Elsevier

Sleep Medicine

Volume 12, Issue 7, August 2011, Pages 652-658
Sleep Medicine

Original Article
Aggressive behavior, bullying, snoring, and sleepiness in schoolchildren

https://doi.org/10.1016/j.sleep.2010.11.012Get rights and content

Abstract

Background

To assess whether urban schoolchildren with aggressive behavior are more likely than peers to have symptoms suggestive of sleep-disordered breathing.

Methods

Cross-sectional survey of sleep and behavior in schoolchildren. Validated screening assessments for conduct problems (Connor’s rating scale), bullying behavior, and sleep-disordered breathing (pediatric sleep questionnaire) were completed by parents. Teachers completed Connor’s teacher rating scale.

Results

Among 341 subjects (51% female), 110 (32%) were rated by a parent or teacher as having a conduct problem (T-score ⩾65) and 78 (23%) had symptoms suggestive of sleep-disordered breathing. Children with conduct problems, bullying, or discipline referrals, in comparison to non-aggressive peers, more often had symptoms suggestive of sleep-disordered breathing (each p < 0.05). Children with vs. without conduct problems were more likely to snore habitually (p < 0.5). However, a sleepiness subscale alone, and not a snoring subscale, predicted conduct problems after accounting for age, gender, a measure of socioeconomic status, and stimulant use.

Conclusions

Urban schoolchildren with aggressive behaviors may have symptoms of sleep-disordered breathing with disproportionate frequency. Sleepiness may impair emotional regulation necessary to control aggression.

Introduction

Aggressive behaviors are common among children and present a major challenge at schools. Conduct problems include destructive tendencies, quarreling, constant fighting, disobedience, and other related behaviors. Children who bully are often diagnosed with conduct disorder, affecting 2–9% of US children [1], [2]. Societal concern about aggressive behaviors has risen exponentially, as reflected by new local, state, and national programs to address it [3], [4], [5]. The prevalence of such behavior among elementary schoolchildren is approximately 25% [6], [7] and higher in boys [8]. Children who bully are at risk for later psychiatric symptoms, delinquency, substance abuse, antisocial behavior, violence, and criminal activity [9], [10], while childhood victims of bullying suffer impaired self-image, depression, and decreased quality of life [11]. Aggression, violence, and related problems are particular concerns in urban, low-income communities with a high representation of minority residents [12]. Causes of aggressive behaviors are heterogeneous and include well-studied social and cultural underpinnings. Strategies to address these challenges could be beneficial if understanding of their childhood antecedents could be improved.

One possible biological contributor to aggressive behaviors may be sleep-disordered breathing (SDB), a spectrum that includes habitual snoring at one end and obstructive sleep apnea at the other. Frank sleep apnea is estimated to affect 1–4% of young children [13] and is characterized by repeated partial or complete upper airway obstruction during sleep, disruption of normal ventilation, hypoxemia, and sleep fragmentation. Sleep-disordered breathing has shown a robust association with hyperactive and inattentive behavior in multiple studies [14], [15], [16], [17], [18] and an early clinical series reported high frequencies of aggressive behavior in children referred for SDB [19]. One cross-sectional study of 2–14-year-old children in general pediatric clinics found that even after adjustment for hyperactivity and stimulant use, children with SDB symptoms (e.g., habitual snoring), in comparison to others, were still more likely to be rated as bullies, constant fighters, quarrelsome, or cruel [20]. These observations are particularly important because childhood SDB, most often occult [21], can be readily diagnosed and treated. Furthermore, behavioral problems may improve substantially after SDB treatment, usually by adenotonsillectomy [22], [23], [24], [25]. However, whereas several studies have focused on aggressive behavior in referred children with and without SDB, none have examined SDB risk in a broader group of school-aged children with and without aggressive behavior. The extent to which aggressive behaviors may be explained by generally occult SDB in elementary schoolchildren, especially in urban community settings, remains largely unstudied, and was therefore the main question in this cross-sectional survey.

Section snippets

Methods

This study was approved by the Institutional Review Board and the School Board. The city of Ypsilanti, in Southeast Michigan, comprises about 24,000 people, including large numbers of immigrants and minorities. Approximately 30% of children live below the poverty line (US Census 2000), 52% of students are male and 58% qualify for school lunch assistance. The racial distribution is 63% African American and 30% Caucasian [26]. In May 2006, parents of children in grades 2–5 of the Ypsilanti Public

Analysis

All data were double-entered to ensure accuracy. Analyses were performed with SPSS, version 15. The main outcome variable was the presence of a conduct problem. Secondary analyses focused on question-items about bullying. Explanatory variables were provided by the SRBD score and its components. Demographic information was compared using T-tests or Chi-squared tests. Logistic regressions were used to model the conduct problem T-score (high vs. not high) or bullying behavior (present vs. absent)

Results

A total of 1221 families were approached, and parents of 341 children (28%) completed the surveys. The mean age of the sample was 9.0 ± 1.3 years and 167 (49%) were male. Information about height and weight that enabled calculation of body mass index (BMI) was available for 236 (69%) of the children and was therefore not entered into the statistical models shown below. However, addition of BMI did not appreciably alter the results. Mean BMI was 19.7 ± 5.7 kg/m [2]. The racial and ethnic composition

Discussion

This cross-sectional study in an urban public school district found that schoolchildren with conduct problems or school discipline referrals, in comparison to peers, have increased symptoms of SDB. The results were robust, in that high SDB risk on a well-validated questionnaire was twice as common among children with symptoms of conduct problems, as compared to children without. However, sleepiness rather than a symptom more specific to SDB—snoring—appeared to drive the association between SDB

Conflict of interest

The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: doi:10.1016/j.sleep.2010.11.012.

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Acknowledgments

We wish to thank the students and parents of the Ypsilanti Public School System who participated in this research, the teachers who took the time to complete teacher rating scales, and the principals and staff who assisted with this study.

Thanks also to Laura Klem, A.B., for statistical advice.

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    Financial support: NIH/NCRR/University of Michigan Medical School Clinical Research Initiatives Program, 5 M01 RR000042.

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