Episode 172: ADHD and Sleep Disordered Breathing

Hi and welcome to episode 172 of the Untethered Podcast. Today it's your host Hallie Balkan joining you and we're going to continue with part two, episode two of this series. We are specifically talking today about another symptom of orofacial myofunctional disorders and that is adhd. In this conversation we're actually going to take a bit of a deeper dive into sleep disorder breathing and continue our conversation from our last episode to understand understand the overlapping connection between ADHD symptoms and those of sleep disorder breathing. So let's jump in. I also want to let you know that doors to the MYO membership are open right now, so go to themyomembership.com if you'd like to join us. They are open this week only, so if you're listening to this the week that it airs, go to the myome membership.com and join us. Cannot wait to see you there. Quick Disclaimer all information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host, Hallie Balkan. I'm a certified orofacial myologist, feeding specialist and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, tethered oral tissue and airway space. I challenge you to keep an open mind and join my mission to get this information out to the masses. Let's get started. Hi and welcome to this episode. We are going to continue our conversation on sleep and airway adhd. It's going to be really intertwined to this learning neurocognitive function. So I'm excited to talk about this especially because I'm an individual who at the age of five was basically told. You know, teachers told my mom when I was younger that I had ADHD like behaviors and they basically wanted her to get me assessed and she talked to a number of professionals and took me to some of them and bottom line was they decided not to medicate me at the end of the day. But come age 19 I was having a hard time in my freshman year of college with studying and just the way that everything was functioning was different than I had. I had done it before and I hadn't really learned a good. I didn't have a good learning style really. I got great Grades, I did well. So everyone's like, oh, don't worry, you got through high school and all of schooling just fine. But yeah, I mean, it was really hard when I got into my freshman year of college. And so I went and I was tested and I was diagnosed with adhd. Now, they said to me, oh, you have a high iq and you know, we don't really want to give you a label of add, but you're a candidate for Ritalin, so, like, here's a prescription. I was a little not surprised. But now that I look back, I wonder why nobody recommended a sleep study or nobody asked me about my sleep before just handing me a prescription. And look, I didn't seek out the professionals who maybe knew how to ask about that, but I also did not know to ask about that at the time. Right. This was, oh, gosh, I don't know, 2000, like fall 2003, spring 2004. So a ways back, and definitely nothing, not anywhere near my radar. I didn't even know I was going to be a speech pathologist at that time. So I ended the last episode talking about how obstructive sleep apnea. Well, and actually, just actually sleep disorder breathing in general. Right. Obstructive is at the most severe end, just sleep disordered breathing, which could be upper airway resistance syndrome or mild sleep apnea, something on the lower end of the totem pole. It's still a problem. And research shows that children with sleep disorder breathing symptoms score significantly lower than those without sleep disorder breathing symptoms on tests of executive function. So obstructive sleep apnea, let's talk about that for a second, just so we can kind of clarify what this looks like. It occurs when muscles that support the soft tissues in your throat, like your tongue, your soft palate, your uvulus, your tonsils, they relax too much. Okay. This narrows or closes off the airway and then breathing is momentarily cut off. Right. An obstructive sleep apnea, there's an obstruction or a stop in the breathing when we are partially blocked. We may hear snoring. When we're completely cut off, we may hear gasps for air or similar noises. Okay. This is a big problem actually in our pediatrics. And the symptoms of sleep disorder breathing, like I mentioned, are associated with poor cognitive function in five year old children. Okay. So there was an October 2004 study where that's where they actually discovered that children with sleep disorder breathing symptoms, or they documented this, scored significantly lower than those without those symptoms. Untested executive function. Okay, that was back in October 2004. What does this tell us? It tells us we need to be looking at and asking about our children's sleep habits and their airways. If children are not getting a proper night's sleep, how can they be expected to perform well in school or act appropriately behaviorally? If they're constantly tired from underlying symptoms of sleep disorder breathing, then they're not going to be able to function at optimal levels of performance or even semi optimal levels. Right? Because hey kids. The study also found that in the absence of obstructive sleep apnea, the children who had those more mild forms of sleep disorder breathing, those type of symptoms, they are still associated with poorer executive functioning and memory skills and lower general intelligence. And this was in 5 year old children back in 2004. This is not a new thing, this is not a new phenomenon. This is not a new conversation or. Well, it is a new conversation and discussion. It's not happening enough. It should be happening more. It's time to start paying attention to sleep. Especially if you or your child have an ADHD diagnosis, Especially if your patient has an ADHD diagnosis. We need to be asking about it, okay? So I know in the MYO community we talk a bit about it, right? We talk quite a bit about it, but it's not mainstream, not a mainstream conversation, it's not mainstream knowledge. And so I really want to encourage you, especially if you're a professional or a parent, a doctor, a therapist, somebody who's not yet in this space, start asking about sleep, whether it's you, your child, your patients, right? There are always fun articles that we can share and everything that may be of interest to you. And so I'm happy to link certain articles to the show notes and we will do that, but I just want everybody to take a step back and ask, what about sleep? What is the mouth doing? What does the mouth look like? I mentioned that childhood sleep apnea is linked to brain damage or lower iq. This is from Johns Hopkins Hopkins Medicine. This was in the online journal Public Library of Science Medicine 2006. And in what was believed to be the first study showing neural changes in the brains of children with serious unrelated sleep apnea, Johns Hopkins researchers conclude that children with this disorder appear to suffer damage in two brain structures tied to their learning ability. They compared 19 children with severe obstructive sleep apnea to 12 children without the disorder. Using a special type of MRI, researchers identified changes to the hippocampus and the right frontal cortex. Then they use IQ tests and standardized performance tests to measure verbal Performance, memory, executive function. The researchers were able to link the changes in the two brain structures to deficits in neuropsychological performance. Why is this important? Well, the hippocampus that I mentioned 30 seconds ago is a structure in our temporal lobe that's vital to learning and it's vital to memory storage. While the right frontal cortex is in charge of higher level, not it is in charge of higher level thinking, like accessing old memories, using them in new situations. We need to be paying attention to what this research has told us. And again, not new research. This is a wake up call. Obstructive sleep apnea causes brain damage. Children with obstructive sleep apnea had lower mean IQ test scores, like 85, for example, versus children without OSA who had, let's say, 101. Children with OSA or obstructive sleep apnea also performed worse on the standardized tests measuring executive functions like verbal working memory, like an 8 versus a 15, for example, and word fluency, a 9.7 versus a 12. In terms of the standardized scores, the cognitive effects of untreated apnea may be actually far more damaging to children than adults because these are critical years when the brain is still developing. Right. The researchers pointed that out. This is occurring during critical developmental periods. And that frontal cortex, which I mentioned in the last episode. Right. That also continues to mature throughout the teen years and even well into your 30s, actually. And so researchers fear that childhood injury to this area might lead to long term cognitive deficits. All right, so we need to have serious conversations. This is, this should be a wake up call for parents, pediatricians and other providers working with pediatrics. Fragmented sleep, interrupted breathing, and oxygen deprivation, those are all hallmarks of sleep apnea. They harm a child's ability to learn and their school performance. Then one impacts the other. Remember what I said before? Children with OSA had lower mean IQ test scores like an 85 compared to children without OSA at 101. It's a 16 point difference. And children with OSA also perform worse on the standardized tests that I mentioned. Okay, so we have to be looking at this. Right? And okay, what if it's not obstructive sleep apnea? What if it's just like sleep disorder breathing, like snoring, but we're not seeing like apnea. Well, research also shows that sleep disorder breathing is associated with cognitive dysfunction. Okay. And in children. And the effect appears to be particularly marked in those who have moderate to severe sleep disorder breathing. That said, snoring alone still impacts neurocognitive function even when sleep disorder breathing is not moderate to severe. This was a study published in 2016, effective sleep disorder breathing severity on cognitive performance measures in a large community cohort of young school age children. And again, we can. I'm happy to add some links to the show notes for some of these articles. So their objective of this study was to look at whether sleep disorder breathing associated adverse changes in neurocognitive functioning. Like are they severity dependent? Does it depend on how severe the sleep disorder breathing is? It's more mild? Is it more moderate to severe? What's going on? So they did look at 10, 10 snoring and non snoring children aged 5 to 7 years and from public school settings that underwent polysomnography and neurocognitive assessments of intellectual attention, memory, language, executive function development. The children are subdivided into four severity groups on the basis of the apnea hypopnea Index ahi and they were followed by comparisons of cognitive function with a particular focus on standardized subtests of intellectual Language, Attention, Memory and Executive function. The bottom line is that there was a significant difference in their scores. It was significant. And we have to be looking at why this is happening. Well, oxygen deprivation to the brain is why it's happening and then the level of that and how frequent that happens, that impacts our body's ability one to get restorative sleep that helps us repair our body while we're sleeping so we can function the next day. But also lack of oxygen to the brain is a serious problem. And that's what's happening during apnea. Right, that's what's happening if we have obstructive sleep apnea where we stop breathing for even a second. So we need to look at the impact of airway access to airway nasal breathing like I was talking about in the last episode. Can you hear the breathing? If you can hear the breathing, you need to have your child evaluated. If you can hear your breathing, you need to be evaluated. Okay. This goes beyond just children. This goes to adults too. So what? You know, we could talk all day long about the different symptoms that we see. But I want to cover just some quick symptoms that you can look for in infants versus young children versus adults so that you know who may need a myofunctional evaluation. Right. It could be enough that your mouth is just hinged open and or you hear the breathing like we talked about in the last episode. But in infants, sleep disorder breathing manifests as mouth breathing. We may see cyanosis which could be blue or gray skin or fingernails, choking or gurgling sounds, daytime sleepiness, maybe having a hard time waking them, failure to thrive related problems like low oxygen or slow heartbeat if you've had to resuscitate them, or other urgent care type situations related to breathing and then snoring, as we've been talking about, there's also symptoms in toddlers and young children, and we're going to cover those as well. One of the ones that we're highlighting here today, right, Behavioral and attention problems like adhd, hyperactive behavior when awake, adhd, irritability from lack of quality sleep, adhd. Are we starting to see how we could maybe diagnose a child with ADHD who might have a sleep disorder? Right. Breathing that stops for a few seconds at a time during sleep. We definitely need a sleep study. Breathing through mouth only, which we've talked about. Mouth breathing, daytime sleepiness, snoring, unusual sleeping positions, wetting the bed. These are all issues that we need to pay attention to. And then in adults, we have an additional list of symptoms as well. So with adults, right, we see a lot of the same symptoms. We see also in addition to some of those same symptoms, we may see difficulty falling or staying asleep. We'll see that daytime fatigue we talked about that we see in kids. There may be unusual breathing patterns. We talked about irritability earlier, but we may see irritability or anxiety. Things have built over time and snowballed. Impaired performance at work. It goes from impaired performance at school when you're younger to work or school, depending on where you are in your life, lack of concentration, depression, weight gain. These are all symptoms that you're kind of like, yes, that's me. Yes, that's me. Oh, yep, that's me. Look at your mouth, look at your sleep. Get a myofunctional. An orofacial myofunctional evaluation completed in elderly individuals too. We also see a shift in sleep schedule. And this is, you know, people will blame this on aging and saying, oh, you need less sleep when you're older and they'll wake up more at night. And you know, there could be other things leading to that as well. But if there's a lot of daytime napping, they have insomnia, longer recovery from changes in a sleep schedule, and maybe if they already have, they may have sleep apnea diagnosis. Ultimately, what we are looking at is what's going on and is it possible that there's an airway issue here that's causing a problem with sleep? Okay, circling back on what we were Talking about in the last episode, we don't want to hear audible breathing awake or asleep. It may happen if you're congested, if you have an infection, if you're tonsils, adenoids or other tissues are enlarged. If you have allergies, turbinates are enlarged, flared nares, deviated septum, chronic otitis media with a fusion, maybe a child's had PE tubes placed. There's all kinds of things that can cause this, but these are all airway issues. And it happens while we're awake, not just while we're asleep. So that's why I like to highlight that sleep disorder breathing is really important to pay attention to, but because we get kiddos who snore as a result of or they have audible breathing, it's again, not normal, even though our culture makes it seem to be the norm. But I want to really highlight too, that audible breathing when awake is also something that we need to pay attention to. And we really need to kind of circle back on the concept that there are all kinds of things that happen whether we're awake or asleep. Another thing that may happen is bruxing or clenching. You may clench and hold your jaws together, tightening those jaw muscles. And kind of with clenching, we see less wear to teeth. With bruxing, we're kind of grinding the jaw forward to open the airway. And that's causing some wear or a lot of wear on the teeth or cracked teeth possibly. But one of the number one reasons we clench and grind in our sleep at night is because of sleep disorder breathing or obstructive sleep apnea. Upper airway resistance syndrome, while this is often unconscious while awake or asleep, by the way, many people are not aware that they're doing this. So again, this is something like a dentist or registered dental hygienist should be monitoring at cleanings, for example. But I want to kind of. I want to wrap this up. I think that what's really important is if you're noticing this, if you have a child struggling in school, if you or your child or patients have been diagnosed with adhd, we need to do our due diligence. We need to work towards a differential diagnosis. Meaning we also, before giving them that diagnosis, we need to find out, are there sleep issues, are there airway issues, are there any airway obstruction? Don't settle for the, oh, my child sleeps 12 hours at night and never wakes up, or never wakes me up. That's not going to tell you any. It's not going to tell you anything about their sleep. There may need to be things like early expansion. In the next episode, we're going to talk about early expansion and, and the results of early expansion and what it's leading to, because there is now some research that's been published, pretty exciting, that talks about the benefits of expansion and the results and what it's doing for our health. And so we need to be talking about that. And so while I am not a expansion provider, I work with a lot of individuals who go through expansion and I can speak to the combination of expansion and, and the impact on the orofacial myofunctional disorder and what it allows us to do in myofunctional therapy and speech therapy and feeding therapy. So that's gonna be our next episode. So be sure to circle back and join me to talk so we can hear about what's going on in the latest research, as well as how skeletal expansion is improving speech and speech and sleep and feeding and all the fun things. All right, so that is everything for today. Thanks for joining me and I'll talk to you guys soon. Thanks for listening to this podcast. If you want to hear more of these Myo Tots, Airway and Feeding related episodes, be sure to leave a review on Apple Podcasts or pledge a small amount on patreon.com the Untethered podcast. If you found value, others you know in this space will too. So be sure to share this episode on your social media platforms and join us over on Facebook on my Facebook page at Hallie Bulk and Biz Instagram at Alibulcan and you can head over to theuntetheredpodcast.com to grab a copy of the Show Notes, where you can also subscribe to be kept up to date on the latest podcast episodes.