Key points

Introduction

The purpose of this article is to review the literature on common disorders seen in pediatric otolaryngology clinics and their related comorbid psychosocial issues and conditions. The article aims to heighten awareness of the cognitive, developmental, behavioral, emotional, and social correlates of these commonly treated conditions. In addition, a screening algorithm is provided for identifying these issues and providing appropriate referrals that are designed to be time efficient to implement in the context of a busy practice.

Introduction

The purpose of this article is to review the literature on common disorders seen in pediatric otolaryngology clinics and their related comorbid psychosocial issues and conditions. The article aims to heighten awareness of the cognitive, developmental, behavioral, emotional, and social correlates of these commonly treated conditions. In addition, a screening algorithm is provided for identifying these issues and providing appropriate referrals that are designed to be time efficient to implement in the context of a busy practice.

Common disorders seen in pediatric otolaryngology clinics with psychosocial comorbidities

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  Hearing loss

  
  
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  Obstructive sleep-disordered breathing (OSDB)

  
  
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  Cleft lip and palate

  
  
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  Psychosocial functioning in the surgery patient

  
  
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  Attention-deficit/hyperactivity disorder (ADHD)

  
  
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  Autism spectrum disorder (ASD)

Hearing loss

In the United States, hearing loss is the most commonly diagnosed birth defect. Every year, hearing loss occurs in 20,000 newborns. Deaf children are at greater risk for a variety of emotional, behavioral, social, developmental, and cognitive problems. It is important for physicians to know how to recognize these problems.

Deaf children face difficulties in all 3 areas of quality of life: physical functioning, social functioning, and mental health ( Table 1 ). More than half of deaf youth have significant impairment in social relationships, and 33.3% have a moderate to severe risk in social functioning. Compared with normal hearing children, deaf children have significantly more depressive symptoms and lower quality of life. Not only is their mental and social health affected, but also their physical health as well. On the positive side, for those who can and do receive cochlear implantation, parents report improvement in social relationships and self-confidence in their child.

Along with a decreased quality of life, deaf youth also suffer from academic, developmental, and behavior impairment. Deaf youth are at greater risk for ADHD, autism, and other developmental and learning disabilities than youth with normal hearing. In fact, about 24% of deaf children have developmental disorders, and 20% of deaf youth are diagnosed with mental retardation. This increase in developmental disorders and cognitive impairments coincides with impairment in school function affecting about 43% of deaf adolescents. Language development and positive social experiences are important to all developing children and often do not proceed smoothly for deaf children. The communication barriers can limit or negatively affect social experience, leading to peer rejection, frustration in social interactions, impulsivity, irritability, and acting out behaviors. Behavioral disorders occur in about 38% of deaf children. Overall, the rates for cognitive, developmental, and behavioral disorders for deaf children are much higher than hearing children, along with related social impairments and poor academic functioning. Physicians need to be cognizant of this in order for them to identify and refer appropriately.

The parents’ ability to cope with the child’s hearing deficits is also important to assess. Parents often do not have adequate information about key aspects of caring for a deaf child, such as alternative forms of communication, developmental concerns, ways to promote social skill development, and ways to promote self-esteem and healthy emotional development. Almost half of parents report that they did not receive the proper education about how to check the function of their child’s hearing aids. Another stressful issue for parents is making the decision for cochlear implantation. An important role the physician plays for the family is parent education, so that they may be guided through the diagnosis and treatment process more easily.

Clearly, deaf children are at risk for a diverse range of psychosocial comorbidities including physical, social, psychological, developmental, and behavioral issues. The complex problems of deaf children illustrate the need for preventative interventions aimed at early recognition. Early recognition and intervention are crucial for deaf children because it allows for significantly better developmental outcomes.

Obstructed sleep-disordered breathing

OSDB is defined as the obstruction of the upper airway during sleep that negatively affects sleep quality and ventilation and/or oxygenation. OSDB is thought to be caused by “either anatomic narrowing of the upper air way, or increased collapsibility of UAW muscles, or abnormal neural control; usually a combination of all three events.” ^(p67) OSDB affects approximately 10% to 33% of the pediatric population. Predisposing factors include enlarged tonsils and adenoids, obesity, genetic syndromes, craniofacial anomalies, and muscle tone abnormalities. Medical complications are numerous: systemic hypertension, impaired cardiac function and structure, cor pulmonale, extraesophageal reflux, impaired somatic growth, failure to thrive, circulating inflammatory mediators, increased insulin resistance, and possible neuronal injury in the hippocampus and frontal cortex.

When a patient with OSDB, or obstructive sleep apnea syndrome, a severe form of OSDB, is seen in otolaryngology clinics, it is typically as a consult regarding possible surgical options. Tonsillectomy and adenoidectomy are usually the first line of treatment for children who have significant disease with enlarged tonsils and adenoids and have been shown to help in most of these children. A wide range of additional surgical options are performed when indicated. However, a significant percentage of children continue to have OSDB following surgery or are poor candidates for surgery. This population includes mainly obese children, and youth with craniofacial anomalies or neuromuscular difficulties. These children require treatment with a positive airway pressure machine, managed typically by pulmonary or sleep physicians. Psychosocial complications are also numerous and affect behavioral, emotional, and cognitive functioning, including executive functioning deficits, behavior, sustained attention, selective attention, and alertness ( Table 2 ). In addition, a review of 61 studies of OSDB found increased risk for typical mood being negative, poor emotion regulation, expressive language deficits, visual perceptual difficulties, and impaired working memory. Another multistudy review found reduced attention, hyperactivity, increased aggression, irritability, emotional and peer problems, and somatic complaints. Depression is common. Quality of life is impaired and is similar to children with asthma or rheumatoid arthritis. Improvements in behavior, neurocognition, and quality-of-life scores occur after adenotonsillectomy in patients wherein surgery is appropriate.

Regardless of treatment options available or whether a successful outcome is achieved, a brief screening of psychosocial comorbidities can be helpful in identifying pediatric patients in need of supportive counseling, behavioral therapy, psychoeducational testing, or other psychosocial services.

Cleft lip and palate

Children born with cleft lip and/or palate (CLP) are commonly seen in otolaryngology clinics, because CLPs are the most frequent craniofacial abnormality. Cleft lip is diagnosed in 0.3 of 1000 live births; cleft palate is diagnosed in 0.4, and the combination CLP is diagnosed in 0.5 per 1000 births. The syndrome is characterized by abnormal development during the gestational period resulting in either failure of the upper lip and nose, or of the roof of the mouth, to fuse properly. The defect can occur as a component of another diagnosed syndrome, or independently (nonsyndromic), and is somewhat more common in Native American and Asian populations.

CLP is associated with several inherent developmental and psychosocial difficulties ( Table 3 ), including increased rates of depression, attention difficulties, hyperactivity, anxiety disorders, and problems with social interactions. Separation anxiety is especially prevalent in children with CLP, as around 24% of these children will be diagnosed with the disorder, compared with only around 4% of the general population. These numbers are more than doubled when the children also have cleft-related impairments in speaking and eating. People with cleft lip, cleft palate, or CLP tend to perform worse in language-based cognitive domains and are likely to struggle academically because of learning disabilities, particularly in reading. Some studies have even suggested CLP is associated with decreased brain volumes for the frontal lobes, caudate, putamen, and globus pallidus.

Parents of these children also face a great deal of stress for several reasons. Children with CLP often will need care from birth through adulthood, putting a gigantic financial and emotional strain on caregivers. They may also experience a great deal of guilt over their child’s condition and increased anxiety about their child’s well-being and are more likely to underreport their children’s psychosocial difficulties because of fear of further stigmatization. Even the decision of whether to pursue further difficult treatments can be a strain on parents.

Psychosocial functioning in the surgery patient

Results suggest by 3 or 4 weeks after tonsillectomy or ear tube insertion, psychosocial functioning improves based on both patient and parent report. Simply put, when children feel better physically, they feel better emotionally and behave better. In fact, patient quality of life is often positively affected by surgery, as found in children after adenotonsillectomy that had been causing upper airway obstruction.

However, there are several groups of surgical patients with comorbid psychosocial conditions that may benefit from screening and referral ( Table 4 ). First, patients needing tympanostomy tube insertion or having a history of recurrent otitis media are at risk for speech, language, learning, and behavioral problems. Although some of these may improve with tube insertion, others may not. Screening and referral postsurgery can be helpful. Second, patients undergoing tonsillectomy and/or adenoidectomy in the context of obstructive sleep apnea have an increased risk of nocturnal enuresis. After surgery, most patients show improvements in apnea-hypopnea index, quality of life, and behavior. However, not all patients have improvements in nocturnal enuresis after surgery. Research suggests key factors in recidivism include prematurity, obesity, family history of nocturnal enuresis, presence of non-monosymptomatic nocturnal enuresis, severity of nocturnal enuresis, and arousal difficulties during sleep. Also, improvements may not be long-lived after surgery. Improvements in sleep experienced by children after adenotonsillectomy for sleep-disordered breathing were not as great 2.5 years after surgery as they were 6 months after surgery, although still significantly better than baseline levels. Some, but not all, behavioral improvements were maintained.

ADHD

ADHD is one of the most well-known childhood neurodevelopmental disorders. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) estimates approximately 5% of children worldwide have a diagnosis of ADHD, while researchers have estimated that number may be as high as 7% to 9.5%. When a diagnosis of ADHD is given, 1 of 3 subtypes is identified: combined presentation, predominantly inattention, predominantly hyperactive/impulsive, based on a cluster of symptoms ( Table 5 ) that are present before age 12 and can be seen in 2 or more settings (eg, both at home and at school). The term “ADD,” or attention deficit disorder, is a misnomer. ADD is an old term that was replaced by ADHD in 1994, with the release of the DSM-IV. Despite its outdated nature, the term ADD continues to be used by many physicians and can cause confusion for families and patients.

A diagnosis of ADHD can be associated with several deficits in social, academic, and, later, occupational functioning. The course of ADHD is chronic, and although many children with symptoms of ADHD will improve with age, they may never catch up with their peers in terms of controlling inattentiveness or impulsive behaviors. As adults, these children are more likely than their peers to be undereducated and underemployed and may be at greater risk for other difficulties, such as conduct problems, depression, and substance abuse. Common treatment components include stimulant and nonstimulant medication, behavioral training for parents and children, and appropriate classroom modifications. An early diagnosis of ADHD allows for earlier interventions, and by being aware of the symptoms, pediatric otolaryngologists can play an integral part in making appropriate referrals.

Pediatric otolaryngologists are likely to see a high prevalence of children with ADHD in their practice. Children who have airway obstruction as a result of adenotonsillar hypertrophy are much more likely to exhibit symptoms of poor attention, hyperactivity, and impulsivity. Studies have also found higher rates of both ADHD and learning disabilities in children who have recurrent otitis media, and that children with these overlapping diagnoses are more likely to struggle with auditory processing and have an increased level of social stress and resulting poorer interpersonal relationships. Even otolaryngologists working in acute care may see a higher rate of children with ADHD, because of the impulsive nature of the disorder. Perera and colleagues found that among children treated in the emergency room for inserting foreign objects into their nasal/aural cavities, 14.3% had a diagnosis of ADHD, and 25% were repeat offenders. Undergoing adenoidectomy or adenotonsillectomy is associated with an improvement in symptoms of ADHD, indicating the importance of otolaryngology in treatment teams for children with ADHD.

A word of caution is needed in relation to diagnosing ADHD in children who have associated breathing problems disrupting sleep. Up to one-third of children who experience difficulty breathing during sleep will also exhibit symptoms related to ADHD, which can in turn lead to misdiagnosis or overdiagnosis. Recurrent middle ear infections can lead to understandable irritability and impulsivity, another oft-mistaken symptom of ADHD. Similarly, there may be an overdiagnosis of ADHD in children with CLP. Overlapping symptoms, such as poor working memory (especially when language demands are high) and difficulty with expressive language, may be difficult to distinguish from true ADHD. It is important to neither miss a diagnosis of ADHD nor inappropriately medicate a child for a condition they do not have. Although an appropriate referral to a psychiatrist or psychologist is definitely warranted, physicians should communicate clearly in their referral that the child is experiencing sleep difficulties, ear infections, or any other comorbid medical condition.