Getting Up on the Wrong Side of the Bed: Sleepiness, Behavior Problems, and Obesity in Children and Teens

Sarah Pedersen, Langan Denhard, Hannah Kalvin and Claire Karlsson, National Center for Health Research

 

Sleep renews and restores the body. Children or adults who don’t get enough tend to become irritable, impatient, unable to concentrate, gain weight, have increases in stress hormone levels, and are less able to ward off disease and illness.[1]

Lack of sleep affects children and young adults in many ways: students are less likely to pay attention or perform well in school; families are more likely to argue; teens are more likely to participate in risky behavior such as smoking, drinking, and drugs; and drivers are more likely to be involved in accidents.[2]

The Link Between Sleep Deprivation and Behavior Problems

Numerous studies show that children and adolescents who don’t get enough sleep are more likely to have behavioral problems. A study published in the Journal of American Academy of Child and Adolescent Psychiatry found a strong link between sleep and aggression, delinquent behavior, and attention problems among 7- to 12-year-old children.[3] Using activity monitors on their belts (actigraphs), the authors found that children who slept on average 9.6 hours per night had fewer symptoms of behavioral problems than children sleeping on average either 8.9 hours or 8 hours per night. Children with the most behavior problems had significantly lower sleep time and poorer sleep quality than children who did not show signs of behavioral problems.

A study of 490 children that were followed from the age of 4 to 15 examined the long-term effects of sleep deprivation. They found that 4-year-olds who did not sleep well on a regular basis were more likely to have aggression and attention problems in mid-adolescence.[4] The authors also found that the link between sleep problems and depression increased significantly between the ages of 4 and 15 years old.

A study of  2700 teenagers ages 13-18, conducted by University of California Berkeley researchers, found that the 30% of teens who stayed up later than 11:30 pm on school nights had worse cumulative GPA’s at graduation and more emotional distress, as measured by questionnaires after graduation. The younger teens were more likely to have lower GPAs and the older teens were more likely to report they were ‘sad,’ ‘down,’ or ‘blue,’ and said they cried frequently.[5]

A study published in Pediatrics in 2012 explored the link between sleep problems in early childhood and behavior at 4 and 7 years old.  Parents completed at least two questionnaires about sleep patterns when their children were between 6 months and approximately 6 years old. Parents reported on children’s snoring, mouth-breathing, and pauses in breathing, and on their children’s behavior when they were ages 4 and 7. The questions asked about sharing and helpfulness, hyperactivity, emotional symptoms (like anxiety and depression), peer problems, and conduct problems (like aggressiveness and rule-breaking). The authors found that the children with sleep problems in infancy were significantly more likely to display behavioral problems at age 4, and the chances of behavioral problems at age 7 were even greater.  Overall, as sleep problems increased, the likelihood of later behavioral problems also increased. Sleep problems had a greater influence on behavior than factors such as socioeconomic status (education and income), family adversity (family history of mental illness, crime, and financial insecurity), household characteristics (family size and home environment score), or other child demographics (race, gender, birth weight, and whether the child was carried full term).[6]

A study published in Journal of School Health in April 2013 looked at increased risk for school violence-related behavior in high school students who reported getting less sleep than is recommended. They found that students with insufficient sleep were more likely to carry a weapon at school in the last 30 days, miss school because they felt unsafe in the last 30 days, report being threatened or injured with a weapon at school in the last 12 months, being bullied at school in the last 12 months, or other types of incidents related to school violence.[7]

A University of Michigan study of 341 Michigan elementary school children found that children who had behavioral problems were twice as likely to have symptoms of sleep-disordered breathing (SDB), which ranges from snoring to obstructive sleep apnea.[8] Obstructive sleep apnea (OSA) is when breathing pauses during sleep because the airway has become narrowed or blocked. The survey used validated assessments to gather information from teachers and parents about children’s in-school behaviors and sleep patterns. They found that 78 children (23%) were reported to snore more than half of the time (frequently) and were sleepier than those who did not snore regularly.

Overall, 110 (32%) of 341 children were classified as having a conduct problem such as destructive tendencies, quarreling, constant fighting, and disobedience by either parents or teachers. Children with conduct problems were more likely to experience sleep-disordered breathing (SDB) than those without (30% vs. 14%). Similarly, children whose parents described them as sometimes bullying were more likely to have sleep-disordered breathing than their classmates (42% vs. 17.5%). In addition, regardless of the cause of sleepiness, students who did not get enough sleep were more likely to bully or have conduct problems.

Lack of Sleep Can Cause Weight Gain

A 2010 study found that for children ages 0 to 4, fewer hours of nighttime sleep was strongly linked to an increased risk of obesity in adolescence.[9] A 2008 study also found that overweight children ages 8 to 11 slept less on average than normal-weight children. For each 1-hour reduction in sleep, the odds of obesity increased by 41%.[10] Researchers at Harvard conclude that children who sleep fewer hours tend to gain more weight (Click here for more information)

A 2013 study by researchers at Cincinnati Children’s Hospital Medical Center investigated the link between eating and sleep patterns in adolescents ages 14 to 16. Students were randomly assigned to a group that had restricted sleep (6.5 hours in bed each night from Monday through Friday), or to a different group that had healthy amounts of sleep (10 hours in bed during the same days as the other group); sleep was measured using activity monitors worn as watches and were reviewed by the students and their parents for accuracy. After a few days in the assigned sleep group, the participants were allowed to sleep however they wanted for two days before they were switched to the other group’s sleep pattern. The study found that when the teenagers had restricted sleep, they chose foods that were higher in sugar, particularly desserts and candy.  Teens with restricted sleep also tended to eat more calories and carbohydrates.[11] This could obviously contribute to obesity.

Similarly, a 2014 study by researchers at McGill University found that eating behaviors in children ages 5 to 12 were related to how long they slept and how continuous their sleep was. They looked at three eating behaviors that happen separate from being physiologically hungry, including emotional eating (eating when distressed), external eating (eating because you see or smell food), and restrained eating (eating a lot after not eating food, often because you are trying to lose weight). The study found that different aspects of sleep such as shorter amount of sleep and waking up frequently during  the night were associated with more emotional, external, and restrained eating behaviors — and that meant eating more calories. Researchers concluded that losing sleep may be related to children not being able to regulate what they eat and therefore being at higher risk for overeating.[12]

In 2015, a study of more than 3,000 teens and young adults between ages 15-28 found that those who go to bed later on weeknights are more likely to gain weight as measured by their Body Mass Index (BMI). The researchers at the University of North Carolina at Chapel Hill concluded that every hour delay in going to sleep resulted in a BMI increase of 2, which is very substantial. A surprising finding was that this average BMI increase occurred regardless of the number of hours they slept, which the authors believe could be explained by the interruptions in metabolism that occur when people chronically stay up late. These findings demonstrate the importance of going to bed earlier in combatting obesity, in addition to the number of hours of sleep[13].

What Causes Sleep Problems in Children and Adolescents?

There are many reasons why children don’t receive the recommended 10 to 12 hours of sleep each night.[14] Inappropriate or inconsistent nap or sleep schedules often lead to difficulty falling asleep and poor sleep quality. Also, noise or too much light in the bedroom can disrupt a child’s sleep rhythm.

For adolescents, the hormonal influences of puberty tend to shift their biological clocks, resulting in less sleep. Teenagers tend to feel awake at night and therefore want to go to bed later and tend to want to sleep later in the morning. This sleep-wake rhythm is contrary to the early-morning start times of many high schools and helps explain why most teenagers get an average of only 7 to 7.5 hours of sleep when they actually require at least 9 hours. Also, as adolescents spend more time with cell phones and computers, they are less likely to get a good night’s rest.

Obesity can also cause sleep deprivation. A 2007 study examining the severity of sleep disorders in obese children found that overweight children had a significantly higher number of apneas and arousals per hour of sleep compared with normal-weight children — mostly due to increased breathing problems.[15] Some of the symptoms of sleep apnea include loud, irregular snoring, daytime sleepiness, morning headaches, weight gain, and irritability.

In a 2022 study of more than 5,000 adolescents ages 11 to 14, researchers found that the COVID-19 pandemic reduced children’s sleep due to increases in their screen time.[16] This increased screen time apparently resulted in later bedtimes. The later bedtimes remained despite starting school in-person again in 2021. The study reported an increase of 45 more minutes on social media and 20 more minutes on video games. These results highlight the importance of parents managing screen time so that it does not interfere with children’s sleep and other important health behaviors.

What Can Parents do to Help Their Children get a Good Night’s Rest

There are many steps parents can take to help their children get regular quality sleep each night. It’s important to set consistent sleep schedules for young children and stick to them. For adolescents, parents can set age-appropriate bedtimes and make rules about cell phone and computer use, especially at night. Along with consistent sleep schedules, it’s also important to make sure that children and adolescents are not exposed to noise or light during sleep hours, because this will disrupt sleep quality. Sleep routines starting about 30 minutes before bedtime also help children understand that bedtime is approaching, giving children time to get into “sleep mode.”

Earlier bedtimes can also improve a child’s good night with a longer duration of rest for all children from infants to teenagers. A study from 2022 saw that with face-to-face interventions where guardians set earlier bedtimes, children saw on average increase of 47 minutes of sleep time per night.[17]

If children suffer from insomnia or nighttime awakenings due to nightmares, parents can use methods such as muscle relaxation through massage, deep-breathing exercises and positive imagery techniques to decrease negative thoughts and help relax children at bedtime.

Many parents also try to help their children get a good night‘s sleep with the help of melatonin. Melatonin is a naturally occurring hormone that is also available as an over-the-counter sleep aid. Naturally occurring melatonin plays an important role in sleep cycles, and is released to signal to the body that it’s time to rest.[18] However, using melatonin as a dietary supplement has not been shown to help children sleep better and using this supplement can have several risks and side effects. For example, research suggests that it can lead to dangerous increases in body temperature and blood sugar levels.

Experts also caution against prolonged use of melatonin for children due to risks including headaches, dizziness, and nausea.[19] Because of its status as a dietary supplement, it doesn’t require FDA approval to be sold over the counter. This could mean that there are inconsistencies in the amount of melatonin in pills that are described as identical, and even between different bottles of the same brand. And like all dietary supplements, melatonin supplements may even be contaminated with substances that are harmful to health. A 2023 study published in the Journal of American Medical Association (JAMA) found that 22 of 25 different melatonin gummy products tested had either much more (up to 347%) or much less (one had no detectable levels of melatonin, others had up to 26% less) than the dosage listed on the bottle.[20] In other words, nearly 90% of the products were mislabeled, and only 3 melatonin products contained melatonin content within 10% of the listed amount. Although 20% of the products had CBD (the active ingredient in cannabis) listed as an ingredient, all were at somewhat higher levels than listed. [20] A Canadian study discovered that of the 31 melatonin products tested, more than two-thirds of the supplements did not meet the melatonin content labeled on the bottle, with the rest having within 10% of the listed amount.[21] In addition, more than a quarter of the melatonin products in the Canadian study contained serotonin, a substance used to treat neurological disorders, which can be potentially harmful for some people, especially those also taking SSRIs (antidepressants).[21].

In addition, more research is also needed to understand if and how melatonin affects children during puberty and what the long-term health effects of over-the-counter melatonin are.[18]

For more serious sleep problems such as apnea, snoring, and other breathing problems, the best place to begin is to help your child lose weight through a healthy diet and exercise. Even modest weight loss can greatly decrease the severity of breathing problems and snoring. If your child continues to experience sleep problems after losing weight, it’s best to speak with a pediatrician about the right solution for you and your child. Common medical treatments include sleeping with an air compressor mask or oral-jaw positioning device to keep the airway open and surgically removing the tonsils, adenoids, or excess tissue to increase the airway path.

Are these treatments effective? A study of air compressor masks, also known as continuous positive airway pressure therapy (CPAC), found that the treatment significantly reduced the severity of obstructive sleep apnea symptoms (OSA) each night.[19] Children reported feeling less sleepy during the day as a result. One problem with the mask, however, is “compliance”–that is the child’s continuing regular use of it.

A study published in 2007 found that removing the tonsils and adenoids for normal-weight children suffering from OSA significantly lowered the severity or completely eliminated symptoms of OSA. For obese children who suffered from OSA, however, the results were less promising and only slightly lowered the severity of symptoms.

Conclusions

Studies show that sleep is an important tool to help your child stay healthy and perform well in school and at home. The findings also present an alternative and preventive approach to reducing emotional distress, aggressive behavior, attention problems, and bullying. Nationally, the prevalence of such behavior among elementary schoolchildren is generally 25% or higher in boys.[22] If parents understand the effects of sleep deprivation and teachers know how to work with parents to improve children’s sleep habits, this could significantly reduce aggressive behavior and long-term health problems related to obesity.

According to the Centers for Disease Control and Prevention, cases of parent-diagnosed ADHD increased by 22% between 2003 and 2007.[23] ADHD symptoms are often identical to those linked to sleep disorders in children.  Before filling a prescription for drugs such as Adderall or Ritalin, known to induce insomnia, discuss any sleep problems your child may be having with your pediatrician. And if you’ve noticed that your child is less able to focus or more hyperactive when he hasn’t slept well, tell your pediatrician.

All articles on our website have been approved by Dr. Diana Zuckerman and other senior staff.

The National Center for Health Research is a nonprofit, nonpartisan research, education and advocacy organization that analyzes and explains the latest medical research and speaks out on policies and programs. We do not accept funding from pharmaceutical companies or medical device manufacturers. Find out how you can support us here.

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