Original ArticleAggressive behavior, bullying, snoring, and sleepiness in schoolchildren☆
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.
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.
References (69)
- et al.
Oppositional defiant and conduct disorder: a review of the past 10 years, part I
J Am Acad Child Adolesc Psychiatry
(2000) - et al.
Effectiveness of universal school-based programs to prevent violent and aggressive behavior: a systematic review
Am J Prev Med
(2007) - et al.
Children involved in bullying at elementary school age: their psychiatric symptoms and deviance in adolescence. An epidemiological sample
Child Abuse Negl
(2000) - et al.
Conduct problems and symptoms of sleep disorders in children
J Am Acad Child Adolesc Psychiatry
(2003) - et al.
DSM-IV diagnoses and obstructive sleep apnea in children before and 1 year after adenotonsillectomy
J Am Acad Child Adolesc Psychiatry
(2007) - et al.
Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems
Sleep Med
(2000) - et al.
Excessive daytime sleepiness and sleep complaints among children with epilepsy
Epilepsy Behav
(2006) - et al.
Symptoms of sleep-disordered breathing in children with nocturnal enuresis
J Pediatr Urol
(2008) - et al.
Spanish version of the pediatric sleep questionnaire (PSQ). A useful instrument in investigation of sleep disturbances in childhood. Reliability analysis
An Pediatr (Barc)
(2007) - et al.
School performance, race, and other correlates of sleep-disordered breathing in children
Sleep Med
(2003)
Symptoms of sleep disturbances among children at two general pediatric clinics
J Pediatr
The impact of inadequate sleep on children’s daytime cognitive function
Semin Pediatr Neurol
Pathways to adolescent health sleep regulation and behavior
J Adolesc Health
Psychopathy as a disorder of the moral brain: fronto-temporo-limbic grey matter reductions demonstrated by voxel-based morphometry
Neuroimage
Reduced regional cerebral blood flow in non-psychotic violent offenders
Psychiatry Res
Psychophysiology of anger and violent behavior
Psychiatr Clin North Am
Heart rate level and antisocial behavior in children and adolescents: a meta-analysis
J Am Acad Child Adolesc Psychiatry
Ontario child health study. II. Six-month prevalence of disorder and rates of service utilization
Arch Gen Psychiatry
School-based secondary prevention programmes for preventing violence
Cochrane Database Syst Rev
The effects of school-based intervention programs on aggressive behavior: a meta-analysis
J Consult Clin Psychol
Bullying behaviors among US youth: prevalence and association with psychosocial adjustment
JAMA
Bullying among young adolescents: the strong, the weak, and the troubled
Pediatrics
Bully/victim problems among middle school children
Br J Educ Psychol
World report on violence and health
Biomedica
Association of bullying with adolescent health-related quality of life
J Paediatr Child Health
Predictors of violent and serious delinquency in adolescence and early adulthood: a synthesis of longitudinal research
Epidemiology of pediatric obstructive sleep apnea
Proc Am Thorac Soc
Natural history of snoring and related behaviour problems between the ages of 4 and 7 years
Arch Dis Child
Sleep and neurobehavioral characteristics of 5- to 7-year-old children with parentally reported symptoms of attention-deficit/hyperactivity disorder
Pediatrics
Symptoms of sleep disorders, inattention, and hyperactivity in children
Sleep
Symptoms of sleep-disordered breathing in 5-year-old children are associated with sleepiness and problem behaviors
Pediatrics
Neuropsychological effects of pediatric obstructive sleep apnea
J Int Neuropsychol Soc
Sleep apnea in eight children
Pediatrics
Sleep problems seldom addressed at two general pediatric clinics
Pediatrics
Cited by (58)
Effect of subjective sleep quality on aggression: A two-year longitudinal and fMRI pilot study
2023, Biological PsychologyParent-Reported Sleep Profile of Children With Early-Life Epilepsies
2022, Pediatric NeurologyAssociation between habitual snoring, middle ear disease, and speech problems in young children with non-syndromic cleft palate anomalies
2022, International Journal of Oral and Maxillofacial SurgeryQuality over quantity? Using sibling comparisons to examine relations between sleep quality, sleep duration, and delinquency
2021, Social Science and Medicine
- ☆
Financial support: NIH/NCRR/University of Michigan Medical School Clinical Research Initiatives Program, 5 M01 RR000042.