It has long been known that sleep problems occur disproportionately among children with a variety of disabilities compared with children who develop normally. The negative impact on behavior of sleep disturbance is also well recongized. To date, however, a clear link between disrupted sleep and later learning difficulties has not been established nor has a bidirectional relationship been ruled out.
We conducted the first large prospective longitudinal study of the effects of both respiratory and behavioral sleep problems on future need for speical education services. We evaluated and followed more than 11,000 children for more than 6 years making the study the largest of its kind.
We found that behavioral sleep problems (BSP) in early childhood (through age 5 years) were associated with 7% increased odds of special education needs at age 8 years. By the same age, the children in who sleep disordered breathing (SDB) was the worst were 60% more likely to have special education needs. We feel the results have strong implications for clinicians, educators, and parents.
A Case for Causation
Previous studies have suggested a possible connection between SDB symptoms and subsequent behavioral problems, but findings have been limited because of small sample size, short follow-ups of only 1 SDB symptom, or limited control of confounding variables. We were able to control for 15 possible confounding factors, including socioeconomic status, maternal smoking during the first trimester of pregnancy, and low birth-weight. We also controlled for IQ—a significant driver of special education need.
To assess SDB, we looked at the combined effects of snoring, apnea, and mouth-breathing on the behavior of children enrolled in the Avon Longitudinal Study of Parents and Children in the United Kingdom. We asked parents to complete questionnaires about their children’s SDB symptoms at several intervals, from 6 to 69 months of age.
When children were ages 4 and 7 years, parents completed the Strengths and Difficulties Questionnaire (SDQ). The SDQ rates for inattention/hyperactivity, emotional symptoms (anxiety and depression), peer difficulties, behavior problems (aggressiveness and rule-breaking), and pro-social behavior (sharing, helpfulness, etc).
Children with SDB were from 40% to 100% more likely to develop neurobehavioral problems by age 7, compared with children without breathing problems. We saw significant increases across all 5 behavioral measures, but the largest was in hyperactivity.
An early peak in SDB symptoms (at 6 or 18 months) conferred a 40% and 50% likelihood, respectively, of behavioral problems at age 7 compared with children who had normal breathing. The worst behavioral problems were seen in children whose SDB symptoms continued throughout the evaluation period and became most severe at 30 months.
Screening and Prevention
It’s clear that we can’t translate even these longitudinal findings into strict cause and effect, but they do make clear the significant risk for long-term developmental deficits that might occur from early respiratory-associated sleep problems. The results also make a significant case for vigilance among pediatricians and primary care physicians for signs and symptoms of sleep problems in infancy and early childhood years. The American Academy of Pediatrics has issued guidelines for screening for sleep disordered behavior.
1. Bonuck K, Rao T, Xu L. Pediatric sleep disorders and special education needs at 8 years: a population-based cohort study. Pediatrics. 2012;130:634-642.
2. Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130:576-584.