Sleep and Mental Health in Children

Though sleep problems are generally considered a physical concern, lack of sleep or too much sleep can have serious negative impacts on mental health in children. Understanding and screening for sleep issues in children and encouraging healthy sleep habits can improve children’s mental health and prevent issues. Katie Reynolds, PhD, a child and adolescent psychologist in our Pediatric Mental Health Institute, offers advice for primary care providers below.

How much sleep do kids need?

The Centers for Disease Control (CDC) recommends the following sleep needs by age group (per 24-hour period):

• Newborn (0 to 3 months): 14 to 17 hours including naps
• Infant (4 to 12 months): 12 to 16 hours including naps
• Toddler (1 to 2 years): 11 to 14 hours including naps
• Preschool (3 to 5 years): 10 to 13 hours including naps
• School aged (6 to 12 years): 9 to 12 hours
• Adolescent (13 to 17 years): 8 to 10 hours

Based on these ranges, the CDC points out that most youth don’t get enough sleep. 

Sleep is important for facilitating healthy digestion, reducing inflammation, encoding memories and improving emotion regulation. In longitudinal studies, sleep problems in childhood have been linked with adolescent and adult internalizing (depression and anxiety) concerns. Further, sleep disturbances in healthy children have been associated with behavior problems, decreased cognitive performance, academic problems and impairment in daily living. 

Conversely, mental health concerns often impact sleep amount and quality. For example, kids who are afraid of the dark have a hard time falling asleep and children with depression may spend all day in bed and get excessive amounts of sleep. But maintaining a regular sleep schedule and healthy sleep hygiene can help prevent mental health issues and serve as an intervention when mental health concerns and sleep problems are present simultaneously.

Early screening for child and infant sleep problems

Asking specific questions about sleep can help you assess a child’s sleep quality. Screening tools validated in children and youth can be useful for assessing sleep concerns. Free and empirically validated screening tools include:

• The Children’s Sleep Habits Questionnaire 
• Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance Measure
• The Brief Infant Sleep Questionnaire (BISQ)
• Epworth Sleepiness Scale for Children and Adolescents (ESS-CHAD)

When you don’t immediately have sleep screening tools, the following questions may help determine if a child needs additional sleep intervention:

• What time does your child get into bed?
• How long does it take them to fall asleep?
• Do they wake up at night? If so, how long does it take them to fall back to sleep?
• Where does your child sleep each night?
• Approximately how many hours of sleep do they get each night? 

Families who report their children receive less than the recommended amount of sleep or whose children regularly take more than 30 minutes to fall asleep could benefit from additional behavioral sleep intervention. Further, for children who have bedtime resistance or increased behavioral problems in the evening, behavioral sleep interventions can be helpful. 

Behavioral sleep interventions for children

• Encourage good sleep hygiene, including getting the developmentally appropriate amount of sleep (see above) each night, both during the week and on the weekend (e.g., allotting a minimum of 9 hours for school aged children over a 24 hour period).
• Use a sleep log to monitor sleep over a longer period of time. Families who notice patterns in their child’s sleep difficulties may be able to prevent issues from arising.
• Use behavioral reinforcement systems for getting up on time. A consistent waketime is the most important factor in creating a new sleep schedule for school aged children and teens. For example, if teens earn additional access to the car on the weekend each school morning they wake up on time (e.g., 30 mins per day) this could be a meaningful reward. Younger children and adolescents who struggle with attention and focus will likely need shorter term or more immediate (i.e., the same day) rewards for a behavioral reinforcement system to be impactful.
• For children who struggle with bedtime and get up multiple times after being put to bed, using a behavioral reinforcement system at bedtime to promote independence can be helpful.
  • For example, if parents give their child a few "bedtime passes" each night, the child can turn in one bedtime pass when they get out of bed to see their parent or ask a question. 
  • These interactions should be short, and the child should return to bed after no more than 5 minutes.
  • In the morning, the child should be able to earn something based on how many bedtime passes they have left (e.g., all bedtime passes = larger reward; 1 bedtime pass = very small reward; 0 passes = no reward).
• Encourage families to treat other mental health symptoms that may be interfering with bedtime and sleep (e.g., fear of the dark; fear of someone breaking into the home; isolating in bed all day in the context of depression). Working with a therapist specifically for sleep can help families who continue to struggle after establishing good sleep hygiene and consistent bedtime routines.

Additional resources for sleep and children

• “What to Do When You Dread Your Bed" by Dawn Huebner: A self-help guide for children and families utilizing cognitive behavioral therapy techniques to support better sleep habits in the context of anxiety
• Pediatric Sleep Council: A resource for parents focused on providing education and recommendations for sleep in young children and babies