Getting Up on the Wrong Side of the Bed: Sleepiness, Behavior Problems, and Obesity in Children and Teens

By Sarah Pedersen and Langan Denhard

Updated March 2013

Sleep is essential for the renewal and restoration of the body. If you don’t get enough, it can result in irritability, impatience, inability to concentrate, weight gain, and increased stress hormone levels, and it alters the body’s ability to ward off disease and illness.1

There are many reasons why people don’t get enough sleep. These may include insomnia, which can be caused by factors such as stress, a health condition or caffeine; sleep apnea, which is a disruption of sleep due to blockage of the upper airways; obesity; inconsistent sleep; and interrupted sleep.

Lack of sleep affects young people in many ways: students are less likely to pay attention or remember information in school; families are more likely to argue; teens are more likely to participate in risky behavior such as smoking, drinking, and drugs; and drivers are more likely to be involved in accidents.2

The Link Between Sleep Deprivation and Conduct Problems

A University of Michigan study found yet another reason to be alarmed about sleep deprivation. Using data collected from 341 elementary school children, the researchers found that children who had behavioral problems were twice as likely to have symptoms of sleep-disordered breathing (SDB), which ranges from snoring to obstructive sleep apnea.3 Obstructive sleep apnea (OSA) is when breathing pauses during sleep because the airway has become narrowed or blocked.

The survey, administered in the city of Ypsilanti in Michigan to a racially and economically diverse sample, used validated screening assessments to gather information from teachers and parents about children’s in-school behaviors and sleep patterns. They found that 78 children (23%) were reported to snore more than half of the time (frequently) and were sleepier than those without habitual snoring.

Overall, 110 (32%) of 341 children were classified as having a conduct problem such as destructive tendencies, quarreling, constant fighting, and disobedience by either parents or teachers. Children with conduct problems were more likely to experience sleep-disordered breathing (SDB) than those without (30% vs. 14%). Similarly, children whose parents described them as sometimes bullying were more likely to have sleep-disordered breathing than their classmates (42% vs. 17.5%). In addition, regardless of the cause of sleepiness, students who did not get enough sleep were more likely to bully or have conduct problems.

What Do Other Studies Say About Sleep and Behavioral Problems?

Although the Michigan study focused primarily on children with sleep apnea, other studies have found that children and adolescents who don’t get enough sleep due to inconsistent sleep schedules, frequent nighttime awakenings, or too few hours of sleep also suffer from behavioral problems. A study published in theJournal of American Academy of Child and Adolescent Psychiatryfound a strong link between sleep and aggression, delinquent behavior, and attention problems among 7- to 12-year-old children.4Using belt-worn activity monitors (actigraphs), the authors found that children who slept on average 9.6 hours per night had fewer symptoms of behavioral problems than children sleeping on average either 8.9 hours or 8 hours per night. Children with the most behavior problems had significantly lower sleep time and poorer sleep quality than children who did not show signs of behavioral problems.

Another study published in theJournal of American Academy of Child and Adolescent Psychiatryhighlighted the long-term effects of sleep deprivation. The study, which followed 490 children from the age of 4 to 15, found that 4-year-olds who did not sleep well on a regular basis were more likely to have aggression and attention problems in mid-adolescence.5The authors also found that the link between sleep problems and depression increased significantly between the ages of 4 and 15 years old.

Finally, a study published inPediatricsin April 2012 explored the link between sleep problems in early childhood and behavior at 4 and 7 years old.  Parents completed at least two questionnaires about sleep patterns when their children were between 6 months and approximately 6 years old.   Parents reported on children’s snoring, mouth-breathing, and observed apnea (pauses in breathing).  Parents filled out a second questionnaire on behavior when their children were ages 4 and 7.  The questions covered pro-social behaviors (like sharing and helpfulness), hyperactivity, emotional symptoms (like anxiety and depression), peer problems, and conduct problems (like aggressiveness and rule-breaking).  The authors found that the children with sleep problems in infancy were significantly more likely to display behavioral problems at age 4, and the chances of behavioral problems at age 7 were even greater.  Overall, as sleep problems increased, the likelihood of later behavioral problems also increased.Sleep problems had a greater influence on behavior than factors such as socioeconomic status (education and income), family adversity (family history of mental illness, crime, and financial insecurity), household characteristics (family size and home environment score), or other child demographics (race, gender, birth weight, and whether the child was carried full term).6

What Causes Sleep Problems in Children and Adolescents?

There are many reasons why children don’t receive the recommended 10 to 12 hours of sleep each night.7 Inappropriate or inconsistent nap or sleep schedules often lead to difficulty falling asleep and poor sleep quality. Also, noise or too much light in the bedroom can disrupt a child’s sleep rhythm.

For adolescents, the hormonal influences of puberty tend to shift their biological clocks, resulting in less sleep. Teenagers tend to feel awake at night and therefore want to go to bed later and tend to want to sleep later in the morning. This sleep-wake rhythm is contrary to the early-morning start times of many high schools and helps explain why most teenagers get an average of only 7 to 7.5 hours of sleep when they actually require at least 9 hours.8Also, as adolescents spend more time with cell phones and computers, they are less likely to get a good night’s rest.

Obesity has also been linked to sleep problems, both as a cause and a result of sleep deprivation. A 2007 study examining the severity of sleep disorders in obese children found that overweight children had a significantly higher number of apneas and arousals per hour of sleep compared with normal-weight children — mostly due to increased breathing problems.9Some of the symptoms of sleep apnea include loud, irregular snoring, daytime sleepiness, morning headaches, weight gain, and irritability.

Lack of Sleep Can Cause Weight Gain

A 2010 study in the Archives of Pediatrics and Adolescent Medicinefound that for children ages 0 to 4, a short duration of nighttime sleep was strongly linked to increased risk of obesity in adolescence.10A 2008 study also found that overweight children ages 8 to 11 slept less on average than normal-weight children. For each 1-hour reduction in sleep, the odds of obesity increased by 41%.11 Researchers at Harvard conclude that children who sleep fewer hours tend to gain more weight (See http://www.hsph.harvard.edu/obesity-prevention-source/obesity-causes/sleep-and-obesity/.)

What Can Parents Do to Help Their Children Get a Good Night’s Rest?

There are many steps parents can take to help their children get regular quality sleep each night. It’s important to set consistent sleep schedules for young children and stick to them. For adolescents, parents can set age-appropriate bedtimes and make rules about cell phone and computer use, especially at night. Along with consistent sleep schedules, it’s also important to make sure that children and adolescents are not exposed to noise or light during sleep hours, because this will disrupt sleep quality. Sleep routines starting about 30 minutes before bedtime also help children understand that bedtime is approaching, giving children time to get into “sleep mode.”12

If children suffer from insomnia or nighttime awakenings due to nightmares, parents can use methods such as muscle relaxation through massage, deep-breathing exercises and positive imagery techniques to decrease negative thoughts and help relax children at bedtime.

For more serious sleep problems such as apnea, snoring, and other breathing problems, the best place to begin is to help your child lose weight through a healthy diet and exercise. Even modest weight loss can greatly decrease the severity of breathing problems and snoring. If your child continues to experience sleep problems after losing weight, it’s best to speak with a pediatrician about the right solution for you and your child. Common medical treatments include sleeping with an air compressor mask or oral-jaw positioning device to keep the airway open and surgically removing the tonsils, adenoids, or excess tissue to increase the airway path.

Are these treatments effective? A study of air compressor masks, also known as continuous positive airway pressure therapy (CPAC), found that the treatment significantly reduced the severity of obstructive sleep apnea symptoms (OSA) each night.13Children reported feeling less sleepy during the day as a result. One problem with the mask, however, is “compliance”–that is the child’s continuing regular use of it.

A study published in 2007 found that removing the tonsils and adenoids for normal-weight children suffering from OSA significantly lowered the severity or completely eliminated symptoms of OSA.14For obese children who suffered from OSA, however, the results were less promising and only slightly lowered the severity of symptoms.

Conclusions

Studies show that sleep is an important tool to help your child stay healthy and perform well in school and at home. The findings also present an alternative and preventive approach to reducing aggressive behavior, attention problems, and bullying. Studies show that sleep is an important tool to help your child stay healthy and perform well in school and at home. The findings also present an alternative and preventive approach to reducing aggressive behavior, attention problems, and bullying. Nationally, the prevalence of such behavior among elementary schoolchildren is generally 25% or higher in boys.16If parents understand the effects of sleep deprivation and teachers know how to work with parents to improve children’s sleep habits, this could significantly reduce aggressive behavior and long-term health problems related to obesity.

According to the Centers for Disease Control and Prevention, cases of parent-diagnosed ADHD increased by 22% between 2003 and 2007.15 ADHD symptoms are often identical to those linked to sleep disorders in children.  Before filling a prescription for drugs such as Adderall or Ritalin, known to induce insomnia,discuss any sleep problems your child may be having with your pediatrician. And if you’ve noticed that your child is less able to focus or more hyperactive when he hasn’t slept well, tell your pediatrician.

1Zuckerman D. Early Morning Classes, Sleepy Students, and Risky Behaviors. National Research Center for Women & Families. July 2010.http://www.center4research.org/2010/09/early-morning-classes-sleepy-students-and-risky-behaviors/

2National Research Center for Women & Families. Survival Guide for Working Moms: Are you getting enough sleep? Are your kids? Issue No. 5.http://www.center4research.org/wp/wp-content/uploads/2010/03/survival-guide-getting-sleep.pdf

3O’Brien LM, Lucas NH, Felt BT, et al. Aggressive behavior, bullying, snoring, and sleepiness in schoolchildren.Sleep Medicine. 2011. doi:10.1016/j.sleep.2010.11.012.

4Aronen ET, Paavonen EJ, Fjallberg M, Soininen M, Torronen J. Sleep and Psychiatric Symptoms in School-Age Children.Journal of American Academy of Child and Adolescent Psychiatry. 2000;39(4):502-508.

5Gregory AM, O’Connor TG. Sleep Problems in Childhood: A Longitudinal Study of Developmental Change and Association with Behavioral Problems.Journal of American Academy of Child and Adolescent Psychiatry.2002;41(8):964-971.

6Bonuck, Karen, et al.  “Sleep-Disordered Breathing in a Population Based Cohort: Behavioral Outcomes at 4 and 7 Years.” Pediatrics.2009; 4(129): e857-e865.

7U.S. Department of Health and Human Services, National Institutes of Health. Your Guide to Healthy Sleep. November 2005.http://www.nhlbi.nih.gov/health/public/sleep/healthy_sleep.pdf

8Moturi S.

9Mitchell RB, Kelly J. Outcome of adenotonsillectomy for obstructive sleep apnea in obese and normal-weight children.Otolaryngology-Head and Neck Surgery. 2007;137:43-48.

10Bell JF, Zimmerman FJ. Shortened Nighttime Sleep Duration in Early Life and Subsequent Childhood Obesity.Archives of Pediatrics and Adolescent Medicine. 2010;164(9):840-845.

11Ievers-Landis, CE, Storfer-Isser, A, Rosen C, Johnson N, Redline S. Relationship of Sleep Parameters, Child Psychological Functioning, and Parenting Stress to Obesity Status Among Preadolescent Children.Journal of Developmental and Behavioral Pediatrics.2008;29(4):243-252.

12Moturi S.

13Marcus CL, Rosen G, Davidson Ward SL, et al. Adherence to and Effectiveness of Positive Airway Pressure Therapy in Children With Obstructive Sleep Apnea.Pediatrics.2006;117:e442-451.

14Mitchell RB.

15Centers for Disease Control and Prevention.  “Attention Deficit/Hyperactivity Disorder (ADHD).”  12, December 2011. http://www.cdc.gov/ncbddd/adhd/data.html

16Nansel TR, Overpeck M, Pilla RS, Ruan WJ, Simons-Morton B, Scheidt P. Bullying behaviors among US youth: prevalence and association with psychosocial adjustment. JAMA. 2001;285(16):2094-100.