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      Executive dysfunction in children affected by obstructive sleep apnea syndrome: an observational study

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          The role of sleep in cognitive processes can be considered clear and well established. Different reports have disclosed the association between sleep and cognition in adults and in children, as well as the impact of disturbed sleep on various aspects of neuropsychological functioning and behavior in children and adolescents. Behavioral and cognitive dysfunctions can also be considered as related to alterations in the executive functions (EF) system. In particular, the EF concept refers to self-regulatory cognitive processes that are associated with monitoring and controlling both thought and goal directed behaviors. The aim of the present study is to assess the impact of the obstructive sleep apnea syndrome (OSAS) on EF in a large sample of school aged children.

          Materials and methods

          The study population comprised 79 children (51 males and 28 females) aged 7–12 years (mean 9.14 ± 2.36 years) with OSAS and 92 healthy children (63 males and 29 females, mean age 9.08 ± 2.44 years). To identify the severity of OSAS, an overnight respiratory evaluation was performed. All subjects filled out the Italian version of the Modified Card Sorting Test to screen EFs. Moreover, to check the degree of subjective perceived daytime sleepiness, all subjects were administered the Pediatric Daytime Sleepiness Scale (PDSS).


          No significant differences between the two study groups were found for age ( P = 0.871), gender ( P = 0.704), z-score of body mass index ( P = 0.656), total intelligence quotient ( P = 0.358), and PDSS scores ( P = 0.232). The OSAS children showed a significantly higher rate of total errors ( P < 0.001), perseverative errors ( P < 0.001), nonperseverative errors ( P < 0.001), percentage of total errors ( P < 0.001), percentage of perseverative errors ( P < 0.001), and percentage of nonperseverative errors ( P < 0.001). On the other hand, OSAS children showed a significant reduction in the number of completed categories ( P = 0.036), total correct sorts ( P = 0.001), and categorizing efficiency ( P < 0.001). The Pearson’s correlation analysis revealed a significant positive relationship between all error parameters and apnea-hypopnea index, oxygen desaturation index, and percentage of mean desaturation of O 2 with a specular negative relationship between the error parameters and the mean oxygen saturation values, such as a significant negative relationship between apnea-hypopnea index, oxygen desaturation index, percent of mean desaturation of O 2, and the number of completed categories.


          Our study identified differences in the executive functioning of children affected by OSAS and is the first to identify a correlation between alteration in respiratory nocturnal parameters and EF that has not yet been reported in developmental age. These findings can be considered as the strength and novelty of the present report in a large pediatric population.

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          Most cited references 62

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          Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force.

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            A modified card sorting test sensitive to frontal lobe defects.

            Milner's (1963) report of impaired performance on the Wisconsin Card Sorting Test (WCST) in a group of patients with frontal lobe lesions suggested that this test might be a useful one in the investigation of individual patients with suspected brain lesions. However, for many of our older hospital population the WCST was found to be too difficult and distressing, and also the inherent ambiguities associated with certain responses limited the test's usefulness for research purposes. Therefore, a simpler and less ambiguous modification was devised (MCS) and a new method of measuring perseverative errors proposed. In a group of 53 patients with unilateral cerebral lesions, those with frontal lobe lesions performed less well with the MCST and made a higher proportion of perseverative errors than those with lesions elsewhere: there were no laterality effects in either frontal or non-frontal groups. The usefulness of the MCST for detecting frontal lobe lesions in individual patients was established, and the use of cut-off scores briefly discussed.
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              Sleep loss, learning capacity and academic performance.

              At a time when several studies have highlighted the relationship between sleep, learning and memory processes, an in-depth analysis of the effects of sleep deprivation on student learning ability and academic performance would appear to be essential. Most studies have been naturalistic correlative investigations, where sleep schedules were correlated with school and academic achievement. Nonetheless, some authors were able to actively manipulate sleep in order to observe neurocognitive and behavioral consequences, such as learning, memory capacity and school performance. The findings strongly suggest that: (a) students of different education levels (from school to university) are chronically sleep deprived or suffer from poor sleep quality and consequent daytime sleepiness; (b) sleep quality and quantity are closely related to student learning capacity and academic performance; (c) sleep loss is frequently associated with poor declarative and procedural learning in students; (d) studies in which sleep was actively restricted or optimized showed, respectively, a worsening and an improvement in neurocognitive and academic performance. These results may been related to the specific involvement of the prefrontal cortex (PFC) in vulnerability to sleep loss. Most methodological limitations are discussed and some future research goals are suggested.

                Author and article information

                Neuropsychiatr Dis Treat
                Neuropsychiatr Dis Treat
                Neuropsychiatric Disease and Treatment
                Neuropsychiatric Disease and Treatment
                Dove Medical Press
                09 August 2013
                : 9
                : 1087-1094
                [1 ]Sleep Clinic for Developmental Age, Clinic of Child and Adolescent Neuropsychiatry, Department of Mental and Physical Health and Preventive Medicine, Second University of Naples, Naples, Italy
                [2 ]Unit of Child and Adolescent Neuropsychiatry, University of Perugia, Perugia, Italy
                [3 ]Child Neuropsychiatry, Department of Psychology, University of Palermo, Palermo, Italy
                [4 ]Department of Psychiatry, Magna Graecia University of Catanzaro, Catanzaro, Italy
                [5 ]Unit of Child and Adolescent Neuropsychiatry, AUSL Umbria 2, Terni, Italy
                Author notes
                Correspondence: Maria Esposito, Sleep Clinic for Developmental Age, Clinic of Child and Adolescent Neuropsychiatry, Department of Mental Health, Physical, and Preventive Medicine, Second University of Naples, Via Sergio Pansini 5 PAD XI, 80131 Naples, Italy, Tel +39 8 1566 6988, Fax +39 8 1566 6694, Email maria.esposito2@
                © 2013 Esposito et al, publisher and licensee Dove Medical Press Ltd

                This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.

                Original Research


                children, osas, polysomnography, executive functions, sleep, sleepiness


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