What do we know about the connection between sleep problems and children’s behavior?

Dr. Mindell: We know a great deal about the impact of sleep deprivation on children's behavior. It affects their mood and can make them cranky and irritable. It also affects their ability to regulate their emotions—they may get more easily frustrated or act silly if they don't get enough sleep. It also has cognitive effects: it has an impact on decisionmaking, creativity, memory, and performance in school.

Sleep-deprived children are also more likely to be overactive and noncompliant. And sleep problems can have an incredible effect on the entire family—the parents get cranky and irritable, too. A child's sleep problem is a family problem.

Dr. Chervin: The interesting thing is that when sleep is poor, children won't necessarily look sleepy during the day. Sometimes they have ADHD (attention deficit hyperactivity disorder) symptoms: inattention, hyperactivity and impulsiveness. They need to create a stimulating environment to keep themselves awake, because they need to stay awake to learn. They will do anything to change their environment, including displaying aggressive behavior.

It isn't surprising that children spend a third of their day sleeping. If their brain isn't able to use sleep for the restorative processes it needs to, then it will function during the waking hours to stay awake in able to learn.

Dr. Fallone: As kids progress through adolescence, they tend to get less and less sleep on school nights. This trend has been observed in many different countries. What are the developmental and physiological implications of that? What are the issues relating to circadian rhythm and "morningness" (which describes a person who is more alert early in the day) and "eveningness" (someone who is most alert later in the day)?

Dr. Rosen: The difficulty with this is that the relationship between academic behavior and sleep problems can go both ways. It can be causal; sleep problems can cause behavior and academic problems. What is less well recognized by parents and healthcare providers is that it is common—and may be even more common—that there is a coincidental relationship between sleep problems and behavioral problems. It is very rare that you fix the sleep problem and the behavioral problem goes away.

What are some of the most common sleep problems in children?

Dr. Owens: One of the sleep problems that has received the most attention is obstructive sleep apnea (OSA) and the relationship to ADHD-type symptoms. Not only is there an overlap between symptoms of OSA and those of ADHD (inattention, hyperactivity, distractibility) but the data suggest that when you treat a child with OSA, usually through removal of the adenoids or tonsils, the child sleeps better and the daytime symptoms are reduced.

Another emerging area of research is inadequate or insufficient sleep not only in adolescents but in middle school and younger students as well. Although these types of studies are difficult to conduct, there is evidence that links sleep deprivation in children and parental perception of behavioral problems, performance on psychological tests measuring reaction time, vigilance and working memory. One study shows verbal creativity is negatively impacted by sleep deprivation.

Dr. Pelayo: Sleeping should be refreshing. If a child wakes up tired, there may be a problem. Children also shouldn't be sleeping in on the weekends. This may signal that the child is trying to make up for lost sleep during the week. Snoring can also be a sign of a problem. Not all snoring is sleep apnea, but routine, habitual snoring is not normal for children.

What should parents and teachers do if they suspect sleep problems in children?

Dr. Meltzer: If your infant or toddler is overtired during the day, he or she should have a set sleep schedule, including an early bedtime and a daily nap. Sometimes when the younger child stays up late or misses a daily nap, it can be harder for them to fall asleep at night. Teachers should look for children who are frequently yawning or falling asleep in class. If they observe this behavior, they should notify the child's parents.

Dr. Owens: It is particularly important that both teachers and parents recognize that there may be that connection between sleep problems and behavior problems. When a potential problem is recognized, parents should seek professional help from their pediatrician. In many cases, daytime behavioral problems may improve once the sleep problem is addressed.

What should pediatricians and other children's health care providers do?

Dr. Broch: A recent study at a pediatric clinic showed that health providers tended to overlook sleep problems in children, as is the case in the adult population. I suggest that physicians ask their patients about their sleep and become educated about sleep disorders. They should know that sleep is an important part of health and medicine.

Dr. Owens: Every child with behavior/mood problems may have a sleep problem. Pediatricians should screen for sleep problems, but often they do not. When their patients get past the toddler stage, they tend not to. They should have a systematic way to ask about bedtime, wake time, and fragmented sleep, as well as excessive daytime sleepiness, awakenings at night, regularity and duration of sleep, and snoring.

Dr. Rosen: In dealing with other physicians, I just try to get sleep on their screen. Kids are "normally" nearly perfect sleepers, so anything that's different from that is not normal. If the kid is snoring or waking frequently during the night, that's not normal.

This article was published in the Spring 2004, Volume 6, Issue 2 of sleepmatters.