Dean W. Beebe

Cognitive, Behavioral, and Functional Consequences of Inadequate Sleep in Children and Adolescents

This article summarizes correlational, case-control, quasi-experimental, and experimental studies that have examined whether sleep during childhood and adolescence is related to daytime functioning. Published findings suggest that inadequate sleep quality and/or quantity can cause sleepiness, inattention and, very likely, other cognitive and behavioral deficits that significantly impact children and adolescents in functional settings. This article then integrates findings from longitudinal studies within a developmental psychopathology model. Important questions remain, but evidence supports the integration of sleep screening and interventions into routine clinical care and also supports advocacy for public policy changes to improve the sleep of children and adolescents.

Neuropsychological effects of pediatric obstructive sleep apnea.

Obstructive sleep apnea (OSA) is a fairly common nocturnal breathing disorder, affecting 2-4% of individuals. Although OSA is associated with medical morbidity, its most functionally disruptive effects in adults appear to be neuropsychological in nature. Research on the neuropsychological effects of pediatric OSA has been limited. This study compared the neuropsychological functioning of school-aged children with OSA to that of healthy children. The primary goal was to clarify the presence and pattern of neuropsychological morbidity associated with pediatric OSA. Sleep was assessed with parent-report questionnaires and laboratory sleep studies. Neuropsychological functioning was assessed by formal tests and parent- and teacher-report questionnaires. Data indicated OSA-related cognitive and behavioral impairment that was particularly marked on measures of behavior regulation and some aspects of attention and executive functioning. Minimal effects were observed on measures of intelligence, verbal memory, or processing speed. Exploratory analyses failed to indicate any clear relationship between neuropsychological functioning and objective indexes of hypoxia or sleep disruption, though the sample was small. These data add to a growing literature which suggests that significant neuropsychological deficits are associated with pediatric OSA. Findings suggest a pattern of neuropsychological morbidity that is similar but not identical to that seen in adult OSA.

Prevalence, Patterns, and Persistence of Sleep Problems in the First 3 Years of Life

OBJECTIVE: Examine the prevalence, patterns, and persistence of parent-reported sleep problems during the first 3 years of life. METHODS: Three hundred fifty-nine mother/child pairs participated in a prospective birth cohort study. Sleep questionnaires were administered to mothers when children were 6, 12, 24, and 36 months old. Sleep variables included parent response to a nonspecific query about the presence/absence of a sleep problem and 8 specific sleep outcome domains: sleep onset latency, sleep maintenance, 24-hour sleep duration, daytime sleep/naps, sleep location, restlessness/vocalization, nightmares/night terrors, and snoring. RESULTS: Prevalence of a parent-reported sleep problem was 10% at all assessment intervals. Night wakings and shorter sleep duration were associated with a parent-reported sleep problem during infancy and early toddlerhood (6–24 months), whereas nightmares and restless sleep emerged as associations with report of a sleep problem in later developmental periods (24–36 months). Prolonged sleep latency was associated with parent report of a sleep problem throughout the study period. In contrast, napping, sleep location, and snoring were not associated with parent-reported sleep problems. Twenty-one percent of children with sleep problems in infancy (compared with 6% of those without) had sleep problems in the third year of life. CONCLUSIONS: Ten percent of children are reported to have a sleep problem at any given point during early childhood, and these problems persist in a significant minority of children throughout early development. Parent response to a single-item nonspecific sleep query may overlook relevant sleep behaviors and symptoms associated with clinical morbidity.

Attention, learning, and arousal of experimentally sleep-restricted adolescents in a simulated classroom.

PURPOSE To experimentally test whether chronic sleep restriction, which is common among adolescents, is causally related to poor learning, inattentive behaviors, and diminished arousal in a classroom-like situation. METHODS Sixteen healthy adolescents underwent a sleep manipulation that included, in counterbalanced order, five consecutive nights of sleep deprivation (6½ hours in bed) versus five nights of healthy sleep duration (10 hours in bed). At the end of each condition, participants viewed educational films and took related quizzes in a simulated classroom. Eight participants also underwent video and electroencephalography monitoring to assess levels of inattentive behaviors and arousal, respectively. RESULTS As compared with the healthy sleep condition, sleep-deprived participants had lower quiz scores (p = .05), more inattentive behaviors (p < .05), and lower arousal (p = .08). CONCLUSIONS These pilot data complement previous correlational reports by showing that chronic sleep restriction during adolescence can cause inattention, diminished learning, and lowered arousal in a simulated classroom.

Feasibility and behavioral effects of an at-home multi-night sleep restriction protocol for adolescents.

BACKGROUND Sleep deprivation is common among adolescents and has been associated with adverse behavioral and educational outcomes. However, it is difficult to draw strong causal conclusions because of a dearth of experimental sleep research. In part, this appears related to methodological challenges when working with this population. This study tested the feasibility and behavioral effects of a multi-night, at-home experimental sleep restriction protocol in a sample of adolescents. METHODS Twenty healthy adolescents aged 13.9-16.9 years were enrolled in a three-week sleep manipulation protocol using a counterbalanced cross-over experimental design. The protocol included a baseline week, followed in random order by a short sleep week (Monday-Friday nights limited to 6.5 hours time in bed) and an extended sleep week (10 hours lights-out time in bed Monday-Friday nights). Sleep was monitored via self-report and objective actigraphy. These were reviewed with participants and parents on the Saturdays at the end of each week, when parents and participants also completed behavior rating questionnaires. RESULTS One participant dropped out of the study, but each of the remaining 19 displayed markedly less sleep in the short sleep condition than the extended sleep condition (average nightly gap approximately 2.5 hours). Data also reflected indirect effects of sleep deprivation that are consistent with an increase in homeostatic sleep drive. Compared to the extended sleep week, parents during the short sleep week reported that the participants displayed significantly greater problems with sleepiness, attention, oppositionality/irritability, behavior regulation, and metacognition. Participant self-report results were similar, though less robust. CONCLUSIONS A multi-night, at-home sleep manipulation protocol for use with adolescents is indeed feasible. This study also provided the first experimental evidence that chronic sleep restriction during adolescence is causally related to a wide range of behavioral deficits.

Validation of the Pediatric Automated Neuropsychological Assessment Metrics in childhood-onset systemic lupus erythematosus.

To evaluate the reproducibility and validity of the Pediatric Automated Neuropsychological Assessment Metrics (Ped‐ANAM) when used in childhood‐onset systemic lupus erythematosus (cSLE).

Sleep in Individuals With Angelman Syndrome: Parent Perceptions of Patterns and Problems

The diagnostic criteria for Angelman syndrome includes sleep disturbance as an associated characteristic. There are, however, few researchers who have examined sleep problems in this population. Our goal in this study was to better characterize the sleep patterns and problems in individuals with Angelman syndrome. Parents of 339 individuals between the ages of 3 and 22 completed a previously validated sleep questionnaire. Results confirmed that a variety of sleep problems exist in a significant portion of individuals with Angelman syndrome, most prominently in the areas of sleep initiation, sleep duration, reliance on sleep facilitators, being awakened by loud noises, and being disoriented when aroused. Developmental trends, syndrome specificity of findings, clinical implications, and directions for future research are discussed.

Associations Between Secondhand Smoke Exposure and Sleep Patterns in Children

OBJECTIVES: The objective of this study was to investigate the relationship between exposure to secondhand smoke (SHS) and child sleep patterns among a group of children with asthma who were exposed regularly to tobacco smoke at home. METHODS: We studied 219 children who were enrolled in an asthma intervention trial and were exposed regularly to SHS. Serum cotinine levels were used to measure exposure to tobacco smoke, and sleep patterns were assessed through parent reports using the Childrens Sleep Habits Questionnaire. Covariates in adjusted analyses included gender, age, race, maternal marital status, education, and income, prenatal tobacco exposure, maternal depression, Home Observation for Measurement of the Environment total score, household density, asthma severity, and use of asthma medications. RESULTS: Exposure to SHS was associated with sleep problems, including longer sleep-onset delay (P = .004), sleep-disordered breathing (P = .02), parasomnias (P = .002), daytime sleepiness (P = .022), and overall sleep disturbance (P = .0002). CONCLUSIONS: We conclude that exposure to SHS is associated with increased sleep problems among children with asthma.

Quality of life and obstructive sleep apnea symptoms after pediatric adenotonsillectomy

BACKGROUND AND OBJECTIVES: Data from a randomized, controlled study of adenotonsillectomy for obstructive sleep apnea syndrome (OSAS) were used to test the hypothesis that children undergoing surgery had greater quality of life (QoL) and symptom improvement than control subjects. The objectives were to compare changes in validated QoL and symptom measurements among children randomized to undergo adenotonsillectomy or watchful waiting; to determine whether race, weight, or baseline OSAS severity influenced changes in QoL and symptoms; and to evaluate associations between changes in QoL or symptoms and OSAS severity. METHODS: Children aged 5 to 9.9 years with OSAS (N = 453) were randomly assigned to undergo adenotonsillectomy or watchful waiting with supportive care. Polysomnography, the Pediatric Quality of Life inventory, the Sleep-Related Breathing Scale of the Pediatric Sleep Questionnaire, the 18-item Obstructive Sleep Apnea QoL instrument, and the modified Epworth Sleepiness Scale were completed at baseline and 7 months. Changes in the QoL and symptom surveys were compared between arms. Effect modification according to race and obesity and associations between changes in polysomnographic measures and QoL or symptoms were examined. RESULTS: Greater improvements in most QoL and symptom severity measurements were observed in children randomized to undergo adenotonsillectomy, including the parent-completed Pediatric Quality of Life inventory (effect size [ES]: 0.37), the 18-item Obstructive Sleep Apnea QoL instrument (ES: –0.93), the modified Epworth Sleepiness Scale score (ES: –0.42), and the Sleep-Related Breathing Scale of the Pediatric Sleep Questionnaire (ES: –1.35). Effect modification was not observed by obesity or baseline severity but was noted for race in some symptom measures. Improvements in OSAS severity explained only a small portion of the observed changes. CONCLUSIONS: Adenotonsillectomy compared with watchful waiting resulted in significantly more improvements in parent-rated generic and OSAS-specific QoL measures and OSAS symptoms.

Does sleep duration predict metabolic risk in obese adolescents attending tertiary services? A cross-sectional study.

STUDY OBJECTIVES To determine, in a clinical sample of obese adolescents, whether shorter sleep duration is associated with metabolic risk and obesity severity. DESIGN Cross-sectional study. SETTING Tertiary care weight-management clinic in Cincinnati, OH, USA. PARTICIPANTS 133 obese adolescents aged 10-16.9 years. INTERVENTIONS N/A. MEASUREMENTS Multifaceted sleep duration data were examined with fasting venipuncture and anthropometric data collected during clinical care. PRIMARY OUTCOME presence of metabolic syndrome. SECONDARY OUTCOMES waist circumference, triglycerides, HDL-cholesterol, blood pressure, glucose, insulin resistance (HOMA-IR), and body mass index (BMI). PREDICTORS Sleep duration by (1) parent-report, (2) self-report, and (3) multi-night actigraphy. ANALYSIS Relationships between sleep duration and each outcome were examined via regression models, adjusted for potential confounders. RESULTS Regardless of how measured, sleep duration showed no strong association with metabolic syndrome (OR 1.1 to 1.5, P = 0.2 to 0.8), BMI (β -0.03 to -0.01, P = 0.2 to 0.8), or most other outcomes. Lower triglycerides were predicted by shorter sleep duration by self-report (β 12.3, P = 0.01) and actigraphy (β 13.6, P = 0.03), and shorter parent-reported sleep duration was associated with higher HDL-cholesterol (β = -2.7, P = 0.002). CONCLUSIONS Contrary to expectations, sleep duration was not associated with metabolic outcomes, and showed limited associations with lipid profiles. Although inadequate sleep may affect other areas of functioning, it appears premature to expect that lengthening sleep will improve BMI or metabolic outcomes in clinical samples of obese adolescents.