The bottom line is that doctors have to look at the big picture and not have tunnel vision. The same is true for Attention Deficit Hyperactivity Disorder ADHD). Just because your child is hyperactive or has difficulty with their schoolwork does not mean they have ADHD.
Even if your child truly has ADHD, they may also have other disorders that contribute to, exacerbate or mimic ADHD. Specific learning differences may exist such as dyslexia, visual or auditory perceptive disorders and a host of other learning disabilities may be present. Hyperactivity may be a reflection of boredom, anxiety or other psychiatric or neurologic disorders. The American Psychiatric Association estimates the incidence of ADHD in school-aged children at 3 to 7 percent. Many, if not most, of these children are placed on stimulant medications.
Many of these children’s symptoms of ADHD improve on these medications, but a signifi- cant proportion of these children not only does not improve with stimulants, but suffer from side effects or show little or no improvement at all. On top of that, these medications are often not covered by insurance and they can be very expensive. There is another saying in medicine that we teach our medical students, interns and residents early in their careers: “If you hear the sound of hoof beats, think horses, not zebras.” In other words, they should think of something common before thinking of an exotic or uncommon diagnosis.
Unfortunately, as a sleep disorders specialist, I see far too often a child that has been labeled with a diagnosis of ADHD without their pediatrician or family physician having also considered two common sleep disorders as possible causes or contributing factors to their symptoms of ADHD. The two common sleep disorders that I refer to are obstructive sleep apnea (OSA) and restless limb syndrome (RLS).
In last month’s Acorn, I wrote about OSA in adults. In the pediatric population, the prevalence of OSA has been estimated at 2 to 3 percent of otherwise normal children. Unlike adults, whose primary symptom is excessive daytime sleepiness, sleepiness is a rather uncommon complaint in children with OSA. Think about what happens to children who do not sleep well at night, the main consequence of OSA. They are cranky and irritable. They don’t pay attention. They act out. They won’t sit still, and they frequently perform poorly in school. These are many of the same symptoms that occur in children with ADHD.
RLS is a disorder in part manifest by an irresistible urge to move the legs. The National Institutes of Health estimate that one million school-aged children in the U.S. have RLS, with onethird having moderate to severe symptoms. In addition, 80 to 90 percent of patients with RLS also have Periodic Limb Movements during Sleep (PLMS), a disorder that disrupts sleep, often without the patient themselves knowing it.
Just like the sleep disruption occurring in OSA, the sleep disturbance associated with PLMS causes daytime symptoms mimicking the inattentiveness, difficulty with concentration, poor school performance, behavioral difficulties and hyperactivity of ADHD. To further support the overlap between RLS and ADHD, a deficiency in central nervous system iron has been found in both disorders. Treating patients with iron supplements has been found to improve symptoms of both RLS and ADHD.
The point of this article is not to debunk a diagnosis of ADHD, a real disorder affecting a signifi cant number of children every year. But two common sleep disorders are often confused with ADHD and should be considered in any diagnosis of ADHD. There is a great deal of overlap in the symptoms of ADHD, OSA and RLS. Furthermore, all of these diagnoses can coexist in the same child, and frequently do.
Treating only ADHD without considering the possibility of coexisting OSA and/or RLS is a prescription for failure and denies your child the greatest opportunity to succeed in school and life.
What should you do if you or a loved one has been diagnosed with ADHD? See your doctor and ask about the possibility of coexisting OSA or RLS. Ask your doctor for a referral to a board certified sleep specialist at an accredited sleep disorders center.
Dr. Ronald Popper is medical director of the Southern California Pulmonary and Sleep Disorders Medical Center. He is board certified in sleep medicine by both the American Board of Sleep Medicine and the American Board of Medical Specialties. For more information, visit www.sleepmd4u.com.