Stacy Bowker, ND

As NDs, we are taught to find and treat the cause of our patients’ symptoms. In the case of children presenting with attention deficit hyperactivity disorder (ADHD), there can be a variety of individual causes and more commonly, multiple causes that lead to this diagnosis. In this article, the correlation between ADHD and obstructive sleep apnea (OSA) will be discussed as well as a naturopathic approach to treatment that addresses this particular cause. The most commonly prescribed conventional treatments for ADHD are stimulant drugs, which cause side effects that are often unacceptable to both the patient and their parents or guardians. Going without treatment can be just as unacceptable, which can leave parents feeling frustrated and open to alternative approaches for their child. Although some of the treatment information presented in this article may not be new to NDs, hopefully it will solidify an understanding of how these therapies work and what expectations to give to parents seeking help for their child.

About ADHD and OSA

Attention deficit hyperactivity disorder is a DSM-IV diagnosis affecting up to 5% of children.¹ Sleep disorders are present in nearly 25% of children diagnosed with ADHD, with sleep-related breathing disorders, such as OSA, being among the most common.² Perhaps the most significant statistic is that successful treatment of OSA (in research studies, the treatment of choice was adenotonsillectomy) can result in improvement in ADHD symptoms even greater than that seen with commonly prescribed medications for children presenting with both ADHD and OSA.³ This is reason enough to screen every child with ADHD or ADHD-like symptoms for OSA and choose a treatment approach that addresses the root cause or causes of the neurobehavioral disorder. Unfortunately, most overnight sleep labs that cater to the pediatric population have long waiting lists, making the feasibility of confirmatory diagnoses unreasonable; however, we can ask appropriate screening questions related to sleep as part of our patient intake as well as conduct a thorough physical exam, including careful inspection for signs of allergies in the ears, nose, sinuses, and throat. Interestingly, a Seattle-area pediatric sleep specialist recently reported at a conference that nearly 100% of the patients with suspected OSA that came to her sleep lab for evaluation were diagnosed with mild to severe OSA, suggesting that many more children with a sleep-related breathing disorder go undiagnosed.⁴

While the goal of allopathic providers treating children with co-existing ADHD and OSA is to treat the cause and get these children off their stimulant medications, the surgical approach to treatment is not without risk. In fact, children with OSA who undergo adenotonsillectomy are at increased risk of breathing complications compared with other children receiving this surgery.⁵ One theory points to an increase in inflammatory cytokines found in the hypertrophied tonsils of children with OSA that are not present in children presenting with infectious tonsillitis.⁶ As NDs, we should be feeling pretty confident right now in our ability to help these children without the need for surgery, and this is where the naturopathic treatment approach for ADHD comes in.

Most NDs who treat children with ADHD use a combination of treatments, including identification and elimination of food sensitivities; cognitive support in the form of amino acids, EPA & DHA, vitamins, and other micronutrients; homeopathy; counseling; craniosacral therapy; and elimination of toxins (especially lead). While there is definitely some overlap in the treatment approach to OSA, a clear goal of the treatment is to remove the inflammation causing the tonsillar hypertrophy (even if the palatine tonsils are not visibly inflamed, there could still be inflammation of the adenoids leading to obstructed breathing).

Diagnosis Protocol

With this in mind, following is my suggested protocol for identifying children who have been previously diagnosed with ADHD or behavioral issues who may also have OSA. Treatment approach is included:

In addition to a thorough patient history and intake, the BEARS sleep screening algorithm for pediatric sleep disorders can be used.⁷

B= Bedtime problems: Does your child have difficulty going to bed? Or falling asleep?

E= Excessive Sleepiness: Does your child seem overly tired or sleepy during the day? Does he/she still take naps?

A= Awakenings: Does your child wake up a lot at night?

R= Routine: What is your child’s normal bed time and wake time?

S= Snoring: Does your child snore or have trouble breathing while asleep?

If the parent/child answers yes to the questions about bedtime problems, excessive sleepiness, awakenings, or snoring, you should consider OSA in your differential diagnosis.

Identify and eliminate potential food sensitivities/intolerances contributing to upper airway inflammation. In my clinical experience, dairy seems to be the most problematic, followed closely by wheat. If the child has tonsillar hypertrophy, strict adherence to dietary recommendations should result in a visible reduction in the size of tonsils.

High doses of fish oil containing both EPA & DHA. I usually recommend a combined total of 1000-2000 mg of these omega-3 fatty acids for children. While the DHA has been shown to help with neurological and cognitive function, the EPA is especially important for its anti-inflammatory properties. For vegetarians and vegans, flax oil may be used, but I have not seen the same clinical results with flax oil as I have with fish oil in the pediatric population, probably because the alpha-linolenic acid in flax oil is not completely converted to EPA and DHA by the body.

Hydrotherapy – either constitutional or local contrast over the upper respiratory tract can be effective at reducing inflammation of the tissues and stimulating the Vis.
Botanical Medicine – botanicals such as Curcuma longa, that reduce inflammatory cytokines and decrease cellular proliferation, should theoretically help with tonsillar hypertrophy associated with chronic OSA.⁸

Homeopathy – some remedies that may be helpful for both symptoms of ADHD and OSA include Lachesis, Opium, and Sulphur.⁹ Other remedies may be indicated as well, so it is important to use whatever remedy best fits the child.

For children with severe tonsillar hypertrophy or severe sleep apnea diagnosed by polysomnogram, a new procedure to reduce tonsil volume may be a safer alternative to surgery. The procedure is called bipolar radiofrequency-induced thermotherapy (RFITT) and according to a study published in 2007 in Acta Oto-Laryngologica, compared with blunt dissection of the palatine tonsils, significantly reduced were perioperative blood loss, postoperative pain, and speaking and swallowing difficulties.¹⁰

While there is no guarantee that following the above steps will cure a child of their ADHD symptoms, there is certainly enough evidence in the literature to support the naturopathic approach with these patients. There is also an opportunity for further research of our therapies in comparison with either conventional pharmaceuticals and/or adenotonsillectomy for ADHD symptoms. Prior to delving into the research, I had not considered high doses of curcumin as a possible treatment for tonsillar hypertrophy. Hopefully a better understanding of the association between OSA and ADHD in children will lead to other novel naturopathic approaches that are supported by research.

Stacy Bowker, ND received her doctor of naturopathic medicine from Bastyr University in 2004. Since then, she has opened a clinic in Snohomish, Wash., where she maintains a private practice. Dr. Bowker is also involved with the Washington Association of Naturopathic Physicians as a member of the board and chair of the governmental affairs committee. Outside of work, she can be found chasing her toddler and spending time with family.

References

Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry. 2007;164(6):942-948.
Betancourt-Fursow de Jiménez YM, Jiménez-León JC, Jiménez-Betancourt CS. Attention deficit hyperactivity disorder and sleep disorders [in Spanish]. Rev Neurol. 2006;42(suppl 2):37S-51S.
Huang YS, Guilleminault C, Li HY, Yang CM, Wu YY, Chen NH. Attention-deficit/hyperactivity disorder with obstructive sleep apnea: a treatment outcome study. Sleep Med. 2007;8(1):18-30.
Chen M. When snoring and sleep apnea intersect: clues and responses for diagnosis and management. Paper presented at: Seattle Children’s Continuing Medical Education: Practical Pediatrics; February 6, 2010; Seattle, WA.
Perez IA, Ward SL. The snoring child. Pediatr Ann. 2008;37(7):465-470.
Kim J, Bhattacharjee R, Dayyat E, et al. Increased cellular proliferation and inflammatory cytokines in tonsils derived from children with obstructive sleep apnea. Pediatr Res. 2009;66(4):423-428.
Owens JA, Dalzell V. Use of the ‘BEARS’ sleep screening tool in a pediatric residents’ continuity clinic: a pilot study. Sleep Med. 2005;6(1):63-69.
Aggarwal BB, Harikumar KB. Potential therapeutic effects of curcumin, the anti-inflammatory agent, against neurodegenerative, cardiovascular, pulmonary, metabolic, autoimmune and neoplastic diseases. Int J Biochem Cell Biol. 2009;41(1):40-59.
Sleep Apnea. University of Maryland Medical Center Web site. http://www.umm.edu/altmed/articles/sleep-apnea-000156.htm. Updated March 13, 2010. Accessed May 14, 2010.
Pfaar O, Spielhaupter M, Schirkowski A, et al. Treatment of hypertrophic palatine tonsils using bipolar radiofrequency-induced thermotherapy (RFITT.). Acta Otolaryngol. 2007;127(11):1176-1181.