Sleep Issues in Children and Teens Leading to Mental and Emotional Health Concerns

Twenty-two in a series.

Chronic lack of sleep in children and teens hurts their physical health, behavior, mood and ability to learn. Mental health can suffer too.

A pediatric panel of the American Academy of Sleep Medicine (AASM) links inadequate sleep to a wide array of concerns: attention and learning difficulty, increased accidents and injuries, and greater likelihood for chronic ailments such as hypertension, obesity and diabetes.

But implications from sleep loss also include depression and higher risk of self-harm and suicidality in teenagers, according to the AASM and other sources. “Unable to sleep or sleeping all the time” shows up as a suicide warning sign.

“Poor sleep patterns can exacerbate anxiety and agitation,” said Joy Crabtree, Psy.D., and a licensed psychologist at Cook Children’s. “Sleep difficulties can exacerbate depression and feelings of sadness and feeling overwhelmed.”

Experts see the interplay going both directions. Insomnia and other sleep disorders can complicate the mental health picture. Conversely, mental illness can disrupt sleep. The good news? By improving kids’ sleep habits – by modifying bedtime routines, use of positive imagery, and relaxation techniques, for instance -- their emotional wellbeing tends to improve as well.

At Cook Children’s we launched the Joy Campaign series in response to an alarming uptrend in young people attempting suicide. From January through September 2021, there were a record 323 patients hospitalized at Cook Children’s after attempting to take their own lives. That sobering statistic so far this year has already surpassed the 294 suicide-attempt hospitalizations in all of 2020.

While examining the factors that drive mental health and suicide, the Joy Campaign highlights a message of hope and help. This story focuses on solutions for those who struggle with sleep.

Pediatric sleep specialist Hilary Pearson, M.D., serves as medical director of Cook Children’s Sleep Center, which averages 210 patients per month. Snoring and insomnia top the list of complaints in patients who seek treatment at the center, Dr. Pearson said. She cited an 80% success rate in treating behavior-related sleep disorders.

Symptoms of sleep disorders can take many forms. Sleeping too much or not enough. Inability to fall asleep. Waking up frequently through the night. Restless sleep. Bad dreams.

Dr. Pearson explained that normal, positive sleep quality goes hand-in-hand with normal, positive mental health. A shift in sleeping patterns can signal the start of depression or another abnormal shift in mental wellness, she said.

“Usually, a change in your sleep precedes feeling sad or feeling worried,” Dr. Pearson said. “The chemicals that change your mood or make you feel depressed or anxious have already made their changes in your sleep.”

Trouble with sleep doesn’t always indicate an underlying mental concern. Many factors can disrupt sleep, such as erratic schedules, excessive phone/computer/TV use before bed, caffeine overload, or nasal congestion. The specialty of sleep medicine aims to find and eliminate the root cause.

The Cook Children’s Sleep Center sometimes refers its patients to therapists at Cook Children’s for psychiatric counseling. And sometimes the therapists refer their patients to the sleep center. Let’s take a closer look at the dynamic between mental health and recurring sleep issues.

The ABCs of ZZZs

For children ages 6-12, the AASM recommends 9-12 hours of sleep routinely to promote optimal health. Teenagers need 8-10 hours. But self-reported data collected by the U.S. Centers for Disease Control and Prevention show that 57.8% of middle school students and 72.7% of high school students fall short of that recommendation.

In other words, many children and teens don’t sleep long enough. Parents and teachers know the repercussions … tired kids can be cranky, impulsive, hyperactive, inattentive, accident prone. Dr. Pearson sums it up like this: “Everything from not being able to remember things as easily to not having patience with people or things, not being willing to try new things, a new food, new way of doing things, being nice to a new friend.”

Adequate sleep on a regular basis, meanwhile, promotes learning, memory, concentration, regulation of emotions and behavior, among other benefits reported by the AASM.

The American Academy of Pediatrics calls for proactively screening adolescents for common sleep disorders. One such screening tool is BEARS, which stands for:

• Bedtime: opposition going to bed or difficulty falling asleep
• Excessive daytime sleepiness – trouble waking up or grogginess in the day
• Awakening at night – interruptions to sleep or difficulty falling back asleep
• Regularity and duration of sleep – no sleep routine during the week and/or the weekend
• Snoring – loudly and regularly

Each individual is unique, but some generalizations apply for the different age groups when it comes to the range of sleep challenges described by Dr. Pearson. Toddlers typically resist going to sleep as a developmental phase. Children ages 5 to 12 might lose sleep because of evening sports practices or early wakeup for school. Sleep problems for teenagers often stem from poor planning and hormonal changes, which make teens natural night owls and late sleepers.

Sleep provides a chance for the heart rate and breathing to slow, muscles and joints to relax, and the brain’s chemicals to refresh, Dr. Pearson said. She emphasized the particular importance of Stage 3 (deep) sleep and rapid eye movement (REM) sleep. Low levels of serotonin, a neurotransmitter, affect both depression and sleep cycles.

“You have to have normal serotonin levels to fall asleep. The brain centers that come together to make sleep happen have to be functioning properly, and they are serotonin related,” Dr. Pearson said. “And we know that depression is caused by decreased serotonin levels.”

The Cook Children’s Sleep Center works to implement behavioral interventions (action steps) and cognitive therapies (thoughts). A sleep psychologist, physicians and others on the team consult with patients to establish what’s called good sleep hygiene – the habits for consistency, a conducive environment, relaxation, managing stress and other tips. Sometimes it’s necessary to correct misconceptions about sleep.

The center conducts an average 120 overnight sleep studies each month, Dr. Pearson said. Options such as CPAP machines, tonsillectomy and allergy medications can help those diagnosed with sleep apnea and snoring. She recommended that parents who have concerns talk to their child’s pediatrician.

Reassurance and Affirmation

In her job providing therapy and psychological testing at Cook Children’s, Crabtree hears quite a bit about sleep issues from patients who deal with mental adversity. Younger patients might report “monsters in the closet” or separation anxiety; Crabtree provides reassurance and helps them reason through their fears.

Teenage patients tend to report they lie awake at 3am because they can’t settle the thoughts in their heads. In those cases, Crabtree starts by ruling out environmental reasons for sleep loss. Did you drink a Red Bull? Did you get up and play video games? Were you on your phone?

“I try to problem solve around the immediate, obvious logistics of the situation and then kind of back things out from there,” she said. “If all those things aren't coming into play and it's a pattern that's continuing, then I would obviously look at medical issues.”

One of those medical issues, bipolar disorder, affects sleep in two extremes. People in the high-energy manic episodes of bipolar disorder don’t feel tired. People in the depressive episodes sleep more than usual.

Depression can cause children and teens to stay up too late at night and then oversleep or nap the next day, Crabtree said. She watches for depression and elevated suicide risk in patients who report frequent nightmares, she said.

Anxiety, meanwhile, keeps children and teens awake because they can’t turn off their thoughts. Crabtree uses a combination of strategies to ease the anxiety. Those strategies include muscle relaxation techniques, breathing exercises, guided imagery and countering the negative voices in their heads with positive affirmations.

Here are three suggestions Crabtree shared for increasing the odds of a good night’s sleep:

1. Keep a calm and predictable routine to wind down in the evening. Turn off electronic devices at least an hour before bed.
2. Write “feel good” points on strips of paper. Keep these upbeat reminders handy in a jar by the bed.
3. Write down whatever is causing anxiety. “Say it out loud: ‘I'm worried about this. And this is bothering me today.’ And problem solve with Mom a little bit on it, and then put it in your Worry Box and close the lid and leave it there. The box has got it for the night so you don’t have to have it in your mind.”

Crabtree encouraged parents to know that occasional bouts of poor sleep can happen for various reasons. Don’t let it drag on, however. “Parents need to trust their instincts. If they feel like something is not right and bothering their kiddo, then certainly get it checked out and get it addressed.”

The Cook Children's Sleep Center in Fort Worth specializes in the diagnosis and treatment of sleep disorders for all pediatric ages from babies to teenagers. We help with insomnia and other abnormal sleep symptoms such as snoring, sleepwalking or bedwetting. For more information, go to Sleep Center | Cook Children's (cookchildrens.org)