Well Spoken welcomes the opportunity to provide input into the Standing Committee on health, Aged Care and Sport’s inquiry into sleep health awareness in Australia.
Poor or inadequate sleep – defined as sleep that does not meet the required quantity or quality for the person in question – is a high-priority public health issue, with ramifications for mental and physical performance, physical health and productivity. Collectively, these consequences have a detrimental impact on the workplace and economy, with obstructive sleep apnoea, for example, costing the US government up to USD165 billion annually. 1
In sleep-deprived children, the four key domains for development, physical (growth, immunity), mental (IQ, focus, problem-solving), emotional (mood and emotional regulation) and social, are all affected. This is a cumulative impact that puts these children behind their peers for years to come. In some cases, these children will never catch up. Unfortunately, while sleep health is a serious issue, there is little public awareness on the importance of sleep and the dangers of poor sleep. There is also a lack of investment into public awareness campaigns and education, which have been shown to play a vital role in the improvement of other public health concerns, such as skin cancer prevention.
Given the severity of this issue, public health campaigns, public health education, standardised sleep screening and further investment are essential measures to ensure every person (particularly every child) is getting the sleep they need every night.
According to a survey conducted by the Centre for Disease Control and Prevention, more than 35% of Americans sleep less than seven hours in a typical day.2 Meanwhile, 30% of adults average fewer than six hours of sleep per day.3
Similarly, the 2016 Sleep Health Survey of Australian Adults found that ‘inadequate sleep, of either duration or quality, and its daytime consequences are very common in Australian adults, affecting 33-45% of adults… Medical sleep conditions are also very common, with diagnosed sleep apnoea affecting 8%, significant insomnia 20% and restless legs 18% of adults.’ 4
This is exacerbated by negative attitudes towards rest in developed cultures, with a focus on productivity over recovery. However, more waking hours can lead to lower productivity and poor mental performance, which accumulates over time.5
When sleep deprived, the human body struggles to extract glucose from the blood stream and the brain is unable to think clearly. This then impacts rational thinking, willpower, self-control, productivity and interactions with colleagues. Sleeping fewer than six hours or more than eight hours a night leads to low scores on logical thinking and vocabulary, along with ageing the brain. 6
Even small amounts of sleep deprivation degrade a person’s abilities and increase the risk of micro sleeps – a dangerous state to be in while driving a car, wielding a scalpel or operating machinery, which can occur at any time. Unsurprisingly, a lack of sleep has been linked to motor vehicle crashes, industrial disasters, and medical and other occupational errors. 7 8 Even the Chernobyl meltdown and the Challenger space shuttle disaster have been linked to sleep deprivation.9 10
Dangerously, most sleep-impaired individuals believe their ability to perform these tasks is at its usual standard, when tests show it is not. One study demonstrated that subjects sleeping fewer than six hours per night were as impaired in their daytime cognitive performance as if they’d completely missed two nights of sleep.11
Beyond issues of performance and productivity, sleep deprivation has profound effects on both physical and mental health. Surrey University scientists discovered that over 700 of the body’s genes, or the expression of those genes, are altered when a person regularly gets less than six hours of sleep a night over one week.12 esearch has also linked sleep fragmentation and disturbed sleep to cancer,13 14 and the risk of pancreatic, lung, kidney and skin cancers is significantly higher in patients with obstructive sleep apnoea.15
Some studies link diabetes, schizophrenia, heart attacks, stroke and Alzheimer’s to sleep deprivation and fragmented sleep. In fact, sleeping five or fewer hours per night instead of the recommended seven to nine hours for adults may increase mortality risk by as much as 15%. 16
If chronic sleep deprivation is bad for individuals, it is also bad for society as a whole. In the US, the 23 million adults with moderate to severe obstructive sleep apnoea cost the government between USD65 billion and USD165 billion annually.17
The costs related to leaving obstructive sleep apnoea untreated are diverse and include health treatments, poor work performance, work absence, depression, relationship breakdown, motor vehicle accidents and occupational errors.
While many investigations into inadequate sleep focus on the ramifications for adults, the truth is that poor sleep is also a significant health issue for children. Up to 24% of all children, and 35% of children under two years of age, have frequent problems sleeping. 18 These are, most commonly, behavioural sleep problems, with psychologist Sarah Blunden estimating that 30-40% of children’s sleep problems are related to habits and behaviours.19 However, many more of these sleep issues are physiological and will have long-term consequences. Leading paediatric sleep specialist Judith Owens and psychologist Jodi Mindell report that 24% of all children experience some type of sleep problem at some point during childhood. 20
When children experience poor sleep, the consequences can look different to those that manifest in adults – behaviourally, physically and mentally. Importantly, these effects compound over time, and can have a significant influence on children’s growth and development.
Behavioural problems resulting from poor sleep and sleep disorders can look a lot like Attention Deficit Hyperactivity Disorder (ADHD): difficulty sitting still, difficulty with concentration, focus and attention, aggression, impulsivity, interrupting, talking out of turn, hyperactivity, anxiety, trouble with literacy and more. 21
Children with ADHD also have difficulty falling sleep and staying asleep and are restless while they are asleep. In fact, snoring is common among children who have ADHD, and 25% of these children may have obstructive sleep apnoea. 22
Children with ADHD have problems sleeping well for many reasons, not the least of which are behaviour traits that make it difficult to settle and stay settled. Medication side effects and depression may also play a role, making it harder for them to fall asleep. Ineffective sleep, in turn, revs up this behaviour further. As Dr Judith Owens says, ‘Every child diagnosed with ADHD should be screened for sleep disorder. Interestingly, some of the chemicals in the brain linked to ADHD are the same involved with sleep, so the deficiency and alteration of brain chemicals necessarily leads to sleep problems.’ 23 This sentiment is echoed by a study at Lurie Children’s Hospital Chicago and the Head and Neck Institute, Cleveland Clinic. 24
Children who are not sleeping properly often do not grow well, have poor appetites and are frequently sick.
Growth hormone (somatotropin) release can be missed in children who do not sleep properly. Melatonin, which stimulates growth hormone, is released between three to four hours after sleep onset, so if sleep onset is delayed or sleep cycles are disrupted, growth hormone release is also delayed. 25 ‘Sleep-disordered breathing, secondary to adenotonsillar hypertrophy, increases the risk of growth failure in children.’ 26
As with adults, the hunger and satiety hormones leptin and ghrelin play a key role in regulating the amount of food that children consume. Imbalances in these hormone levels lead children to crave high-energy foods like sweets, biscuits and chips, followed by not realising when they are full, leading to weight gain. Obesity then contributes to poor sleep, and possibly obstructive sleep apnoea, which turns into a vicious cycle where disordered sleeping further contributes to obesity due to its effect on hormone levels. 27
Cortisol also increases with poor sleep because it causes the body to work harder to breathe, preventing the body from fully entering deep sleep cycles. These factors may make it harder for children to wind down, go to sleep or stay asleep. The combination of poor sleep and increased cortisol leads to impaired memory, increased anxiety and aggression. 28
Children with increased levels of cortisol may also have poor immunity, as immune memory is formed during deep sleep. Consequently, children with sleep-disordered breathing (which induces light sleep and sleep fragmentation) get sick more often because their immune systems are weakened. 29
Children who don’t get the right amount or right quality of sleep have problems with their moods as well as their ability to focus, solve problems and self-regulate. A press release by the Johns Hopkins Medicine media department reported that childhood sleep apnoea was linked to brain damage, 30 and this is borne out with other studies. Even small increments of sleep loss (as little as 30 minutes per night) can result in reduced performance on intelligence tests and affect learning in a significant way.
If a child’s sleep problem is connected to disordered breathing, blood-oxygen levels drop. Low oxygenation then affects every aspect of a child’s health, growth and development: it worsens virtually all medical, emotional and developmental problems; it compromises a child’s growth, immunity and IQ; and it impedes recovery and wellness in medically compromised patients. 31
Obstructive sleep apnoea is one sleep disorder that is associated with a of range neurocognitive deficits, 32 eaning that children are unable to focus, reason and problem solve as expected for their age. They have ‘impaired attention and visual-fine motor coordination and reduction in regional grey matter. 33 Indeed, the disorder can reduce a child’s IQ by as many as 10 points compared to their IQ with proper sleep. 34 35 One study conducted in 2006 speculated that ‘untreated childhood OSA could permanently alter a developing child’s cognitive potential’. 36
Meanwhile, a study at Duke University in 2015 showed that children with attention problems in early childhood were 40% less likely to graduate from high school. 37 With an estimated 10% of children starting school with developmental delays, we can only wonder – how much of this is linked to sleep disorders?
With the known impacts of sleep problems on executive brain function (emotional regulation, reasoning and problem solving) and language and speech development, this necessarily effects how children learn to communicate and form and sustain relationships.
Research has found that insufficient sleep interferes with the capacity to regulate behaviour and emotion, increasing the risk of anxiety, negative moods and impulsivity while compromising children’s ability to respond appropriately to social stresses. 38
The waking synchronisation of several behaviours governed by the prefrontal cortex is also sensitive to sleep loss, meaning that sleep loss may interfere with the processing required for effective social interaction. 39
Additionally, children who struggle to self-regulate have been found to be more likely to be rejected by their peers. 40
This creates a vicious cycle where poor behavioural control fuels peer rejection, which contributes to worse behaviour, thereby establishing patterns of poor social-emotional function from early primary school. 41
Social competence is a pivotal component of children’s psycho-emotional development and mental health and has implications for society as a whole.
Simply, children who sleep poorly have a lower quality of life, and lower development potential, than those who sleep well. In fact, children with obstructive sleep apnoea have been found to have a higher incidence of unsatisfactory life quality in all areas. 42
Children with special needs are particularly susceptible to sleep problems. As Dr Judith Owens points out, ‘There’s a very high prevalence of insomnia in autism spectrum disorders – 34-89% of children with autism spectrum disorders also have sleep disorders. Early intervention is critical for caregivers with these children, given the demands of the day, and parents’ sleep disturbance on top of it.’ 43
Due to the nature of their difficulties, many children with disabilities may need to spend time in hospital for treatments and surgeries, which make it more difficult to sleep. Common medications can also have side effects that can complicate sleep efficacy. 44
At home, autistic children, or those with varying degrees of developmental delay, often have trouble settling into sleep and back to sleep. Due to their susceptibility to sensory overload, these children can become wired and anxious, unable to wind down and self-soothe before bed. It can take up to two or three hours for them to fall asleep after bedtime. If they go to sleep late or wake early, they are consistently not getting enough sleep, and the quality of the sleep they do get is disrupted by night waking. This could be due to habit, waking in transition between sleep cycles or remaining in light sleep throughout the night. This all then exacerbates the cycle of overwhelm. After a night of poor sleep, the next day is then pre-set for more ‘wired but tired’ behaviour and anxiety.
Additionally, children with disabilities, chronic medical conditions like Down syndrome, joint laxity (such as Ehlers-Danlos syndrome) and craniofacial syndromes (such as Pierre Robin, Crouzon, Apert, Prader-Willi and Pfeiffer syndromes) are airway challenged due to the shape, size and position of the bones that make up the head and face. 45 hese conditions are associated with smaller or constricted upper airways such as small or uneven nasal passages, which may lead to habitual mouth breathing. This then leads to disruption of oxygen to the brain and is on the spectrum of sleep-disordered breathing. 46 Weak, low-tone muscles in the upper airway also make children more susceptible to upper airway collapse during sleep.
Australian Indigenous children are at a higher risk of inadequate sleep than non-Indigenous children. 47 Just some areas that put Indigenous children at a disadvantage include:
- Asthma and sleep: Secondary sleep disturbance is a common complaint of children suffering from asthma, with 48% of sufferers reporting sleep disturbance. 48, 49 While prevalence rates of childhood asthma range from 14-16% 50 in the general population, in Indigenous children, this rises to 14-28%. 51
- Sleep disordered breathing: Sleep disordered breathing is an umbrella term for a range of breathing-related sleep disorders, ranging from snoring through to obstructive sleep apnoea. In Indigenous children, a 2004 study found that the prevalence of comorbid sleep disordered breathing and asthma was 14.2%. 52
- Childhood obesity: Obesity is a known risk factor for sleep disordered breathing and, consequently, sleep problems. While obesity is a growing concern for the general population of Australian children, Indigenous children (aged six to 11 years) are 1.4 times more likely to be obese than their non-Indigenous peers. In Indigenous 15-19 year olds, the likelihood of obesity increases to 2.6 times. 53 , 54
- Childhood diabetes: A growing body of research demonstrates the relationship between diabetes and sleep quality. Indigenous Australians experience higher rates of diabetes than the general population, with the incidents of Type 2 diabetes on the increase for Indigenous children and adolescents. 55
- Mental health and sleep: One study found that 88% of children with anxiety disorders had at least one sleep problem, while 55% had three or more sleep problems. 56 There is also a strong relationship between sleep problems and depression, with two thirds of depressed children suffering from sleep problems. 57 With 26% of Indigenous children between four and 11 years old being at risk of mental health difficulties (compared to 17% of non-Indigenous children), and 21% of Indigenous 12-17 year olds at risk (compared to 13% of non-Indigenous adolescents), these children are also at a greater risk of sleep problems as a result. 58
These factors all put Indigenous children at a higher risk of experiencing inadequate sleep, and the behavioural, physical and mental consequences that arise as a result. Indigenous children have been found to have poorer sleep quality than their non-Indigenous counterparts, along with less total sleep time.
While the immediate consequences of sleep problems are clear, it is essential to recognise the long-term costs of these patterns.
By this I mean that the effects of poor sleep and sleep disorders compound over time. Dr Kate Williams from Queensland University of Technology analysed the sleep behaviour of 2,800 children born in 2004 until they reached six to seven years of age in the landmark study, Growing up in Australia: The Longitudinal Study of Australian Children. She found that, while 70% of children were regulating their own sleep by five years of age, the remaining 30% might find their lack of regulation developmentally detrimental over time. 59
Prolonged exposure to poor sleep quality, sleep deprivation and fragmentation means children experience ongoing behavioural, physical and emotional consequences, with Professor Karen Bonuck demonstrating that behavioural difficulties at seven years of age (eight years for children in special education) were linked to having had sleep problems prior to five years of age. 60
In addition, sleep-deprived children are at risk of developing the associated health issues such as increased blood pressure and cardiac problems. Furthermore, both sleep disordered breathing and short sleep duration significantly and independently increase children’s odds of becoming overweight. 61
Consequently, it’s vital to get children’s sleep behaviours right by the time they turn five. ‘If these sleep issues aren’t resolved by the time children are five years old, then they are at risk of poorer adjustment to school,’ Williams said. This has been backed by other studies. 62 Simply getting children to bed earlier than 9:30pm improves behaviour, 63 and children who soothe themselves back to sleep from an early age adjust to school more easily than those who don’t.64,65
If children get adequate sleep, many of these problems are reversible. Bruno Giordani, professor of neurology, psychiatry, psychology and nursing at the University of Michigan, wrote, ‘Regardless of intellectual level, we can expect to see some behavioural improvement along with better sleep. Once behaviour improves, attention in school improves, and emotional ability and behavioural and impulsivity control improve.’ 66
Unfortunately, support and treatment is not always easy to find. Diagnosing a sleep disorder is a very specialised area of medicine – to the point that many doctors and health professionals don’t know how to recognise or fix it. One of Well Spoken’s clients visited 23 medical specialists in Australia and the US before finding the right type of help for her child. Others visit the family doctor or paediatrician regarding their child’s tiredness, only to be told that their children need more exercise or to make dietary changes. In an estimated 90% of cases, sleep is not addressed.
Additionally, there is little education and awareness on the importance of sleep health, which means individuals and parents do not know the right questions to ask, and professionals don’t consider sleep as a potential contributor to the symptoms they are addressing.
Recommendations to improve Australian sleep health
Sleep health is a serious Australian public health issue, with consequences that affect the individual, their families and relationships, and the economy as a whole. When it comes to sleep health in children, poor sleep and sleep disorders can contribute to behavioural, physical and mental issues that may stunt children’s development, resulting in unforeseeable albeit avoidable costs over their life time. In children it is not only a major public health issue, but an education issue as well with the known consequences of poor sleep on children’s brain development, learning, focus, attention and behaviour.
With this in mind, our recommendations for addressing this issue include public awareness campaigns, sleep health education, and blanket sleep health screening.
In the medical community, in the workplace, in the education system and in families there is a lack of awareness around the importance of sleep health, and the costs of poor sleep. In fact, common myths and misconceptions about sleep perpetuate this lack of awareness. Consequently, there is also a lack of awareness on effective avenues for treating sleep issues. Even where awareness exists, there is a lack of knowledge on how to fix the problem.
Public health campaigns are an initial step to start building awareness and pave the way for structured education on sleep health. We can see the effectiveness of such campaigns in Australia in the areas of skin cancer awareness and quitting smoking.
A 2002 study showed the incidence rates of non-melanoma skin cancer in Australians aged under 60 has stabilised, while they are increasing in people aged over 60. This difference is consistent with the commencement of Slip, Slop, Slap campaigns and the exposure the younger age group would have had to them. 67
Meanwhile, ‘Quit’ campaigns, which have been running in Australia since the early 1980s, have been reported to help smokers decide to quit and to prevent the relapse of ex-smokers. 68 A time-series analysis of monthly smoking prevalence in Australia over 11 years also found that greater exposure to Quit media campaigns was associated with a faster decline in adult smoking prevalence. 69
In both examples, these campaigns have been a cost-effective way to increase awareness, reduce the incidence of skin cancer and smoking addiction, and reduce the burden on the health system caused by these ailments.
Similar campaigns focusing on the importance of sleep and the dangers of inadequate or low-quality sleep are advised as an initial step to build public awareness of sleep health, along with promoting the importance of early screening for sleep problems.
The target audiences for these campaigns would include parents and families, all health and education professionals (particularly those who interface daily with children and families), and work places (particularly those where sleep problems have a high potential to impact safety of workers or individuals in the surrounding environment, such as customers and colleagues).
Recommendation: Implement a public health campaign to increase awareness of the importance of sleep health and resources for improving sleep health.
Beyond building awareness, it is also important to educate individuals, parents and health professionals on the importance of sleep health, the red flags that signify potential sleep problems, and the range of problems.
Sleep health education should be a three-pronged approach, encompassing:
- The education of health professionals: Health professionals need to be made aware of the importance of sleep health, along with understanding how to identify potential sleep issues. This includes: general practitioners, and practice nurses, medical specialists like paediatricians, early childhood nurses and all allied health professionals. They also need to be made aware of solutions that they can share with their patients, ranging from changes those patients can make at home to referrals to specialists with an expertise in sleep.
- The education of childcare and education professionals: Given the devastating impact sleep problems can have on a child’s growth, development and overall wellbeing, it is essential that childcare and education professionals understand not only the importance of sleep health, but the ability to recognise the red flags of potential issues. Such professionals should also be connected with professionals to whom their can refer affected families.
- The education of parents: As we have discussed at length, it is critical to ensure children are sleeping well as early as possible, due to the ongoing developmental ramifications of poor sleep. With this in mind, educating parents on the importance of their children’s sleep should also be a priority, along with identifying the signs that their children are not getting the sleep they need, and when they should seek help.
- The education of new and expecting mothers: It is critical to get sleep right from day one – even before day one, with the potential for expecting mothers’ sleep issues to affect the health and development of their children in utero. Pre-birth education will focus on helping the expectant mother get sufficient, good quality sleep along with preparing her for the first weeks and months with a new baby, while post-birth education will focus on teaching children good habits from a young age, from which they will benefit for a lifetime.
- The education of individuals: It is important for individuals to understand that sleep is an essential pillar of their wellbeing, and to recognise that poor sleep may be a contributor to other symptoms they may be experiencing. This includes kids themselves.
This education should be made available in the form publicly funded presentations by sleep advocates in venues that are convenient for these audiences. For health professionals, this education could form a part of their professional development and be organised via industry organisations. For individuals, events can be promoted via local media and shared by local health practitioners with their patients. Meanwhile parents would benefit from events run at their children’s schools, pre-schools and childcare centres. Finally, education in hospitals would support new mothers and facilitate community support networks, particularly through the ‘mummy group’ forum.
The content of this education should encompass sleep problems broadly, as well as sleep problems related to sleep disordered breathing.
Recommendation: Invest in public education in the importance of sleep health, with targeted content for the health and education professional audience, the individual audience and the parent audience.
Early diagnosis is the cornerstone for successful treatment across all areas of health – cancer diagnosis, weight management, organ health and more.
While the Australian government does not enforce mandatory screening, education around the importance of prevention, early diagnosis and treatment has ensured that our culture benefits from a high prevalence of opportunistic screening. This attitude encompasses voluntary skin checks, breast examinations, prostate examinations, bowel cancer screening and the cervical screening test, due to the level of public education in these areas.
This is not the case with sleep health. Unless a sufferer of poor sleep approaches a sleep specialist directly, they cannot expect to receive any sleep screen or evaluation from other professionals they might be consulting about their health, such as their General Practitioner or their child’s paediatrician. Consequently, an area of significant health risk is often overlooked and left untreated.
The signs and symptoms of sleep problems can be recognised early, rather than waiting until their damaging effects are having a significant impact. This can make a major contribution to the overall health and functioning of Australians, particularly our most vulnerable members. Blanket sleep screening should be used as a standard diagnostic tool among all General Practitioners. Additionally, given the significant risks facing sleep deprived children, we recommend sleep screening as a tool to be used by all health professionals who interface daily with children, along with childcare and education professionals.
Recommendation: Establish a policy of blanket sleep screening for General Practitioners, along with all health and education professionals who interface with children.
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