December 3, 2003
Gottlieb et. al. (1) report the association of parent defined sleep
disordered breathing with positive parent responses to questionns about
hyperactivity, inattention, and aggression. They conclude that sleep
disordered breathing (SDB) “may contribute substantially to the prevalence
of sleepiness, hyperactivity, and inattention and should be considered as
a possible cause when evaluating these common problem behaviors” and that
“the pediatrician may want to consider SDB –associated problem behaviors,
in addition to polysomnographic measures of physiologic compromise, when
considering therapeutic options for SDB.”
But are the behaviors reported in these children really problems? We don’t
know. The use of a proxy for ADHD, in this case a single question each
for inattention and hyperactivity, makes the clinical importance of these
findings suspect. Would the research concerning effectiveness of
adenoidectomy and PE tubes be acceptable if parental report of “otalgia”
were used as a substitute for the physician diagnosis of otitis media
(which has its own, well known problems with reliability), or, in research
about renal imaging following pyelonephritis, “malodorous urine” instead
of culture proven urinary tract infection? Although not always possible,
research with clinical consequences should have even more stringent
criteria for case diagnosis than clinical practice; in this case, the
reverse is true.
Although the authors are careful to specify “problem behaviors”
instead of attention deficit hyperactivity disorder (ADHD), their use of
the parental Conners’ scale as a validation tool and the prevalence of
ADHD as a cause of hyperactivity and inattention imply ADHD as the linked
condition. In any case, many other medical causes of hyperactivity (2),
including mental retardation, pervasive developmental disorder, sensory
defects, medication use, and child and sexual abuse, would seem to have
little relationship with sleep problems as an etiology. The parental
perception of hyperactivity and/or inattention, in response to the single
questionnaire item, and in a study group that may already be hypervigilant
as part of a long term research study, would need further clinical
evaluation to differentiate normal childhood behavior in a group of 5 year
old children from “problem behavior.”
In clinical practice, watchful waiting and further evaluation might
be the best choice in a 60-month-old child who “seems not to listen when
spoken to directly” or has a positive parental screening for behavior
problems. ADHD is a chronic condition; the AAP has promulgated
diagnostic guidelines (2) to better define this diagnosis and hopefully
diminish both under and over-diagnosis. Further research into the
relationships between sleep problems and behavior problems should use
these criteria. Because the evaluation and treatment of potentially SDB
caused behaviors could involve expensive and invasive procedures, it is
important that research be specific in diagnosis, and then demonstrate
objective, long-term gains from therapy, before recommending changes in
clinical practice. The paper by Gottlieb et. al. presents interesting
findings that serve as a road map for further research but do not reach
the level of proof necessary for a change in clinical practice.
Sincerely,
William N. Marshall, Jr. M.D.
Department of Pediatrics
University of Arizona College of Medicine
P.O. Box 245073
1501 North Campbell Avenue
Tucson, Arizona 85724-5073
References
1 Daniel J. Gottlieb, Richard M. Vezina, Cynthia Chase, Samuel M. Lesko,
Timothy C. Heeren, Debra E. Weese-Mayer, Sanford H. Auerbach, and Michael
J. Corwin. Symptoms of Sleep-Disordered Breathing in 5-Year-Old Children
Are Associated With Sleepiness and Problem Behaviors. Pediatrics 2003;
112: 870 - 877.
2 American Academy of Pediatrics. Committee on Quality Improvement and
Subcommittee on Attention-Deficit/Hyperactivity Disorder. Clinical
Practice Guideline: Diagnosis and Evaluation of the Child with Attention-
Deficit/Hyperactivity Disorder. Pediatrics 2000; 105:1158-1170.
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