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ANN ARBOR,
MI - Children who snore often are nearly twice as likely as
other children to have attention and hyperactivity problems, and
the link is strong for other sleep problems, a new University
of Michigan Health System study finds. The results, published
in the March issue of the journal Pediatrics,
provide some of the most solid evidence ever of a link between sleep
problems and behavior.
The link is
strongest in boys under 8 years of age; habitual snorers in this
group were more than three times more likely than non-snorers to
be hyperactive. The study, based on a survey of the parents of 866
children that was conducted in the waiting rooms of U-M pediatrics
clinics, is among the largest ever to explore the connection between
sleep and inattention/hyperactivity.
While the study
does not provide any clues as to whether and how sleep problems
might contribute to behavior issues, or vice versa, the evidence
of a link between the two is strong enough to warrant further and
thorough investigation, says lead author Ronald Chervin, M.D., M.S.,
director of the Michael
S. Aldrich Sleep Disorders Laboratory and associate professor
of neurology at the U-M
Medical School.
"If there
is indeed a cause-and-effect link, sleep problems in children could
represent a major public health issue," says Chervin. "It's
conceivable that by better identifying and treating children's snoring
and other nighttime breathing problems, we could help address some
of the most common and challenging childhood behavioral issues.
But more research will be necessary to show whether this is the
case."
Until then,
he suggests, all parents should pay attention to their children's
sleep behaviors - and their own. Sleep problems in both children
and adults are under-diagnosed, even though they can have a major
impact on daytime activity and health. Better sleep habits, and
medical attention for issues such as snoring, daytime sleepiness,
and breathing interruptions known as apnea, could help people of
all ages function better during the day.
Chervin and
his colleagues from UMHS, the University of Pittsburgh and Stanford
University designed the study to gather as much information as possible
on a large number of children, to overcome the limitations of previous
studies that only looked at small groups of children who had been
referred to sleep specialists.
They combined
three different validated survey instruments: two asking parents
about their children's behavior patterns, and one asking about snoring,
sleepiness and characteristics that may indicate sleep-disordered
breathing problems. The children were all over the age of 2 and
under the age of 14, and parents were asked to seek their children's
help in completing the survey. Fifty-four percent of the children
assessed were boys.
The sleep portion
of the survey asked about frequency and severity of snoring, as
well as the tendency to struggle to breathe or stop breathing temporarily
during the night, to breathe through the mouth during the day, to
wake up feeling unrefreshed, or to have a hard time waking up. All
these can mean a child has sleep-disordered breathing, which can
affect the quality of their sleep.
Scores for
snoring frequency and severity, and for sleepiness and sleep-disordered
breathing, were tallied for each child, to allow each tendency to
be considered on its own. And, children were designated either habitual,
or non-habitual, snorers.
The behavior
portion of the survey asked about attention to tasks and schoolwork,
distraction, forgetfulness, fidgeting, inappropriate action and
excessive talking, as well as other symptoms of attention-deficit
hyperactivity disorder. The children were assigned scores based
on the total number of attributes their parent said applied to them,
and how often.
Sixteen percent
of the children were reported to snore frequently, and 13 percent
scored high on the hyperactivity index. But 22 percent of habitual
snorers had high hyperactivity scores, compared with only 12 percent
of those whose parents said they did not snore regularly. Similar
differences were found when the researchers looked at hyperactivity
scores among children who scored high on measures of sleepiness,
snoring severity and sleep-disordered breathing.
The contrast
in behavior between children with and without some symptoms of sleep-disordered
breathing changed significantly when the researchers divided the
group by age and sex. Boys under 8 years old had the biggest difference:
30 percent of those who snored regularly had high hyperactivity
scores, as opposed to 9 percent of those who did not snore often.
In contrast, daytime sleepiness - perhaps because it can result
from many causes other than sleep-disordered breathing - was associated
with hyperactivity in all age and sex groups.
Because scores
for daytime sleepiness and snoring were linked closely, the researchers
corrected for the effect. But they still found that those children
with high sleepiness scores, regardless of snoring, tended to have
high hyperactivity scores, as did children with high snoring scores,
regardless of sleepiness. This suggests that sleep-disordered breathing
or sleepiness from other causes could each contribute, independently,
to the risk of disruptive behavior.
Fortunately,
sleep breathing problems, poor sleep habits and other conditions
that contribute to sleepiness - and perhaps inattention and hyperactivity
-- can be corrected, Chervin notes. Evaluation and treatment by
sleep specialists is important for those with apnea, severe snoring,
and other conditions. And parents should make sure their children
get a full night's sleep, have a consistent bedtime and wakeup time,
and follow other good sleep hygiene habits.
Besides Chervin,
the study's authors are former U-M nurse Kristen Hedger Archbold,
Ph.D., now at the University of Washington; U-M child psychiatrist
James Dillon, M.D; U-M pediatricians Parvis Panahi, M.D. and Kenneth
Pituch, M.D., and sleep specialists Ronald Dahl, M.D. of the University
of Pittsburgh and Christian Guillemenault, M.D. of Stanford University.
The study was funded by the National
Institutes of Health and the U-M Health System.
Full citation: Pediatrics 2002; vol. 109, pp. 449-456
Written by Kara Gavin
For more
information, contact Kara Gavin or Carrie Hagen, UMHS Public
Relations, 734-764-2220, or by e-mail.
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