Dr. Steven Park, a reader, and a sleep specialist from New York, wrote last week, in response to my posting on obstructive sleep apnea and ADHD in children from March 16th:
Great post. I agree wholeheartedly that a significant number of children with ADHD on medications actually have an underlying sleep-breathing disorder. Various studies (including Dr. Chervin's) estimate this figure to be anywhere from 25% to 50%. My personal guess is that it's a lot higher. But even if you say that it's conservatively 25%, up to half of these children can be cured with a simple adenotonsillectomy.
Unfortunately, large tonsils alone do not determine the degree of sleep apnea. Facial and jaw narrowing due to various factors is the major reason for obstructive sleep apnea, with enlarged tonsils as a secondary component. This is why taking out tonsils, although helpful in most cases, doesn't cure sleep apnea in all children. One promising study by Dr. Guilleminault at Stanford showed that if you add rapid palatal expansion to tonsillectomy, the results are much better.
This is pure speculation, but in the 50s to 70s, when tonsillectomy was almost routine, there was essentially no ADHD (or awareness of this condition). As the rate of tonsillectomies slowly diminished in the 70s to 90s, the rate of ADHD started to go up. It would be interesting to pull the numbers and draw a graph. I'm willing to bet that you'll see a definite pattern.
Thank you very much for your feedback and comments. Your point about the contribution of factors other than enlarged tonsils and adenoids leading to upper airway obstruction during sleep, such as craniofacial abnormalities, in addition to others such as soft tissue inflammation and low muscle tone, is very well taken. I, too, see children in my clinic who continue to have significant upper airway obstruction while sleeping, despite having had their tonsils and adenoids removed, and without having underlying obesity or muscle tone abnormalities. Many of these children have benefited from jaw expansion, craniofacial reconstructive surgery, and targeted orthodontic interventions, specifically rapid maxillary expansion (which results in the hard palate being widened, giving the tongue more room and avoiding it being pushed back into the throat where it can impede airflow). While these may sound like extreme measures, for some children with severe obstructuve sleep apnea who have difficulty tolerating CPAP, they offer the possibility of a cure for the obstructive sleep apnea, and becoming free of the need for CPAP or tracheostomy.
These interventions (adenoidectomy, tonsillectomy, jaw expansion, maxillary expansion, craniofacial reconstructive surgery) are not routinely done in adults with obstructive sleep apnea, and almost never as the first line of therapy the way adenotonsillectomy is in children suffering from it. This only serves to underscore the first rule of pediatrics, which all medical students learn on the first day of their rotation in the pediatric department: kids are not little adults. Because children are constantly growing and developing, certain interventions can (and sometimes must) be made which do not work in adults, but which can bring about a cure in children. Conversely, there are some therapies which are standard in adults which are unsuited for children. There are also outcomes of certain disease states in children, not seen in adults (for example, some of the behavioral, developmental and cognitive effects of obstructive sleep apnea), of which of which one needs to be aware. Because of this, when one has a child with a medical problem, finding a specialist who is familiar with treating children with that problem is very important, as the approach to treatment can be substantially different between children and adults.
