Elsevier

Sleep Medicine

Volume 9, Issue 4, May 2008, Pages 418-424
Sleep Medicine

Original article
Risk for sleep-disordered breathing and executive function in preschoolers

https://doi.org/10.1016/j.sleep.2007.06.004Get rights and content

Abstract

Background

Pediatric sleep-disordered breathing is known to negatively impact cognitive development. While a theoretical basis has been proposed for the developmental effect of pediatric sleep-disordered breathing on executive function specifically, this had not been directly examined among preschool-age children. This population may be particularly vulnerable if school-readiness is compromised. The purpose of the current study was to use a multi-dimensional approach to assessing executive function among preschool-age children at risk for sleep-disordered breathing.

Methods

Thirty-nine preschool children were administered executive function tasks assessing the dimensions of inhibition, working memory, and planning as part of a larger study. A parent or guardian completed a validated questionnaire concerning the child’s snoring and other behaviors indicating risk for sleep-disordered breathing.

Results

After controlling for age in a series of regressions, higher parent-reported risk for sleep-disordered breathing was associated with substantially lower performance on each executive function dimension. In comparing the group means of children at high and low risk for sleep-disordered breathing, the single snoring frequency item also showed that children who snored frequently or almost always had lower performance on each executive function dimension.

Conclusions

The results suggest that sleep-disordered breathing may be associated with impaired executive function in preschoolers, with its strongest impact on the inhibition dimension, further emphasizing the importance of early intervention for sleep-disordered breathing in this early age group.

Introduction

The impact of pediatric sleep-disordered breathing (SDB) on preschool-age children’s cognitive development has begun to receive significant attention due both to increasing evidence of a high prevalence of this type of sleep disorder among children, and to a growing body of evidence for somatic and biobehavioral effects related to disrupted sleep during early development. Research conducted with adults and school-age children has linked SDB with deficits in executive function [1].

Habitual snoring is considered the cardinal symptom of SDB, which is generally characterized by repeated events of partial or complete upper airway obstruction during sleep [2]. These upper airway changes induce disruption of normal alveolar ventilation and sleep structure, and lead to blood gas abnormalities and sleep fragmentation [3]. Obstructive sleep apnea (OSA) lies within the SDB spectrum and is the most frequently diagnosed pediatric sleep disorder, affecting at least 1–3% of children [4], [5], [6]. Children with OSA experience more frequent pulmonary hypertension [7], systemic hypertension and other cardiovascular disturbances such as left ventricular hypertrophy [8], [9], [10], [11], somatic growth problems [12], comorbid chronic illnesses [13], [14], poor quality of life [15], [16], [17], [18], depressed mood [15], [16], and increased healthcare utilization [19], [20]. An additional 6–27% of children display habitual snoring, indicating the presence of increased upper airway resistance [4], [5], [13], [21], [22], [23], [24], [25], [26], [27], [28].

Pediatric SDB has been repeatedly found to impose substantial adverse effects on cognition and school performance [6], [25], [29], [30], [31], [32], [33], [34], [35]. In particular, for school-age children, daytime biobehavioral comorbidities are understood to be the most crucial consequence of SDB. Of note, daytime sleepiness, behavioral hyperactivity, learning problems, and restless sleep are all significantly more common in habitual snorers [4], [21], [25], [29], [36].

Executive function (EF) is comprised of several dimensions related to prefrontal cortex functioning, such as planning, inhibition, coordination and control of action sequences [37]. In the current study, EF is operationalized as a multi-dimensional construct using a framework that includes planning (goal-directed behavior and problem solving), inhibitory control (the ability to inhibit a dominant, prepotent response), and working memory (WM; [38]). These dimensions are frequently used in the cognitive developmental literature and a series of standardized laboratory tasks have been developed to assess each. Skills in these three EF dimensions improve between the ages of 3 and 5 years and contribute to the outcomes of higher-order cognition and goal-directed behaviors [39].

The relation between specific EF impairment and SDB has been examined in adults and less frequently among school-age populations [1], [40]. As reviewed by Beebe [1], these few studies in children have had mixed results with the strongest impact of SDB in relation to impairment of sustained attention and behavioral inhibition, with weaker or non-existent findings for WM [1]. In 2002, Beebe and Gozal theorized that the relation between EF and SDB is due to disruption of the restorative features of sleep that results in subsequent prefrontal cortical dysfunction [41]. This is supported by recent imaging work demonstrating that children, ages 6–16 years with moderate to severe OSA, had EF impairment indicated by their verbal WM and word fluency, as well as lower neuronal metabolate N-acetyl aspartate/choline in both the left hippocampus and right prefrontal cortex [42].

However, these studies have not included a multi-dimensional conceptualization of EF (e.g., planning, inhibition, WM), and work relating EF to SDB in preschool populations has not been previously reported. The objective of the current study was to examine preschoolers with risk factors for SDB using a multi-dimensional conceptualization of EF. While the negative effects of SDB on development and behavior in children are well established, its relation to EF is particularly important because learning is incremental and adversely affected by deficits in EF [31], [41], [43]. The negative effects of SDB may have an impact on school-readiness among children with risk for SDB, emphasizing the importance of early detection. Consistent with a large body of research on these EF measures, we expected that there would be a significant improvement in performance on the EF measures with age. However, we hypothesized that children’s risk for SDB would have a negative impact on EF performance over and above the effects of age.

Section snippets

Methods

The study was approved by the Office of Research Compliance at West Virginia University. Informed consent was signed by a parent or guardian for participation in both the current retrospective sleep questionnaire study and the original study from which the children were initially recruited.

Results

Descriptive statistics for each of the tasks of the planning, inhibition, and working memory dimensions of EF are presented in Table 1. In order to give roughly equivalent weight to each task in the composite variable, scores on each task were standardized and summed. These composite measures showed a high degree of internal consistency (Planning α = 0.94, Inhibition α = 0.89, WM r = 0.84). As expected, children showed significant improvements with age on each of the EF tasks as well as the composite

Discussion

Consistent with previous studies and our expectations, children’s performance on the planning, inhibition, and WM dimensions of EF all showed marked improvements between the ages of 3 and 5 years. Our hypothesis was also supported: inclusion of PR-RDSB scores in regression models resulted in significant additional variance accounted for on each EF dimension. Children with higher PR-RSDB scores performed significantly lower on each EF dimension. Using the single-item snoring frequency question,

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