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Sleepless in America: inadequate sleep and relationships to health and well-being of our nation's children.

Article Excerpt
INADEQUATE SLEEP DURING childhood is an invisible phenomenon that fails to receive attention from primary care providers until it interferes with the child's behavior, mood, or performance. (1-4) Community and multi-site studies have consistently reported that up to 20% to 25% of US children and adolescents experience a range of sleep problems). (5-10) Inadequate sleep takes many forms: difficulty with sleep onset, length, or circadian rhythms with resulting daytime sleepiness experienced by otherwise healthy children; disturbed sleep associated with acute and chronic illness; and primary sleep disorders. The least attention has been paid to the first group, and there is little consensus about the second.

Normative requirements for adequate sleep based on epidemiologic and laboratory studies (11-13) reflect the need for progressively less sleep by developmental stage with averages of 10 hours for 5- to 13-year-olds (declining from 11.1 at 5 years to 9.0 hours at 13 years) and 8 to 9 hours for adolescents 14 to 18 years of age. (11) More recent reports suggest that adolescent needs may be underestimated: especially during midadolescence. (14) Evidence is accumulating that US children and teens typically sleep less than the required hours recommended: (8-10,15,16) Primary care providers inadequately assess, diagnose, or treat sleep problems even when parents and children offer complaints. (1) Strength of associations between sleep disturbances and cognition, behavior, or mood in otherwise healthy children range from robust to unknown. (17)

Relationships between sleep disturbance and chronic health conditions during childhood have been investigated. The association of sleep and attention-deficit/hyperactivity disorder (ADHD) is not well understood. The consequences of impaired sleep may resemble and/or exacerbate ADHD symptomatology. Conversely, ADHD symptoms and psychostimulant medication may exacerbate sleep impairment. Although as many as 50% of parents of children and adolescents with ADHD report sleep problems, (18-20) studies using more objective polysomnography have failed to demonstrate differences in sleep architecture between children with and without ADHD. (20)

Similarly, both research and clinical experience supports the relationship between sleep problems and mood and anxiety disorders, although it is unclear whether the sleep problem or the psychiatric disorder is the primary problem. (21,22) In some studies, primary psychopathology is associated with or worsened by sleep impairment: Consistently, sleep impairment and mood and anxiety disorders are comorbid conditions. Atopic disorders, such as asthma and allergic rhinitis, have also been associated with increased sleep impairment. (2,23,24)

The purpose of this study was to describe the prevalence and characteristics of inadequate sleep as perceived by parents of a random national sample of school-aged and adolescent children and reported as part of the 2003 National Survey of Children's Health (NSCH). We use a multi-domain conceptual approach incorporating child, family, and environmental factors. The assumptions are made that children require regular patterns and specific hours of sleep according to developmental stage and that inadequate sleep is undesirable and potentially deleterious to health.

METHODS

Data Source

Data for this study come from the responses of parents or caregivers of 68 418 children between the ages of 6 and 17 years interviewed as part of the 2003 NSCH who responded to the question "During the past week, on how many nights did your child get enough sleep for a child his/her age?" "Enough sleep" was broadly interpreted as however the parent/caregiver defined it for a particular child. Parents of children <6 years of age were not asked this question as part of the survey. The survey design is described briefly in the article by Kogan and Newacheck (25) in this issue; more in-depth information can be found elsewhere: (26)

Variables

We stratified children by age into 2 groups: school-aged children (6-11 years) and adolescents (12-17 years). Independent variables were organized by the following categories: demographic characteristics, child health (health status, comorbid conditions, and reported child behaviors); school and activities (problems in school physical activity, and television viewing), and family/ community life (family structure, parental health, and family stress). The dependent variable, inadequate sleep, was a response to the question on the survey indicating that the child did not sleep well on at least 1 night of the preceding week.

Some variables and/or response categories were merged into broader categories before inclusion in bivariate or multivariate models. Race and ethnicity variables were merged to encompass non-Hispanic white, non-Hispanic black, Hispanic, and other race. The category "other race" was inclusive of children identified as Asian or Native American. We dichotomized responses to questions about time spent watching television, watching videos, or playing video games at [greater than or equal to] 2 hours and <2 hours in accord with the guidelines established by the American Academy of Pediatrics (37) We merged responses to 3 questions that asked parents whether a doctor or other health professional had told them that their child had asthma, hay fever or another respiratory allergy, or eczema or another skin allergy to create the variable "atopic condition."

A variable "depressive symptoms" was created from collective responses to 4 questions that asked about level of parental concern regarding the following child behavioral characteristics: stubborn, sullen, or irritable; feeling worthless or inferior; unhappy, sad, or depressed; and withdrawn and does not get involved with others. We quantified level...