Aren’t they angels when they sleep? But sometimes troublesome behavior during the day is caused by what happens each night during sleep. If your child seems to have ADHD and also snores, the two may be related.

A study published online in the March 2003 issue of Pediatrics looked at thousands of 5 to 7 year olds and found that snoring is significantly more common among children with mild ADHD than it is in the general population.

Snoring can be a symptom of poor breathing during sleep (obstructive sleep apnea), which can lead to chronic poor quality sleep, which can lead to behavior and attention problems during the day. Treating the snoring may be a much better option than treating the child with ADHD medicines.

For some children, this will get to the cause of the problem, rather than just treating the symptoms.

If you think your child may have ADHD, make sure you know whether he or she snores.

Parents are quick to mention some things to their pediatrician: fevers, seizures, bleeding. Snoring is another important symptom that your child’s doctor needs to know about, though it often goes unreported. Snoring can be the sign of obstructive sleep apnea syndrome (OSAS), where there is prolonged partial blocking, or intermittent blocking, of breathing during sleep.

OSAS can cause growth problems. It has also been linked to ADHD, poor school performance, learning difficulties, bedwetting, high blood pressures, and even death.

OSAS is different from primary snoring (PS), the name given to snoring that doesn’t cause sleep disruption or breathing problems. Primary snoring is more common than OSAS, which occurs in about 2 percent of children.

The American Academy of Pediatrics has issued important April 2002 guidelines for diagnosing and managing OSAS. They state that OSAS and PS cannot be distinguished from each other based on the history and physical examination alone. Other tests must be used.

A sleep study is the gold standard test for telling the difference. Thus, snoring needs to be reported to the doctor, and when snoring lasts longer than a brief respiratory infection, it deserves thorough evaluation.

Snoring is fairly common among school-age children, but it is more than twice as common among children with attention deficit-hyperactivity disorder (ADHD), according to information presented at the May 2001 meeting of the American Thoracic Society.

This suggests a connection. Snoring can lead to decreased sleep quality, which can produce all of the symptoms of ADHD. When the snoring is treated, the ADHD often becomes much better or completely disappears, decreasing or eliminating the need for medicines.

Exposure to passive tobacco smoke may indirectly lead to ADHD symptoms, because kids who are exposed to second-hand smoke have over a 100% – 300% increased chance of snoring.

In anger I threw my pager across the on-call room, slamming it against the wall. I don’t anger easily or often, but I was a pediatric resident who had been awake for 36 hours. The pager had gone off one time too many. Sleep deprivation had changed me from a calm, caring person into an irritable, impulsive mess.

As if it shouldn’t have been obvious, research has shown that the sleep deprivation associated with residents’ on-call schedules brings about significant “impairment of physician mood” as the sleep deprivation increases (Journal of Occupational Medicine, Dec 1992).

The surprising news is that partial, or low-level, sleep deprivation has a bigger effect on behavior than either the short or long-term complete sleep deprivation experienced by residents (Sleep, May 1996). Until recently, the effects of partial sleep deprivation have been seriously underestimated.

We know, based on common sense, that inadequate sleep makes kids more moody, more impulsive, and less able to concentrate. We’ve known for more than 20 years that sleep deprivation makes it difficult to learn (Journal of Experimental Psychology, Mar 1975).

Recent research has verified that chronic poor sleep results in daytime tiredness, difficulties with focused attention, low threshold to express negative emotion (irritability and easy frustration), and difficulty modulating impulses and emotions (Seminars in Pediatric Neurology, Mar 1996). These are the same symptoms that can earn kids the diagnosis of attention deficit hyperactivity disorder (ADHD, popularly known as ADD).

ADD is an important problem in its own right, but research in sleep laboratories has shown that some (and perhaps a great many) kids are mislabeled with ADD when the real problem is chronic, partial sleep deprivation.

When children are identified with symptoms of ADD, often no one thinks to explore the child’s sleeping habits, and whether they might be responsible for the symptoms. (People also forget to consider childhood depression as a possible cause for these symptoms — but that is another story.)

Sometimes it is obvious to parents that their children are not sleeping well — but not always!

Any child who snores may not be getting adequate sleep. Obstructive sleep apnea is a common medical condition that is now being identified in more and more children. The peak age for this is 2 to 5 years old, but it can occur at any age. Not all kids who snore have sleep apnea. Classically, those with sleep apnea snore quite loudly for a bit, then are silent, then snort briefly, move about, and resume snoring. If snoring is accompanied by nighttime breathing difficulty and pauses in breathing, then it may well be sleep apnea. This should be brought to the attention of your pediatrician. You might want to make a cassette tape of your child’s sleep noises to bring with you.

Children with sleep apnea do not get sound sleep. They may also get suboptimal oxygen to the brain at night. Obstructive sleep apnea can have a serious negative impact on a child’s intellect and behavior. The common symptoms of sleep apnea are difficulty paying attention during the day, decreased academic performance, oppositional behavior, and restlessness. Not all kids with sleep apnea snore. Even when they do, sleep apnea is often overlooked. Instead, the child is diagnosed with a behavioral disorder — most commonly ADD (Journal of Clinical Child Psychology, Sep 1997).

Children with sleepwalking, restless leg syndrome, narcolepsy, insomnia, or other sleep problems may also be misdiagnosed with ADD (Neurology, Jan 1996).

When parents of children with ADD are interviewed, they usually identify their kids as poor or restless sleepers (Journal of Pediatric Psychology, Jun 1997). Kids who have been diagnosed with ADD do wake up more often at night than their peers (Pediatrics, Dec 1987). Poor sleep is a common feature of ADD — a problem that can be made worse by the use of stimulant medications such as Ritalin or Dexedrine. In fact, recent studies have reported sleep problems in 25% to 50% of children and adolescents with ADHD, two to three times the rate of sleep problems in children without ADHD! (Sleep. Aug 1, 2007)

In an individual child, it can be very difficult to tease apart whether interrupted sleep is the cause or the result of ADD. The good news is that even when ADD is the correct diagnosis, addressing the sleep issues can dramatically improve the behavior of the child (Journal of Pediatric Psychology, Apr 1991).

A 10-year-old girl in Pittsburgh, Pennsylvania who had true ADD also had significant sleep difficulties. She had long delays before falling asleep. She would often wake up at night and have difficulty falling back asleep. She received professional help for her sleep problem (chronotherapy combined with a behavior modification program), which resulted in an increase of sleep from 7.2 to 9.2 hours per night. There was significant, measurable improvement in her schoolwork, teacher evaluations, and behavior. These changes were observed by teachers and peers who were not aware of her treatment.

If your child has ADD symptoms or other behavior problems, he or she should be carefully assessed for sleep problems. If sleep disturbances are present, they need to be addressed, regardless of whether or not they are the root cause. If your child is not getting sound, uninterrupted sleep, discuss this with your pediatrician. You may also want to contact the National Sleep Foundation (202 785-2300) or the American Sleep Disorders Association (507 287-6006) for information or referrals. There are now more than 3,000 Sleep Disorders Centers that can provide the kind of help the little girl from Pittsburgh received. Another great resource is Helping Your Child Sleep Through the Night, by Joanne Cuthbertson and Susie Schevill.

How do we know how much sleep our children need? First and foremost, every child is different. In general, toddlers and preschoolers sleep approximately 12 hours per day with one nap. School-age children need less, about 10 hours per day. Most preteens and teens need around 9 hours of sleep per day – though we all know that many teens get much less!

These are just averages! Some children need much more sleep than these numbers, other much less. Many sleep experts recommend asking yourself some questions to determine if your child is getting too little sleep.

These include:

• Does your child seem sleepy or irritable during the day?
• Does your child have difficulty staying awake when sitting still?
• Does your child have trouble paying attention at school or at home?
• Does your child seem to perform below his or her potential?
• Does your child have emotional outbursts?

As parents, we all know what it feels like to be grumpy, contrary, and “not at our best” from lack of sleep. If our kids often feel this way, we owe it to them to find solutions to this problem.