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

摘要

We appreciate the opportunity to further discuss our recent study on the potential for behavioral and psychiatric functioning to mediate the relationship between sleep-disordered breathing (SDB) and cognitive functioning ( 1 ), in the context of the recent commentary raising various critiques on this report ( 2 ). In the following paragraphs, it will become clear that such commentary unfortunately falls outside the realm of providing substantive and informative reporting based on an adequate understanding of the current state of sleep medicine as it pertains to SDB in children, neuropsychological assessment, or current practices in statistics. The bulk of concerns as raised by Barwick and Guilleminault appears to involve our use of several highly validated scales of behavioral and cognitive functioning in children. In support of their arguments, the authors take the somewhat confusing and misleading stance that our discussion of the wide applicability of these measures to various clinical populations does not necessarily imply that such measures are adequate or extensively validated in our population involving sleep-disordered children. A cursory examination of the recent literature in this field should illustrate the common clinical use and relevance of these measures to this child sleep medicine [e.g., review articles such as Ref. ( 3 – 5 )]. In addition, although concerns regarding use of individual subscores are not particularly novel, the authors gloss over how these measures were used in our report and seem out of touch with how they are currently being extensively applied in this field. We should first state that inferences were never made based exclusively on any of these individual subtests in our report but were instead made regarding general domains, within which these measures have been shown to provide valid information alongside other associated measures. Furthermore, the authors appear to rely on inadequate review of the years of research that has been conducted and subsequently published in peer-reviewed contexts, within the domains of developmental psychopathology, pediatric neuropsychology, adult clinical neuropsychology and psychopathology, and in collaborative research within medicine, where the examination of groups of single test performances as well as aggregate factors from the measures utilized, such as has been done with our studies, are in fact the norm when addressing components of both cognitive and behavioral status. The authors interestingly choose to reference both Wechsler and Sattler [from their citations ( 2 , 3 )], ignoring that neither of these individuals ever discussed that research concerning cognitive and behavioral domains of functioning should not be examined at both the individual subtest and aggregate factor level, as we have done with our studies. In fact, what Wechsler and Sattler discuss is the importance of looking at aggregate information when making clinical decisions , and not research inferences, something we agree with as well. They also do not reference other informative psychometricians within neuropsychology (i.e., it is important to recognize that neither Sattler nor Wechsler were neuropsychologists), who have addressed how research addressing cognition and behavior can be well informed by the examination of sets of appropriate data [e.g., Ref. ( 6 – 10 )]. Furthermore, none of the papers referenced by Barwick and Guilleminault expressed any specific rationale as to why both subtest performances and aggregates of subtests contributing to the factors of broader interest could not be useful information and provide informative data regarding cognitive capacities; indeed, they do not address how measures are utilized for research purposes at all. Similarly, while Achenbach’s and Conner’s measures are developed to provide information at a global level, they also have a long standing history of consideration at the individual domain level [e.g., Anxiety; Disruptive Behavior; and Attention ( 11 – 14 )], particularly with regard to psychopathology and behavioral functioning. The wealth of articles published in premier peer-reviewed journals, including those with some of the highest impact factors in the developmental neuropsychology field (e.g., Child Development; Pediatrics; NEJM; and The Lancet) that includes consideration of subtest and aggregate subscale data is substantial [e.g., Ref. ( 12 , 15 – 17 )], which includes a paper utilizing a single Conner’s hyperactivity subscore as an outcome that was in fact coauthored by Guilleminault ( 18 ). That such extensive implementation of such approaches is ignored or glossed-over by Barwick and Guilleminault is unfortunate and misrepresents how researchers in clinical domains frequently and appropriately make use of cognitive and behavioral assessment measures. Also misleading is the authors’ contention that the plausibility of other model specifications (e.g., cognition as a mediator) was simply not assessed o