Sleep Apnea Can Be Misdiagnosed as Attention Deficit Disorder

About nine years ago, my then 15-year-old son, Philip, began to seem unusually tired much of the time. He was slender, healthy, an “A” student, and never used drugs, but most days after school, he just wanted to nap. At a visit to his pediatrician, an x-ray revealed a sinus infection. I was surprised, since he had none of the typical symptoms, such as congestion or headache.

Both the doctor and I assumed the source of the fatigue had been discovered. A round of antibiotics did seem to improve his sleepiness for a while, and the problem appeared to be solved. However, for the next couple of years, Philip contracted sinus infections on a fairly regular basis, at least every three to four months. Without frequent colds or allergies, it was a bit odd.

During those two years, Philip’s grades began to slip a bit. He was distracted, could not remember to complete daily tasks, and didn’t concentrate during ordinary conversations as a person normally would. Philip’s physician referred him to a clinical psychologist to be tested for attention deficit disorder. Sure enough, a formal diagnosis of ADHD was made. His pediatrician then prescribed methylphenidate, and the medication did indeed seem to help his concentration and the sleepiness. It seemed unusual, though, that Philip had not exhibited symptoms of attention deficit as a younger child.

Strangely, however, the sleepiness soon returned. His pediatrician then ran an exhaustive battery of blood tests in an attempt to discover the difficulty, and she screened him for depression. Philip was not at all depressed, nor was he anemic, nor did he have a thyroid disorder, nor were there any other abnormalities in his blood test results. When his grandmother offered to take him on an all-expense-paid trip to Hawaii, he thanked her but said he really didn’t want to go. He said he was simply too tired to manage the trip.

On a return visit to the pediatrician, the doctor decided to refer him to a sleep specialist. Philip did not report awakening at night, nor was he in the slightest overweight, nor did he snore. He was an unlikely candidate for sleep apnea, but no other test was yielding helpful information.

A sleep specialist interviewed Philip before ordering a sleep study, noting that he scored a 12 on a test called the “Epworth Sleepiness Scale,” when <10 is the upper range for normal. Philip then went to a hospital overnight for a sleep test, which was about 6.5 hours long. During that night, test results showed that he had 30 total apneas and partially awoke 94 times due to not breathing properly. The sleep specialist formerly diagnosed him with obstructive sleep apnea. Philip was given a prescription to use a continuous positive airway pressure (CPAP) machine at night, and he was immediately amazed at how much better and more alert he felt. He said he didn't know it was possible to be so rested. A follow-up sleep study later recorded only a couple of apneas, down from 30, and there were no partial awakenings at all. Philip had always wanted to become a professional pilot and was disappointed to learn that individuals diagnosed with ADHD cannot be granted a license to fly. When we learned that an inability to concentrate is a symptom of sleep apnea, his pediatrician ordered that he be formally tested again for ADHD at a nearby university. A day-long neuropsychological evaluation revealed that all symptoms of ADHD were gone, and that Philip had been misdiagnosed originally. The university report stated,
“The patient’s performance on the Brown Adult ADD scale did not reveal an adult ADD diagnosis. His total score was 12 (normal < 55)… This patient does not currently have adult ADD. His obstructive sleep apnea does not currently impact his cognitive functioning, since he is on CPAP." When petitioned, the Federal Aviation Administration (FAA) considered Philip’s case. They eventually agreed with the conclusion in the psychological evaluation that he was originally misdiagnosed, did not need ADHD medication, and was able to concentrate without difficulty. Philip then earned an airline transport pilot license, became a flight instructor, and now flies for a regional carrier at the age of 24. Eventually, the FAA also approved a specially constructed oral appliance, much like a retainer, to take the place of Philip’s CPAP machine. This device has been proven to be just as effective in opening his airways at night as the loud and bulky apparatus he had been using previously, and it is well suited for travel. In retrospect, the original symptoms Philip experienced fit with what is known about obstructive sleep apnea. Obstructive sleep apnea is associated with frequent sinus infections and an inability to concentrate, which may masquerade as ADD or ADHD. In addition, the methylphenidate he was originally prescribed is a stimulant medication, so it may temporarily mask the symptom of sleepiness. The most important lesson I’ve learned is that some medical conditions are not diagnoses in themselves, but rather symptoms of another problem. Although Philip did not fit the stereotypical picture of someone with sleep apnea (middle-aged, overweight, prone to snore, frequently awakening in the night), the inability to get a good night’s rest was his underlying problem, rather than a lack of focus or an infection. Since obstructive sleep apnea can lead to heart disease, it is critical that parents and pediatricians consider a sleep study when a child’s sleepiness is chronic. Present quality of life will be greatly improved, and early treatment could prevent a major problem later in life.