Judith A. Owens

Sleep habits and sleep disturbance in elementary school-aged children.

&NA; Relatively little is known about sleep habits, sleep disturbances, and the consequences of disordered sleep in school‐aged children. This descriptive study examined a variety of common sleep behaviors in a group of 494 elementary school children, grades kindergarten through fourth, using a battery of sleep questionnaires that included parent, teacher, and self‐report surveys. The prevalence of parent‐defined sleep problems ranged from 3.7% (Sleep‐Disordered Breathing) to 15.1% (Bedtime Resistance), with 37% of the overall sample described as having significant sleep problems in at least one sleep domain. Younger children were more likely than older children to have sleep problems noted by parents (particularly bedtime struggles and night wakings), as well as by teacher and self‐report. Children tended to identify more sleep problems by self‐report, particularly sleep‐onset delay and night wakings, than did their parents. Overall, approximately 10% of the sample was identified by all three measures as having significant problems with daytime sleepiness. The results of this study emphasize the importance of screening for sleep disorders in this age group in the clinical setting. The need for consensus regarding the use of sleep screening instruments and the definition of “problem” sleep in school‐aged children is also discussed.

Television-viewing Habits and Sleep Disturbance in School Children

Objective. To investigate the relationship between specific television-viewing habits and both sleep habits and sleep disturbances in school children. Methods. The parents of 495 children in grades kindergarten through fourth grade in three public elementary schools completed two retrospective survey questionnaires, one assessing their childrens sleep behaviors and the other examining television-viewing habits of both the child and the family. Sleep domains assessed included bedtime resistance, sleep onset delay, sleep duration, anxiety around sleep, parasomnias, night wakings, and daytime sleepiness. Teachers from all three schools also completed daytime sleepiness questionnaires (N = 402) for the sample. Results. Most of the television-viewing practices examined in this study were associated with at least one type of sleep disturbance. Despite overall close monitoring of television-viewing habits, one quarter of the parents reported the presence of a television set in the childs bedroom. The television-viewing habits associated most significantly with sleep disturbance were increased daily television viewing amounts and increased television viewing at bedtime, especially in the context of having a television set in the childs bedroom. The sleep domains that appeared to be affected most consistently by television were bedtime resistance, sleep onset delay, and anxiety around sleep, followed by shortened sleep duration. The parents threshold for defining “problem sleep behavior” in their child was also important in determining the significance of the association between sleep disturbance and television-viewing habits. Conclusion. Health care practitioners should be aware of the potential negative impact of television viewing at bedtime. Parents should be questioned about their childrens television-viewing habits as part of general screening for sleep disturbances and as part of anticipatory guidance in regards to healthy sleep habits in children. In particular, the presence of a television set in the childs bedroom may be a relatively underrecognized, but important, contributor to sleep problems in school children.

Sleep patterns and sleep problems among schoolchildren in the United States and China.

Objectives. Sleep patterns and sleep problems in children are not only influenced by a large number of biological and psychologic factors but also by cultural and social factors. Little is known about similarities and differences in sleep patterns and sleep problems among children across countries. We attempted to compare sleep patterns and sleep problems among schoolchildren from 2 countries with distinctive cultural contexts: the United States and China. Methods. The data come from 2 cross-sectional surveys in 3 elementary schools of Jinan City, Peoples Republic of China, and 3 elementary schools from a suburban school district in southeastern New England, United States. The Chinese sample consisted of 517 elementary school children (grades 1 to 5), and the US sample consisted of 494 elementary school children (grades kindergarten through 4). We used the Childrens Sleep Habits Questionnaire (CSHQ) to assess childrens sleep patterns and sleep problems as reported by parents. Parents of the Chinese sample completed a Chinese version of the CSHQ. Results. For children in both the US and Chinese samples, reported bedtime was delayed and sleep duration decreased with increasing age. Compared with the US children (grades 1–4), Chinese children went to bed approximately half an hour later (9:02 vs 8:27 pm) and woke up half an hour earlier (6:28 vs 6:55 am), resulting in an average sleep duration that was 1 hour less (9.25 vs 10.15 hours). Chinese children were rated significantly higher than the US children on almost all CSHQ scales, indicating more sleep problems in Chinese children. Common sleep problems observed for all children were difficulty falling asleep, having a fear of sleeping in the dark, sleep talking, restless sleep, teeth grinding during sleep, and daytime sleepiness. Shorter daily sleep duration was associated with difficulty falling asleep, struggling at bedtime, and trouble sleeping away for the US children, and with going to bed at different times and having a fear of sleeping alone for Chinese children. Short sleep duration was a main predictor of daytime sleepiness for Chinese children, whereas restless sleep and snoring predicted daytime sleepiness for the US children. Conclusions. As reported by parents, children in China went to bed later and woke up earlier and their sleep duration was 1 hour shorter than the US children. Chinese children were reported to have more sleep problems than their US counterparts. Daytime sleepiness was determined by sleep duration only for those who slept insufficiently. Unique school schedules and sleep practices may contribute to the differences in the sleep patterns and sleep problems of children from the United States and China.

Insufficient sleep in adolescents and young adults: an update on causes and consequences.

Chronic sleep loss and associated sleepiness and daytime impairments in adolescence are a serious threat to the academic success, health, and safety of our nation’s youth and an important public health issue. Understanding the extent and potential short- and long-term repercussions of sleep restriction, as well as the unhealthy sleep practices and environmental factors that contribute to sleep loss in adolescents, is key in setting public policies to mitigate these effects and in counseling patients and families in the clinical setting. This report reviews the current literature on sleep patterns in adolescents, factors contributing to chronic sleep loss (ie, electronic media use, caffeine consumption), and health-related consequences, such as depression, increased obesity risk, and higher rates of drowsy driving accidents. The report also discusses the potential role of later school start times as a means of reducing adolescent sleepiness.

The ADHD and sleep conundrum: a review.

ABSTRACT. The relationship between attention-deficit hyperactivity disorder (ADHD) and sleep is a complex one that poses many challenges in clinical practice. Recent studies have helped to elucidate the nature of the brain mechanisms and neuromodulator systems underlying the theoretical associations among sleepiness, arousal, and attention. Studies of sleep disturbances in children with academic and behavioral problems have also underscored the role that primary sleep disorders such as obstructive sleep apnea hypopnea syndrome play in the clinical presentation of symptoms of inattention and behavioral dysregulation. In addition, new methodologies used in examining sleep and sleep patterns in children diagnosed with ADHD have shed further light on the prevalence, type, risk factors for, and impact of sleep disturbances in these children. The following discussion of the multilevel relationships among sleep quality and quantity, neurobehavioral functioning, and the clinical syndrome of ADHD expands on previous reviews of the literature and synthesizes what is currently known about the interaction of sleep and attention/arousal in children to propose possible underlying mechanisms, integrate more recent findings, and highlight important areas for future study. In addition, guidelines are provided for a clinical approach to evaluation and management of children with ADHD and sleep problems.

Sleep and Daytime Behavior in Children With Obstructive Sleep Apnea and Behavioral Sleep Disorders

Objective. The purpose of this study was: 1) to examine both bedtime sleep behaviors and daytime behaviors associated with daytime sleepiness in a group of children with a primary medical sleep disorder (obstructive sleep apnea syndrome [OSAS]) compared with a group of children with a primary behavioral sleep disorder (BSD) (limit setting sleep disorder or sleep onset association disorder); and 2) to investigate the impact of a comorbid BSD on sleep and daytime behavioral consequences of OSAS. Methods. Children referred to a pediatric sleep disorders clinic during a 3-year period with a primary diagnosis of either polysomnographically-confirmed OSAS (n = 100) or a BSD (n = 52) were compared on several parent report measures assessing the following domains: symptoms of sleep disordered breathing, other sleep behaviors (primarily parasomnias), bedtime behaviors, and externalizing daytime behavior problems. The OSAS sample was then divided into a pure OSAS group (n = 78) and an OSAS plus a behavioral sleep diagnosis group (n = 22) based on the presence or absence of delayed sleep onset and/or prolonged nightwakings and compared on the parent-report symptom domains. Results. Almost one-quarter of the OSAS group had clinically significant behavioral sleep problems, primarily bedtime resistance, in addition to OSAS. Bedtime resistance was associated with a significantly shortened sleep duration in both the BSD and OSAS-BSD groups. Although the OSAS-BSD group had less severe disease, as defined by polysomnographic variables, than the pure OSAS group, they were rated by their parents as having more daytime externalizing behavior problems associated with daytime sleepiness. Conclusions. The results of this study suggest that evaluation for comorbid BSD should be done in all children presenting with symptoms of OSAS. The coexistence of such BSDs may contribute significantly to sleep deprivation, and thus to behavioral manifestations of daytime sleepiness in these children.

The effects of sleep loss and fatigue on resident-physicians: a multi-institutional, mixed-method study.

Purpose. To identify and model the effects of sleep loss and fatigue on resident–physicians’ professional lives and personal well-being. Method. In 2001–02, 149 residents at five U.S. academic health centers and from six specialties (obstetrics–gynecology, emergency medicine, family medicine, internal medicine, pediatrics, surgery) were recruited for the study. Residents were all in good standing in their programs. In a mixed-methods design, focus groups consisted of an average of seven (range, three to 14) individuals in the same year of training and residency program, for a total of 60 interns and 89 senior residents. Trained moderators conducted focus groups using a standardized, semistructured discussion guide. Participants also completed a 30-item quantitative questionnaire assessing sleepiness and workplace sleep attitudes that included the Epworth Sleepiness Scale (ESS). Results. Residents described multiple adverse effects of sleep loss and fatigue on learning and cognition; job performance, including professionalism and task performance; and personal life, including personal well-being and relationships with spouse or significant other and family. Only 16% of the sample scored within the “normal” range on the ESS; 84% scored in the range for which clinical intervention is indicated. Sleepiness was consistent across institution, specialty, years of training, age, gender, marital status, and having children. Conclusions. More residents perceived that sleep loss and fatigue had major impact on their personal lives during residency, leaving many personal and social activities and meaningful personal pleasures deferred or postponed. Sleep loss and fatigue also had major impact on residents’ abilities to perform their work. This finding further substantiates the growing concern about the potential impact on professional development. These observations should be taken into account in developing new training guidelines and educational interventions for housestaff.

Neuropsychological and behavioral correlates of obstructive sleep apnea syndrome in children: A preliminary study

Study Objectives: The purpose of this pilot study was to evaluate a group of children with mild to moderate Obstructive Sleep Apnea Syndrome (OSAS) for baseline neurocognitive deficits and behavioral dysfunction. A subset of the sample were also reassessed, using the same test battery, after treatment with adenotonsillectomy.Design: Baseline and post-treatment neuropsychological and behavioral assessment.Setting: Pediatric sleep disorders clinic at a children’s teaching hospital.Patients: 18 children (12 males, 6 females, mean age 7.3 years ±2.0) meeting polysomnographic criteria for OSAS underwent baseline assessment; 8 children (6 males, 2 females, mean age 8.4 years ±2.6) also completed the post-treatment assessment phase.Measurements: An age appropriate neuropsychological battery including measures of global cognitive functioning, language, executive functioning and attention, memory, visual perception/visual motor skills and motor skills; two parent rating scales of behavior.Results: Modest impairments, largely in executive functioning/attention and motor skills, were found at baseline. Parents endorsed a variety of behavioral problems, especially somatic complaints and problems with learning. There appeared to be relatively little association between impairment and disease severity, although there was a trend for the children with less severe disease, who were also older, to have relatively more behavioral problems. Post treatment, there were modest improvements in executive functioning/attention and motor skills, as well as in parent-reported internalizing and externalizing behaviors.Conclusions: The preliminary results with a small sample suggest mild deficits in executive functions and motor skills in children with mild to moderate OSAS, with modest improvements in the same neuropsychological domains post-treatment. A variety of parent-reported behavioral problems were found at baseline, again with modest improvement post-adenotonsillectomy.

Neurocognitive and behavioral impact of sleep disordered breathing in children

The consequences of poor quality and/or inadequate sleep in children and adolescents have become a major public health concern, and one in which pediatric health care professionals have become increasingly involved. In particular, insufficient and/or fragmented sleep resulting from primary sleep disorders such as obstructive sleep apnea (OSA), often compounded by the presence of comorbid sleep disorders as well as by voluntary sleep curtailment related to lifestyle and environmental factors, has been implicated in a host of negative consequences. These range from metabolic dysfunction and increased cardiovascular morbidity to impairments in mood and academic performance. The following review will focus on what is currently known about the effects of sleep disordered breathing (SDB) specifically on neurobehavioral and neurocognitive function in children. Because of the scarcity of literature on the cognitive and behavioral impact of sleep disorders in infants and very young children, this review will target largely the preschool/school‐aged child and adolescent populations. In addition, the focus will be on a review of the most recent literature, as a supplement to several excellent previous reviews on the topic.1–4 Pediatr Pulmonol. 2009; 44:417–422.

Changes in Children’s Sleep Duration on Food Intake, Weight, and Leptin

OBJECTIVE: To examine the effect of experimental changes in children’s sleep duration on self-reported food intake, food reinforcement, appetite-regulating hormones, and measured weight. METHODS: Using a within-subjects, counterbalanced, crossover design, 37 children, 8 to 11 years of age (27% overweight/obese) completed a 3-week study. Children slept their typical amount at home for 1 week and were then randomized to either increase or decrease their time in bed by 1.5 hours per night for 1 week, completing the alternate schedule on the third week. Primary outcomes were dietary intake as assessed by 24-hour dietary recalls, food reinforcement (ie, points earned for a food reward), and fasting leptin and ghrelin. The secondary outcome was child weight. RESULTS: Participants achieved a 2 hour, 21 minute difference in the actigraph defined sleep period time between the increase and decrease sleep conditions (P < .001). Compared with the decrease sleep condition, during the increase condition, children reported consuming an average of 134 kcal/day less (P < .05), and exhibited lower fasting morning leptin values (P < .05). Measured weights were 0.22 kg lower during the increase sleep than the decrease sleep condition (P < .001). There were no differences in food reinforcement or in fasting ghrelin. CONCLUSIONS: Compared with decreased sleep, increased sleep duration in school-age children resulted in lower reported food intake, lower fasting leptin levels, and lower weight. The potential role of sleep duration in pediatric obesity prevention and treatment warrants further study.