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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2017  |  Volume : 35  |  Issue : 2  |  Page : 123-127

Decreased sleep in children and their behavioral problems in dental operatory

1 Department of Pedodontics and Preventive Dentistry, SMBT Dental College and Hospital, Sangamner, Maharashtra, India
2 Department of Pedodontics and Preventive Dentistry, Modern Dental College and Research Centre, Indore, Madhya Pradesh, India

Date of Web Publication10-May-2017

Correspondence Address:
Vinaya Kumar Kulkarni
Department of Pedodontics and Preventive Dentistry, SMBT Dental College and Hospital, Ghulewadi, Sangamner - 422 608, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_117_16

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Purpose: This study was conducted to examine the contribution of inadequate sleep and its associated factors, on behavior and cooperation of children in the dental operatory. Materials and Methods: A cross-sectional study was conducted on 100 healthy children at the time of their initial visit to the dental hospital, ranging from preschoolers to adolescents. Data acquisition was done by a questionnaire. Interview with the accompanying person was done to ask about the sleep duration, naps, and sleep habits of the child. Children's behavior during their preliminary examination was studied and categorized according to Frankl's behavior rating scale. Data were analyzed by linear regression analysis and Spearman's correlation with the aid of SPSS 16.0 software. Results: Total duration of sleep accounted for a small but significant contribution in behavioral problems of children. Significant correlation was found between duration of sleep and cooperative behavior in dental operatory (R = 0.478). However, the duration of sleep was negatively correlated to the number of siblings and socioeconomic status of the family. Conclusion: Children who had shorter total sleep duration had increased behavioral problems in dental operatory.

Keywords: Externalizing behavior, neurobehavioral functioning, night waking, sleep duration

How to cite this article:
Kulkarni VK, Kandya A, Arora S, Singh G. Decreased sleep in children and their behavioral problems in dental operatory. J Indian Soc Pedod Prev Dent 2017;35:123-7

How to cite this URL:
Kulkarni VK, Kandya A, Arora S, Singh G. Decreased sleep in children and their behavioral problems in dental operatory. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2021 Oct 28];35:123-7. Available from: https://www.jisppd.com/text.asp?2017/35/2/123/206030

   Introduction Top

Pediatric dental practitioners often have to win a battle before treating their child patient, due to disruptive behavior. Out of many reasons for externalizing behavior in kids, sleep may be one. It is estimated in cross-sectional studies that overall 20%–30% of young children are reported to have significant bedtime problems and/or night waking.[1],[2],[3] Although their types may vary, infants and toddlers find difficulty in settling down or falling asleep, preschoolers show increased cases of sleep bruxism, somnambulism, and enuresis, and adolescents present more problems due to insomnia and daytime sleepiness.[4] It is reported that children who have less total sleep duration are at a higher risk for developing behavioral problems such as anger, anxiety, overactivity, tantrums, and aggression.[5] The reason for shorter total sleep duration may be attributed to late night sleeps along with early rise due to schools, further enhanced by missing of naps due to afterschool activities, tuitions, and coaching.

Children mostly show bedtime resistance due to their enjoyment in other activities, they may be not tired yet, or their siblings/friends are still awake or because of any fear.[6] However, bedtime resistance is not the sole reason; sleep problems also occur when children frequently wake up in the middle of the night and do not fall asleep quickly or independently.[6]

Sleep needs change according to age, being 14.2 h average at 6 months of age and decreasing to 8.1 h average at 16 years of age.[7] Researchers showed that insufficient sleep causes changes in behavior as well as executive functioning skills of children. Many previous studies have proven that duration of sleep is significantly influenced by cultural and environmental factors, family disputes, maternal stress, and socioeconomic status (SES).[8],[9],[10],[11] By having correct knowledge regarding problems and duration of sleep at different ages, we can determine how it affects the development of behavior in them.

The purpose of this study was to find correlation between total duration of sleep and behavior of children in dental operatory and also to find whether secondary factors such as SES, working of mother, number of siblings, type of family, presence of sleep habits such as bruxism and use of electronic media (EM) at bedtime have an influence on the duration of sleep and hence affecting the behavior of children.

   Materials and Methods Top

A cross-sectional study was carried out after obtaining ethical clearance from the institutional ethical committee and informed consent from parents/guardians. One hundred healthy children with age range of 3–16 years, who were reporting to the department of pedodontics for the first time, were selected randomly. Children with history of any systemic disorder, on constant medication, whose consent was not obtained from parents/guardians, or whose behavior modification has already been done, were excluded from the study.

Questionnaire was completed by interviewing the accompanying person. Questions were asked by a single inquisitor in the local language, about total sleep duration (including daytime naps) during weekdays and weekends, completion of nap, sleep habits (e.g., bruxism, sleep talking, sleep walking, and sleeping with a toy), type of family (nuclear or combined), major caregiver for the child, working of mother, number of siblings (and sequence of birth of child), pattern of sleep (normal or disturbed), SES (according to Kuppuswamy's SES scale),[12] and use of EM (television, computers, cell phones etc.) before sleep time. The diagnosis for age-related proper/shorter total sleep was determined according to the recommended sleep duration by the National Sleep Foundation's sleep time duration recommendations which proposes following hours of sleep according to age:[13]

  • For 1–2 years – 11–14 h
  • For 3–5 years – 10–13 h
  • For 6–13 years – 9–11 h
  • For 14–17 years – 8 –10 h.

In the dental operatory, child's behavior during his/her preliminary examination was rated according to Frankl's behavior rating scale into definitely negative, negative, positive, and definitely positive.[14] The following traits were included:

  • 1 = Definitely negative (−−): Cries forcefully, refuses treatment, extreme negativism, fearful
  • 2 = Negative (−): Reluctant to accept treatment, uncooperative, negative attitude but not very pronounced, i.e., sullen, withdrawn
  • 3 = Positive (+): Acceptance of treatment, at times cautious, willing to comply but at times with reservations, usually follows dentist's directions
  • 4 = Definitely positive (++): Develops good rapport, takes interest, enjoys the treatment.

   Results Top

Statistical analysis was performed by SPSS 16.0 softwere (IBM, Armonk, New York, USA). First, linear regression analysis was done to know the relation of child's behavior in dental operatory with total sleep duration and followed by duration of sleep with various variables such as pattern of sleep (sound/disturbed), working of mother, type of family (combined/nuclear), SES, and EM usage. After which Spearman's correlation was carried out to assess how well the relationship can be explained between the qualitative variables. Correlation was statistically significant for P < 0.05.

Of 100 children participated in the study, 57% were male and 43% were female and majority of them belonged to low SES. Among all the children, 21% had decreased sleep according to their age and only 10% of the children had sleep habits [Table 1]. Not all the children who take afternoon nap could able to complete it as shown in [Table 2]. The mother was the major caregiver in all the cases and only 24% of them were working. Behavior rating of the participated children according to Frankl's behavior rating scale is depicted in [Graph 1].
Table 1: Distribution of children with associated sleep habits

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Table 2: Distribution of the children taking afternoon nap

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Linear regression analysis was carried out to determine the relationship between behavior of children in dental operatory and duration of sleep. According to Spearman's correlation, duration of sleep was positively correlated with cooperative behavior of child in dental operatory, which was highly significant statistically (P < 0.001, R = 0.478) [Table 3] and [Graph 2]. However, the duration of sleep was negatively correlated with number of siblings (P = 0.005, R = −0.28) and SES of the family (P = 0.019, R = −0.254) [Table 4].
Table 3: Correlation between duration of sleep and behavior of children in dental operatory

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Table 4: Correlation of different influencing factors with duration of sleep

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   Discussion Top

This study evaluated the correlation between total duration of sleep and behavior of children in dental operatory. To the best of our knowledge, this is the first kind of study in which behavior of children in dental operatory was correlated with the duration of sleep.

In this 24 h lifestyle, we do not give enough emphasis on the role which quality sleep plays in the development of brain and how it may influence not only the performance but also the behavior and mood of the child. In the present study, children with shorter (than recommended) sleep duration presented with more negative behavior and duration of sleep was positively correlated with cooperative behavior of child in dental operatory, which was statistically highly significant. These results are supported by some studies and they found a correlation between difficult sleep (reported by parents) and hyperactivity, aggressive behavior and anxiety in children.[15],[16],[17],[18],[19],[20] This not only hinders their process of learning but also may cause inappropriate neurobehavioral functioning.[6],[15],[16],[21]

By knowing the prevalence, we infer that the problems with sleep are more common in period of early childhood in comparison to later childhood, which further poses a greater risk at ongoing neurological and psychological development.[6] According to a study done by Scharf et al.,[22] preschoolers with shorter duration of sleep at night had higher reports for annoying behaviors which may be ignored or misunderstood by the parents as anger, tantrums, and irritability of the child. Dahl [23] in his study found that short sleep may decline cognitive development in children, thus worsening their behavior. Many studies showed that psychopathology (i.e., internalizing and externalizing behavior) and sleep covary in young children.[22],[23],[24],[25],[26] Both internalizing behavior (depression and anxiety) and externalizing behavior (aggression, overactivity, and tantrums) are seen with children who had problems either getting into sleep or maintaining their sleep.[19],[20],[21],[22],[23],[24],[25],[26],[27] Keeping this relation in mind, a pediatric dentist may not only facilitate in behavior modification of the child but may also make the parents understand about the its root cause and the factors allied with it.

Studies observing sleep in early childhood have recognized environmental factors such as cultural differences,[8],[9] family issues,[20],[28] child to parents relation,[10] and SES [11] influencing their behavior. The present study demonstrated that total sleep duration was decreased with increase in the number of siblings and lower SES; this is in accordance with the studies done by Mindell et al.[3] and Buckhault.,[29] which may be attributed to the fact that lower SES may increase parental stress and depression affecting the child's sleep and hence the behavior. Studies by El-Sheikh et al.[30] and Goodnight et al.[31] found that increased conflicts in family or maternal stress ultimately lead to arousal in children and cause increased chances of behavioral problems. Similarly, Seifer et al.[32] and Lavigne et al.[33] also reported that familial conflicts are related to sleep disturbances in children.

Other important factor which also contributes majorly in these problems is EM usage, especially during bedtimes. The current study found that total sleep period decreased with an increase in the use of EM at bed time; however, the relation was not found to be significant. These results are in agreement with the study by Owens et al.[34] who stated that behavioral problems are more frequently seen in children who had more than 2 h of media time daily. Mechanism behind it is proposed by Higuchi et al.[35] which states that exposure of bright light during late evenings may suppress the secretion of melatonin and thus delay the circadian rhythm leading to loss of or decrease in sleep.

   Conclusion Top

This study clarified that total sleep duration has a significant effect on behavior of children in dental operatory and total sleep duration is influenced by many secondary factors. It can be noticed that poor sleepers have a higher risk for behavioral problems than normal sleepers. Although there is increasing knowledge regarding normal sleep and its disorders, its influence on development of behavior remains a little unjustified. Further studies are needed to justify each factor separately. Learning more about sleep habits and problems in children may lead us to a definite result of how it may vary with different factors and their solutions. Nonetheless, pedodontists having added knowledge about required sleep duration and its effect on behavior may not only aid in managing the child in dental clinics but also in better psychological development of children.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]


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