The Psychosocial Aspects of Obstructive Sleep Apnea

 

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ABSTRACT

The primary events of obstructed breathing during sleep, snoring and obstruction of the upper airway, cause hypoxemia, sleep fragmentation, and daytime sleepiness. Obstructed breathing during sleep can have negative effects on mental processes, behavior, and interpersonal relations. This article reviews some of the cognitive, emotional, and social aspects of obstructive sleep apnea in adults and children. Apnea is associated with cognitive impairments but these are generally mild. Most studies suggest that these impairments improve with CPAP but evidence suggests that some changes may be permanent. Even mild apnea may worsen depression and quality of life. Apnea may have more profound effects in children but the findings are inconclusive. This may be due to difficulty in recognizing sleep apnea in children, the subtle nature of the disorder, the lack of daytime sleepiness, and the imposition of adult norms on children's sleep studies.

REFERENCES

• 1 Golden C J, Strider M A, Ariel R, Golden E. Neuropsychology and medical disorders. In: Filskov, SB and Boll, TJ Handbook of Clinical Neuropsychology, Vol 2 New York; John Wiley and Sons 1986: 257-278
  Google Scholar
• 2 Tune G S. Psychological effects of hypoxia: review of certain literature from the period 1950-1963.  Percept Mot Skills. 1964;  19 551-562
  PubMedGoogle Scholar
• 3 Heath D, Williams D R. Man at High Altitude: The Pathophysiology of Acclimatization and Adaptation. Edinburgh; Churchill, Livingstone 1981: 314-318
  Google Scholar
• 4 Berry D T, Webb W B, Block A J, Bauer R M, Switzer D A. Nocturnal hypoxia and neuropsychological variables.  J Clin Exp Neuropsychol. 1986;  8 229-238
  PubMedGoogle Scholar
• 5 Grant I, Heaton R K, McSweeny A J, Adams K M, Timms R M. Brain dysfunction in COPD.  Chest. 1980;  77 308-309
  PubMedGoogle Scholar
• 6 Huppert F. Memory impairment associated with chronic hypoxia.  Thorax. 1982;  37 858-860
  PubMedGoogle Scholar
• 7 McSweeny A J, Heaton R K, Grant I, Cugell G, Solliday N, Timms R M. Chronic obstructive pulmonary disease: socioemotional adjustment and life quality.  Chest. 1980;  77(2 Suppl) 309-311
  PubMedGoogle Scholar
• 8 Grant I, Heaton R K, McSweeny A J, Adams K M, Timms R M. Neuropsychologic findings in hypoxemic chronic obstructive pulmonary disease.  Arch Intern Med. 1982;  142 1470-1476
  CrossrefPubMedGoogle Scholar
• 9 Prigatano G P, Parsons O, Wright E, Levin D C, Hawryluk G. Neuropsychological test performance in mildly hypoxemic patients with chronic obstructive pulmonary disease.  J Consult Clin Psychol. 1983;  51 108-116
  CrossrefPubMedGoogle Scholar
• 10 Jacobs E A, Winter P M, Alvis H J, Small S M. Hyperoxygenation effect on cognitive functioning in the aged.  N Engl J Med. 1969;  281 753-757
  PubMedGoogle Scholar
• 11 Krop H D, Block A J, Cohen E. Neuropsychologic effects of continuous oxygen therapy in chronic obstructive pulmonary disease.  Chest. 1973;  64 317-322
  PubMedGoogle Scholar
• 12 Gulevich G, Dement W, Johnson L. Psychiatric and EEG observations on a case of prolonged (264 hours) wakefulness.  Arch Gen Psychiatry. 1966;  15 29-35
  PubMedGoogle Scholar
• 13 Passnau R O, Naitoh P, Stien S et al.. The psychological effects of 205 hours of sleep deprivation.  Arch Gen Psychiatry. 1968;  18 496-505
  PubMedGoogle Scholar
• 14 Pilcher J J, Huffcutt A I. Effects of sleep deprivation on performance: a meta-analysis.  Sleep. 1996;  19 318-326
  PubMedGoogle Scholar
• 15 Hartman E, Orzack M H, Branconnier R. Deficits produced by sleep deprivation: reversal by d- and l-amphetamine.  Sleep Res. 1974;  3 151
  PubMedGoogle Scholar
• 16 Parkes J D. Sleep and Its Disorders. London; WB Saunders 1985 19
  Google Scholar
• 17 Horne J. Sleep loss and “divergent” thinking ability.  Sleep. 1988;  11 528-536
  PubMedGoogle Scholar
• 18 Binks P G, Waters W F, Hurry M. Short-term total sleep deprivations does not selectively impair higher cortical functioning.  Sleep. 1999;  22 328-334
  PubMedGoogle Scholar
• 19 Bonnet M H. Effect of sleep disruption on sleep, performance and mood.  Sleep. 1985;  8 11-19
  PubMedGoogle Scholar
• 20 Bonnet M H. Performance and sleepiness following moderate sleep disruption and slow wave sleep deprivation.  Physiology and Behavior. 1986;  37 915-918
  CrossrefPubMedGoogle Scholar
• 21 Bonnet M H. Cognitive effects of sleep and sleep fragmentation.  Sleep. 1993;  16 S65-S67
  PubMedGoogle Scholar
• 22 Culebras A. Normal sleep. In: Lee-Chiong TL, Sateia MJ, Carskadon MA Sleep Medicine. Philadelphia; Hanley and Belfus 2002 6
  Google Scholar
• 23 Riley T L, Ferber R. Behavioral aspects of sleep. In: Riley TL Clinical Aspects of Sleep and Sleep Disturbance. Boston; Butterworth 1985: 39-60
  Google Scholar
• 24 Roth T, Costa e Silva J A, Chase M H. Sleep and cognitive (memory) function: research and clinical perspectives.  Sleep Med. 2001;  2 379-387
  PubMedGoogle Scholar
• 25 Garcia-Rill E. Mechanisms of sleep and wakefulness. In: Lee-Chiong TL, Sateia MJ, Carskadon MA Sleep Medicine Philadelphia; Hanley and Belfus 2002 36
  Google Scholar
• 26 Mendelson W B. Human Sleep: Research and Clinical Care. New York; Plenum 1987
  Google Scholar
• 27 Levine B, Roehrs T, Stepanski E, Zorick F, Roth T. Fragmenting sleep diminishes its recuperative value.  Sleep. 1987;  10 590-599
  PubMedGoogle Scholar
• 28 Lavie P. Nasal obstructions, sleep, and mental function.  Sleep. 1983;  6 244-246
  PubMedGoogle Scholar
• 29 Guilleminault C, van der Hoed J, Mitler M. Clinical overview of the sleep apnea syndromes. In: Guilleminault C, Dement WC Sleep Apnea Syndromes New York; Alan R. Liss 1978: 1-12
  Google Scholar
• 30 Watson R, Greenberg G, Deptula D. Neuropsychological performance following treatment of sleep apnea.  Sleep Res. 1984;  14 136
  PubMedGoogle Scholar
• 31 Kales A, Caldwell A, Cadieux R, Vela-Bueno A, Ruch L, Mayes S. Severe obstructive sleep apnea, II: Associated psychopathology and psychosocial consequences.  J Chronic Dis. 1985;  38 427-434
  CrossrefPubMedGoogle Scholar
• 32 Findley L J, Barth J T, Powers D C et al.. Cognitive impairment in patients with obstructive sleep apnea and associated hypoxemia.  Chest. 1986;  90 686-690
  CrossrefPubMedGoogle Scholar
• 33 Greenberg G D, Watson R K, Deptula D. Neuropsychological dysfunction in sleep apnea.  Sleep. 1987;  10 254-262
  PubMedGoogle Scholar
• 34 Nichols C D, Kapen S, Greiffenstein M F. Determinants of neuropsychological deficits in obstructive sleep apnea.  J Sleep Res. 1988;  17 227
  PubMedGoogle Scholar
• 35 Montplaisir J, Bedard M A, Richer F, Rouleau I. Neurobehavioral manifestations in obstructive sleep apnea syndrome before and after treatment with continuous positive airway pressure.  Sleep. 1992;  15(suppl 6) S17-S19
  PubMedGoogle Scholar
• 36 Adams N, Strauss M, Schluchter M, Redline S. Relation of measures of sleep-disordered breathing to neuropsychological functioning.  Am J Respir Crit Care Med. 2001;  163 1626-1631
  PubMedGoogle Scholar
• 37 Beebe D W, Groesz L, Wells C, Nichols A, McGee K. The neuropsychological effects of obstructive sleep apnea: a meta-analysis of norm-referenced and case controlled data.  Sleep. 2003;  26 298-307
  PubMedGoogle Scholar
• 38 Sateia M J. Neuropsychological impairment and quality of life in obstructive sleep apnea.  Clin Chest Med. 2003;  24 249-259
  CrossrefPubMedGoogle Scholar
• 39 Cheshire K, Engelman H, Deary I, Shapiro C, Douglas N J. Factors impairing daytime performance in patients with sleep apnea/hypopnea sybdrome.  Arch Intern Med. 1992;  152 538-541
  CrossrefPubMedGoogle Scholar
• 40 Bedard M A, Montplaisir J, Richer F, Malo J, Rouleau I. Persistent neuropsychological deficits and vigilance impairments in sleep apnea syndrome after treatment with continuous positive airway pressure.  J Clin Exp Neuropsychol. 1993;  15 330-341
  PubMedGoogle Scholar
• 41 Ferini-Strambi L, Baietto C, Di Gioia M R et al.. Cognitive dysfunction in patients with obstructive sleep apnea (OSA): partial reversibility after continuous positive airway pressure (CPAP).  Brain Res Bull. 2003;  61 87-92
  CrossrefPubMedGoogle Scholar
• 42 Boland L L, Shahar E, Iber C, Knopman D S, Kuo T F, Nieto F J. Measures of cognitive function in persons with varying degrees of sleep-disordered breathing: the Sleep Heart Health Study.  J Sleep Res. 2002;  11 265-272
  CrossrefPubMedGoogle Scholar
• 43 Lojander J, Kajaste S, Maasilta P, Partinen M. Cognitive function and treatment of obstructive sleep apnea syndrome.  J Sleep Res. 1999;  8 71-76
  CrossrefPubMedGoogle Scholar
• 44 Telekavi T, Kajaste S, Partinen M, Koskenvuo M, Salmi T, Kaprio J. Cognitive function in middle-aged snorers and controls: role of excessive daytime somnolence and sleep related hypoxic events.  Sleep. 1988;  11 454-462
  PubMedGoogle Scholar
• 45 Telekavi T, Kajaste S, Partinen M, Brander P, Nyhlom A. Cognitive function in obstructive sleep apnea.  Sleep. 1993;  16 S74-S75
  PubMedGoogle Scholar
• 46 Block A J, Berry D, Webb W. Nocturnal hypoxemia and neuropsychological deficits in men who snore.  Eur J Resp Dis Suppl. 1986;  146 405-408
  PubMedGoogle Scholar
• 47 Valencia-Flores M, Bliwise D L, Guilleminault C, Cilveti R, Clerk A. Cognitive function in patients with sleep apnea after acute nocturnal nasal continuous positive airway pressure (CPAP) treatment: sleepiness and hypoxemia effects.  J Clin Exp Neuropsychol. 1996;  18 197-210
  PubMedGoogle Scholar
• 48 Gall R, Isaac L, Kryger M. Quality of life in mild obstructive sleep apnea.  Sleep. 1993;  16 S59-S61
  PubMedGoogle Scholar
• 49 Kim H C, Young T, Matthews C G, Weber S M, Woodard A R, Palta M. Sleep disordered breathing and neuropsychological deficits.  Am J Respir Crit Care Med. 1997;  156 1813-1819
  PubMedGoogle Scholar
• 50 Klonoff H, Fleetham J, Taylor R, Clark C. Treatment outcome of obstructive sleep apnea: Physiological and neuropsychological concomitants.  J Nerv Ment Dis. 1987;  175 208-212
  PubMedGoogle Scholar
• 51 Aikens J E, Mendelson W B. A matched comparison of MMPI responses in patients with primary snoring or obstructive sleep apnea.  Sleep. 1999;  22 355-359
  PubMedGoogle Scholar
• 52 Aikens J E, Caruana-Montaldo B, Vanable P A, Tadimeti L, Mendelson W B. MMPI correlates of sleep and respiratory disturbance in obstructive sleep apnea.  Sleep. 1999;  22 362-369
  PubMedGoogle Scholar
• 53 Watson R, Greenberg G, Bakos L. Sleep apnea and depression. Sleep Res 1987 16: 293
  Google Scholar
• 54 Ramos Platon M J, Espinar Sierra J. Changes in psychopathlogical symptoms in sleep apnea patients after treatment with nasal continuous positive airway pressure.  Int J Neurosci. 1992;  62 173-195
  PubMedGoogle Scholar
• 55 Reynolds C F, Kupfer D J, McEachran A B, Taska L S, Sewitch D E, Coble P A. Depressive psychopathology in male sleep apneics.  J Clin Psychiatry. 1984;  45 287-290
  PubMedGoogle Scholar
• 56 Reynolds C F, Coble P A, Spiker P G, Neil J F, Holzer B C, Kupfer D J. Prevalence of sleep apnea and nocturnal myoclonus in major affective disorders: clinical and polysomnographic findings.  J Nerv Ment Dis. 1982;  170 565-567
  PubMedGoogle Scholar
• 57 Gierz M, DuPont R, Morehouse R, Irwin M, Gillin J C. Oxygen saturation during sleep in a psychiatric population.  Sleep Res. 1988;  17 180
  PubMedGoogle Scholar
• 58 Vandeputte M, de Weerd A. Sleep disorders and depressive feelings: a global survey with the Beck depression scale.  Sleep Med. 2003;  4 343-345
  PubMedGoogle Scholar
• 59 Pillar G, Lavie P. Psychiatric symptoms in sleep apnea syndrome: effects of gender and respiratory disturbance index.  Chest. 1998;  114 697-703
  PubMedGoogle Scholar
• 60 Weaver T E. Outcome measurement in sleep medicine practice and research, I: Assessment of symptoms, subjective and objective daytime sleepiness, health-related quality of life and functional status.  Sleep Med Rev. 2001;  5 103-128
  CrossrefPubMedGoogle Scholar
• 61 Weaver T E. Outcome measurement in sleep medicine practice and research, II: Assessment of neurobehavioral performance and mood.  Sleep Med Rev. 2001;  5 223-236
  CrossrefPubMedGoogle Scholar
• 62 Yu B H, Ancoli-Israel S, Dimsdale J E. Effect of CPAP treatment on mood states in patients with sleep apnea.  J Psychiatr Res. 1999;  33 427-432
  CrossrefPubMedGoogle Scholar
• 63 Borak J, Cieslicki J K, Koziej M, Matuszewski A, Zielinski J. Effects of CPAP treatment on psychological status in patients with severe obstructive sleep apnea.  J Sleep Res. 1996;  5 123-127
  CrossrefPubMedGoogle Scholar
• 64 Cartwright R D, Knight S. Silent partners: the wives of sleep apnea patients.  Sleep. 1987;  10 244-248
  PubMedGoogle Scholar
• 65 Veale D, Poussin G, Benes F, Pepin J L, Levy P. Identification of quality of life concerns with obstructive sleep apnoea at the time of initiation of continuous positive airway pressure: a discourse analysis.  Qual Life Res. 2002;  11 389-399
  CrossrefPubMedGoogle Scholar
• 66 Bergner M, Bobbit R, Carter W B, Gilson B S. The sickness impact profile: development and final revision of a health status measure.  Med Care. 1981;  19 787-805
  CrossrefPubMedGoogle Scholar
• 67 Ware J, Snow K, Kosinski M et al.. SF-36 Health Survey. Manual and Interpreatation Guide. Boston; The Health Institute, New England Medical Center 1990
  Google Scholar
• 68 D'Ambrosio C, Bowman T, Mohsenin V. Quality of life in patients with obstructive sleep apnea: effect of nasal continuous positive airway pressure: a prospective study.  Chest. 1999;  115 123-129
  CrossrefPubMedGoogle Scholar
• 69 Fornas C, Ballester E, Arteta E et al.. Measurement of general health status in obstructive sleep apnea hypopnnea patients.  Sleep. 1995;  18 876-879
  PubMedGoogle Scholar
• 70 Weaver T, Maislin G, Chugh D et al.. Change in OSA symptoms after three months of CPAP use: a multisite study.  Sleep. 1998;  21(suppl) 250
  PubMedGoogle Scholar
• 71 Jenkinson C, Stradling J, Peterson S. Comparison of three measures of three measures of quality of life outcome in the evaluation of continuous positive airway pressure for sleep apnoea.  J Sleep Res. 1997;  6 199-204
  CrossrefPubMedGoogle Scholar
• 72 Akashiba T, Kawahara S, Akahoshi T et al.. Relationship between quality of life and mood or depression in patients with severe sleep apnea syndrome.  Chest. 2002;  122 861-865
  CrossrefPubMedGoogle Scholar
• 73 Baldwin C N, Griffith K A, Nieto J, O'Connor G T, Walsleben J A, Redline S. The association of sleep-disordered breathing and sleep symptoms with quality of life in the sleep heart health study.  Sleep. 2001;  24 96-105
  PubMedGoogle Scholar
• 74 Guilleminault C. Clinical features and evaluation of obstructive sleep apnea. In: Kryger MN, Roth T, Dement WC Principles and Practice of Sleep Medicine. 2nd. Philadelphia; WB Saunders 1994: 667-677
  Google Scholar
• 75 Schmidt H S, Wise H A. Significance of impaired penile tumescence and associated polysomnographic abnormalities in the impotent patient.  J Urol. 1981;  126 348-351
  PubMedGoogle Scholar
• 76 Pressman M R, Diphilippo M A, Kendrick J I et al.. Problems in the interpretation of nocturnal penile tumescence studies: disruption of sleep by occult sleep disorders.  J Urol. 1985;  136 595-598
  PubMedGoogle Scholar
• 77 Fanfulla F, Malaguti S, Montagna T et al.. Erectile dysfunction in men with obstructive sleep apnea: an early sign of nerve involvement.  Sleep. 2000;  23 775-781
  PubMedGoogle Scholar
• 78 Hirshkowitz M, Karacan I, Gurakar A, Williams R L. Hypertension, erectile dysfunction and occult sleep apnea.  Sleep. 1989;  12 223-232
  PubMedGoogle Scholar
• 79 Santamaria J D, Prior J C, Fleetham J A. Reversible reproductive dysfunction in men with obstructive sleep apnea.  Clin Endocrinol (Oxf). 1988;  28 461-470
  CrossrefPubMedGoogle Scholar
• 80 Seftel A D, Strohl K P, Loye T L, Bayard D, Kress J, Netzer N C. Erectile dysfunction and symptoms of sleep disorders.  Sleep. 2002;  25 643-647
  PubMedGoogle Scholar
• 81 Smith R, Ronald J, Delaive K, Walld R, Manfreda J, Kryger M. What are obstructive sleep apnea patient's being treated for prior to this diagnosis?.  Chest. 2002;  121 164-172
  CrossrefPubMedGoogle Scholar
• 82 Grunstein R R, Stenlof K, Hedner J A, Sjostrom L. Impact of self-reported sleep-breathing disturbances on psychosocial performance in the Swedish obese subjects (SOS) study.  Sleep. 1995;  18 635-643
  PubMedGoogle Scholar
• 83 Young T, Blustein J, Finn L, Palta M. Sleep-disordered breathing and motor vehicle accidents in a population-based sample of employed adults.  Sleep. 1997;  20 608-613
  PubMedGoogle Scholar
• 84 Carroll J L. Sleep-disordered breathing in children. In: Lee-Chiong T, Sateia MJ, Carskadon M Sleep Medicine. Philadelphia; Hanley and Belfus 2002 265
  Google Scholar
• 85 Ali N J, Pitson D J, Stradling J R. Snoring, sleep disturbance, and behavior in 4-5 year-olds.  Arch Dis Child. 1993;  68 360-366
  CrossrefPubMedGoogle Scholar
• 86 Ali N J, Pitson D, Stradling J R. Natural history of snoring and related behavior problems between the ages of 4 and 7 years.  Arch Dis Child. 1994;  71 74-76
  PubMedGoogle Scholar
• 87 Gislason T, Benediktsdottir B. Snoring, apneic episodes, and nocturnal hypoxemia among children 6 months to 6 years old: an epidemiologic study of lower limit of prevalence.  Chest. 1995;  107 963-966
  CrossrefPubMedGoogle Scholar
• 88 Owen G O, Canter R J, Robinson A. Snoring, apnoea and ENT symptoms in a paediatric community.  Clin Otolaryngol. 1996;  21 130-134
  PubMedGoogle Scholar
• 89 Blunden S, Lushington K, Kennedy D. Cognitive and behavioural performance in children with sleep-related obstructive breathing disorders.  Sleep Med Rev. 2001;  5 447-461
  CrossrefPubMedGoogle Scholar
• 90 Carroll J L. Obstructive sleep-disordered breathing in children: new controversies, new directions.  Clin Chest Med. 2003;  24 261-282
  CrossrefPubMedGoogle Scholar
• 91 Gaultier C. Clinical and therapeutic aspects of obstructive sleep apnea syndrome in infants and children.  Sleep. 1992;  15 S36-S38
  PubMedGoogle Scholar
• 92 Goodwin J L, Kaemingk K L, Fregosi R F et al.. Clinical outcomes associated with sleep disordered breathing in Caucasian and Hispanic children: the Tucson children's assessment of sleep apnea study (TuCASA).  Sleep. 2003;  26 587-591
  PubMedGoogle Scholar
• 93 Marcus C, Omlin K, Basinki D et al.. Normal polysomnographic values for children and adolescents.  American Review of Respiratory Disease. 1992;  146 1235-1239
  PubMedGoogle Scholar
• 94 Brouilette R T, Fernbach S K</, Hunt C E. Obstructive sleep apnea in infants and children.  J Pediatr. 1982;  100 31-40
  PubMedGoogle Scholar
• 95 Stradling J R, Thomas G, Warley A R. Effect of adenotonsillectomy on nocturnal hypoxaemia, sleep disturbance, and symptoms in snoring children.  Lancet. 1990;  335 249-253
  CrossrefPubMedGoogle Scholar
• 96 Gozal D. Sleep-disordered breathing and school performance in children.  Pediatrics. 1998;  102(3 pt 1) 616-620
  CrossrefPubMedGoogle Scholar
• 97 Weissbluth M, Davis A T, Poncher J, Reiff J. Signs of airway obstruction during sleep and behavioral, developmental, and academic problems.  J Dev Behav Pediatr. 1983;  4 119-121
  PubMedGoogle Scholar
• 98 Blunden S L, Lushington K, Kennedy D, Martin J, Dawson D. Behaviour and neurocognitive function in children aged 5-10 years who snore compared to controls.  J Clin Exp Neuropsychol. 2000;  22 554-568
  CrossrefPubMedGoogle Scholar
• 99 Ali N J, Pitsn D, Stradling J R. Sleep disordered breathing: effects of adenotonsillectomy on behaviour and psychological functioning.  Eur J Pediatr. 1996;  155 56-62
  CrossrefPubMedGoogle Scholar
• 100 Owens J, Spirito A, Marcotte A, McGuinn M, Berkelhammer L. Neuropsychological and behavioral correlates of obstructive sleep apnea syndrome in children: A preliminary study.  Sleep Breath. 2000;  4 67-78
  Article in Thieme ConnectPubMedGoogle Scholar
• 101 Rhodes S K, Shimoda K C, Waid L R et al.. Neurocognitive deficits in morbidly obese children with obstructive sleep apnea.  J Pediatr. 1995;  127 741-744
  PubMedGoogle Scholar
• 102 Guilleminault C, Pelayo R, Leger D, Clerk A, Bocian R CZ. Recognition of sleep disordered breathing in children.  Pediatrics. 1996;  98 871-882
  PubMedGoogle Scholar
• 103 Gozal D, Pope D W. Snoring during early childhood and academic performance at ages thirteen to fourteen years.  Pediatrics. 2001;  107 1394-1399
  CrossrefPubMedGoogle Scholar
• 104 Guilleminault C, Winkle R, Korobkin R, Simmons B. Children and nocturnal snoring: evaluation of the effects of sleep related respiratory resistive load and daytime functioning.  Eur J Pediatr. 1982;  139 165-171
  CrossrefPubMedGoogle Scholar
• 105 O'Brien L M, Holbrook C R, Mervis C B et al.. Sleep and neurobehavioral characteristics of 5- to 7-year-old children with parentally reported symptoms of attention deficit/hyperactivity disorder.  Pediatrics. 2003;  111 554-563
  CrossrefPubMedGoogle Scholar
• 106 Chervin R D, Dillon J E, Bassetti C, Ganoczy D A, Pituch K J. Symptoms of sleep disorders: inattention and hyperactivity in children.  Sleep. 1997;  20 1185-1192
  PubMedGoogle Scholar
• 107 Goldstein N A, Fatima M, Campbell T F, Rosenfeld R M. Child behavior and quality of life before and after tonsillectomy and adenoidectomy.  Arch Otolaryngol Head Neck Surg. 2002;  128 770-775
  CrossrefPubMedGoogle Scholar
• 108 Carroll J L, McColley S A, Marcus C L, Curtis S, Loughlin G M. Inability of clinical history to distinguish primary snoring from obstructive sleep apnea syndrome in children.  Chest. 1995;  108 610-618
  CrossrefPubMedGoogle Scholar
• 109 Rosen C, D'Andrea L, Haddad C. Adult criteria for obstructive sleep apnea do not identify children with serious obstruction.  American Review of Respiratory Disease. 1992;  146 1231-1234
  PubMedGoogle Scholar
• 110 Landgraf J, Abetz L, Ware J. The CHQ User's Manual. 2nd. Boston; HealthAct 1999
  Google Scholar
• 111 Rosen C L, Palmero T M, Larkin E K, Redline S. Health-related quality of life and sleep-disordered breathing in children.  Sleep. 2002;  25 657-666
  PubMedGoogle Scholar

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