Sleep Problems: Overview
Sleep Problems: Overview
– Leslie E. Packer, PhD
Sleep dysfunction has been linked to both academic and social/behavioral problems. Since many adolescents don’t get enough sleep because high schools start too early for an adolescent’s sleep and melatonin cycles, we shouldn’t be surprised that some students’ functioning seems significantly impaired compared to their potential. Teenagers who don’t get enough sleep are at risk for more car crashes, poorer performance in school, poorer performance in sports, and poorer performance at work. Students with the kinds of neurological disorders described on this web site are likely to have additional sleep-related problems as well, as many of these disorders are associated with significant sleep disorders.
Sleep disorders are also fairly common in children. One study found that 37% of school children they tested (from grades K – 4) suffered from at least one sleep-related problem.
Restless Legs Syndrome, Periodic Limb Movements of Sleep, narcolepsy, insomnia, and sleep apnea are different types of sleep disorders that may all contribute to a poorer night’s sleep, but they do not all have the same effect on daytime functioning, and not all neurological conditions have the same types of sleep problems associated with them. Most parents, however, will not be able to indicate what type of specific sleep disorder their child has other than to tell the school that the child is either up late, has trouble falling asleep, has trouble staying asleep, has trouble waking up, or has some other type of sleep disturbance.
In addition to sleep problems associated with the disorders, some children and adolescents also suffer from sleep-related side effects of medications that are used to treat the disorders. Stimulant medications used to treat Attention Deficit Hyperactivity Disorder, medications used to treat mood disorders, and some of the medications used to treat tics can all produce sleep problems that can affect the child in the classroom. Some medications do not affect sleep per se but may make the student very drowsy or sleepy shortly after they take their medication (e.g., Catapres that is used to treat ADHD and tics).
ATTENTION DEFICIT HYPERACTIVITY DISORDER AND SLEEP IMPAIRMENT
Sung, Hiscock, et al. (2008) investigated the prevalence of sleep problems in 239 children with ADHD and attempted to correlate sleep meausres with quality of life (QOL), daily functioning, and school attendance, caregiver mental health and work attendance; and family functioning. The study did not use objective measures of sleep problems, and used caregiver reports as their mesaures of severity of sleep problems, if any. They found that sleep problems were common: only 26.7% of caregivers reported that the child had no sleep problems, while 28.5% reported mild problems and 44.8% reported moderate or severe sleep problems. Moderate or severe sleep problems were associated with poorer child psychosocial QOL and child daily functioning including the ability to be on time for school.
Shochat et al. (2009) studied 45 children with ADHD. Not surprisingly, they found a correlation between parental reports of sleep problems and behavior, but the relationship was not as strong as we might have expected once they took sensory defensiveness into account. Tactile sensitivity was a significant predictor for sleep, while sensation seeking and tactile sensitivity were significant predictors for behavior. Although this was just a preliminary study, it suggests that treating any tactile sensitivity might improve sleep and improve behavior.
MOOD DISORDERS AND SLEEP IMPAIRMENT
Sleep problems are a cardinal feature of mood disorders. Students who are depressed may go home from school and sleep all afternoon and into the evening, missing homework time. They are then often up late at night, and have difficulty waking in the morning when it is time to get up for school. Some studies indicate that lack of sleep is associated with increased risk of suicidal ideation and increased risk of suicide attempts in the general population, independent of the impact of any comorbid disorders.
Students with Bipolar Disorder may have different sleep patterns. Staton (2008) provides a review of sleep problems in childhood-onset Bipolar Disorder in terms of subtypes of bipolar patterns as they relate to sleep onset and need for sleep. Whereas children and adolescents with part-day manic cycles and chronic mixed conditions typically exhibit delayed sleep onset but not a decreased need for sleep, children with days-long manic cycles or chronic mania typically report decreased need for sleep.
Children and adolescents with Tourette’s Syndrome (TS) report significantly more sleep problems than their non-TS peers. In boys with TS, sleep problems occur even more often when there is also comorbid Attention Deficit Hyperactivity Disorder. For children or teenagers with Tourette’s, sleep onset may be delayed because they first have to “get their tics out.” They lie down to go to bed and may tic explosively or vigorously for an hour or more.
Students with Obsessive-Compulsive Disorder also experience sleep problems, but of a different kind. Students with OCD may stay up late into the night working to get a paper “perfect,” or may be so anxious about a school assignment that they can’t get a good night’s sleep. Other children and adolescents with OCD may have time-consuming rituals that they must engage in at night that prevent them from getting to sleep at a reasonable hour: toys must be lined up “just so,” or the bedding must be in a particular way, or they may have extensive “good night” rituals involving a parent. Some children and teenagers with OCD may have time-consuming hygiene rituals and land up in the shower for hours instead of being able to take a quick shower and get ready for bed. These are just some examples — the parents of the student can let you know the extent of the problem their child is experiencing.
Storch, Murphy et al. (2008) assessed 66 children and adolescents with OCD. They found that 92% of the children experienced at least one sleep-related problem; 27.3% reported five or more types of sleep-related problems. The total number of sleep-related problems were positively correlated with OCD severity, anxiety severity, and parent ratings of internalizing problems. Significantly, some sleep-related problems decreased following cognitive-behavioral treatment.
Sleep problems have long been noted in autistic children, but the impression of the extent and nature of difficulties depends, in part, on what methodology the investigators use to study the problem. Of particular note for educators is a study by Elia et al. (2000), who found that some of the sleep measures were significantly correlated with the child’s functioning. Nonverbal communication showed significant correlation with sleep period time, wakefulness after sleep onset, and total sleep time. Relating to people and activity level items were found to be significantly correlated with rapid eye movement density.
WHAT TO DO
If the student or parents report sleep problems to you, scheduling a meeting with the student and parents to discuss what might be helpful is in order. But do not count on the parents remembering to mention sleep problems to you. They are often aware of them, but are so busy dealing with the symptoms of the primary diagnosis (or diagnoses) that they may neglect to tell you that the child is not sleeping well, is up all or night, or can’t wake up in the morning.