Short Sleep Duration: Children's Mental, Behavioral, and Developmental Disorders and Demographic, Neighborhood, and Family Context in a Nationally Representative Sample, 2016–2019

Angelika H. Claussen, PhD; Lina V. Dimitrov, MPH; Sivapriya Bhupalam, MPH; Anne G. Wheaton, PhD; Melissa L. Danielson, MSPH

Disclosures

Prev Chronic Dis. 2023;20(7):e58

Abstract and Introduction

Abstract

Introduction: Many children and adolescents experience insufficient sleep, which poses risks for their short- and long-term health and development. This study examined the concurrent associations of contextual factors, including child, demographic, neighborhood, and family factors, with short sleep duration.

Methods: We combined data on children aged 3 to 17 years from the 2016–2019 National Survey of Children's Health (N = 112,925) to examine the association of parent-reported child short sleep duration (ages 3–5 y, <10 h; 6–12 y, <9 h; 13–17 y, <8 h) with mental, behavioral, and developmental disorders (MBDDs); selected physical health conditions; and demographic, neighborhood, and family factors.

Results: Overall, 34.7% of children experienced short sleep duration. The prevalence was highest among children aged 6 to 12 years (37.5%); children from racial and ethnic minority groups, especially non-Hispanic Black children (50.0%); children from low-income households (44.9%); children with an MBDD (39.6%); children experiencing negative neighborhood factors (poor conditions and lack of safety, support, and amenities, 36.5%); and family factors such as inconsistent bedtime (57.3%), poor parental mental (47.5%) and physical health (46.0%), and adverse childhood experiences (44.1%). The associations between sleep and demographic, neighborhood, and family factors, and MBDD remained significant after controlling for all other factors.

Conclusion: This study identified several individual, family, and community factors that may contribute to children's short sleep duration and can be targeted to improve healthy development, particularly among children with an MBDD, from households with low socioeconomic status, or from racial and ethnic minority groups who are at increased risk for short sleep duration.

Introduction

Sleep is an essential function that predicts long-term health and well-being.^[1] Insufficient sleep has been associated with poor physical health,^[1–3] poor mental health, and problems with attention, behavior, learning, and memory.^[1,4–6] Insufficient sleep includes poor sleep quality and short sleep duration. This study focused on short sleep duration, which is common among children: during 2016–2018, 35% of US children aged 0 to 17 years had shorter sleep duration than recommended for their age^[1] based on parent report.^[7] However, research on sleep among children is less extensive than among adults.^[4,8]

Child, family, and environmental factors can all influence sleep.^[5,9,10] Sleep is negatively influenced by internal and external signals of danger and disruption.^[11] Psychological stressors within the family, such as parental health and well-being,^[12–15] and psychological stressors in the social context, such as neighborhood disadvantage and lack of perceived safety, affect sleep.^[9,10,16,17] Sleep is also affected by child characteristics, such as special health care needs and mental disorders,^[7,18] and family factors, such as regular bedtimes.^[7,19,20]

Children experiencing poverty are at increased risk for insufficient sleep.^[7,21–23] Poverty is related to risks that impair sleep, such as health risks, danger and stress, crowding, lack of suitable sleep spaces, or food insecurity.^[9,10,15] Children from racial and ethnic minority groups experience increased risk for insufficient sleep,^{[7,9,21,22,24]} potentially through mental stress from experiencing racism and discrimination,^[9,23] and through structural racism and the associated higher prevalence of socioeconomic risks related to poor sleep.^[21,22]

Previous studies examined the association between sleep and factors such as mental health and environmental factors, and between social context and children's mental health, but not comprehensively in a single sample of young and older children. Given that demographic, social, and environmental risk factors co-occur, understanding the independent associations between different types of risks and poor sleep requires examination of these different risk factors in a comprehensive data set. Our study expands on previous research^[7] that documented short sleep duration in a nationally representative sample of children and adolescents. We examined concurrent and independent associations between demographic, social, and environmental factors, mental disorders, and sleep duration in this comprehensive data set based on a nationally representative sample of children and adolescents to identify potential targets for public health intervention.

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Abstract and Introduction
Methods
Results
Discussion
References
Sidebar

Table 1. Weighted Prevalence of Short Sleep Duration Among Children Aged 3–17 Years, by Demographic, Neighborhood, and Family Characteristics, National Survey of Children's Health, United States, 2016–2019
Characteristic	No. of children	Short sleep duration,^a weighted % (95% CI)	Prevalence ratio (95% CI)
Individual demographic factors
Sex ^b
Male	58,341	35.1 (34.1–36.0)	1.02 (0.98–1.06)
Female	54,584	34.4 (33.4–35.3)	1 [Reference]
Age, y
3–5	19,966	35.0 (33.5–36.6)	1.14 (1.08–1.21)
6–12	46,897	37.5 (36.5–38.5)	1.22 (1.17–1.28)
13–17	46,062	30.7 (29.6–31.7)	1 [Reference]
Race and ethnicity ^b
Hispanic	12,885	38.6 (36.7–40.5)	1.33 (1.26–1.40)
Non-Hispanic American Indian/Alaska Native	665	37.5 (31.2–44.2)	1.29 (1.09–1.53)
Non-Hispanic Asian	5,767	32.7 (30.2–35.1)	1.12 (1.04–1.21)
Non-Hispanic Black	7,048	50.0 (47.9–52.0)	1.72 (1.64–1.80)
Non-Hispanic Native Hawaiian/Pacific Islander	277	36.3 (25.5–48.2)	1.25 (0.93–1.69)
Non-Hispanic White	78,733	29.0 (28.4–29.6)	1 [Reference]
Non-Hispanic other (2016–2018 only)	647	36.1 (29.3–43.3)	1.24 (1.03–1.50)
Non-Hispanic ≥2 races	6,903	33.5 (31.2–35.8)	1.15 (1.07–1.24)
Parental education ^b
Less than high school	2,680	45.6 (42.1–49.1)	1.66 (1.53–1.80)
High school	14,570	42.5 (40.8–44.3)	1.55 (1.48–1.63)
Some college or associate degree	26,325	38.6 (37.3–39.9)	1.41 (1.35–1.47)
College degree or higher	68,484	27.4 (26.7–28.2)	1 [Reference]
Family income, % of FPL ^c
<100%	12,371	44.9 (43.0–46.8)	1.73 (1.63–1.82)
100% to ≤199%	18,205	39.3 (37.5–41.0)	1.51 (1.43–1.59)
200% to ≤399%	34,700	33.4 (32.2–34.7)	1.29 (1.22–1.35)
≥400%	47,649	26.0 (25.2–26.9)	1 [Reference]
Negative neighborhood factors
Overall
≥1 Negative neighborhood factors^d	83,770	36.5 (35.7–37.3)	1.28 (1.22–1.34)
No negative neighborhood factors	27,901	28.5 (27.3–29.7)	1 [Reference]
Safety
Unsafe neighborhood^e	3,589	46.2 (42.7–49.7)	1.36 (1.26–1.47)
Safe neighborhood	107,376	34.0 (33.3–34.7)	1 [Reference]
Support
Neighborhood lacks support^f	23,813	40.6 (39.1–42.0)	1.25 (1.20–1.30)
Neighborhood provides support	86,446	32.4 (31.7–33.2)	1 [Reference]
Condition
Neighborhood in bad condition^g	23,196	40.3 (38.8–41.9)	1.24 (1.19–1.29)
Neighborhood in good condition	87,560	32.6 (31.9–33.3)	1 [Reference]
Amenities
Neighborhood lacks amenities^h	70,140	35.8 (35.0–36.7)	1.10 (1.06–1.15)
Neighborhood has amenities	40,522	32.6 (31.5–33.7)	1 [Reference]
Family factors
Consistency of bedtime
Inconsistentⁱ	12,448	57.3 (55.4–59.2)	1.82 (1.75–1.90)
Consistent	100,103	31.4 (30.7–32.1)	1 [Reference]
Mental health of parent
≥1 Parent with fair/poor mental health	7,988	47.5 (45.0–50.1)	1.43 (1.35–1.51)
No parent with fair/poor mental health^j	101,120	33.3 (32.6–34.0)	1 [Reference]
Physical health of parent
≥1 Parent with fair/poor physical health	10,269	46.0 (43.7–48.3)	1.40 (1.32–1.47)
No parent with fair/poor physical health^k	98,946	33.0 (32.3–33.7)	1 [Reference]
No. of ACEs^l
0	64,843	28.9 (28.1–29.8)	1 [Reference]
1	24,776	39.2 (37.7–40.6)	1.35 (1.29–1.42)
2	10,517	42.1 (40.0–44.2)	1.45 (1.37–1.54)
3	5,305	44.4 (41.3–47.4)	1.53 (1.42–1.65)
≥4	6,364	47.2 (44.4–49.9)	1.63 (1.53–1.74)

Abbreviations: ACEs, adverse childhood experiences; FPL, federal poverty level.
^aFor children aged 3–5 years: "During the past week, how many hours of sleep did this child get during an average day (count both nighttime sleep and naps)?" For children aged 6–17 years for 2018–2019: "During the past week, how many hours of sleep did this child get on most weeknights." The question in 2016–2017 asked about "an average weeknight." Short sleep duration was defined as <10 h for children aged 3–5 years, <9 h for children aged 6–12 years, and <8 h for children aged 13–17 years.
^bIf missing, this variable was imputed by using hot-deck imputation methods.
^cIf missing, family income was imputed by using sequential regression as an input to FPL; FPL was multiply imputed and contained 6 implicates.
^dCategory comprised 4 subcategories: "unsafe neighborhood," "neighborhood lacks support," "neighborhood in bad condition," and "neighborhood lacks amenities." Endorsement of any of these subcategories was counted as a respondent having ≥1 negative neighborhood factor.
^eA response of definitely disagree/somewhat disagree (vs somewhat agree/definitely agree) when asked whether the child is safe in their neighborhood.
^fA response of definitely disagree/somewhat disagree (vs somewhat agree/definitely agree) when asked whether people in the neighborhood help each other out, watch out for each other's children, and know where to go for help in their community when they encounter difficulties.
^gA response of yes to any of these 3 items: 1) litter or garbage on the street or sidewalk, 2) poorly kept or rundown housing, or 3) vandalism such as broken windows or graffiti in their neighborhood.
^hA response of no to any of these 4 items: 1) sidewalks or walking paths, 2) a park or playground, 3) a recreation center, community center, or boys' and girls' club, and 4) a library or bookmobile in the neighborhood.
ⁱA response of child never/rarely/sometimes (vs usually/always) goes to bed at the same time on weeknights.
^jParent (both parents if 2 primary caregivers) reported fair/poor (vs good/very good/excellent) mental health.
^kParent (both parents if 2 primary caregivers) reported fair/poor (vs good/very good/excellent) physical health.
^lChild's ACEs included 9 items: 1) lived in a household where it was very hard to cover the basics, like food or housing, on the family's income; 2) parent or guardian divorced; 3) parent or guardian died; 4) parent or guardian served time in jail; 5) child saw or heard parents or adults slap, hit, kick, punch one another in the home; 6) was victim of violence or witnessed violence in neighborhood; 7) lived with anyone who was mentally ill, suicidal, or severely depressed, or 8) anyone who had a problem with alcohol or drugs; and 9) treated or judged unfairly because of his or her race or ethnic group. Data on ACEs related to child maltreatment were not available because the survey was based on parent report.

Table 2. Weighted Prevalence of Short Sleep Duration Among Children Aged 3–17 Years, by Current Diagnoses, National Survey of Children's Health, United States, 2016–2019
Diagnosis	No. of children with disorder or condition^a	Short sleep duration,^b weighted % (95% CI)	Unadjusted PR (95% CI)	Adjusted PR^c (95% CI)
Mental, behavioral, or developmental disorder (MBDD)^d
No MBDD	83,772	33.2 (32.5–34.0)	1 [Reference]	1 [Reference]
Any MBDD^e	26,288	39.6 (38.2–40.9)	1.19 (1.14–1.24)	1.06 (1.02–1.11)
Any mental, emotional, or behavioral disorder^f	20,974	40.9 (39.4–42.4)	1.23 (1.18–1.28)	1.11 (1.06–1.16)
ADHD	11,370	40.3 (38.4–42.2)	1.21 (1.15–1.28)	1.08 (1.02–1.15)
Behavior problems	8,220	44.6 (42.3–47.0)	1.34 (1.27–1.42)	1.10 (1.03–1.17)
Anxiety	11,053	40.9 (38.9–42.9)	1.23 (1.17–1.30)	1.14 (1.08–1.21)
Depression	4,845	48.0 (44.8–51.1)	1.44 (1.35–1.55)	1.24 (1.14–1.34)
Tourette syndrome	275	39.4 (27.1–52.9)	1.19 (0.87–1.63)	1.39 (1.13–1.71)
Any developmental, learning, or language disorders^g	12,812	38.6 (36.7–40.6)	1.16 (1.10–1.23)	1.00 (0.94–1.06)
Physical health conditions^h
No physical health condition	72,361	34.0 (33.2–34.8)	1 [Reference]	1 [Reference]
Any physical health condition	36,956	36.1 (35.0–37.2)	1.06 (1.02–1.10)	1.00 (0.97–1.04)

Abbreviations: ADHD, attention-deficit/hyperactivity disorder; PR, prevalence ratio.
^aCategories of mental, behavioral, or developmental disorders are not mutually exclusive; children with multiple conditions are included in each applicable category.
^bFor children aged 3–5 years: "During the past week, how many hours of sleep did this child get during an average day (count both nighttime sleep and naps)?" For children aged 6–17 years for 2018–2019: "During the past week, how many hours of sleep did this child get on most weeknights." The question in 2016–2017 asked about "an average weeknight." Short sleep duration was defined as <10 h for children aged 3–5 years, <9 h for children aged 6–12 years, and <8 h for children aged 13–17 years.
^cAdjusted PR calculated by controlling for sex, age, race and ethnicity, parental education, poverty, neighborhood factor composite (ie, ≥1 negative neighborhood factors vs no negative neighborhood factors), inconsistent bedtime, ≥1 parent with fair/poor mental health, ≥1 parent with fair/poor physical health, and ACEs.
^dFor each analysis in each group of MBDDs, children with a specific disorder were compared with children without any MBDDs. 83,772 children had no MBDDs; 2,865 children did not have information on all MBDDs and were not included in this analysis.
^eA response of yes to current mental, behavioral, or developmental disorder (includes attention-deficit/hyperactivity disorder), behavior problems, anxiety, depression, learning disability, developmental delay, intellectual disability, speech and language disorder, autism spectrum disorder, and Tourette syndrome.
^fA response of yes to current mental, emotional, or behavioral disorder (includes attention-deficit/hyperactivity disorder, behavior problems, anxiety, depression, Tourette syndrome).
^gA response of yes to current developmental, language, or learning disorder (includes learning disability, developmental delay, intellectual disability, speech and language disorder, and autism spectrum disorder).
^hA response of yes to current allergies, arthritis, asthma, blood disorder, brain injury, cerebral palsy, cystic fibrosis, diabetes, Down syndrome, epilepsy, heart condition, headaches, deafness, or blindness.

Table 3. Independent Contribution of Children's Mental, Behavioral, or Developmental Disorders, Demographic, Neighborhood, and Family Factors to Short Sleep Duration, National Survey of Children's Health, United States, 2016–2019
Variable	Short sleep duration,^a adjusted prevalence ratio (95% CI)^b
Mental, behavioral, or developmental disorders
None	1 [Reference]
Any^c	1.06 (1.02–1.11)
Demographic characteristics
Sex^d
Male	1.01 (0.98–1.05)
Female	1 [Reference]
Age, y
3–5	1.29 (1.22–1.36)
6–12	1.33 (1.27–1.38)
13–17	1 [Reference]
Race and ethnicity^d
Hispanic	1.12 (1.06–1.19)
Non-Hispanic American Indian/Alaska Native	1.00 (0.82–1.21)
Non-Hispanic Asian	1.15 (1.06–1.24)
Non-Hispanic Black	1.44 (1.36–1.51)
Non-Hispanic Native Hawaiian/Pacific Islander	1.03 (0.76–1.39)
Non-Hispanic White	1 [Reference]
Non-Hispanic other (2016–2018 only)	1.05 (0.85–1.29)
Non-Hispanic ≥2 races	1.05 (0.98–1.12)
Parental education^d
Less than high school	1.34 (1.22–1.48)
High school	1.25 (1.18–1.32)
Some college or associate degree	1.18 (1.13–1.24)
College degree or higher	1 [Reference]
Family income level, % of FPL^e
<100%	1.12 (1.04–1.20)
100% to ≤199%	1.08 (1.01–1.15)
200% to ≤399%	1.07 (1.02–1.12)
≥400%	1 [Reference]
Negative neighborhood factors^f
≥1	1.10 (1.05–1.15)
None	1 [Reference]
Family factors
Consistency of bedtime
Inconsistent^g	1.70 (1.63–1.78)
Consistent	1 [Reference]
Mental health of parent
≥1 Parent with fair/poor mental health	1.09 (1.01–1.17)
No parent with fair/poor mental health^h	1 [Reference]
Physical health of parent
≥1 Parent with fair/poor physical health	1.09 (1.02–1.16)
No parent with fair/poor physical healthⁱ	1 [Reference]
No. of ACEs^j
0	1 [Reference]
1	1.19 (1.13–1.25)
2	1.22 (1.15–1.30)
3	1.25 (1.15–1.35)
≥4	1.28 (1.19–1.39)

Abbreviation: ACEs, adverse childhood experiences; FPL, federal poverty level.
^aFor children aged 3–5 years: "During the past week, how many hours of sleep did this child get during an average day (count both nighttime sleep and naps)?" For children aged 6–17 years for 2018–2019: "During the past week, how many hours of sleep did this child get on most weeknights." The question in 2016–2017 asked about "an average weeknight." Short sleep duration was defined as <10 h for children aged 3–5 years, <9 h for children aged 6–12 years, and <8 h for children aged 13–17 years.
^bAdjusted prevalence ratio calculated by controlling for all other factors in the model: sex, age, race and ethnicity, parental education, poverty, neighborhood factor composite (ie, ≥1 negative neighborhood factors vs no negative neighborhood factors), inconsistent bedtime, ≥1 parent with fair/poor mental health, ≥1 parent with fair/poor physical health, ACEs, and mental, behavioral, or developmental disorders.
^cA response of yes to current mental, behavioral, or developmental disorder (includes attention-deficit/hyperactivity disorder), behavior problems, anxiety, depression, learning disability, developmental delay, intellectual disability, speech and language disorder, autism spectrum disorder, and Tourette syndrome.
^dIf missing, this variable was imputed by using hot-deck imputation methods.
^eIf missing, family income was imputed by using sequential regression as an input to the FPL; FPL was multiply imputed and contained 6 implicates.
^fCategory comprised 4 subcategories: "unsafe neighborhood," "neighborhood lacks support," "neighborhood in bad condition," and "neighborhood lacks amenities." Endorsement of any of these subcategories was counted as a respondent having ≥1 negative neighborhood factor.
^gA response of child never/rarely/sometimes (vs usually/always) goes to bed same time on weeknights.
^hParent (both parents if 2 primary caregivers) reported fair/poor (vs good/very good/excellent) mental health.
ⁱParent (both parents if 2 primary caregivers) reported fair/poor (vs good/very good/excellent) physical health.
^jChild's ACEs included 9 items: 1) lived in a household where it was very hard to cover the basics, like food or housing, on the family's income; 2) parent or guardian divorced; 3) parent or guardian died; 4) parent or guardian served time in jail; 4) child saw or heard parents or adults slap, hit, kick, punch one another in the home; 6) was victim of violence or witnessed violence in neighborhood; 7) lived with anyone who was mentally ill, suicidal, or severely depressed, or 8) anyone who had a problem with alcohol or drugs; and 9) treated or judged unfairly because of his or her race or ethnic group. Data on ACEs related to child maltreatment were not available because the survey was based on parent report.