PEDIATRICS Vol. 107 No. 4 April 2001, p. e60
ELECTRONIC ARTICLE:
Sleep and Behavior Problems in School-Aged Children
,, and
From the * Departments of Pediatrics and Psychiatry, George
Washington University School of Medicine and Children's National
Medical Center, Washington, DC; Department of Pediatrics, University
of Chicago, Chicago, Illinois; and § Department of Psychiatry,
University of Wisconsin, Madison, Wisconsin.
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ABSTRACT |
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Abstract
Methods
Results
Discussion
Conclusion
References
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Objectives. The primary purposes of the present study were to survey the prevalence of sleep problems in school-aged children and to examine these associations with parental perception of sleep problems, medical history, and childhood psychopathology.
Methods. Sleep and medical history questionnaires and the Child Behavior Checklist were administered to the parents of 472 children between ages 4 and 12 years receiving routine pediatric care from urban, rural, and suburban pediatric practices.
Results. Although sleep problems were reported for 10.8% of the sample during the past 6 months, less than one half of the parents who identified sleep problems reported that they had discussed sleep with their child's pediatrician. The best predictor of current sleep problems was a history of sleep problems before age 2 years. Sleep problems such as snoring, tiredness during the day, and taking excessive time to fall asleep were very common, occurring at least 1 night per week in over 20% of the total sample. Factor analysis of the sleep problems questionnaire resulted in 5 sleep problem factors that accounted for 58.7% of the variance. Specific sleep problem factors include: parasomnias, enuresis/gags, tiredness, noisy sleep, and insomnia. Sleep problem factor scores were differentially associated with medical history variables and measures of childhood psychopathology. Children rated highly on parasomnias were more likely to have frequent falls and to display pica. Parasomnias and noisy sleep were inversely associated with socioeconomic status (SES). Children from lower SES families were rated higher on these factors than children from higher SES families. Enuresis/gags was the only sleep problem factor associated with age. Younger children scored higher on this factor. Duration of naps was highly correlated with age and with bed times during the week and weekends. As expected, younger children were more likely to nap for longer periods and to have earlier bed times. In addition, higher tiredness factor scores were associated with napping and with later bed times during the week and weekend. Boys were much more likely than were girls to have higher scores on enuresis/gags, and higher enuresis/gags scores were associated with an increased prevalence of trauma and falls. Bed times were not associated with any other sleep problem factor score. Children rated highly on tiredness were more likely to have a history of hospitalizations. Tiredness factor scores were strongly associated with the sleep practice of sharing a bed but not with sharing a room. Sharing a room was not associated with any sleep problem factor score. High scores on noisy sleep were associated with allergies, falls frequently, and with sharing a bed. Children with high scores on the insomnias were also more likely to display an increased prevalence of allergies.
Conclusions. Parental perception of global sleep problems was surprisingly common in school-aged children receiving routine pediatric care. Parental reports of their children's sleep problems may be a red flag for specific sleep problems and psychiatric, social, or medical problems. Sleep problems should be queried about during pediatric visits for school-aged children. Key words: sleep problems, insomnia, behavioral problems.
Sleep problems are common across the lifespan, although the
prevalence of particular kinds of problems may vary with age. For
example, difficulties settling down or sleeping through the night are
common in infants and toddlers, whereas preadolescent school-aged
children are thought to have fewer such problems but display an
increased incidence of parasomnias, such as sleepwalking, nightmares,
bruxism, and enuresis.1,2 Adolescents and adults develop
more severe problems with insomnia and daytime sleepiness. In adults,
it has been increasingly recognized that chronic sleep difficulties are
associated with significant functional impairment and psychiatric
illness. For example, most adult patients with psychiatric illness show
polysomnographic evidence of disturbed sleep.3 Surveys of
community samples suggest that one third to one half of adults with
insomnia have psychiatric disorders,4,5 whereas over three
quarters of patients seen in medical settings for sleep problems are
diagnosed with psychiatric disorders.6 Thus, in adults,
sleep disturbance may be an important marker for the presence of
psychiatric illness.
Much less is known about the clinical significance of sleep
abnormalities in school-aged children. In contrast to adults, children
seldom complain of poor sleep or seek treatment on their own. As noted
by Horne,7 "Often, sleep problems in children are not of
the child but of the parents, who may have unwittingly created the
problem in the first place, or worry unduly about a relatively minor
matter that is inflated out of proportion, or transmit their anxieties
to the child... . " There seems little doubt that sleep problems
can be environmentally induced or influenced, especially by cramped and
chaotic settings and inconsistent parenting. In other instances, children's sleep problems may be the result of or mask serious medical
problems that can be treated successfully, such as untoward effects of
medications, epilepsy, or sleep apnea.
In preschool-aged children, sleep problems have been correlated with
childhood behavior problems.8,9 Both subjective (parental)
reports and objective (actigraphic) documentation of sleep disturbance
in toddlers have been associated with temperamental
variables.10 In a study of healthy preadolescents, sleep
problems were associated with an increased risk of learning and
behavioral problems.11 Parental reports of sleep problems
have also been associated with several child psychiatric disorders,
including attention-deficit/hyperactivity disorder
(ADHD),12-14 mental retardation,15 and
childhood depression.16 However, polysomnographic
evaluation of children and adolescents with depression has demonstrated
fewer abnormalities than in adult depressives, but prolonged latency to
sleep onset and reduced sleep efficiency in comparison to normal
controls are characteristically observed.3 Similarly,
polysomnographic studies of sleep in hyperactive children indicate few
abnormalities in sleep architecture,17,18 despite parental
reports of frequent sleep disturbance in children with
ADHD.19
The goals of the present study were to survey the prevalence of sleep
problems in a nonpsychiatric-referred population of preadolescent
children (ages 4-12 years) and to determine whether sleep problems
were associated with medical or psychiatric symptomatology. Preadolescent school-aged children were chosen for study because of the
relative lack of data for this age group, the availability of reliable
instruments to rate behavior, and the widely held beliefs that sleep is
not particularly problematic and that daytime alertness is high in this
age group. A pediatric rather than a psychiatric clinic sample was
chosen to control for possible ascertainment biases related
to referral for psychiatric problems.
Sample
The reference population consisted of children between 4 and 12 years old who were receiving routine pediatric care. To obtain a
geographically representative and ethnically and socioeconomically diverse sample, participants were recruited from a pediatric clinic located within an urban teaching hospital and from 3 pediatric practices located in suburban Illinois (Hoffman Estates and Flossmore, respectively) and a rural/suburban area (Merrillville, Indiana). All
practices were staffed by board-certified pediatricians. Participants were entered over a 6-month period. The refusal rate was unknown.
Survey Method
Parents were requested to complete the questionnaires during
pediatric outpatient visits while waiting for their child's
appointment. Each questionnaire was accompanied by a cover letter
describing the study and requesting participation.
Instruments
METHODS
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Abstract
Methods
Results
Discussion
Conclusion
References
The study protocol was approved by the institutional review board of the University of Chicago.
Data Analysis
The present study had a primarily descriptive focus in that it
sought to investigate the prevalence of specific sleep problems and
their association with medical history and psychological functioning. P values from 
2 analyses describe
the extent of association among sleep problems and health history and
demographic variables.
To examine the factor structure of the 14 sleep problems surveyed on
the sleep behavior questionnaire, exploratory factor analytic
procedures, following the recommendations of Cattell,21
were used. Principal factor analysis with squared multiple correlations as communality estimates were conducted using oblique (Oblimin) rotation criteria (SPSS for Windows, Version 7.0, SPSS,
Chicago, IL). Because presumably sleep problem factors are interrelated and nonorthogonal, oblique rotation was conducted to enhance the interpretability of the factors. The number of factors to extract was
determined based on examination of the scree plot and eigen values >1.
Correlation, 2, and multiple regression
analyses were used to examine the association among sleep, behavior
problems, demographics, and medical history variables.
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RESULTS |
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Methods
Results
Discussion
Conclusion
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Study Population
Demographic and descriptive information on the sample is reported in Table 1. Sleep questionnaires were completed on 472 children (253 boys and 219 girls) between 4 and 12 years old. Although all Hollingshead socioeconomic status (SES) classes were represented,22 77% were middle SES or above (classes I, II, and III; Table 1). On the CBCL, the mean is 50 and a T score >70 is considered clinically significant.20
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Prevalence of Global and Specific Sleep Problems
Global reports of sleep problems were defined as an affirmative
response to the question, "During the past 6 months, has your child
had sleep problems for 2 weeks or longer?" and were reported for
10.8% (n = 50) of the sample. Sleep problems were not
associated with the demographic variables of SES
(2 = 1.16; not significant [NS]) or gender
(2 = 2.31; NS), or with sleep practices of
sharing a room (2 = 13; NS), or sharing a bed
(2 = 1.6; NS). However, parents of children
with sleep problems were more likely to speak with their child's
pediatrician about sleep (2 = 16.8;
P < .001). In the entire sample, however, only 20 parents reported discussing sleep with the pediatrician (8 from
families with sleep problems and 12 from families without sleep
problems).
The prevalence of specific types of sleep problems by age is reported in Table 2. As can be seen, problems such as snoring, tiredness during the day, and taking excessive time to fall asleep were very common, occurring at least 1 night per week in over 20% of the sample. It should be noted that for some sleep behaviors the prevalence was higher than for parents' global report of sleep problems. Head banging and sleep walking were less common, occurring at least 1 night per week in <5% of the sample.
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Table 3 compares the results of the current study with previous sleep surveys of community samples not selected for presence of sleep problem.11,23-27
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As can be seen, rates of sleep-specific problems such as daytime tiredness and difficulty falling asleep were slightly higher in the current study relative to previous studies.
Association Among Current Sleep Problems, Previous Sleep Problems, and Demographics
In the present study, sleep problems were reported to have been
present in 17.2% of the sample before age 2 years, indicating that
parents reported that their children had more sleep problems when their
children were in the preschool age range. Children with current sleep
problems were more likely to have displayed sleep problems at age 2 years (2 = 26.16; P < .001).
However, approximately two thirds of those with sleep problems at age 2 years were not rated as displaying current sleep problems. For some
children, sleep problems were of recent onset because over one half
(n = 27) of those with current sleep problems did not
display sleep problems at age 2 years.
A stepwise logistic regression was performed to evaluate the relative
contributions of sleep problems at age 2 years, SES, and gender to the
prediction of current sleep problems. The results were highly
significant (2 = 23.5; P < .0001), resulting in 89.6% classified correctly. However, sleep
problems before age 2 years was the only significant predictor. Thus,
although the prevalence of sleep problems declines with age, parents of
school-aged children continue to report sleep problems for a
significant percentage of the sample, and previous sleep problems were
the single best predictor of current sleep problems.
Sleep Problems and Medical History
The associations among parent perception of global sleep problems and 14 previous lifetime medical and developmental problems identified as the most common medical problems through the Heath and Family Information Questionnaire are reported in Table 4. As can be seen, global reports of sleep problems were associated with parental report of children's allergies, ear infection, and hearing problems.
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Factor Analysis of Sleep Problems
Principle factor analysis of the 14 sleep items was conducted and resulted in a 5-factor solution that accounted for 58.7% of the variance. Factor loadings <0.35 were required for inclusion on that factor. The factor score structure matrix is reported in Table 5.
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The first and largest factor, factor I, parasomnias, accounted for 25% of the variance. This factor is defined by items reflecting parasomnias, such as walking in sleep, nightmares, night terrors, and banging head or rocking in sleep. Snoring, talking in sleep, and waking in sleep had secondary loadings on this factor as well. Factor II, enuresis/gags, accounted for 9.5% of the variance and is defined by 2 items suggesting neurodevelopmental immaturity, enuresis, and choking. Banging head or rocking in sleep also loaded on this factor. Factor III, tiredness, accounted for 9.3% of the variance and was saturated with items reflecting increased need for sleep and snoring. Factor IV, noisy sleep, accounted for 7.6% of the variance and was saturated by items that produce noise, such as bruxism and talking in sleep. Factor V, insomnia, accounted for 7.1% of the variance and was defined by items reflecting difficulty falling asleep, frequent waking, and excess energy.
Association of Sleep Problem Factor Scores With Sleep Practices and Perceptions
Factor scores were generated for each child and were correlated with demographic variables and measures of sleep practices (see Table 6).
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Parasomnias and noisy sleep were inversely associated with
socioeconomic status. Children from lower SES families were rated higher on these factors than were children from higher SES families. Enuresis/gags was the only sleep problem factor inversely associated with age. Younger children scored higher on this factor. Duration of
naps was highly correlated with age (r = 
0.22;
P < .001) and with bed times during the week
(r = 0.37; P < .01) and weekends (r = 0.39; P < .001). As expected,
younger children were more likely to nap for longer periods and to have
earlier bed times. In addition, higher tiredness factor scores were
associated with napping and with later bed times during the week
(r = 0.13; P < .02) and weekend
(r = 0.10; P < .04). Bed times were
not associated with any other sleep problem factor score.
Sleep Problem Factors, Sleep Practices, and Medical History
To examine the relationship among severity of sleep problem factor
and medical and developmental history variables, each sleep problem
factor score was stratified into high, medium, and low problem groups
using the 0.33 and 0.66 percentile as cutoff scores. 2 analysis was used to examine the
relationship among sleep problem factor scores and dichotomous medical
history and demographic measures, parental global ratings of recent
sleep problems, history before age 2 years of sleep problems, and
whether sleep problems were discussed with the child's doctor.
Parental subjective global ratings of sleep problems were associated
with higher sleep factor scores for insomnia
(2 = 41.7; P < .001),
parasomnias (2 = 19.5; P < .001), enuresis/gags (2 = 8.89;
P < .01) and noisy sleep (2 = 7.0; P < .05), but not with tiredness
(2 = 0.64; NS). Thus, with the exception of
tiredness, global ratings were strongly associated with specific sleep
problem factor scores.
Children who rated highly on parasomnias were more likely to have
frequent falls (2 = 11.2; P < .01) and to display pica (2 = 9.86;
P < .01). Children with high scores on this factor
were more likely to be rated by their parents as displaying significant sleep problems during the past 6 months (2 = 23.47; P < .001). There was a trend for this group to
speak to their child's pediatrician about sleep
(2 = 6.3; P < .05), and these
children were more likely to be taking medication
(2 = 6.18; P < .05) than were
children who rated low on this factor. In addition, children with high
parasomnias scores were viewed as having an early history of early
sleep problems with onset before age 2 years but were not more likely
to share a room or bed than children with low scores
(2 = 9.16; P < .01). There
were no differences on any other medical or demographic variable.
Boys were much more likely than were girls to have higher scores on
factor II, enuresis/gags (2 = 7.2;
P < .05). Higher enuresis/gags scores were associated with an increased prevalence of trauma (2 = 10.2; P < .01) and falls (2 = 7.42; P < .01). Additionally, children with high
scores on enuresis/gags were more likely to be perceived by their
parents as displaying sleep problems over the previous 6 months
(2 = 9.90; P < .01) than were
those with low factor scores.
Children rated highly on factor III, tiredness, were more likely to
have a history of hospitalizations (2 = 10.02;
P < .01). Tiredness factor scores were strongly
associated with the sleep practice of sharing a bed
(2 = 12.33; P < .01), but not
with sharing a room (2 = 3.23; NS). Sharing a
room was not associated with any sleep problem factor score.
High scores on factor IV, noisy sleep, were associated with allergies
(2 = 9.47; P < .001), falls
frequently (2 = 8.65; P < 01), and with sharing a bed (2 = 15.5;
P < 01).
Children with high scores on factor V, insomnia, were also more likely
to display an increased prevalence of allergies
(2 = 11.81; P < .01). In
addition, these children were more likely to display an early history
of sleep problems before age 2 years (2 = 14.5; P < .001).
Sleep Problems and Psychopathology
As portrayed in Table 7, sleep problems factor scores were highly correlated with CBCL internalizing and externalizing scores and with the majority of CBCL factor scores. Multivariate stepwise regression analyses for each of the sleep problem factors revealed that although each sleep problem factor score was predicted by CBCL scores, there was a differential pattern of CBCL scores for each factor (see Table 8).
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The sleep problem factors parasomnias, tiredness, and insomnia were strongly predicted by CBCL factor scores with 17% to 22% of the variance in sleep problem factor scores accounted for by 3 CBCL scores. In contrast, enuresis/gags and noisy sleep were weakly associated with psychopathology, because only 4% and 6% of the variance was accounted for, respectively.
Over one fifth of the variance in parasomnias was accounted for by 3 CBCL factors: anxious/depressed, thought problems, and social problems. Factor III, tiredness, was predicted by social problems and somatic complaints. Thus, children who rated highly on physical symptoms and social difficulties were more prone toward tiredness and snoring. Nearly 20% of the variance in the insomnia factor was accounted for by 3 CBCL factors, anxious/depressed, attention problems, and somatic complaints. Thus, children with anxiety or attention symptoms had more difficulty getting to sleep and maintaining sleep.
Enuresis/gags was predicted by one CBCL factor, thought problems. Finally, noisy sleep was predicted by CBCL aggression, indicating that children rated as aggressive were more likely to be noisy sleepers.
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DISCUSSION |
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Abstract
Methods
Results
Discussion
Conclusion
References
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The present study adds to our knowledge of parental perception of sleep problems in school-aged children and their association with psychopathology and medical history variables. Parental perception of global sleep problems was surprisingly common in school-aged children receiving routine pediatric care: nearly 11% of parents surveyed believed that their child had a sleep problem. Over one fifth of the sample reported specific sleep abnormalities at least weekly, including prolonged sleep latency, snoring, and tiredness during the day, suggesting that parental perceptions of specific sleep problems are even more prevalent than previously indicated. The obtained prevalence rates for specific sleep problems are somewhat higher than in previous studies conducted in rural areas or in Europe, especially for tiredness during the day and difficulty falling asleep. It is certainly possible that the prevalence of these sleep problems may have increased during the 7- to 14-year period since the publication of the earlier studies. Also, studies differ in sample characteristics, clinical thresholds, and duration criteria for defining a sleep problem. For example, Kahn et al11 required sleep problems to persist for >6 months and to occur at least twice a week. Another study of US children of the same age required the problem to occur 3 times per night.23 Different criteria between studies may explain some of the differences in prevalence. However, studies are consistent in suggesting some sleep problems in 30% to 50% of children in this age range. Moreover, the functional impairment of these sleep difficulties is further supported by the findings of Kahn et al (1989), who reported that >28% of the parents expressed a desire for counseling on sleep difficulties and 4% were relying on regular use of sedatives.
As suggested by Owens et al28, both sociological factors (eg, over scheduling of children, television use, day care, family stress) and medical predisposing factors (eg, increases in asthma, upper respiratory infections, otitis media) may contribute to an increased rate of sleep deprivation, snoring, and other sleep problems in American school children. Sleep practices (such as room sharing or bed sharing) that are commonly practiced in the United States may further contribute to these difficulties. Certainly, more cross-cultural and epidemiologic studies are needed to determine whether differences among studies are the result of different measures of sleep problems, sampling techniques, cohort effects, or societal trends reflecting an increase in sleep problems and poor sleeping habits in today's youth.
Factor analysis of 14 sleep problems resulted in a 5-factor solution: parasomnias, enuresis/gags, tiredness, noisy sleep, and insomnia. For several of the sleep problem factors, these results are generally in keeping with a recent factor analysis of 9 sleep behaviors in ADHD children that resulted in a 3-factor solution: dyssomnias, sleep-related involuntary movements, and parasomnias.12 However, unlike the current study, snoring and enuresis were not included in their analysis.
In the present study, snoring and tiredness emerged on the same factor. Snoring can contribute to daytime sleepiness and is associated with obstructive sleep apnea, often related to hypertrophy of tonsils and/or adenoids or obesity. When snoring is present, additional evaluation is needed to differentiate benign or primary snoring from obstructive sleep apnea. Once identified, treatment with nasal continuous positive airway pressure or surgical removal of the adenoids may improve daytime alertness.29
Additional evaluation is also needed for the child who takes excessive time to fall asleep, because this may be the result of a host of factors including insufficient limit setting, environmental events, psychological factors, such as anxiety or oppositional behavior, or related to acute or chronic medical disorders and treatments.
In contrast to the above is the younger child with high scores on enuresis/gags: this factor had the lowest associations with measures of psychopathology. Such children may be less likely to require additional psychological evaluation, unless these problems persist. This is consistent with previous research showing that the relationship between enuresis and psychopathology is highly influenced by ascertainment and referral biases and that the majority of children with enuresis do not display significant psychopathology.30
There are several limitations that should be considered in interpreting the results. With regard to our sample of primarily middle to upper middle class families receiving pediatric care, we attempted to increase diversity in the sample by surveying several different practices. However, the results may not be generalizable to individuals without health care providers or from lower SES or rural populations. Nonetheless, it is likely that the sample is representative of children seen in urban and suburban pediatric clinics. Unfortunately, we were not able to look at site differences within our sample or differences between those who responded and those who declined. It is unknown whether those who did not complete the questionnaires differed in important ways from those who elected to participate.
The second limitation is the reliance on parental report and the possibility of rater biases. Sleep problems, medical history, and child psychopathology were all evaluated based on the parent as the primary informant. The validity of parent-report measures of childhood sleep and medical history is uncertain, and traditional self-report measures of sleep have not correlated highly with objective measures.31 Consequently, the present study is an examination of parental perceptions of sleep problems rather than sleep problems per se and subject to a host of rater biases.10 Nonetheless, parent reports may be valid in the relative rather than in the absolute sense.16 Future studies should examine the relationship among sleep, medical history, and psychopathology that are confirmed using independent sources of information, including medical records and polysomnographic measures of sleep.
The third limitation is the design of the study, which was correlational in nature. Such a design can lead to hypotheses about the relationship between sleep problems and psychopathology, but causality cannot be inferred. The association between sleep problems and psychopathology is complex, because sleep problems can be a cause, an effect, or a correlate of psychopathology.
The results are in keeping with a recent study by Lavigne et al32 that demonstrated that preschool-aged children who slept less were more likely to display psychiatric disorders. Moreover, when a continuous measure of psychopathology, the CBCL was used, there was an association between CBCL scores and the amount of sleep obtained during the previous 24 hours.32
Studies in adults have suggested that sleep disturbance may be a risk factor for the development of depression.5 Our results raise the possibility that the increasing prevalence of depression, ADHD, and other psychiatric disorders in children and adolescents could be at least in part attributable to sleep problems early in life. Additional studies will be needed to determine whether childhood sleep difficulties are causally related to the development of psychiatric or other medical illnesses.
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CONCLUSION |
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Discussion
Conclusion
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This study highlights several important reasons why pediatricians should ask about sleep in preadolescent children. These include the frequent prevalence of sleep difficulties in this age range, the possibility of identifying treatable problems, such as apnea or enuresis, and the fact that sleep problems are so strongly related to other psychological and medical problems. Inquiring about sleep problems may provide valuable information about behavioral (noncompliance), emotional (fears, depression), or medical problems (asthma, medication) that are co-occurring with reports of sleep problems. Inquiring about sleep may be an important keystone behavior that can provide insight into a variety of other behaviors, including those related to psychiatric and medical functioning. The fact that so few of the parents who reported sleep problems in their children discussed sleep with their pediatrician suggests that interviewing parents and children about sleep needs to be emphasized more during routine pediatric visits. Moreover, discussing sleep patterns provides an opportunity to learn more about the child and family, to evaluate environmental and family interaction, and to educate the parents about good sleep hygiene with the hope of preventing more serious or chronic sleep-related problems.
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ACKNOWLEDGMENTS |
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This study was supported, in part, by a grant from the Home Health Care Foundation of the University of Chicago, by National Institutes of Health Grant MH01823-02, and by the Children's Research Institute of Children's National Medical Center.
We gratefully acknowledge the assistance of David Nadelman, MD; Joel Schwab, MD; Bruce Berget, MD; and Lawrence Hagerman, MD.
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FOOTNOTES |
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This study was presented in part at the Society for Pediatric Research Meeting; May 1-5, 2000; Seattle, WA.
Received for publication Jun 15, 2000; accepted Nov 22, 2000.
Reprint requests to (M.A.S.) Neuroscience and Behavioral Medicine Research Center, Children's National Medical Center, 111 Michigan Ave NW, Washington, DC 20010. E-mail: mstein{at}cnmc.org
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ABBREVIATIONS |
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ADHD, attention-deficit/hyperactivity disorder; CBCL, Child Behavior Checklist; SES, socioeconomic status; NS, not significant.
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Pediatrics (ISSN 0031 4005). Copyright ©2001 by the American Academy of Pediatrics
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