Later Emotional and Behavioral Problems Associated With Sleep Problems in Toddlers

Mi Jin Kim, Mercer University College of Pharmacy 2015

The National Sleep Foundation (NSF) reports that more than two-thirds of children experience frequent sleep problems. 1 The NSF also states that sleep is crucial for children as it directly influences mental and physical development.2 According to a review of the association between sleep and emotional and behavioral problems in children, sleep problems in older children and young adolescents correlated to the later development of emotional and behavioral difficulties.3 A recently published study investigated the association between sleep problems in toddlers and later emotional behavioral problems.4

Title: Later emotional and behavioral problems associated with sleep problems in toddlers
Design A large population-based longitudinal, prospective cohort study


To examine whether sleep problems in toddlers aged 18 months are related to both concurrent and subsequent emotional and behavioral problems in preschool children aged 5 years
Study Groups Data from the Norwegian Mother and Child Cohort study; a total of 32,662 mother-infant pairs
Methods Sleep duration and nocturnal awakenings were assessed by mother-reported questions. Emotional and behavioral problems were measured with items from the Child Behavior Checklist (CBCL). Short sleep duration (≤10 hours) occurred in 556 children (1.7%) while frequent nocturnal awakenings (≥3 times) occurred in 1033 children (3.2%) at 18 months.
Duration From June 1, 1999 to December 31, 2008
Primary outcome measure Association between short sleep duration and emotional/behavioral problems, which can be expressed in relative risks (RRs)
Baseline Characteristics Mothers: mean age 30.6, high school degree 67.2%

Children: girls 48.9%, nightly awakening 26.9%

Sleep hours per day: 13 to 14 hours 58.9%, 11 to 12 hours 36.2%, 10 or fewer hours 1.9%

Results Relative risks (RRs) for internalizing problems were 1.59 (95% CI, 1.23-2.08) for short sleep duration and 1.57 (95% CI, 1.28-1.93) for nocturnal awakenings. RRs for externalizing problems were 1.77 (95% CI, 1.37-2.30) and 1.25 (95% CI, 1.00-1.58), respectively.
Adverse Events Common Adverse Effects: Not reported
Serious Adverse Events: Not reported
Percentage that Discontinued due to Adverse Events: None reported
Study Author Conclusions Early sleep problems predict later development of emotional and behavioral problems. Intervention studies are needed to examine whether sleep programs targeting early childhood may avoid the onset of later adverse outcomes.

This cohort study reported that short sleep duration and frequent nocturnal awakenings at 18 months significantly predicted both emotional and behavioral problems at 5 years. The findings showed an association between sleep problems and subsequent emotional/ behavioral problems in young children. These results were consistent with findings from the review of sleep and associated problems in children and extended the outcomes to a younger age group. However, this study was not a randomized controlled trial, so there could be residual confounding. This study did not look at maternal health status, which can affect their children’s sleep condition. Other possible parental behaviors and environmental factors may affect both sleep and emotional and behavioral problems.


  1. National Sleep Foundation. 2004 Children and Sleep. Accessed April 16, 2015.
  2. National Sleep Foundation. Children and sleep. Accessed April 16, 2015.
  3. Gregory AM, Sadeh A. Sleep, emotional and behavioral difficulties in children and adolescents. Sleep Med Rev. 2012;16(2):129-36.

4.Sivertsen B, Harvey AG, Reichborn-kjennerud T, Torgersen L, Ystrom E, Hysing M. Later Emotional and Behavioral Problems Associated With Sleep Problems in Toddlers: A Longitudinal Study. JAMA Pediatr. 2015. doi: 10.1001/jamapediatrics.2015.0187.

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