Hiperactividad En Niños

DOI: 10.1542/peds.2008-2164

Pediatrics 2009;123;e857-e864

Tarja Porkka-Heiskanen

Anu-Katriina Pesonen, Anna-Liisa Järvenpää, Timo Strandberg, Eero Kajantie and

E. Juulia Paavonen, Katri Räikkönen, Jari Lahti, Niina Komsi, Kati Heinonen,

Attention-Deficit/Hyperactivity Disorder in Healthy 7- to 8-Year-Old Children

Short Sleep Duration and Behavioral Symptoms of

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ARTICLE

Short Sleep Duration and Behavioral Symptoms of

Attention-Deficit/Hyperactivity Disorder in Healthy

7- to 8-Year-Old Children

E. Juulia Paavonen, MD, PhDa,b, Katri Ra¨ikko¨ nen, PhDa, Jari Lahti, MAa, Niina Komsi, MAa, Kati Heinonen, PhDa, Anu-Katriina Pesonen, PhDa,

Anna-Liisa Ja¨rvenpa¨a¨ ,MDc, Timo Strandberg, MD, PhDd,e, Eero Kajantie, MD, PhDc,f, Tarja Porkka-Heiskanen, MD, PhDg

Departments of aPsychology and gPhysiology, University of Helsinki, Helsinki, Finland; bNational Institute for Health and Welfare, Helsinki, Finland; cHospital for Children

and Adolescents, Helsinki University Central Hospital, Helsinki, Finland; dInstitute of Health Sciences/Geriatrics, University of Oulu, Oulu, Finland; eUnit of General Practice,

Oulu University Hospital, Oulu, Finland; fNational Public Health Institute, Helsinki, Finland

The authors have indicated they have no financial relationships relevant to this article to disclose.

What’s Known on This Subject

Children withADHDoften have sleeping difficulties, and children with sleep apnea often

display behavioral symptoms. The few experimental studies in children suggest that

sleep restriction impairs attention and cognitive performance.

What This Study Adds

Children who get less sleep have higher behavioral symptoms scores than those who

get more sleep. This association was not explained by sleeping difficulties or confounding

factors; short sleep duration and sleeping difficulties were both related to behavioral

symptoms.

ABSTRACT

OBJECTIVE. It has been hypothesized that sleep deprivation may manifest in children as

behavioral symptoms rather than as tiredness, but only a few studies have investigated

this hypothesis. The objective of our study was to evaluate whether short sleep

is associated with behavioral symptoms of attention-deficit/hyperactivity disorder in

7- to 8-year-old children.

METHODS.We performed a cross-sectional study of children born in 1998 in Helsinki,

Finland. The participants included 280 (146 girls, 134 boys) children with a mean age

of 8.1 years (SD: 0.3; range: 7.4–8.8). Sleep quality was measured by using actigraphs.

The Sleep Disturbance Scale for Children and the Attention-Deficit/Hyperactivity

Disorder Rating Scale IV were administered to parents.

RESULTS. Children whose average sleep duration as measured by actigraphs was short

(
10th percentile, ie,
7.7 hours) and had a higher hyperactivity/impulsivity score

(9.7 vs 7.8 or 7.5) and a higher attention-deficit/hyperactivity disorder total score

(17.3 vs 14.5 or 13.1) but a similar inattention score (7.6 vs 6.7 or 5.6) compared

with children sleeping 7.7 to 9.4 hours or 9.4 hours. In multivariate statistical

models, short sleep duration remained a statistically significant predictor of hyperactivity/

impulsivity, and sleeping difficulties were associated with hyperactivity/

impulsivity, inattention, and the total score. There were no significant interactions

between short sleep and sleeping difficulties.

CONCLUSIONS. Children’s short sleep duration and sleeping difficulties increase the risk

for behavioral symptoms of attention-deficit/hyperactivity disorder. Pediatrics 2009;

123:e857–e864

INATTENTION AND HYPERACTIVITY/IMPULSIVITY, the key dimensions in attention-deficit/hyperactivity disorder

(ADHD), have long ago been hypothesized to be hallmarks of sleep deprivation among healthy children,1 but

studies assessing the effects of sleep deprivation on children’s behavior have been scanty; thus, this statement is based

mainly on practical experience or clinical observations.

The few experimental sleep restriction studies in children have mainly concentrated on the cognitive consequences

of sleep deprivation.2–7 However, the studies by Fallone et al,2,3 also covered behavioral aspects and a

significant increase in inattention scores was reported, whereas the increases in hyperactivity and impulsivity scores

were not statistically significant. Moreover, a few surveys have also associated parent-reported short sleep duration

with externalizing symptoms,8,9 depression,10 or inattention.11 Only 2 studies to date have assessed the consequences

of short sleep using actigraphs: Aronen et al12 associated short sleep duration with inattention and externalizing

symptoms in 49 children aged 8 to 12 years, and Nixon et al13 with emotional instability but not inattention or

hyperactivity in a sample of 519 children aged 7 years. However, in the latter study, the actigraph registration

www.pediatrics.org/cgi/doi/10.1542/

peds.2008-2164

doi:10.1542/peds.2008-2164

Key Words

attention deficit/hyperactivity disorder,

behavioral symptoms, child, sleep, sleep

deprivation, sleep disorders

Abbreviations

ADHD—attention-deficit/hyperactivity

disorder

DIMS—disorder of initiating and

maintaining sleep

SBD—sleep breathing disorder

DA—disorder of arousal

SWTD—sleep-wake transition disorder

DES—disorder of excessive somnolence

SHY—sleep hyperhydrosis

Accepted for publication Jan 12, 2009

Address correspondence to E. Juulia

Paavonen, MD, PhD, National Institute for

Health and Welfare, Child and Adolescent

Mental Health, PO Box 30, Il-00271, Helsinki,

Finland. E-mail: juulia.paavonen@helsinki.fi

PEDIATRICS (ISSN Numbers: Print, 0031-4005;

Online, 1098-4275). Copyright©2009 by the

American Academy of Pediatrics

PEDIATRICS Volume 123, Number 5, May 2009 e857

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included only 1 night, and the unidimensional actigraphs

were worn on a belt around the waist, which

may lead to inaccurate sleep parameters.14,15 Thus, there

is a clear need to further explore the behavioral effects of

short sleep in large epidemiologic cohorts.

The main objective of our study was to test whether

short sleep duration as measured by actigraphs or parental

reports is associated with behavioral symptoms in

7- to 8-year-old children. Our main hypothesis was

that short sleep duration is related to behavioral symptoms

of ADHD. We also tested whether short sleep is

related to behavioral symptoms independently of sleeping

difficulties.

METHODS

The children came from a random, population-based

urban cohort initially comprising 1049 infants born in a

large maternity hospital from March 1 through November

30, 1998, in Helsinki, Finland, and their mothers.16

The eligible infants were defined as those born as

healthy singletons between 35 and 42 weeks of gestation.

In 2006, children and their parents were invited to

participate in a follow-up. The local ethical committees

approved the project. Each child’s parent gave written

informed consent. Nine hundred twelve (86.9%) mothers

of the initial cohort agreed to be included in the

follow-up, and 890 (84.8% of the initial cohort) mothers

were traced.

Because 1 of the major study objectives of this multidisciplinary

follow-up study was to assess how maternal

licorice use during pregnancy exerts effects on the

child’s developmental outcomes, the sample was

weighted according to maternal licorice use during pregnancy.

The study reported here is not related to that

research question, but the sampling method was taken

into account in the statistical analysis. We invited all 88

children belonging to the group who were prenatally

exposed to high levels of glycyrrhizin in licorice (
500

mg/week); 64 children participated. The other invited

children had to live within a 35 mile radius from Helsinki

to manage costs (n  325). The latter group consisted

of 271 (42.4%) children with low (250 mg/

week) maternal licorice exposure and 54 (42.5%)

children with moderate (250–499 mg/week) maternal

licorice exposure; of these 211 and 46 children participated,

respectively.

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