sex; children aged 11-17 years of age were more likely than those 4-10 years of age to take medication, and boys are 2.8 times more likely to take medication than girls.

Remember that these are 2007 statistics. Ten percent of the pediatric population has ADHD, and 6-7% are on medications! As a population, we’re much heavier than we were 5 years ago, which means that these figures are probably an underestimation. The children that we’re medicating now are mostly likely the ones that we’re going to have to give even more medications to later in life after they develop the medical complications of untreated obstructive sleep apnea (diabetes, depression, anxiety, hypertension, high cholesterol, obesity, heart disease, heart attack and stroke). In my mind, all these conditions are connected. They are all one and the same disease, but with different manifestations.

Missing Teeth = Poor Health?

Ever since I began seeing patients in my new position at Montefiore medical center, I’ve been surprised by how many patients have missing teeth. In fact, many have no teeth at all, and often have to wear dentures, especially if they’re in the elderly years. Not too surprisingly, these same patients also have a number of chronic medical conditions, such as hypertension, diabetes, high cholesterol, heart disease, as well as numerous medications for these respective conditions. Many are obese.

Being in a major tertiary-care referral-based hospital, it’s expected that patients will have complex medical issues. But this observation only supports what dentists have been saying for years—that poor dental health equals poor general health. Not only do I see multiple missing teeth, there’s also significant jaw narrowing and crowding of the soft tissues of the mouth. Having smaller airways due to missing teeth and smaller jaws can aggravate significant medical problems, such as hypertension, diabetes, high cholesterol, and heart disease.

We’re seeing an epidemic of jaw underdevelopment these days, with dental crowding and numerous orthodontic and airway issues that arise as a result. The rise in premature babies, modern feeding habits, nutritional factors, and various toxins in our environment can prevent proper facial growth and development. It’s no wonder that we’re seeing increasing rates of ADHD, autism, and various other developmental delays. These are the same kids that will go on the develop high blood pressure, diabetes, obesity, high cholesterol, and heart disease later in adulthood.

You could argue that having bad teeth is a consequence of the particular population that we serve, but knowing what we know about the importance of proper jaw development and dental health, it’s likely that poor dental issues also predisposes people to chronic medical problems.

 

What do you think about my observations? 

Teens Are Using More ADHD Medications

Attention deficit hyperactivity disorder seems to be an epidemic these days. A new study revealed that the rate of children using stimulant medications increased from 2.4% to 3.5% from 1996 to 2008. However, in teens aged 13 to 18, it rose from 2.3% to 5%. The article also mentions that 9% of all children have been diagnosed with ADHD at some time in their lives. 

My question is, why do stimulant medication help to calm already hyperactive children? A study published in the journal Pediatrics in 2006 showed that about 27% of children who were scheduled for routine tonsillectomy had ADHD by official criteria (compared to 7% in controls). After surgery, the rate of ADHD in these children dropped 50%. Clearly, there are a number of other possible aggravating factors involved with ADHD, but I’m willing to bet that problems breathing at night is a major factor, if not the the most important factor. 

It’s clear that the reason stimulants work in most children with ADHD is because they’re chronically sleep deprived. Many parents will agree with my experiences with my 2 year old—if he’s overly tired or skips a nap, he’s “bouncing off the walls,” It’s not surprising that many of the children that I see who are on ADHD medications also tend to be mouth breathers, have an elongated face, and has an “adenoid facies” appearance.

If you have a child with ADHD, what is the quality of his sleep? Can she sleep on her back? Which of the parents of a child with ADHD snore heavily?

 

The ADHD & Autism Spectrum Disorder Epidemic

A recent guest post on KevinMD’s blog points out that the rate of autism spectrum disorders (ASD) has increased 57% from 2002 to 2006. Currently, about 1 out of every 100 children born are thought to have ASD. It’s estimated that about 60 to 70% of ASD are from environmental factors, whereas 30-40% are due to genetic issues. The writer, Philip Landrigan, focuses on the possible environmental causes of autism and ADHD (attention deficit hyperactivity disorder), arguing that there are now over 80,000 synthetic chemicals that have been developed over the past 50 years. Many of these compounds have been shown to be toxic to developing brains in children. Currently 200 are toxic in adult humans, and another 1,000 are toxic in experimental models.

I have no doubt that many synthetic chemicals can be toxic to childen and adults, including some pharmaceutical products. In the world that we live in, with all the conveniences of modern life, we’re inundated to a multitude of synthetic chemicals, many of which are safe, but some are not.

However, one area that ASD and ADHD researchers almost never bring up during discussions is the fact that sleep-breathing problems are also progressing over time. Having smaller jaws and dental crowding leads to smaller airways, with leads to frequent breathing problems during sleep, with fragmented sleep. Lack of continuous, deep, efficient sleep has been shown to cause a number of biochemical, hormonal, and neurologic changes in the brain, usually for the worse. Countless times, I see children on stimulants for ADHD come off their medications after their large tonsils are taken out. Almost invariably, one or both parents of children with ASD or ADHD have major snoring or sleep apnea. 

Clearly, not everyone with ADHD or ASD has sleep-breathing problems, and not all areas of obstruction are due to large tonsils. However, even if 1/3 of these children have an underlying sleep-breathing problem (some have suggested 50%), wouldn’t it make sense to routinely screen for snoring and sleep apnea in any child with ADHS or ASD? 

Sleep Apnea Causes High Blood Pressure In Children

A new study out of Australia showed that in children with obstructive sleep apnea, their blood pressure levels were higher while awake just before sleep onset and during sleep. Overall, their blood pressure was 10-15 mm Hg higher compared with controls. Blood pressure was elevated, regardless of the severity of sleep apnea. The authors argue that thresholds for mild forms of sleep-disordered breathing needs to be reassessed, and that benign snoring should not be considered benign anymore.

I totally agree with the study authors. Sleep apnea doesn’t begin in middle age—it begins during the early childhood years. Having smaller jaws and more narrow airways predisposes to additional inflammation, causing lymphoid tissues (tonsils and adenoids) to become larger, which causes even more breathing problems. Taking out tonsils and adenoids are usually the first line therapy for most children with sleep apnea, but a significant number of children will have persistent sleep apnea, despite surgery. Since most children undergoing adenotonsillectomy don’t have sleep studies before and after their procedures, we’re probably missing a large number of children with persistent obstructive sleep apnea, despite subjective and clinical improvement in their symptoms.

Addressing these issues early on could potentially prevent many of the complications that may occur later in adulthood. A child that doesn’t sleep well due to breathing problems can manifest with a number of medical conditions, such as ADHD, asthma, developmental delay, bedwetting, ear infections, or even mood disorders. The public health implications are potentially huge.

 

 

 

 

 

 

 

 

 

 

Do Bullies Have Sleep Apnea?

Recent research shows that snoring children are more likely to display aggressive behavior. Furthermore, children with conduct problems, bullying, or discipline referrals had a higher likelihood of having a sleep-breathing disorder. This study is not too surprising, since lack of sleep can inhibit higher level cortical thinking and cognition, and bring to the surface the more primitive, emotional, deeper-brain centers.

These children are also probably more likely to be diagnosed with ADHD, or any of the other various behavioral or developmental problems that can occur with poor sleep quantity or quality. One of the most common complaints that I hear amongst parents at my sons’ schools is that no one in the family can sleep well. This is such a huge, but preventable problem that’s essentially being ignored by the schools and parents, thinking that it’s just a part of modern life. Many parents are happy with giving their children stimulant medications, rather than to take care of the root cause of their child’s problems.

Do you know any children that fits what I describe?

ADHD & Autism Rates Spike—Is Sleep Apnea Responsible?

Researchers were surprised that that rate of ADHD and autism have spiked over the last 10 years. ADHD increased 33%, whereas autism increased from 0.19% to 0.74% over the same time period. Honestly, I’m not surprised by these results. Here’s my explanation for the continued rise in these two common developmental disorders:

1. There’s definitely more awareness of these two conditions (ADHD and autism), as well as more inclusive criteria for diagnosis
2. Implementation of the back to sleep campaign about 20 years ago
3. Worsened diet
4. Bottle-feeding
5. Environmental endocrine disruptors
6. Less total sleep time
7. increased incidence of allergies and food sensitivities.

There’s even evidence showing that common motor-skill milestones are often coming in delayed, since infants are not spending as much time on their tummies, even during the day. As expected, skull deformities (flat head) are much more common since the back to sleep campaign.

What does this have to do with obstructive sleep apnea? Here are 3 important reasons:

1. Factors 2 to 6 all significantly increase your risk for obstructive sleep apnea, through either poor jaw development or inflammation of the upper airway.
2. Obstructive sleep apnea can predispose to obesity, which narrows your airway even further
   
3. Sleep-breathing problems begin during infancy, and the lack of deep, efficient sleep, not to mention frank hypoxia from apneas, can be detrimental to the infant’s brain development and biochemical pathways.

I realize that there are a number of other possible reasons for ADHD or autism (probably a combination of many factors), but not getting deep sleep can be a major barrier to proper brain development. Studies are definitely needed in this matter. Unfortunately, the medical/pharmaceutical industry is unlikely to change the status quo.

What do you think about this study? It is from over-reporting or more awareness, or is it for real?

 

 

 

25% of Children In The United States With Sleep Apnea?

Here’s some heartbreaking news that was recently published in the Wall Street Journal and commented on at KevinMD: That 25% of all children in the United States is on regular prescription medications. According to the report, 45 million children are on asthma medications, 24 million on ADHD medications, another 10 million on antidepressants and 6.5 million on antipsychotics. You also have the antihypertensives, sleeping pills, diabetes medications, and high cholesterol medications. This list doesn’t include prescriptions used in acute situations or over-the-counter medications.

You might be asking by now, “What does all this have to do with sleep apnea?”

My answer is, everything. If you happen to follow my blog, I’ve shown studies linking obstructive sleep apnea to almost every chronic health condition out there. This is based on published, peer-reviewed studies. What I did was only to connect all the dots, so to speak, to conceive of my sleep-breathing paradigm: That all modern humans, due to jaw underdevelopment, have various degrees of sleep-breathing problems, where only the end result is called obstructive sleep apnea. This problem begins while you’re an infant, and is aggravated by dietary and behavioral factors such as bottle-feeding, thumb-sucking, and eating the Standard American Diet (SAD). It’s also possible that the back to sleep campaign (although it lowered the SIDS rate by 40%), by forcing infants to sleep on their backs, may inadvertently prevent quality deep sleep in infants. Babies need good amounts of deep sleep for memory consolidation and brain development.

We also know that multiple breathing pauses can cause your stomach juices to reflux into your throat, and then into your lungs (or nose). This can cause various degrees of inflammation. Neurologically, your lungs will tend to over-react to weather changes, such as cold air, or even temperature or humidity changes. Breathing problems can also cause poor quality sleep, leading to major alterations in your brain biochemistry.

Poor sleep can also aggravate or promote the onset of depression. Faulty neurotransmitters or even structural damage from poor sleep can also cause your brain signals to misfire, or activate disinhibition of certain behaviors.

It’s no wonder that in one way or another there are studies (or will be studies) that connect all the various medical conditions already mentioned to one another. So it’s not too far fetched to argue that a large proportion of these children on chronic long-term medications may also have some kind of a sleep-breathing problem.

What do you think about my arguments? A realistic, but scary possibility, or too far fetched?

How Breast Feeding Improves Children’s Behavior

There are numerous studies on the health benefits of breast feeding, and here’s another one that supports my sleep-breathing paradigm, that your overall state of health is directly proportional to how well formed your jaws are as you age (and subsequently your breathing passageways).

Researchers from Oxford University in the UK found that infants who were breast-fed for at least 4 months had a 33% less chance of having behavioral problems by age 5. They speculate that breast milk has higher amounts of healthy fatty acids, growth factors and hormones that contribute to healthier brain development.

The one thing that all these studies fail to address is that bottle-feeding can cause malocclusion and jaw narrowing. The smaller your jaws, the less room there is for your tongue, which can cause breathing problems when the infant is placed on his back. Add muscle relaxation from deep sleep, and you’re going to deprive infants of quality deep sleep which is vital for proper brain development. With the addition of back sleeping in infants to bottle-feeding, it’s likely that this combination is a major reason for the significant rise in pediatric developmental problems that are so rampant these days.

If you have obstructive sleep apnea, were you breast or bottle-fed as an infant?

Asthma Rates Spike, Helped By Sleep Apnea?

Researchers are puzzled as to why there seems to be a significant rise on rates of asthma in children compared to previous years. A new study released from the CDC reported that nearly one in 10 children and one in 12 Americans have asthma. From 2001 to 2009, the overall rate of asthma increased 12.3%. In 2007, it cost $57 billion to care for asthma patients.

Despite lower rates of smoking and second-hand smoke, the prevalence of asthma increased in all demographic groups, including men, women, whites, blacks, and Hispanics. Possible reasons for this sudden increase include various allergens, traffic fumes, pesticides, certain plastics, diet and obesity.

Here’s one more possibility: Obstructive sleep apnea. We know that children are more overweight than ever, and along with this it’s expected that sleep apnea will increase as well. Multiple breathing pauses at night can literally suction up your stomach juices into your throat, which can then reach your nose or your lungs. This causes your nose and your lungs to become inflamed and overreactive to allergies, fumes, and even weather changes. Lack of deep sleep also causes your nervous system and your immune system to become hypersensitive, aggravating this vicious cycle.

Notice how it’s not just asthma rates that are going up. Many of the other childhood related conditions are going up as well: obesity, ADHD, autism, allergies, etc. These are all part of the same continuum that unfortunately, are treated as independent conditions. With multiple breathing pauses at night, any of these conditions can occur or aggravate an already existing condition.

If you have asthma, how many of you can’t sleep on your back? (I’ll tell you why I ask this question a bit later.)

 

 

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