Journal of the International Neuropsychological Society (2012), 18, 212–222. Copyright E INS. Published by Cambridge University Press, 2011. doi:10.1017/S1355617711001743 Changes in Neuropsychological and Behavioral Functioning in Children with and without Obstructive Sleep Apnea Following Tonsillectomy Bruno Giordani, 1 Elise K. Hodges, 1 Kenneth E. Guire, 2 Deborah L. Ruzicka, 3 James E. Dillon, 4 Robert A. Weatherly, 5 Susan L. Garetz, 6 AND Ronald D. Chervin 3 1 Neuropsychology Section, Department of Psychiatry, University of Michigan, Ann Arbor, Michigan 2 Biostatics Department, School of Public Health, University of Michigan, Ann Arbor, Michigan 3 Sleep Medicine, Neurology Department, University of Michigan, Ann Arbor, Michigan 4 MDCHC/Corrections and Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Michigan, Ann Arbor, Michigan 5 Department of Pediatrics, The University of Missouri Kansas City School of Medicine, Kansas City, Missouri 6 Otorhinolaryngology Department, University of Michigan, Ann Arbor, Michigan (RECEIVED April 11, 2011; FINAL REVISION November 21, 2011; ACCEPTED November 21, 2011) Abstract The most common treatment for sleep disordered breathing (SDB) is adenotonsillectomy (AT). Following AT, SDB resolves in most cases, and gains in cognitive and behavior scores are consistently reported, although persistent neuropsychological deficits or further declines also have been noted. This study presents results of the comprehensive 1-year follow-up neuropsychological examinations for children in the Washtenaw County Adenotonsillectomy Cohort I (95% return rate). After adjusting for normal developmental and practice-effect related changes in control children, significant improvements 1 year following AT were noted in polysomnography and sleepiness, as well as parental reports of behavior, although cognitive outcomes were mixed. Children undergoing AT with and without polysomnography- confirmed obstructive sleep apnea improved across a range of academic achievement measures, a measure of delayed visual recall, short-term attention/working memory, and executive functioning, along with parental ratings of behavior. On the other hand, measures of verbal abstraction ability, arithmetic calculations, visual and verbal learning, verbal delayed recall, sustained attention, and another measure of visual delayed recall demonstrated declines in ability, while other measures did not improve over time. These findings call into question the expectation that AT resolves most or all behavioral and cognitive difficulties in children with clinical, office-based diagnoses of SDB. (JINS, 2012, 18, 212–222) Keywords: Polysomnography, Neuropsychology, Sleep-disordered breathing, Adenotonsillectomy, Tonsillitis, Snoring INTRODUCTION Obstructive sleep disordered breathing (SDB) includes a range of respiratory disturbances from primary snoring to frank obstructive sleep apnea (OSA), all related to increased upper airway resistance or obstruction during sleep. Accounts from the public press and expectations among parents and clinicians suggest that childhood SDB is associated with neuropsychological and behavioral deficits, especially hyper- activity, inattention, impaired memory, and learning deficits (Beebe, 2006; Hodges, Bloomfield, Coulas, & Giordani, 2008). On the other hand, a recent, comprehensive review of research on cognitive and behavioral difficulties in children with SDB pointed out that parents most frequently associate mood disorders in their children (e.g., depression) to SDB, in contrast to the usually held expectations that hyperactivity and inattention are the most prevalent concomitants of SDB (Kohler, Lushington, & Kennedy, 2010). This same review also noted, however, that the most common findings from direct cognitive testing of children with SDB are impairment in attention (71% of studies reviewed) and verbal intelligence (40%), with impairments in executive functioning also evi- dent, along with less common deficits in memory, visual- spatial ability, language skills, academic achievement, and sensorimotor functions. The most common treatment for SDB is adenotonsillectomy (AT; Marcus & Loughlin, 1996). It is now performed at Correspondence and reprint requests to: Bruno Giordani, Neuropsychology Section, Department of Psychiatry, University of Michigan, Suite C, 2101 Commonwealth Blvd, Ann Arbor, MI 48105. E-mail: giordani@umich.edu 212