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Which Came First? The Behavior Problems, or the Poor Sleep?

It’s a classic which-came-first question: Is the child not getting enough sleep because of problem behaviors, especially at bedtime, or is the child behaving problematically because of not getting enough sleep? The answers are most likely yes and yes, and the back-and-forth currents can drag a child down developmentally.

In an editorial in JAMA Pediatrics in 2015, Michelle M. Garrison, a research assistant professor at the University of Washington in the division of child and adolescent psychiatry, described this intersection of sleep and behavior problems in early childhood as a “feedback whirlpool.” Dr. Garrison was commenting on a longitudinal study of more than 32,000 Norwegian mothers and their children who were followed from birth to age 5; the children with sleep problems at 18 months, including short sleep duration (sleeping 10 hours or less) or frequent nocturnal awakenings (three times a night or more) had more emotional and behavioral problems at the age of 5. This held true even when the researchers adjusted for emotional and behavioral problems already present in the 18-month-olds; compared to children at the same behavioral baseline, the kids with sleep problems ran into more difficulties as they developed.

“Sleep really does drive behavior problems and behavior problems are driving sleep problems, it really is bidirectional,” Dr. Garrison said. “A child can start having problems with emotional regulation, melting down more, and that makes it more difficult for the family to do all the things they have to do so the child can get good sleep. Sleep gets worse; behavior gets worse. It can really be an awful cycle for the kid and the family both.”


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