Biological Rhythm Research

Vol. 41, No. 3, June 2010, 217223

Etiologies of associations between childhood sleep disorders and

behavioral problems in China
Jian-ning Mai* and Gui-feng Xu
Department of Pediatrics, Guangzhou Childrens Hospital, Guangzhou, China
(Received 8 February 2010; nal version received 8 February 2010)
In this article, the major studies on the etiologies of associations between
childhood sleep disorders and behavioral problems in children in China are
reviewed. PUBMED was used to locate original articles published in China and
international journals in both the Chinese and English languages. About 50
articles were selected on the basis of their having a suciently high scientic
standard. Reviewing these articles indicates that there has been an increased
interest in recent years in the association between sleep disorders and behavioural
problems in young children. Behavioural problems include attention decit
hyperactivity disorder, ADHD, emotional problems (including anxiety and
depression), Tourettes syndrome and autism. Possible reasons for these
associations are discussed; they appear to be complex and diverse, and many
aspects of the problems and details of causal links are still poorly understood.
Further work is required to address these problems specically and so provide
advice to clinicians, healthcare workers and parents.
Keywords: sleep disorders; behavioral problems; China

Introduction
Studies indicate that sleep problems in infants and children are highly prevalent,
aecting childrens health, cognitive and neurobehavioral development. This article
aims to briey review the research data on the association between sleep
characteristics and children with behavioral problems in China.
Good-quality sleep is crucial for brain function, behavior and normal
metabolism in infants and children. Consistently, sleep deprivation has been linked
to behavioral and attention problems, learning and memory impairments,
psychiatric disorders and obesity. Sleep problems are common among children in
China; ranging from transient ones like diculty falling asleep and sleep-related
anxiety, to chronic problems like snoring, somnambulism and nocturnal enuresis.
The prevalence of sleep problems in Western countries has been estimated to range
from 1045% for school-age children (Mindell 1993; Owens et al. 2000), and
1013% for adolescents (Roberts et al. 2004). In 12 provinces of China, for children
aged 25 years old, the total incidence of sleep disorders is 20%. Gender dierence
exists; there are relative higher rates of somnambulism and night terrors for girls,

*Corresponding author. Email: gzchmjn@126.com

ISSN 0929-1016 print/ISSN 1744-4179 online
2010 Taylor & Francis
DOI: 10.1080/09291011003687973
http://www.informaworld.com

218

J. Mai and G. Xu

and buccal and molar respiration for boys (Huang et al. 2007a). For children aged 0
23 months, the total incidence of sleep disorders is 22%; the main problems among
them are diculty falling asleep, night-time waking and snoring (Huang et al.
2007b). However, data from dierent cities in China diers widely (see Table 1)
(Jiang et al. 2001; Wang et al. 2004; Hao et al. 2005; Wang et al. 2005; Yu et al. 2005;
Gan et al. 2006; Yang et al. 2007; Chen et al. 2007; Jia et al. 2007; Lei and Yang
2007; Wang et al. 2007; Zhang et al. 2007), which may be the result of dierent
methods of assessment in the studies.
With progress being made in assessing and monitoring methods for sleep
behavior and quality, increasing attention has been paid to sleep disorders from
neurological, psychological and psychiatric elds in China. Substantial progress has
been made over the past decade in our understanding of the complex relationship
between sleep, emotional, and neurobehavioral development in infants, children and
adolescents.
Sleep problems in children with attention decit hyperactivity disorder
Attention decit hyperactivity disorder (ADHD) is a common pediatric neurodevelopmental disorder, with prevalence of 316%. It is characterized by symptoms
of inattention, hyperactivity and impulsivity (American Academy of Pediatrics
Committee on Quality Improvement 2000). Recently, studies have been carried out
to probe the association between sleep disorders and ADHD (Crabtree et al. 2003;
Owens et al. 2009). Although there are dierences between subjective and objective
studies (Sadeh et al. 2006; Rosalia Silvestri et al. 2009), Corkum et al. (1998)
conducted a comprehensive literature review of subjective and objective studies of
sleep in children with ADHD; results indicated an almost ve-fold increase in sleep
complaints in children with ADHD ranging from 25% to 50% compared with
normal controls in whom the rate of sleep problems averaged 7%.
In mainland China, Lam and Yang (2008) have found that there is a negative
association between duration of sleep and ADHD tendency after adjusting for
potential confounding factors, including age, sex and fathers educational level. It
was the rst study to examine the issue of sleep and ADHD tendency among Chinese
adolescents. Li et al. (2009) have investigated the prevalence of parent-reported
Table 1.

Prevalence of sleep disorders in some cities of China.

City

Number

Age (y)

Rate (%)

Symptoms

Beijing
Shanghai
Wuhan
Wuxi
Xian
Yanji

6060
1812
3460
2354
2037
582

612
16
36
312
713
26

21.20
46.97
52.95
25.50
33.90
28.57

Chongqing
Shenyang
Guangzhou
Chengdu
Chengdu
Changchun

1405
1297
1734
1600
628
2500

05
26
212
212
25
612

25.70
27.40
35.40
37.88
25.32
28.41

snoring, choking, buccal respiration

somnambulism, sleep talking, bruxism
sleep-onset association disorders, sleep talking
bruxism, snoring, sleep talking
diculty falling asleep, sleep talking, snoring
bruxism, restless legs syndrome (RLS),
snoring, buccal respiration
diculty falling asleep, snoring, bruxism
diculty falling asleep, snoring, bruxism
diculty falling asleep, snoring, sleep terror
snoring, insucient sleep
diculty falling asleep, snoring, bruxism
snoring, buccal respiration, insucient sleep

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219

ADHD and assessed its association with sleep problems among urban school-aged
children in China. After adjusting for gender, parents educational level, family
income, family structure, and use of medical stimulants, there was a higher
prevalence of sleep problems, especially parasomnia, sleep-disordered breathing and
daytime sleepiness in children with a history of ADHD. Li et al. suggested that there
is a high incidence of snoring in school-age children from Changsha City; snoring
was correlated with attention decit and hyperactivity-impulsivity (Huang et al.
2004; Li et al. 2009).
To our knowledge, there have been several studies regarding sleep disorders and
ADHD in children from Taiwan, but no relevant study has been reported in Hong
Kong or Macao. Huang et al. (2004) have assessed Obstructive Sleep Apnea
Syndrome (OSAS) and Periodic Restless Legs Syndrome (RLS) in children aged 6
12 years in Taiwan with ADHD, and found that nearly 57% and 19% of ADHD
children suered from OSAS and RLS, respectively, while the percentages of the
control group were 3.7% and 0%, respectively. Another similar study in Taiwan
recruited 2463 school-aged children to investigate the six-month prevalence rates of
sleep-related problems and their association with inadvertent daytime napping,
inattention, hyperactivity/impulsivity and oppositional symptoms. Dysomnia, sleepdisordered breathing problems, inadvertent daytime napping and sleep schedules
were related to ADHD-related symptoms as assessed by mothers and teachers, and
parasomnia was associated with ADHD-related symptoms as assessed by the
mothers. The results suggested that there was a trend with age in sleep problems
similar to that found in the literature, as well as an association between inadvertent
daytime napping, inattention, hyperactivity/impulsivity and oppositional symptoms
and sleep-related problems (Shur and Gau 2006). Gau and Chiang (2009) also found
that adolescents with a childhood diagnosis of ADHD according to DSM-IV
criteria, regardless of persistent ADHD, were more likely to have current and
lifetime sleep disorders, according to DSM-IV criteria (insomnia, sleep terrors,
nightmares, bruxism, and snoring). The presence of at least one psychiatric comorbid condition increased the risks of insomnia and nightmares. Their study also
suggests that mental health professionals should screen for sleep problems and
psychiatric co-morbidities among adolescents with a childhood diagnosis of ADHD,
regardless of the severity of current ADHD symptoms.
Many possible reasons could be responsible for the association between ADHD
and sleep disorders. The most intuitive one is a potential biological link between
ADHD and sleep. A growing body of studies suggests that ADHD is a complex,
polygenetic disorder in which dysfunctions in dopaminergic and serotonin systems
are possibly involved (Bobb et al. 2005a, 2005b). It has been found that
neurotransmitters such as serotonin and GABA are important in the sleep
mechanism. In particular, serotonin is found to be involved in the onset of sleep
and also plays an important role in non-rapid-eye-movement (non-REM) sleep. A
disruption of serotonin secretion will induce insomnia, and substances that inhibit
the destruction of serotonin will also enhance sleep (Rosenthal 1998). Thus, it is
possible that the association between duration of sleep and ADHD is manifested via
such a neurobiological linkage, which provides an interesting lead for further
investigation. Another possible explanation originated from the characteristics and
symptoms of ADHD. Behavioral manifestations of ADHD impulsivity, restlessness and becoming easily distracted by irrelevant sights and sounds may also
play an important role in the relationship between ADHD tendency and sleep,

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J. Mai and G. Xu

particularly the duration of sleep. Because of these ADHD-associated behavioral

problems, children may have a higher tendency to feel restless and be distracted
while they are in bed. As a result, the onset of sleep may be disrupted and this, in
turn, reduces total sleep. By contrast, it could be possible that, instead, sleep
problems are responsible for behavioral symptoms of ADHD among adolescents
(Lawrence et al. 2008).
Sleep problems in children with emotional problems
Sleep problems are commonly concurrent with problems of abnormal emotional
behavior and can also be thought of as a symptom of these diculties. In Western
countries, many studies have been carried out to probe the associations between
sleep problems and anxiety and/or depression. These studies have shown that the
presence of sleep problems correlates strongly not only with the symptoms of anxiety
but also with those of depression (Johnson et al. 2000; Dahl and Lewin 2001;
Garland 2001; Gregory and OConnor 2002). However, there are also some
inconsistencies with this view (Forbes et al. 2008).
So far few such studies have been performed in China. The only information we
can nd is the study done by Chen et al. (2008) in Ningxia province. In this study,
children with sleep disorders were investigated using the Obstructive Sleep Apnea
(OSA)-18 questionnaire, while social status, family inuences and emotional
behavior were evaluated professionally. OSA is a common sleep apnea caused by
obstruction of the airway. It is characterized by pauses in breathing during sleep. The
dierences from control groups in prevalence of aggressive or hyperactive behavior,
variable mood, ill temper, and poor discipline were signicant in some age groups
and in some urban areas. Thus, there was no signicant dierence between OSA
children in the group aged 78 years and controls in urban areas, and there was no
signicant dierence in poor discipline between OSA children in the group aged 11
12 years and controls in rural areas. In addition, among children having sleep
disorders, the incidence of abnormal emotional behavior was higher in urban than
rural areas (P 5 0.05).
Children diagnosed with emotional disorders should be treated for their primary
psychiatric disorder. In many cases, successful treatment of such disorders results in
the improvement of sleep-related symptoms such as diculties falling asleep,
nocturnal awakenings, night-time worries and nightmares. Behavioral (systemic
desensitization, exposure and response prevention, extinction, counter-conditioning
and modeling), cognitive-behavioral, psychodynamic therapies and family therapy
are the recommended treatments for anxiety disorders.
Sleep problems in children with Tourettes syndrome and autism
Tourettes syndrome (TS) is a childhood-onset movement disorder characterized by
both motor and phonic tics that uctuate in severity and last for more than one year
(Swain et al. 2007). Current estimates of the prevalence of TS are approximately 46/
1000 children (Kurlan et al. 2002; Khalifa and Knorring 2003; Wang and Kuo 2003;
Jin et al. 2005). About 20% of children with TS continue to experience a moderate
level of impairment of global functioning by the age of 20 years (Robertson 2003).
Autism spectrum disorders (ASD) are pervasive developmental disorders
characterized by decits in social interaction, language development and

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communication, as well as restricted and stereotyped behavior patterns or interests.

ASDs are comprised of Autistic Disorder, Aspergers Disorder, and Pervasive
Developmental Disorder Not Otherwise Specied (PDD-NOS).
The existing literature from Western countries suggests that the prevalence of
sleep problems in children with TS and ASDs is markedly higher than in normal
children (Voderholzer et al. 1997; Lesperance et al. 2004; Wiggs and Stores 2004;
Couturier et al. 2005; Cortese et al. 2008). Such studies are very rare in China.
However, some information can be gained from study of Yang et al. (2005), who
have explored the type and prevalence rate of co-morbidities associated with TS. The
results showed that co-morbidities of TS included ADHD (42%), ObsessiveCompulsive Disorder (26%), anxiety (5%), conduct disorders (8%), self-injurious
behavior (3%) and sleep disorders (2%).
In conclusion, there are few studies from China on the etiologies of childhood
sleep disorders and behavioral problems and associations between them, particularly
studies which focus on ADHD, emotional problems, TS and ASDs. In mainland
China, most current studies place emphasis on epidemiological information relating
to sleep disorders, whilst in Taiwan, Hong Kong and Macao, studies begin to focus
more on the simultaneous occurrence of sleep disorders and disorders of
development or emotional behavior. However, no evidence has yet shown clear
causal relationships between them, and this is an area which should be emphasized in
future studies.
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