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Sleep and Behavioral Problems in Kids: Common Bedfellows

April 24, 2023 – Tamar L, a patient advocate based in Maryland, has a daughter who was a very heavy sleeper during childhood.

“She had always slept extremely deeply,” says Tamar, who asked that her name not be revealed for this article to protect the privacy of her daughter, who is now a 26-year-old paralegal. “But when she was in her ‘tweens,’ it got worse and she also started to snore. We used to joke that a troop of elephants could march through her room, and it wouldn’t wake her. And she was tired during the day, no matter how much sleep she got at night.”

As she moved through adolescence, Tamar’s daughter became more withdrawn. “I wouldn’t say that she was ‘shy’ – she definitely had friends – but she wasn’t very social or wasn’t interested in interacting with them outside of school,” Tamar said. “She didn’t start blossoming socially until she was in her second year of college, when she began to come out of herself.” 

It turns out that Tamar’s daughter had sleep apnea – a sleep disorder where your breathing repeatedly starts and stops – and “probably wasn’t getting enough oxygen to her brain even though she was sleeping enough hours during the night.”

A new Australian study has linked sleep problems during the transition from childhood to adolescence with later psychiatric symptoms. The researchers used data on 10,000 children between 9 and 11 years old, who they then reassessed 2 years later to study the potential relationship between sleep problems and emotional or behavioral issues.

Children who had sleep problems also had “internalizing” and “externalizing” problems at the second wave of the study.

“Internalizing” symptoms are those that are “directed inwardly or towards the self,” said lead study author Rebecca Cooper, a PhD candidate at the Melbourne Neuropsychiatry Centre at the University of Melbourne and Melbourne Health in Australia. This includes symptoms of depression, anxiety, and withdrawal.

“Externalizing” symptoms are “typically projected outwardly, toward others, like aggression or rule-breaking behavior,” she said.

The study found that greater sleep problems were linked to both internalizing and externalizing behaviors, “highlighting the importance of healthy sleep to prevent a range of different emotional and behavioral problems,” she said.

Vulnerable Period

Cooper and her colleagues were “interested in examining how sleep problems change over time, especially during the important transition period from late childhood into early adolescence.”

She calls this a “time of increased vulnerability for many young people for developing psychopathology and psychiatric symptoms.” The researchers “wanted to determine whether and how sleep problems – and changes in sleep problems – might play a role in the emergence of these psychopathology symptoms.”

To investigate the question, they used data from the Adolescent Brain Cognitive Development (ABCD) Study, the largest long-term study of child and adolescent brain development in the United States.

The researchers included 10,313 children whose sleep problems were tested at the beginning of the study and 2 years later, using a questionnaire called the parent-reported Sleep Disturbance Scale for Children. Internalizing and externalizing behavior was tested using the parent-reported Child Behavior Checklist.

Sleep problems included total sleep disturbances, as well as arousal problems (like sleepwalking or nightmares), excessive sweating, sleep breathing disorders, sleep-wake transitions (such as limb movement), difficulties falling asleep, difficulties remaining asleep, and excessive daytime sleepiness.

Behavioral problems included internalizing symptoms (such as feeling withdrawn and depressed, having physical symptoms of pain or fatigue, and feeling anxious), while externalizing problems included rule-breaking and aggression.

The researchers divided the children’s sleep profiles into four categories:

  • Low disturbance
  • Sleep onset-maintenance problems
  • Mixed disturbance (which were moderate and not specific)
  • High disturbance

Early Intervention and Treatment Important

Kids in the three more severe sleep problem profiles showed a greater risk of having internalizing as well as externalizing symptoms. For example, children with high sleep disturbance had a 44% higher chance of having internalizing problems and a 24% higher chance of having externalizing symptoms. 

Developing a sleep problem over time was linked to developing these behavioral problems, but developing a behavioral problem over time did not necessarily predict whether a child would also develop a sleep problem.

“There are likely multiple underlying mechanisms linking these symptoms,” Cooper said. “Insufficient sleep leads to difficulties in regulating our emotion – we have a shorter temper or are more likely to become upset over smaller stresses.”

People are also “more likely to perceive others as more negative or hostile when sleep-deprived, which may lead to increases in internalizing symptoms,” she said. “In the same way, difficulties in emotion regulation can lead to greater aggression over smaller nuisances.”

She said poor sleep may also lead to being more impulsive and taking more risks. “We tend to think less about the consequences of our actions without proper sleep, which could lead to greater rule-breaking behavior in adolescents.”

The findings “show that sleep problems are highly prevalent in young adolescents and their severity is associated with a greater risk for both internalizing and externalizing symptoms,” Cooper said.

“It is crucial that parents, teachers, and health care providers regularly ask about their young adolescents’ sleep and sleep problems and support them in making healthy choices about their sleep behavior,” she said. “

Importance of Sleep Health in Mental Wellbeing

Carol Rosen, MD, a professor emerita of pediatrics at Case Western Reserve School of Medicine, and a member of the board of directors of the American Academy of Sleep Medicine, said that when children “struggle with sleep, many parents worry about whether sleep problems are a sign that their child may have emotional or behavioral problems or will develop them in the future.”

Many studies have “confirmed this two-way relationship between sleep problems and emotional and behavioral problems,” she said.

“Not surprisingly,” the current study confirmed this relationship. “The new finding was that worsening sleep problems in late childhood contributes to the appearance and worsening of emotional and/or behavioral problems in early adolescence, but not the reverse,” she said. “These findings underscore the importance of sleep health in supporting mental well-being in young teens.”

Tamar wishes she had handled her daughter’s sleep problems better at an earlier age. 

“I think she could have had a very different high school experience if her sleep apnea had been diagnosed and properly treated,” she said. 

“Looking back, I think she might have been going through some depression in high school, which was finally diagnosed at the end of college, together with the sleep problem.”

Today, Tamar’s daughter is thriving, enjoying her career and her wide circle of friends. “I’m glad she finally understands that both problems needed to be addressed and that she’s gotten help for them,” Tamar says. “I’m very proud of her.”

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