Learning Objectives
By the end of this section, you will be able to:
- Examine the effects of insufficient sleep in children
- Recognize the effects of insufficient sleep in adults
- Analyze behavioral effects of insufficient sleep
Sleep has so many functions throughout the life span. In early development, much neurological growth and development occurs during sleep. At any stage, recuperative, healing, and rejuvenating events happen primarily while a person sleeps. Sleep is also necessary simply for feeling adequately energized and ready for the expectations and activities of a normal day.
Insufficient sleep caused by either a total lack of sleep or a lack of quality sleep can affect people in many ways. For children, sleep insufficiency may influence growth and development, and, for both children and adults, sleep inadequacy can have behavioral, psychological, and physiological implications.
Insufficient Sleep in Children
Problems sleeping affect 25 to 50 percent of young children, and approximately 40 percent of adolescents (Pacheco, 2023). Results of insufficient sleep may be apparent in growth and development, mental health, behavior, and performance issues. It also places these children at higher risk for obesity and related health concerns.
Growth and Development
Insufficient sleep can affect a child’s normal growth and development. Inadequate sleep has direct effects on cognitive operations, alertness, the ability to focus and pay attention, the acquisition of vocabulary, and memory (Liu et al., 2024; Pacheco, 2023). Growth hormone has a relationship to circadian rhythms, with typical release during sleep. Not enough sleep during infancy can result in secretion of insufficient amounts of growth hormone, therefore potentially impacting normal growth at such a critical time (Pacheco, 2023). Chronic lack of growth hormone results in reduced growth, impaired focus and alertness, and inability to regulate moods or positively adapt and develop resiliency. For toddlers, napping is needed to consolidate memories and to develop motor skills and high-level attention.
The impact of insufficient sleep on adolescents is seen physically through development of risk factors for, or diagnosis of, cardiovascular, metabolic, and inflammatory disorders. Hypertension, cardiovascular disease, and diabetes mellitus (especially type 2) are becoming more commonplace in adolescence and even childhood, and insufficient sleep is one major factor (Liu et al., 2024; Pacheco, 2023). Behavioral, mental health, and performance issues in this age group are also associated with sleep insufficiency.
Link to Learning
Watch this video about typical development and consider what effects are likely without adequate sleep.
Behavioral and Mental Health Concerns
Insufficient sleep can impact the behavior and mental health of children in many ways. It has the potential to influence the ability to
- pay attention,
- focus,
- plan,
- tolerate frustrating circumstances,
- regulate moods,
- adapt,
- develop resilience, and
- learn (Liu et al., 2024; Pacheco, 2023).
Children and adolescents who have no history of mental health concerns may experience such issues as depression or anxiety when sleep deprived; those who have an existing mental health diagnosis are at greater risk for such challenges to worsen (Columbia Psychiatry, 2022).
Patient Conversations
An Angry, Irritable First Grader
Scenario: A young mother has brought her 6-year-old child to the pediatrician’s office because the child is becoming increasingly difficult to control.
Nurse: Good morning, Ms. Solange, I’m Susan, Dr. Jackson’s nurse. And this must be Lorene? Hi, Lorene.
Patient: Hi, Susan.
Nurse: Lorene, I’m going to ask your mom some questions, okay? If you have something to add, you can. Is that okay?
Patient: Sure.
Nurse: Ms. Solange, tell me more about what’s going on with Lorene.
Patient’s mother: She started first grade in August. She loved school. She would even help me in the mornings. Then, about a month ago, she brought home a note from the principal. She’d been in a scuffle at school.
Patient: She slapped me first, Mom.
Patient’s mother: I know, Lorene. But I have to tell the nurse what happened.
Nurse: Any other events?
Patient’s mother: Yes. She’s been bringing home notes from the teacher that she’s not reading up to grade level, and her spelling is getting worse, not better.
Nurse: How is her behavior at home?
Patient’s mother: She’s been grumpier. Sometimes she acts . . .
Patient: I’m not grumpy!
Patient’s mother: I’m sorry, honey, but sometimes you seem unhappy and get a little angry about things. Don’t you?
Nurse: It’s okay, Lorene, sometimes we all get a little grumpy. Do you feel like you’re getting enough sleep at night?
Scenario follow-up: Lorene and her mother were a little startled by the question, but it opened a flood of emotions.
Patient: Mom, you know about Emeline, at school?
Patient’s mother: Yes. She’s the one who slapped you, and you slapped back, right?
Patient: Yeah. That’s her. Well, she didn’t stop after that day.
Nurse: Is this girl still bothering you at school, Lorene?
Patient: Yes. She hasn’t hit me again, but she’s so mean.
Patient’s mother: Oh Lorene, baby. You didn’t tell me.
Scenario follow-up: Susan and the Solanges discuss that Ms. Solange will contact the teacher and principal and determine what can be done to resolve the situation. Lorene is seen by the pediatrician who confirms stress-related insomnia.
Nurse: Now, as for Lorene’s being grumpy at home and not doing well at school, it’s complicated but likely because she’s not sleeping well and has significant stress going on at school. The stress has affected her sleep, which affects her ability to handle Emeline and whatever else was difficult. Then she’d worry at home, and not sleep even more. Did I miss anything, Lorene?
Patient: I think you got it. Am I in trouble?
Patient’s mother: No, you’re not. I’m sorry it went on so long, Lorene. But now we know some things to do.
Nurse: So, you’ve got some work to do with the school, and I’ll give you some ways to improve Lorene’s ability to reduce stress and improve sleep. In one week, let me know how it goes with the school and how Lorene is doing.
Link to Learning
Behavioral and mental health consequences of insufficient sleep are described in this video. Some of the recommendations for improving sleep quantity and quality may be helpful for nursing care and patient education.
Performance Deficits
Neurophysiological development requires sleep to provide the circumstances that foster certain healing and restorative actions that cannot be accomplished while awake (Nunez & Lamoreux, 2023). Without these revitalizing benefits, performance may suffer. Possible effects on performance include
- lack of alertness,
- inability to concentrate and complete tasks,
- impaired cognitive and reasoning abilities,
- poor memory,
- slowed reaction times,
- poor development of motor skills, and
- lack of academic achievement (Liu et al., 2024; Nunez & Lamoreux, 2023).
Risk for Obesity
Obesity is an issue in pediatric populations as well in the adult population. Insufficient sleep is associated with development of some of the physiologic (e.g., metabolic) and psychologic (e.g., depression) factors involved in the occurrence of obesity in children (Pacheco, 2023). Studies have noted an inverse relationship between sleep duration and occurrence of overweight and/or obesity (Morrissey et al., 2020). Research indicates that lack of sleep leads to alterations in hormone regulation, which results in an energy imbalance, a subsequent reduction of activity level, and increased intake of calories. Many sleep-related factors affect children’s weight, including quality of sleep (as measured by polysomnography), quantity of sleep, where in the twenty-four-hour day sleep occurs, and whether it is easy for a child to fall asleep and stay asleep.
Obesity tends to be accompanied by metabolic disorders, including insulin resistance and cardiovascular-related concerns such as hyperlipidemia (elevated blood lipids) and dyslipidemia (abnormal blood lipids), hypertension, and coronary artery disease. Anxiety and depression can also contribute to obesity. Additionally, such mental health concerns perpetuate the cycle of insomnia, and all the associated consequences.
Insufficient Sleep in Adults
Some of the same factors that affect children’s sleep are involved in insufficient sleep occurring in adulthood. Chronic sleep insufficiency negatively affects mental and physical health and wellness. Cognitive and behavioral outcomes include decreased reasoning skills; risky, impulsive actions; and poor mood and judgment.
Depression, anxiety, mood disorders, and attention deficit hyperactivity disorder (ADHD) are examples of psychological disorders commonly impacted by lack of sleep (Suni, 2024). Physiological issues that may have a connection to sleep deprivation include cardiovascular, respiratory, gastrointestinal, and metabolic disorders.
Psychological and Cognitive Concerns
Sleep insufficiency is associated with anxiety, depression, concentration, memory, and mood (Suni, 2024). This relationship sometimes occurs in a bidirectional manner, whereby lack of sleep can be both a contributor to, and the effect of, a mental disorder (Columbia Psychiatry, 2022; Suni, 2024). Even patients who have no history of a mental health disorder might experience issues after episodes of insomnia, especially if the sleep problems become chronic. Psychological distress and insomnia can then become a self-perpetuating problem. Treating the sleep disorder sometimes improves the mental health problem (Suni, 2024).
Anxiety
Anxiety can be a cause of sleep insufficiency or an occurrence secondary to lack of sleep (Columbia Psychiatry, 2022; Pacheco, 2023; Roddick & Cherney, 2024). Anxiety can be mild or any level of severity up to and including a panic attack. Furthermore, the influence on sleep may be mild, and merely cause a slightly lengthened time to fall asleep. Or it may involve enough worry to cause fear and result in hyperarousal, with not only slower time to achieve sleep, but fragmented sleep and an inability to reach the REM stage because of frequent awakenings and difficulty returning to sleep.
Acute episodes of insomnia in people who have no longstanding history of an anxiety disorder will likely result only in mild anxiety. Chronic anxiety is likely to be more severe when coupled with chronic insufficient sleep (Pacheco, 2023; Suni, 2024). PTSD, involving a combination of hyperarousal and recurrent episodes based on trauma, can worsen sleep issues with nightmares and sudden traumatic awakenings (Suni, 2024). Likewise, insomnia can worsen the consequences of PTSD.
Depression
Another psychological concern frequently associated with insufficient sleep is depression. Similar to anxiety, depression may lead to insufficient sleep, or the loss of sleep may result in depression (Suni, 2024). Depression may occur as a result of an event, such as the death of a family member or friend. In such an acute case, the situational depression and linked problem sleeping is relatively short-lived and tends to resolve without interventions. Chronic depression and related insomnia may necessitate a variety of treatments.
Patients may also turn to substance use as a way of self-medicating depression and feeling better temporarily. This, unfortunately, may result in increasing the negative cycle of poor sleep worsening depression and depression worsening sleep (Pacheco, 2023). Additionally, suicidal risk may increase as a consequence of inadequate sleep, even when the patient has no history of depression (Suni, 2024).
Concentration and Memory
While sleeping, the brain is able to recover from the day’s demands, including those involved in learning, concentration, and memory consolidation (Pacheco, 2023; Suni, 2023). Insufficient sleep, especially a lack of SWS and REM sleep, negatively impacts these functions and impedes development of healthy adaptations to stress (Suni, 2024). Hypersomnolence may also be implicated in poor memory, confusion, or an inability to concentrate (Cherry, 2023). Other psychological disorders such as ADHD; seasonal affective disorder (SAD), which is depression occurring relative to lack of light; and symptoms of bipolar disorder and schizophrenia can all be adversely affected by insufficient sleep. Manifestations tend to involve worsening of symptoms, including those involved with concentration and the ability to recall information.
Severe Mood Swings
Mood swings may be a result of, or worsened by, insufficient sleep. Without proper rest, patients may feel easily frustrated, tense, and irritable (Cherry, 2023; Suni, 2024). Adequate, restorative sleep fosters positive coping and resilience; sleep deprivation reduces normal brain function and can increase tension, reactivity, and aggression (Cherry, 2023). Such mood changes contribute to negative results in home, school, and/or work environments. Treating the insufficient sleep is likely to improve the mood swings and often begins by discussing sleep hygiene and habits with the patient. Further workup by the healthcare provider may include polysomnography and medication therapy.
Hallucinations
Ineffective sleep can cause neuronal stimulation and excitability in the region of the brain involved in movement. This can result in intensified processing of information and hallucinations with chronic lack of sleep (HealthMatch, 2022). In fact, chronic lack of sleep is associated with a fourfold increase in the potential to experience hallucinations; those experiencing only mild insomnia are at two to three times the risk of such distorted perceptions than someone with adequate sleep (HealthMatch, 2022).
Hallucinations may manifest as simple or complex and may involve changes in an object’s color, an object’s size, or distance and depth perception (HealthMatch, 2022). Persons experiencing hallucinations may be unable to recognize common items and sounds. Those who have a diagnosis involving altered perception of reality, such as schizophrenia, may experience hallucinations at baseline, with worsening symptoms if sleep deprived.
Physiological Concerns
Insufficient sleep also affects the body’s physiologic responses or maintenance of homeostasis. Various neurohormonal responses occur during sleep cycles, including healing and restoring actions as well as the secretion of hormones that sustain normal physiological functions. Sustaining the normal function of the human body involves complex, coordinated activities between the brain and the different organ systems. Sleep is necessary for these systems to perform their necessary tasks and sustain a homeostatic state.
Gastrointestinal
The gastrointestinal system is affected by quantity and quality of sleep, in a bidirectional fashion. Therefore, insufficient or poor sleep can contribute to gastrointestinal disorders, and gastrointestinal problems can result in ineffective sleep (Orr et al. 2020; Vernia et al., 2021). Gastrointestinal distress often leads to fragmented sleep. Subsequently, the shortened sleep duration contributes to actual and perceived gastrointestinal symptoms, such as reflux, pain, and bloating. Some of the gastrointestinal disorders commonly exacerbated by lack of sleep include
- gastroesophageal reflex disease (GERD),
- irritable bowel syndrome (IBS),
- irritable bowel disease (IBD),
- colon cancer, and
- nonalcoholic fatty liver disease (NAFLD).
There is a pathophysiological relationship observed between OSA and NAFLD. The intermittent hypoxia associated with OSA also contributes to other metabolic disorders, including hyperlipidemia and cellular resistance to insulin (Orr et al., 2020). Secretion of some hormones, growth hormone (GH), prolactin, melatonin, serotonin, and testosterone, can be affected by nutrient intake and circadian rhythms (Vernia et al., 2021).
Nutrition is also potentially contributory to gastrointestinal health or illness. Vernia et al. (2021) noted the psychophysiological relationship of healthy diet and lifestyle and good sleep. Dietary habits such as the following can disrupt sleep:
- eating fast
- irregular or skipped meals
- overeating
- poor-quality food selections
- caffeine
- alcohol
Cardiovascular
The cardiovascular system is particularly sensitive to insufficient sleep. Implications can be seen in inflammatory responses and the development of atherosclerosis, hypertension, hyperlipidemia, hyperglycemia/diabetes mellitus (DM), obesity, and subsequent myocardial infarction (MI) and stroke (Cleveland Clinic, 2020; Suni, 2023). More specifically, lack of sleep can result in excess calcium deposited in the coronary arteries. This, along with hyperlipidemia and inflammation, contribute to plaque formation. Plaque increases the risk for MI and stroke. Chronic hypertension causes stress on the heart and can contribute to MI and heart failure (HF). The kidneys and brain are also prone to damage secondary to poor perfusion (Suni, 2023).
The interplay between insufficient sleep and these cardiovascular problems can themselves contribute to poor sleep. Depending on the stage of HF, symptoms may include fluid retention and subsequent difficulty breathing. Patients often worry about their physical status and the potential for the condition to worsen. These actual and potential symptoms can negatively impact the quality and quantity of sleep.
Seven to eight hours of quality sleep is recognized as an optimal amount for adults, with lack of sleep contributing to negative cardiac effects. While in NREM sleep, especially stage III, the parasympathetic nervous system counters the effects of stress: heart rate and blood pressure reduce, and respirations become slower and shallower. Without sufficient time spent in stage III NREM sleep to foster relaxation and rejuvenation, pathological changes may appear (Cleveland Clinic, 2020; Suni, 2023).
Metabolic
Metabolism is influenced by sleep and insufficient sleep in a few ways. The intermittent hypoxia involved in obstructive sleep apnea (OSA) is related to such metabolic disorders as insulin resistance and hyperlipidemia (Orr et al., 2020). Diet is also influenced by sleep, as lower levels of the hormones ghrelin and leptin result in not feeling full and food cravings for choices high in fats and carbohydrates.
Related lipid abnormalities, especially the combination of high triglycerides and low high-density lipoprotein (HDL), insulin resistance, hyperglycemia, hypertension, and weight gain, are commonly associated with metabolic syndrome and DM (Chasens et al., 2021). Those who sleep less than five hours, or more than nine hours per day, are at elevated risk for development of metabolic syndrome.
Immunity
Sleep fosters normal immune function, and insufficient sleep is related to both adaptive and innate immune function alterations (Garbarino et al., 2021). Sleep supports the body’s immunological memory. Immune cells are among those produced primarily during sleep (Heid, 2023). Adequate sleep is necessary for maintenance of normal immune function, homeostasis, the ability to fight microbial invasions, and/or to mount a normal and effective inflammatory response. Patients who do not receive the sleep they need are more susceptible to infections, autoimmune reactions, and exaggerated inflammatory responses resulting in infections and chronic inflammatory responses. These may include pathological changes in the cardiovascular and metabolic systems, autoimmune and neurodegenerative diseases, and cancers, especially colorectal, prostate, and breast cancers (Garbarino et al., 2021). Autoimmune disorders, such as systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), are also more common in those who experience chronic sleep loss. Due to chronic illness, the normal immune response becomes unregulated and intensified, causing a more drastic inflammatory response and continuation of chronicity (Garbarino et al. 2021).
Behavioral Effects of Insufficient Sleep
Decision-making can become impaired by lack of sleep, resulting in behavior changes, including impulsive actions. Misuse of substances and risky, dangerous driving are two potentially damaging behaviors that can be associated with inadequate sleep. Additionally, hypersomnia can negatively affect all different types of behaviors.
Increased Risk for Substance Misuse
Insufficient sleep can have various psychological results, which can then impact behavior because inadequate sleep can have deleterious effects on clear thinking, coping, and decision-making. Many people self-medicate with substances, such as alcohol, OTC medications, marijuana, and other illicit drugs in order to stay awake, fall asleep, and cope with feelings of anxiety, mood changes, frustration, and insecurity. Some look for ways to feel happier, and some search for methods to calm down, even when such relief is temporary and may even result in worsening long-term effects.
Substance use often backfires when it comes to improving sleep. Alcohol is an example: while it may contribute to falling asleep, it is not typically a good quality sleep and, as the alcohol is metabolized, it often results in wakening with symptoms of feeling overheated and dehydrated. Using substances as a coping mechanism also contributes to the chronicity of ineffective sleep patterns and continues the negative cycle, which can be very hard to break.
Motor Vehicle Accidents
According to the National Sleep Foundation (NSF, 2022), driving while drowsy equals driving while impaired. The NSF (2022) estimates that approximately 21 percent of motor vehicle accidents (MVAs) resulting in death are attributable to drowsy driving; about 13 percent of drowsy driving MVAs result in hospitalizations. These statistics are significant and frightening, and the morbidity, mortality, and healthcare costs are enormous. The NSF goes on to describe drowsy driving as worthy of being classified as the fourth “D” regarding driving:
- drunk
- drugged
- distracted
- drowsy
Driving while drowsy is preventable but requires the necessary recognition and respect of its influence on safe driving. The NSF (2022) describes three to five hours of sleep within the previous twenty-four hours as likely to cause impaired driving for most people.
Link to Learning
The NSF’s Breaking Reportshares information regarding drowsy driving, including the graphs about frequency, perceptions about risk, hours of sleep needed for safety, and driving ability confidence.