Parent-Reported Behavioral and Psychiatric Problems Mediate the Relationship between Sleep-Disordered Breathing and Cognitive Deficits in School-Aged Children

Abstract

Background: Numerous studies over the past several decades have illustrated that children who suffer from sleep-disordered breathing (SDB) are at greater risk for cognitive, behavioral, and psychiatric problems. Although behavioral problems have been proposed as a potential mediator between SDB and cognitive functioning, these relationships have not been critically examined.

Methods: This analysis is based on a community-based cohort of 1,115 children who underwent overnight polysomnography, and cognitive and behavioral phenotyping. Structural model of the relationships between SDB, behavior, and cognition, and two recently developed mediation approaches based on propensity score weighting and resampling were used to assess the mediational role of parent-reported behavior and psychiatric problems in the relationship between SDB and cognitive functioning. Multiple models utilizing two different SDB definitions further explored direct effects of SDB on cognition as well as indirect effects through behavioral pathology. All models were adjusted for age, sex, race, BMI z-score, and asthma status.

Results: Indirect effects of SDB through behavior problems were significant in all mediation models, while direct effects of SDB on cognition were not. The findings were consistent across different mediation procedures and remained essentially unaltered when different criteria for SDB, behavior, and cognition were used.

Conclusion: Potential effects of SDB on cognitive functioning appear to occur through behavioral problems that are detectable in this pediatric population. Thus, early attentional or behavioral pathology may be implicated in the cognitive functioning deficits associated with SDB, and may present an early morbidity-related susceptibility biomarker.

Keywords: attention deficit hyperactivity disorder; behavior problems; cognition; mediation; sleep apnea; sleep-disordered breathing; snoring.

Figure 1

Unadjusted mediation model. Note: estimates were obtained using full information maximum likelihood and represent estimates prior to adjusting for demographic covariates. Behavioral variable abbreviations represent hyperactive, psychosomatic, and inattention CPRS subtest scores, and internalizing and externalizing CBCL subtest scores. Cognitive abbreviations represent design copying, phonological processing, tower, speed naming and arrows NEPSY subtests, and DAS verbal and non-verbal subtests.