ROLE OF MOUTH BREATHING IN THE MISDIAGNOSIS OF ADHD

Medically Reviewed and Updated by Dr. Rae Osborn, Ph.D. - August 22, 2024

ADHD (Attention deficit hyperactivity disorder), a common neurodevelopmental condition, can affect people of all ages. Hyperactivity, impulsivity, and difficulty concentrating are hallmark symptoms of ADHD. According to the Centers for Disease Control and Prevention (CDC), approximately 7 million children in the United States have been diagnosed with ADHD.

However, recent studies have shown a potential link between mouth breathing, sleep apnea, and the misdiagnosis of ADHD. Mouth breathing can be a potential contributor to sleep-disrupted behaviors and child development, which can often be mistaken for ADHD.

This article sheds light on what mouth breathing is, the connection between ADHD and mouth breathing, and its implications for those diagnosed with ADHD.

What Is Mouth Breathing?

Mouth breathing is a habit of breathing through the mouth instead of the nose. While breathing through the mouth occasionally is normal, chronic mouth breathing can negatively affect sleep and overall health.

Taking air in through the nose is the body's natural and preferred way of breathing. The nasal passages filter, warm, and humidify the air, making it easier for the body to absorb oxygen. When a person breathes through the mouth, the air bypasses the nasal passages.^[1]

Breathing through the nose:

• Improves the brain's ability to function correctly by providing more oxygen
• Boosts the production of nitric oxide, a gas that helps regulate the circadian rhythm.

On the other hand, mouth breathing can lead to several issues, such as:

• Snoring
• Dry mouth
• Lower oxygen intake
• Sleep disturbances

Sleep disturbances can affect one's energy levels and focus throughout the day. Children heavily affected by mouth breathing are prone to an ADHD misdiagnosis.

Snoring, teeth grinding, snorting, and other sounds of congestion during breathing are some signs your child is mouth breathing during sleep.^[2]

Mouth breathing is prevalent in children. Various factors cause mouth breathing, such as^[3]:

• Nasal congestion due to allergies, colds, sinus infections, or structural abnormalities.
• Enlarged adenoids or tonsils that lead to obstruction of the nasal passages.
• Allergies to pollen, dust mites, pet dander, or certain foods.
• Chronic rhinitis (persistent inflammation of the nasal passages).
• Structural aberrations such as a deviated septum or narrow nasal airways.

If children develop a habit of mouth breathing, it can remain with them for life unless corrected.

Prolonged mouth breathing can contribute to a child's jaw shape and increase the risk of an overbite. This formation leads to more mouth breathing.

Identifying the underlying cause of mouth breathing in children is essential to address potential health issues and promote proper breathing habits. By addressing mouth breathing and promoting nasal breathing, individuals can get better quality sleep and reduce the danger of sleep apnea and other sleep-related issues.

If you suspect your child is a mouth breather, consult a healthcare professional for a proper diagnosis and appropriate treatment.

How Are Mouth Breathing and Sleep Apnea Linked?

Sleep apnea is a health condition distinguished by pauses or shallow breathing during sleep. These pauses can last from a few moments to minutes and occur multiple times throughout the night.

There are three types:

• Obstructive sleep apnea (OSA) ensues when the muscles in the throat loosen, causing the airway to become partially blocked.
• Central sleep apnea is when the brain does not signal the breathing muscles properly.
• Complex sleep apnea syndrome is when obstructive sleep apnea transitions to central sleep apnea after CPAP therapy.

Sleep-Disordered Breathing and Mental Health

When the breathing pauses, it can cause the individual to rouse during the night due to a lack of oxygen.

Even if the person affected does not wake up, sleep-disordered breathing can interrupt deep sleep, which relies on a very slow and specific breathing pattern.^[4]

Good-grade sleep is vital to mental health and overall well-being. Disturbed sleep prevents adequate memory consolidation, and learning. Due to sleep disruption and lower oxygen levels, children with OSA are more prone to learning difficulties and behavioral problems.

A shortage of sleep can also lead to irritability, mood swings, difficulty concentrating, and other symptoms that are often associated with ADHD.

Mouth Breathing In Sleep Apnea

Mouth breathing is a symptom of OSA. When the airway is precluded, the body switches to mouth breathing to make up for the lack of oxygen. Mouth breathing can also contribute to airway obstruction and OSA by promoting jaw misalignment, placing more pressure on the airway, and increasing dental issues that can cause nasal blockages.

Either condition can lead to a cycle of mouth breathing and sleep apnea, resulting in poor sleep quality, daytime sleepiness, and other symptoms associated with sleep apnea.

Sleep disorders similar to sleep apnea include restless leg syndrome^[5] and delayed sleep phase syndrome^[6]. All of these conditions are more prevalent in children with ADHD.^[7]

The Link Between Sleep Apnea, Mouth Breathing, and ADHD

When comparing sleep apnea to ADHD, the symptoms share a great deal of overlap:

Sleep Apnea and ADHD Symptoms
Symptom	Obstructive Sleep Apnea (OSA)	ADHD
Sleep-related	Yes	No
Snoring (loud, with snorts or gasps)	Very common	Not common
Gasping for air during sleep	Frequent	Not common
Restless sleep	Common	Can occur
Excessive daytime sleepiness	Very common	Common
Morning headaches	Can occur	Not common
Behavioral and Cognitive	Can occur	Very common
Poor concentration	Common	Very common
Irritability	Can occur	Very common
Behavioral problems (hyperactivity, aggression)	Can occur	Very common
Difficulty remembering things	Can occur	Can occur
Mood swings	Can occur	Can occur
Physical	Can occur	Less common
Slow growth (severe cases)	Can occur	Rare
Bedwetting (regression)	Can occur	Less common
Attention	Can impact	Very impacted
Inattention to details	Can occur	Very common
Difficulty focusing	Common	Very common
Easily distracted	Can occur	Very common
Activity Level	Can vary	Often high
Hyperactivity	Can occur	Very common
Fidgeting or squirming	Can occur	Very common
Running or climbing excessively	Can occur	Can occur
Communication	Can impact	Can impact
Talking excessively	Can occur	Can occur
Interrupting others	Can occur	Very common
Blurting out answers	Can occur	Can occur

According to a data review, restricted, disordered, or disrupted sleep can also cause symptoms similar to ADHD. The same review uncovered that 25-30% of people with ADHD have OSA, compared to only 3% on average in the general population.

Further findings suggest the following:

• Consecutive days of sleep restriction can lead to a cumulative deficit in sustained attention.
• Poor sleep may decrease inhibitory control and increase impulsivity.
• There are similar cognitive deficits between children with ADHD and those with poor sleep quality.
• Sleep deprivation in early childhood may increase the risk of ADHD in middle childhood.

One study suggests that children with ADHD misdiagnosis are prone to daytime sleepiness, whereas those with ADHD are not. However, psychostimulant medication for ADHD can impact sleep, making diagnosis and treatment complex. It is helpful to rule out primary sleep disorders before starting ADHD medication.

Behavioral interventions to improve sleep may be beneficial for patients receiving medication.

Significance of Proper ADHD Diagnosis and Treatment

As explained, sleep disorders related to mouth breathing can easily be overlooked in children with ADHD and can contribute to a misdiagnosis.

By considering the possibility of sleep disorders and addressing any underlying sleep problems, healthcare professionals can ensure a more accurate diagnosis and provide appropriate treatment options for children with mouth breathing and sleep disorders.

The Dangers of Misdiagnosis

Misdiagnosis of ADHD can have serious consequences. Misdiagnosed children may need to take prescription ADHD medications, which can have side effects such as decreased appetite, weight loss, and sleep problems.

Additionally, misdiagnosis can delay the proper treatment of sleep disorders, which are associated with long-term health problems.

It is essential to rule out chronic sleep disturbance before diagnosing for ADHD to avoid misdiagnosis.

Recognizing Mouth Breathing and Sleep Disorders

If your child displays any of the following symptoms, they might be a mouth breather and have sleep-related problems:

1. Irregular Breathing: Look out for mouth breathing, especially during sleep.
2. Snoring: Loud or consistent snoring may indicate a sleep disorder.
3. Drooling: If your child drools on their pillow at night, they probably slept with their mouths open.
4. Daytime Fatigue: Consistent tiredness during the day despite getting enough sleep.
5. Restless Sleep: Tossing and turning, difficulty staying asleep, or waking up frequently.
6. Chapped Lips, Dry Mouth, or Throat: Waking up with a dry mouth or throat in the morning.
7. Behavioral Issues: Irritability, difficulty concentrating, and mood swings could be related to poor sleep quality.
8. Teeth Grinding: Nighttime teeth grinding is a sign of mouth breathing and jaw misalignment.

If you suspect your child may have mouth breathing or a sleep disorder, it is crucial to seek professional evaluation from a sleep specialist or ENT doctor. They can diagnose and recommend appropriate treatment options to improve your child's sleep and overall well-being.

Diagnosis of Sleep Apnea and ADHD

Diagnosing ADHD can be challenging, especially in children with undiagnosed mouth breathing and when sleep disorders are present. Symptoms of ADHD and sleep disorders share commonalities and can lead to potential misdiagnosis.

Healthcare professionals overcome these challenges by conducting a thorough assessment, including a full medical history, physical examination, and diagnostic tests for sleep apnea.

These tests may include:

1. Sleep Study (Polysomnography): This test monitors sleep patterns, breathing, heart rate, and brain activity to diagnose sleep disorders and breathing issues.
2. Nasal Endoscopy: A camera is inserted into the nose to examine the airway and identify obstructions or structural abnormalities.
3. Allergy Testing: Identifies allergies contributing to nasal congestion and mouth breathing.

This information is crucial in determining whether mouth breathing and related issues are contributing to the child's symptoms before considering an ADHD diagnosis.

If mouth breathing and sleep disorders are ruled out, cognitive and behavioral assessments can diagnose ADHD properly. They can also help differentiate between ADHD symptoms and those related to sleep-disordered breathing or sleep disorders.

Healthcare professionals may use standardized questionnaires, such as the Conners' Rating Scale or the ADHD Rating Scale, to evaluate the child's attention, impulsivity, and hyperactivity.

Treatment Options for Mouth Breathing

Addressing mouth breathing and sleep disorders can improve sleep quality, reduce ADHD symptoms, and provide health benefits overall.

By ensuring proper airflow through the nose and addressing any underlying issues, individuals can experience better sleep, increased energy levels, enhanced concentration, and improved quality of life.

The most common treatment options include:

• Nasal sprays to help relieve nasal blockages and improve airflow through the nose.
• Allergy management to reduce nasal congestion and improve breathing through the nose.
• Orthodontic interventions, such as braces, to correct jaw misalignment and improve nasal breathing.
• Adenoid or tonsil surgery may be recommended to remove obstructions and improve nasal breathing.
• Treatment for sleep apnea, which can include CPAP therapy (mask worn during sleep), oral appliances, surgery, and lifestyle changes like weight loss and avoiding alcohol/sedatives before bed.

In addition to these options, several lifestyle interventions can help to encourage nasal breathing and better quality sleep, such as:

• Practicing breathing exercises to strengthen the nasal passages.
• Using nasal strips or dilators to open the nasal passages.
• Keeping the bedroom cool and well-ventilated to promote nasal breathing.
• Using a humidifier to keep the air moist and reduce congestion.
• Seeking treatment for any underlying allergies or sinus problems.

Conclusion

The link between mouth breathing, sleep apnea, and the misdiagnosis of ADHD is a complex and often overlooked issue. Healthcare practitioners need to consider the possible presence of mouth breathing when diagnosing ADHD, as proper correction can improve symptoms and overall quality of life. If you or your child has been diagnosed with ADHD, it may be worth discussing the possibility of sleep apnea with your doctor.

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