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Sleepless in America

boy in bed

Jim Franco

Almost all parents have concerns about their child's sleep habits --that's partly why there are more than 50 books in print on getting children to fall asleep. But here's a fact that'll wake you up: Though it's common for children to suffer from either insufficient or disrupted sleep, bedtime battles are not necessarily normal and children may not outgrow them. A small but growing body of research suggests that childhood sleep disturbances are associated with cognitive problems, irritability, moodiness, hyperactivity, oppositional behavior, and behavior that resembles Attention Deficit Hyperactivity Disorder (ADHD, called ADD when hyperactivity is not involved). The encouraging news is that doctors are doing more than ever to unearth the causes and best treatments for sleep problems.

"Lately there's been a dramatic boom in pediatric sleep research," says Jodi A. Mindell, Ph.D., associate director of the Sleep Disorders Center at the Children's Hospital of Philadelphia and author of Sleeping Through the Night. In fact, the National Institutes of Health in Bethesda, MD, recently set aside more than $4 million to fund research on sleep and sleep disorders in children. "It's become obvious how common sleep problems in children are and how important it is that we know what causes them and how to treat them," she says.

What's contributed to this need is the growing realization that some parents don't recognize that their children are suffering from poor sleep. A study conducted last year at Tel Aviv University in Israel found that although 18% of children were considered poor sleepers based on overnight sleep studies, their parents were not aware that their children were sleep-deprived.

In the meantime, doctors continue to uncover important -- and startling -- findings about the effects of poor sleep on children's health, development, and behavior.

Put simply, a problem sleeper suffers from either too little sleep or interrupted sleep. This can be brought on by parental styles or environmental factors, such as stress. Even mundane events like starting school or going on vacation can trigger sleep difficulties. And though these are usually short-lived, they can easily turn into long-term problems if a parent doesn't respond quickly and appropriately, says Dr. Mindell.

Some experts believe our fast-paced lifestyle has resulted in more children suffering from poor sleep. "Sleep is much less a priority in our society than it used to be," says Judith Owens, M.D., associate professor of pediatrics at Brown University School of Medicine and director of the Pediatric Sleep Disorders Clinic at Hasbro Children's Hospital in Providence. "We're a 24-hour-a-day society." And if kids are involved in after-school programs, then evening activities like dinner, homework, and bedtime routines get pushed back. Parents who are at work all day may want to spend more time with their children at night, so they gladly delay their kids' bedtimes, she adds.

Children also tend to go to sleep later as they get older and their circadian rhythm shifts. It's a normal phenomenon called sleep phase drift. But because they have to wake early -- high schools are starting class earlier than ever, says Dr. Owens -- they end up losing sleep. Though sleep drift has long been reported in adolescents and has recently compelled some high schools to begin classes later, new research shows that signs of sleep drift are evident in kids as young as 10 or 11.

The Hidden Causes of Sleep Problems

Some cultural factors are clearly at work. Increasingly, though, doctors are finding that many childhood sleep problems are medically based -- and closely linked to behavioral problems. These problems can be serious: "Sleep deprivation affects a child's motor skills, creativity, problem-solving skills, and attention span, and it leads to hyperactivity and poor impulse control," says Dr. Owens. The most common medical cause of poor sleep is obstructive sleep apnea syndrome (OSAS), which affects 1% to 3% of kids, generally between the ages of 2 and 6. It's usually caused by large tonsils and adenoids, which block the throat and decrease the oxygen flow, leading to mini-disruptions in sleep.

Obesity sometimes causes this kind of blockage, says Michael Anstead, M.D., assistant professor of pediatric pulmonology at the University of Kentucky in Lexington. When this is the case, OSAS is relatively easy to treat: While sleeping, the child wears a breathing mask, which pumps higher-pressure air through the nose to help keep the airway open. (Masks can be used by any child with sleep apnea.) But when obesity is not a factor, many doctors miss the connection between sleep apnea and behavior problems. This was the case with 6-year-old Steven of Fenton, MI. When he started kindergarten last year, his mother, Mary (who did not want her family's last name used), noticed a change in his behavior. "He started yelling, talking back, and acting out of control," she recalls. "His school called me almost every day." Eventually, she took her son to a child psychologist, who diagnosed him with ADHD and recommended medicating him with Ritalin. She couldn't do it. "I don't like the idea of medicating, and I had this gut feeling that he was just exhausted," she says.

Soon after, at a well-child visit with a colleague of Steven's pediatrician, a doctor determined that the boy's tonsils were unusually large. (Steven's own doctor hadn't believed it to be a problem.) When the doctor learned that Steven had been snoring since infancy, he was referred to a sleep lab, where he was monitored overnight. It turns out that his enlarged tonsils were causing OSAS, which led him to briefly stop breathing and awaken many times during the night, drastically cutting back on his restorative sleep. Steven then had a tonsillectomy and his behavior changed almost immediately. "He was much more relaxed, learning more quickly, and not acting out," says Mary. The psychologist retracted Steven's ADHD diagnosis.

The most convincing evidence that sleep may be partly responsible for behavioral problems comes from studies conducted in pediatric sleep labs such as the one Steven visited. Of the roughly 600 children seen annually at the Sleep Disorders Center at Arkansas Children's Hospital in Little Rock, a full 50% of them have behavioral problems, says May L. Griebel, M.D., the center's pediatric neurologist. They've been referred to the lab by a pediatrician (often at parents' urging) or a teacher who notices ongoing problems with a student's daytime behavior. Between 60% and 70% of children who visit the Sleep Disorders Center will end up being diagnosed with a sleep disorder, most commonly OSAS, periodic limb movement disorder (PLMD), or enlarged tonsils and adenoids, says Dr. Griebel. They'll then be referred to the appropriate specialist, such as an ear, nose, and throat physician or a nutritionist. After the start of treatment -- which usually consists of surgery, a weight-loss regimen, or medication -- kids return to the clinic to determine if they need additional care.

Sleep lab studies suggest links between ADHD and sleep problems. For example, kids with ADHD tend to have high rates of medically caused sleep disorders like restless leg syndrome (RLS), characterized by prickly, painful, twitching sensations when legs remain still, and PLMD, in which leg muscles repeatedly contract at night, temporarily waking the child. One study from the University of Illinois at Urbana-Champaign looked at 69 children diagnosed with ADHD and found that 26% suffered from PLMD, a disorder that's rare in the rest of the population.

In another study, conducted by Ronald D. Chervin, M.D., director of the University of Michigan Sleep Disorders Center in Ann Arbor, it was found that habitual snoring, a symptom of OSAS, occurred in 33% of kids ages 2 to 18 diagnosed with ADHD, compared to 9% of a control group. "Sleep disorders won't explain the majority of behavioral problems in children, but even if they affect a small fraction of hyperactive kids, it's still a lot of kids," he says.

Yet sleep habits are not typically considered when kids are assessed for behavioral or learning issues. "Absolutely every child who's being evaluated for academic problems, learning problems, behavioral problems, or ADHD should be screened for sleep issues," says Dr. Owens.

Could You Spot a Sleep Disorder?

As the research from Tel Aviv shows, parents are often unsure of what constitutes a sleep problem. Indeed, most parents don't consider it worrisome if their baby wakes up and cries in the middle of the night, nor if their child has an overly lengthy bedtime ritual and the parents have to be present while the child falls asleep, explains Thomas F. Anders, M.D., professor of psychiatry at the University of California at Davis. But unless that child is a newborn, those issues are in fact cause for concern. "Parents tend to see their child's behavior as routine because they've adapted to it, or they may be unwilling to label the behavior as problematic," says Dr. Anders. And as children reach school age, parents may simply be left in the dark about their kids' sleep problems because older children are less likely to alert their parents every time they wake up in the middle of the night.

Parents aren't the only ones who miss the problem, says Dr. Owens. She believes that many pediatricians tend not to encourage conversations about sleep problems with their patients' parents because they may not know how to help solve them. A recent survey she conducted backs this up: Of more than 600 pediatricians interviewed, only 25% said they felt comfortable diagnosing and treating sleep problems.

It's also difficult to identify kids as problem sleepers because they act differently during the day than do adults, says Dr. Griebel. "While adults with sleep problems may appear exhausted, no self-respecting child wants to go to sleep during the day," she says, adding that once they're past the napping age, only those kids with serious disorders, such as narcolepsy, tend to sleep then. Rather than give in to tiredness, the child will fight it, resulting in fidgeting, aggression, and an inability to concentrate or pay attention.

Experts agree that while there are different approaches to resolving sleep problems, one factor rises above the rest as a predictor of success: family dynamics. "A child's temperament is certainly key, but in the end it's really the family's commitment that can change his behavior," says Dr. Mindell. "If the parents follow through with their doctor's advice, consistently put it into practice, and place importance on it, things can definitely improve."