Misdiagnosis: ADHD may really be a Sleep Disorder!

[NateS]

Diagnosing the Wrong Deficit

A study published in February in the journal Nature Neuroscience found that the amount of delta sleep in seniors correlates with performance on memory tests. And a study published three years ago in Sleep found that while subjects who were deprived of sleep didn’t necessarily report feeling sleepier, their cognitive performance declined in proportion to their sleep deprivation and continued to worsen over five nights of sleep restriction.

… what if doctors, before diagnosing A.D.H.D. in their patients, did have to find evidence of a sleep disorder? Psychiatric researchers typically don’t have access to the equipment or expertise needed to evaluate sleep issues. It’s tricky to ask patients to keep sleep logs or to send them for expensive overnight sleep studies, which can involve complicated equipment like surface electrodes to measure brain and muscle activity; abdominal belts to record breathing; “pulse oximeters” to measure blood oxygen levels; even snore microphones. (And getting a sleep study approved by an insurance company is by no means guaranteed.) As it stands, A.D.H.D. can be diagnosed with only an office interview.

Sometimes my patients have resisted my referrals for sleep testing, since everything they have read (often through direct-to-consumer marketing by drug companies) identifies A.D.H.D. as the culprit. People don’t like to hear that they may have a different, stranger-sounding problem that can’t be fixed with a pill — though this often changes once patients see the results of their sleep studies.

Attention-deficit problems are far from the only reasons to take our lack of quality sleep seriously. Laboratory animals die when they are deprived of delta sleep. Chronic delta sleep deficits in humans are implicated in many diseases, including depression, heart disease, hypertension, obesity, chronic pain, diabetes and cancer, not to mention thousands of fatigue-related car accidents each year.

Sleep disorders are so prevalent that every internist, pediatrician and psychiatrist should routinely screen for them. And we need far more research into this issue. Every year billions of dollars are poured into researching cancer, depression and heart disease, but how much money goes into sleep?

Vatsal G. Thakkar is a clinical assistant professor of psychiatry at the N.Y.U. School of Medicine.


http://www.nytimes.com/2013/04/28/opini ... 30428&_r=0

[ChicagoGranny]

Many, many children who have been diagnosed with ADD and ADHD actually have sleep-disordered breathing and other sleep disorders. They get treated with drugs and the underlying problem goes undiagnosed. A few pediatricians are becoming aware of this and are ordering PSGs.

[NateS]

I only included excerpts - those interested might want to read the whole article - url above - as well as the many (177! as of latest count) comments from interested patients, family, physicians, etc.

Regards, Nate

[chunkyfrog]

Sadly, sleep is still misunderstood--especially where it should be respected and understood.
Too many people, including those who should know better, regard sleep as an inconvenience.
an interruption of all the "important" things.

[Drowsy Dancer]

The article implies a dichotomy between the two. I would have liked to read more discussion of comorbidity of these two conditions.

[SleepingUgly]

Many, many children who have been diagnosed with ADD and ADHD actually have sleep-disordered breathing and other sleep disorders.

The majority of children with ADHD symptoms do not have SDB; only a small proportion do (although I wouldn't be surprised if there is a high incidence of ADHD-like symptoms in kids with significant SDB). Of course the possibility of a sleep disorder, as well as other disorders, should be explored prior to concluding that it's ADHD (what I call "primary ADHD", as in not caused by another disorder).

The article implies a dichotomy between the two. I would have liked to read more discussion of comorbidity of these two conditions.

There is a high comorbidity of periodic limb movements and ADHD. It's not known why. One theory is that they are both dopamine issues. No one knows.

[PreemieNrsTiffy]

When I was resisting the OSA diagnosis and fussing with my sleep doctor he was trying to get me to understand how SDB can have many manifestations including a previous pedi patient of his that was thought to have depression and ADHD but was remarkably "cured" after starting CPAP for SBD.

There is a high comorbidity of periodic limb movements and ADHD. It's not known why. One theory is that they are both dopamine issues. No one knows.

My husband just started CPAP after he was evaluated for snoring and possible RLS and PLMD. I really didn't think the CPAP would help either his RLS or PLMD. Thankfully I was wrong, he still gets RLS prior to falling asleep but once he falls asleep (on the CPAP) his limb movements stop. I can't tell you what a blessing this is as his bed partner, as well as the lack of snoring.

[Todzo]

The majority of children with ADHD symptoms do not have SDB; only a small proportion do (although I wouldn't be surprised if there is a high incidence of ADHD-like symptoms in kids with significant SDB). Of course the possibility of a sleep disorder, as well as other disorders, should be explored prior to concluding that it's ADHD (what I call "primary ADHD", as in not caused by another disorder).

Citation?

[Jahbulon]

One symptom of sleep deprivation is hyperactivity (the symptoms of ADD/ADHD).

The rest, you know.

[49er]

The majority of children with ADHD symptoms do not have SDB; only a small proportion do (although I wouldn't be surprised if there is a high incidence of ADHD-like symptoms in kids with significant SDB). Of course the possibility of a sleep disorder, as well as other disorders, should be explored prior to concluding that it's ADHD (what I call "primary ADHD", as in not caused by another disorder).

Citation?

Todzo,

I have seen a 30 to 35% figure quoted regarding kids with SDB being misdiagnosed as having ADHD. Unfortunately, there is no information on where it came from.

49er

[Drowsy Dancer]

The phrase to google would be "differential diagnosis" of ADHD and sleep disorders. This is CME material, not scholarly work, but it is interesting reading:

http://www.primarypsychiatry.com/aspx/a ... icleid=395

The paragraph cited in the first post sets up a bit of a straw man (and the author should know better). An ADHD workup goes a lot deeper than an "office interview," although it includes interviewing the patient.

[49er]

The phrase to google would be "differential diagnosis" of ADHD and sleep disorders. This is CME material, not scholarly work, but it is interesting reading:

http://www.primarypsychiatry.com/aspx/a ... icleid=395

The paragraph cited in the first post sets up a bit of a straw man (and the author should know better). An ADHD workup goes a lot deeper than an "office interview," although it includes interviewing the patient.

DD,

I am confused as to which panel member you are referring to. It is the 2nd guy, Timothy Wilkens, who talks about ADHD and sleep disorders. He said, inadequate amount of sleep is also related to diminished attention, focus, academic performance, and occupational performance, as well as a number of mood symptoms.2 If the ADHD symptomatology is related to sleep apnea or duration of sleep, treatment should provide immediate reversal of ADHD symptoms.""

Well, that isn't true with adults. I am not sure how he can assume that is true with kids since they also could have gone years without treatment.

By the way, I found it interesting how many drug companies they consulted with. It doesn't necessarily mean their information is biased but I think it is something to keep in mind.

Regarding the first guy, Dr. Barkley, who seemed to be linking ADHD to LD, uh, if you have learning disabilities for example that affect your processing abilities, what looks like ADHD issues isn't. The key is if your LD issues are accommodated, your ADHD problems should disappear. Sorry, that is a hot button issue of mine as I know people who are midiagnosed as having ADHD and put on meds when it turns out they had LD.

49er

[Drowsy Dancer]

The paragraph cited in the first post sets up a bit of a straw man (and the author should know better). An ADHD workup goes a lot deeper than an "office interview," although it includes interviewing the patient.

DD,

I am confused as to which panel member you are referring to.

I was referring to this statement:

As it stands, A.D.H.D. can be diagnosed with only an office interview.

contained in the New York Times article quoted in the first post to this thread.

It would be more accurate to state that ADHD can be diagnosed only with (not "with only") determining patient history, as opposed to, say, a blood test, but the interviewing process can be quite extensive and involve collateral contacts, review of medical and academic records, etc., etc. The implication of "only an office interview" makes it seem like the interview process is superficial and fails to consider differential diagnoses. Now, that may in fact be true of some clinicians, especially PCPs, but I don't think that's the standard of practice for psychiatrists, especially experts in ADHD.

Of course, the wording could have been an editing error on the part of the NYT. The difference between "with only" and "only with" is subtle.

Sorry for the confusion...

[SleepingUgly]

once he falls asleep (on the CPAP) his limb movements stop. I can't tell you what a blessing this is as his bed partner, as well as the lack of snoring.

In that case, my guess would be that he didn't have true "periodic limb movements", but rather muscle contractions associated with respiratory events. Great news!

[SleepingUgly]

The majority of children with ADHD symptoms do not have SDB; only a small proportion do (although I wouldn't be surprised if there is a high incidence of ADHD-like symptoms in kids with significant SDB). Of course the possibility of a sleep disorder, as well as other disorders, should be explored prior to concluding that it's ADHD (what I call "primary ADHD", as in not caused by another disorder).

Citation?

I have plenty of articles on this topic, but no time to dig through my file cabinet now to satisfy your predictable request for a citation. The research suggests that in children mild ADHD symptoms may be caused by SDB. Severe ADHD is unlikely to be solely due to SDB.