"The groundwork of all happiness is health." - Leigh Hunt

Sleep and behavior problems in children: common bedmates

April 24, 2023 – Tamar L, a patient advocate from Maryland, has a daughter who was a really deep sleeper as a baby.

“She had always been a very deep sleeper,” says Tamar, who asked that her name not be used for this text to guard the privacy of her daughter, now a 26-year-old paralegal. “But when she was in her tweens, it got worse and she also started snoring. We always joked that a herd of elephants could march through her room and she wouldn't wake up. And she was tired during the day, no matter how much sleep she got at night.”

As she went through adolescence, Tamar's daughter became more withdrawn. “I wouldn't say she was 'shy' – she definitely had friends – but she wasn't very social or interested in interacting with them outside of school,” Tamar said. “She didn't really start to blossom socially until her sophomore year of college, when she started to come out of her shell.”

It turned out that Tamar’s daughter Sleep apnea – a sleep problem through which respiratory repeatedly pauses and stops – and “her brain was probably not getting enough oxygen, even though she had had enough sleep at night.”

A new Australian study has linked sleep problems throughout the transition from childhood to adolescence to later psychiatric symptoms. The researchers used data from 10,000 children between the ages of 9 and 11, whom they then re-examined 2 years later to look at the possible link between sleep problems and emotional or behavioral problems.

Children with sleep problems also showed problems with “internalization” and “externalization” within the second wave of the study.

“Internalizing” symptoms are those which are “directed inward or toward the self,” said lead study creator Rebecca Cooper, a PhD student on the Melbourne Neuropsychiatry Centre on the University of Melbourne and Melbourne Health in Australia. They include symptoms of depression, anxiety and withdrawal.

“Externalizing” symptoms are “typically projected outward, onto others, such as aggression or rule-breaking behavior,” she said.

The study found that major sleep problems were related to each internalizing and externalizing behavior, “underscoring the importance of healthy sleep in preventing a range of different emotional and behavioral problems,” she said.

Dangerous time

Cooper and her colleagues desired to “investigate how sleep problems change over time, particularly during the important transition period from late childhood to early adolescence.”

She describes this as “a time when many young people are more vulnerable to developing psychopathological and psychiatric symptoms.” The researchers “wanted to find out whether and to what extent sleep problems – and changes in sleep problems – might play a role in the development of these psychopathological symptoms.”

To investigate this query, they used data from the Adolescent Brain Cognitive Development (ABCD) Study, probably the most comprehensive long-term study of brain development in children and adolescents within the United States.

The researchers studied 10,313 children whose sleep problems were tested at first of the study and two 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 general sleep disturbances and problems waking up (resembling sleepwalking or nightmares), excessive sweating, sleep-related respiratory disorders, sleep-wake transitions (resembling limb movements), difficulty falling asleep, difficulty staying asleep, and excessive daytime sleepiness.

Behavioral problems included internalizing symptoms (resembling withdrawal and depression, physical pain or fatigue, and anxiety), while externalizing problems included rule violations and aggression.

The researchers divided the kids’s sleep profiles into 4 categories:

  • Minor disruption
  • Problems falling asleep and sleeping through the night
  • Mixed disorders (which were moderate and non-specific)
  • High disturbance

Early intervention and treatment essential

Children with the three more severe sleep problem profiles showed the next risk of getting each internalizing and externalizing symptoms. For example, children with severe sleep problems were 44% more prone to have internalizing problems and 24% more prone to have externalizing symptoms.

The development of sleep problems over time was related to the event of those behavioral problems, but the event of behavioral problems over time was not a essential predictor of whether a baby would also develop sleep problems.

“There are probably several underlying mechanisms that link these symptoms together,” Cooper said. “Insufficient sleep causes us to become less able to regulate our emotions – we are more short-tempered or more likely to get upset over minor stresses.”

People “are also more likely to perceive others as more negative or hostile when sleep deprived, which can lead to increased internalizing symptoms,” she said. “Similarly, difficulties with emotion regulation can lead to greater aggression over minor annoyances.”

She said poor sleep may also result in being more impulsive and taking more risks. “Without adequate sleep, we think less about the consequences of our actions, which could lead to more rule-breaking among adolescents.”

The results “show that sleep problems are common among young adolescents and their severity is associated with a higher risk of both internalizing and externalizing symptoms,” Cooper said.

“It is critical that parents, teachers and healthcare professionals regularly ask their young adolescents about their sleep and sleep problems and support them in making healthy choices about their sleep behaviors,” she said.

Importance of healthy sleep for mental well-being

Carol Rosen, MD, professor emerita of pediatrics at Case Western Reserve School of Medicine and member of the board of the American Academy of Sleep Medicinesaid that when children “have sleep problems, many parents worry whether the 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 reciprocal relationship between sleep problems and emotional and behavioral problems,” she said.

“Not surprisingly,” the present study confirmed this link. “The new finding was that exacerbation of sleep problems in late childhood contributes to the onset and exacerbation of emotional and/or behavioral problems in early adolescence, but not vice versa,” she said. “These findings underscore the importance of healthy sleep in supporting psychological well-being in young teenagers.”

Tamar wishes she had gotten her daughter's sleep problems under control sooner.

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

“Looking back, I think she may have suffered from depression in high school, which was eventually diagnosed at the end of college along with the sleep problems.”

Today, Tamar's daughter is doing well, having fun with her profession and her large circle of friends. “I'm glad that she finally understands that both problems need to be addressed and that she has received help to do so,” says Tamar. “I'm very proud of her.”