Sleep is not for slackers
Sleep is a central part of child development. In the first two years of life, children spend more time asleep than awake. For older children and adolescents, sleep continues to account for approximately 40 percent of a child's day (Mindell & Owens, 2010). Yet for many youth, sleep is highly problematic, with 25-40 percent of children having a sleep issue at some point in their life (Owens, 2005). Common sleep disorders include obstructive sleep apnea, parasomnias, narcolepsy and insomnia. Sleep problems include sleep-related anxiety, deficient sleep and poor sleep hygiene. Some sleep issues may resolve on their own as children grow older. However, for many children and adolescents, untreated sleep problems and sleep disorders persist (Byars, Yolton, Rausch, Lanphear, & Beebe, 2012; Dregan & Armstrong, 2010; Lam, Hiscock, & Wake, 2003), resulting in a chronic issue that severely impacts daytime functioning. Children with comorbid psychiatric, neurodevelopmental, or medical conditions have even more sleep issues than their healthy, typically-developing peers (Konofal, Lecendreux, & Cortese, 2010; Lewandowski, Ward, & Palermo, 2011; Reynolds & Malow, 2011). The relationship between sleep and these types of disorders is quite complex, with disturbed sleep often considered both a symptom and a functional outcome.
Deficient or disrupted sleep in youth has been linked with a number of negative outcomes, including difficulties with concentration and learning, inattention and impulsivity (Beebe, 2011; Gruber, Cassoff, Frenette, Wiebe & Carrier, 2012; Sadeh, Gruber, & Raviv, 2003), poor emotional regulation and increased risk for depression (Gregory & Sadeh, 2011), as well as more accidents and risk taking behaviors (McKnight-Eily et al., 2011; O'Brien & Mindell, 2005; Owens, Fernando, & McGuinn, 2005; Pizza et al., 2010). Recent studies also show that sleep deficiency is related to physical health outcomes, including hypertension, hypercholestemia, insulin resistance and obesity (Flint et al., 2007; Gangwisch et al., 2010; Javaheri, Storfer-Isser, Rosen & Redline, 2008; Javaheri, Storfer-Isser, Rosen & Redline, 2011) . Furthermore, children's sleep issues have a significant impact on parental sleep and daytime functioning, which in turn can impact parent mood, marital quality, family functioning, work performance and general parenting (Boergers, Hart, Owens, Streisand, & Spirito, 2007; Meltzer & Mindell, 2007; Meltzer & Montgomery-Downs, 2011).
Why are pediatric sleep issues under-recognized in primary care?
There are multiple reasons why sleep issues have historically been unrecognized by primary care providers (Erichsen et al., 2012; Meltzer, Johnson, Crosette, Ramos & Mindell, 2010). Training in general sleep medicine, let alone pediatric sleep medicine, is extremely limited for primary care providers. For example, 2 recent studies show that, on average, pediatricians receive less than 4 hours of sleep-related training across medical school and residency (Mindell et al., 2011; Mindell et al., 2013) . This results in primary care providers being unsure about not only what to ask, but also about what to do if a sleep issue is identified (Faruqui, Khubchandani, Price, Bolyard, & Reddy, 2011). Training in sleep for clinical psychologists is also lacking, with only 6 percent of programs in the U.S. and Canada offering formal didactic training in sleep, and most programs reporting that they were ineffective in providing education about sleep, let alone pediatric sleep (Meltzer, Phillips & Mindell, 2009) . Along with a lack of provider training, parents often neglect to raise sleep issues during well-child visits (Blunden et al., 2004; Chervin, Archbold, Panahi, & Pituch, 2001). This may stem from either the need to cover multiple aspects of a child's daytime functioning during a brief well-child visit, or from parents not realizing their child has poor sleep habits that result in deficient or disrupted sleep (Owens & Jones, 2011).