Toddler Sleep Problems Linked to Later Behavioral Problems

Jenni Laidman

April 14, 2015

Children who had sleep problems at age 18 months were at an increased risk for behavioral and emotional problems at both age 18 months and age 5 years, according to a study published online April 13 in JAMA Pediatrics.

B&oshalsh;rge Sivertsen, PhD, from the Division of Mental Health, Norwegian Institute of Public Health, Bergen, Norway, and colleagues used the Child Behavior Checklist to measure the effect of sleep issues on child behavior among 32,662 children enrolled in the Norwegian Mother and Child Cohort Study from June 1, 1999, to December 31, 2008.

The researchers asked mothers how often children woke during the night and how long the 18-month-olds slept each day. They also asked mothers about their child's emotional and behavioral issues at 18 months and 5 years of age, although they did not study sleep patterns of the 5-year-olds. The researchers considered behaviors as either "internalizing," which included emotional reactivity, anxiousness/depression, and somatic complaints, or "externalizing," which included attention problems and aggressive behavior.

The study, which the authors say may be the largest investigation of its type, showed that children who slept 10 hours or fewer daily at age 18 months were more likely to exhibit externalizing and internalizing behaviors at age 5 years. Toddlers who slept 10 or fewer hours had an adjusted relative risk (ARR) of internalizing behaviors of 1.59 (95% confidence interval [CI], 1.23 - 2.08) at age 5 years compared with children who slept 13 or more hours. The researchers calculated relative risk for 5-year-olds after adjusting for maternal age and education, pregnancy duration, parity, birth weight, and sex, plus their Child Behavior Checklist subscale scores at 18 months. Sleeping 10 or fewer hours at 18 months was associated with an ARR of 1.77 (95% CI, 1.37 - 2.30) for externalizing behaviors at 5 years.

Children who woke three or more times nightly at age 18 months had an ARR of 1.57 (95% CI, 1.28 - 1.93) for internalizing behaviors and an ARR of 1.25 (95% CI, 1.00 - 1.58) for externalizing behaviors at age 5 years. Children who woke one to two times nightly had an ARR for internalizing behaviors of 1.29 (95% CI, 1.16 - 1.44) at age 5 years. However, the ARR for externalizing behaviors was not statistically significant at age 5 years.

The association for behavior issues was strongest at age 18 months; children who slept 10 or fewer hours had an ARR for internalizing behaviors at 18 months of 3.12 (95% CI, 2.75 - 3.54) compared with children who slept 13 or more hours At 18 months, after adjusting for maternal age and education, pregnancy duration, parity, birth weight, and sex, children who slept 10 or fewer hours daily had an ARR of 1.93 (95% CI, 1.65 - 2.25) for externalizing behaviors. Children who slept 11 to 12 hours were also at increased risk for internalizing behaviors, with an ARR of 1.41 (95% CI, 1.32 - 1.51), and at an increased risk for externalizing behaviors, with an ARR of 1.26 (95% CI, 1.18 - 1.34).

Eighteen-month-olds who woke three or more times nightly were at a higher risk for internalizing behaviors (ARR, 3.19; 95% CI, 2.87 - 3.54) at 18 months than for externalizing behaviors (ARR, 1.69; 95% CI, 1.48-1.92) compared with children who seldom or never woke during the night. Children who woke one to two times during the night also were at increased risk for internalizing behaviors (ARR, 1.72; 95% CI, 1.61 - 1.84) compared with children who slept through the night.

Michelle M. Garrison, PhD, MPH, principal investigator at the Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Washington, and acting assistant professor, Health Services Department, University of Washington, says the study shows that sleep problems impede development.

"Although all groups showed the expected decrease in [Child Behavior Checklist] internalizing and externalizing scores from 18 months to 5 years that happens as young children mature and gain self-regulation skills, those children with sleep problems at 18 months experienced significantly fewer expected behavioral and emotional gains compared with their peers," she writes in an accompanying editorial.

Further, the study underlines the role of sleep problems on the social determinants of health. "Poverty, conflict in the home, living in an unsafe environment, and other adverse childhood experiences are all significant risk factors for child sleep problems that may affect how the child's neuroendocrine system responds to the stresses in their environment and impair executive function and emotional regulation, leading to increased risks for a wide range of adverse health and social consequences," Dr Garrison writes. "The need to improve early childhood sleep is not only a family issue or a clinical problem but may be critical from a public health perspective as well."

The authors of the study and editorial report no relevant financial relationships.

JAMA Pediatr. Published online April 13, 2015. Article abstract, Editorial extract

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