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NY Times Highlights The Importance of Sleep in ADHD

Here’s an important article that everyone should read in the New York Times.  The author highlights the fact that in many cases of attention deficit hyperactivity disorder (ADHD), the real deficit may in your child’s sleep.

Can Snoring As A Baby Predict Behavior Problems?

Here’s a new study which reinforces what I’ve been saying about sleep-breathing problems and children: That it’s a major undiagnosed cause of developmental and behavior problems in childhood. Researchers from Albert Einstein College of medicine followed over 11,000 children over a 6 year period. Parents were asked about snoring in sleep surveys from 6 months on, and at 7 years, they filled out a behavioral assessment. Not too surprisingly, children who snored as early as 6 months of age had a 50% increased risk of developing behavior problems by age 7 compared to controls. 

We know that children who are sleep deprived become paradoxically hyperactive. In contrast, adults get sleepy (there are always exceptions to this observation). This study supports another study which I mentioned in the past showing that in children with ADHD who undergo tonsillectomy, about 50% can be cured for their ADHD condition. It’s no wonder that stimulants like Ritalin can help to calm a hyperactive child. 

It’s important to note that I’m not saying all cases of ADHD are due to sleep-breathing disorders. However, it’s been estimated that a significant number of children (25 to 50%) with an ADHD diagnosis could have a treatable sleep-breathing problem. With these numbers in mind, wouldn’t it make sense to routinely screen for obstructive sleep apnea or a sleep-breathing problem before being given an ADHD diagnosis?

 

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? 

Myths About Tonsillectomy, Sleep Apnea, and Bedwetting

One of the biggest myths within the sleep community is that taking out tonsils in children can cure sleep apnea. Yes, it can work to various degrees, sometimes dramatically, but it doesn’t work in all children. In fact, a recent large-scale meta-analysis showed that adenotonsillectomy was found to be significantly effective in about 60% of children. My 11 year old son was one such child. He had a dramatic response initially when he had his tonsils and adenoids taken out at age 5. But now, it’s slowly coming back, as expected.

Two recent studies continue to repeat the same kind of studies showing that removing tonsils and adenoids can help many children with their sleep apnea or bedwetting (sleep apnea is known to cause bedwetting in children as well as having to go often at night in adults). When the press reports on these kind of studies, they imply that surgery can be a “cure” for sleep apnea or bedwetting.

The adenotonsillectomy for sleep apnea article reported significant drops in the AHI in the mild group (2.6 to 1.5) as well as in the severe group (16.3 to 2.7). But notice that if you use the accepted AHI level of 1 as being abnormal, then their results weren’t that good. What they stressed, however, was that left heart enlargement improved with sleep apnea treatment.

The bedwetting article showed that in children who wet their beds only at night, they had about a 50% drop in bedwetting episodes. Those that had problems at night and during the day didn’t see any significant improvement. They went on to list various risk factors such as prematurity, such as prematurity, higher BMI, male sex, severe bedwetting and family history of bedwetting.

The reason why many of these children don’t respond to adenotonsillectomy (as well as those that respond only partially or relapse later on) is that they still continue to have narrow jaws and dental arches. They have various degrees of craniofacial narrowing and underdevelopment. Having smaller jaws and dental crowding can also make your tonsils larger (which causes more obstructed breathing).

I’m not minimizing the importance of these two studies. However, I wanted to point out that these type of solid scientific studies only perpetuate our black and white understanding of any type of intervention for obstructive sleep apnea.

If you had your child’s tonsils and/or adenoids taken out, did his/or problems improve? And if so, did it last?

Can Tonsils Grow Back After Removal?

Tonsillectomy is one of the most common surgical procedures that’s performed today. One question that I’m often asked is, can it grow back? The answer is…it depends. Overall, once you take out all your tonsils, it’s unlikely to come back. However, if you’ve only had most or some of your tonsils removed, as long as there’s inflammation, there’s increased risk that it can slowly grow back. 

Tonsils are made of lymphoid tissue and make up a part of Waldeyer’s ring, with your adenoids at the top in the back of your nose, your two palatine tonsils in your throat, and your single midline lingual tonsils lower down at the base of your tongue.

During early development, your tonsils, like all the other lymph nodes in your body, educates your immune system to tell it what’s part of the body and what’s not. Normally, after childhood, the these tonsillar tissues shrink down to small nubbins.

However, if you have chronic inflammation in your nose or throat, such as from allergies or acid reflux, chronic irritation causes these “glands” in your throat to swell up. One they enlarge, they take up more space in your throat, aggravating various degrees of breathing obstructions.

Adenoids and lingual tonsils are different from palatine tonsils in that the lymphoid tissues are attached directly to the back of the nose or the tongue muscle layer. However, palatine tonsils are surrounded by a thin fibrous capsule that separates the lymphoid tissue from the muscles of the throat.

Traditional tonsillectomy usually involves removing the tonsils along with the fibrous capsule, leaving only the thin membrane covering the muscles. With adenoids, however, it’s usually scraped out, charred or debulked using various devices. It’s literally impossible to remove everything, since you’ll have to remove normal tissues.

Another recent variation of tonsillectomy involves removing only a portion of the tonsils, leaving a thin cuff of tonsil tissues that sit right next to the capsule. Common procedure names you may see include Coblation or sub capsular tonsillectomy. These type of procedures are done more for obstruction and sleep apnea, rather than for infection, where you normally want to take out everything. In theory, having residual tonsil tissues can make you more likely to have tonsillar growth, if you have constant inflammation.

Or if you have small amounts of adenoids remaining, and let’s say you have chronic allergies, then you have a higher chance of your adenoids growing back. I’ve seen this many times in my career. Overall, however, it’s still rare.

Another common condition that’s not often addressed is lingual tonsils. Many people with obstructive sleep apnea will have persistently enlarged lingual tonsils. Chronic stomach juice exposure from apnea is one major reason for these lymphoid tissues to become enlarged. If you have small jaws and a large tongue to begin with, even slightly enlarged lingual tonsils can take up more space behind your tongue, aggravating further collapse and obstruction.

What I often see is that when symptoms of sleep apnea persist or come back after tonsillectomy, it’s usually blamed on your tonsils growing back. Usually when I look, there are no tonsils remaining, but they have large lingual tonsils or significant palatal or tongue collapse. In most cases, the main reason for the multiple levels of narrowing is due to small jaws and dental crowding. Taking out huge tonsils can definitely help in some people, but most people will have persistent sleep apnea, since there will be persistent obstruction due to tongue and/or soft palate collapse.

Can Tonsils Grow Back After Removal?

My son Jonas had his tonsils taken out about 5 years ago. Initially, his sleep quality improved dramatically, and his snoring disappeared. These days, I hear him snore occasionally, and he does seem tired, but only when he doesn't sleep long enough. Does this mean that his tonsils have grown back?

The short answer is no. When you take out your tonsils, just like taking out your appendix, it can't grow back. If you undergo an appendectomy and still have abdominal pain, than that means that there's another problem that's causing the problem. Similarly, if your snoring comes back after tonsillectomy or any other procedure that opens up the airway, persistent or recurrent symptoms means that, there was something else that was not addressed.

If your child has persistent or recurrent snoring after undergoing tonsillectomy, it usually means that there are other areas in the upper airway that is causing narrowing of the breathing passageways, from the tip of your nose to the space behind your tongue. 

Does Everyone in Your Family Have Sleep Apnea?

More and more often, I'm coming across entire family members that are on CPAP for sleep apnea, or undergoing various other treatments for this condition. If one parent has sleep apnea, your children have an increased risk of developing sleep apnea, but if both parents have it, then it's safe to assume that your children will have it too, given that fact that they inherit your facial anatomy. 

As I describe in my book, Sleep, Interrupted, all modern humans are on a continuum, where we're all susceptible to breathing problems at night. Only the end extreme is called obstructive sleep apnea. Since sleep apnea is caused by narrow facial structures, young children and even infants can have it too. Many of the various childhood maladies, such as frequent colds, ear infections, bedwetting, night terrors, and even ADHD are probably related to poor breathing and inefficient sleep, aggravating inflammation in the upper airways. There's even speculation that the rate of autism increased after doctors recommended placing infants on their backs during sleep. It's not surprising then, that parents of autistic children are found to have a higher rate of obstructive sleep apnea.

Most young children are treated with tonsillectomy and adenoidectomy for their sleep apnea, and many children do very well. However, about 1/3 who undergo tonsillectomy don't improve significantly. These are the children that probably have smaller jaws. Smaller jaws leads to more reflux and inflammation, leading to enlarged tonsils, causing more frequent obstructions. In these children, rapid palatal expansion was found to be equivalent to tonsillectomy. If you combine both procedures, the results were additive.

Some young children are able to tolerate CPAP, but for most, this is not a practical option. One advantage that children have over adults is the malleability of their jaws. Orthodontics can not only help to straighten teeth, but to expand the jaws as well. Traditional orthodontic dentists tend to remove teeth to make more room for the other teeth, but that ends up making the jaws even smaller. Forward thinking orthodontists make more room for the teeth by enlarging the jaws, both in the front to back and side to side dimensions. The earlier you start, the better the long-term results. Many dentists are beginning treatment as soon as the permanent teeth have come in.

Does everyone in your family have sleep apnea? If not, do you suspect that they all do? Please describe how you're handling this situation in the comments box below.

Do You Really Grow Out Of Your Tonsils? The Possible Link Between Sleep Apnea and Autism

In the 1950s to 1970s, it used to be a rite of passage for young children to get their tonsils taken out. These days, we're a lot more conservative with tonsillectomy, and frequently, parents are told that their child will grow out of their tonsils. While this is true in some cases, there's a consequence to the watching and waiting option. 

 

Your tonsils are lymphoid tissue that's part of Waldeyer's ring, which is a ring of lymphoid tissue made of the palatine tonsils (your typical tonsils), the adenoids (in the back of the nose), and the lingual tonsils (at the base of the tongue in the midline). In some children with overdeveloped lymphoid tissues, you'll see a communication between all four of these glands, forming a complete circle. These tissues are normally involved in educating your immune system, since everything you breathe or swallow has to go through this ring. As a result, it's expected that the tonsils (and adenoids) will be enlarged during the ages of 3-5. 

 

However, with the shrinking size of modern human jaws, now there's less room for the normal-sized tonsils, which takes up relatively more space. This aggravates more frequent obstructions and arousals, leading to more inflammation from refluxed stomach contents and more swelling of the tonsils. The chronic negative pressure created from this process can prevent proper jaw enlargement, similar to what can occur with bottle-feeding. In many children, their snoring and sleep problems will prompt the parents to see an ENT for tonsillectomy. For children with mild to moderately enlarged tonsils that are not causing any symptoms, or those that are symptomatic but are told that they'll outgrow it, there can be permanent long-term consequences.

 

In children with huge tonsils, one of the reasons why they look so big is that the space that the tonsils sit in is too narrow. Taking out the tonsils can make a dramatic difference is most children, but there are some children that won't respond to tonsillectomy or only partially. One recent meta-analysis showed that adenotonsillectomy was helpful in about 2/3 of all children. But the remaining 1/3 still had residual symptoms or signs of obstructive sleep apnea. These are the children that have smaller jaws than the children who responded to the procedure.

 

In a recent Stanford University study, children who were scheduled for tonsillectomy were divided into two groups. One group underwent standard tonsillectomy, and the other under went rapid maxillary palatal expansion. The results were equivalent for both groups. When children in both groups were crossed over and given the other procedure, the overall results were additive. This just goes to show that one reason why you can have large tonsils that that your jaw is too small. Of course, everyone is on a continuum, and as usual in modern medicine, you're treated only if you are at the extreme end of the continuum. 

 

This is pure speculation, but I wonder if the significant increase in the rate of ADHD in the 1980s and 1990s could be related to the dramatic decline in the rate of tonsillectomies. Furthermore, since the peak incidence of autism is around ages 3-4, it's interesting that this is also the time that the tonsils become enlarged in most children. If you have enlarged tonsils to begin with, any simple cold or infection (even vaccines!) can cause swelling which starts a vicious cycle, leading to a sudden increase in breathing problems and poor sleep. Sleep apnea by definition causes systemic inflammation and an increased susceptibility to form microscopic clots in the brain. 

 

This is also the time (around age 4) when the voice box reaches its' final position below then tongue as it descends from its' original position behind the tongue. A space is created behind the tongue and between the soft palate and the epiglottis called the oropharynx, which exist only in humans, and allows for complex speech.

 

One last interesting phenomenon to point out is that in the early 1990s, parents were recommended to place infants on their backs, to prevent SIDs. We know that back sleeping lowers your time spent in deep sleep and leads to more frequent arousals. 

 

All these factors taken together may be what's developed into the "perfect storm," leading to the dramatic rise in ADHD and autism in our current times. Obviously, there are many other dominant theories for ADHD and autism, but from a sleep-breathing standpoint, what I propose is something that definitely needs to be proven in clinical studies. 

 

What do you think about all this? Please enter your responses in the comments box below.

Q: If You Need Your Tonsils, Why Take Them Out?

Q:
If You Need Your Tonsils, Why Take Them Out?

A: Tonsils are part of the immune system, but when they are too large or are prone to frequent infections, then surgical removal is a consideration. One or two infections every year is not too worrisome, but having an infection every month can be debilitating for most people. For many children (and some adults), very large tonsils can lead to breathing problems at night.

For more information on tonsils visit: http://doctorstevenpark.com/what-everyone-should-know-about-tonsillectomy

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