Objective. The purpose of this study was: 1) to examine both bedtime sleep behaviors and daytime behaviors associated with daytime sleepiness in a group of children with a primary medical sleep disorder (obstructive sleep apnea syndrome [OSAS]) compared with a group of children with a primary behavioral sleep disorder (BSD) (limit setting sleep disorder or sleep onset association disorder); and 2) to investigate the impact of a comorbid BSD on sleep and daytime behavioral consequences of OSAS.
Methods. Children referred to a pediatric sleep disorders clinic during a 3-year period with a primary diagnosis of either polysomnographically-confirmed OSAS (n = 100) or a BSD (n = 52) were compared on several parent report measures assessing the following domains: symptoms of sleep disordered breathing, other sleep behaviors (primarily parasomnias), bedtime behaviors, and externalizing daytime behavior problems. The OSAS sample was then divided into a pure OSAS group (n = 78) and an OSAS plus a behavioral sleep diagnosis group (n = 22) based on the presence or absence of delayed sleep onset and/or prolonged nightwakings and compared on the parent-report symptom domains.
Results. Almost one-quarter of the OSAS group had clinically significant behavioral sleep problems, primarily bedtime resistance, in addition to OSAS. Bedtime resistance was associated with a significantly shortened sleep duration in both the BSD and OSAS-BSD groups. Although the OSAS-BSD group had less severe disease, as defined by polysomnographic variables, than the pure OSAS group, they were rated by their parents as having more daytime externalizing behavior problems associated with daytime sleepiness.
Conclusions. The results of this study suggest that evaluation for comorbid BSD should be done in all children presenting with symptoms of OSAS. The coexistence of such BSDs may contribute significantly to sleep deprivation, and thus to behavioral manifestations of daytime sleepiness in these children.
- OSAS =
- obstructive sleep apnea syndrome •
- BSD =
- behavioral sleep disorder •
- CSBS =
- Children's Sleep Behavior Scale •
- SHQ =
- Sleep Habits Questionnaire •
- ∼OSASQ =
- Obstructive Sleep Apnea Screening Questionnaire •
- ECBI =
- Eyberg Child Behavior Inventory •
- MANOVA =
- multivariate analysis of variance •
- P =
Obstructive sleep apnea syndrome (OSAS), as part of the spectrum of sleep disordered breathing, has been relatively recently recognized as an important clinical phenomenon in children and adolescents. OSAS is estimated to affect 1% to 3% of children,1 and has a peak prevalence in the preschool and early elementary school-aged years.2 One of the first detailed clinical descriptions of OSAS in children, by Guilleminault et al3 in 1976, suggested that behavioral and learning problems and impaired school performance were among the potential sequelae. The underlying pathophysiologic mechanisms for the described neurobehavioral consequences of OSAS in children have been proposed to be intermittent nocturnal hypoxia secondary to apnea/hypopneas, and frequent electroencephalogram arousals from sleep4 that result in significant sleep fragmentation.5 Daytime sleepiness resulting from fragmented or disturbed sleep is often manifested in young children by behaviors such as increased activity, aggression, impulsivity, acting out behavior, poor concentration, and inattention.6–8 The association of OSAS with these types of externalizing behavioral symptoms has subsequently been described in a number of other clinical studies.9–11
Children with behaviorally-based sleep disorders also often have significant sleep disturbance, with irregular sleep-wake schedules, and/or fragmented or insufficient sleep. Thus, they may present with daytime behavioral problems related to daytime sleepiness that are similar to those described in children with OSAS. Behaviorally-based sleep problems, such as prolonged bedtime struggles and frequent and/or prolonged night awakenings, are among the most common behavioral problems presenting to pediatricians in preschool and school-aged children.12 However, no studies to date have compared the degree and intensity of daytime behavioral problems in children with a primary behavioral sleep disorder (BSD) to those found in children with OSAS. Furthermore, no studies have addressed how the coexistence of a behavioral sleep problem, such as limit setting sleep disorder (characterized by significant bedtime resistance) or sleep onset association disorder (presenting with frequent or prolonged night wakings) might affect the neurobehavioral consequences of OSAS in children.
The objectives of this pilot study were as follows: 1) to compare bedtime and sleep-associated behaviors in children with polysomnographically documented OSAS to similar behaviors in children diagnosed with a BSD (ie, limit-setting and sleep onset association disorder); 2) to compare daytime behaviors associated with sleepiness in children with OSAS to children with a BSD; and 3) to examine these sleep and daytime behaviors in children with both OSAS and a comorbid BSD.
The study sample consisted of 52 girls and 100 boys who ranged in age between 2 years, 1 month and 12 years, 7 months (mean age = 5 years, 9 months). All children were referred to a pediatric sleep disorders subspecialty clinic during a 3-year period. The Pediatric Sleep Disorders Clinic is based in a tertiary care children's hospital and consists of a multidisciplinary team of pediatricians and psychologists. Children are generally referred to this clinic by their primary care physician or consulting subspecialist (ie, otolaryngologist, neurologist).
Children were selected for participation in this study based on having received a primary diagnosis of either OSAS or a BSD after their evaluation in the Pediatric Sleep Disorders Clinic. Children with OSAS or BSD who also had significant developmental delays (ie, moderate or severe mental retardation) or serious chronic medical conditions (eg, congenital heart disease) were excluded from the group. Eight children were excluded based on these criteria resulting in a final sample of 152 children.
The participants in this study represented a broad range of socioeconomic classes: 36% of the families reported income levels <$15 000 per year; 13% were between $15 000 to $25 000; 29% were between the $25 000 to $50 000 range; and 20% reported incomes >$50 000 per year. The study sample was approximately 6.2% African-American, 7.3% Hispanic, 0.5% Asian, and 86.0% White/Caucasian.
Parents were asked to complete an extensive packet of sleep and behavior questionnaires, routinely used as part of the clinical evaluation, before their child's appointment. The questionnaires included measures of child sleep and daytime behaviors. During the Pediatric Sleep Disorders Clinic appointment, all children received an extensive diagnostic evaluation including review of questionnaires, interviews with a pediatrician and psychologist, and physical exam. After the evaluation, diagnoses were reached by multidisciplinary team consensus using the International Classification of Sleep Disorders Diagnostic and Coding Manual 13 criteria.
All children identified with symptoms of sleep apnea during the initial evaluation (eg, loud snoring, breathing problems, snoring/gasping) were scheduled for a single overnight polysomnographic evaluation to confirm the preliminary clinical findings. The basis for diagnosis of OSAS was the widely accepted pediatric diagnostic criteria of apnea/hypopnea index (apnea/hypopnea index of >1 episode/hour, nadir O2desaturation <92).14 Electroencephalogram arousals were also recorded, but a standard cutoff in terms of number of arousals per hour in children does not currently exist.
BSD was defined as either a diagnosis of limit setting sleep disorder or sleep onset association disorder. Diagnoses were based on theInternational Classification of Sleep Disorders Diagnosis and Coding Manual 13 criteria. Limit setting sleep disorder is defined as: a) difficulty initiating sleep; b) stalling or refusal to go to bed at an appropriate time; c) once the sleep period is initiated, sleep is of normal quality and duration; d) no evidence of significant underlying medical or psychiatric disorder to account for the complaint; and e) does not meet criteria for any other sleep disorder causing difficulty initiating sleep. Sleep onset association disorder is defined as: a) insomnia; b) insomnia temporarily associated with absence of certain conditions; c) disorder present for at least 3 weeks; d) sleep with particular association present is normal in onset, duration, and quality; e) no underlying medical or psychiatric disorder to account for complaint; and f) does not meet criteria for any other sleep disorder causing difficulty initiating sleep.
The following measures were used to obtain information across the domains of sleep disordered breathing, other sleep behaviors, bedtime behavior problems, and daytime behavior problems.
Children's Sleep Behavior Scale (CSBS)
The CSBS15 is a 22-item parent-report measure that assesses children's sleep related behaviors during the previous 6-month period. Items are based on a 5-point Likert scale ranging from “never” to “quite often.” This measure covers a wide range of sleep behaviors including sleep onset, restless sleep, night wakings, behaviors that occur while sleeping (eg, smiling, bruxism), nightmares, and morning waking. The CSBS has demonstrated good 2-week test-retest reliability, with the majority of the items >0.70 and only 2 items with a reliability <0.50.15 ,16
Children's Sleep Habits Questionnaire (SHQ)
The SHQ17 is a 52-item instrument that assesses domains of bedtime behavior, sleep behaviors such as parasomnias, other night wakings, morning waking, and daytime sleepiness. This parent report measure is rated on a 3-point scale ranging from “rarely” to “usually.” This measure also includes an open-ended question that asks parents to record their child's usual amount of sleep per day including both sleep during the night and daytime naps. One-week test-retest reliability coefficients, the majority of which were >0.60, have been reported.18
Obstructive Sleep Apnea Screening Questionnaire (OSASQ)
The OSASQ is a 13-item questionnaire designed for use in the Pediatric Sleep Disorders Clinic to screen for nighttime breathing problems. This measure was designed as a brief screen to evaluate the presence of sleep related symptoms of obstructive sleep apnea. Items on this screening questionnaire include: snorts/gasp, wheezes/whistles, snores, snores loudly, chokes, holds breath, stops breathing, breaths with an open mouth, breathing problems, tosses/turns, kicks/jerks, restless, and sweats. This parent report measure is rated on a 5-point scale ranging from “never” to “every night.” Interitem agreement for this measure based on the current study sample was 0.89.
Eyberg Child Behavior Inventory (ECBI)
The ECBI19 is a 36-item measure that assesses conduct problem behaviors in children ranging from 2 to 17 years old. Parents are asked to rate the frequency of occurrence for each of 36 behaviors using a 5-point Likert scale ranging from “never” to “always.” They also rate whether they perceive the behavior to be a problem for their child on a “yes”/“no” scale. This measure yields two scales; a problem scale and a frequency scale. This measure has demonstrated good discriminant, convergent, and concurrent validity.20
There were three domains of sleep behavior that we examined: sleep disordered breathing, bedtime behavior problems, and other sleep behaviors. There are currently no standard pediatric sleep questionnaires that include sufficient items to thoroughly assess these behaviors. Therefore, we chose to select individual items from the multiple measures (ie, CSBS, SHQ, OSASQ) that reflected each of the domains of interest. Items were selected based on the consensus decision of a behavioral pediatrician and two child psychologists. α coefficients were calculated for each of the three sleep-related domains to assess degree of interitem agreement.
The following eight items were selected to represent sleep disordered breathing: snorts/gasps, wheezes/whistles, stops breathing, chokes, breathing problems, breathes with an open mouth, snores, and holds breath. Interitem agreement based on the entire sample for this set of variables was 0.92. The following six items reflected bedtime behavior problems: goes to bed willingly, falls asleep easily, gets out of bed at night, ready for bed at bedtime, resists bed at bedtime, and struggles at bedtime. Interitem agreement for this set of variables was 0.81. Items selected to represent the domain of other sleep behaviors included: restless, smiling, talks, walks, sits up while asleep, laughs, nightmares, and terrified at night. Interitem agreement for this set of variables was 0.78.
The fourth behavioral domain of interest in this study was daytime behavior problems. This variable was assessed using the well-established Eyberg Problem and Frequency Scales.20
Comparisons of Children With OSAS and BSD on Descriptive Characteristics
Analysis of age and gender revealed that children in the OSAS and BSD groups differed on age but not gender variables. Children in the OSAS group were significantly older at time of diagnosis (6.4 years) than children in the BSD group (4.9 years; t = 2.95;P < .01). (Because of age differences between groups, all analyses were run both with and without age as a covariate. No differences were found in the pattern of results when we controlled for age. To present straightforward statistics, and means and standard deviations consistent with analyses conducted, we are reporting on the results from analyses that did not control for age.) In both groups there were more males than females, but the two groups did not differ between each other in gender composition. The OSAS group was 70% male and the BSD group was 58% male (χ2 = 2.30;P = NS).
Comparisons of Clinical Symptomatology of Children With OSAS Versus BSD
Children in OSAS and BSD groups were compared on parent reported symptoms across the following four domains of clinical symptomatology: 1) sleep disordered breathing, 2) other sleep behaviors, 3) bedtime behavior, and 4) daytime behavior. Multivariate analysis of variance (MANOVA) procedures using group status as the independent variable were used to compare the groups across each of these domains. A significant main effect for group was found on the MANOVA for sleep disordered breathing (F[8,99] = 18.64; P < .001; multivariate effect size = 0.60). Follow-up univariate analysis revealed that the OSAS group had significantly more frequent symptoms of gasping, wheezing, holding breath, stopping breathing, breathing problems, choking, snoring, and breathing with an open mouth than the BSD group. In contrast, there was no group difference between the OSAS and BSD groups found with the MANOVA for other sleep behaviors (F[8,115] = 1.32; P = NS; Table 1).
Significant group differences were found on the MANOVAs for bedtime behavior problems (F[6,87] = 8.79;P < .001; multivariate effect size = 0.38) and daytime behavior problems (F[2,119] = 7.22;P < .01; multivariate effect size = 0.11). As seen in Table 2, follow-up analyses revealed that children in the BSD group had significantly more problems with being ready for bed at bedtime, going to bed willingly, struggling at bedtime, falling asleep easily, and getting out of bed at night. Similarly, in terms of daytime behaviors, children in the BSD group had greater frequency and problem scores for externalizing behavior problems than the children with OSAS.
The groups were also compared on average time spent sleeping per night. Children in the OSAS group were reported to sleep significantly more than children in the BSD group (t = 3.68;P < .001). On average, children in the OSAS received 10.1 hours of sleep per night as compared with 8.4 hours for children in the BSD group.
Comparisons of Clinical Symptomatology in Children With Pure OSAS, OSAS With a Secondary Behavioral Diagnosis, BSD
Because a number of children in the OSAS group were found to have behavioral sleep problems, this sample was divided into a pure OSAS group (OSAS-P) (n = 78) and an OSAS plus BSD group (OSAS-BSD) (n = 22). Assignment to the OSAS-BSD group was based on a coexisting limit setting sleep disorder and/or sleep onset association disorder. The International Classification of Sleep Disorders Diagnosis and Coding Manual 13 criteria defined previously were used to make diagnostic decisions. There were no significant differences in the age or gender composition of the two groups. Children in the OSAS-P group were on average 6.2 years old, whereas children in the OSAS-BSD group were 7.1 years old (t = 1.42; P= NS). Both groups were predominantly male; the OSAS-P group was 68% male and the OSAS-BSD group was 77% male (χ2 = 0.71;P = NS). Children in the pure OSAS group were found to have significantly more severe apnea based on two of the three polysomnographic indicators (Respiratory Distress Index, nadir O2, arousals per hour) than children in the OSAS-BSD group. Mean standard deviation scores for the groups across these measures were as follows: Respiratory Distress Index: OSAS-P-12.6 (11.2), OSAS-BSD = 6.1 (4.8), t(96) = 2.57, P< .05; nadir O2: OSAS-P = 90.6 (4.2), OSAS-BSD = 92.4 (2.7), t(94) = 1.92, P= .05; arousals per hour: OSAS-P = 14.2 (11.5), OSAS-BSD = 10.4 (4.4), t(92) = 1.5, P = NS.
To examine differences in parent reported symptoms, comparisons were made between children in the OSAS-P, OSAS-BSD, and BSD groups across the domains of sleep disordered breathing, other sleep behaviors, bedtime behavior problems, and daytime behavior problems. MANOVA procedures using group status as the independent variable were used to compare the groups across each of the four domains. Significant group effects were further analyzed using follow-up univariate analysis of variance procedures with Sheffe tests used for post hoc comparisons.
A significant main effect for group was found on the MANOVA for sleep disordered breathing (F[16,198] = 8.37;P < .001; multivariate effect size = 0.41). Follow-up univariate tests revealed significant group differences across all eight indices of sleep disordered breathing. As shown inTable 3, the OSAS-P and OSAS-BSD groups had significantly worse symptoms of sleep disordered breathing than the BSD group. The OSAS-P and OSAS-BSD groups differed from each other only on holding breath during sleep, with the OSAS-P group having more symptomatology. No overall group differences were found on the MANOVA for other sleep behaviors (F[16,230] = 1.55;P = NS).
Overall group differences were also found for both bedtime behavior problems (F[12,174] = 6.35; P < .001; effect size = 0.31) and daytime behavior problems (F[4,238] = 5.03; P < .01; effect size = 0.08). In terms of bedtime behaviors, across indices, children in the OSAS-P group had significantly fewer problems than children in either the OSAS-BSD or BSD groups. There was no difference in the bedtime behavior problems between children in the OSAS-BSD and BSD groups (Table 4). As seen in Table 4, children in the OSAS-P group only, had less frequent and problematic daytime behavior problems than the BSD group.
Finally, the usual amount of sleep per day was compared across the three groups. Children in the OSAS-P group slept significantly more than children in either of the other two groups (F[2,124] = 15.7; P < .001). On average, children in the OSAS-P group received 10.5 hours per night whereas children in the OSAS-BSD and BSD groups received 8.2 and 8.4 hours, respectively.
The results of this study suggest that there are qualitative and quantitative differences in both sleep-associated and daytime behaviors in children, depending on the primary and comorbid sleep disorder diagnoses. First, as expected, the OSAS group had a significantly greater frequency of symptoms of sleep disordered breathing than did the BSD group, although the BSD group did exhibit some degree of snoring. When the OSAS group was divided into pure (OSAS-P) and comorbid (OSAS-BSD) groups, these two groups were found to be clinically similar to one another in terms of sleep disordered breathing. However, when severity of OSAS was defined by polysomnographic variables (number of apneas and hypopneas/hour and the nadir O2 saturation), the OSAS-P group had significantly more severe disease than the OSAS-BSD group. In fact, the children in the OSAS-P group had more than twice the number of apneas and hypopneas/hour on polysomnography than did the OSAS-BSD group (12.6 vs 6.1 hypopneas/h). Despite having less severe disease, the OSAS-BSD group was subsequently found to have more significant daytime behavior problems than the OSAS-P group. This suggests that variables other than the severity of sleep-disordered breathing have an important influence on daytime behavioral problems associated with OSAS.
The other sleep behaviors examined in this study, which were primarily parasomnias such as sleep-walking, sleep-talking, and nightmares, were not significantly different in the OSAS versus BSD groups. Several studies have suggested that children with OSAS have an increased incidence of parasomnias, especially the partial arousal parasomnias (such as sleep walking and night terrors) that occur during delta or slow-wave sleep.21 The mechanism for the increased incidence of partial arousal parasomnias in OSAS has been postulated to be OSAS-associated intermittent hypoxia and/or a rebound increase in the percentage of delta sleep in OSAS. We recently reported that the incidence of parasomnias in a group of children with OSAS was higher when compared with a control group, but was similar to the incidence of parasomnias in children with a BSD.22 This suggests that factors common to both OSAS and BSDs, such as sleep fragmentation resulting in increased rebound delta sleep, may be more important than hypoxia in determining the occurrence of parasomnias in both of the sleep-disordered groups.
A particularly striking sleep behavior finding in this study was a significantly shorter sleep duration in the BSD groups compared with the OSAS group. This occurred despite the fact that the BSD group was younger and would thus be expected, on average, to have a longer sleep duration. When compared with age-adjusted norms,23 ,24 the average sleep duration for the BSD group of 8.4 hours (compared with 10.5 hours in the OSAS group) was significantly below even the lower limit of age norms. This was not accounted for by a concomitant increase in the BSD group in daytime sleep (napping), and suggests that the shortened sleep duration in these children is not being compensated for by daytime sleep periods. The average sleep duration of the OSAS-BSD group was also significantly shorter than either the OSAS-P group or age-appropriate norms and almost identical to the average sleep duration in the BSD group. The increased frequency of bedtime struggles in both the BSD and OSAS-BSD groups presumably resulted in significantly delayed sleep onset and thus in the shortened sleep duration. It is interesting to speculate that the ability to at least partially compensate for the sleep fragmentation resulting from OSAS arousals by an increased or at least normal sleep duration may play an important role in mitigating the neurobehavioral consequences of OSAS.
By definition, the OSAS-BSD group, which represented a substantial proportion of children in the total OSAS group, had clinically significant bedtime behavior problems, which were comparable to those in a group of children whose degree of bedtime resistance had led to referral to a pediatric sleep disorders clinic. A few studies have anecdotally reported a relatively high incidence of behavioral sleep problems in childhood OSAS; Guilleminault et al3 describe significant bedtime refusal, behavioral “hyperactivity” at bedtime, and significant anxiety related to falling asleep in three of eight children diagnosed with OSAS. Similarly, Miyazaki et al25noted that 60% (9 of 15) of children with a diagnosis of OSAS had “significant bedtime struggles” but did not define these in more detail. In contrast, Carroll and Loughlin26 state that, in their experience, although bedtime problems exist, they “are not common” in children with OSAS. Our finding that nearly one-fourth of the OSAS group met the criteria for a clinical diagnosis of either a limit setting sleep disorder or a sleep onset association disorder is similar to the prevalence of these BSDs found in other studies of corresponding age groups in the general population.27–30However, failing to clinically screen children with OSAS for a comorbid BSD may have more significant consequences than do unrecognized or untreated BSDs in a normal population because the resultant sleep deprivation or disruption could have an additive effect on any daytime behavioral sequelae of the OSAS.
Finally, the BSD group overall had a greater number and severity of externalizing daytime behavior problems, as measured by the problem and intensity scores on the ECBI, than did children with OSAS. When the OSAS group was divided, the BSD group also had a greater frequency and intensity of daytime behavior problems than did the OSAS-P group. The OSAS-BSD group scored in between the OSAS-P and BSD groups on these scales, and was not significantly different from either group. Our conceptualization of an elevated problem and intensity score on the ECBI as potentially indicative of daytime sleepiness is similar to that of other studies7 31–33 that have examined the complex association among daytime externalizing behavior problems, daytime sleepiness, and sleep deprivation or fragmentation in school-aged children.34–37
To further address this issue of the relationship between externalizing daytime behavior problems and daytime sleepiness, we also examined the relative frequencies among the various OSAS and behavioral groups of several daytime sleepiness items that had been included on the sleep questionnaires. Although most of these items (including falling asleep during various activities) were not significantly different among the OSAS-P, OSAS-BSD, and the BSD groups, two daytime sleepiness variables were significantly more common in the same groups that also had more externalizing behavior problems: disrupting family activities because of sleepiness (P < .05), and difficulty waking in the morning (P < .05). This finding lends some additional support to the hypothesis that these externalizing behaviors were at least partially reflective of daytime somnolence, and thus of underlying sleep disturbance.
The behavioral manifestations of daytime sleepiness in young children, such as hyperactivity, clearly overlap with problematic behaviors that do not result from sleep deprivation/disruption. The results of a cross-sectional study, such as this one, do not allow us to draw direct conclusions about the nature of the relationship between sleep disturbance and daytime sleepiness-associated behavior. Alternative explanations for the finding of increased externalizing behavior problems in the BSD groups include the possibility that children with oppositional or aggressive behavior during the day are also likely to manifest similar behavior at bedtime. Other factors, such as an overall negative parental perception of both their child's bedtime and daytime behavior, may be operative. It would be important in future studies to correlate more objective sleepiness measures, such as the Multiple Sleep Latency Test,39 and multiple observer ratings with parental behavioral observations.
Several additional limitations of this study exist. First, the fact that the BSD group did not undergo polysomnographic evaluation to rule out OSAS is a limitation of the study; ie, there may have been children with undiagnosed OSAS or other forms of sleep disordered breathing in the BSD group. Previous studies have failed to show that any constellation of clinical symptoms in children who do snore reliably predicts which children will subsequently have polysomnographically-confirmed OSA versus primary or benign snoring (defined as snoring without respiratory compromise).38However, all children presenting to our pediatric sleep clinic are systemically clinically screened for risk factors and symptoms of OSAS, and an overnight sleep study is obtained on all children with habitual snoring. Second, the design of the study did not allow us to examine the role of other possible confounding factors in the association among OSAS, bedtime behavior, and daytime behavior. For example, parental anxiety about symptoms of sleep disordered breathing, a variable previously shown to correlate with polysomnographic severity of disease,40 may have resulted in a reduced willingness on the part of those parents to enforce bedtime rules, resulting in a limit setting sleep disorder. This study also relied on parental report to define sleep disturbances. Although several studies have shown a correlation between parent reports and more objective measures of sleep disturbance, such as actigraphy,18 some authors have suggested that parental report data may actually underestimate the frequency of some sleep disturbances, such as night waking, especially in older children who are often not directly observed by parents during sleep. Finally, our study population, because it consisted exclusively of children referred to a pediatric sleep disorders clinic in a children's teaching hospital, may not have been comparable to a general pediatric population in terms of the severity of both OSAS symptoms and behavioral sleep problems; therefore, the generalizability of our results may be limited.
The results of this study suggest the need for increased awareness on the part of physicians screening and treating children for obstructive sleep apnea, of the common comorbid occurrence of behaviorally-based sleep disorders in these children. Children with OSAS are often evaluated by medical subspecialists, such as otolaryngologists and pulmonologists, who may not screen these children for BSDs. Alternatively, children with BSDs may present to nonmedical mental health professionals, who may not be familiar with the clinical consequences of OSAS and thus may fail to recognize its coexistence with a BSD. Although further confirmation is needed, our results suggest that these comorbid BSDs may have a significant impact on the daytime behavioral consequences of OSAS, and that all children with OSAS should be clinically screened for BSD. In addition, assessment of average sleep duration in children with OSAS should be part of the clinical evaluation for risk factors for daytime sleepiness and behavioral problems. Finally, future studies examining the neurobehavioral consequences of childhood OSAS should include evaluation for comorbid BSDs.
- Received March 6, 1998.
- Accepted June 30, 1998.
Reprint requests to (J.O.) Department of Pediatrics, Division of Pediatric Ambulatory Medicine, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903.
This article was presented at the Society of Behavioral and Developmental Pediatrics Annual Meeting, Boston, MA, in October 1997.
- Guilleminault C,
- Eldridge FL,
- Simmons FB,
- et al.
- McGrath-Morrow SA,
- Carroll JL,
- McColley SA,
- et al.
- ↵Loughlin GM. Obstructive sleep apnea in children. In: Barness EL, ed. Advances in Pediatrics, XXXVII. St Louis, MO: Mosby Year Book; 1992
- Lozoff B,
- Wolff AW,
- Davis NS
- ↵Thorpy M, Broughton R, Cohn M, et al. The International Classification of Sleep Disorders. Diagnostic and Coding Manual. Rochester, MN: American Sleep Disorders Association; 1990
- Seifer R,
- Sameroff A,
- Dickstein S,
- Hayden L,
- Schiller M
- Acebo C,
- Sadeh A,
- Seifer R,
- et al.
- Guilleminault C,
- Pelayo R,
- Leger D,
- et al.
- Owens-Stively J,
- Spirito A,
- Arrigan M
- Roffwarg HP,
- Munzio JN,
- Dement WC
- ↵Ferber R. Solve Your Child's Sleep Problems. New York, NY: Simon and Schuster; 1985
- ↵Carroll JL, Loughlin GM. Obstructive sleep apnea syndrome in infants and children: clinical features and pathophysiology. In: Principles and Practice of Sleep Medicine in the Child. Philadelphia, PA: WB Saunders Company; 1995;18:163–191
- Fisher BE,
- Wilson AE
- Blader JC,
- Koplewicz HS,
- Abikoff H,
- Foley C
- ↵Mindell JA, Schultz AL. Sleep problems and daytime behavior problems in young children: is there a relationship? Poster Sessions at the 28th Annual AABT Convention; November 1993; New York, NY
- ↵Carskadon MA, Harvey K, Dement WC. Acute restriction of nocturnal sleep in children. Percept Mot Skills. 1981,53:103–112
- Frank Y,
- Kravath RE,
- Pollak CP,
- et al.
- ↵Richman N. Surveys of sleep disorders in children in a general population. In: Guilleminault C, ed. Sleep and Its Disorders in Children. New York, NY: Raven Press; 1987
- Azi JH,
- Pitson A,
- Stradling JR
- ↵Marcus C, Carroll J. Obstructive sleep apnea syndrome. In: Loughlin GM, Elgen H, eds. Respiratory Disease in Children: Diagnosis and Management. Baltimore, MD: Williams & Wilkins; 1993:475–499
- Copyright © 1998 American Academy of Pediatrics