Sleep health and sleep inequities in children

Introduction

Research tells us that sleep is important to children’s growth, development, health and mental wellbeing (Lam & Lam, 2021; Spruyt, 2019; Tarokh, Saletin, & Carskadon, 2016). Among children, poor sleep is linked to poorer emotional regulation and mood, increased likelihood of developing a mood or anxiety disorder and increased risk of having suicidal thoughts (Short, Bartel & Carskadon, 2019). Some evidence suggests that children experiencing stress and anxiety symptoms are more likely to have poorer sleep patterns than those with good sleep patterns (Gregory & Sadeh, 2012). Growing empirical evidence also indicates that children’s sleep patterns and problems are influenced by their individual, family, social and environmental circumstances (Johnson, Billings, & Hale, 2018). These differences in children’s sleep between population groups due to social, environmental or structural factors may be described as ‘sleep inequities’.

This short article describes what sleep health and good sleep are for children aged 0–12 years and outlines the determinants of sleep inequities. It also provides considerations for how practitioners can support and encourage good sleep health among children and their families.

What is sleep health and good sleep?

Sleep behaviours in early childhood can have short-term and long-term impacts on children’s health and mental wellbeing (Schlieber & Han, 2021). For example, an Australian study of 1,460 infants and their mothers found that infants with persistent sleep problems were more likely than settled infants to experience mental health difficulties in later years (i.e. when parents were resurveyed as their children reached ages four and 10 years) (Cook et al., 2020). An evidence review found a significant and possible cause-effect relationship between early childhood sleep disorders and the development of mental health problems in later childhood (Lam & Lam, 2021).

Sleep behaviours, or ‘sleep health’, refers to factors related to satisfaction, timing, duration and level of alertness during waking hours (Buyesse, 2014). Good sleep may be different for individuals at different ages, depending on their situation. However, good sleep generally includes:

• feeling satisfied after sleep
• having appropriate timing of sleep
• having enough hours of sleep (over a 24-hour period)
• falling asleep relatively easily; and
• being alert during waking hours (i.e. not dozing or nodding off) (Buyesse, 2014; Meltzer, Williamson, & Mindell, 2021).

Sleep-related behaviours that can have a positive effect on children’s sleep health include a consistent sleep schedule and bedtime routine, and parent–child interactions at bedtime. Other activities that provide a cue for sleep (sleep onset associations), such as reading a bedtime story, can also help (Meltzer, Williamson, & Mindell, 2021). Conversely, the use of electronic devices before bedtime, at bedtime and overnight and consuming caffeine¹ can have a negative effect on a child’s sleep health (Meltzer, Williamson, & Mindell, 2021).

¹ Evidence from US-based studies indicates that caffeine is widely available and consumed by a substantial proportion of youth, including 28–58% of preschoolers and 41–87% of school-aged children (Meltzer et al., 2021).

What are sleep inequities?

There is an emerging body of evidence (largely international) that indicates that children’s sleep patterns and problems are influenced by their individual, family and school circumstances, and by their neighbourhood and community context (Hale et al., 2020; Johnson et al., 2018; Meltzer, Williamson, & Mindell, 2021; Muller et al., 2022; Singh & Kenney, 2013). Research has also identified differences in sleep health among children from different sociodemographic backgrounds (e.g. Deacon-Crouch et al., 2019; Giddens et al., 2022; Muller et al., 2022). For example, Aboriginal and Torres Strait Islander children have been recorded as having shorter sleep times than non-Indigenous children in Australia (Blunden, Fatima, & Yiallouru, 2021). A study using data from the Longitudinal Study of Australian Children found that children (aged 0–7 years) from lower family socioeconomic backgrounds were more likely to have sleep problems than those from higher family socioeconomic backgrounds (Nicholson, Lucas, Berthelsen, & Wake, 2012).

Sleep inequities (also known as ‘sleep disparities’) are a type of health inequity (Johnson, Billings, & Hale, 2019). Health inequities are differences in health status between population groups (e.g. by gender or racial/ethnic background) that are caused by social, environmental and structural factors that are unfair or unjust (Whitehead & Dahlgreen, 2006). According to Muller and colleagues (2023), sleep inequities between different racial and ethnic groups occur within the broader context of social and economic environments, which includes colonisation and systemic racism.

What contributes to sleep inequities?

More research is needed to understand how and which environmental and social factors contribute to sleep health, which populations are most at risk for poor sleep health and what interventions, policies or treatments are effective at improving sleep health (Hale, Troxel, & Buysse, 2020; Johnson, Billings, & Hale, 2018).

Examples from the emerging research on determinants of sleep inequities among children include:

• Experiences of discrimination (Priest et al., 2020; Sharif et al., 2021; Shepherd et al., 2017). For example, a study of 1,239 Aboriginal and Torres Strait Islander (5–10 years old) found that primary carer and child experiences of racial discrimination were associated with more sleep difficulties (e.g. they had trouble getting to sleep) (Shepherd et al., 2017).
• Family socioeconomic and educational background (Giddens et al., 2022; Nicholson, Lucas, Berthelsen, & Wake, 2012). A systematic review of 46 studies that examined the association between parental socioeconomic background and sleep health in children 18 years and under found that higher household income was associated with fewer sleep problems and higher sleep quality (Cameron et al., 2022). It also identified that higher parental education was also associated with longer childhood sleep duration (Cameron et al., 2022).
• Living in a disadvantaged neighbourhood (e.g. a neighbourhood with high levels of socioeconomic deprivation) (Graham et al., 2020; Muller et al., 2022; Singh & Kenney, 2013; Spilsbury et al., 2006). For example, a study of 1,280 schools and surrounding communities in the United States found that kindergarten children from disadvantaged neighbourhoods experienced later bedtimes than children from more advantaged areas (Graham et al., 2020).

How can practitioners support and encourage sleep health?

Practitioners have an important role to play in promoting good sleep health among children and families. Since sleep is a modifiable behaviour, when working with children and their families, practitioners can support good sleep health by encouraging healthy sleep behaviours, which in turn can promote children’s mental health and wellbeing. Practitioners can do this in several ways:

• Speak with children and their parents about their sleep related behaviours, routines and habits. This may include number of hours of sleep, how long it takes them to fall asleep and if they sleep through the night. (See Child sleep problems for further advice.)
• Learn more about the importance of good sleep to children’s mental health and wellbeing, and the different factors that affect sleep health in children. This includes awareness of the social and environmental factors (while recognising that these can be challenging for practitioners to influence directly). Also share this information with parents and families. See the Further resources section of this article for more information on sleep health, including resources that can be shared with parents and carers.
• Practise awareness of sleep inequities – that some individuals and families from disadvantaged backgrounds are less likely to experience good sleep and that this may affect child health.
• Refer the parents or carers of children with suspected sleep disorders (e.g. sleep-disordered breathing) to a GP or other relevant professional for further assessment and treatment.

Conclusion

Sleep is an important part of children’s mental health and wellbeing, growth and development. Children’s sleep health is influenced by various individual, social and environmental factors. Increased knowledge and understanding of the importance of sleep health, along with the factors that impact sleep health for children and families, can help support and promote good sleep behaviours and habits. This can ultimately lead to better child mental health and wellbeing.

How was this resource developed?

This short article summarises evidence and literature gathered from the peer-reviewed academic literature on research examining sleep health and child mental health, and sleep inequities.

Resources from Emerging Minds and the Australian Institute of Family Studies

• Child sleep problems (Emerging Minds) describes child sleep problems and includes advice on how professionals can support parents to support their child’s sleep health.
• Promoting adequate sleep in young people (Australian Institute of Family Studies) provides evidence for promoting adequate sleep for young people. It outlines research-based implications for professionals working with young people and their parents.

Further resources

The following is a range of resources related to child sleep health:

• The fact sheet Sleep problems – babies and toddlers provides information about sleep and sleep problems for babies and toddlers (Royal Children’s Hospital Melbourne).
• The Bedtime problems – children fact sheet provides information about sleep and sleep problems for preschool and primary-school aged children (Royal Children’s Hospital Melbourne).
• The SleepHealth Foundation website is a not-for-profit health promotion organisation that provides practitioners, parents and carers with information about child sleep health, how to improve it and addressing common sleep disorders.
• The Australian Government Department of Health and Aged Care website has information about sleep for children aged 0–5 years, and children and young people aged 5–17 years on ensuring good sleep. The Department also provides a guideline on the amount of sleep and activity needed for children from birth to five years.
• The Red Nose website includes information on safe sleeping for children from birth to five years of age.
• The Raising Children Network also has resources for parents related to sleep, including:
  • Sleep problems and solutions
  • Persistent sleep problems in children and teenagers

References

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