Expert strategies for solving common bedtime battles.
Almost all parents have concerns about their child's sleep habits --that's partly why there are hundreds of 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 growing body of research suggests that childhood sleep disturbances are associated with obesity, cognitive problems, irritability, moodiness, 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 Center at The Children's Hospital of Philadelphia and coauthor of Take Charge of Your Sleep: The All-in-One Resource for Solving Sleep Problems in Kids and Teens .
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 nearly 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.
The Roots of Bad Rest
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 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. A common medical cause of poor sleep is obstructive sleep apnea (OSA), 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. Being overweight or obese is an important risk factor as well.
OSA occurs in about 3 percent of children. The majority of the time it is due to enlarged tonsils or adenoids, says Michael Anstead, M.D., assistant professor of pediatric pulmonology at the University of Kentucky in Lexington. When this is the case, OSA is relatively easy to treat by removing their tonsiles and adenoids. (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.
Obesity can also cause sleep apnea by depositing fat in the airway and limiting airflow. This is an increasing problem in children due to the epidemic problem of obesity in the U.S. Children who are obese with sleep apnea may not completely benefit from having their tonsils and adenoids removed. "They may need to wear a special mask while sleeping called a CPAP instead of, or in addition to, having their tonsils removed. This mask pumps higher pressure air through their nose to help keep the airway open while the child is asleep," says Dr. Anstead. Recognizing and treating sleep apnea is very important in children because of its link to school performance and behavior problems. According to Dr. Anstead, children with OSA have poor quality sleep and either can't pay attention during school or fall asleep during the day. Sleep apnea in children is the link to poor school performance and behavior problems such as ADHD. "Any child with poor school performance or ADHD should be evaluated by their pediatrician. The child's doctor should do a thorough sleep history if problems are present such as snoring, nocturnal sweating or restless sleep. Further evaluation, including an overnight sleep study, may be indicated to determine if sleep apnea is present," advices Dr. Anstead.
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 OSA, 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 1200 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 and professor at the University of Arkansas for Medical Sciences. 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 an obstructed breathing pattern or OSAS, often in association with obesity 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, intervention by a behavioral psychologist,or medication -- kids return to the clinic to determine if they need additional care. Some of the children need positive pressure breathing support while they sleep, or CPAP, and are enrolled in the center?s adherence program to improve use of the CPAP equipment.
The ADHD Factor
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 legs syndrome (RLS), characterized by an urge to move, or even tingling or painful sensations when legs remain still, and periodic limb movement disorder (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 OSA, 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 only a smaller fraction of hyperactive kids, it's still a lot of people," 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 may differ in their definition of what constitutes a sleep "problem". Some of these differences may be culturally-biased. For example, some parents do not consider an overly lengthy bedtime ritual and the need for parental presence at bedtime in young children to be problematic. "However, if these behaviors persist (and they often do), they may be much more difficult to eliminate once the child is older," according to Dr. Owens. "Parents also 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. Owens. 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 number of studies backs this up: In a survey she conducted 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 may 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, or the most severe levels of obstructed breathing, tend to nod off during the day or nap. 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: consistency. "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."
Copyright © 2001. Reprinted with permission from the October 2001 issue of Child magazine.Updated 2010
All content here, including advice from doctors and other health professionals, should be considered as opinion only. Always seek the direct advice of your own doctor in connection with any questions or issues you may have regarding your own health or the health of others.