Children's academic performance and sleep

This article explains how academic performance in children is affected by their sleep.

Making sure school-aged kids get to sleep at a regular hour is often a struggle for parents. But a study by researchers at McGill University and the Douglas Mental Health University Institute in Montreal suggests it's well worth the effort: the researchers found that a good night's sleep is linked to better performance in math and languages -- subjects that are powerful predictors of later learning and academic success.

In findings published recently in the journal Sleep Medicine, the researchers reported that "sleep efficiency" is associated with higher academic performance in those key subjects. Sleep efficiency is a gauge of sleep quality that compares the amount of actual sleep time with the total time spent in bed.

While other studies have pointed to links between sleep and general academic performance, the Montreal scientists examined the impact of sleep quality on report-card grades in specific subjects. The upshot: with greater sleep efficiency, the children did better in math and languages -- but grades in science and art weren't affected.

"We believe that executive functions (the mental skills involved in planning, paying attention, and multitasking, for example) underlie the impact of sleep on academic performance, and these skills are more critical in math and languages than in other subjects," says Reut Gruber, a clinical child psychologist who led the study. Low academic achievement in children is a common and serious problem that affects 10-20 % of the population. "Short or poor sleep is a significant risk factor for poor academic performance that is frequently ignored," says Gruber, who is a researcher at the Douglas Institute and professor in McGill's Department of Psychiatry.

Gruber's research team, in collaboration with the Riverside School Board in Saint-Hubert, Quebec, studied 75 healthy children between 7 and 11 years of age. The children's nighttime sleep was monitored by actigraphy, which uses a wristwatch-like device to evaluate sleep by measuring movements. "We averaged the data over five nights to build the children's habitual sleep patterns and correlated the data with their report-card grades," Gruber says.

The takeaway for parents

The findings underscore the importance of identifying sleep issues that may otherwise go unnoticed, Gruber says. That doesn't mean parents need to rush out and have their kids tested at sleep clinics -- but it does point to a need for pediatricians to incorporate questions about sleep into routine checkups, she adds.

"I think many kids might have some sleep issues that nobody is aware of," she says. "And if the pediatrician doesn't ask about it, we don't know that it's there. Regular screening for possible sleep issues is particularly important for students who exhibit difficulties in math, languages or reading."

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Children with ADHD perform worse than peers in second grade

A study shows that children with ADHD perform below their peers as early as second grade.

Children with attention-deficit/hyperactivity disorder (ADHD) perform well below their peers who do not have ADHD on multiple functional domains as early as grade 2, a new community-based study shows.

Daryl Efron, MD, Murdoch Children's Research Institute, Melbourne, Australia, and colleagues found that children with ADHD between 6 and 8 years of age were 11.0 times more likely to meet criteria for externalizing disorders than non-ADHD control children (P < .001).

They were also almost 3 times more likely than control individuals to meet criteria for internalizing disorders (P = .02).

On both reading and math computation, "striking" differences in academic performance were again observed between children who had ADHD and control children, equating to nearly a full standard deviation for both literacy and numeracy, the researchers report.

Children with ADHD were also more likely than control children to have problems with their peers according to both parent and teacher reports.

Yet prior to study enrollment, only 17% of children in the ADHD group had been diagnosed with ADHD, and only 13% were taking a medication for it.

"In their second year of school, children who had ADHD performed worse than controls across all functional domains, yet only a minority had been formally diagnosed with ADHD," investigators write.

"Findings highlight the need for earlier diagnosis and intervention."

The study was published online September 29 in Pediatrics.

High Comorbidity Burden

Participants were recruited from 43 elementary schools in metropolitan Melbourne, Australia.

The Conners 3 ADHD Index was distributed to parents of all second grade children in participating schools. Teachers completed the same measure.

Children were defined as screening negative for ADHD if their score on the ADHD Index was less than the 75th percentile (boys) or less than the 80th percentile (girls) by both parent and teacher reports and there was no parent-reported diagnosis of ADHD.

Each positive screen was randomly matched on sex and school to a negative screen.

ADHD Index cases were confirmed, and the presence of mental health comorbidities was assessed using the National Institute of Mental Health's Diagnostic Interview Schedule for Children, Version IV, conducted face-to-face with parents.

Children were classified as having an internalizing disorder if they met criteria for separation anxiety disorder; social phobia; generalized anxiety disorder; posttraumatic stress disorder; obsessive-compulsive disorder; hypomania; or manic episode.

Children were classified as having an externalizing disorder if they met criteria for oppositional defiant disorder or conduct disorder.

Academic achievement was assessed using the word reading and math computation subtests of the Wide Range Achievement Test 4, and social functioning was assessed by using the 5-item parent- and teacher-reported peer problems scale of the Strengths and Difficulties Questionnaire.

A total of 179 children with ADHD and 212 children without were compared across the various functional domains. Among those with ADHD, 93 had the combined ADHD subtype; 64, the inattentive subtype; and 22, the hyperactive subtype.

The most prevalent comorbid mental health disorder in children with ADHD was oppositional defiant disorder, affecting 54.2% of the group.

Children with ADHD were also significantly more likely than control children to have multiple impairments (P < .001).

The authors note that only 11% of children with ADHD had no functional impairments, compared with 57% of non-ADHD control children.

Children with ADHD "had a high burden of mental health comorbidities, were performing markedly worse academically, and had poorer peer relations," the investigators write.

"Our findings suggest that comorbidities are identifiable by early primary school age if symptoms are inquired about systematically."

"This is important," they add, "as children who have ADHD and comorbidities respond optimally to a combination of medication and behavioral interventions."

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Sleep, academics, and behavior all improved by limited screen time

A study shows that limiting screen time improves sleep quality, academic performance, and behavior in children. JR

Parents may not always see it, but efforts to limit their children's screen time can make a difference. A new study, published inJAMA Pediatrics, found children get more sleep, do better in school, behave better and see other health benefits when parents limit content and the amount of time their children spend on the computer or in front of the TV.

Douglas Gentile, lead author and an associate professor of psychology at Iowa State, says the effect is not immediate and that makes it difficult for parents to recognize. As a result, parents may think it is not worth the effort to monitor and limit their children's media use. But Gentile says they have more power than they realize.

"When parents are involved it has a powerful protective effect across a wide range of different areas that they probably never would have expected to see," Gentile said. "However, parents aren't likely to notice that putting limits on the children's media is having these effects seven months later."

Considering that children average more than 40 hours of screen time a week, not counting time spent on a computer at school, even small changes can make a difference, researchers said. They are not suggesting parents completely eliminate screen time, but find a healthy balance.

The study found there is a ripple effect associated with the benefits of limiting both screen time and media content. Gentile is not surprised to see a direct impact on sleep, academics and behavior. However, limited screen time also indirectly affects body mass index. The study found that children got more sleep if parents limited screen time, which also resulted in lower risk of obesity. Parents limiting exposure to violent media resulted in increased prosocial behavior and lowered aggressive behavior seven months later.

Researchers analyzed the media habits of more than 1,300 school children who were recruited to participate in an obesity prevention program. Students and parents were surveyed about everything from screen time limits, to violent media exposure, to bedtimes and behavior. Teachers reported grades and commented on student behavior and school nurses measured each student's height and weight.

Data were collected at the start of the program and seven months later at the end of the program. By looking at these factors collectively with a group of children over a school year, it was easier for researchers to identify patterns that are hard to recognize in individual children.

"As parents, we don't even see our children get taller and that's a really noticeable effect. With media, what we're often looking for is the absence of a problem, such as a child not gaining weight, making it even more difficult to notice," Gentile said.

"Even with changes that we do notice, we really don't recognize in the moment how all these things are related to each other across time," he added. "Yes, as screen time goes up, school performance goes down, but that doesn't happen overnight. If I watch a lot of TV today, I don't get an F in my class tomorrow."

Doctors can make a difference, too

The American Association of Pediatrics recommends no more than one to two hours of screen time a day for children two years and older. Reality far exceeds those recommendations, which might explain why doctors feel it is futile to talk with parents about guidelines for media use, Gentile said. The study provides further evidence of why pediatricians need to have that conversation.

"Hopefully, this study will give pediatricians a better sense of efficacy that it's worth taking the time to talk to parents," Gentile said. "Even if doctors only influence 10 percent of the parents, that's still millions of children having much better health outcomes as a result."

Researchers recommend doctors talk with parents about setting limits and actively monitoring media use. This can include talking with children about media content, explaining the purpose of various media and providing overall guidance.

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Study: Teenagers who go to sleep late have lower grades

A study shows that teenagers with late bedtimes have lower grades than those who go to sleep earlier.

Teens with late bedtimes during the school year and schooldays that start early have lower academic performance and are at risk for later emotional distress. A new study in the Journal of Adolescent Health provides further evidence for a growing body of research that supports a movement to delay school start times for adolescents.

"Going to bed after 11:30 pm, particularly in younger adolescents, predicted worse cumulative grade point average (GPA) at high school graduation and more emotional distress in the college years and beyond," said the study's lead author Lauren D. Asarnow, MA, a doctoral student in the department of psychology at the University of California, Berkeley.

The study gathered data on sleep and the number of hours slept from 2,700 teens age 13 to 18 participating in the National Longitudinal Study of Adolescent Health in two cohorts, one in 1995, the second in 1996. In 2001-2002, as respondents aged, data on academic performance and self-reported emotional health were collected for longitudinal comparison. The overall goal of the study was to examine the relationship between the sleep/circadian patterns of high school adolescents in a nationally representative sample, their overall academic performance in high school and rates of emotional distress reported post graduation.

For both high school cohorts, 23 percent of participants reported going to bed at 11:15 pm or later. By the time these teens reached graduation and college age, late school year bedtimes in high school predicted both lower cumulative GPA at graduation and more emotional distress between age 18 and 26. The researchers noted previous research found that adolescents who prefer late activities and bedtimes (a pattern of behavior often referred to as an evening circadian preference) were tested in the morning; they performed worse on cognitive tasks.

Asarnow urged parents to help youngsters get to bed earlier and added that a teen's sleep behavior is highly modifiable with proper support. However, shifting a teen's bedtime from a late to an earlier hour can be hard, she added, in part because for 30 percent to 40 percent of teens, delayed bedtimes have a biological basis tied to the onset and progress of puberty. Furthermore, academic pressure, habits around technology use and the bedtimes of friends also influence a teen's choice to turn in or stay up late.

Timothy Monk, Ph.D., director of the Human Chronobiology Research Program at the University of Pittsburgh agreed that the need to rise very early for school can put students at risk for underperformance academically and for other problems tied to a lack of sleep. "An early school start time both limits the sleeping time of the student and asks him or her to learn at what is close to the nadir of their circadian cycle."

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Parent's goals for their children determine ADHD treatment

A study shows that parents who are interested in the academic success of their child are more likely to start their child on medication whereas parents who are interested in behavior modification are more likely to start behavior therapy.

Parents' goals and concerns for their children with attention-deficit/hyperactivity disorder may influence their decision to start behavior therapy or medication, according to a new study that researchers say supports a shared decision-making approach to ADHD treatment.

Researchers found parents who were focused on their child's academic achievement were twice as likely to have the child started on medications, which include Adderall and Ritalin, as other parents.

Parents who expressed goals of improved behavior and interpersonal relationships were 60 percent more likely to start behavior therapy - which involves parents meeting with a counselor to learn how to manage a child's behavior.

"Studies like this really suggest that taking a shared decision-making approach may be one way to match the kids for whom (treatment) is warranted to the best treatment," Dr. Alexander Fiks, from The Children's Hospital of Pennsylvania in Philadelphia, said.

"For parents, the real thing is to ask pediatricians to really explain the pluses and minuses of all of the different options, and to make sure they can articulate what they're really most hoping to achieve," Fiks, the study's lead author, told Reuters Health.

According to 2011 guidelines from the American Academy of Pediatrics, "family preference is essential in determining the treatment plan" for children diagnosed with ADHD.

But Fiks said no one had looked at whether there were benefits to assessing parents' preferences and goals for treatment.

"There are barriers in real-world settings," he noted. "It takes time, people are busy."

For their study, Fiks and his colleagues surveyed the parents and guardians of 148 children with ADHD, ages six to 12, about their goals for treatment and the acceptability, feasibility and side effects they associated with different treatment options.

None of the children were using a combination of behavior therapy and medication at the outset, although some were using one or the other.

Six months later, 46 of the 108 children not initially using medication had started on the drugs and 30 out of 124 had started behavior therapy, according to findings published in Pediatrics.

Not surprisingly, researchers said, parents who had initially agreed with statements such as, "Medication is a reasonable way to help my child" and, "I would have trust in my doctor to treat my child's ADHD with medicine" were more likely to go that route.

Likewise, children whose parents rated behavior therapy as more acceptable and said they would be comfortable working with a counselor were more likely to be receiving therapy six months later.

What was newer and more surprising, Fiks said, was how closely treatment goals aligned with which families opted for medication and which started behavior therapy.

Dr. Laurel Leslie, who has studied treatment of ADHD at the Tufts University School of Medicine in Boston, said those goals and subsequent choices are consistent with scientific evidence.

"What we do know is, a lot of the medications last under eight hours. So if you're taking a medication, it's probably only working during school time," Leslie, who wasn't involved in the new study, told Reuters Health.

Behavior therapy, on the other hand, is going to have the strongest effects with the family, at night and on weekends, she said.

According to the Centers for Disease Control and Prevention, parent reports suggest close to one in 10 kids and teens in the U.S. has ever been diagnosed with ADHD, and two-thirds of those with a current diagnosis are taking medication.

"I think this particular study speaks to the need to spend a little bit more time getting to know families … their own hopes and wishes for what is going to improve and preferences for how to go about making those benefits happen," said Dr. Alice Charach, the head of neuropsychiatry at The Hospital for Sick Children in Toronto.

Charach, who also wasn't involved in the new research, recommended parents collect ideas and information before meeting with their child's pediatrician.

"It's helpful to have thought about what you hope to get out of the appointment and what your goals are for the child," she told Reuters Health.

By the time children get to be nine or 10 years old, Charach added, they should be involved in the shared decision-making process as well.

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Sleep and academic success in children

This article discusses how important sleep is to academic success for young children.

CHILDREN who have trouble sleeping tend to do worse in school than their peers who get a good night’s sleep, a new study suggests.

Researchers in Brazil looked at children aged seven to 10 who attended São Paulo public schools. They found children with symptoms of sleep disorders or sleep breathing disorders earned lower grades than those without problems sleeping, on average.

Thirteen percent of children with difficulty sleeping had failing grades in Portuguese, compared with 9% of those without sleep problems. Likewise, 25% of children with disrupted sleep had failing maths grades, versus 8% of children without trouble sleeping.

"Because (symptoms of sleep disorders) and particularly (sleep breathing disorders) are highly prevalent, we suggest that all health professionals and educators become aware of this striking effect and take appropriate actions to solve or mitigate what could very well constitute a public health issue," researchers led by Dr Luciane Bizari Coin de Carvalho from the Universidade Federal de São Paulo write.

In the US, experts estimate that roughly a quarter of children have disrupted sleep at some point during childhood. There are no definitive statistics on how many South African children have disrupted sleep patterns, but experts say rates are likely to be as high, if not slightly higher in this country, for a variety of socioeconomic reasons.

Erratic bedtime hours and anxiety, either at school or at home, may contribute.

Sleep disorders

Other children may have unrecognised sleep disorders, such as sleep walking, nightmares or insomnia, or sleep breathing disorders such as sleep apnea. Some medications, including those for asthma or attention-deficit/hyperactivity disorder, can affect sleep. The underlying medical problems may also cause sleep disturbances.

Poor sleep among children has been tied to obesity, which over the long term increases the risk of heart disease and diabetes. And poor school performance has been linked to early dropout rates, so the new findings may have implications beyond getting a good night’s sleep, researchers say.

From 1999 to 2001, the researchers distributed 5,400 questionnaires asking about symptoms of sleep disorders and sleep breathing disorders to children in São Paulo public schools.

Then they looked at the Portuguese and maths grades of 2,384 children whose parents filled out and returned the questionnaire.

The study team found about 31% of the children had symptoms of sleep disorders — such as difficulty falling or staying asleep, or feeling sleepy all the time — and close to 27% had sleep breathing disorders. Those students’ grades were significantly lower than the grades of children without sleep disorder symptoms.

In Brazil, grades are based on a scale of 0 to 10, with 5 considered passing. Average Portuguese grades were 6.6 for children with sleep problems, compared with 7.1 among those with no sleeping trouble.

Likewise, children with symptoms of sleep disorders or sleep breathing disorders earned an average grade of 6.3 in maths, compared with 7.1 for other children, according to findings published in the journal Sleep Medicine.

Dr Carl Bazil, a neurologist and director of the division of epilepsy and sleep at New York-Presbyterian/Columbia University Medical Centre in New York City, notes that this study fills a research void.

Learning information

"There’s growing information, mainly in adults, that you need good quality sleep to process and learn new information," Dr Bazil says.

"It stands to reason that, if anything, sleep would be more important in children, but there’s very little information in children about sleep disturbance and learning."

Research has shown that sleep deprivation might affect certain parts of the brain, especially the frontal lobes. The frontal lobes control executive function, which is the ability to make decisions, form memories, plan for the future and inhibit socially undesirable behaviour, such as fighting with a classmate.

However, the new study cannot say definitively that sleep problems were to blame for poor grades, researchers say.

"This study doesn’t prove that a sleep disturbance causes decreased academic performance," Dr Bazil says, "but it shows an association. Basically every category of sleep disturbance the authors looked at correlated with decreased academic performance."

The researchers relied on parents’ reports of their children’s sleep, rather than bringing children into a sleep lab overnight, for example.

The study is "far from perfect", Dr Bazil says. But, "it’s a first step in emphasising that sleep in children is something that’s important, not only to prevent them from being sleepy but to make sure that they learn.

"I think this study will help raise awareness that sleep is particularly important in children."

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Healthy diet and sleep help children learn

For children, success at school is influenced by a healthy diet and getting enough sleep.

Backing what many parents already believe, experts say that healthy eating and good sleep habits can help youngsters do well at school.

"Your brain can't work if you're not consuming enough calories, and in general that's not a problem," Krista Casazza, an assistant professor in the nutrition sciences department at the University of Alabama at Birmingham, said in a university news release. "But when kids go to school without eating breakfast, their [thinking and learning skills] can be affected."

Children should start the day with fruits, proteins and whole grains. They should avoid sugary cereals because they cause a sugar high followed by a crash.

"A balanced breakfast will fuel the body for a long period and help sustain their attention level through lunch, when they need to eat well again," Casazza said. "This will hold them until dinner, and they won't snack ravenously after school."

If their kids do need to eat something before dinner, parents can offer healthy choices such as yogurt, fruits and vegetables. Baked chips, in moderation, can be an option if children want "kid stuff." For a drink, give them water instead of soda.

Sleep is another important part of success at school.

"Children need a good night's sleep for their overall school performance," Kristin Avis, an associate professor in the pulmonary and sleep medicine division in the pediatrics department at UAB, said in the news release.

"Lack of sleep can lead to problems with attention and memory in the classroom, affect impulse control and mood regulation [and] lead to anxiety and even depression," she explained.

Children aged 6 to 12 should get nine hours sleep per night, as should teens aged 13 to 18. However, they typically average little more than seven hours per night, Avis said.

"Often parents think one night of sleep loss won't matter, but that's all it takes to affect them the next day," she said. "If they are chronically deprived, it can snowball and make matters worse."

Trying to catch up on lost sleep on the weekend can compound the problem.

"If kids sleep in Saturday, they have a hard time going to bed Saturday night; so they sleep in Sunday and have a hard time going to bed Sunday night. Monday morning they are tired, and it's hard to wake up for school. They struggle to get back on a good sleep schedule," Avis said.

Children and teens need a consistent bedtime seven days a week.

"It keeps their clock set so they can go to bed at a certain time, sleep well through night and wake up well rested the next morning," Avis said.

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