Nonsignificance of sleep relative to IQ and neuropsychological scores in predicting academic achievement

Prevalence and Correlates of Poor Safety Awareness and Accidental Injury in AASD, ADHD, ASD + ADHD, and Neurotypical Youth Samples

The purpose of the present study is to compare risk and predictors of poor safety awareness and accidental injuries in ASD, ADHD, and neurotypical samples. Neurodivergent groups (ADHD-I n = 309; ADHD-C n = 747; ASD-only n = 328; ASD + ADHD n = 1,108) were 2-17 years old. The neurotypical group (n = 186) was 6-12 years of age. Maternal ratings on the Pediatric Behavior Scale examined safety awareness, accidental injury, and psychological problems. Children with ASD + ADHD had significantly poorer safety awareness and accidental injury ratings than all other groups. Predictors of poor safety awareness in the total ASD and/or ADHD sample were: impulsivity, younger age, lower IQ, and hyperactivity. Predictors of accidental injuries were: incoordination, hyperactivity, and conduct problems. Clinicians working with children who have ASD and ADHD are encouraged to screen for poor safety awareness, discuss child safety measures, and provide evidence-based intervention to improve safety awareness and mitigate the risk of injury.

Edward O. Bixler, PhD: from the Apollo project and chimpanzees to sleep epidemiology

What an honor to write about Dr. Edward O. Bixler's contributions to the sleep field. In 1967, Dr. Bixler published a case report on a chimpanzee with implanted brain electrodes while working at an Air Force base in New Mexico. A few years later, in 1971, he published on the sleep effects of flurazepam in individuals with insomnia together with Dr. Anthony Kales, data that he had collected when the Sleep Research & Treatment Center (SRTC) was housed at the University of California Los Angeles. Dr. Bixler, a meticulous scientist, learned from Dr. Kales, a devoted clinician, to study "the whole patient, and all aspects of sleep," a legacy that continued when the SRTC moved to Penn State in Hershey. Indeed, Dr. Bixler's tenure at Penn State from 1971 until 2019 kept the science of the SRTC focused on that premise and helped translate scientific evidence into clinical care. He not only contributed early to the pharmacology of sleep and the effects of hypnotics, but he was also a pioneer in "sleep epidemiology." His "Prevalence of sleep disorders in the Los Angeles metropolitan area" study of 1979 was the first rigorous epidemiological study on sleep disturbances. Starting in 1990, he established the Penn State Adult Cohort to estimate the prevalence and natural history of sleep-disordered breathing and other sleep disorders in adults. Inspired by life-course epidemiology, he established in 2001 the Penn State Child Cohort to estimate the same phenomena in children. This Living Legend paper captures and highlights Dr. Bixler's enduring legacy to sleep science.

Nocturnal sleep duration trajectories in early childhood and school performance at age 10 years

Sleep plays a fundamental role in brain development and resultant functions. The aim was to verify whether nocturnal sleep duration during early childhood has long-term associations with academic achievement at age 10 years. The present study is part of the Quebec Longitudinal Study of Child Development, a representative cohort of infants born in 1997-1998 in the province of Quebec, Canada. Children with known neurological conditions were excluded from this cohort. Four trajectories of parent-reported nocturnal sleep duration at ages 2.5, 3, 4, 5 and 6 years were determined using a SAS procedure named PROC TRAJ. Sleep duration at age 10 years was also reported. Teachers provided data on academic performance when the children were age 10 years. These data were available for 910 children (430 boys, 480 girls; 96.6% Caucasians). Univariate and multivariable logistic regressions were performed using SPSS. Children who slept less than 8 hr per night at 2.5 years but normalized later on (Traj1) had three-five times the odds of having grades below the class average in reading, writing, mathematics and science compared with children who slept sufficiently (Traj3-4: 10-11 hr per night). Children who slept about 9 hr per night throughout childhood (Traj2) had two-three times the odds of being below the class average in mathematics and science. Sleep duration at age 10 years was not correlated with the academic performance. These results point to the presence of a very important early period during which sufficient sleep is needed to fine-tune the functions necessary for academic achievement later on.

Associations between sleep, reading, and mathematics in Taiwanese children

BACKGROUND

Some research shows a link between sleep behaviours and school achievement in English-speaking children and adolescents.

AIMS

The current study aimed to examine the relationship between children's sleep behaviours and aspects of their school achievement in Mandarin-speaking children who are living in Taiwan.

SAMPLE

The present study reports on 69 second-grade children (age range = 6.84-8.4 years) recruited in Taipei City, Taiwan.

METHODS

Children's sleep behaviours were assessed through two standardized parent self-report questionnaires: the Children's Sleep Habits Questionnaire (CSHQ) and the Sleep Disturbance Scale for Children (SDSC). Children undertook three standardized tests of word reading, reading comprehension and math.

RESULTS

Key findings include: (i) sleep disturbances are more prevalent when using the CSHQ scale than the SDSC scale, (ii) around half of second graders struggle with general sleep disturbances as observed by the CSHQ scale, (iii) children who go to bed before 22:00 and have at least 9-h sleep tend to exhibit fewer sleep disturbances, (iv) parasomnias as measured by the CSHQ are negatively correlated with reading comprehension after controlling age and nonverbal IQ, and (v) the amount of sleep (naps) during daytime is negatively correlated with Chinese character recognition, reading comprehension and math after controlling age and nonverbal IQ.

CONCLUSIONS

There is growing awareness of the value of research that spans culturally and linguistically diverse populations. Our study contributes to ongoing discussions about the relationship between sleep, and skills in reading and math in school-aged children in Taiwan.

Behavioral, neurocognitive, polysomnographic and cardiometabolic profiles associated with obstructive sleep apnea in adolescents with ADHD

BACKGROUND

A high comorbidity between attention-deficit/hyperactivity disorder (ADHD) and obstructive sleep apnea (OSA) as well as similar impairments across neurobehavioral outcomes has been described in children. However, there is a paucity of research examining the comorbidity of these two disorders in adolescents. This study examined the association of OSA with sleep, neurobehavioral, and cardiometabolic outcomes in adolescents with ADHD from the general population.

METHODS

421 adolescents (16.9 ± 2.3 years, 53.9% male) underwent 9-hr polysomnography, neurobehavioral, and physical evaluation. ADHD was ascertained by a parent-or-self-report of a lifetime diagnosis/treatment of ADHD. OSA was defined as an apnea hypopnea index of ≥2 events/hour. Groups of controls (n = 208), OSA-alone (n = 115), ADHD-alone (n = 54), and ADHD+OSA (n = 44) were studied. Multivariable-adjusted general linear models tested group differences in PSG parameters, neurobehavioral, and cardiometabolic outcomes after controlling for sex, race/ethnicity, age, and/or body mass index percentile.

RESULTS

The ADHD+OSA group had significantly longer sleep onset latency, shorter total sleep time, lower sleep efficiency, and higher percent of stage 1 sleep, as compared with all other groups, however, these differences were diminished by excluding adolescents on psychoactive medication. The ADHD-alone group showed significantly higher periodic limb movements than controls. The ADHD+OSA and ADHD-alone groups did not significantly differ on any measure of neurocognitive or behavioral functioning. The ADHD+OSA and OSA-alone groups showed significantly worse cardiometabolic and inflammatory biomarkers when compared to controls or the ADHD-alone, but did not significantly differ between each other.

CONCLUSIONS

Adolescents with a diagnosis ADHD+OSA showed phenotypic risk factors for OSA (i.e., overweight/obesity, visceral adiposity, metabolic syndrome, and inflammation) but not worse neurobehavioral outcomes when compared with ADHD-alone. While comorbidity is possible, these data support that adolescents with a suspicion of ADHD should be screened for OSA, before a diagnosis is reached and psychoactive medication initiated.

Cross-Sectional Age Analysis of Sleep Problems in 2 to 17 Year Olds with ADHD Combined, ADHD Inattentive, or Autism

Sleep problems are common in autism and ADHD. No study has compared sleep problems by age in 2 to 17 year olds with autism versus ADHD-Combined versus ADHD-Inattentive type. Mothers rated 1415 youth with autism and 1041 with ADHD on 10 Pediatric Behavior Scale sleep items. Nighttime sleep problems were most severe in autism, followed by ADHD-Combined, and then ADHD-Inattentive. Difficulty falling asleep, restless during sleep, and waking during the night were the most common problems. Adolescents slept more at night than other age groups, and youth who slept more at night were sleepier during the day. Sleep problems declined with age, but correlations were small. In adolescence, 63% with autism, 53% with ADHD-Combined, and 57% with ADHD-Inattentive had difficulty falling asleep. Given that the majority of children in all age groups had one or more sleep problem, developmentally appropriate interventions are needed to address sleep difficulties and limit their adverse effects.

Sleep, academic achievement, and cognitive performance in children with attention-deficit hyperactivity disorder: A polysomnographic study

The objective of this study was to examine the influence of parent-reported and polysomnography (PSG)-measured sleep patterns on the academic and cognitive performance of children with attention-deficit hyperactivity disorder (ADHD). We assessed 91 children (18 girls) diagnosed with ADHD aged 7-11 years (29 ADHD-Inattentive, 32 ADHD-Hyperactive/Impulsive, and 31 ADHD-Combined). The Paediatric Sleep Questionnaire (PSQ) and Paediatric Daytime Sleepiness Scale (PDSS) were used to assess subjective sleep quality, as perceived by parents, and objective sleep variables were assessed by PSG. Cognitive performance was evaluated using the Wechsler Intelligence Scale for Children (WISC), and the final average grade of the last school year was used as a measure of academic performance. Academic performance was predicted by the following sleep variables: Sleep time, time in bed, night awakenings, and daytime sleepiness. The best predictors of cognitive performance in children with ADHD were rapid eye movement latency, light sleep, periodic limb movements index (PLMs), awakenings, and daytime sleepiness. In conclusion, sleep parameters are closely associated with the academic and cognitive functioning of children with ADHD.

Prospective relations between sleep in preschool years and academic achievement at school entry

It is often assumed that adequate sleep is a key ingredient of children's school success. Research to date, however, suggests modest associations between child sleep and academic achievement. Adopting a developmental perspective, this report investigates the associations between age-related changes in sleep across the preschool period and academic achievement at school entry. Sleep was assessed by actigraphy at ages 2, 3 and 4 among 128 children from mostly White middle-class families, and their performance in reading and mathematics was tested in Grade 1. The results revealed that children whose sleep duration decreased more rapidly across the preschool period showed better performance in both reading and mathematics. These results suggest that age-related developments may be a key characteristic of sleep in the preschool years.

The Functional Impact of Sleep Disorders in Children With ADHD

Objective: Children with ADHD display higher rates of sleep problems, and both sleep disorders and ADHD have been shown to affect functioning in childhood. The current study examines the frequency and relationship between sleep problems and ADHD, and their impact on quality of life (QoL) and functional impairment. Method: Parents of 192 children with ADHD (M = 10.23 years) completed measures regarding their child's ADHD symptoms (Swanson, Nolan and Pelham [SNAP]), sleep disorders (Pediatric Sleep Questionnaire [PSQ]), QoL (Child Health Illness Profile [CHIP-PE]), and functioning (Weiss Functional Impairment Rating Scale-Parent Report [WFIRS-P]). Results: Common sleep complaints in participants were insomnia, excessive daytime sleepiness (EDS), and variability in sleep schedule. Regression analysis indicated that sleep problems and ADHD symptoms independently predicted lower levels of QoL (ΔR² = .12, p < .001) and social functioning (ΔR² = .12, p < .001). Conclusion: The results suggest that ADHD may coexist with somnolence and that both conditions have a significant impact on a child's functioning and QoL.

Effects of the environment of a simulated shelter in a gymnasium on sleep in children

Effects of the environment of a simulated shelter in a gymnasium on sleep were investigated in 20 healthy school-aged children. Measurements were obtained during a one-night stay in a school gymnasium during the summer (C). Activity levels were monitored using a wrist actigraph, and temperature and humidity of the bedrooms in the subjects' homes were monitored from 3 days before to 3 days after C. The subjects were asked to provide information regarding subjective sleep estimations and thermal sensations. The results for the days before C (BC), C, the first day after C (A1), and the second day after C (A2) were compared. The bedroom temperature was significantly lower on BC than on the other nights. No significant difference was observed in bedtime, whereas wake-up time was significantly earlier on C and later on A1 than on the other nights. Total sleep time was significantly decreased on C (3.6 h) and increased on A1 when compared to the other nights. Daytime nap was significantly increased on A1 when compared to the other days. Subjective estimation of sleep quality was decreased and sweat sensation before sleep was increased on C when compared to the other nights. The main reason for sleep disturbances on C was heat. These results indicate that the environment of the simulated shelter in the gymnasium severely disturbed sleep in children. The resulting loss of sleep was compensated for by increased nocturnal sleep time and daytime napping on the next day.

Behavioral Profiles Associated with Objective Sleep Duration in Young Children with Insomnia Symptoms

Based on previous studies reporting on the association of objective sleep duration and physiologic changes (i.e., increased cortisol) in children, we examined the role of objective sleep duration on differentiating behavioral profiles in children with insomnia symptoms. Seven hundred children (ages 5-12, 47.8% male) from the Penn State Child Cohort underwent a nine-hour polysomnography and parent completed Pediatric Behavior Scale. Insomnia symptoms were defined as parent report of difficulty falling and/or staying asleep, sleep disordered breathing as an AHI of ≥1, and objective short sleep duration as a total sleep time < 7.7 h. Children with insomnia symptoms demonstrated more overall behavioral problems than controls. Significant interactions between insomnia symptoms and objective sleep duration on scores of externalizing behaviors, mood variability and school problems were found. Profile analyses showed that children with insomnia symptoms and normal sleep duration were associated with clinically elevated externalizing behaviors, inattention, mood variability, and school problems, while children with insomnia and short sleep duration were associated with an overall elevated profile in which internalizing behaviors were more prominent. Childhood insomnia symptoms are associated with a wide array of behavioral problems, for which objective sleep duration is useful in differentiating behavioral profiles. Children with insomnia symptoms and normal sleep duration had a behavioral profile consistent with limit-setting and rule-breaking behaviors, while children with insomnia symptoms and short sleep duration had a behavioral profile more consistent with internalizing behaviors resembling that of psychophysiological disorders.

The association between Disruptive Mood Dysregulation Disorder symptoms and sleep problems in children with and without ADHD

BACKGROUND

Many youth experience persistent irritability and recurrent temper outbursts, conceptualized by DSM-5 as Disruptive Mood Dysregulation Disorder (DMDD). Sleep deprivation impairs emotion regulation which could increase rates of DMDD symptoms, especially in those with preexisting regulatory impairments, as seen with ADHD. However, there has been little examination of the relationship between chronic sleep problems and DMDD symptoms.

METHODS

Associations between DMDD symptoms and sleep parameters in children were assessed using parent-report and objective measures of sleep in a general population sample (N = 665) and an ADHD sample (N = 784). Irritability, temper outbursts, sleep problems and other psychological problems were assessed with the Pediatric Behavior Scale. The general population study also completed overnight polysomnography (PSG).

RESULTS

DMDD symptoms were reported in 9.2% of the community sample and 31.4% of the ADHD sample. In both samples, children with DMDD symptoms had significantly higher parent-reported sleep problems than children without DMDD symptoms. Children with sleep problems had significantly higher DMDD scores than children without sleep problems. However, DMDD symptoms were most strongly associated with oppositional behavior. Sleep problems were not a significant contributor. Hyperactivity-impulsivity was most strongly associated with sleep problems, and DMDD was not a significant contributor. Children with and without DMDD symptoms did not differ significantly on any PSG parameter.

CONCLUSIONS

Associations between parent-reported sleep problems and DMDD symptoms were due to their shared relationship with other behavioral problems. Therefore, chronic sleep problems do not appear to be a primary source of DMDD symptoms in children with or without ADHD.

Sleep disordered breathing symptoms and daytime sleepiness are associated with emotional problems and poor school performance in children

This study examined the prevalence of sleep disordered breathing (SDB) symptoms and their associations with daytime sleepiness, emotional problems, and school performance in Chinese children. Participants included 3979 children (10.99±0.99 years old) from four elementary schools in Jintan City, Jiangsu Province, China. Children completed a self-administered questionnaire on sleep behavior and emotional problems, while parents completed the Child Sleep Habit Questionnaire (CSHQ). SDB symptoms included 3 items: loud snoring, stopped breathing, and snorting/gasping during sleep. Teachers rated the children's school performance. The prevalence rates of parent- and self-reported SDB symptoms were 17.2% and 10.1% for "sometimes" and 8.9% and 5.6% for "usually". SDB symptoms, more prevalent in boys than in girls, increased the risks for depression, loneliness, and poor school performance. Daytime sleepiness mediated the relationship between SDB symptoms and depression, loneliness, and poor school performance. This study suggests the importance of early screening and intervention of SDB and daytime sleepiness in child behavioral and cognitive development.

Children's Sleep and Academic Achievement: The Moderating Role of Effortful Control

Poor sleep is thought to interfere with children's learning and academic achievement (AA). However, existing research and theory indicate there are factors that may mitigate the academic risk associated with poor sleep. The purpose of this study was to examine the moderating role of children's effortful control (EC) on the relation between sleep and AA in young children. One hundred and three 4.5- to 7-year-olds (M = 5.98 years, SD = 0.61) wore a wrist-based actigraph for five continuous weekday nights. Teachers and coders reported on children's EC. EC was also assessed with a computer-based task at school. Additionally, we obtained a standardized measure of children's AA. There was a positive main effect of sleep efficiency to AA. Several relations between sleep and AA were moderated by EC and examination of the simple slopes indicated that the negative relation between sleep and AA was only significant at low levels of EC.

What Is Specific and What Is Shared Between Numbers and Words?

Reading and spelling performance have a significant correlation with number transcoding, which is the ability to establish a relationship between the verbal and Arabic representations of numbers, when a conversion of numerical symbols from one notation to the other is necessary. The aim of the present study is to reveal shared and non-shared mechanisms involved in reading and writing of words and Arabic numerals in Brazilian school-aged children. One hundred and seventy-two children from second to fourth grades were evaluated. All of them had normal intelligence. We conducted a series of hierarchical regression models using scores on word spelling and reading single words and Arabic numerals, as dependent variables. As predictor variables we investigated intelligence, the phonological and visuospatial components of working memory (WM) and phonemic awareness. All of the writing and reading tasks (single word spelling and reading as well as number reading and number writing) were significantly correlated to each other. In the regression models, phonological WM was specifically associated to word reading. Phonemic awareness was the only cognitive variable that systematically predicted all of the school skills investigated, both numerical and word tasks. This suggests that phonemic awareness is a modular cognitive ability shared by several school tasks and might be an important factor associated to the comorbidity between dyslexia and dyscalculia.

Sleep efficiency (but not sleep duration) of healthy school-age children is associated with grades in math and languages

OBJECTIVE

The objective of this study was to examine the associations between objective measures of sleep duration and sleep efficiency with the grades obtained by healthy typically developing children in math, language, science, and art while controlling for the potential confounding effects of socioeconomic status (SES), age, and gender.

STUDY DESIGN

We studied healthy typically developing children between 7 and 11 years of age. Sleep was assessed for five week nights using actigraphy, and parents provided their child's most recent report card.

RESULTS

Higher sleep efficiency (but not sleep duration) was associated with better grades in math, English language, and French as a second language, above and beyond the contributions of age, gender, and SES.

CONCLUSION

Sleep efficiency, but not sleep duration, is associated with academic performance as measured by report-card grades in typically developing school-aged children. The integration of strategies to improve sleep efficiency might represent a successful approach for improving children's readiness and/or performance in math and languages.

The impact of daytime sleepiness on the school performance of college students with attention deficit hyperactivity disorder (ADHD): a prospective longitudinal study

This prospective longitudinal study evaluated the impact of daytime sleepiness on the school performance of 62 college students diagnosed comprehensively with attention deficit hyperactivity disorder. The primary goal of the study was to determine if self-reported daytime sleepiness rated at the beginning of the academic year could predict academic and overall functioning at the end of the academic year while also considering potentially important covariates, including symptoms of inattention, hyperactivity and impulsivity, medication status and whether or not students lived at home or on-campus. Self-reported daytime sleepiness predicted longitudinally school maladjustment, overall functional impairment and the number of D and F grades (i.e. poor and failing) students received in courses above and beyond both self- and parent-report of symptoms, but did not predict overall grade point average. Living at home served as a protective factor and was associated with less school maladjustment and overall impairment. Gender was the only significant predictor in the overall grade point average model, with female gender associated with higher overall grades. The implications of these findings for monitoring and treatment of sleep disturbances in college students with attention deficit hyperactivity disorder are discussed.

Prevalence of insomnia symptoms in a general population sample of young children and preadolescents: gender effects

OBJECTIVE

Our population-based study examined the prevalence of insomnia symptoms and its sociodemographic, subjective, and polysomnographic (PSG) sleep risk factors in young and preadolescent children.

METHODS

We performed a cross-sectional study of 700 children, ages 5-12 years who underwent a 9-h PSG and parent-completed sleep and development questionnaires (Penn State Child Cohort). Insomnia symptoms were defined as parent report of difficulty falling or staying asleep and sleep-disordered breathing (SDB) as an apnea hypopnea index of ≥1.

RESULTS

The prevalence of insomnia symptoms was 19.3% and did not significantly change (20.2%) when children with SDB were excluded. A significant interaction between gender and age revealed that the prevalence of insomnia symptoms was highest in girls ages 11 to 12 years (30.6%). This gender difference was not associated with significant differences between girls and boys ages 11-12 years in anxiety and depressive symptoms. In contrast girls ages 11-12 years with insomnia symptoms, but not boys of the same group, demonstrated clinically significant PSG sleep disturbances compared to those without insomnia symptoms.

CONCLUSIONS

These data suggest that one out of five young children and preadolescents of the general population have insomnia symptoms. Importantly, the prevalence of insomnia symptoms peaks in girls ages 11 to 12 years and is associated with objective sleep disturbances which may be related to hormonal changes associated with the onset of puberty rather than anxiety and depression.

Clinical implications of daytime sleepiness for the academic performance of middle school-aged adolescents with attention deficit hyperactivity disorder

This study investigated the relative impact of total time slept per night and daytime sleepiness on the academic functioning of 100 middle school-aged youth (mean age = 11.9) with attention deficit hyperactivity disorder (ADHD). The primary goal of the study was to determine if total time slept per night and/or daytime sleepiness, as measured by youth self-report on the Pediatric Daytime Sleepiness Scale (PDSS), predicted academic functioning above and beyond symptoms of ADHD and relevant covariates, such as intelligence, achievement scores and parent education level. Self-reported daytime sleepiness but not self-reported total time slept per night was associated significantly with all academic outcomes. When examined in a hierarchical regression model, self-reported daytime sleepiness significantly predicted parent-rated homework problems and academic impairment and teacher-rated academic competence above and beyond symptoms of ADHD and relevant covariates, but did not predict grade point average or teacher-rated academic impairment. The implications of these findings for understanding more clearly the association between ADHD and sleep and the functional implications of this relationship are discussed.

Sleep and neurocognitive functioning in children with eczema

Sleep disruption in childhood is associated with clearly defined deficits in neurocognition and behaviour. Childhood eczema is also a potent cause of sleep disruption though it is unknown whether it too results in neurocognitive deficits. To test this hypothesis, neurocognitive (WISC-IV), parental-reported sleep quality (Sleep Disturbance Scale of Children (SDSC)) and overnight polysomnographic (PSG) data were collected in 21 children with eczema and 20 healthy controls (age range 6-16 years). Children with eczema had worse sleep quality on both PSG (notably increased nocturnal wakefulness, a higher number of stage shifts and a longer latency to REM onset) and parental report. In addition, they demonstrated significant neurocognitive deficits (especially verbal comprehension, perceptual reasoning and to a lesser extent working memory) with a composite Full Scale IQ 16 points lower than controls. Parental reported sleep problems but not PSG parameters were correlated with reduced neurocognitive performance. However, hierarchical regression analyses revealed that eczema status was predictive while sleep fragmentation (parental or PSG) was not predictive of neurocognitive performance. As this is the first study to systematically examine neurocognitive functioning in children with eczema and given the finding of significant deficits it merits replication especially given the prevalence of the condition. The unanswered question is whether these cognitive deficits normalise with effective eczema treatment and if this is mediated by improvements in sleep architecture.

Pediatric sleep disorders and special educational need at 8 years: a population-based cohort study

OBJECTIVES

To examine associations between sleep-disordered breathing (SDB) and behavioral sleep problems (BSPs) through 5 years of age and special educational need (SEN) at 8 years.

METHODS

Parents in the Avon Longitudinal Study of Parents and Children reported on children's snoring, witnessed apnea, and mouth-breathing at 6, 18, 30, 42, and 57 months, from which SDB symptom trajectories, or clusters, were derived. BSPs were based on report of ≥ 5 of 7 sleep behaviors at each of the 18-, 30-, 42-, and 57-month questionnaires. Parent report of SEN (yes/no) at 8 years was available for 11049 children with SDB data and 11467 children with BSP data. Multivariable logistic regression models were used to predict SEN outcome by SDB cluster and by cumulative report of SEN.

RESULTS

Controlling for 16 putative confounders, previous history of SDB and BSPs was significantly associated with an SEN. BSPs were associated with a 7% increased odds of SEN (95% confidence interval [CI] 1.01-1.15), for each ∼1-year interval at which a BSP was reported. SDB, overall, was associated with a near 40% increased odds of SEN (95% CI 1.18-1.62). Children in the worst symptom cluster were 60% more likely to have an SEN (95% CI 1.23-2.08).

CONCLUSIONS

In this population-based longitudinal study, history of either SDB or BSPs in the first 5 years of life was associated with increased likelihood of SEN at 8 years of age. Findings highlight the need for pediatric sleep disorder screening by early interventionists, early childhood educators, and health professionals.

Sleep problems, fatigue, and cognitive performance in Chinese kindergarten children

OBJECTIVE

To examine sleep problems and fatigue and their associations with cognitive performance in Chinese kindergarten children.

STUDY DESIGN

A cross-sectional analysis of baseline data from Jintan Child Cohort Study was conducted, which includes a cohort of 1656 kindergarten children in Jintan City, Jiangsu Province, China. The sample used in the current study consisted of 1385 children (44.8% girls, mean age 5.72 [SD = 0.42] years) for whom data on sleep problems or cognitive performance were available. Child Behavior Checklist was used to measure child sleep problems and fatigue, and Wechsler Preschool and Primary Scale of Intelligence-Revised was used to assess child IQ.

RESULTS

Sleep problems were prevalent, ranging from 8.9% for difficulty maintaining sleep to 70.5% for unwilling to sleep alone. Other reported sleep problems were difficulty initiating sleep (39.4%), nightmares (31.6%), sleep talking (28%), sleeping less (24.7%), and sleep resistance (23.4%). Fatigue was also prevalent, with 29.6% of children reported to be overtired and 12.6% lack of energy. Children with difficulty maintaining sleep, sleep talking, sleep resistance, or nightmares scored 2-3 points lower in full IQ than children without sleep problems. Children reported to have fatigue scored 3-6 points lower in full IQ than those children without fatigue.

CONCLUSIONS

Sleep problems and fatigue are prevalent in Chinese kindergarten children. Furthermore, sleep problems and fatigue are associated with poor cognitive performance.

Sleep problems, fatigue, and cognitive performance in Chinese kindergarten children

OBJECTIVE

To examine sleep problems and fatigue and their associations with cognitive performance in Chinese kindergarten children.

STUDY DESIGN

A cross-sectional analysis of baseline data from Jintan Child Cohort Study was conducted, which includes a cohort of 1656 kindergarten children in Jintan City, Jiangsu Province, China. The sample used in the current study consisted of 1385 children (44.8% girls, mean age 5.72 [SD = 0.42] years) for whom data on sleep problems or cognitive performance were available. Child Behavior Checklist was used to measure child sleep problems and fatigue, and Wechsler Preschool and Primary Scale of Intelligence-Revised was used to assess child IQ.

RESULTS

Sleep problems were prevalent, ranging from 8.9% for difficulty maintaining sleep to 70.5% for unwilling to sleep alone. Other reported sleep problems were difficulty initiating sleep (39.4%), nightmares (31.6%), sleep talking (28%), sleeping less (24.7%), and sleep resistance (23.4%). Fatigue was also prevalent, with 29.6% of children reported to be overtired and 12.6% lack of energy. Children with difficulty maintaining sleep, sleep talking, sleep resistance, or nightmares scored 2-3 points lower in full IQ than children without sleep problems. Children reported to have fatigue scored 3-6 points lower in full IQ than those children without fatigue.

CONCLUSIONS

Sleep problems and fatigue are prevalent in Chinese kindergarten children. Furthermore, sleep problems and fatigue are associated with poor cognitive performance.

Cognitive, behavioral, and functional consequences of inadequate sleep in children and adolescents

This article summarizes correlational, case-control, quasi-experimental, and experimental studies that have examined whether sleep during childhood and adolescence is related to daytime functioning. Published findings suggest that inadequate sleep quality and/or quantity can cause sleepiness, inattention and, very likely, other cognitive and behavioral deficits that significantly impact children and adolescents in functional settings. This article then integrates findings from longitudinal studies within a developmental psychopathology model. Important questions remain, but evidence supports the integration of sleep screening and interventions into routine clinical care and also supports advocacy for public policy changes to improve the sleep of children and adolescents.

Prevalence and risk factors of excessive daytime sleepiness in a community sample of young children: the role of obesity, asthma, anxiety/depression, and sleep

STUDY OBJECTIVES

We investigated the prevalence and association of excessive daytime sleepiness (EDS) with a wide range of factors (e.g., medical complaints, obesity, objective sleep [including sleep disordered breathing], and parent-reported anxiety/depression and sleep difficulties) in a large general population sample of children. Few studies have researched the prevalence and predictors of EDS in young children, none in a general population sample of children, and the results are inconsistent.

DESIGN

Cross-sectional

SETTING

Population -based.

PARTICIPANTS

508 school-aged children from the general population.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

Children underwent a 9-hour polysomnogram (PSG), physical exam, and parent completed health, sleep and psychological questionnaires. Children were divided into 2 groups: those with and without parent reported EDS. The prevalence of subjective EDS was approximately 15%. Significant univariate relationships were found between children with EDS and BMI percentile, waist circumference, heartburn, asthma, and parent reported anxiety/depression, and sleep difficulties. The strongest predictors of EDS were waist circumference, asthma, and parent-reported symptoms of anxiety/depression and trouble falling asleep. All PSG sleep variables including apnea/hypopnea index, caffeine consumption, and allergies were not significantly related to EDS.

CONCLUSIONS

It appears that the presence of EDS is more strongly associated with obesity, asthma, parent reported anxiety/depression, and trouble falling asleep than with sleep disordered breathing (SDB) or objective sleep disruption per se. Our findings suggest that children with EDS should be thoroughly assessed for anxiety/depression, nocturnal sleep difficulties, asthma, obesity, and other metabolic factors, whereas objective sleep findings may not be as clinically useful.

Executive summary of respiratory indications for polysomnography in children: an evidence-based review

OBJECTIVE

This comprehensive, evidence-based review provides a systematic analysis of the literature regarding the validity, reliability, and clinical utility of polysomnography for characterizing breathing during sleep in children. Findings serve as the foundation of practice parameters regarding respiratory indications for polysomnography in children.

METHODS

A task force of content experts performed a systematic review of the relevant literature and graded the evidence using a standardized grading system. Two hundred forty-three evidentiary papers were reviewed, summarized, and graded. The analysis addressed the operating characteristics of polysomnography as a diagnostic procedure in children and identified strengths and limitations of polysomnography for evaluation of respiratory function during sleep.

RESULTS

The analysis documents strong face validity and content validity, moderately strong convergent validity when comparing respiratory findings with a variety of relevant independent measures, moderate-to-strong test-retest validity, and limited data supporting discriminant validity for characterizing breathing during sleep in children. The analysis documents moderate-to-strong test-retest reliability and interscorer reliability based on limited data. The data indicate particularly strong clinical utility in children with suspected sleep related breathing disorders and obesity, evolving metabolic syndrome, neurological, neurodevelopmental, or genetic disorders, and children with craniofacial syndromes. Specific consideration was given to clinical utility of polysomnography prior to adenotonsillectomy (AT) for confirmation of obstructive sleep apnea syndrome. The most relevant findings include: (1) recognition that clinical history and examination are often poor predictors of respiratory polygraphic findings, (2) preoperative polysomnography is helpful in predicting risk for perioperative complications, and (3) preoperative polysomnography is often helpful in predicting persistence of obstructive sleep apnea syndrome in patients after AT. No prospective studies were identified that address whether clinical outcome following AT for treatment of obstructive sleep apnea is improved in association with routine performance of polysomnography before surgery in otherwise healthy children. A small group of papers confirm the clinical utility of polysomnography for initiation and titration of positive airway pressure support.

CONCLUSIONS

Pediatric polysomnography shows validity, reliability, and clinical utility that is commensurate with most other routinely employed diagnostic clinical tools or procedures. Findings indicate that the "gold standard" for diagnosis of sleep related breathing disorders in children is not polysomnography alone, but rather the skillful integration of clinical and polygraphic findings by a knowledgeable sleep specialist. Future developments will provide more sophisticated methods for data collection and analysis, but integration of polysomnographic findings with the clinical evaluation will represent the fundamental diagnostic challenge for the sleep specialist.

The association between sleep disordered breathing, academic grades, and cognitive and behavioral functioning among overweight subjects during middle to late childhood

STUDY OBJECTIVES

(1) to determine the associations of sleep disordered breathing (SDB) with behavioral functioning, cognitive test scores, and school grades during middle- to late-childhood, an under-researched developmental period in the SDB literature, and (2) to clarify whether associations between SDB and school grades are mediated by deficits in cognitive or behavioral functioning.

DESIGN

cross-sectional correlative study.

SETTING

Office/hospital, plus reported functioning at home and at school.

PARTICIPANTS

163 overweight subjects aged 10-16.9 years were divided into 4 groups based upon their obstructive apnea+hypopnea index (AHI) during overnight polysomnography and parent report of snoring: Moderate-Severe OSA (AHI > 5, n = 42), Mild OSA (AHI = 1-5, n = 58), Snorers (AHI < 1 + snoring, n = 26), and No SDB (AHI < 1 and nonsnoring, n = 37).

MEASUREMENTS

inpatient overnight polysomnography, parent- and self-report of school grades and sleep, parent- and teacher-report of daytime behaviors, and office-based neuropsychological testing.

RESULTS

The 4 groups significantly differed in academic grades and parent- and teacher-reported behaviors, particularly inattention and learning problems. These findings remained significant after adjusting for subject sex, race, socioeconomic status, and school night sleep duration. Associations with SDB were confined to reports of behavioral difficulties in real-world situations, and did not extend to office-based neuropsychological tests. Findings from secondary analyses were consistent with, but could not definitively confirm, a causal model in which SDB affects school grades via its impact on behavioral functioning.

CONCLUSIONS

SDB during middle- to late-childhood is related to important aspects of behavioral functioning, especially inattention and learning difficulties, that may result in significant functional impairment at school.

The influence of sleep quality, sleep duration and sleepiness on school performance in children and adolescents: A meta-analytic review

Insufficient sleep, poor sleep quality and sleepiness are common problems in children and adolescents being related to learning, memory and school performance. The associations between sleep quality (k=16 studies, N=13,631), sleep duration (k=17 studies, N=15,199), sleepiness (k=17, N=19,530) and school performance were examined in three separate meta-analyses including influential factors (e.g., gender, age, parameter assessment) as moderators. All three sleep variables were significantly but modestly related to school performance. Sleepiness showed the strongest relation to school performance (r=-0.133), followed by sleep quality (r=0.096) and sleep duration (r=0.069). Effect sizes were larger for studies including younger participants which can be explained by dramatic prefrontal cortex changes during (early) adolescence. Concerning the relationship between sleep duration and school performance age effects were even larger in studies that included more boys than in studies that included more girls, demonstrating the importance of differential pubertal development of boys and girls. Longitudinal and experimental studies are recommended in order to gain more insight into the different relationships and to develop programs that can improve school performance by changing individuals' sleep patterns.

No relationship between neurocognitive functioning and mild sleep disordered breathing in a community sample of children

STUDY OBJECTIVES

Our objective was to examine the relationship between sleep disordered breathing (SDB) and neurocognitive functioning in a large general-population sample of children who underwent a full-night polysomnogram and comprehensive neuropsychological testing.

METHODS

A population-based study of 571 school-aged children (6-12 years) underwent a 9-hour polysomnogram and a comprehensive neuropsychological battery.

RESULTS

No significant relationship was found between children with a mild apnea-hypopnea index (1 < or = apnea-hypopnea index < 5) and any measure of neuropsychological functioning (intelligence, verbal and nonverbal reasoning ability, attention, executive functioning, memory, processing speed, and visual-motor skill). Partial correlations between apnea-hypopnea index and neuropsychological test scores and polynominal trend analysis were all nonsignificant.

CONCLUSIONS

Children with mild SDB showed no significant neuropsychological impairment compared to children without SDB. This study suggests that children with mild SDB are not at risk for neuropsychological impairment and that the coexistence of mild SDB with any neuropsychological impairment should be considered comorbid and not causal. However, the association between neurobehavioral issues and children with mild SDB remains uncertain.

ADHD subtypes and comorbid anxiety, depression, and oppositional-defiant disorder: differences in sleep problems

OBJECTIVE

Sleep problems were analyzed in children with ADHD (Attention-deficit hyperactivity disorder).

METHODS

Scales were completed by parents of 135 control children and 681 children with ADHD combined type (ADHD-C) or inattentive type (ADHD-I) with or without comorbid oppositional defiant disorder (ODD), anxiety, or depression.

RESULTS

Children with ADHD-I alone had the fewest sleep problems and did not differ from controls. Children with ADHD-C had more sleep problems than controls and children with ADHD-I. Comorbid anxiety/depression increased sleep problems, whereas ODD did not. Daytime sleepiness was greatest in ADHD-I and was associated with sleeping more (not less) than normal. Medicated children had greater difficulty falling asleep than unmedicated children.

CONCLUSIONS

Differences in sleep problems were found as a function of ADHD subtype, comorbidity, and medication.